Every finding on record at Pruitthealth - Blue Ridge

Based on observations, staff interviews, record review and review of the facility's document titled, Water Management Plan, the facility failed to ensure residents were free of accident hazards as evidenced by water temperatures above 110 degrees Fahrenheit (F) in seven out of 49 shared resident bathrooms (Room A-12, C-10, C-12, D-2, D-3, D-5, D-6). The deficient practice had the potential to cause injury to residents residing in these rooms.Findings include:Review of the facility's document titled Water Management Plan, dated 8/23/2024, Under the section titled Risk Factor: Water Heater revealed that the lower control limit for hot water heaters should not be below 122 F, and the upper control limit should not exceed 140 F.During observation on 7/29/2025 from 1:15 pm to 1:40 pm with the Environmental Manager, water temperature checks were conducted on A, B, and D corridors using a non-digital meat thermometer that revealed the following water temperatures: Room A-12: 130 F, Room C-10: 117 F, Room C-12: 120 F, Room D-2: 130 F, Room D-3: 140 F, Room D-5: 138 F, and Room D-6: 128 F. A follow-up observation was conducted on 7/29/2025 at 5:40 pm revealed, the following adjusted water temperatures: Room A-12: 100.3 F, Room C-10: 100 F, Room C-12: 100 F, Room D-2: 85 F, Room D-3: 95 F, Room D-5: 106 F, and Room D-6: 87 F.A review of facility water temperature logs showed that the water temperature checks had not been completed during the weeks of 7/21/2025 and 7/14/2025. Water temperature logs from earlier weeks (7/7/2025, 6/30/2025, 6/23/2025, 6/9/2025, 5/19/2025, and 5/12/2025) indicated temperature ranges between 105 F and 110 F. An interview conducted on 7/29/2025 at 1:25 pm with the Environmental Manager confirmed that weekly water temperature checks had not been conducted for two weeks. Further review of the facility's records confirmed that no residents sustained burn injuries related to hot water temperatures. In addition, the facility implemented new procedures to ensure compliance and resident safety: Thermometers were provided to housekeeping staff for regular temperature checks; Shower rooms were equipped with thermometers for monitoring water temperatures before use; In-service education on water temperature management was conducted on 7/29/2025 for the shower team, housekeeping, and laundry staff. A service invoice dated 7/31/2025 from Rapid Flow Plumbing revealed repairs to the water heaters. The invoice noted that water heater # (number) 1 could not be adjusted below 120 F and was temporarily connected to water heater #2. New copper water lines and ball valve cut-off valves were installed, and the water temperature was set to 110 F. Further review revealed, the plumber planned to return to install a new mixing valve at water heater #1 during week of 8/4/2025. Until this time the Administrator stated all showers would be conducted in shower room on front hall. Hot water to rooms served by this mixing valve was turned off until repair was completed.During an interview on 7/30/2025 at 3:30 pm, with the Administrator revealed that a new hire to fill the role of Maintenance Director at the facility should start during the week of 8/4/2025.

Based on observations, staff interviews, record review and review of the facility's policy titled Cleaning Schedule Policy, Dietary Partner Hygiene and Dress Code, and Handwashing: Dietary Services, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This deficiency had the potential to affect 64 of 67 residents who ate meals from the facility's kitchen. Findings include: A review of the facility's policy titled Cleaning Schedule Policy, dated 9/29/2022, under the section titled Policy Statement revealed, It is the policy of [the facility] that the Dietary Manager [DM] prepares a list of all cleaning tasks and posts them in the Dietary Department. It is the Dietary Manager's responsibility to develop and enforce the cleaning schedules and to monitor the completion of assigned cleaning tasks to promote a sanitary environment. Under the section titled Procedure revealed, 1. The cleaning schedule: daily, weekly, and monthly lists all cleaning tasks, specifies frequency of the task, and the position (job title) responsible for completion of the task. The dietary partner will initial the form once the cleaning tasks is completed. 2. The cleaning schedules are posted in the Dietary Department. 3. Completed daily, weekly, and monthly cleaning schedules should be kept on file for six months. 4. The Dietary Manager or designee will complete the Kitchen Observation in [an electronic log]. A review of a facility document titled Cleaning Assignments Form - Daily, dated 4/27/2016, included the following: - Work tables: top/shelves/legs clean. - Freezer/Refrigerator Reach-In: Clean inside and outside. - Hand sink Area: Clean sink. Replace soap and hand towels as needed. Clean inside and outside the trash can. - Floors: All areas (behind & [and] under equipment) swept/mopped. - Dish Room: Worktables/shelves-clean. - Range: Clean Surface Areas. - Can Opener: Clean and sanitize blade and base. A review of a facility document titled Cleaning Schedule Form - Weekly, dated 4/27/2016, revealed the following: - Floors: Scrub and deck brush all floor areas - including under shelves, along baseboards, and in corners. - Walk-in Freezer & Refrigerator: Sweep and mop floors and under shelves. - Food Carts: Detail clean and sanitize inside and out. - Dish Dollies / Cart /Rack: Clean and sanitize. - Utility Carts & Bun Racks: Clean and Sanitize. - Trash Can: Clean and scrub trash cans. A review of a facility document titled Cleaning Schedule Form - Monthly, dated 4/27/2016, revealed the following: - Floors: Clean floor drains. - Store room(s): Clean shelving units. - Walk-in Freezer: Clean shelving units. - Walk-in Refrigerator: Clean shelving units. - Food Storage Containers: Clean inside & out all food storage bins (sugar, flour corn mill, etc. [et cetera]). - Can Opener: Clean base inside. Remove base from table and clean under base and table area. A review of the facility's policy titled Dietary Partner Hygiene and Dress Code, dated 6/14/2016, under the section titled Policy Statement revealed, It is the policy of [the facility] for partners working in the Dietary Department to dress in a manner appropriate for preparing, handling, and serving food that prevents contamination and spread of bacteria. Under the section titled Scope revealed, This applies to all dietary partners, and any person(s) who handles and serves food employed by [the facility]. Under the section titled Hygiene revealed, 2. Hair is covered with hair net and/or cap. 5. Eating or drinking is not permitted while in the kitchen. 7. Handwashing must take place prior to the start of each shift, during their shift, upon returning to the kitchen area, after using the restroom, and returning from breaks. A review of the facility's policy titled Handwashing: Dietary Services, dated 4/14/2016, , under the section titled Policy Statement revealed, It is the policy of [the facility] to prevent the spread of bacteria which may lead to foodborne illnesses by using proper hand washing techniques. Under the section titled Scope revealed, This applies to all partners employed by [the facility]. A review of a document titled January RD [Registered Dietician] Inspection, dated 1/31/2024, completed by the RD, indicated that food preparation equipment was not clean and that the floor of a walk-in needed to be cleaned. A review of a Kitchen Observation document, dated 2/12/2024, completed by DM #21, the previous DM, indicated that the food preparation equipment was not clean and that a refrigerator needed to be swept. The document revealed that DM #21 documented Floor a mess. Observation on 3/4/2024 at 8:35 am, during the initial tour of the kitchen, revealed that the floors were covered with dirt and crumbs and felt sticky to walk on. The handwashing sinks by the bathroom had a film covering the entire sink, which was removed when wiped. The top of the trashcan under the sink was discolored, and the lid appeared to be a red/rust color. There were boxes on the floor, making it impossible to walk around the area, and only the floor directly inside the door was visible. In the cooler, dirt, paper, and food crumbs covered the floor and underneath the shelves. The floor of the freezer was dirty, covered with paper and crumbs. Individualized cartons of ice cream were observed under one of the shelving units. Boxes covered the middle of the floor, making it impossible to walk around the freezer, and only the floors directly around the door were visible. A layer of dirt and fuzz covered the metal shelving units that sat between the freezer and walk-in cooler. The fuzz could be scraped off with a finger. Boxes covered the floor of a dry food storage room. Under the shelving units were large amounts of trash, single-serving size cereal boxes, and crumbs. The front of the convection oven was covered with a large amount of grease build-up. Floors under all the cooking equipment were covered with dirt, crumbs, and trash; the floors were sticky to walk on. During an interview at the time of the observation, Dietary Aide (DA) #20 stated that he had only been working at the facility for about two weeks and did not know anything about the cleaning schedules. During an interview on 3/5/2024 at 10:50 am, the RD stated that the previous Dietary Manager (DM) was suspended on Friday, 3/1/2024, for poor performance. The RD stated that she was at the facility the previous Friday and saw that the kitchen was in poor condition. During an interview on 3/5/2024 at 11:54 am, the RD stated she used the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Pathway as her checklist for her kitchen inspections. The RD stated she thought the DM only used the daily checklist and not the weekly or monthly checklists to track cleaning. During an observation on 3/6/2024 starting at 9:40 am, Cook #14 was cooking. A cart next to the food preparation table with condiments had a thick layer of dirt along the edge that could be scraped off with a finger. At 9:43 am, Cook #14 was not wearing gloves as she cut up fresh squash, put them in a pan, and then added salt and pepper. She cut up more squash and put it in a smaller pan. Cook #14 wore a hat with no hair net on, and her hair hung down past her shoulders. She added the smaller pan of squash to a steamer. A larger pan of squash was in the steamer already. She pulled the larger pan out and set it on the counter. She placed the smaller pan of squash in the steamer and then placed the larger pan in with the heaping pan of squash, touching the bottom of the larger pan above it, and closed the door. She donned gloves without washing her hands, cleaned up some of her mess where she cut up the squash, then removed the gloves and did not wash her hands. She grabbed two smaller pans and sat them by a food processor. She put ham from the steamer into the food processor, ground the meat, and then removed her gloves. Without washing her hands, she pulled the cornbread out of the oven, put foil over the ground ham, and then put it in the oven. She removed the gloves and did not wash her hands. Cook #14 pulled the cornbread out of the oven and put the small pan of ham in. During an observation on 3/6/2024 at 9:50 am, Certified Dietary Manager (CDM) #16 was in the kitchen and not wearing a hairnet. Cook #14 wore gloves to prepare the pureed foods and then removed her gloves, touched the inside of a trashcan, and grabbed foil to put over the pureed ham. At 10:30 am, Cook #14 began cleaning up the food preparation table and carried all the dishes into the dish room. She rinsed the dishes, put them through the dishwasher, and then immediately went back to rinsing dishes again. She washed 11 loads of dishes and did not wash her hands at all during the 30-minute observation. Cook #14 put away the dishes, then loaded more dishes onto a cart to put them away. She continued to move back and forth between the dirty and clean sides and did not wash her hands. After the last load of dishes, she took two paper towels, dried her hands, threw the paper towels in the trashcan, and pushed the cart out to put the dishes away without washing her hands. During an observation on 3/6/2024 at 11:00 am, Cook #14 wet a hand towel with water from a sink and then wiped off the food preparation table. She did not have a sanitizer bucket out with water to use to clean off the counter. Cook #14, then put the rest of the dishes away, including the food processor, without washing her hands. She then pushed the cart back into the dish room. Cook #14 placed a piece of parchment paper on a baking sheet. During this time, Certified Nurse Aide (CNA) #17 entered the kitchen and walked into the food preparation area to get three cups of coffee. CNA #17 did not put on a hairnet before entering the kitchen. Cook #14 left the baking sheet on the counter in the food prep area, went into the office, and obtained a bottle of water to drink. She took the water into the food preparation area and sat it on the counter by the three-compartment sink. At 11:10 am, Cook #14, without washing her hands or putting on gloves, pulled rice out of the steamer to check the temperature. She put her fingers down into the pan, pulled some rice out, and ate it while she rolled a piece around her fingers. She then pulled a piece of rice off the thermometer and ate it. During an interview on 3/6/2024 at 12:55 pm, CNA #17 stated that she usually wore a hairnet in the kitchen. She stated that she did not wear one that day because she was in a hurry. During an interview on 3/6/2024 at 1:15 pm, the Administrator stated that they identified there was a problem in the kitchen about a month ago, and disciplinary action was taken against the previous DM. He stated that they gave the previous DM a chance to make things better, but they did not see any improvement. He stated that on Friday, 3/1/2024, they suspended the previous DM and brought in staff from a sister facility to begin working to make improvements. During an interview on 3/6/2024 at 1:25 pm, Cook #14 stated that staff should wash their hands every chance they get, after coming from the bathroom, between changing gloves, when their hands were dirty, and every five to ten minutes. She stated that staff were supposed to wash their hands between dirty and clean dishes and acknowledged that she did not do that. She stated that staff should wash their hands after touching trash cans or taking out the trash. Cook #14 stated that she probably did not wash her hands enough that day. She stated that staff should have a hairnet on as soon as they entered the kitchen. She stated that she forgot to put on a hairnet until someone told her. Cook #14 stated that she could wear a hat, but she had to have a hairnet under the hat. During an interview on 3/6/2024 at 2:45 pm, Cook #15 stated she did not have a lot of training in the kitchen. She stated that she did not know they needed to have sanitizer in buckets. She stated that she started doing that a couple of days ago and that no one had ever trained her on that. She stated that the kitchen staff did not have assigned tasks to clean every day, every month, or every week; she just kept her work area clean, swept, and washed the dishes. She stated that everyone did what they could, but there were only two of them in the kitchen a lot of the time. During an interview on 3/6/2024 at 3:00 pm, CDM #16 stated that she should wear a hairnet anytime she was in the kitchen. During an interview on 3/7/2024 at 9:35 am, Cook #14 stated dietary staff should use the sanitizer to wipe things down. She stated that they did not do that the day prior because the sanitizer dispenser was messed up and did not work; they were supposed to be working on it. During an interview on 3/7/2024 at 9:36 am, the RD stated that staff should use sanitizer buckets that had been tested . She stated that staff should not put water on a rag and wipe a counter down. She was unaware of an issue with the sanitizer dispenser but stated that CDM #16 thought there was an issue with how the dispensers were connected. She stated that they should have someone who swept the floor, and each person should have assignments, and stated that had not been done. The RD stated that all staff were assigned to do the deep cleaning. She stated that staff should wash their hands every time they touched themselves, after using the bathroom, and when they prepared food. The RD stated that staff should also wash their hands between changing their gloves or when changing tasks between dirty and clean dishes. She stated that staff should wear gloves when touching the food on the serving line, rolling silverware, or when touching dirty trays in the dish room. The RD stated that dietary staff should not taste test food with their bare hands. She stated that staff should wear hairnets in the kitchen any time they were around food being prepared. She stated that she did not think hats were a good alternative to hairnets but stated they could wear them if there was not more than one inch of hair hanging out. The RD stated that CNAs should wear hairnets in the kitchen or wait at the door to get whatever they need. Per the RD, staff should not have drinks in the kitchen; they could keep them in the office or the breakroom. During an interview on 3/7/2024 at 10:51 am, the Director of Health Services (DHS) stated that she expected the kitchen staff to follow all infection control standards and the Department of Public Health standards. She stated that the kitchen should be clean and a place where someone would want to eat. She stated that staff should always wear hairnets in the kitchen. The DHS stated that staff should always adhere to hand hygiene and infection control policies. She stated that staff should wash their hands a lot, including any time they were soiled or after handling dirty dishes, before they touched clean dishes. During an interview on 3/7/2024 at 11:36 am, the Administrator stated he had been at the facility for about a month. He stated that the kitchen needed to be cleaned. He stated that the facility had a daily cleaning schedule that needed to be followed, as well as a monthly and weekly schedule that was more deep cleaning. He stated that the DM should be taking the lead on that. He stated that they were not following the weekly or monthly schedules, but he thought, as of recently, they were working to be better at it. He stated that he depended on the RD and the DM for cleaning schedules. The Administrator stated that part of the daily cleaning schedule should address the use of sanitizers to clean the food preparation areas. He stated that staff should wear a hairnet but thought hats were acceptable. He stated that the RD talked to him about hairnets and agreed that all hair should be covered. He stated that CNAs should stay at the kitchen entrance door, and if they go into the kitchen, they should have a hairnet on. The Administrator stated that he expected staff to wash their hands during meal preparation, before meal preparation, before cleaning dishes, or after touching a trash can. He stated that he expected staff to wash their hands whenever they touched something that would be considered dirty.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Patient/Resident Voting, the facility failed to support three out of 37 sampled Residents (R) (R#54, R#55, and R#56) with their rights to vote. In addition, the facility failed to promote dignity by using disposable cutlery at meals for four out of 37 sampled Residents (R) (R#28, R#49, R#41, and R#55) observed during dining. Findings include: 1. A review of a facility's policy titled Patient/Resident Voting, dated 1/5/2015, under the Policy Statement revealed, It is the policy of this Healthcare Center for each patient/resident's civil right to vote be promoted and opportunities will be provided within the healthcare center for patients/residents to exercise this right. Under the section titled Procedure revealed, 1. All patients/residents who are registered to vote and have a desire to vote and have the ability to make such a decision will be identified through the initial assessment process. 3. Each patient/resident will be informed in advance of voting procedures and schedules. A review of R#54's Resident Face Sheet indicated the facility admitted Resident #54 on 8/10/2023. A review of R#54's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/9/2024, revealed R#54 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. A review of Resident #54's electronic health record did not reveal a completed activity assessment. During an interview on 3/4/2024 at 1:07 pm, R#54 stated that they were interested in voting but was not aware they could ask staff for assistance with voting. A review of R#55's Resident Face Sheet revealed the facility admitted Resident #55 on 8/11/2023. A review of R#55's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/9/2024, revealed R#55 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. A review of R#55's Activity Assessment, completed on 1/24/2024, indicated that R#55 wished to vote. A review of R#56's Resident Face Sheet indicated the facility admitted R#56 on 8/11/2023. A review of R#56's quarterly MDS, with an ARD of 2/19/2024, revealed R#56 had a BIMS score of 15, which indicated the resident was cognitively intact. A review of R#56's Activity Assessment, completed on 2/12/2024, indicated that R#56 wished to vote. During a Resident Council meeting on 3/5/2024 at 2:30 pm, the following residents had concerns about voting: -R#55 stated that they wanted to vote but had not voted since their admission to the facility. --R#55 stated that no one at the facility had assisted them with changing their address, receiving an absentee ballot, or going to a polling place to vote. - R#56 stated they had voted since they were the legal age to vote. R#56 stated it was important for them to vote, but they had not voted since they were admitted to the facility in the summer of 2023. R#56 stated that no one at the facility had assisted them with changing their address, receiving an absentee ballot, or going to a polling place to vote. During an interview on 3/7/2024 at 9:12 am, the Activity Director (AD) stated that she asked residents quarterly if they wanted to vote. The AD stated that if a resident wanted to vote, she would discuss it with the Social Services Director (SSD) to determine if the resident was competent to vote. She stated that as far as she was aware, after asking a resident if they wanted to vote, there had not been any follow-up until recently. The AD confirmed that no one had come to the facility to assist residents with voting. The AD stated she was unsure if R#54 had a completed activity assessment that addressed the resident's wishes regarding voting. During an interview on 3/7/2024 at 10:55 am, the Social Services Director (SSD) stated that he and the AD had contacted the county registrar on 3/6/2024 to confirm which residents were registered to vote. The SSD stated he was unaware of any residents voting in the three years he had worked at the facility. The SSD stated that he did not know what happened with the activity assessment when a resident indicated they wanted to vote. During an interview on 3/7/2024 at 11:41 am, the Director of Health Services (DHS) stated it was the residents' right to vote, and the facility staff should assist residents with voting. During an interview on 3/7/2024 at 11:57 am, the Administrator stated that residents had the right to vote, and the facility staff should assist with that process. 49044 2. A review of a facility's policy titled Resident Rights, dated 12/1/2023, under the section titled Policy Statement revealed, It is the policy of this healthcare center to promote and protect the rights of the patients/residents residing in the center. In addition, all patients/residents and their responsible parties must sign a written statement of acknowledgment and be given a copy of the center's patient/resident rights and responsibilities. Under the section titled Procedure revealed, 1. Patients/residents are entitled to fully exercise their personal and legal rights and privileges if possible. 2. The center will make every effort to assist the patient/resident in understanding and exercising his/her rights to assure the patient/resident is always treated with respect, kindness, and dignity. A review of an untitled list of the number of sets of silverware on hand at the facility, dated 3/6/2024, provided by the Registered Dietician (RD), revealed that the facility had a census of 67, and per the dietary staff, they usually ran out of silverware around the second to last meal cart. The document revealed they estimated they had 47 sets of silverware. A review of R #28's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/23/2024, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. During an observation and interview on 3/4/2024 at 8:56 am, R#28's meal tray had a plastic spoon on it. R#28 stated they hated plasticware and could not use it as well as silverware. A review of R #49's admission MDS, with an ARD of 2/12/2024, revealed the resident had a BIMS score of five, which indicated the resident had severe cognitive impairment. An observation on 3/5/2024 at 1:00 pm revealed R#49 was eating their lunch using plasticware. A review of R#21's quarterly MDS, with an ARD of 1/12/2024, revealed R #21 had a BIMS score of 15, which indicated the resident was cognitively intact. An observation and interview on 3/5/2024 at 1:05 pm, revealed R #21 ate the noon meal. R#21 stated that they could not cut up the porkchop with the plasticware. A review of R#55's quarterly MDS, with an ARD of 1/12/2024, revealed the resident had a BIMS score of 14, which indicated the resident was cognately intact. During an interview on 3/5/2024 at 1:20 pm, R#55 stated that they had often been given plastic silverware with lunch and dinner. R#55 stated that they had been given paper plates recently as well. R #55 stated that they kept metal silverware in their room and used them when staff brought them plasticware. During an interview on 3/5/2024 at 2:30 pm, R #55 stated that they had notified staff about the kitchen staff sending out plasticware. R #55 stated that they despised using disposable silverware and plates. R#55 stated that they were told by staff that they were short on silverware. R#55 stated that when staff brought them plasticware, they told staff that they did not want disposable plasticware. An observation on 3/6/2024 at 12:49 pm revealed that staff passed meal trays to residents on the D-hall, and each tray included a package of plasticware. During an interview with Dietary Aide (DA) #13 and the Registered Dietician (RD) on 3/6/2024 at 10:17 am, DA #13 stated that they gave silverware for one meal and then did not have any for the rest of the day. The RD stated that they seemed to lose silverware as fast as they replaced it. During an interview on 3/7/2024 at 9:36 am, the RD stated that it had not been brought to her attention that the residents did not like the plastic silverware. She stated that she could imagine that they did not like using the plasticware. She stated that forks and spoons were ordered last in December 2023. During an interview on 3/7/2024 at 10:51 am, the Director of Health Services (DHS) stated that residents should not use plastic utensils or paper plates. She said there had been a problem with this, that it was terrible for residents to use plasticware, and that it was a dignity issue. During an interview on 3/7/2024 at 11:36 am, the Administrator stated that the RD told him about the issues with residents using plasticware. He stated that typically the plasticware and paper plates should only be used in an emergency when they had dishwasher concerns. He stated that for the most part, they should use silverware.

