Every finding on record at Robert Lee Care Center

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #31) reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan that addressed Resident #31's behaviors. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs.Findings included: Record review of Resident #31's face sheet dated 12/31/25, revealed admission on [DATE] to the facility. Diagnoses included dementia with psychotic disturbance, delusions, hallucinations, and depression. Record review of Resident #31's quarterly MDS dated [DATE], revealed a BIMS score of 2 indicating severe cognitive impairment and disorganized thinking was also coded in this section. Mood was not coded. Behaviors section E - Rejection of care and wandering were both coded as a 1 which indicated these behaviors occurred 1 to 3 days during this look back period. Record review of Resident #31's Care Plan dated 4/16/2025, revealed there was no focus, goal, or intervention section for Resident #31's history of wandering or rejection of care. During an interview on 12/31/25 at 1:45 PM, with the DON she stated these behaviors should have been care planned because it was part of the resident's behavior and needed to be documented. The DON stated the MDS department was responsible for ensuring that it was care planned. The DON stated the purpose of the care plan was to provide the care for the resident and for everyone to know what the resident needed. The DON stated that it was necessary for the care of the resident. During an interview on 12/31/25 at 2:29 PM, with the MDS coordinator, she stated it was the responsibility of the MDS department to ensure the care plans were correct. The MDS coordinator stated there was no wandering or rejection of care, care planned for Resident #31. The MDS coordinator stated it should have been care planned for Resident #31's wandering to be able to keep an eye on her. The MDS coordinator stated the purpose of the care plan was to notify the staff of Resident #31's behaviors. The MDS coordinator stated the risk could be needs not being met. Record review of the facility Care Planning policy dated 03/2022, revealed 1. The IDT in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.7. The comprehensive person-centered care plan:b. Describes the services that are to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #3) reviewed for transfers in that: NA A and CNA B failed to safely transfer Resident #3 with a gait belt. CNA C and CNA D failed to demonstrate the skills to safely transfer the DON. These failures could place residents at risk for injuries due to not receiving the appropriate level of assistance to prevent accidents.Findings included: Review of Resident #3's admission Record, dated 12/30/25 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease (a neurological disorder causing movement and cognitive impairment), muscle weakness, and unsteadiness on feet. Resident #3 was on hospice. Review of Resident #3's admission MDS Assessment, dated 11/25/25, revealed:Resident #3 had a BIMS score of 3 of 15 (indicating severe cognitive impairment). He showed signs of delirium including inattention and disorganized thinking that fluctuated.Resident #3 had upper and lower range of motion impairment on both sides.Resident #3 used a wheelchair.Resident #3 needed substantial to maximum assistance with transfers. Review of Resident #3's Care Plan revealed:Initiated 11/28/25: Focus: Resident had an ADL self-care performance deficit related to activity intolerance, and Parkinson's Disease. Goal: Declines will be addressed promptly. Identified interventions included: Transfer with one assist. Initiated 11/28/25 Focus: The resident has Parkinson's. Goal: Discomfort or complications related to Parkinson's disease through review date will be addressed promptly. Identified interventions included: encourage daily exercise, mobility as tolerated. Observation on 12/30/2025 at 10:42 AM revealed Resident #3 was in the recliner, CNA B put a gait belt on Resident #3. NA A and CNA B locked the wheelchair and helped Resident #3 slide forward to the edge of the recliner. NA A held the gait belt in the back and slid her arm under Resident #3's arm. CNA B held the front of the gait belt and held Resident #3's pants by the waistband. The aides assisted Resident #3 in standing and pivoting to the wheelchair. Interview on 12/30/2025 at 11:14 AM NA A stated she was a new aide and received training on transfers prior to working the floor. NA A stated she was trained to make sure the gait belt was on, the wheels were locked, the resident had non-slip footwear on, and make sure the resident's knees touched the sitting surface prior to the resident sitting down. NA A said she thought the transfer went pretty well and they completed the transfer how they were shown. NA A said she might be wrong in putting her arm under Resident #3's arm. NA A said she thought being lifted by the arm felt tight and pressured and was not comfortable. Interview on 12/30/2025 at 11:43 AM CNA B said she worked at the facility for 4 years. CNA B said she received training in how to do a two-person gait-belt transfer. CNA B stated she was trained to have each aide stand on either side of the resident, put on the gait belt, make sure the resident was ready, that the resident had a good foot surface, then help them stand, pivot and sit down. CNA B said she was trained that an arm went under the resident's arm when assisting the resident to stand. CNA B stated she thought she did that and was confident in how she did. CNA B said pulling up a resident by the seat of the pants could cause a skin tear and could be uncomfortable. Interview on 12/31/2025 at 9:50 AM the PTA E stated she was at the facility for over two years. PTA E stated Resident #3 was receiving therapy services and they worked on standing and safety awareness. PTA E stated the level of assistance Resident #3 needed fluctuated from a one person to a two-person transfer. PTA E stated for two-person assistance, the staff needed to put a gait belt on, one staff stand in front of the resident while the other stood behind guiding the resident to the wheelchair. PTA E stated hooking under a resident's arm was not supposed to be done during transfers. PTA E said she was not sure about the consequences, but it could hurt the shoulder. PTA E stated she did see the aides transfer by hooking under the arms. PTA E said she did not usually transfer residents by the waistband of their pants. Interview on 12/31/2025 at 10:02 AM the PT stated a safe two-person gait-belt transfer looked like someone in front of the resident and someone behind the resident controlling the transfer from the resident's hips. The PT stated the therapy department did not do specific training with the aides on how to do a transfer, but they did talk to the aides constantly about what kind of transfer a resident needed. The PT said aides did not want to lift residents by the shoulders because the aides needed more control and it was not safe. The PT said aides needed to be careful with the arms because it could pull or dislocate the arm. The PT said using the gait belt in front and grabbing the waistband was not the safest and did not give enough control. Interview on 12/31/2025 at 10:21 AM the DON stated the facility did train aides to complete a two person gait belt transfer. The DON stated they trained the staff to have one staff in front and one staff behind to assist with the stand and pivot maneuver. Observation on 12/31/2025 at 10:27 AM CNA C and CNA D demonstrated a two-person gait-belt transfer on the DON. The CNAs placed the gait belt around DON's waist. Each held the gait-belt in the back and assisted the DON to stand by holding the DON's forearm. The CNAs completed the sitting transfers also by holding the DON's forearm. Interview on 12/31/2025 at 10:29 AM the DON stated the ADON did train the aides to complete the transfer that way. The DON said the ADON was out of town on vacation and unable to be reached. The DON said aides were instructed not to pull or tug on the residents' arms. The DON said hooking an arm under the resident's arm was uncomfortable could cause skin tears and bruising and it was not a safe transfer. The DON stated grabbing a resident by the waistband could cause a wedgie and was not comfortable. The DON said the consequence of holding a resident under the arm could cause injury like skin tears or bruising. The DON said the facility did a skills fair training where they checked aides off on two-person gait-belt transfers. The DON said the purpose of the gait belt was to slow down a fall. The DON said transfers were not continuously monitored. The DON said the ADON and charge nurses were responsible for keeping an eye on transfers. Review of the facility's policy and procedure on Safe Lifting and Movement of Residents, revised 7/2017, revealed: In order to protect the safety and wellbeing of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents.Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Review of the Training Inservice Summary for Skills Fair, completed 5/27/25, revealed the facility in-serviced staff for annual compliance and competency training. CNAs were trained in mechanical lifting and incontinent care. Methodology included lectures, handouts, and demonstration with a hands on skills training.