Based on observations, staff interviews, record review, and review of the facility's policy titled Patient/Resident Council, the facility failed to complete an investigation, response, and resolution to the residents' concerns that attended the Resident Council Meetings. The facility census was 67 residents. Findings include: A review of a facility policy titled Patient/Resident Council, dated 10/20/2017, under the section titled Procedure revealed, 1. The Patient/Resident Council will meet as a group to: Discuss and offer suggestions about healthcare center policies and procedures affecting patients/residents' care, treatment, and quality of life. 2. Issues raised/discussed, and recommendations made by the Patient/Resident Council will be communicated to the healthcare center administration, considered in center planning, and responded to promptly. 10. Issues, concerns, ideas or complaints of the Council will be transferred to the Patient/Resident Council/Family Council Department Response Form by the staff liaison person and given to the Administrator for distribution and response by the appropriate department. The response/action will be documented on this form, returned to the Administrator for review and signature and returned to the Council staff liaison for communication back to the Council Presiding Officer and presentation at the next council meeting. The department response form will be attached to the minutes of the meeting in which the issue was brought up. During a Resident Council meeting on 3/5/2024 at 2:30 pm, Residents (R) R#9, R#41, R#55, and R#56 expressed concerns about staff giving the residents disposable silverware and plates with meals, food temperatures, food seasoning, meat being served too tough, staff not following the dietary menu, and the font on the activity calendar being too small to read. A review of Patient/Resident Council Minutes/Report, dated 1/1/2024, indicated that the Resident Council brought forth their concerns that Certified Nurse Aide (CNAs) needed to bring seasonings with trays, the chicken was still too tough, they wanted more alternative options for diabetic residents, and calendars needed to be on bigger paper. A review of the Patient/Resident Council/Family Council Department Response Form for the 1/1/2024 Resident Council meeting concerns revealed that the nursing Department Investigation, Response, and Resolution indicated that the nursing department educated CNAs and nurses delivering trays to residents were to ask, Would you like any additional seasonings for your meal? The dietary Department Investigation, Response, and Resolution revealed staff failed to investigate and respond to the concern that the chicken was still too tough and that there needed to be more alternative options for diabetic residents. The activity Department Investigation, Response, and Resolution indicated that the activity department was working on February's calendars and getting them printed on bigger paper. A review of Patient/Resident Council Minutes/Report, dated 2/19/2024, indicated that the Resident Council brought forth their concerns of keeping food warm. A review of the Patient/Resident Council/Family Council Department Response Form for the 2/19/2024 Resident Council meeting concerns revealed that the nursing Department Investigation, Response, and Resolution indicated that as soon as trays were on the hall's food was delivered to each resident. A review of Patient/Resident Council Minutes/Report dated 12/6/2023 indicated that the Resident Council brought forth their concerns, including that plastic silverware did not work. A review of the Patient/Resident Council/Family Council Department Response Form for the 12/6/2023 Resident Council meeting concerns revealed that residents identified concerns that included food was often over or undercooked, trays were often cold, the food needed more seasoning, and staff were not serving what was on the facility menus. The dietary Department Investigation, Response, and Resolution indicated that the facility would educate on the importance of silverware, timing while cooking, and the menus. The dietary Department Investigation, Response, and Resolution revealed that the facility failed to respond to the concerns regarding the trays often being cold and the food needing more seasoning. A review of Patient/Resident Council Minutes/Report, dated 11/8/2023, indicated that the Resident Council brought forth their concerns, including no salt packets on meal trays. A review of the Patient/Resident Council/Family Council Department Response Form for the 11/08/2023 Resident Council meeting concerns revealed staff failed to indicate that the Resident Council had identified a concern with not receiving salt packets on meal trays. The form revealed the facility failed to respond to the Resident Council's concern about no salt packets on trays. A review of Patient/Resident Council Minutes/Report dated 10/2/2023 indicated that residents in attendance brought forth their concerns, including staff not providing salt with meals and menus not being followed. A review of the Patient/Resident Council/Family Council Department Response Form for the 10/2/2023 Resident Council meeting concerns revealed that the dietary Department Investigation, Response, And Resolution failed to address and respond to the dietary concern about salt with meals and menus not being followed. A review of Patient/Resident Council Minutes/Report dated 9/4/2023 indicated that the Resident Council brought forth their concerns, including food coming out of the kitchen being cold and raw and the facility serving tough meat that was hard to cut and chew. A review of the Patient/Resident Council/Family Council Department Response Form for the 9/4/2023 Resident Council meeting concerns revealed that the facility's Department Investigation, Response, and Resolution to the identified concerns was new covers and carts were ordered. A review of the form revealed the facility failed to complete an investigation, response, and resolution to the Resident Council's concern that the tough meat was hard to cut and chew. On 3/5/2024 at 1:01 pm, dining observations were conducted. Plastic silverware was observed being passed on residents' lunch trays delivered to residents on the D Hall. During an interview on 3/5/2024 at 9:31 am, the Activity Director (AD) indicated that they assisted with the Resident Council and scheduled the Resident Council meetings. During an interview on 3/6/2024 at 10:17 am with the Registered Dietitian (RD) and Dietary Aide (DA) #13, DA #13 indicated that they gave the residents one set of regular silverware a day, and the facility did not have enough regular silverware for the rest of the day. DA #13 stated that she felt like the residents would rather have the plasticware instead of the real stuff. The RD also stated that she felt like the residents would rather have the plasticware instead of the real stuff. During an interview on 3/6/2024 at 1:30 pm, the RD stated that she imagined that the chicken that was served to the residents the day prior was not great based on how it was cooked. The RD stated that the staff put frozen chicken patties in the oven with no seasoning, cooked them for a bit, and then put some seasoning on them. The RD stated cooking the chicken that way dried it out. During an interview on 3/7/2024 at 9:36 am, the RD stated the dietary staff had been putting seasoning packets in cups on top of the carts, and the nursing staff were supposed to grab them when they passed the tray. The RD stated they had to throw out any extra packets that had been in the cups on the hall. The RD stated that if they posted the menu too early, the residents would be disappointed if they had to replace menu items; if they posted it at least the night before, the dietary staff would know they had all the items listed on the menu. The RD stated that there were complaints with the Resident Council regarding alternative meal choices. The RD indicated that the facility staff should be meeting with residents to determine preferences and then adding preferences in the meal tracker. During an interview on 3/7/2024 at 12:09 pm, the AD stated that the residents hold Resident Council meetings on the first Monday of every month, and they encourage the residents to come. The AD indicated she was given directions from the facility to take notes and report problems. The AD stated that she never knew what her role was in the Resident Council. The AD stated that the concerns that the Resident Council brought forward were given to the appropriate department managers, and at the following Resident Council meeting, the residents would report if the concerns were resolved. The AD stated that last month, the Resident Council identified that the activity calendars in residents' rooms needed to be bigger. The AD stated that they had not been able to print calendars on larger paper and were still being printed on 8.5-inch by 11-inch paper. During an interview on 3/7/2024 at 10:51 pm, the Director of Health Services (DHS) stated that she expected the facility to have and be able to use regular utensils. The DHS stated that it was terrible for residents to use plasticware and that it was a dignity issue. During an interview on 3/7/2024 at 1:32 pm, the Director of Health Services (DHS) indicated that the AD was responsible for overseeing the Resident Council meetings, including bringing the Resident Council's concerns to the department heads by writing a grievance for each concern. The DHS indicated that every topic/concern was worth an investigation. The DHS indicated that they had addressed reoccurring food concerns with current and prior administrators, the social worker, the facility consultant, and the ombudsman. During an interview on 3/7/2024 at 3:32 pm, the Administrator indicated that he expected all concerns brought forth by the Resident Council to be documented on the forms (Patient/Resident Council Minutes/Report and the Patient/Resident Council/Family Council Department Response Form) following a Resident Council meeting. The Administrator indicated that repetitive Resident Council concerns raised a bigger concern.

Based on observations, staff and resident interviews, record review and review of the facility's policy titled How to Puree Foods, the facility failed to ensure they served food that was prepared by methods that conserved the nutritive value, flavor, and appearance, and that the foods served from the facility's kitchen was palatable and attractive. This deficiency affected three out of 37 sampled Residents (R) (R#62, R#49, and R#17) but had the potential to affect all 37 residents on a regular consistency diet and all 10 residents with orders for pureed diets. Findings include: 1. A review of the facility document titled Consistency Census Report, printed on 3/6/2024, revealed the facility had 37 residents on a regular consistency diet. A review of the facility's 2023 Diet Guide Sheet revealed the lunch menu for Tuesday, day 24, included herb baked chicken, parslied noodles, creamed spinach, and a breadstick. A review of the recipes provided by the facility staff, used for the lunch meal on Tuesday, 3/5/2024, revealed a recipe for herb-baked chicken. The recipe revealed instructions for staff to use boneless and skinless chicken thighs, salt, pepper, and ground rosemary. The recipe revealed the procedure included instructions for staff to do the following: - Wash the chicken and place pieces of the chicken on baking sheets. - Combine salt, pepper, and rosemary, and season the chicken with the herb mixture. - Cover and bake at 350 degrees Fahrenheit (F) for about one to one and a half hours. Remove cover for at least 30 minutes of baking. During an observation and interview on 3/5/2024 at 12:53 pm, R#62 was in their room eating the noon meal. The resident began having trouble swallowing their chicken and started coughing. R#62 stated that the chicken was dry. During an interview on 3/5/2024 at 1:00 pm, as R#49 ate their noon meal, R#49 stated that their meal was not good. An observation of a test tray of the noon meal on 3/5/2024 at 1:11 pm revealed the chicken was chicken breast, not a thigh, and it was very dry. The breadstick was overcooked on the bottom, and the top was wet and appeared to be undercooked. During an interview on 3/5/2024 at 1:44 pm, R#17 stated that the chicken was too tough and dry so one of the Certified Nurse Aides (CNA) got them ground chicken. R#17 stated that it was still too dry and now they felt like they had a piece stuck in their mouth. R#17 stated that there was a breadstick that was overcooked and was hard as a rock. During an interview on 3/6/2024 at 2:45 pm, Cook #15 stated that she did not have a lot of kitchen training. She stated that she sometimes would taste test the food, but she did not the day prior. She stated that she usually talked to the residents about the food. Cook #15 stated that some of the residents would tell her they liked the food and others would say they did not. During an interview on 3/6/2024 at 1:30 pm, the Registered Dietician (RD) stated that staff should taste test the food, and she usually did, but she did not test it the day prior. She stated that she imagined the chicken was not great based on how Cook #15 cooked it. She stated that Cook #15 put frozen chicken patties in the oven with no seasoning, cooked them for a bit, and then put seasoning on it. The RD stated that cooking the chicken that way would dry it out. 2. A review of an undated facility policy titled How to Puree Foods under the section titled What is the correct pureed texture revealed, Pureed foods should be soft and moist, cohesive (holds together, not runny), smooth (without lumps) and spoon-thick (does not flow or drip continuously through fork prongs). Properly pureed foods should be 'swallow ready' and not require chewing. Under the section titled Preparation Steps revealed, 1. Depending on the resident's dietary restrictions, follow the proper recipe. 5. If required, for hot foods add a small amount of hot liquid, such as gravy, sauce, or cooking liquid, to the cooked hot foods. For cold food, add cold liquid such as milk or fruit juice; Do not add water. Under the section titled Notes revealed, Some foods, typically vegetables, have a higher water content than others, such as squash, cauliflower, broccoli, carrots, tomatoes, greens, peas, green beans, etc. [et cetera]. When processing these foods, thickener may be needed. If thickener is required, use as little as possible. Use one half teaspoon at a time until proper consistency is reached. A review of a facility document titled Consistency Census Report, printed on 3/6/2024, revealed that the facility had 10 residents who received puree food. A review of the facility's 2023 Diet Guide Sheet revealed the lunch menu for Wednesday, day 25, included baked ham with chipotle peach glaze, wild rice, squash au gratin, tossed salad with dressing, and a cornbread muffin. A review of the recipes provided by the facility revealed a recipe for baked glazed ham that included ham, light brown sugar, cornstarch, light corn syrup, and pineapple juice. The recipe revealed the procedure included instructions for staff to do the following: - Place the ham in a roasting pan or on a steam table pan. - Bake the ham at 325 degrees Fahrenheit (F) for 15 minutes per pound or until the internal temperature reaches 155 degrees F for a minimum of 15 seconds. - While the ham is baking, prepare the glaze so it can be placed on top of the ham approximately 30 minutes before it is done. - Glaze: combine the brown sugar, cornstarch, light corn syrup, and pineapple juice in a small bowl. - Approximately 30 minutes before the ham is done, pull the ham from the oven and spoon the glaze over the ham. - Return the ham to the oven and bake until the internal temperature has reached. A review of the recipes provided by the facility revealed a recipe for pureed glazed baked ham. The recipe included instructions for staff to do the following: - Weigh the ham according to the recipe and place it in the food processor. - Puree the baked ham until the consistency is pureed, noting that it would not be smooth, but there would be no large pieces. - Reheat the baked ham to 165 degrees F for a minimum of 15 seconds. - Maintain the temperature of the ham at a minimum temperature of 140 degrees F or according to the policy. - Serve a #10 scoop per serving, which is 3.25 ounces (oz). Ensure a 2 oz serving of sauce or gravy is placed on top of the ham during service. A review of the recipes provided by the facility revealed a recipe for summer squash. The recipe revealed instructions for staff to use zucchini squash, margarine, black pepper, and onion powder. The recipe included instructions for staff to do the following: - Steam or boil the summer squash in water. - Do not overcook. - Drain most of the water off the summer squash. - Add the margarine, pepper, and onion powder, then toss lightly. An observation and interview on 3/6/2024, beginning at 9:40 am, revealed Cook #14 prepared ham, rice, squash, and cornbread. The ham and cornbread were in the oven and ready to be served. A small pan of ham was on the counter. Observation at this time showed Cook #14 cut up squash and added salt and pepper to the pan with the squash. She cut up more squash, put it in a smaller pan, and left it on the counter. She did not put any seasoning on the small pan. She did not have any recipes out. Cook #14 pulled a small pan of ham out of the steamer and added the smaller pan of squash to the steamer. She put the ham from the steamer into the food processor and ground the meat. Cook #14 then added an unmeasured amount of ham and an unmeasured amount of broth to the food processor, added more broth, and then used the food processor to puree the ham. She checked the consistency and asked the Certified Dietary Manager (CDM) #16 to look at the puree. Cook #14 then added an unmeasured amount of water to the food processor. CDM #16 told Cook #14 she needed to add thickener to the ham to thicken it up. Cook #14 added one tablespoon of thickener. Cook #14 then pulled the squash out of the steamer and added a pan of rice into the steamer. The squash had a large amount of pepper on it. Cook #14 placed the steamed squash in a smaller pan and put it on the steam table. At 11:23 am, Cook #14 placed an unmeasured amount of squash in the food processor and blended it. She placed two tablespoons of thickener in the food processor, then sprinkled the remainder of the thickener from the can into the food processor and continued to blend. She then checked the temperature of the pureed squash and put it back in the steamer. During an interview on 3/6/2024 at 1:25 pm, Cook #14 stated she found out Monday, 3/4/2024, that she was coming to this facility to work. She stated that the recipes were probably somewhere, but she did not have the recipes for rice, squash, or ham. She stated that she should measure liquids. Cook #14 stated that pureed food should be a milkshake consistency. She stated that she did not put any seasoning on the pureed squash and that she usually tried to season it. During an interview on 3/6/2024 at 1:15 pm, the Administrator stated that they identified that there was a problem in the kitchen about a month ago and took disciplinary action against the previous Dietary Manager (DM) and gave her a chance to make things better, but they did not see any improvement. He stated that on Friday, 3/1/2024, they suspended the previous DM and brought in staff from a sister facility to begin working to make improvements. During an interview on 3/7/2024 at 9:36 am, the Registered Dietician (RD) stated that the previous DM told her there were complaints from the Resident Council that residents did not like the food and asked if she could change the menu, so she did change it to an older one. She stated that dietary staff should follow the recipes, use the correct chicken, make sure the food looked more pleasing, talk to the residents, ask what they thought, and sample test trays to see if the meal was something they would want to eat. She stated that she found a lot of cooks did not use the recipes. She stated that there were multiple missing recipes. During an interview on 3/7/2024 at 10:51 am, the Director of Health Services (DHS) stated that she had not eaten the food from the facility's kitchen in a while. She stated that the food quality started to go down while the previous DM was there. The DHS agreed that the food should be to the residents' liking, appealing, and flavorful. She stated that the food should not be bland and should not cause someone to cough when eating. She stated that she felt sad that the residents were excited to eat food on Wednesday, 3/6/2024, which could be considered subpar. During an interview on 3/7/2024 at 11:36 am, the Administrator stated he had been at the facility for about a month. He stated that he had taste-tested the food. He stated that their goal was to make sure staff followed recipes and the food was presentable and tasty. The Administrator stated that he leaned on the dietary staff to follow the recipes. He stated that some of the older cooks thought they had memorized the recipes but that they should still have them available for reference.

Based on staff interviews, record review, and review of the facility's policy titled, Care Plans, the facility failed to develop a comprehensive care plan that addressed activity preferences and accurately reflect the level of assistance required with transfers for one out of 37 sampled Residents (R) (R#17) reviewed for care plans. Findings include: A review of the facility's policy titled Care Plans, dated 7/27/2023, under the section titled Admission Comprehensive Plan of Care revealed, 3. The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/resident's medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan should describe the following- The services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Under the section titled Care Plan Review and Update revealed, 2. Discontinued problems, goals or approaches should be indicated directly on the care plan. A line should be drawn through the discontinued item. Updates to the care plans should be made with any changes in condition at the time the change occurred. For MatrixCare [electronic medical record] users, all updates are made electronically. Further review revealed, 4. Care plans will be updated by nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so that the care plan will reflect the patient/resident's needs at any given moment. A review of R #17's Resident Face Sheet revealed the facility admitted R#17 with diagnoses that included type 2 diabetes mellitus, polyneuropathy, anxiety disorders, dysuria, and muscle weakness. A review of R#17's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/29/2024, revealed R#17 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS revealed R#17 was dependent on staff for transfers, toileting hygiene, going from sitting to standing, and from lying to sitting on the side of the bed. A review of R#17's Care Plan revealed a Problem statement dated 5/24/2023, which indicated that R #17 required assistance with activities of daily living related to impaired mobility and generalized weakness. Further review of the care plan revealed nothing was indicated for the level of assistance required with transferring and no problem or goal statements were written that addressed activities. A review of R#17's Activity assessment dated [DATE] revealed the resident preferred activities in their own room with the most common use of the resident's time being spent watching TV and visiting with family. Per the activity assessment, barriers to participation included the ability to understand, ambulation/mobility, and physical endurance. During an interview on 3/6/2024 at 4:04 pm, Certified Nurse Aide (CNA) #1 stated he knew what type of assistance residents required from their care plan. CNA #1 stated R#17 required total assistance with a mechanical lift, and he did not see anything in the care plan addressing how the resident was transferred. During an interview on 3/7/2024 at 7:55 am, CNA #5 stated she would find out what care a resident needed from reviewing the residents' care plan and from communication with other staff. During an interview on 3/7/2024 at 9:12 am, the Activity Director (AD) stated the MDS Coordinator was responsible for the care plans. During an interview on 3/7/2024 at 10:24 am, CNA #6 stated staff were to read the care plan for the amount of assistance a resident required and if the care plan were wrong the resident could get hurt. During an interview on 3/7/2024 at 10:30 am, Licensed Practical Nurse (LPN) #2 stated the amount of care and assistance required for a resident should be in their care plan. LPN #2 stated if something was not written in the care plan, the CNAs should ask a nurse and if the care plan was incorrect, the nurse should correct it. LPN #2 confirmed that R#17 required a mechanical lift to be transferred. LPN #2 stated she did not know what R#17's care plan had written on it but if care plans were inaccurate residents could be hurt. During an interview on 3/7/2024 at 10:35 am, LPN #7 stated the CNAs knew the amount of assistance a resident needed from reviewing the care plan. LPN #7 stated if a care plan was incorrect, the MDS Coordinator was responsible for correcting the care plans. LPN #7 stated if a care plan were inaccurate a resident injury could occur. During an interview on 3/7/2024 at 10:49 am, LPN #8 stated the amount of assistance a resident required was in their care plan. LPN #8 stated if the care plan was missing information or incorrect it was a problem and either a nurse or the MDS Coordinator should have corrected it immediately. During an interview on 3/7/2024 at 11:02 am, the MDS Coordinator stated she developed and updated care plans based on MDS assessments and from visiting with the resident. The MDS Coordinator stated the care plan should be developed or updated as care needs changed but at least quarterly. The MDS Coordinator stated she had been helping with the activity care plans and all residents should have an activity care plan, so staff knew what activities a resident liked. The MDS Coordinator stated care plans indicated the amount of assistance a resident required. The MDS Coordinator confirmed that R#17's care plan did not reveal the amount of assistance required for transfers. The MDS Coordinator stated it was important for care plans to be accurate, so staff knew if a resident had a decline. During an interview on 3/7/2024 at 11:41 am, the Director of Health Services (DHS) stated her expectation was that care plans were based on the MDS assessment and developed or updated whenever a resident had a change in condition. The DHS stated a nurse, a department head, or the MDS Coordinator could have updated a care plan. The DHS stated that CNAs used care plans to provide care to residents and if the care plan was incorrect a resident could have received the wrong care. The DHS confirmed that Resident #17's care plan did not address transfer status or activities. The DHS stated the care plan should address transfer status and activities. During an interview on 3/7/2024 at 11:57 am, the Administrator stated he expected the DHS to manage care plans.

Based on staff interviews, record review, and review of the facility's policy titled Care Plans, the facility failed to ensure that resident care plans were revised to include appropriate interventions for two out of 37 sampled Residents (R) (R#10 and R #17) reviewed for care plans. Findings include: A review of the facility's policy titled Care Plans, dated 7/27/2023 under the section titled Care Plan Review and Update revealed, 1. Comprehensive care plans should be reviewed not less than quarterly according to the OBRA [Omnibus Budget Reconciliation Act] MDS [Minimum Data Set] schedule, following the completion of the assessment. Care plan updates/ reviews will be performed within 7 days of each quarterly assessment, each acute change, and as needed following each hospital stay. 2. Discontinued problems, goals or approaches should be indicated directly on the care plan. A line should be drawn through the discontinued item. Updates to the care plans should be made with any changes in condition at the time the change in condition occurred. For MatrixCare users, all updates are made electronically. 4. Care plans will be updated by nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so that the care plan will reflect the patient/resident's needs at any given moment. 1. A review of a facility policy titled Occurrences, dated 1/11/2024 under the section titled Policy Statement revealed, The healthcare center recognizes that due to the frailty of the patients/residents served, there is an increased risk of occurrences that may result in injury to the patient/resident and/or others. To prevent occurrences, each patient/resident will be observed and assessed for risk. Appropriate, realistic interventions will be implemented in accordance with their plan of care. Under the section titled Investigation and Follow-up revealed, 5. The licensed nurse will be responsible for updating the patient/resident's care plan with appropriate occurrence prevention interventions. 6. Director of Health Services will be responsible to review each occurrence for thorough investigation, documenting the investigation in the patient/resident care software occurrence report and appropriate care plan interventions are put in place to decrease risk for repeated occurrences. A review of R#10's Resident Face Sheet revealed the facility admitted R #10 with diagnoses which included Alzheimer's disease, primary generalized (osteoporosis) arthritis, unspecified dementia with behavioral disturbance, polyneuropathy, muscle weakness, anxiety disorder, and difficulty in walking. A review of R #10's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/24/2024, revealed a Staff Assessment for Mental Status (SAMS) that indicated the resident had short- and long-term memory problems and severely impaired cognitive skills for daily decision making. A review of R #10's Care Plan, with a Problem statement dated 12/24/2021, revealed that R#10 was at risk for falls related to impaired mobility, impaired cognition, and a history of falls. An intervention initiated on 1/24/2024 directed staff to keep the resident's call light within reach. Further review of the Care Plan revealed an intervention dated 12/14/2022 that revealed R#10 was unable to be educated on using a call light for assistance due to their cognitive impairment. A review of an Event Report dated 1/23/2024 revealed R#10 had an unwitnessed fall in their room without injury. Per the report, an intervention measure was check marked, which denoted the box other-up into BRODA CHAIR [type of geriatric wheelchair] was the measure taken. A review of a Resident Progress Notes dated 1/22/2024 at 7:21 pm revealed R#10 had an unwitnessed fall and was found sitting on the floor at the foot of their bed. Per the note, the Certified Nurse Aide (CNAs) had not gotten R #10 up because they were waiting for the resident to get a shower. A review of an Event Report dated 1/12/2024 revealed R#10 had an unwitnessed fall in their room without injury. Per the report, intervention measures taken had a check-marked box that denoted None of Above measures were implemented. The report revealed that under the section titled Describe measures, if necessary, staff had documented N/A [not applicable]. A review of Resident Progress Notes dated 1/12/2024 at 5:55 pm revealed that a CNA had assisted the resident on the toilet to help with incontinence care. The note revealed that the CNA went to get the resident's incontinence supplies and clothes when the resident tried to stand up and walk. Per the note, the resident then fell on the floor. A review of R#10's Care Plan revealed interventions for falls were not updated after the resident's fall on 1/12/2024. During an interview on 3/7/2024 at 10:10 am, Licensed Practical Nurse (LPN) #9 stated that when a resident had a fall, she updated the care plan with an intervention to prevent a future fall. LPN #9 stated that changes regarding the residents' care plans were communicated to CNAs verbally, or they looked at the residents' care plans. LPN #9 stated she worked on 1/12/2024 and had responded to R#10's fall. LPN #9 stated CNA #18 had stepped away from the resident to gather supplies when R#10 fell . LPN #9 stated the intervention that was put into place following R#10's fall on 1/12/2024 was when CNAs assisted the resident to the bathroom; they had to make sure supplies were within reach and not leave the resident alone. LPN #9 stated she did not put that new intervention in R#10's care plan. LPN #9 stated she also worked on 1/22/2024 and was called to R#10's room to assess the resident, who was found lying on a floor mat. LPN #9 stated it was R#10's shower day, and an intervention after the 1/22/2024 fall was to make sure if the resident was awake to get the resident up and out of bed on shower days. LPN #9 stated that follow-up after the fall consisted of ensuring R #10's bed was in a low position, and a floor mat was put in place. During an interview on 3/7/2024 at 1:32 pm, the Director of Health Services (DHS) stated that following a resident fall, it was expected that licensed nursing staff added an intervention to the resident's care plan. DHS stated that each resident's fall was investigated and reviewed with the clinical team to ensure that any follow-up interventions needed were added to the resident's care plan. The DHS stated that R #10's care plan was not updated with an intervention following the 1/12/2024 fall. The DHS stated that R#10's care plan was updated with an intervention of having a call light within reach, but that was not a good intervention for R#10 as the resident was unable to use a call light. During an interview on 3/7/2024 at 3:55 pm, The Administrator stated he expected interventions to be determined after a resident falls, and interventions should be added to a resident's care plan. Cross Reference F689 45849 2. A review of R#17's Resident Face Sheet revealed the facility admitted R #17 with diagnoses that included type 2 diabetes mellitus, polyneuropathy, anxiety disorders, dysuria, and muscle weakness. A review of R#17's Quarterly MDS, with an Assessment Reference Date (ARD) of 1/29/2024, revealed R #17 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS revealed R#17 was dependent on staff for transfers, toileting hygiene, going from sitting to standing, and from lying to sitting on the side of the bed. The MDS further revealed R#17 was always incontinent of bowel and bladder. A review of R #17's Care Plan revealed a Problem statement dated 5/24/2023, which indicated that R #17 had occasional incontinence episodes and required assistance with toileting and toileting hygiene. The Care Plan revealed a Problem statement dated 5/24/2023 which indicated that the resident was at risk for falls. Interventions directed staff to ensure the resident was wearing nonskid socks when ambulating. During an interview on 3/6/2024 at 4:04 pm, Certified Nursing Assistant (CNA) #1 stated he knew what type of assistance residents required from their care plan. CNA #1 confirmed that R#17's care plan revealed the resident had occasional incontinence and needed assistance with toileting. CNA #1 stated R #17 was always incontinent of bowel and bladder. CNA #1 stated the care plan for R #17 had not been updated because the plan listed non-skid socks and the resident no longer ambulated. During an interview on 3/7/2024 at 7:55 am, CNA #5 stated she would find out what care a resident needed from reviewing the residents' care plan and from communication with other staff. During an interview on 3/7/2024 at 10:30 am, Licensed Practical Nurse (LPN) #2 stated the amount of care and assistance required for a resident should be in their care plan. LPN #2 confirmed that R #17 was always incontinent of bowel and bladder. LPN #2 stated she did not know what R#17's care plan had written on it but if care plans were inaccurate residents could be hurt. During an interview on 3/7/2024 at 10:35 am, LPN #7 stated the CNAs knew the amount of assistance a resident needed from reviewing the care plan. LPN #7 stated if a care plan was incorrect, the MDS Coordinator was responsible for correcting the care plans. LPN #7 stated if a care plan were inaccurate a resident injury could occur. During an interview on 3/7/2024 at 10:49 am, LPN #8 stated the amount of assistance a resident required was in their care plan. LPN #8 stated if the care plan was missing information or incorrect it was a problem and either a nurse or the MDS Coordinator should have corrected it immediately. During an interview on 3/7/2024 at 11:02 am, the MDS Coordinator stated she developed and updated care plans based on MDS assessments and from visiting with the resident. The MDS Coordinator stated the care plan should be updated as care needs changed but at least quarterly. The MDS Coordinator stated care plans indicated the amount of assistance a resident required. The MDS Coordinator confirmed that R #17's care plan was listed inaccurately for the resident's incontinence status. The MDS Coordinator stated it was important for care plans to be accurate, so staff knew if a resident had a decline. During an interview on 3/7/2024 at 11:41 am, the Director of Health Services (DHS) stated her expectation was that care plans were based on the MDS assessment and updated whenever a resident had a change in condition. The DHS stated a nurse, a department head, or the MDS Coordinator could have updated a care plan. The DHS stated that CNAs used care plans to provide care to residents and if the care plan was incorrect a resident could have received the wrong care. The DHS confirmed that R#17's care plan was incorrect regarding their incontinence status. During an interview on 3/7/2024 at 11:57 am, the Administrator stated he expected the DHS to manage care plans.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Medication Administration: General Guidelines, the facility failed to ensure that care and services were provided according to accepted standards of clinical practice. The facility failed to document medication administration of an as-needed (PRN) pain medication in a timely manner for one out of 37 sampled Residents (R) (R#8) reviewed for medication administration. Findings include: A review of the facility's policy titled Medication Administration: General Guidelines, dated 4/10/2019, under the section titled Policy Statement revealed, Medications are administered as prescribed, in accordance with good nursing principles and practices. Under the section titled Procedure revealed, 9. Only the licensed or legally authorized personnel that prepare a medication may administer it. This individual records the administration on the patient/resident's MAR [Medication Administration Record] at the time the medication is given. 12. When PRN [pro re nata; as needed] medications are administered, the following documentation is provided: Date and time of administration, dose, route of administration (if other than oral), and, if applicable, the injection site. A review of a facility Inservice Education Program Summary Record Form, dated 4/10/2023, revealed, MARS must match your narcotic books, when you administer a narcotic you must sign it off on the MAR immediately as well as sign it out in the narcotic book. A review of R#8's Resident Face Sheet revealed the facility admitted with diagnoses that included osteoarthritis and chronic pain. A review of R#8's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/22/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS revealed the resident had an active diagnosis of arthritis. The MDS revealed the resident had experienced occasional pain and received PRN pain medication within five days of the assessment. A review of R#8's Care Plan revealed a Problem area with a start date of 9/28/2023 that indicated the resident had pain related to diagnoses of osteoarthritis (OA), diabetes mellitus type two (DMII), muscle weakness, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Interventions included the administration of pain medications per physician's orders. A review of R#8's Physician Order Report revealed an order dated 12/30/2023 for hydrocodone-acetaminophen (a narcotic pain medication) 7.5-325 milligrams (mg) one tablet by mouth every six hours as needed for chronic pain. During an observation and interview on 3/5/2024 at 1:30 pm, Licensed Practical Nurse (LPN) #9 placed a round white pill into a medication cup. LPN #9 then took this medication into R#8's room and administered the medication to the resident. LPN #9 said the medication was a pain medication for R#8. During an interview on 3/5/2024 at 3:13 pm, R#8 said they received hydrocodone from LPN #9 earlier that day. A review of the MAR for R#8 revealed LPN #9 had documented the administration of hydrocodone-acetaminophen 7.5/325 milligram (mg) at 9:51 pm on 3/5/2024. This was the only documented administration of hydrocodone to R#8 on 3/5/2024. A review of the Controlled Drug Record revealed LPN #9 had documented the administration of R#8's prescribed hydrocodone 7.5/325 mg at 6:00 pm on 3/5/2024. There was no additional documentation indicating any other doses of hydrocodone were removed from the medication cart on 3/5/2024. During an interview on 3/6/2024 at 8:31 am, the Director of Health Services (DHS) said the time written in the Controlled Drug Record should be the time the medication was given. She said she expected the nurse to document the actual time the medication was given on the MAR. The DHS said LPN #9 had issues with documentation in the past. She said LPN #9 stayed late on 3/5/2024 to document and said that was why the MAR showed a 9:51 pm administration time. She said the MAR showed the time the documentation was completed but should have reflected the actual time the medication was given. During a phone interview on 3/6/2024 at 8:32 am, LPN #9 said the medication given to R#8 on 3/5/2024 at 1:30 pm was hydrocodone. She said she thought she documented the administration of hydrocodone in the MAR. She said she could not document in the computer located on the medication cart and documented the administration of the medication later that day. Regarding the Controlled Drug Record, which showed the only time hydrocodone was given on 3/5/2024 was at 6:00 pm, LPN #9 said that was a new sheet and said there was a completed Controlled Drug Record that may show the documentation of the observed 1:30 pm dose. She said completed Controlled Drug Record sheets were placed in the unit manager box at the nurse's desk. During an observation and interview on 3/6/2024 at 8:42 am, the DHS looked in the unit manager box for a completed Controlled Drug Record for R#8's prescribed hydrocodone-acetaminophen. She could not find the record. An additional staff member, LPN #8, said she would continue looking for the document. During an interview on 3/6/2024 at 10:12 am, LPN #8 said they were not able to find the completed Controlled Drug Record for R#8's hydrocodone. During an observation and interview on 3/6/2024 at 10:22 am, LPN #7 compared R#8's hydrocodone tablet count in the medication cart to the documentation found on the available Controlled Drug Record with only two entries. LPN #7 verified that the count was correct at 57. She said she would document the administration of a medication in the MAR when the medication was given. She said when administering a controlled medication, the nurse should document the time the medication was administered in the MAR and the Controlled Drug Record. LPN #7 said the MAR and the Controlled Drug Record should match. She said the MAR would automatically timestamp the document at the time the documentation was completed. LPN #7 said there was no option to document a late entry for a PRN medication, only for scheduled medications, which prompted the nurse to document a reason for administering a scheduled medication late. She said that could throw things off. LPN #7 said if an administered pain medication was documented late, it could cause confusion when nurses on the night shift look to see if enough time had passed since the last dose to administer another needed dose. She said if a resident requested a PRN pain medication, she would look in the MAR for the last time the medication was documented as given. LPN #7 said she would give the completed Controlled Drug Records to the unit manager. During an interview on 3/7/2024 at 9:35 am, the Administrator said the timeliness of medication administration was important. The Administrator said documentation of medication administration should be done shortly after the medication was given. During an interview on 3/7/2024 at 10:40 am, LPN #9 added that she administered a second dose of hydrocodone to R#8 on 3/5/2024 in the evening between 6:30 pm and 7:00 pm. She said she only documented the second dose of hydrocodone given and completed the documentation later that day. LPN #9 said the documentation was in the MAR and that she should have documented the first dose of hydrocodone after administering it as well. LPN #9 stated the documentation found in the MAR for 9:51 pm on 3/5/2024 and the documented time of 6:00 pm on 3/5/2024 on the Controlled Drug Record was for the second dose of hydrocodone given. Cross Reference F880

Based on observations, staff and resident interviews, record review, review of the facility's policy titled Resident Rights, the facility failed to provide incontinence care for a resident who requested it. Specifically, the facility failed to provide incontinence care during mealtime for one out of 37 sampled Residents (R) (R#17) reviewed for activities of daily living. Findings Include: A review of the facility's policy titled Resident Rights, dated 12/1/2023, Under the section titled RESPECT AND DIGNITY revealed, You have the right to be treated with respect and dignity, including, c. The right to reside and receive services in the center with reasonable accommodation of your needs and preferences except when to do so would endanger your health and safety or that of other patients. A review of R#17's Resident Face Sheet revealed the facility admitted R#17 with diagnoses that included type 2 diabetes mellitus, polyneuropathy, anxiety disorders, dysuria, and muscle weakness. A review of R#17's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/29/2024, revealed R#17 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS revealed that R#17 depended on staff for transfers, toileting hygiene, going from sitting to standing, and from lying to sitting on the side of the bed. The MDS further revealed R#17 was always incontinent of bowel and bladder. A review of R#17's Care Plan revealed a Problem statement dated 5/24/2023, which indicated that R#17 had occasional incontinence episodes and required assistance with toileting and toileting hygiene. Further review revealed a Problem statement dated 5/24/2023, which indicated that R#17 required assistance with activities of daily living related to impaired mobility and generalized weakness. During an interview on 3/6/2024 at 12:53 pm, R#17 stated they had told staff not to bring in their lunch tray until after staff provided incontinence care. During an observation on 3/6/2024 at 12:55 pm, Certified Nurse Aide (CNA) #1 took R#17's tray into the resident's room. R#17 was heard telling CNA #1 that they did not want their tray until after someone had provided incontinence care. CNA #1 left the meal tray on the overbed table and exited the room. During an observation on 3/6/2024 at 1:03 pm, R#17's call light was on, and CNA #1 entered the resident's room at 1:04 pm, turned the call light off, and exited the room. During an interview on 3/6/2024 at 1:05 pm,, CNA #1 stated he had checked on R#17's roommate when he entered the room. CNA #1 stated they could not provide incontinence care during meals. CNA #1 stated he would have to wait until R#17's roommate was done eating before he could provide incontinence care to R#17. During an interview on 3/6/2024 at 1:07 pm,, Licensed Practical Nurse (LPN) #2 stated incontinence care could not be provided while meal trays were in the room. LPN #2 stated a CNA had gone in to change R#17 before the meal. LPN #2 stated once R#17's roommate was done eating, they could remove R#17's tray, provide incontinence care, and then take the meal tray back in the room. During an observation and interview on 3/6/2024 at 1:45 pm,, CNA #3 was observed leaving R#17's room. CNA #3 stated she had provided incontinence care to R#17 before lunch and did not know if they needed incontinence care at that time, but the resident was eating. During the interview, CNA #3 opened R#17's door and asked if they needed incontinence care, and R#17 stated they did not need it now. CNA #3 stated that if a resident needed incontinence care during a meal, she removed the food from the area, closed both curtains and provided care. During an interview on 3/7/2024 at 7:48 am, CNA #4 stated staff were not supposed to provide incontinence care during mealtimes while someone else was eating. CNA #4 stated if someone requested incontinence care, she would ask them to wait until everyone was done eating. During an interview on 3/7/2024 at 7:55 am, CNA #5 stated if a resident needed incontinence care during a meal, she removed the food tray and provided the care. CNA #5 stated if a resident had a roommate, she would ask the roommate if they wanted to leave the room or move to the dining room while the roommate received incontinence care. CNA #5 stated she tried to make sure everyone was provided incontinence care before meals, so this issue did not happen frequently. During an interview on 3/7/2024 at 10:24 am, CNA #6 stated if a resident requested incontinence care during mealtime and the food trays were not in the room, she would provide the care. CNA #6 stated if the resident had a roommate who was eating, the resident would have to wait for incontinence care until the roommate was done eating because of cross-contamination. CNA #6 stated she was not sure how long a resident would have to wait for incontinence care during mealtime. During an interview on 3/7/2024 at 11:36 am, LPN #7 stated there was no specific policy on providing incontinence care during mealtime. LPN #7 stated staff should remove the tray from the resident who needed incontinence care, close the curtain, and then provide care to the resident. LPN #7 stated staff should provide incontinence care before meals to avoid this becoming an issue. During an interview on 3/7/2024 at 10:49 am, LPN #8 stated if a resident required incontinence care during meals and there were no trays in the room, staff could have provided care before the meal tray was delivered. LPN #8 stated that if a meal tray had already been delivered, staff could ask the roommate to step out, go to the dining room, or just cover their food, but staff should never deny a resident incontinence care. During an interview on 3/7/2024 at 11:41 am, the Director of Health Services (DHS) stated it was the resident's right not to sit in a bowel movement. The DHS stated if food was already in the room and the resident had a roommate, the roommate should be asked if they would like to leave the room or get permission to provide incontinence care to their roommate during their meal. The DHS stated she educated the staff on providing incontinence care before mealtimes to minimize this issue. During an interview on 3/7/2024 at 11:57 am, the Administrator stated his expectation for incontinence care during meals was that either the roommate could leave the room or the resident who required incontinence care could be taken out of the room for care. The Administrator stated residents should not have to wait for incontinence care.

Based on staff interviews, record review, and review of the facility's document titled Position Description, the facility failed to ensure they employed a qualified Activity Director (AD) for the facility. This deficient practice had the potential to affect all the residents residing in the facility. The facility census was 67 residents. Findings include: A review of the facility's document titled Position Description for the Activities Director dated November 2016, under the section titled, JOB PURPOSE revealed, Assumes administrative authority, responsibility, and accountability for the provision of a program of activities designed to meet the interest and enhance the functional abilities and self-esteem of each Resident. Manages employees to provide Recreation Services according to the facility's philosophy. In collaboration with the Administrator, allocates resources in an efficient and economic [sic] manner to ensure each resident achieves the highest practicable physical, mental, and psychosocial well-being. MINIMUM EDUCATION REQUIRED: Minimum two (2) years college education with courses in recreation, education, social work, other behavioral sciences or clinical services. MINIMUM EXPERIENCE REQUIRED: Two (2) years' [sic] experience in a social or recreational program within the past five years, with one (1) year full-time employment in a resident activities program in a long term [sic] health care [sic] setting; or, One (1) year in a supervisory role within a recreation program. MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW: Eligible for certification as therapeutic Recreational Specialist or as an Activities professional by a recognized accrediting body. ADDITIONAL QUALIFICATIONS: (preferred qualifications) Qualified as an Occupational Therapist or Occupational Therapist Assistant, or satisfactory completion of an approved training course in state [sic] of employment. Under the section titled KNOWLEDGE, SKILLS, ABILITIES revealed, Attend and participate in continuing education programs to keep abreast of changes in your field as well as to maintain current license/certification, as required. A review of the facility's AD personnel file revealed a document titled New Hire, Rehire and/or Transfer, effective 6/29/2023. During an interview on 3/7/2024 at 12:09 pm, the AD indicated that she had worked in the AD role since July 2023 but had to take off for three months (October, November, and December 2023) for personal reasons. The AD stated that she had worked in a social or recreation role in a nursing home setting for a total of five months. The AD stated that she had no formalized training pertaining to the AD role. During an interview on 3/7/2024 at 12:44 pm, the AD stated that there was no plan in place for her to receive formal training for her role. The AD stated that she was unaware of the regulations pertaining to the activity department; however, she was aware that food brought in and served to the residents needed to be store-bought. During an interview on 3/7/2024 at 1:32 pm, the Director of Health Services (DHS) stated that she was unaware of the requirements for an AD. The DHS stated that there was no plan for the AD to receive formalized training for the AD role. During an interview on 3/7/2024 at 3:40 pm, the Administrator stated that he was not 100% [percent] sure of the requirements for an AD. The Administrator stated that he would expect the qualifications, experiences, and education of the facilities AD to match the regulation requirements.