Based on observation, interview and record review, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 1 (Resident #3) of 4 residents reviewed for competent nursing staff, in that: NA A and CNA B failed to safely transfer Resident #3 with a gait belt. CNA C and CNA D failed to demonstrate the skills to safely transfer the DON using a gait belt. These failures could place residents at risk for injuries due to not receiving the appropriate level of assistance to prevent accidents.Findings included: Review of Resident #3's admission Record, dated 12/30/25 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease (a neurological disorder causing movement and cognitive impairment), muscle weakness, and unsteadiness on feet. Resident #3 was on hospice. Review of Resident #3's admission MDS Assessment, dated 11/25/25, revealed:Resident #3 had a BIMS score of 3 of 15 (indicating severe cognitive impairment). He showed signs of delirium including inattention and disorganized thinking that fluctuated.Resident #3 had upper and lower range of motion impairment on both sides.Resident #3 used a wheelchair.Resident #3 needed substantial to maximum assistance with transfers. Review of Resident #3's Care Plan revealed:Initiated 11/28/25: Focus: Resident had an ADL self-care performance deficit related to activity intolerance, and Parkinson's Disease. Goal: Declines will be addressed promptly. Identified interventions included: Transfer with one assist. Initiated 11/28/25 Focus: The resident has Parkinson's. Goal: Discomfort or complications related to Parkinson's disease through review date will be addressed promptly. Identified interventions included: encourage daily exercise, mobility as tolerated. Observation on 12/30/2025 at 10:42 AM revealed Resident #3 was in the recliner, CNA B put a gait belt on Resident #3. NA A and CNA B locked the wheelchair and helped Resident #3 slide forward to the edge of the recliner. NA A held the gait belt in the back and slid her arm under Resident #3's arm. CNA B held the front of the gait belt and held Resident #3's pants by the waistband. The aides assisted Resident #3 in standing and pivoting to the wheelchair. Interview on 12/30/2025 at 11:14 AM NA A stated she was a new aide and received training on transfers prior to working the floor. NA A stated she was trained to make sure the gait belt was on, the wheels were locked, the resident had non-slip footwear on, and make sure the resident's knees touched the sitting surface prior to the resident sitting down. NA A said she thought the transfer went pretty well and they completed the transfer how they were shown. NA A said she might be wrong in putting her arm under Resident #3's arm. NA A said she thought being lifted by the arm felt tight and pressured and was not comfortable. Interview on 12/30/2025 at 11:43 AM CNA B said she worked at the facility for 4 years. CNA B said she received training in how to do a two-person gait-belt transfer. CNA B stated she was trained to have each aide stand on either side of the resident, put on the gait belt, make sure the resident was ready, that the resident had a good foot surface, then help them stand, pivot and sit down. CNA B said she was trained that an arm went under the resident's arm when assisting the resident to stand. CNA B stated she thought she did that and was confident in how she did. CNA B said pulling up a resident by the seat of the pants could cause a skin tear and could be uncomfortable. Interview on 12/31/2025 at 9:50 AM the PTA E stated she was at the facility for over two years. PTA E stated Resident #3 was receiving therapy services and they worked on standing and safety awareness. PTA E stated the level of assistance Resident #3 needed fluctuated from a one person to a two-person transfer. PTA E stated for two-person assistance, the staff needed to put a gait belt on, one staff stand in front of the resident while the other stood behind guiding the resident to the wheelchair. PTA E stated hooking under a resident's arm was not supposed to be done during transfers. PTA E said she was not sure about the consequences, but it could hurt the shoulder. PTA E stated she did see the aides transfer by hooking under the arms. PTA E said she did not usually transfer residents by the waistband of their pants. Interview on 12/31/2025 at 10:02 AM the PT stated a safe two-person gait-belt transfer looked like someone in front of the resident and someone behind the resident controlling the transfer from the resident's hips. The PT stated the therapy department did not do specific training with the aides on how to do a transfer, but they did talk to the aides