Based on staff interviews, record review, and review of the facility's policy titled Occurrences, the facility failed to develop, implement, and document appropriate interventions to prevent further falls for one out of 37 sampled Residents (R) (R#10) reviewed for accidents. Findings include: A review of the facility's policy titled Occurrences, dated 1/11/2024, under the section titled Policy Statement revealed, The healthcare center recognizes that due to the frailty of the patients/residents served, there is an increased risk of occurrences that may result in injury to the patient/resident and/or others. To prevent occurrences, each patient/resident will be observed and assessed for risk. Appropriate, realistic interventions will be implemented in accordance with their plan of care. Under the section titled Investigation and Follow-up revealed, 1. Occurrence investigation and follow-up is a joint responsibility within the healthcare center. 2. Communication between all parties is essential for identifying the events and circumstances that resulted in the occurrence and for identifying interventions that limit the risk of the occurrence being repeated. 4. The licensed nurse will be responsible for notifying the Director of Health Services and the Occurrence Reduction Coordinator of all occurrences. 5. The licensed nurse will be responsible for updating the patient/resident's care plan with appropriate occurrence prevention interventions. 6. Director of Health Services will be responsible to review each occurrence for thorough investigation, documenting the investigation in the patient/resident care software occurrence report and appropriate care plan interventions are put in place to decrease risk for repeated occurrences. A review of the Resident Face Sheet for R#10 revealed the resident was admitted with diagnoses which included Alzheimer's disease, primary generalized (osteoporosis) arthritis, unspecified dementia with behavioral disturbance, polyneuropathy, muscle weakness, anxiety disorder, and difficulty in walking. A review of the Quarterly Minimum Data Set (MDS) for R#10, with an Assessment Reference Date (ARD) of 1/24/2024, revealed a Staff Assessment for Mental Status (SAMS) that indicated the resident had short- and long-term memory problems and severely impaired cognitive skills for daily decision making. A review of the Care Plan, with a Problem statement dated 12/24/2021 for R#10, revealed that R#10's was at risk for falls related to impaired mobility, impaired cognition, and a history of falls. Interventions included: - Initiated 1/24/2024, staff were directed to keep the resident's call light within reach, - Initiated 9/18/2023, staff were directed to place a mat at bedside, - Initiated 7/23/2023, staff were directed to have the resident up in a geriatric wheelchair for comfort/positioning, - Initiated 6/19/2023, staff were directed to assist the resident to position away from the edge of the bed as needed, - Initiated 6/10/2023, staff were directed to keep the resident within sight when noted to be more active during the day, - Initiated 3/15/2023, staff were directed to assist in keeping the resident's bed in a lower position, and -Initiated 12/14/2022, staff were directed to observe the resident frequently for performing unassisted activities of daily living and to assist with activities of daily living as needed. Further review of the Care Plan revealed an intervention dated 12/14/2022 that revealed she was unable to be educated on using a call light for assistance due to their cognitive impairment. A review of an Event Report dated 1/12/2024 revealed R#10 had an unwitnessed fall in their room without injury. Per the report, intervention measures taken had a check-marked box that denoted None of Above measures were implemented. The report revealed that under the section titled Describe measures, if necessary, staff had documented N/A [not applicable]. A review of Resident Progress Notes dated 1/12/2024 at 5:55 pm revealed that a CNA had assisted the resident on the toilet to help with incontinence care. The note revealed that the CNA went to get the resident's incontinence supplies and clothes when the resident tried to stand up and walk. Per the note, the resident then fell on the floor. A review of a Resident Progress Notes dated 1/22/2024 at 7:21 pm revealed she had an unwitnessed fall and was found sitting on the floor at the foot of their bed. Per the note, the Certified Nurse Aide (CNAs) had not gotten R#10 up because they were waiting for the resident to get a shower. A review of an Event Report dated 1/23/2024 revealed she had an unwitnessed fall in their room without injury. Per the report, an intervention measure was check marked, which denoted the box other-up into BRODA CHAIR [type of geriatric wheelchair] was the measure taken. During a telephone interview on 3/7/2024 at 9:40 am, CNA #18 stated she was in the room with R#10 when the resident fell on [DATE]. CNA #18 stated she was assisting R#10 to the bathroom and the resident became agitated and fell . CNA #18 stated she notified a nurse that R#10 had fallen. CNA #18 stated fall interventions in place prior to R#10's fall on 1/12/2024 included a fall mat and putting the resident in a Broda chair so the resident could relax. During an interview on 3/7/2024 at 10:10 am, Licensed Practical Nurse (LPN) #9 stated that when a resident had a fall, she assessed the resident, took vitals, looked for an injury, got the resident off the floor, notified the doctor and the Director of Health Services (DHS), called the resident representative, entered a progress note or event note/fall report, and updated the care plan with an intervention to prevent a future fall. LPN #9 stated that changes regarding the residents' care plans were communicated to CNAs verbally, or they looked at the residents' care plans. LPN #9 stated she worked on 1/12/2024 and had responded to R#10's fall. LPN #9 stated CNA #18 had stepped away from the resident to gather supplies when R#10 fell . LPN #9 stated the intervention that was put into place following R#10's fall on 1/12/2024 was when CNAs assisted the resident to the bathroom; they had to make sure supplies were within reach and not leave the resident alone. LPN #9 stated she did not put that new intervention in R#10's care plan. LPN #9 stated she was unsure of other interventions for assisting R#10 to the bathroom except to ensure the resident had grippy socks on. LPN #9 stated she also worked on 1/22/2024 and was called to R#10's room to assess the resident, who was found lying on a floor mat. LPN #9 stated it was R#10's shower day, and an intervention after the 1/22/2024 fall was to make sure if the resident was awake to get the resident up and out of bed on shower days. LPN #9 stated that follow-up after the fall consisted of ensuring R#10's bed was in a low position, and a floor mat was put in place. During an interview on 3/7/2024 at 1:32 pm, the Director of Health Services (DHS) stated that following a resident fall, it was expected that licensed nursing staff assessed residents, performed neurological checks, notified the medical doctor and resident representative, got the resident off the floor, created a fall report/event, entered a progress note, and added an intervention to the resident's care plan. DHS stated that each resident's fall was investigated and reviewed with the clinical team to ensure that any follow-up interventions needed were added to the resident's care plan. The DHS stated that R#10's care plan was not updated with an intervention following the 1/12/2024 fall. The DHS stated that R#10's care plan was updated with an intervention of having a call light within reach, but that was not a good intervention for R#10 as the resident was unable to use a call light. During an interview on 3/7/2024 at 3:55 pm, The Administrator stated resident falls are discussed in risk meetings and during interdisciplinary team reviews to determine root causes for a fall. The Administrator stated he expected interventions to be determined after a resident falls, and interventions should be added to a resident's care plan. Cross Reference F657

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Infection Prevention - Hand Hygiene, and Medication Administration: General Guidelines, the facility failed to follow standard precautions during the administration of medications. In addition, the facility failed to ensure that staff demonstrated proper use of gloves and hand hygiene during medication administration for one out of 37 sampled Residents (R) (R#8) reviewed for medication administration. Findings include: A review of the facility's policy titled Infection Prevention - Hand Hygiene, dated 3/8/2019, under the section titled Definition revealed, Indication for Hand Hygiene is the moment during health care when hand hygiene must be performed to prevent harmful germ transmission and/or infection. Under the section titled Indications Requiring Hand Wash or Hand Rub revealed, 1. Before and after contact with the resident. A review of the facility's policy titled Medication Administration: General Guidelines dated 4/10/2019, under the section titled Policy Statement revealed, Medications are administered as prescribed, in accordance with good nursing principles and practices. A review of the Resident Face Sheet for R#8 revealed, the resident admitted with diagnoses that included osteoarthritis and chronic pain. A review of the Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/22/2023 for R#8, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS revealed the resident had an active diagnosis of arthritis. The MDS revealed the resident had experienced occasional pain and received as needed (PRN) pain medication within five days of the assessment. A review of the Physician Order Report for R#8 revealed an order dated 12/30/2023 for hydrocodone-acetaminophen (a narcotic pain medication) 7.5-325 milligrams (mg) one tablet by mouth every six hours as needed for chronic pain. A review of the Care Plan for R#8 revealed a Problem area with a start date of 9/28/2023 that indicated the resident had pain related to diagnoses of osteoarthritis (OA), diabetes mellitus type two (DMII), muscle weakness, congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD). Interventions included the administration of pain medications per physician's orders. During an observation and interview on 3/5/2024 at 1:30 pm, Licensed Practical Nurse (LPN) #9 placed a round white pill she was holding in her ungloved hand into a medication cup. LPN #9 then took the medication into R#8's room and administered the medication without gloves on. LPN #9 did not perform hand hygiene prior to or after administering the medication. LPN #9 said the medication was a pain medication for R#8. She said she did not know why she had the medication in her bare hand and said she should have dispensed the medication straight from the package into the medication cup without touching it. LPN #9 said she was rushing and that she usually did not wear gloves while dispensing medications because she would dispense the medication directly into the medication cup from the package. During an interview on 3/5/2024 at 3:13 pm, R#8 said they received hydrocodone from LPN #9 earlier that day. During an interview on 3/6/2024 at 8:31 am, the Director of Health Services (DHS) said she expected staff to avoid touching oral medications with bare hands and said staff should use gloves if handling medications. She said if staff touched a medication with bare hands, they should waste the medication and dispense a new one. During a phone interview on 3/6/2024 at 8:32 am, LPN #9 said the medication that was observed to be given to R#8 was hydrocodone. During an interview on 3/6/2024 at 10:22 am, LPN #7 said medications came to the facility from the pharmacy in individual packets. She said that when administering medications, she would open the packet and dispense the medication directly into the medication cup. LPN #7 said she would not touch the pill with bare hands. She said if she was going to handle the medication with her hands, it should be with gloves on. During an interview on 3/6/2024 at 2:43 pm, the Infection Preventionist (IP) said she had completed in-service training with staff on the topic of hand hygiene and glove use within the past two months. She said other than verbally reminding staff to use gloves when handling medications, there was no in-service training specific to hand hygiene during medication administration. The IP said the only time staff would need to touch a pill was if they had to separate a capsule. She said staff should wear gloves when handling medications. She said if a staff member touched a medication with bare hands, they should dispose of the medication and dispense a new one. The IP said there were no specific policies related to hand hygiene and medication administration and said that was why they were verbally reminding staff to use gloves and perform hand hygiene during medication pass. During an interview on 3/7/2024 at 9:35 am, the Administrator said he was somewhat familiar with the medication administration process. He said the timeliness of medication administration was important, as was following physician's orders and infection control procedures. He said he expected staff to dispense medications without touching them with ungloved hands. During an interview on 3/7/2024 at 9:40 am, the IP said the conversations she had with staff in the past regarding hand hygiene during medication administration were not official in-services and said that was because the medication administration policy did not contain anything regarding hand hygiene or glove use during medication administration. She said those conversations were not documented. She said she could recall having that conversation with LPN #9. She said she thought there was an additional policy that addressed the need for staff to avoid touching medications during administration. This policy was requested from the IP but was not provided. Cross Reference F658

Based on observations, staff interviews, and review of policies titled, Foodborne Illness, Labeling, Dating, and Storage, Patients/Residents' Personal Food, Nourishments, and Dishwashing, the facility failed to ensure opened food items in the walk-in cooler and dry storage area were labeled and dated; failed to discard food items by expiration date; failed to ensure staff and resident food items were not stored together in same refrigerators; failed to maintain temperature logs on nursing unit refrigerators. In addition, the facility failed to ensure high temperature dish machine was maintained in working order. This deficient practice had the potential to affect 59 residents who received an oral diet. Findings include: 1. Review of the policy titled Foodborne Illness revised [DATE], revealed foods will be used before the expiration date, use by date, and the sell by date indicated on the food item. Foods not used by these dates must be discarded. The Dietary Manager (DM) is responsible for maintain safe food preparation to prevent spread of bacteria and proper storage of food to reduce chance of foodborne illness. 2. Review of the policy titled Labeling, Dating and Storage revised [DATE], revealed food and beverage items will have identifying labels with received date/opened date as appropriate and for foods prepared onsite a use by date will be indicated. Foods will be stored in their original container. Observation on [DATE] at 9:30 a.m., with cook SS, revealed the following: Walk-in cooler: Mild cheddar cheese package opened and not dated. Pitcher of brown colored liquid - no label or date. Low fat cottage cheese five-pound container opened and not dated. one French Vanilla 32-ounce (oz) coffee creamer with employee's name on it, no date. Dry Storage: Imperial thickened Apple Juice, 46 oz, expired on [DATE] x 7 boxes. Tomato Juice, 46 oz, expired on [DATE] x 5 boxes. Apple Juice Blend, 33.8 oz, box opened on [DATE] no expiration date on container [NAME] Corn Starch, 16 oz, expired on [DATE], x 9 boxes. Interview on [DATE] at 9:35 a.m. with Cook SS, confirmed expired items in the walk-in cooler and dry storage and stated expired items should be discarded on expiration date. Interview on [DATE] at 9:45 a.m., the Registered Dietitian (RD) revealed her expectation is that all expired foods are to be discarded. 3. Review of the policy titled Patients/Residents' Personal Food revised [DATE], revealed the facility allows family to provide food items for resident consumptions following specific guidelines. The guidelines include but are not limited to food must be in a covered container and must be consumed during the visit and leftovers will not be refrigerated or reheated at the facility. 4. Review of the policy titled Nourishments revised date [DATE], revealed the staff are to offer nourishments routinely to residents. The Dietary department is responsible for stocking the nourishment kitchens by delivering nutritional supplements to the nursing stations at designated times. Dietary is to label and date all items sent from their department to the nourishment refrigerator, discard all items according to their use by date. Refrigerator temperatures must be recorded daily on the refrigeration temperature log. Staff are not permitted to store their food or drinks in the nourishment refrigerators. Observation on [DATE] at 3:25 p.m., two breakroom refrigerators revealed staff and resident food items were being stored together in the same refrigerators. There was no temperature log located on or near either refrigerator. The following items were discovered it the A/B hall breakroom refrigerator to be expired: one 46 oz box of thickened lemon-flavored water opened on [DATE] expired [DATE] two 46 oz boxes of thickened apple juice expired on [DATE] Observation on [DATE] at 10:15 a.m., revealed in C/D hall breakroom refrigerator a pizza box with a resident's name on it and no date. The Director of Health Services (DHS) confirmed this was a left-over pizza that should not be in this refrigerator, and stated all leftovers brought in from outside must be discarded and cannot be kept for later consumption. Interview on [DATE] at 3:25 p.m. with Cook TT, stated resident drinks and food items are stored in both breakroom refrigerators. She confirmed staff foods and resident foods both were in the A/B hall breakroom refrigerator. During further interview, she confirmed there was no temperature log located on or around this refrigerator. She stated Nursing department was responsible for keeping temperature logs for this refrigerator. She confirmed all items that were found to be expired in this refrigerator. She immediately removed all expired items and disposed of them. Interview on [DATE] at 3:40 p.m. with Licensed Practical Nurse (LPN) LL, revealed the dietary staff stock the breakroom refrigerator with resident foods. She stated the dietary staff are responsible for maintaining the temperature logs for the breakroom refrigerators. She verified there was staff food and resident foods in the A/B hall breakroom refrigerator. During further interview, she confirmed there was no temperature log on or around the refrigerator, and stated dietary staff were responsible for maintaining the temperature log for the breakroom refrigerators. Interview on [DATE] at 9:00 a.m. with the Dietary Manager (DM), stated the dietary staff were responsible for stocking the breakroom refrigerators with resident food/drinks. She stated she was not sure who was responsible for monitoring the temperature of the break-room refrigerators. During further interview, she stated no left-over foods brought into the facility should be kept in the resident's refrigerator. She stated that resident and staff foods should not be in the same refrigerator. Interview on [DATE] at 10:15 a.m., the Director of Health Services (DHS) revealed the resident refrigerators are located in the medication rooms behind each nursing station. She stated the refrigerators in the breakrooms are staff refrigerators. She verified resident food was stored in both breakroom refrigerators, and stated her expectation is that no resident food or drinks should be in either of the staff refrigerators. She stated the breakroom refrigerators are monitored by housekeeping, and she was unsure of where the temperature logs were. Interview on [DATE] at 10:15 a.m. with housekeeping supervisor RR stated the dietary department was responsible for maintaining the temperature log for the refrigerator in each break room. 5. Review of the policy titled Dishwashing revised [DATE], revealed dietary staff are to record temperatures of wash and rinse cycle on the dish machine temperature log. It is policy to adhere to the manufacturer's guideline for appropriate temperature ranges. The dish machine temperature log must be completed by staff directly involved in the dishwashing process. All temperatures out of range are to be reported immediately to the DM. Observation on [DATE] at 9:00 a.m. the dish washing area revealed a high temperature dishwasher. Two consecutive wash and rinse cycles revealed the wash temperature reached 145 degrees Fahrenheit (F) and the rinse cycle temperature reached 168 degrees Fahrenheit. Interview on [DATE] at 9:00 a.m., the Dietary Manager (DM), verified the dishwasher wash and rinse temperatures were below the requirement for proper sanitization of dishes. She stated the dishwasher had preventative maintenance a few weeks ago. Interview on [DATE] at 9:35 a.m., the Registered Dietitian (RD), stated if the dishwasher is not reaching the minimal temperatures recommended by the manufacturer, then the machine should be taken out of service, call maintenance for repairs, and use disposable tableware until the dishwasher is repaired. She stated the manufacturers recommended high temperature dishwasher was 150 degrees F. for wash cycle and 180 degrees F. for rinse. Interview on [DATE] at 12:00 p.m., the Administrator stated the dietary staff are responsible for the temperature log for the refrigerators in the breakrooms. He stated his expectation was that all foods that are expired are to be discarded. He stated the nurses are responsibility for discarding expired items from resident refrigerators, as well as documenting the temperatures. He stated he expected the dietary staff who is washing dishes to notify the DM if the temperatures are not reaching the minimum temperature recommended by the manufacturer for proper sanitization of the dishes remove the machine from use, and then the DM is to notify maintenance of issues, in the meantime they are to use disposable table ware while the dishwasher is not in service.

Based on observation, interviews, and review of the policy titled Infection Control-Linen and Laundry, the facility failed to ensure that essential equipment in the laundry was in working order to properly sanitize facility linens, as evidenced by a non-functioning boiler. The facility was currently in COVID-19 outbreak status and had no hot water for laundry. The census was 69 residents. Findings: Review of facility policy titled Infection Control-Linen and Laundry, revised on 4/2/2020, revealed it is the policy to mitigate or decrease infections caused by sources of microbial contamination through collection, handling, sorting, transportation, processing, and storage of laundry. Procedure F. number 5 v. revealed that soiled laundry is washed with an organization approved detergent and hypochlorite product at a temperature of >120 degrees to 160 degrees. If hypochlorite product is not utilized in the laundry process, soiled laundry is washed at >160 degrees. Review of documents provided by the facility revealed that a replacement boiler request was submitted on 11/10/2022. Two quotes were sent with the request. The document revealed it received final approval by the Chief Executive Officer (CEO) on 2/3/2023. Observation on 2/9/2023 at 9:35 a.m. during a tour of the laundry room with Laundry Aide SS, stated that there were three washers. She was asked about checking the temperature of the water and she stated, I guess it is this right here and pointed to a digital gauge on the washer. She stated she checks the washer to make sure that the chemical level is what it should be though. She revealed that she does not clean the washer out after soiled laundry is completed. Interview on 2/9/2023 at 12:45 p.m. with the Maintenance Director, revealed the boiler has been non-functioning for about three years. He stated that he requested the boiler be replaced and completed the appropriate requestions with quotes for replacement. He stated it was approved, but then the approval was cancelled due to pricing. Interview on 2/9/2023 at 1:05 p.m. with Housekeeping Manager revealed that she has been the manager for [AGE] years. She stated the Maintenance Director has been trying to get the boiler replaced since 2021. She stated that she has been using extra bleach in the soiled, contaminated laundry to make up for no hot water. Interview on 2/9/2023 at 3:00 p.m. with Certified Nursing Assistant (CNA) II and JJ stated they have seen some linens that were dirty, and stated it was mostly sheets. Interview on 2/9/2023 at 3:33 p.m. with the Administrator, revealed the process of replacing the boiler had been started when he came to the facility in 12/2021. He stated he received an updated quote and submitted it for approval. During further interview, he stated the requisition was approved in January 2023. When asked what his expectations were for sanitizing the laundry without hot water, he stated it's the chemicals that are the cleaning agents, not the hot water.

Based on observations, resident and staff interviews, the facility failed to ensure staff provided privacy for two of two residents (R) (R#22 and R#47) during medication administration. The sample size was 32. The findings include: 1.Review of the clinical record revealed R#22 was admitted to the facility on [DATE] with diagnoses that include but not limited to congestive heart failure (CHF), hypertension HTN), diabetes, and dementia. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as zero, which indicated severe cognitive impairment. Observation on 2/8/2023 at 8:22 a.m., Registered Nurse (RN) GG was observed administering medications to Resident #22. The RN entered the resident's room without knocking on the door nor closing the door to the room or pulling the curtain to provide privacy, the RN administered medications to resident followed by a cup of water. 2. Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses that include but not limited to stroke, depression, brain cancer, and prostate cancer. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Observation on 2/8/2023 at 9:04 a.m., RN GG was observed preparing medications for administration for R#47. RN GG entered the resident's room without knocking on the door, did not close the door, or pull the curtain to provide privacy, while resident took his medications. Interview on 2/8/2023 at 10:55 a.m., R#47 revealed They never close the door. Interview on 2/8/23 at 11:53 a.m. the Director of Health Services (DHS), stated she expects the staff to knock on the resident's door and announce themselves before entering the room. During further interview, she stated residents should be provided privacy during the medication pass. The facility did not have a policy that addressed providing privacy during medication pass.

Based on record review, staff interviews, and review of the policy titled Advance Directives: Georgia, the facility failed to ensure that the health record including physician orders, accurately reflected the code status for one resident (R) (R#47) of 31 sampled residents. Findings: Review of the policy titled Advance Directives: Georgia revised [DATE], revealed the healthcare center recognizes the right of patients/residents to control decisions related to their medical care. Advance Directives relate to the provision of care when the patient/resident lacks the capacity to make healthcare decisions. Advance Directives executed in accordance with state law will be honored by the healthcare center. Number 5. Revocation of Advance Directive: The healthcare center shall enter in the patient's/resident's medical record any change in or termination of the advance directive for health care that becomes known to the healthcare center. Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses that include but not limited to stroke, depression, brain cancer, and prostate cancer. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Review of the current Physician Order's (PO) in the electronic medical record, revealed an order for Code Status: Full Code, with order date of [DATE]. Further review of the medical record revealed a Physician's DNR (do not resuscitate) Order Form dated [DATE] and signed by R#47's son or daughter, and two physicians. The banner in the electronic medical record indicated that resident is a DNR. Review of care plan created [DATE] revealed Advance Directive-Allow Natural Death-do not attempt resuscitate. The longterm goal revealed if the resident's heart stops, or if they stop breathing, Cardiopulmonary Resuscitation (CPR) will not be initiated in honor of the DNR wishes. Approaches to care include all staff to be made aware of the patient/resident's wishes. Interview on [DATE] at 2:23 p.m. with the Director of Health Services (DHS), revealed it is the responsibility of the unit manager or charge nurse to enter Physician Orders for Code Status when they are received. She stated the facility does an audit to make sure that documents, orders, and care plans match, and does not know how it this one got missed. Interview on [DATE] at 2:35 p.m. with the Social Services Director (SSD), stated he does a code status audit quarterly, and revealed the last audit was conducted in ,d+[DATE]. He stated the audit is to ensure that the EMR banner, care plan, physician's orders, and documents match.

Based on observations and staff interviews, the facility failed to ensure the confidentiality of resident electronic medical records during medication administration for two residents (R) (R#14 and R#53) on one of four nursing units. The sample size was 31. Findings include: Observation on 2/8/23 at 9:26 a.m., Licensed Practical Nurse (LPN) KK was observed administering medication to R#14 on C hall. LPN KK left the medication cart to administer R#14 medications in her room, without providing privacy of the Electronic Medication Administration Record (EMAR). Observation on 2/8/23 at 9:16 a.m., Licensed Practical Nurse (LPN) KK was observed administering medication to R#53 on C hall. LPN KK left the medication cart to administer R#53 medications in her room, without providing privacy of the residents' EMAR. Interview on 2/8/23 at 10:15 a.m., LPN KK revealed she was aware she should have concealed residents EMAR while giving the resident their medications. Interview on 2/8/23 at 11:53 a.m., the Director of Health Services (DHS) revealed it is her expectation for the nursing staff to provide privacy for all medication records while administering medications to residents.

Based on record review and interviews, the facility failed to coordinate with the appropriate State designated authority, one resident (R) (R#8) who was admitted to the facility with a diagnosis of bipolar disorder and depression, for a Level II Preadmission Screening and Resident Review (PASRR) evaluation, to ensure resident received care and services in the most integrated setting appropriate to his needs. The sample size was 31residents. Findings Include: Review of the clinical record revealed R#8 was admitted to the facility on [DATE] with diagnosis of but not limited to bipolar disorder and unspecified depressive disorder. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) was coded as 15, indicating no cognitive impairment. Section A. indicated the resident had not been evaluated for a Pre-admission Screening and Resident Review (PASARR) Level II assessment. Section I- Active Diagnoses include depression and bipolar. Section N revealed antipsychotics and antidepressants were received 7 out of 7 days. Antipsychotics were received on a regular basis. Review of Pre-Admission Screening/Resident Review (PASRR) Level I Assessment (Form: DMA-613) dated 4/13/2022 revealed the resident did not have a severe mental illness, developmental disability or related condition and no evidence of a Level II PASRR. Further review revealed if the nursing facility admits the applicant and discovers information that was not disclosed to the PASRR screeners, the nursing facility is required to contact the [screening authority] immediately. Interview on 2/8/2023 at 3:00 p.m., the Admission Director, stated he wasn't sure who was responsible for requesting PASARR II evaluations. During further interview, he stated if he identifies a PASARR II is needed, he passes the information to the Director of Health Services (DHS) or the Social Services Director (SSD). He revealed there is no system in place to assure Level II PASSAR evaluations are captured. Interview on 2/8/2023 at 3:10 p.m. with the MDS Director, stated the Admission Director is responsible for making sure residents with appropriate diagnoses have a PASARR Level II completed. She confirmed R#8 did not have a PASARR Level II. Interview on 2/8/2023 at 4:45 p.m. with Registered Nurse (RN) CC stated the facility does not have a policy regarding PASARR Level II. She stated the facility follows federal requirements for PASARR II. Interview on 2/9/2023 8:45 a.m. with the Administrator revealed the Admission Director is responsible for obtaining a PASARR II if needed. During further interview, the Administrator revealed if a PASARR II is needed, the Admission Director or Social Worker (SW) would input the information into Georgia Medicaid Management Information System (GAMMIS) to obtain a PASARR II so that Psych services could be initiated. He stated both the Admission Director and Social WW received training on how to obtain a PASARR II but revealed there is no documentation of the training. Interview on 2/9/23 at 10:45 a.m. with the SW revealed PASARR 's are presented at the time of admission or the DMA-6 is requested in GAMMIS, from the transferring facility. He stated he does not know how to request a Level II. He revealed he has had no training on how to request a Level II PASARR. The Social Worker stated if a resident is exhibiting behaviors or needs psychiatric services they are discussed in the weekly Patient At Risk (PAR) meetings.

Based onobservation, record review, interviews, and review of the policy titled Care Plans, the facility failed to develop a comprehensive person-centered care plan with measurable goals and interventions for one resident (R) (R#16) who required assistance with eating. The sample size was 32. Findings include: Review of the policy titled Care Plans dated12/31/1996, revealed the comprehensive person-centered care plan is developed by the interdisciplinary team for each resident within seven days after completion of the comprehensive assessment. The care plan should be reviewed quarterly, each acute change in condition, and as needed following each hospital stay. Care plans will be updated by nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so the care plan will reflect the residents needs at any given moment. The comprehensive person-centered care plan is developed to include measurable goals and timeframes to meet a patient/residents medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses including but not limited to cerebral vascular accident (CVA), atrial fibrillation, respiratory failure with hypoxia, hemiplegia/hemiparesis, and chronic kidney disease stage 3. The residents quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14, which indicates no cognitive impairment. Section G indicated resident required limited assistance of one person for eating. Review of the Care Area Assessment (CAA) on the Significant Change MDS dated [DATE] indicated resident functional status was extensive assistance with one person for eating. Review of the care plan, dated 11/23/2022, indicated a problem of left hemiplegia and requires training and skill practice in grooming and passive range of motion (PROM). Approaches to care include restorative nursing program: assist patient daily with grooming tasks of brushing teeth, washing face, washing hands, and combing hair, PROM of left shoulder, elbow, wrist, and fingers. There were no interventions to address residents need for assistance with eating. Observation on 2/7/2023 at 2:49 p.m. resident noted in her room and was wearing a splint to left hand. Interview on 2/7/2023 at 2:49 p.m. R#16 stated she was left-handed and has a hard time feeding herself because of the splint on her left hand. She stated her husband comes to feed her every day, because the staff do not feed her when he is not there. Interview o 2/8/2023 at 8:45 a.m., resident stated her husband didn't come to feed her breakfast this morning and she tried to feed herself cereal, and stated the cereal kept falling off the spoon. She stated no-one offered to assist her with her breakfast. Interview on 2/9/2023 at 9:00 a.m. with Licensed Practical Nurse (LPN) LL confirmed resident's Activities of Daily Living (ADL) care plan does not address the need for assistance with eating. Interview on 2/9/2023 at 9:28 a.m. with Registered Nurse (RN) NN, confirmed residents care plan for restorative care did not address residents need for assistance with meals. She stated based on the Care Area Assessment (CAA) on the 7/22/2022 Significant Change MDS, an update to her care plan should have been done. Interview on 2/9/2023 at 11:42 a.m., the Director of Health Services (DHS) confirmed R#16 did not have a care plan that addressed the need for assistance with meals. She stated her expectation was that residents be care planned for identified areas of concern, including assistance with feeding. Interview on 2/9/2023 at 2:00 p.m., Certified Nursing Assistant (CNA) PP stated residents care plan directs the care that is needed for each resident. He stated he was unaware of R#16 being left-hand dominant or her need for assistance during meals. He stated her husband usually is visiting and feeds her during meals.

Based on observation, record review, interviews, and review of policy titled Restorative Nursing Program, the facility failed to identify the need and assist one resident (R) (R#16) with meals. The sample size was 32. Findings include: Review of policy titled Restorative Nursing Program revised 11/4/2021, revealed the policy is to provide restorative nursing which actively focuses on achieving and maintain optimal physical, mental, and psychological functioning and wellbeing. Restorative nursing services are provided by Restorative Nursing Assistants (RNAs) and Certified Nursing Assistants (CNAs), and other qualified nursing staff. Screening and care planning: 1. Nurse will complete a restorative nursing screening tool 2. Determine appropriate restorative services based on the screening 3. Develop a care plan for each restorative service with measurable goals and individualized interventions Review of the clinical record revealed resident was admitted to the facility on [DATE] with diagnoses including but not limited to cerebral vascular accident (CVA), atrial fibrillation, respiratory failure with hypoxia, hemiplegia/hemiparesis, and chronic kidney disease stage 3. The residents quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14, which indicates no cognitive impairment. Section G indicated resident required limited assistance of one person for eating. Review of updated care plan for R#16, dated 11/23/2022, indicated Left hemiplegia and requires training and skill practice in grooming and skill practice in grooming. Approaches to care include restorative nursing program: assist patient daily with grooming tasks of brushing teeth, washing face, washing hands, and combing hair. There were no interventions to address residents need for assistance with eating. Observation on 2/7/2023 at 2:49 p.m. resident noted in her room and was wearing a splint to left hand. Interview on 2/7/2023 at 2:49 p.m. with R#16's spouse stated resident is not receiving assistance from staff with meals. Her spouse stated she is left-handed and has a splint on her left hand. He spouse stated he comes to visit every day and spends the whole day with her and feeds her every meal because the facility doesn't feed her when he is not there. R #16 confirmed that staff do not feed her. Interview on 2/8/2023 at 8:45 a.m., R #16 stated her spouse had not arrived at the facility before breakfast. She stated she had Rice Krispie's cereal for breakfast and was unable to feed herself properly because the cereal kept falling off the spoon. She stated no one offered to assist her with her breakfast. Review of the documented meal consumption on 2/8/2023 revealed an intake of 25-50%. Interview on 2/9/2022 at 9:00 a.m. with Licensed Practical Nurse (LPN) LL, confirmed R#16 was on restorative nursing care for left hand splint, passive range of motion (PROM) to left upper extremity, and train and skill practice with grooming tasks. During further interview, she stated she was unaware of R#16's left hand dominance and her need for assistance with meals. Interview on 2/9/2023 at 9:28 a.m. with Registered Nurse (RN) NN, revealed she was unaware that R#16 was left hand dominate. She confirmed the care plan for restorative care did not address residents need for assistance with meals. Interview on 2/9/23 at 11:42 a.m., the Director of Health Services (DHS) revealed she was unaware that R#16 was left hand dominate and needed assistance with feeding. She confirmed the resident did not have a care plan that addressed the need of assistance with meals. She stated her expectation was that residents are assessed and care planned for activity of daily living (ADL) decline, when needed. During further interview, she stated staff should notice when a resident doesn't eat much, is frequently fed by family, or those residents who spill most of their food. Interview on 2/9/2023 at 2:00 p.m., CNA PP stated residents care plan directs the care that is needed for each resident. He stated R#16 is usually fed by her husband and only requires meals to be set up. He stated he was unaware of her left-hand dominance and her need to be fed if her husband was not present during meals. Interview on 2/9/2023 at 2:09 p.m. with CNA II, stated they refer to the resident's care plan to see what kind of assistance each resident requires. She stated that she has noticed residents that need assistance with eating, but it would not be on their care plan, so she would report to the charge nurse the resident needed assistance with eating, and then a care plan is developed for assistance with eating. Interview on 2/9/2023 at 3:00 p.m., R #16 stated she does not refuse assistance with meals, but she stated assistance has not been offered to her before today. She stated someone offered and assisted her with every meal today and stated today was the first time this had occurred. Cross Refer F656

Based on clinical record review, review of the facility's Occurrence Reduction Program revised 11/21/17 and staff interviews revealed that the facility failed to comply with their established polices for fall reduction. Specifically, the facility failed to consistently determine the root cause after each fall in an effort to develop resident centered care plans with appropriate interventions. Failure to document consistent evidence of interdisciplinary team (IDT) input into the development and revision of interventions for falls and evaluation of the effectiveness of current interventions to prevent falls for five residents (R) (R#43, R#62, R#3, R#48, R#61). A total of five residents were reviewed for falls with injury, and the sample size was 23. Review of the facility Resident Census and Condition of Residents Form CMS-672 dated 7/16/2018 revealed the current facility census was 94 residents. 80 residents were identified by the facility at high risk for falls. On 7/18/18, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 7/18/18 at 2:00 p.m. The facility Administrator, Director of Health Services (DHS), Consultant Nurse NN, and the Clinical Competency Coordinator were informed of the Immediate Jeopardy (IJ). The noncompliance related to the immediate jeopardy was identified to have existed on 2/16/18. The immediate jeopardy is outlined as follows: 1. The IJ was determined to exist as of 2/16/18 when R#43 had a witnessed fall. The resident was noted to have pain, [MEDICAL CONDITION] and bruising to right lower extremity on 2/18/18 and was sent to the emergency room (ER). The resident was found to have a Bimalleolar type fracture to the right ankle with mild subluxation of the right tibia on the talus. The resident had falls without injury on 2/20/18, 3/1/18, 3/6/18 and 4/14/18. The facility failed to determine the root cause of the falls or put interventions in place to prevent further falls after the fall on 2/16/18 nor was the care plan documented as updated. 2. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R#62 had a Brief Interview for Mental Status (BIM'S) score of 9 which indicates moderate cognitive impairment. The resident had 8 falls in the past 6 months on, 4/3/18, 5/4/18, 5/21/18 and 6/25/18 without injury. On 1/12/18 the resident had a fall, and was sent to the ER with a laceration to the head and steri-strips were applied. R#62 had a fall on 2/23/18 with a skin tear and also on 6/29/18 a fall with arm pain the resident was sent to the ER with a [DIAGNOSES REDACTED]. On 7/3/18 R#62 had a fall which resulted in a hematoma and laceration. R#62's falls were not assessed to determine root cause or care planned to prevent further falls. 3. Review of a Quarterly MDS assessment dated [DATE] revealed that R#3 had a BIM's score of 99 which indicates severe cognitive impairment. R#3 had three falls in the past six months. A fall on 2/26/18 with no injury, a fall on 3/19/18 which caused bruising to right elbow and right forehead and severe pain in the right thigh area and sent to the emergency room (ER) and diagnosed to have a right [MEDICAL CONDITION] and surgical intervention. R#3 had a fall on 6/27/18 without injury. The facility failed to assess the cause of the falls or to put interventions in place to prevent further falls and the care plan was not updated. 4. Review of a Quarterly MDS assessment dated [DATE] revealed that R#48 had a BIM's score of 11 which indicates mild cognitive impairment. R#48 had 24 falls in the past six months. On 1/7/18, 1/8/18, 1/10/18, 1/13/18, 1/17/18, 1/20/18, 1/23/18, 1/26/18, 1/30/18, 2/22/18, 3/19/18, , 4/1/18 (fell twice) and sustained skin tears, falls documented on 4/19/18, 4/24/18, 6/4/18 and 6/19/18 without injury. On 3/1/18 the resident had a fall with an abrasion to the back, left side of his head, 3/4/18 (fell twice) and sustained an abrasion to the right hip, a fall on 3/12/18 with an abrasion to the right middle toe, a fall on 3/23/18 with a left little finger laceration, on 3/27/18 a fall which resulted in a skin tear and 6/2/18 a fall with an abrasion to the right elbow and left knee. The resident was not assessed for the cause of the falls or assessed possible interventions to prevent further falls. 5. Review of the Quarterly MDS assessment dated [DATE] revealed that R#61 had a BIM's score of 99, which indicates severe cognitive impairment. R#61 had seven falls in the past six months. The resident fell on [DATE] and 7/10/18 without injury. On 4/23/18 the resident had a witnessed fall hitting his right ear on the foot of the bed, on 4/26/18 the resident had a fall with a skin tear to the right forearm, on 6/28/18 the resident fell behind the nurses station and bumped his head on the filing cabinet resulting in a one inch abrasion to the crown of his head, 6/30/18 resulting in a skin tear and on 7/4/18 the resident had a fall resulting in a skin tear. The cause of the R#61's falls were not assessed, there was no evidence that a root cause was determined, or interventions developed to prevent further falls and the care plan was not updated. The Immediate Jeopardy was related to the facilities non-compliance with the program requirements as follows: CFR 483.21(b)(1) Develop/Implement Comprehensive Care Plans (F 656 Scope and Severity (S/S): J); CFR 483.25(d) Free of Accident Hazards/Supervision/Devices (F 689 S/S: J); CFR 483.5(a) Sufficient Nursing Staff (F 725 S/S: J); CFR 483.70(d) Administration (F 835 S/S: J); CFR 483.75(d) Quality Assurance and Performance Improvement (F 867 S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25(d) Quality of Care (F 689 S/S): J). At the time of exit on 7/21/18, an Allegation of Compliance (AoC) had not been received, therefore the IJ remains on going. Findings include: Review of the facility's Occurrence Reduction Program, revised 11/21/17 revealed: All residents will be assessed and scored for risk for falls by a licensed nurse upon admission, readmission, quarterly and with significant change (decline or improvement). For residents scoring 10 or higher on the Fall Risk Observation Form, an individualized care plan will be implemented with appropriate and realistic goals and interventions for these residents and they will be placed in the Occurrence Reduction Program as indicated; Determining Placement of Patients/Residents on Occurrence Reduction program; If a resident has had a fall in the past 30 days, regardless of injury or fall risk assessment score, the resident will be placed in the Occurrence Reduction Program with appropriate interventions as indicated: - One fall with or without injury. - A skin tear requiring physician intervention and treatment such as stitches, staples, etc. - Three skin tears in a 30-day period, regardless of type of treatment required. Occurrence Reduction Program Meeting; The committee will meet at least weekly or as need based upon patient/resident occurrences (understand that some patients/resident occurrences indicated the need for immediate placement on the Occurrence reduction) 1. Review of the clinical record for R #43 revealed an original admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment for R#43 dated 2/16/18, revealed a Brief Interview for Mental Status (BIMS) score of 5 (a score of 0-7 indicates severe cognitive impairment) and noted to display acute signs and symptoms (s/s) of inattention and disorganized thinking. The functional assessment revealed R#43 suffered two falls since the prior assessment, one without injury and one with major injury. Review of the Fall Risk Observation Form dated 1/14/18 revealed an assessment score of 8 with four falls noted in the previous three months as well as intermittent confusion. There was also a comment to see falls care plan but there was no documentation on the care plan dated 1/14/18. The care plan did not reflect a complete list of falls for R#43 or any documented evidence that the current interventions were effective. On 2/16/18, R#43 had a witnessed fall subsequently on 2/18/18 the resident was noted to have pain, [MEDICAL CONDITION] and bruising to right lower extremity on 2/18/18 and was sent to the emergency room (ER). The resident was found to have a Bimalleolar type fracture to the right ankle with mild subluxation of the right tibia on the talus On 2/27/18, R#43 was admitted to a local hospital for a surgical procedure known as open reduction and internal fixation of the Bimalleolar [MEDICAL CONDITION] ankle (a three-fold [MEDICAL CONDITION]). Problems list in the Pre-op notes for R#43 regarding the surgery, dated 2/27/18, includes shoulder joint pain; right rotator cuff syndrome; closed fracture of upper end of humerus; right closed bimolecular fracture-onset 2/26/18; injury of head; injury of shoulder region; fell on same level from slipping, tripping or stumbling; accidental fall. The current clinical record for R#43 lacked evidence to determine if the interventions noted on the care plan was reviewed to determine if they were effective. On 3/1/18, 4:20 p.m., documentation on a Resident Incident Report revealed an unwitnessed fall in R#43's room where she was found seated on her rear-end on the floor beside her bed. She was assessed and found to have no apparent injury, returned to bed, encouraged to call for assistance and ensure bed alarms are sounding properly. It is listed on the care plan for 3/1/18 which stated, 'Slid OOB (out of bed) at bedside, no injury noted. On 3/2/18 it is documented on the care plan two falls resulting in two fractures with repair of right ankles currently NWB (non-weight bearing). There was no evidence that the care plan was reviewed to determine if the current interventions were effective. On 3/6/18 at 3:00 p.m., the Resident Incident Report revealed R#43 climbed out of her chair and was seen by staff kneeling on the floor stating, I want to get back in bed. She was assessed and found to have no apparent injury and assisted back to bed. There was no evidence that the care plan interventions were reviewed for effectiveness nor were there any additional care plan interventions/entries for this date. It is documented on 4/14/18, 11:31 a.m. on a Resident Incident Report an unwitnessed fall which noted R#43 was found sitting on the floor in front of her wheelchair; the wheels were not locked. She attempted to transfer herself from the bed to her wheelchair. R#43 was assessed and found to have no apparent injury and assisted back into her wheelchair. There were no corresponding interventions added nor evidence that the current interventions were effective. The interventions on the care plan include; remind the resident to use walker and/or call for assistance, remind resident to wear non-side socks and remind the resident to sit further back on bed when attempting to put shoes on. There was no documented evidence the interventions were appropriate or effective for a resident with a noted BIM's score which coded the resident as cognitively impaired. Review of R#43's risk for injury related to the falls comprehensive care plan with a problem onset date of 3/13/17 stated R#43 is at risk for falls as evidenced by a history of falls; is receiving [MEDICAL CONDITION] medications; requires some ADL (activities of daily living) assistance at night PRN (as needed). Review of R#43's fall care plan revealed the following interventions: - Monitor for changes in Resident's condition that may warrant increased supervision/assistance and notify physician. - Evaluate effectiveness and side effects of [MEDICAL CONDITION] drugs for possible decrease in dosage or elimination of drug. - Remind resident/patient to call for assistance with transfers and/or ambulation PRN. - Keep call light within reach while in room. - Keep pathways clear and free of obstacles. - - - Physical Therapy (PT) to evaluate as warranted/ordered. -- - Maintain safety with transfers. - - Maintain proper shoes size with non-skid soles. - - Remind resident to sit further back on bed when attempting to put on shoes. - - Discourage resident from picking things off the floor under beds without assistance. Updated interventions related to falls: - 2/16/18: remind resident to wear non-skid socks and shoes. - 2/18/18: mat at bedside - 3/2/18: noted two falls resulting in two fractures with repair of right ankles currently NWB *(non-weight-bearing). - 5/21/18: continue plan of care. - 7/18/18: all interventions for falls appropriate. - 7/19/18: resident to always use walker and/or call for assistance. Further clinical record review revealed R#43 fell on [DATE],2/20/18, 3/1/18, 3/6/18 and 4/14/18; none of which resulted in any apparent injury. There was no documented evidence that the current care plan intervention was reviewed after each fall to determine if the interventions were appropriate and effective. 2. Review of R#62's clinical record revealed she was admitted to the facility on [DATE]. Further record review for R#62 revealed she fell on [DATE], suffering a superficial laceration and on 2/23/18 sustaining a skin tear and on 6/29/18 which resulted in a right [MEDICAL CONDITION]. Falls which occurred on 5/4/18, 5/21/18 and 6/25/18 noted no injuries. The following examples are falls in which R#62 sustained injury, on 1/12/18, 2/23/18 and 6/29/18. Review of R#62's care plan revealed no entry of the fall on 1/12/18 or additional interventions to prevent falls and additional injuries from falls. This was confirmed by an entry on the Resident Incident Follow-up Report, dated 1/13/18 documents there were no environmental factors noted and R#62 was using her walker and wearing non-skid shoes when she fell . The same report also revealed a laceration with hematoma and bruising to the left side of the face. The report also checked the incident was addressed in the care plan, however, there was no documentation for this incident noted on the care plan. Review of the fall care plan with an onset date of 8/12/16 includes the following interventions: - Remind resident to call for assistance with transfers and/or ambulation - Toilet upon rising, before and after meals, at bedtime, upon request and PRN - Keep call light within reach while in room - Keep pathways clear and free of obstacles - PT to veal as warranted/ordered - Maintain safety with transfers - Ensure nonskid footwear when out of bed - Add pressure alarm to bed when in bed and wheelchair alarm - Place raised toilet seat over toilet - Ensure frequently used items are placed within reach. Review of the Resident Incident Report for R#62 dated 2/23/18 at 11:00 p.m. revealed unwitnessed fall in her room where she landed on the right side of her face. She developed an oval-shaped knot to the right side of her head and a skin tear, approximately 2.5 inches in length, to the right elbow area. The Immediate Post-Incident Action notes: Encouraged pt (patient) to call for assist with working in closet as an intervention. Review of the care plan revealed no entry of the fall nor the intervention noted on the Immediate Post-Incident Action form. On 6/29/18 at 4:40 a.m. R#62 fell and was heard yelling, I broke my arm. She was left on the floor until the emergency medical service (EMS) arrived to take her to the emergency room (ER). X-rays revealed a Colles [MEDICAL CONDITION] arm and a parietal hemorrhage. 3. Review of the clinical record for R#3 revealed she was admitted to the facility on [DATE]. Further review of the clinical record revealed R#3 fell on [DATE] at 2:10 a.m. and was assessed with [REDACTED]. She complained of pain in the right thigh area when staff tried to help her to her feet. She was sent to the local ER for evaluation and treatment of [REDACTED]. Review of R#3's fall care plan with an onset date of 12/8/17 included the following interventions: - Remind resident to ask for assistance for all ambulation - Call light within reach while in room - Maintain clutter free room and well lit room. - PT to eval as warranted/ordered - Ensure frequently used items are placed within reach - Residents condition may warrant increased supervision/assistance and notify physician 4. Review of the clinical record for R #48 revealed he was admitted to the facility on [DATE]. The clinical record revealed R#48 fell 24 times without major injury on 1/7/18, 1/8/18, 1/10/18, 1/13/18, 1/17/18, 1/20/18, 1/24/18, 1/26/18, 1/30/18, 2/22/18, 3/1/18, 3/4/18-(twice), 3/12/18, 3/19/18, 3/23/18, 3/27/18, 4/1/18-(twice), 4/19/18, 4/24/18, 6/2/18, 6/4/18 and 6/19/18 for a total of 24 falls from 1/1/18 through 6/30/18. Review of R#48's fall care plan with an onset date of 1/26/17 included the following interventions: -Notify the charge nurse or supervisor if pain is noted PRN -Assess type of pain, location, duration and severity -Evaluate other comfort measures and implement as necessary -Administer medications/[MEDICATION NAME] as ordered by MD -Coordinate with MD to manage pain medication for optimum control of pain PRN -Assess effectiveness of medication on an ongoing basis and report any problems to MD 5. Review of the clinical record for R#61 revealed he was admitted to the facility on [DATE]. Further review of the clinical record revealed R#61 fell on [DATE], 4/23/18, 5/11/18 and on 7/10/18 without injuries. R#61 also fell on [DATE], 6/30/18 and 7/4/18 sustaining skin tears with each fall. Review of R#61's fall care plan with an onset date of 12/8/17 included the following interventions: - Resident needs a night light on to help see at night - Remind Resident to ask for assist for all ambulation - Refer Resident for PT evaluation - Observe for changes in Resident's condition that my warrant increased supervision/assistance and notify the physician - Call light within reach when in room - Maintain clutter free room and well lit room - Place frequently used items close to resident - Resident will sit or lay on floor to fix things - Ensure non-skid foot wear when out of be/transferring and walk Interviews: During an interview on 7/17/18 at 8:42 a.m. with the MDS Director regarding falls in the facility, she revealed that she completes the MDS assessments. When asked how she handles high risk falls, she stated that the care plan would be different with interventions and each fall should be listed on the care plan and an intervention put in place. She stated she does the initial care plan, but the nurses are responsible for adding and updating the interventions. During an interview with the DHS on 7/18/18 at 11:00 a.m. she stated when a fall happens they go in and assess the resident to ensure there is no injury and try to determine the root cause analysis, come up with interventions, and care plan them. She stated the responsible party (RP) and the physician are notified and the incident should be noted in the nurse's notes. When asked where is the documentation located for R#48 regarding his 24 falls in the last six months because there is no documentation in the nurse's notes. The DHS stated R#48 is non-compliant, but all his falls should be documented on the care plan with new interventions put in place. She stated they bought pool noodles to define the bed parameters, looked at Quality Assurance (QA) and referrals to therapy. The DHS stated each of his falls should be noted on the chart. The DHS stated the assessment for each of his falls should have been on the chart. When asked about the Occurrence Reduction Program Meeting that is mentioned in their fall policy, the DHS stated that there has been no Occurrence Reduction Program Meeting because she hasn't had a chance to do it. The DHS stated she has been focused on significant weight loss and had put things in place to decrease the issues with weight loss. The DHS stated she had several hospice residents who were finally gaining weight, but hospice came in and told her not to make changes to their patients. The next thing she knew, everything she had done was stopped. When asked how they were following and managing falls she stated they do an assessment when they are admitted , when they go out to the hospital, and when they return from a hospital stay, they do a whole new admission process which includes the fall assessment. When asked if the problem with falls and falls with injuries and major injuries were in Quality Assurance and Performance Improvement (QAPI), the DHS stated she put falls into QAPI a month ago. She stated, I've had no unit managers for over two months and they were supposed to be doing all the fall stuff and when they left I found out they weren't doing it and I've been trying a plan of correction, but I've just had no help.