constantly about what kind of transfer a resident needed. The PT said aides did not want to lift residents by the shoulders because the aides needed more control and it was not safe. The PT said aides needed to be careful with the arms because it could pull or dislocate the arm. The PT said using the gait belt in front and grabbing the waistband was not the safest and did not give enough control. Interview on 12/31/2025 at 10:21 AM the DON stated the facility did train aides to complete a two person gait belt transfer. The DON stated they trained the staff to have one staff in front and one staff behind to assist with the stand and pivot maneuver. Observation on 12/31/2025 at 10:27 AM CNA C and CNA D demonstrated a two-person gait-belt transfer on the DON. The CNAs placed the gait belt around DON's waist. Each held the gait-belt in the back and assisted the DON to stand by holding the DON's forearm. The CNAs completed the sitting transfers also by holding the DON's forearm. Interview on 12/31/2025 at 10:29 AM the DON stated the ADON did train the aides to complete the transfer that way. The DON said the ADON was out of town on vacation and unable to be reached. The DON said aides were instructed not to pull or tug on the residents' arms. The DON said hooking an arm under the resident's arm was uncomfortable could cause skin tears and bruising and it was not a safe transfer. The DON stated grabbing a resident by the waistband could cause a wedgie and was not comfortable. The DON said the consequence of holding a resident under the arm could cause injury like skin tears or bruising. The DON said the facility did a skills fair training where they checked aides off on two-person gait-belt transfers. The DON said the purpose of the gait belt was to slow down a fall. The DON said transfers were not continuously monitored. The DON said the ADON and charge nurses were responsible for keeping an eye on transfers. Review of the facility's policy and procedure on Safe Lifting and Movement of Residents, revised 7/2017, revealed: In order to protect the safety and wellbeing of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents.Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Review of the Training Inservice Summary for Skills Fair, completed 5/27/25, revealed the facility in-serviced staff for annual compliance and competency training. CNAs were trained in mechanical lifting and incontinent care. Methodology included lectures, handouts, and demonstration with a hands on skills training.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's one of one kitchen. The facility failed to ensure: Food debris was not on the floor in the freezer. Staff did not transport dishes by holding them against their body. Staff completed hand hygiene appropriately. Dishes were stored in a manner to prevent contamination. Prevention of contamination of salad bar containers by staff handling practices. Frozen meat was stored in a manner to prevent contamination in the event of thawing. These failures could affect residents who received meals prepared from the kitchen at risk for food borne illness and cross contamination. Findings included: Observation on 9/24/24 between 9:18 a.m. and 9:36 a.m. revealed: Bowls stored against the long wall of the kitchen were stored face up. The outside walk-in refrigerator had a bucket of pickles on the ground. The walk-in freezer had meat stored over vegetables and bread. The dry storage had individual serving of jelly and packets of sugar on the floor under the shelves. The inside of the walk-in refrigerator had a brisket thawing over pickles, eggs and bacon. During the noon meal preparation on 9/25/24 beginning at 9:50 a.m. and 11:35 a.m. revealed: Cook B was observed washing her hands turning off the faucet with her bare hands three times. DA D had a stack of dishes she was putting up from the clean dish area. DA D had the plates stacked directly against her body as she brought them to the storage area. DA C had containers for the salad bar that she carried from the clean dish area to the food preparation area with her bare hands and her fingers in each container touching the food surface. DA D returned from outside of the kitchen, did not wash her hands, did don gloves and continued with food preparation. In an interview on 9/26/24 at 2:03 p.m. the Dietary Manager said the staff knew to have dishes face down, she clarified which bowls were face up and stated those were the bowls used for the salad bowls. The Dietary Manager said the pickle bucket was the only thing that would be on the floor in the refrigerator, but everything needed to be at least six inches