Based on observation, clinical record review and review of the Occurrence Reduction Program, and interviews it was determined that the facility failed to provide supervision to prevent accidents; failed to provide evidence that falls were consistently discussed in the Occurrence Reduction Program Meeting per facility policy so that the root cause of each fall could be determined; and failed to provide evidence that the interventions in place at the time of each fall were effective. The facility failed to implement the Occurrence Reduction Program Meeting, policy that states the committee will meet at least weekly or as needed based upon patient/resident occurrences (understanding that some patient/resident occurrences indicate the need for immediate placement on the Occurrence Reduction Program). A total of four residents were reviewed for falls with fractures, and one resident (R#48), for repeat falls without interventions in place to prevent the reoccurrence of falls. The sample size was 23 residents. Review of the facility Resident Census and Condition of Residents Form CMS-672 dated 7/16/18 revealed that the current facility census was 94 residents. 80 residents were identified by the facility as high risk for falls. On 7/18/18, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 7/18/18 at 2:00 p.m. The facility Administrator, Director of Health Services (DHS), Consultant Nurse NN, and the Clinical Competency Coordinator were informed of the Immediate Jeopardy (IJ). The noncompliance related to the immediate jeopardy was identified to have existed on 2/16/18. The immediate jeopardy is outlined as follows: 1. The IJ was determined to exist as of 2/16/18 when R#43 had a witnessed fall. The resident was noted to have pain, [MEDICAL CONDITION] and bruising to right lower extremity on 2/18/18 and was sent to the emergency room (ER). The resident was found to have a Bimalleolar type fracture to the right ankle with mild subluxation of the right tibia on the talus. The resident had falls without injury on 2/20/18, 3/1/18, 3/6/18 and 4/14/18. The facility failed to determine the root cause of the falls or put interventions in place to prevent further falls after the fall on 2/16/18 nor was the care plan documented as updated. 2. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R#62 had a Brief Interview for Mental Status (BIM'S) score of 9 which indicates moderate cognitive impairment. The resident had 8 falls in the past 6 months on, 4/3/18, 5/4/18, 5/21/18 and 6/25/18. On 1/12/18 the resident had a fall, and was sent to the ER with a laceration to the head and steri-strips were applied. R#48 had a fall on 2/23/18 with a skin tear, and on 6/29/18 a fall with arm pain the resident was sent to the ER with a [DIAGNOSES REDACTED]. The resident also had a fall on 7/3/18 which resulted in a hematoma and laceration. R#62's falls were not assessed to determine root cause nor care planned to prevent further falls. 3. Review of a Quarterly MDS assessment dated [DATE] revealed that R#3 had a BIM's score of 99 which indicates severe cognitive impairment. R#3 had three falls in the past six months. A fall on 2/26/18 with no injury, a fall on 3/19/18 causing bruising to right elbow and right forehead and severe pain in the right thigh area and sent to the emergency room (ER) and was diagnosed to have a right [MEDICAL CONDITION] and surgical intervention. R#3 also had a fall on 6/27/18 without injury. The facility failed to assess the cause of the falls or to put interventions in place to prevent further falls and the care plan was not updated. 4. Review of a Quarterly MDS assessment dated [DATE] revealed that R#48 had a BIM's score of 11 which indicates mild cognitive impairment. R#48 had 24 falls in the past six months. On 1/7/18, 1/8/18, 1/10/18, 1/13/18, 1/17/18, 1/20/18, 1/23/18, 1/26/18, 1/30/18, 2/22/18, 3/19/18, 4/1/18 (fell twice) and sustained skin tears), falls documented on 4/19/18, 4/24/18, 6/4/18 and 6/19/18 without injury. On 3/1/18 the resident had a fall with an abrasion to the back, left side of his head, 3/4/18 (fell twice) and sustained an abrasion to the right hip, a fall on 3/12/18 with an abrasion to the right middle toe, a fall on 3/23/18 with a left little finger laceration, on 3/27/18 a fall with a skin tear, and a fall on 6/2/18 with an abrasion to the right elbow and left knee. The resident was not assessed for the cause of the falls or assessed possible interventions to prevent further falls. 5. Review of the Quarterly MDS assessment dated [DATE] revealed that R#61 had a BIM's score of 99, which indicates severe cognitive impairment. R#61 had seven falls in the past six months. The resident fell on [DATE] and 7/10/18 without injury. On 4/23/18 the resident had a witnessed fall hitting his right ear on the foot of the bed, on 4/26/18 the resident had a fall with a skin tear to the right forearm, on 6/28/18 the resident fell behind the nurses station and bumped his head on the filing cabinet resulting in a one inch abrasion to the crown of his head, a fall on 6/30/18 resulting in a skin tear and on 7/4/18 the resident had a fall resulting in a skin tear. The cause of the R#61's falls were not assessed, there was no evidence that a root cause was determined, or interventions developed to prevent future falls and the care plan was not updated. The Immediate Jeopardy was related to the facilities non-compliance with the program requirements as follows: CFR 483.21(b)(1) Develop/Implement Comprehensive Care Plans (F 656 Scope and Severity (S/S): J); CFR 483.25(d) Free of Accident Hazards/Supervision/Devices (F 689 S/S: J); CFR 483.5(a) Sufficient Nursing Staff (F 725 S/S: J); CFR 483.70(d) Administration (F 835 S/S: J); CFR 483.75(d) Quality Assurance and Performance Improvement (F 867 S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25(d) Quality of Care (F 689 S/S): J). At the time of exit on 7/21/18, an Allegation of Compliance (AoC) had not been received, therefore the IJ remains on going. Finding include: Review of the facility's Occurrence Reduction Program/Policy: with a revision date of 11/21/17 revealed: Policy Statement: This healthcare center recognizes that due to the frailty of the patients/residents served, there is an increased risk of occurrences that may result in injury to the patient/resident and/or others. In an effort to prevent occurrences, each patient/resident will be assessed for risk and appropriate and realistic interventions will be implemented upon identification of risk and after a fall. These interventions will be included in the care plan. Occurrence Reduction Program Meeting: The committee will meet at least weekly or as needed based upon patient/resident occurrences (understanding that some patient/resident occurrences indicate the need for immediate placement on the Occurrence Reduction Program). The committee will perform the following functions: - Review all new admissions/readmissions to include the scored Fall Risk - Access and review all occurrence and investigation reports. - Access and review the Occurrence Log located in the electronic records for trending analysis. - Access and review electronic data for patients/residents at risk for falls. - Determine which patients/residents should be placed on the occurrence program. - Discuss all patients/residents who are currently on the Occurrence Reduction Program. - Brainstorm and assess for potential causes and risks of occurrence(s) based upon the patient/resident's clinical history, occurrence investigation reports and disciplinary findings and expertise. - Develop interventions, as indicated by above, that would decrease risk of reoccurrence, with documentation on Certified Nursing Assistant (CNA) Care Intervention Record Form, or in electronic charting, and patient/resident's care plan. - Occurrence Reduction Program documentation will be completed in the nurse's notes. - Reassess and revise, if indicated, interventions for each patient/resident on the program, weekly. - The patient/resident will be discontinued from the Occurrence Reduction Program when they are occurrence free for four weeks or when deemed appropriate. Determining Placement of Patient/Resident on Occurrence Reduction Program: If a patient/resident has had a fall in the past 30 days regardless of injury or fall risk assessment score he/she will be placed on the Occurrence Reduction Program with appropriate interventions as indicated: - One fall with or without injury. - A skin tear requiring physician intervention and treatment such as stitches, staples, etc. - Three skin tears in a 30-day period, regardless of type of treatment required. 1. Review of R#43's clinical record revealed an admission date of [DATE] and that she had a [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R#43 had a Brief Interview for Mental Status (BIMS) score of 5 (a score of 0 to 7 indicates severe cognitive impairment); needed limited assistance for walking in her room and in the corridor; had one fall with no injury, and one fall with major injury since the prior assessment. Review of her Quarterly MDS assessment dated [DATE] revealed a BIM's score of 8 (indicating moderate cognitive impairment) and revealed that her balance during transition and walking is not steady but only able to stabilize with human assistance; needed extensive assistance for walking in room and corridor; has had two or more falls with no injury, and one fall with major injury since the prior assessment. Review of Incident Log for (MONTH) (YEAR) through (MONTH) (YEAR) revealed on 2/13/18, R#43 had an witnessed fall according to the incident report dated 2/13/18 the narrative of incident and description of injuries reads: This nurse was passing by room in hallway and observed resident coming out of bathroom when her left foot slipped out from under her and she sat down on the floor. Nurse unable to get there quick enough to intervene. Immediate Actions Taken: Vital signs taken, resident assessed for injuries, Range of Motion within normal limits, assisted to bed. Post-Incident Actions dated 2/13/18 at 12:00 p.m. revealed the same narrative as is on the incident report, Immediate Post-Incident Action: Resident did not have her walker with her, educated resident about using walker or calling for assistance. There is no documentation that a Facility Event Investigation Form was completed, or that R#43 was placed on the Occurrence Reduction Program after the fall on 2/13/18. On 2/16/18 R#43 had a witnessed fall the narrative of the incident and description of injuries reads: On 2/16/18, when R#43 was witnessed by a Registered Nurse (RN) coming out of the bathroom using her walker and slipped and was unable to assist and with her legs. She was very weak and unsteady. Denied any pain, just weakness. Immediate Actions Taken: Assisted back to bed, non-slid socks in place, labs ordered for a.m. to rule out underlying metabolic causes of altered mental status (AMS). Post-Incident Actions reveal the same narrative of the incident as listed on the Incident Report, Immediate Post-Incident Action: Non-slid socks, bed in lowest position, educated to use call bell, frequent observation by staff, positioned med cart outside of room. There is no documentation that a Facility Event Investigation Form was done, or that R#43 was placed on the 'Occurrence Reduction Program' after the 2/16/18 fall. Review of a Situation, Background, Assessment, and Recommendation (SBAR) dated 2/18/18 revealed R#43 was noted to have [MEDICAL CONDITION]/bruising to the right ankle/foot and has had several falls this week with no apparent injuries. Currently on antibiotics for a Urinary Tract Infection [MEDICAL CONDITION], altered mental status, now having difficulty swallowing this a.m. Pupils dilated. Recommendation of the Nurse Practitioner (NP) was to send R#43 to the emergency room for evaluation. X-ray report dated 2/18/18 revealed a Bimalleolar type right ankle fracture with mild anterior subluxation of the right tibia on talus with soft tissue swelling about the right ankle generally. On 2/18/18 Nurse's Note at 1:20 p.m. reads: Emergency Medical Technician (EMT) transported resident back to facility. No signs and symptoms of distress noted. Soft cast currently in place on right lower extremity. No new medication orders received. Follow up appointment ordered for several days. Further review of the record revealed an Operative report dated 2/27/18, surgical indications read: The patient sustained a right Bimalleolar ankle fracture after a fall. The patient was educated on the fact that the ankle is unstable and requires surgical fixation to prevent the patient form having ankle instability and severe posttraumatic arthritis. The facility failed to put new interventions in place and failed to assess R#43, to determine if the interventions in place at the time of the fall were effective to prevent further falls. The facility did not complete a Facility Event Investigation tool. Interventions on the care plan dated 2/16/18 include remind resident to wear non-skid socks and shoes which is the same intervention in place since 3/13/17. On 2/20/18 an Incident Report for R#43 revealed an unwitnessed fall, the narrative of the incident and description of injuries read: Resident taking legs off bed. Slid off bed. Found sitting on mat. Bed was low. Immediate Actions Taken: Vitals, neuro checks. Post-Incident Actions dated 2/20/18 at 9:30 p.m. has the same narrative as the incident report. Immediate Post Incident Action reads: Remind resident not to try to get up. Use call light if needing assistance. Immediate actions taken is the same on the incident report. There is no documentation that a Facility Event Investigation Form was completed, or that R#43 was placed on the Occurrence Reduction Program after the 2/20/18 fall. Review of an Incident Report dated 3/1/18 revealed an unwitnessed fall in R#43's room. The narrative of incident and description of injuries read: Resident found on floor beside bed on bottom. No apparent injuries. Immediate Actions Taken: Observe for signs and symptoms of injury. Vital signs taken, assist back to bed. Review of Post-Incident Actions dated 3/1/18 at 4:20 p.m. revealed the same narrative as in the incident report, Immediate Post-Incident Action: Encourage resident to call for assist, assure bed alarms are sounding properly, Immediate actions taken are the same as on the incident report. There is no documentation that a Facility Event Investigation Form was completed, or that R#43 was placed on the Occurrence Reduction Program for the fall on 3/1/18. Review of R#43's risk for falls, as evidenced by a history of falls, comprehensive care plan with a problem onset date of 3/13/17, with an intervention to include, Maintain proper shoes size with non-skid soles. The care plan was updated on 2/16/18 to reflect a fall while going to the bathroom with no injury. An undated intervention of, remind resident to wear non-skid socks and shoes, is written on the care plan. Further review of this care plan revealed an intervention dated 2/18/18 of mat at bedside; on 3/1/18 slid out of bed at bedside with no injury, no new interventions put in place; on 3/2/18 two falls resulting in two fractures with repair. Right ankle currently no weight bearing; on 4/14/18 fall without injury. On 3/6/18 R#43 had an unwitnessed fall in her room. Resident climbed out of chair and seen on her knees on floor by CNA as she walked by. Resident stated, I wanted to get back in bed. No injury, no complaints of pain. Assisted to bed by staff. Immediate Actions Taken: Resident assessed for injury. Assisted to bed. (sic) There was no Immediate Post-Incident Action form or documentation that a Facility Event Investigation Form was completed and no evidence that R#43 was placed on the Occurrence Reduction Program after the fall on 3/6/18. Review of an Incident Report dated 4/14/18 revealed R#43 had an unwitnessed fall in her room, the narrative of the incident and description of injuries read: Resident attempted to transfer herself from the bed into the wheelchair and was found sitting on the floor in front of the wheelchair and the breaks on the wheelchair were not locked so the resident sat on the floor in front of the wheelchair. No injuries. Immediate Actions Taken: Vitals taken, assessed for injuries, and assisted into wheelchair. Post-Incident Actions form dated 4/14/18 at 11:31 a.m. with the same narrative as the Resident Incident Report. Immediate Post-Incident Action: Resident re-oriented to call light, reminded to ask for assistance and re-oriented to brakes on wheelchair and shown how to use them. Immediate Actions Taken are the same as noted on the Resident Incident Report. There is no documentation that a Facility Event Investigation Form was completed or that R#43 was placed on the Occurrence Reduction Program after the fall on 4/14/18. Review of the quarterly Fall Risk Observation form for R#43 dated 5/11/18 revealed a total score is (18) which indicates high risk for falls. Review of clinical record for R#43 revealed she received Occupational Therapy (OT)/Physical Therapy (PT) 2/1/18 through 2/12/18, 3/15/18 through 3/28/18, and 4/19/18 through 6/29/18 related to weakness and Activities of Daily Living (ADL's). Observation on 7/16/18 at 2:00 p.m. in R#43 room revealed her bed to be in a low position. Falls mats were noted next to the wall. During interview with R#43 regarding the mats, she said she is unsure exactly why the mats are there but stated she had a fall and cannot remember the date it happened. Observation on 7/19/18 at 11:49 p.m. revealed R#43 walking in the hallway using her walker. R#43 stated she was on her way to lunch. 2. On 1/12/18 R#62 had a witnessed fall with injury of approximately 4 four inch long laceration to left side of her forehead, and a skin tear to her left wrist, resident complained of hurting when staff tried to move her, emergency medical service EMS was called, received a [MEDICATION NAME] agent to the laceration and dressing to skin tear. Post-Incident Actions form dated 1/12/18 at 3:30 p.m. revealed an immediate post-incident action to educate resident and remind her that she needs assistance when ambulating. Resident Incident Follow-up Report, 24-hour follow-up, revealed the resident has a laceration with hematoma to left side of face with quarter size bruising noted on left side of face. Residents cognition has not changed from baseline. Elbow skin tear treated by wound care nurse. Additional Follow-up on 1/14/18 revealed no new interventions. There are no environmental factors noted. Resident was wearing non-skid shoes and using walker. On 2/23/18 R#62's had an unwitnessed fall and received approximately a 2.5 x 3.5-inch, oval bump knot to the right side of head and received approximately 2.5-inch skin tear on right elbow area. Post-Incident Actions form dated 2/23/18 with Immediate Post-Incident Action of: Encouraged patient to call for assist with working in closet as intervention. On 4/3/18, fell in room, witnessed, no apparent injury. On 5/4/18, fell in room, unwitnessed, no apparent injury. Review of R#62's clinical record revealed she had an un-witnessed fall on 6/29/18 at 4:50 a.m. while ambulating without assistance and fell on her right arm, face down on the floor yelling, I broke my right arm! Discharge instructions from the Hospital Emergency Department dated Friday, 6/29/18, revealed a the resident sustained [REDACTED]. The facility did not complete a Facility Event Investigation Form. A care plan intervention dated 6/29/18 reads Send to ER for evaluation and treatment. Pressure alarm when in bed and wheelchair. The same interventions were in place from the last revision date 6/19/18 through 9/9/18. There is no documentation that R#62 was placed on the Occurrence Reduction Program, as stated in their policy, for any of the falls listed. The facility failed to assess for the root cause of the falls for R#62 and failed to update the care plan with new interventions. 3. Resident #3 had an unwitnessed fall on 2/26/18 in her room with no apparent injury. The facility did not complete the Facility Event Investigation Form. Review of an Incident Report for R#3 dated 3/19/18 revealed she had an un-witnessed fall at 2:10 a.m. and upon assessment patient was noted with bruising to right elbow and right forehead area to which she stated she hit in the fall. She complained of pain to right thigh area post fall. Immediate actions taken was patient assessment and prepare to send resident to the emergency room for evaluation and treatment. Review of an x-ray report dated 3/19/18 revealed a subcapital fracture of right hip with varus angulation. Post-surgical x-ray dated 3/19/18 revealed radiographically satisfactory position of a recently placed total right hip prosthesis. R#3 returned to the facility on [DATE]. On 6/27/18 R#3 also had an unwitnessed fall in her room with no injury. An undated, written intervention on the care plan reads: Keep resident in lobby while up in wheelchair. There is no documentation that R#3 was placed on the Occurrence Reduction Program' as stated in their policy, for any of the falls listed. The facility failed to assess the cause of the falls and failed to put interventions in place to prevent further falls. The facility also failed to update the care plan with new interventions. 4. Review of the Incident Log and Incident Report Form revealed R#48 had falls on the following dates: - 1/7/18 in his room, unwitnessed with no apparent injury, - 1/8/18 in his room, unwitnessed with no apparent injury, - 1/10/18 in his room, unwitnessed with no apparent injury, - 1/13/18 in his bathroom on the floor, unwitnessed with a small bruise to his right hip, - 1/17/18 in his room, witnessed with no apparent injury - 1/20/18 in his room unwitnessed with no apparent injury - 1/23/18 B Hall and C Hall, witnessed with no apparent injury - 1/26/18 in his room, unwitnessed with no apparent injury, - 1/30/18 in his room, unknown if witnessed or unwitnessed, obtained skin tear. - 2/22/18 in his room, unwitnessed with no apparent injury, - 3/1/18 in his room, witnessed with an abrasion noted to the left side of the back of the head and an First- in room, witnessed with injury noted to right hip with abrasions and bruises, Second Fall - in room, witnessed with no apparent injury, (sic) - 3/12/18 in room, unwitnessed, with injury noted to middle toes on right foot, - 3/19/18 in his bathroom, unwitnessed with no apparent injury, - 3/23/18 in his room, unwitnessed with a superficial laceration to the fifth finger of his left hand, - 3/27/18 No Incident Report done but is indicated on the Incident Log as a skin tear - 4/1/18 (fell twice) in his room, unwitnessed with no apparent injury, - 4/19/18 In his room, unwitnessed with no apparent injury, - 4/24/18 in his room, unwitnessed with no apparent injury, - 6/2/18 in his room, unwitnessed with abrasions to right and left knees, - 6/4/18 in his room, unwitnessed with no apparent injury, - 6/19/18 at the nurses' station, witnessed with no apparent injury. A Facility Event Investigation form was completed for falls on 3/4/18 (fell twice) 3/12/18, 3/19/18, 3/23/18, 4/1/18 (fell twice) 4/19/18, and 4/24/18. There is no documented evidence that R#48 was placed on the Occurrence Reduction Program, as stated in their policy, for any of the falls listed. The facility failed to assess the cause of the falls and failed to put interventions in place to prevent further falls. The facility also failed to update the care plan with new interventions. 5. Review of the Incident Log for R#61 revealed he had 4 falls from (MONTH) (YEAR) through (MONTH) (YEAR). On 4/23/18 R#61 had a witnessed fall in his room. He was being assisted to bed when his foot slipped causing him to fall and hit his right ear on the foot of the bed. Incident Report indicates no apparent injury. Immediate Action Taken: Assisted to bed. R#61 record reveals on 4/26/18 location unknown, unwitnessed, ½ cm V shaped superficial skin tear. Narrative does not reveal location of skin tear. Immediate Action Taken: Wound care provided. On 5/11/18 R#61 had a witnessed fall in hallway on unit. Narrative of incident and description of injuries reads: Resident had been restless all shift. Staff having to constantly get him out of things. I had just redirected him from going into another patient's room, walking beside him with my hand on his elbow, he stumbled and fell on his right elbow. Did not have hard fall because I caught him before he hit his arm. No apparent injury. Immediate Actions Taken: Staff did one on one supervision until his daughter arrived. On 6/28/18 R#61 had an unwitnessed fall with an approximately 1-inch skin abrasion to the crown of his head. Immediate Actions Taken: Assessed for injuries and assisted back into chair. Neuro checks implemented. There is no documentation that R#61 was placed on the Occurrence Reduction Program, as stated in their policy, for any of the falls listed. The facility failed to assess the cause of the falls and failed to put interventions in place to prevent further falls. The facility also failed to update the care plan with new interventions. Interviews: During an interview on 7/17/18 at 6:00 a.m. at Station 1 with Licensed Practical Nurse (LPN) PP revealed, when asked if she could tell me about the number of resident falls in the facility, LPN PP stated that she believes if they were staffed appropriately, with enough staff, the number of falls would decrease greatly. When asked if there is a fall policy she would follow if a fall occurred she states that when she was first hired the fall policy was part of the Nursing Procedure Policy, but now is no longer a policy but an option. She stated, We don't have a set policy for falls that I am aware of. During an interview on 07/18/18 at 11:00 a.m. with the Director of Health Services (DHS) revealed she has worked in the facility approximately 8 months and that the Policy titled Occurrence Reduction Program is not in place. She states she does not currently have Unit Manager's (UM) and states the two UM's she had quit 2 months ago, and she just doesn't have enough help to follow what the policy says. When asked what the facility did when a fall occurred the DHS responded, Assess resident for injury, determine the Root Cause Analysis (RCA), put things in place to prevent further falls, and update care plan interventions. The family and responsible party are notified, and the resident is screened for PT and OT. The DHS stated falls was put into their Quality Assurance Performance Improvement (QAPI) one month ago when asked where the documentation was located regarding R#48 who fell 24 times in six months because there was no documentation found in the nurse's notes. The DHS stated R#48 was non-compliant, but all his falls should have been documented on the care plan with new interventions put in place. She stated they bought pool noodles to define the bed parameters used physical therapy and looked at Quality Assurance (QA) on Centers for Medicare and Medicaid (CMS) website. She stated the assessment for each of his falls should have been in the chart. During an interview on 7/18/18 at 1:21 p.m. with the Consultant Nurse NN regarding the number of falls over the past 6 months, and she stated she has told the facility that any time a resident is found on the floor it should be assumed that it was a fall and treat it like a fall. During an interview with the Administrator on 7/18/18 at 2:12 p.m. regarding the volume of falls in the facility he stated ,they had been focused on Dietary, but the team talked about falls at every morning meeting, I understand completely it's hard. We have staff burn out. The lack of documentation is getting us in trouble. When you have unstable staff, there is not much I can do but we have done our best and how am I going to work a plan of correction. During an interview on 7/20/18 at 8:30 a.m. with the Administrator, in his office, revealed that he has only been at the facility for four weeks. He stated falls are a concern everywhere but falls in this facility are discussed every day in their morning meetings. He stated he should have paid more attention to falls. He further stated he wasn't aware of the seriousness of falls in the facility. When asked if he was aware of the incident with R#61 on or around 6/22/18 when he was found on the floor, the Administrator stated, yes, he was aware. He also stated that QAPI was not made aware of the issues of wandering and falls with R#61 and the only thing mentioned about falls was during the QAPI meeting on 6/21/18, and stated that was only the number of falls they had, and that Dietary has been their focus. When asked if the QA Committee had ever developed a corrective action plan for falls in the facility he stated, no development of correction action was ever put in place for falls. When asked about staffing he stated that there is to be three CNA's in Restorative, but they get called to the floor. He further stated he wasn't aware about the staffing issue until he walked in the door as Administrator and found out, over time through staff, that the reason people were leaving was because of the DHS. During an interview on 7/20/18 at 10:05 a.m. with the Physical Therapist (PT), in the conference room, revealed that she gets a daily fall report, a referral, and a Medical Doctor (MD) order for evaluation of a resident who has had a fall, or if they come from the hospital, she gets an Physician order [REDACTED]. During further interview with PT at this time, she stated she is in the facility Wednesday through Saturday and doesn't see all the falls that come through their department but stated when a resident is discharged from therapy she will make a referral to the Restorative Nursing Program. She stated that there is an Interdisciplinary Team (ID) referral form that the CNA, or nurse, can utilize to make a referral and then get an Medical Doctor (MD) order. PT stated all CNA's are trained in restorative and that the PT Department trains them. When asked if the restorative training was done yearly she stated it was only done on a case by case basis. During an interview on 7/20/18 at 2:10 p.m. in the conference room with the DHS, 2 Consultant Nurses NN and OO, and the Administrator, revealed that all the management team is involved in the morning meetings and there are no records and no notes taken during that meeting. Consultant Nurse NN states that a staff member gathers the numerical documentation during the morning meeting, that goes to corporate. When ask about post fall assessments to find the root cause of each fall, and to provide documentation on what interventions were in place at the time of each fall so that the effectiveness of current interventions to prevent falls could be reassessed the DHS stated that they are supposed to be using an Investigation Form that they just re in-serviced on 5/31/18 that not all staff are doing it, not all the falls have one, not all of them were done. When asked who, and at what times is the resident evaluated for their risk for falls, including assessment for new admissions the DHS stated they are done quarterly, on admission, with a significant change, and upon re-admission. She stated with new residents they look at their medications, diagnosis, the way they can move about, and if they are cognit (TRUNCATED)