off the floor due to contamination. The Dietary Manager said staff needed to wash their hands when they returned in from the kitchen due to cross contamination issues. The Dietary Manager asked for clarification on the salad bar container food surface being touched all at once, she said she had previously had numerous conversations with that staff member about that and that putting clean dishes against dirty scrubs just contaminated the dishes. The Dietary Manager said it did not matter what kind of container the meat was being thawed in it still could not be thawed over other food. In an interview on 9/26/24 at 2:22 p.m. the Administrator was informed of the kitchen observations, he stated they were pretty straight forward, and they would monitor it. Review of the Cleaning Schedule revealed the cook was responsible for cleaning the refrigerator and freezer and the outside coolers were last documented as completed on 9/24/24. Review of the 5/24/24 in-service on Maintaining a Clean Kitchen revealed: food items are not stored on the floor. Example of Monthly list: clean under and behind equipment Review of the Dietary In-service dated 1/25/24 revealed: Dry storage - what items, how far off the ground and proper storage methods. Store food at least 6 inches from the floor to prevent contamination and allow cleaning. Cold Storage - Don't store any items on the floor. Keeping appliances and equipment clean - cleaning interior and exterior Floors - keeping floors free of debris and trash to prevent accidents and help to prevent rodent and pest infestations. Keeping interior walk-ins free of spills, meat or food drippings etc. Personal Hygiene - when and how often to wash hands. Avoid cross-contamination - letting microorganisms from one food get into another store meats on the bottom shelf of your refrigerator so juices will not contaminate other foods.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #24) reviewed for care plans in that: Resident #24 did not have a care plan addressing the use of her ankle splint. This failure could affect resident by placing her at risk of not receiving individualized care and services to meet her needs. The findings included: Review of Resident #24's Admission Record dated 9/26/24 revealed she was a [AGE] year-old female admitted to the facility for paralysis following a stroke affecting her dominant side. Review of Resident #24's Quarterly MDS Assessment, dated 9/12/24 revealed: She scored a 13 of 15 on her mental status exam (indicating she was cognitively intact); She had range of motion impairment of the upper and lower extremities on one side; She used a walker and wheelchair; She needed supervision to walk 150 feet. She received 170 minutes of physical therapy in the previous 7 days. Splint use was not identified. Review of Resident #24 Care Plan, last reviewed 9/19/24, revealed no care plan for the splint. Review of Resident #24' 9/26/24 revealed no order for the splint. Observation and interview on 9/24/24 at 10:26 a.m. revealed Resident #24 had a hard ankle splint at the end of her bed. Resident #24 stated it was bed because she had a stroke, and her foot did not work right. In an interview on 09/26/24 at 1:38 PM the MDS Coordinator and DON stated Resident #24 was a stroke victim who came to the facility within the last three months. The DON stated Resident #24's main issue was balance. The DON stated Resident #24 used a specialized walker with therapy and an electric wheelchair when not with therapy. The DON stated Resident #24 did have a brace. The MDS Coordinator stated she was unaware of a brace. The DON told the MDS Coordinator it was to prevent drop foot (a condition where the front of the foot/toes drag). The MDS Coordinator said she did not see the brace on Resident #24's care plan or MDS. The MDS Coordinator stated Resident #24 just had a care plan update on 9/19/24. The DON said Resident #24 came in with the brace, but now that surveyor asked, she could picture Resident #24 wearing it. The DON stated Resident #24 took it on and off at will. Review of the facility's policy and procedure on Care Planning - Interdisciplinary Team, revised March 2022, revealed: The interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation. Resident care plans are developed according to the timeframes and criteria established by regulation. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team. Review of the facility's policy and procedure on Resident Mobility and Range of Motion, revised July 2017, revealed: Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed. The care plan will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives.