Based on observation, clinical record review, and interviews, it was determined that the facility failed to have sufficient staff to provide supervision to prevent accidents for five residents (R) (R#43, R#62, R#3, R#48, and R# 61). A total of five residents were reviewed for falls with injuries. The sample size was 23 residents. Review of the facility Resident Census and Condition of Residents Form CMS-672 dated 7/9/18 revealed that the current facility census was 94 residents. 80 residents were identified at high risk for falls. On 7/18/18, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 7/18/18 at 2:00 p.m. The facility Administrator, Director Health Services (DHS), Consultant Nurse NN, and the Clinical Competency Coordinator were informed of the Immediate Jeopardy (IJ). The noncompliance related to the immediate jeopardy was identified to have existed on 2/16/18. 1. The IJ was determined to exist as of 2/16/18 when R#43 had a witnessed fall. The resident was noted to have pain, [MEDICAL CONDITION] and bruising to right lower extremity on 2/18/18 and was sent to the emergency room (ER). The resident was found to have a Bimalleolar type fracture to the right ankle with mild subluxation of the right tibia on the talus. The resident had falls without injury on 2/20/18, 3/1/18, 3/6/18 and 4/14/18. The facility failed to determine the root cause of the falls or put into place to prevent further falls after the fall on 2/16/18 nor was the care plan updated. 2. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R#62 had a Brief Interview for Mental Status (BIM'S) score of 9 which indicates moderate cognitive impairment. The resident had 8 falls in the past 6 months on, 4/3/18, 5/4/18, 5/21/18 and 6/25/18 without injury. On 1/12/18 the resident had a fall and was sent to the ER with a laceration to the head and steri-strips were applied. On 2/23/18 the resident had a fall with a skin tear, 6/29/18 a fall with arm pain the resident was sent to the ER with a [DIAGNOSES REDACTED]. On 7/3/18 a fall which resulted in a hematoma and laceration. R#62's falls were not assessed to determine root cause nor care planned to prevent further falls. 3. Review of a Quarterly MDS assessment dated [DATE] revealed that R#3 had a BIM's score of 99 which indicates severe cognitive impairment, had three falls in the past six months. A fall on 2/26/18 with no injury, a fall on 3/19/18 which caused bruising to right elbow and right forehead and severe pain in the right thigh area and sent to the ER. R#3 was found to have a right [MEDICAL CONDITION] with surgical intervention, and a fall on 6/27/18 without injury. The facility failed to assess the cause of the falls or to put interventions in place to prevent further falls and the care plan was not updated. 4. Review of a Quarterly MDS assessment dated [DATE] revealed that R#48 had a BIMS score of 11 which indicates mild cognitive impairment, had 24 falls in the past six months. On 1/7/18, 1/8/18, 1/10/18, 1/13/18, 1/17/18, 1/20/18, 1/23/18, 1/26/18, 1/30/18, 2/22/18, 3/19/18,, 4/1/18 (fell twice) 4/19/18, 4/24/18, 6/4/18 and 6/19/18 without injury. On 3/1/18 the resident had a fall with an abrasion to the back, left side of his head, on 3/4/18 a fall with an abrasion to the right hip, a fall on 3/12/18 with an abrasion to the right middle toe, a fall on 3/23/18 with a left little finger laceration, on 3/27/18 the resident fell and sustained a skin tear, a fall on 4/1/18 with a skin tear and on 6/2/18 a fall with an abrasion to the right elbow and left knee. The resident was not assessed for the cause of the falls or assessed for interventions to prevent further falls. 5. Review of the Quarterly MDS assessment dated [DATE] revealed that R#61 had a BIMS score of 99, which indicates severe cognitive impairment, had seven falls in the past six months. The resident fell on [DATE] and 7/10/18 without injury. On 4/23/18 the resident had a witnessed fall hitting his right ear on the foot of the bed, on 4/26/18 the resident had a fall with a skin tear to the right forearm, on 6/28/18 the resident fell behind the nurses station and bumped his head on the filing cabinet resulting in a one inch abrasion to the crown of his head, 6/30/18 resulting in a skin tear, 7/4/18 the resident had a fall resulting in a skin tear. The cause of the R#61's falls were not assessed, there was no evidence that a root cause was determined, or interventions developed to prevent further falls and the care plan was not updated. The Immediate Jeopardy was related to the facilities non-compliance with the program requirements as follows: CFR 483.21(b)(1) Develop/Implement Comprehensive Care Plans (F 656 Scope and Severity (S/S): J); CFR 483.25(d) Free of Accident Hazards/Supervision/Devices (F 689 S/S: J); CFR 483.5(a) Sufficient Nursing Staff (F 725 S/S: J); CFR 483.70(d) Administration (F 835 S/S: J); CFR 483.75(d) Quality Assurance and Performance Improvement (F 867 S/S: J),. Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25(d) Free of Accident Hazards/Supervision/Devices (F 689 S/S: J) At the time of the exit on 7/21/18 at 11:30 a.m. Allegation of Compliance (AoC) had not been received therefore the IJ remains on going. Findings include: The entrance conference on 7/16/18 at 10:15 a.m. with the Director of Health Services (DHS) and Administrator in Administrator's office revealed the DHS stated she was working on D-Hall Med Cart this morning and has had to come in and work the floor at different times because of a call-in or being short staffed. She stated that corporate does not allow them to use agency nurses and must depend on their PRN (as needed) pool. The DHS stated. I'm just going to be honest with you. Interview on 7/16/18 at 11:30 a.m. with the DHS revealed that the facility is short staff. The DHS stated we are all doing everything we can. The DHS had to work as a charge nurse. Information provided by the DHS revealed the DHS has worked on the cart as charge nurse on the following dates: Date Shift Census 5/15/18 Third 94 5/19/18 Second 94 5/28/18 Second 93 6/6/18 Third 94 6/18/18 Third 94 6/21/18 First & Third 93 6/28/18 First & Second 93 7/7/18 Third 94 7/16/18 First 94 7/21/18 First 94 Interview on 7/16/18 at 11:00 a.m. with Licensed Practical Nurse (LPN) HH revealed the facility is short staff and have open positions for nurses and nursing assistants, we are so short staffed I hope you can help us. LPN HH stated that the facility is short staff most days. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#42 has a BIM's score of 14 which indicates the resident is cognitively intact. The resident was observed at the nursing station and stated, When am I going to get my 12 o'clock medicines? If I don't get my medication when I'm supposed to then my pain gets out of control. The DHS was observed coming up the hall towards Station 2 and was advised that R#42 was asking for pain medication and she stated she would get it for her. Interview with R#92 on 7/16/18 at 2:06 p.m. regarding facility staffing, he stated there were not enough Certified Nursing Assistants (CNAs) or nurses in the facility. He stated staff were leaving, going to other places for more money and better staffing. He stated staff were called at home constantly to work extra shifts. Review of R#92 Quarterly MDS assessment dated [DATE] revealed a BIM's score of 15 which indicated no cognitive impairment. During an interview on 7/17/18 at 6:00 a.m. with LPN PP regarding facility staffing, she stated there is one nurse and two CNAs for both A and B halls and this is not uncommon. She stated on rare occasions there is a nurse for both A and B halls. She stated that the CNAs use to work eight-hour shifts but the end of last year were forced to go to 12-hour shifts and it's burning them out. She stated she was told there would be three CNAs on each station for the night shift, but it has never happened. When asked about the number of resident falls she stated she believes if they were staffed appropriately, the number of falls would decrease greatly. When asked if there is a fall policy she would follow if a fall occurred, she stated when she was first hired the fall policy was part of the Nursing Procedure Policy but is no longer a policy but an option. She stated we don't have a set policy for falls. She also stated they are trying to put so many baths on nights because there isn't enough staff on day shift to bathe all that need to be bathed. She stated the CNAs are too tired to keep up and there have been ads in the paper that they are hiring but nothing is changing. In an interview on 7/17/18 at 6:20 a.m. with CNA UU and CNA YY regarding facility staffing, revealed from 6:30 p.m. to 7:00 a.m. there are two CNAs for A and B hall. They stated they are expected to fill the linen carts, empty the soiled linen, wash the wheelchairs, in addition to answering call lights, keeping residents clean and dry, and doing the number of baths they have to do on their shift. When asked why residents were up out of bed sitting in Geri-chairs and wheelchairs at 5:00 a.m., CNA YY stated she and CNA UU both stated they were told it was too much on day shift to have to get all of the residents up and ready for breakfast and they had to get those more dependent residents up and in their chairs between 4:00 a.m. and 5:00 a.m. CNA UU stated they start their last round to clean and dry residents at 4:00 a.m. so if they don't get the residents up at that time, they won't be able to get to everyone to get them cleaned and dried before their shift ends. Both CNA UU and CNA YY stated if they had the correct number of staff on every shift that there would also be less falls. An interview on 7/17/18 at 6:30 a.m. with LPN QQ stated she has been working in the facility for [AGE] years and there has always just been one nurse for each hall and one CNA on each hall on the night shift. She stated there is not enough staff to take care of the residents. She stated, during the day they have eight CNAs, two for each hall, but two of those CNAs are restorative aides who are pulled to the floor because they are so short-staffed and the residents who are supposed to be getting restorative services aren't getting them. She stated there is an increase in falls with injuries. With the staff they have, if an alarm goes off and they are in a room doing something they can't just drop and go, and if the CNAs are in giving incontinent care or assisting a resident to the bathroom that requires a two-person assist they can't leave that resident. She stated, if she can stop what she is doing, she goes when the CNAs can't, and answers lights and handles bed alarms. She stated they have a large number of residents who are high risk for falls. She stated falls are going to happen, but staffing is such a big issue and could be better. More staff would help decrease falls. Interview on 7/17/18 at 6:00 a.m. at Station 1 with LPN MM revealed there is one nurse and two CNA's for both A and B halls and stated this is not uncommon. She stated on rare occasions there is a nurse for both A and B halls. LPN MM also stated that they are trying to put so many baths on nights because there isn't enough staff on day shift to bathe all that need to be bathed and the CNA's are too tired to keep up. There has been ads in the paper that they are hiring but nothing is changing. Interview on 7/17/18 at 6:30 a.m. with LPN PP, D hall nurse at Station 2, revealed that she has been working in the facility for [AGE] years and there has always just been one nurse for each hall and one CNA on each hall. She stated there is not enough staff to take care of the residents. She stated that during the day they have eight CNA's, two for each hall, but two of those CNA's are restorative who are pulled to the floor because they are so short staffed. She stated that there was an increase in falls with injuries. With the staff they have she stated that if an alarm goes off and they are in a room doing something they can't just drop and go, and if the CNA's are in giving incontinent care or assisting a resident to the bathroom that requires a two person assist they can't leave that resident. LPN PP further stated if she can stop what she is doing, she goes when the CNA's can't, and answer call lights, and handles bed alarms. She stated they have a large number of residents who are high risk for fall. LPN PP stated falls are going to happen, but staffing is such a big issue and could be better. Interview on 7/18/18 at 4:10 p.m. with CNA JJ revealed that the unit works short two to three times per week. CNA JJ stated that on those days all the work does not get completed. The CNA further stated that the call lights are not answered quickly but they do the best they can. Interview with on 7/18/18 at 4:30 p.m. with LPN FF revealed the units work short a nurse several times a week. When that happens the staff pull together and do the best they can. Interview on 7/19/18 at 8:10 a.m. with the business office manager (BOM) and the staffing coordinator (SC) who also works as a CNA, revealed that the BOM and SC work together in relation to the nursing staffing. The SC stated that her responsibilities include completing the schedule for the nursing department, both licensed and non-licensed staff. She further stated that she calls most of the staff that are not working two to three times daily trying to get coverage. The SC further stated the facility currently has 4-day shift (7:00 a.m.-3:00 p.m.) licensed positions, 4 evening shift (3:00 p.m.-11:00 p.m.) licensed positions, and 2 night shift (11:00 p.m.-7:00 a.m.) licensed positions. In addition, the facility has 4 certified nursing assistant positions on the 7:00 a.m.-7:00 p.m. shifts and 2 certified nursing assistant positions on the 7:00 p.m.-7:00 a.m. shift. The SC stated that the facility is running ads in the local papers and online programs. Interview on 07/19/18 at 8:37 a.m. with LPN BB regarding facility staffing, she stated she and her daughter, CNA JJ, resigned from the facility last night. She stated the nursing staff was asked by management to sign the attendance log for an in-service on 7/18/18 regarding insufficient staffing. She stated she and other staff didn't want to sign it feeling that signing the attendance log meant the staff agreed with the training directives. She stated the in-service stated, 'if residents' basic needs were met: they had been fed and were clean and dry, the residents' needs have been met and staff may leave the facility at the end of their shift. She stated staff were urged to sign the attendance log because, otherwise, it would cause the facility a lot of trouble. LPN BB stated she accepted the position as wound treatment nurse about a month ago but was assigned to a medication cart on her very first day without any orientation due to insufficient staffing. She was later asked to accept on-call duties as well, meaning she would be obligated to come in to work or stay past her shift for any facility staffing needs. She stated the on-call status was 24 hours per day, Friday night through Sunday at midnight. She stated she stepped down as the wound treatment nurse about ago to work on the floor full time. LPN BB stated on 6/23/18 on the 7:00 a.m. to 7:00 p.m. shift, there was discussion in the morning regarding staff coverage for the next shift between herself and the scheduling coordinator where she was promised a bourns if she worked extra on that day since there was insufficient nursing coverage for the 7:00 p.m. to 7:00 a.m. shift. Interview on 7/19/18 at 8:40 a.m. with the DHS and the Corporate Nurse Consultant NN revealed the nursing department is short by six licensed staff. The DHS is not sure how many unlicensed staff positions are opened. The facility is running ads in local paper, post positions on the Internet. The DHS states that agency or contract labor is not allowed per corporate. The Corporate Health Nurse Consultant NN verified that the corporate office had mandated that no contract or agency staff be utilized. Interview on 7/20/18 at 8:30 a.m. with the Administrator, when ask about staffing he stated that there is to be three CNA's in Restorative, but they get called to the floor. He states he wasn't aware about the staffing issue until he walked in the door and found out through staff that the reason people were leaving was because of the DHS. We've talked about doing a job fair, advertising in the paper, handing out fliers at a local department store. My plan is finding the good staff and maintaining them. The Administrator currently the facility is down seven licensed personnel and eight CNA's. Interview on 7/20/18 at 2:55 p.m. with CNA KK regarding facility staffing, she stated she had been working here about six months and only worked weekends. When asked specifically about facility staffing, she stated they were short-staffed today which made it tough. She stated the CNA's try to work together as a team.