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 residents reviewed for quality of care. (Resident #24) The facility did not assess, obtain orders or monitor Resident #24's ankle splint. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings included: Review of Resident #24's Admission Record dated 9/26/24 revealed she was a [AGE] year-old female admitted to the facility for paralysis following a stroke affecting her dominant side. Review of Resident #24's Quarterly MDS Assessment, dated 9/12/24 revealed: She scored a 13 of 15 on her mental status exam (indicating she was cognitively intact); She had range of motion impairment of the upper and lower extremities on one side; She used a walker and wheelchair; She needed supervision to walk 150 feet. She received 170 minutes of physical therapy in the previous 7 days. Splint use was not identified. Review of Resident #24 Care Plan, last reviewed 9/19/24, revealed no care plan for the splint. Review of Resident #24's Order Summary Report, dated 9/26/24, revealed orders: There was no order for the ankle splint. OT/PT evaluate and treat for decline in personal hygiene, toileting and bed mobility beginning 6/17/24. Observation and interview on 9/24/24 at 10:26 a.m. revealed Resident #24 had an ankle splint at the end of her bed. Resident #24 stated it was bed because she had a stroke, and her foot did not work right. In an interview on 09/26/24 at 01:38 PM the MDS Coordinator and DON stated Resident #24 was a stroke victim who came to the facility within the last three months. The DON stated Resident #24's main issue was balance. The DON stated Resident #24 used a specialized walker with therapy and an electric wheelchair when not with therapy. The DON stated Resident #24 did have a brace. The MDS Coordinator stated she was unaware of a brace. The DON told the MDS Coordinator it was to prevent drop foot (a condition where the front of the foot/toes drag). The MDS Coordinator said she did not see the brace on Resident #24's care plan or MDS. The MDS Coordinator stated Resident #24 just had a care plan update on 9/19/24. The DON said Resident #24 came in with the brace, but now that surveyor asked, she could picture Resident #24 wearing it. The DON stated Resident #24 took it on and off at will. The DON said the nurses checked Resident #24's skin to make sure there was no break down from the brace. In an interview on 09/26/24 at 01:48 PM the DON said Resident #24 got the splint from an outpatient rehabilitation provider prior to coming to the facility. The DON said the staff were aware Resident #24 had the splint but were not aware that therapy did not initiate the order for the splint. The DON said Resident #24 could take the splint on and off at will so she was probably not wearing it when Resident #24 was admitted . In an interview on 09/26/24 at 01:56 PM the DON stated the therapist who originally worked with Resident #24 and was aware of the splint no longer worked with the facility. The DON said the nurses were educated about taking on and off the splint and checking skin integrity. The DON said they called for orders that just didn't get initiated here. Review of the facility's policy and procedure on Resident Mobility and Range of Motion, revised July 2017, revealed: Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. During the resident's assessment, the nurse will identify the underlying factors that contribute to his or her range of motion or mobility problems, if any, including: conditions that limit or immobilize movement of limbs or digits (e.g. splints). The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed. The care plan will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. The care plan will include the type, frequency and duration of interventions, as well as measurable goals and objectives.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #19) of 6 residents observed for oxygen management. The facility failed to ensure Oxygen (O2) in use signage was on Resident #19's doorway. This failure could place residents at risk of not receiving appropriate respiratory care. The findings were: Record review of Resident #19 's admission record dated 09/26/2024 revealed Resident #19 was a [AGE] year-old male with an admitted to the facility of 07/19/2024. Admission record revealed Resident #19 had diagnoses that included Chronic obstructive pulmonary disease (progressive lung disease characterized by chronic respiratory symptoms and airflow limitation), shortness of breath, heart failure, dependence on supplemental oxygen, and muscle weakness. Record review of Resident #19 's MDS revealed the resident had a BIMS of 14 indicating the resident was cognitively intact. Record review of Resident #19 's order summary dated 09/26/24 revealed an order of OXYGEN AT 2-5 LITERS PER NASAL CANNULA. every day and night shift related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED (COPD). Record review of Resident #19 's Care plan dated 08/15/2024 revealed a focus of is dependent on staff for meeting physical and social needs. He has Heart Failure. SOB (Shortness of breath) r/t (Related to) COPD and is on oxygen. chooses not to attend activities or monthly events. He prefers to stay in his room. Observation on 09/24/24 at 09:52 AM during revealed that there was not a No smoking oxygen in use sign on Resident #19's door. Interview on 09/26/24 at 01:55 PM the DON stated that the residents who had an oxygen sign on the doorway was to inform anyone who entered the resident's, room that the resident was on oxygen. The DON stated that the sign was for safety, even though no one was supposed to smoke inside the facility, they had to put the sign indicating there was a combustible material in the room. The DON stated the sign was on the room that Resident #19 was in previously to being moved on 09/11/2024. The DON states that the medical record staff was responsible for ensuring the residents had a No smoking oxygen in use sign on the door. Interview on 09/26/24 at 02:16 PM with the Medical Records, stated that she was responsible for ensuring the residents who were admitted into the facility that were on oxygen received the sign for the door. The Medical Records stated that she was aware that the resident had moved rooms but did not know the sign was not moved. The Medical Records stated that if the residents were moved when she was off that the floor staff would move the sign to the new room. The Medical Records stated that the sign was used to indicate who was using oxygen in the building. The Medical Records did not think there was a negative outcome of not having the sign on the door. Record review of the facility's policy titled Oxygen Administration with a revision date of October 2010 revealed that under the section steps in the procedure - 2. Place an Oxygen in Use sign on the outside of the room entrance door.