Based on observation, staff interviews, clinical record review, review of the facility's Occurrence Reduction Program revised 11/21/17, the facility failed to be administered in a manner to ensure there was an effective fall prevention program that consistently determined the root cause of falls, adequate supervision to prevent falls and update and implementation of interventions of the care plans after each fall for five residents (R), R#43, R#62, R#3, R#48, R#61. A total of five residents were reviewed for falls with injury, three of whom suffered fractures. The sample size was 23 residents. The facility census was 94 residents, 80 of whom were identified as high risk for falls, scoring 10 or more points on the facility's fall risk assessment tool. On 7/18/18, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or was likely to cause serious injury, harm, impairment or death to its residents. On 7/18/18 at 2:00 p.m., the facility's Administrator, Director of Health Services (DHS), Consultant Nurse NN and the Clinical Competency Coordinator (CCC) were notified of the Immediate Jeopardy (IJ). The noncompliance related to the IJ was identified to have existed on 2/16/18. 1. The IJ was determined to exist as of 2/16/18 when R#43 had a witnessed fall. The resident was noted to have pain, [MEDICAL CONDITION] and bruising to right lower extremity on 2/18/18 and was sent to the emergency room (ER). The resident was found to have a Bimalleolar type fracture to the right ankle with mild subluxation of the right tibia on the talus. The resident had falls without injury on 2/20/18, 3/1/18, 3/16/18 and 4/14/18. The facility failed to determine the root cause of the falls. There was no evidence that the care plan was reviewed or revised after the fall on 2/16/18. Review of the Quarterly Minimum Data (MDS) assessment dated [DATE] revealed that R#43 had a Brief Interview Mental Status (BIM's) score of 8 which indicates moderate cognitive impairment. 2. Review of a Quarterly MDS assessment dated [DATE] revealed that R#62 had a BIM'S score of 9 which indicates moderate cognitive impairment. The resident had 8 falls in the past 6 months on, 4/3/18, 5/4/18, 5/21/18 and 6/25/18 without injury. On 1/12/18 the resident had a fall and was sent to the ER with a laceration to the head and steri-strips were applied. R#62 had a fall on 2/23/18 with a skin tear and a fall on 6/29/18 a fall with arm pain. The resident was sent to the ER with a [DIAGNOSES REDACTED]. R#62's falls were not assessed to determine root cause nor care planned to prevent further falls. 3. Review of a Quarterly MDS assessment dated [DATE] revealed that R#3 had a BIM's score of 99 which indicates severe cognitive impairment, had three falls in the past six months. A fall on 2/26/18 with no injury, a fall on 3/19/18 which caused bruising to right elbow and right forehead and severe pain in the right thigh area and sent to the emergency room (ER). R#3 was found to have a right [MEDICAL CONDITION] and surgical intervention. The resident also had a fall on 6/27/18 without injury. The facility failed to assess the cause of the falls or to put interventions in place to prevent further falls and the care plan was not updated. 4. Review of a Quarterly MDS assessment dated [DATE] revealed that R#48 had a BIM's score of 11 which indicates mild cognitive impairment. The resident had 24 falls in the past six months. On 1/7/18, 1/8/18, 1/10/18, 1/13/18, 1/17/18, 1/20/18, 1/23/18, 1/26/18, 1/30/18, 2/22/18, 3/19/18, 4/1/18, 4/19/18, 4/24/18, 6/4/18 and 6/19/18 without injury. On 3/1/18 the resident had a fall with an abrasion to the back, left side of his head, 3/4/18 the resident fell (twice) sustaining an abrasion to the right hip, a fall on 3/12/18 with an abrasion to the right middle toe, a fall on 3/23/18 with a left little finger laceration, on 3/27/18 the resident fell and sustained a skin tear, a fall on 4/1/18 with a skin tear and a fall on 6/2/18 with an abrasion to the right elbow and left knee. The resident was not assessed for the cause of the falls or assessed for possible interventions to prevent further falls. 5. Review of the Quarterly MDS assessment dated [DATE] revealed that R#61 had a BIM's score of 99, which indicates severe cognitive impairment, had seven falls in the past six months. The resident fell on [DATE] and 7/10/18 without injury. On 4/23/18 the resident had a witnessed fall hitting his right ear on the foot of the bed, on 4/26/18 the resident had a fall with a skin tear to the right forearm, on 6/28/18 the resident fell behind the nurses station and bumped his head on the filing cabinet resulting in a one inch abrasion to the crown of his head, a fall on 6/30/18 resulting in a skin tear, 7/4/18 the resident had a fall resulting in a skin tear. The cause of the R#61's falls were not assessed, there was no evidence that a root cause was determined or interventions developed to prevent future falls the care plan was not updated. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements as follows: CFR 483.21(b)(1) Develop/Implement Comprehensive Care Plans (F 656 Scope and Severity (S/S): J); CFR 483.25(d) Free of Accident Hazards/Supervision/Devices (F 689 S/S: J); CFR 483.5(a) Sufficient Nursing Staff (F 725 S/S: J); CFR 483.70(d) Administration (F 835 S/S: J); CFR 483.75(d) Quality Assurance and Performance Improvement (F 867 S/S: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25(d) Free of Accident Hazards/Supervision/Devices (F 689 S/S: J) At the time of exit on 7/21/18, an Allegation of Compliance (AoC) had not been received, therefore, the IJ remains ongoing. Findings include: Review of the facility's document titled Job Title: Administrator job description with a created date of 9/2008 and modified date of 12/2016 revealed : Job Description: Directs the day-to-day functions of the Nursing Center in accordance with current federal, state, and local regulations that govern long-term care centers, and as may be directed by the Area Vice President, to provide appropriate care for our patients/residents. Knowledge , Skills , Abilities include: Able to foster interdisciplinary cooperation and coordination of quality assurance and quality improvements efforts. Review of the facility's Occurrence Reduction Program, revised 11/21/17 revealed the following: This healthcare center recognizes that due to the frailty of the patient/residents served, there is an increased risk of occurrences that may result in injury to the patient/resident and/or others. In an effort to prevent occurrences, each patient/resident will be assessed for risk and appropriate and realistic interventions will be implemented upon identification of risk and after a fall. These interventions will be included in the care plan. The Administrator will designate an appropriate staff person as the Occurrence Reduction Coordinator: to be responsible for the following duties (a designee will be appointed to provide backup for the following duties in the absence of the Occurrence Reduction Coordinator): 1. Providing staff education on occurrence policies, occurrence trends and patterns and specific Occurrence Reduction Program patient/resident interventions. 2. Reviewing occurrence reports daily for the previous 24 hours and forwarding them to the DHS upon completion of the review. 3. Reporting all occurrences of unknown origin to the Administrator or designee immediately. Participating on the entity's Performance Improvement Committee, providing the committee with monthly occurrence trend reports that include but are not limited to: trends of patients/residents, times of day occurrences occur, equipment involved, staff involved, environmental issues, etc. The Occurrence Report Coordinator or designee will be responsible for initiating the development and implementation of any Performance Improvement Action Plans on occurrence trends. 4. Assessing all patients/residents that fall for placement in the restorative program. Occurrence Program Documentation Requirements: -Occurrence Reports and investigations will be completed electronically and will be maintained in the occurrence policy. - Occurrence Reduction Program interventions for each patient/resident will be documented and maintained on the patient/resident's nurse notes, care plan and ADL (activities of daily living) Care Intervention Record. -Occurrence Reduction Committee Weekly Meeting Minutes will be maintained in the patient/resident's nurses notes and maintained by the Occurrence Reduction Coordinator. During an interview on 7/20/18 at 8:30 a.m. with the Administrator in his office regarding the number and severity of falls in the facility, he stated he had only been at this facility for four weeks. He stated falls are a concern everywhere and are discussed every day in their morning meetings. He stated that he should have paid more attention to falls and was not really aware of the seriousness. When asked if he was aware of the incident with R#61 on or around 6/22/18 when this resident was found on the floor, he stated he was aware and it was discussed in the first morning meeting following the incident. He stated they discussed what they could do to keep R#61 safe. He stated he discussed with another facility about placing him there because they have a locked unit. He stated he's waiting to discuss it with R#61's daughter until he was sure the facility could take him. When asked how he gets his information regarding resident behaviors/incidents which are clearly significant enough to be included on the resident's care plan, he stated that the morning meeting is where he gets his information. He also stated that QA was not made aware of the issues of wandering and falls with R#61. He stated the only thing mentioned in QAPI about falls was on 6/21/18 and it was only concerning the number of falls in the facility. He stated Dietary services has been their main focus. When asked if the QA Committee had developed a corrective action plan for falls in the facility, he stated no plan was ever put in place. When asked about staffing he stated there are supposed to be three Certified Nursing Assistants (CNAs) in Restorative Therapy but they get called to work the floor. He stated he wasn't aware about the staffing issue until he walked in the door and found out through the existing staff that the reason people were leaving was because of the DHS. He stated, we've talked about doing a job fair, advertising in the paper and handing out fliers at a local department store. My plan is finding good staff and maintaining them. He stated currently the facility has open positions for seven licensed personnel and eight Certified Nursing Assistants (CNAs). Observations, clinical records review and staff interviews revealed the facility was not in substantial compliance during the standard/extended survey of 7/16/18 through 7/21/18. Refer to the following deficiencies for specific details of the noncompliance: Cross reference to F656 The facility failed to provide evidence that they consistently revised the care plan with interdisciplinary input after each fall with a new intervention and/or with appropriate intervention to prevent further falls for five residents: R#43, R#62, R#3, R#48, R#61. Cross reference to F689 The facility failed to provide supervision to prevent accidents; failed to provide evidence that falls were consistently discussed in skilled services or interdisciplinary meetings per facility policy so the root cause of each fall could be determined and failed to provide evidence of what interventions were in place at the time of each fall so the effectiveness of current interventions to prevent falls could be assessed for five residents: R#43, R#62, R#3, R#48, R#61. Cross reference to F725 The facility failed to have sufficient staff to provide supervision to prevent falls and accidents for five residents (R): R#43, R#62, R#3, R#48, R#61. A total of five residents were reviewed for falls with injuries and the sample size was 23 residents. Review of the facility Resident Census and Condition of Residents Form CMS-672 dated 7/9/18 revealed that the current facility census was 94 residents. Cross reference to F867 The facility failed to maintain a Quality Assessment and Assurance (QAA) committee that identified, developed, implemented and analyzed the effectiveness of corrective action plans for residents that sustained falls with injuries for five residents: R#43, R#62, R#3, R#48 and R#61.

Based on observation, clinical record review of the facility's Quality Assurance-Performance Improvement (QAPI) and interviews with staff it was determined that the facility failed to ensure the Quality Assurance program effectively identified, developed, implemented and monitored corrective action plans for five residents (R), (R#48, R#43, R#62, R#3 R#61) that sustained multiple falls and some with major injury. A total of four residents were reviewed with fractures and one resident, R#48, who had multiple falls. Review of the facility Resident Census and Condition Forms CMS-672 revealed that the current facility census was 94 residents. 80 residents were identified by the facility being at high risk for falls. On 7/18/18, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 7/18/18 at 2:00 p.m. The facility Administrator, Director of Health Service (DHS) Consultant Nurse NN, and the Clinical Competency Coordinator were informed of the Immediate Jeopardy (IJ). The noncompliance related to the immediate jeopardy was identified to have existed on 2/16/18. 1. The IJ was determined to exist as of 2/16/18 when #43 had a witnessed fall. The resident was noted to have pain, [MEDICAL CONDITION] and bruising to right lower extremity on 2/18/18 and was sent to the emergency room (ER). The resident was found to have a Bimalleolar type fracture to the right ankle with mild subluxation of the right tibia on the talus. The resident had falls without injury on 2/20/18, 3/1/18, 3/6/18 and 4/14/18. The facility failed to determine the root cause of the falls or put into place to prevent further falls after the fall on 2/16/18 nor was the care plan updated. Review of the Quarterly Minimum Data (MDS) assessment dated [DATE] revealed that R#43 had a Brief Interview Mental Status (BIM's) score of 8 which indicates moderate cognitive impairment. 2. Review of a Quarterly MDS assessment dated [DATE] revealed that R#62 had a BIM's score of 9 which indicates moderate cognitive impairment. The resident had 8 falls in the past 6 months on, 4/3/18, 5/4/18, 5/21/18 and 6/25/18 without injury. On 1/12/18 the resident had a fall, and was sent to the ER with a laceration to the head and steri-strips were applied, 2/23/18 a fall with a skin tear, 6/29/18 a fall with arm pain the resident was sent to the ER with a [DIAGNOSES REDACTED]. R#62's falls were not assessed to determine root cause nor care planned to prevent further falls. 3. Review of a Quarterly MDS assessment dated [DATE] revealed that R#3 had a BIM's score of 99 which indicates severe cognitive impairment, had three falls in the past six months. A fall on 2/26/18, a fall on 3/19/18 causing bruising to right elbow and right forehead and severe pain in the right thigh area and sent to the ER. R#3 was found to have a right [MEDICAL CONDITION] and surgical intervention, and a fall on 6/27/18 without injury. The facility failed to assess the cause of the falls or to put interventions in place to prevent further falls and the care plan was not updated. 4. Review of a Quarterly MDS assessment dated [DATE] revealed that R#48 had a BIM's score of 11 which indicates mild cognitive impairment, had 24 falls in the past six months. On 1/7/18, 1/8/18, 1/10/18, 1/13/18, 1/17/18, 1/20/18, 1/23/18, 1/26/18, 1/30/18, 2/22/18, 3/19/18, 4/1/18 (fell twice), 4/19/18, 4/24/18, 6/4/18 and 6/19/18 without injury. On 3/1/18 the resident had a fall with an abrasion to the back, left side of his head, 3/4/18 a fall with an abrasion to the right hip, 3/12/18 with an abrasion to the right middle toe, 3/23/18 with a left little finger laceration, on 3/27/18 a fall which resulted in a skin tear, on 4/1/18 a fall with a skin tear and 6/2/18 with an abrasion to the right elbow and left knee. The resident was not assessed for the cause of the falls or assessed possible interventions to prevent further falls. 5. Review of the Quarterly MDS assessment dated [DATE] revealed that R#61 had a BIM's score of 99, which indicates severe cognitive impairment, had seven falls in the past six months. The resident fell on [DATE] and 7/10/18 without injury. On 4/23/18 the resident had a witnessed fall hitting his right ear on the foot of the bed, on 4/26/18 the resident had a fall with a skin tear to the right forearm, on 6/28/18 the resident fell behind the nurses station and bumped his head on the filing cabinet resulting in a one inch abrasion to the crown of his head, a fall on 6/30/18 resulting in a skin tear, 7/4/18 the resident had a fall resulting in a skin tear. The cause of the R#61's falls were not assessed, there was no evidence that a root cause was determined or interventions developed to prevent future falls the care plan was not updated. The Immediate Jeopardy was related to the facilities non-compliance with the program requirements as follows: CFR 483.21(b)(1) Develop/Implement Comprehensive Care Plans (F 656 Scope and Severity (S/S): J); CFR 483.25(d) Free of Accident Hazards/Supervision/Devices (F 689 S/S: J); CFR 483.5(a) Sufficient Nursing Staff (F 725 S/S: J); CFR 483.70(d) Administration (F 835 S/S: J); CFR 483.75(d) Quality Assurance and Performance Improvement (F 867 S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25(d) Quality of Care (F 689 S/S): J). At the time of exit on 7/21/18, an Allegation of Compliance (AoC) had not been received, therefore the IJ remains on going. Findings Include: Review of the facility's Occurrence Reduction Program/Policy: with a revision date of 11/21/17 revealed: Policy Statement: This healthcare center recognizes that due to the frailty of the patients/residents served, there is an increased risk of occurrences that may result in injury to the patient/resident and/or others. In an effort to prevent occurrences, each patient/resident will be assessed for risk and appropriate and realistic interventions will be implemented upon identification of risk and after a fall. These interventions will be included in the care plan. Review of a form titled Draft, Quality Assurance-Performance Improvement (QAPI) policy with (no effective date) revealed the following: The purpose of QAPI at (facility name) is to continually take a proactive approach to assure and improve the way we provide care and engage with our patient, partners, and other stakeholders so that we may fully realize our vision, mission and commitment to caring pledge. Guiding Principles: (Facility name) mission, vision, and core values, creates the foundation for organizational QAPI performance. (Facility name) uses quality assurance and performance in improvement to make decisions and guide our day-to-day operation. (In establishing the system, we remain cognizant that QAPI is not a program; rather, it is the way we do our work.) (Facility name) QAPI includes all departments and all services. QAPI is comprehensive regarding systems of care, management practices, and business practices. (Facility name) QAPI is data-driven and is guided by our five performance improvement pillars: People, Service, Quality, Finance, and Growth and the respective business drivers in each performance improvement pillar. (Facility name) QAPI decisions are based on data, which is collected in a systematic format in alignment with our infrastructure and aggregated on the company-Health Connect Dashboard.(Facility name) sets annual goals for performance and measures progress toward these goals. (Facility name) supports QAPI through the concept of team management and encouraging our partners to support each other and be account able for their professional performance and practice. (Facility name) focuses on systems and processes, rather than individuals. The emphasis is on identifying system gaps and correcting them rather than on blaming individuals. (Facility name) sets high expectations for ethical practice through the Code of Conduct and rigorous compliance program. Direction of QAPI Activities: It is the expectation of the Governing Body that the center will follow the established QAPI process in order to guide and direct the operations of that location. The executive leadership of (facility name) sets the expectation and provides the resources for implementation. The center's QA&A committee (QAPI Committee) has overall responsibility to develop and modify their respective QAPI plan, review data, and set priorities for performance improvement projects (PIPs). The Governing Body is responsible for: 1. Incorporating resident and staff input that reflects organizational processes, functions, and services provided to residents. 2. Ensuring that corrective actions address gaps in the system and are evaluated for effectiveness. 3. Setting clear expectations for safety, quality, rights, choice, and respect. 4. Ensuring adequate resources exist to conduct QAPI efforts The QA&A Committee will have multidisciplinary representation but at a minimum must include the Medical Director, Administrator, Director of Health Services, the partner monitoring Infection Control and Prevention, a Care Ambassador, and a Committed to Caring Council Representative. Performance Improvement Projects (PIPs): PIPs will be a concentrated effort on a particular problem in one area of the nursing center or on a facility-wide basis. They will involve gathering information systematically to clarify issues or problems and intervening for improvements. The nursing center will conduct PIPS to examine and improve care or services in areas that the nursing center identifies as needing attention. Once opportunities are prioritized, focus areas are selected for the quarter. The QA&A Committee will appoint a subcommittee to develop a Performance Improvement Project Plan for each identified focus area. This includes development of Performance Improvement Project charter or scope of work, conducting root cause analysis, developing the performance improvement plan and monitoring the plan for success. PIP Determination Process: Areas for improvement are identified by routinely and systematically assessing quality of care and service, and include high risk, high volume, and problem prone areas. The center reviews a consistent list of metrics routinely and considers the incidence, prevalence, and severity of problems, especially those that affect health outcomes, resident safety, autonomy, choice, quality of life, and care coordination. The QA&A Committee is responsible for assisting in the identification of opportunities for improvement and are subject to selection for participation in subcommittees for PIPs. When a performance improvement opportunity is selected, the QA&A Committee will initiate the process to charter a subcommittee/team. Team members will be identified by the QA&A Committee or designated project manager, and with relationship to their skills, service provision job function, and/or area of expertise to address the performance improvement topic. A designated subcommittee leader/facilitator is selected. The PIP subcommittee is provided a problem statement, so the team working it has a clear understanding of what they are being asked to accomplish. Developing the problem statement and scope of work indicates that the team has a specific mission and that the team will report back to the steering committee at defined intervals. The scope of work/charter includes: - Designation of team/project leader and team members. - Designated facilitator/leader - prefer someone with authority, knowledge of the issue and ability to build consensus. - A description of the project and brief background. - Project/PIP timeline. The PIP subcommittee has a designated project leader who will manage the day to day operations of the PIP and will report directly to the QA&A committee. The QA&A Committee has direct responsibility for oversight of each PIP subcommittee to ensure adequate progress is being made in the time frame provided. PIPs will be documented in the system. The documentation will include the overall goals for the project and will identify team members, define appropriate measures, root cause analysis findings, interventions, meeting minutes, target dates, and overall conclusions. Systematic Analysis and Systemic Action: (Facility name) uses a systematic approach to determine when in-depth analysis is needed for identifying contributing causal factors that underlie variations in performance. This structured method of analysis is designed to get to the underlying cause of a problem - which then leads to identification of effective interventions to make improvements. It is the goal of the organization to use the many and various sources of data to do early and ongoing review to proactively identify incremental change in expected outcomes. The goal of early intervention balanced against targeted goals and outcomes, ensures consistent delivery in care and business outcome. Unexpected/unanticipated process failures or outcomes are evaluated to determine the root cause (RCA). RCA is a process for identifying the factors that cause variation in performance, in order to identify and implement the most effective solution. This process requires an in-depth look at processes and systems to determine: - What happened? - Why did it happen? - What can be done to prevent it from happening again? We conduct a systematic analysis to ensure we are not trying to identify a sole root cause. Often there is a relationship between multiple causes and focusing on a single cause limits finding a solution to correct all causes of an issue. In order to get to the root cause(s), first we have to determine and list all the contributing factors. Once the contributing factors are all identified, then it is necessary for the team to determine if they are causing factors (root cause(s)). In order to do this, we utilize the Five-Why's Method, which asks WHY each factor happened. The answer becomes the next effect to determine the cause and ask why, until there is nothing further to ask about. This is necessary and recommended to discover the true root cause(s). Using the root cause(s) will determine procedures needed or systemic changes necessary to ensure that improvement is achieved. Identifying a Working QAPI Plan: On an annual basis, or as needed. The QAPI Self-Assessment will be conducted. This will be completed in the input from the entire QAPI team and organizational leadership. The result of this assessment will direct us to areas we need to work on in order to establish and improve QAPI programs and processes in our organization. The system provides an electronic platform for documenting QAPI Self Assessments and tracking changes in the QAPI Self-Assessment results over time. Review of the Incident Log for January, February, March, April, May, and (MONTH) of (YEAR) revealed 146 total falls, 4 falls with major injury - fractures, numerous falls with injury skin tears and abrasions, and one resident with a total of 24 falls over the 6 months period. For every fall in this 6-month period, there is no evidence that QAPI implemented the Occurrence Reduction Program, as stated in their policy to be in place for any of the falls. The facility failed to assess the cause of the falls and failed to put interventions in place to prevent further falls. The facility also failed to update the care plan with new interventions. During an interview with the Director of Health Services (DHS) on 7/18/18 at 11:00 a.m., when ask about the Occurrence Reduction Program Meeting that is mentioned in their fall policy, she stated that there has been no Occurrence Reduction Program Meeting because she hasn't had a chance to do it. When asked how they were following and managing falls she stated they do an assessment when the resident is admitted , when they go out to the hospital, and when they return from a hospital stay they do a whole new admission which includes the fall assessment. When asked if the problem with falls, falls with injuries, and falls with major injuries were in QAPI she stated she put falls in QAPI a month ago. DHS further stated she had two Unit Managers that quit a little over two months ago and it was their responsibility to be making sure the policy was followed and all the paperwork related to the policy was done and when they left she discovered they weren't doing it and stated I have been trying a plan of correction but I have gotten no help. During an interview on 7/20/18 at 8:30 a.m. with the Administrator, in his office, revealed that he has only been the Administrator in the facility for four weeks. He stated falls are a concern everywhere but falls in his facility are discussed every day in their morning meetings and he now realizes he should have dug into falls more. He stated a flag didn't pop up, and he should have paid more attention to falls. He further stated he wasn't aware of the seriousness of falls in the facility. When asked how he, the Administrator, gets information regarding resident behaviors/incidents which are clearly significant enough to be included on the resident's care plan, he stated that the morning meeting is when he gets information. He also stated that QAPI was not made aware of the seriousness of the issue regarding falls. Review of the QAPI book with the Administrator revealed falls were only discussed on 6/21/18. When asked if the QA Committee had ever developed a corrective action plan for falls in the facility he stated, no development of corrective action was ever put in place for falls. Observations, clinical records review, and staff interviews revealed the facility was not in substantial compliance during the standard/extended survey of 7/16/18 through 6/21/18. Refer to the following deficiencies for specific details of the noncompliance: Cross reference to F656 The facility failed to provide evidence that they consistently revised the care plan with interdisciplinary input after each fall with a new intervention and/or with an appropriate intervention to prevent further falls for five residents (R) (R#43 R#62, R#3, R#48, R#61). Cross reference to F689 The facility failed to provide supervision to prevent accidents; failed to put their fall policy, Occurrence Reduction Program in place so that an effort was made to decrease the risk of occurrences that may result in injury to the resident; and failed to provide evidence of what interventions were in place at the time of each fall so that the effectiveness of current interventions to prevent falls could be reassessed for five residents (R#43 R#62, R#3, R#48, R#61). Cross reference to F725 The facility failed to have sufficient staff to provide supervision to prevent falls for five residents with multiple falls (R#43 R#62, R#3, R#48, R#61). Cross reference to F835 The facility failed to be administered in a manner to ensure there was an effective falls program that consistently determined the root cause of falls and provided adequate supervision to prevent falls for five residents (R#43 R#62, R#3, R#48, R#61). Cross reference to F 837 The facility's Governing Body failed to ensure that there was an effective falls program including consistently determining the root cause of falls and ensure the Quality Assurance (QA) program was effective in developing, implementing, and analyzing falls data to address falls for five residents (R#43 R#62, R#3, R#48, R#61).

Based on observation, record review and staff interview, it was determined that the facility failed to ensure that residents at risk for fractures during transfers had interventions that were implemented correctly and consistently for one (1) resident #1 of three (3) sampled residents. This failure resulted in harm to one (1) resident #1, as evidenced by the resident being hospitalized with a fractured leg following a transfer. Findings include: During orientation tour on 12/16/09 at 9:20 a.m., it was observed that outside each resident's room door, a color coded sticker with letters had been applied to each resident's name plate. In an interview with the Administrator at that time, she indicated that these letters identified which type of transfer was required to be used by staff. The letter "T" appeared on the sticker on the name plate for resident #1. The Administrator stated that this directed staff to use a total mechanical lift when transferring this resident. Review of the clinical record for resident #1 revealed the resident had a history of [REDACTED]. Review of the resident's Minimum Data Set (MDS) dated 11/05/09 revealed that the resident was assessed as having the need for two (2) staff members to perform a safe transfer. Review of the facility's Lift/Transfer Program Patient Lift Roster revealed that resident #1 required two (2) staff and the use of the total mechanical lift for transfers. Further record review revealed that on 12/07/09 at approximately 7:30 p.m. Certified Nurse Assistant (CNA) "BB" had transferred the resident (who required a mechanical lift) from a shower chair to a bed without using the mechanical lift and without the assistance of another staff person. During the transfer the resident complained of severe pain in the lower left leg. Further review of the clinical record revealed a Nurses Note dated 12/08/09 at 4:00 a.m. indicating that resident #1 complained of severe pain in the left leg. At that time a ten centimeter (10 cm) bruise was also noted on that leg. An x-ray was obtained and the report dated 12/08/09 indicated that the left tibia-fibula demonstrated an ACUTE oblique displaced fracture of the leg. The resident was transferred to the local emergency room . Review of the facility's Supervisory Investigation Report indicated that the CNA did not follow proper procedure when transferring this resident.