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident status for 1 of 12 residents (Resident #3) whose MDS assessments were reviewed, in that: Resident #3's MDS assessment dated [DATE] was coded as not being PASRR positive when the resident was positive. This failure could affect residents in the facility and put them at risk of inadequate care based on inaccurate assessment. The findings were: Record review of Resident #3's admission record dated 09/26/2024 indicated she was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder and mild intellectual abilities. She was [AGE] years of age. Record review of Resident #3's PASRR level 1 screening dated 05/25/2021 indicated in part: Is there evidence or an indicator this is an individual that has a mental illness? Yes. Is there evidence or an indicator this is an individual that has an intellectual disability? Yes. Is there evidence or indicators that this is an individual that has a developmental disability (related condition) other than an intellectual disability (e.g., Autism, Cerebral palsy, Spina bifida)? Yes. Review of Resident #3's MDS assessment dated [DATE], indicated in part: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Coded 0 indicating No. Level II Preadmission Screening and Resident Review (PASRR) Conditions. Check all that apply A. Serious mental illness. B. Intellectual Disability - None checked. Active Diagnoses - checked for Schizophrenia (e.g., schizoaffective and schizophreniform disorders). During an interview on 09/26/24 at 02:56 PM the MDS coordinator said Resident #3 was indeed PASRR positive as she would be seen for PASRR services although Resident #3 had refused them. The MDS coordinator said Resident #3 had been PASRR positive since admission. The MDS coordinator was asked regarding Resident #3's annual MDS assessment having Resident #3 coded as no for the resident having a have serious mental illness or intellectual disability. The MDS coordinator said she had not noticed that she had accidentally coded the wrong answer and that it should have been coded yes for PASRR for Resident #3. The MDS coordinator said she would change that to the correct code. The MDS coordinator said they did not have particular policy for MDS, and they went based on the Resident Assessment Instrument (RAI) manual instructions. During an interview on 09/26/24 at 03:18 PM the DON was made aware of Resident #3's MDS being coded as no for PASRR when it should have been yes. The DON said it was due to human error and they would get that fixed. During an interview on 09/26/24 at 03:22 PM the Administrator was made aware of Resident #3's MDS being coded as no for PASRR when it should have been yes. The Administrator said he was aware of the error and that they would get that fixed. Record review of CMS's RAI version 3.0 manual dated October 2019 indicated in part: A1500: Preadmission Screening and Resident Review (PASRR). Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions.

Based on observation, interview, and record review, the facility failed to post daily information that included the facility name, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 2 days (09/25/2024 to 09/26/2024) of 3 days observed for staff posting. The facility failed to post the daily staffing information for 09/25/2024 and 09/26/2024. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census. The findings included: During an observation and record review on 09/25/2024 and 09/26/2024 at 11:50 a.m. revealed the facility's daily nursing posting located behind the nurses' station failed to indicate the actual hours worked for each direct care staffing, the facility name, the total number and actual hours worked by the staff and resident census. The posting indicated the following CMA - 2, CNA-4, LVN-1, RN-1, Admin - 1, RN-1 and LVN 2. During an interview on 09/26/24 at 11:22 AM the DON and Administrator said the postings boards placed behind each nurse's station was their daily staffing post. They said the number by each staff title was the number of that particular staff working the floor. They said they were not aware the posting had to indicate the number of hours, the facility name and census. Record review of the facility's policy titled Nurse staffing posting information and dated August 2024 indicated in part: It is the policy of this facility to make sure staffing information readily available in a readable format to residents and visitors at any given time. The nurse staffing sheet will be posted on a daily basis and will contain the following information: Facility name. The current date. Facility's current census. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses. Licensed Practical Nurses/Licensed Vocational Nurses. Certified Nurse Aides.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents, for 1 of 2 Medication Carts and 1 of 2 Treatment Carts reviewed for pharmacy services. - The facility failed to ensure the Medication Cart did not include the following expired medications: Eszopiclone 1 mg tablets, Olmesartan Medoxomil 40mg tablets, Aspirin 81mg, and Carboxymethylcellulose Sodium 0.5% lubricating eye drops. These failures could place residents at risk of receiving expired medications. Findings included: Medication Cart In an observation on 08/16/23 at 09:18AM, inventory of the Medication Cart with LVN A revealed: - one card (28 tablets) of Eszopiclone 1mg, expired 05/17/23 - one card (30 tablets) of Olmesartan Medoxomil 40mg, expired 07/23 - one bottle (29 tablets) of Aspirin 81mg, expired 02/22 - one opened box (4 sealed packages inside) of Carboxymethylcellulose Sodium Lubricating eye drops Single Use, expired 05/23 In an interview on 08/16/23 at 10:40 AM, the LVN stated the carts are checked for expired medications one time monthly. The LVN stated they try to check the carts for expired medications before the Pharmacist comes each month. The LVN stated there was no documentation to validate if the medication cart had been checked for expired medications. The LVN stated she knew the importance of checking the expiration date prior to administration. In an interview on 08/17/23 at 10:55 AM, the DON stated the Pharmacist month and reviews the medications in the medication carts and medication room storage areas for expiration dates. The DON stated the CNA's review the medication carts weekly for expired medications and review the medication expiration dates as they are being administered. Review of the facility policy titled Storage of Medications revised April 2019, reads in part: Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled and stored in locked compartments , for 1 of 2 Medication Carts and 1 of 2 Treatment Carts reviewed for pharmacy services. - The facility failed to ensure the Medication Cart did not include the following medications found loose in the medication drawer: Gabapentin 100mg x 2 capsules, Namenda 10 mg x 1 tablet, Buspar 15 mg x 1 tablet and Buspar 5mg x 1 tablet. - The Treatment Cart was unlocked and had Insulin, Oral Glucose, syringes, and lancets. These failures could place residents at risk of receiving expired medications. Findings included: Medication Cart In an observation on 08/16/23 at 09:18AM, inventory of the Medication Cart with LVN A revealed: - two capsules of Gabapentin 100 mg, found loose in medication drawer - one tablet of Namenda 10 mg found loose in medication drawer - one tablet of Buspar 15 mg found loose in medication drawer - one tablet of Buspar 5 mg found loose in medication drawer Treatment Cart In an observation on 08/15/23 10:00AM, the treatment cart was found unlocked. The following items were identified: Top Drawer: - 2 tubes Oral glucose gel lemon flavored 15 grams - 6 packages of Sani-Cloth Germicidal Disposable Wipes - 1 pen Novolog Flex Pen 100Units/ML (Insulin) Second Drawer: - 1 box of approximately 33 count Insulin pen needles - 1 box of approximately 50 count Lancets Fourth drawer: - 2 boxes of 100 count lancets - One box of approximately 100 count 1ml Insulin Safety Syringes In an interview on 08/16/23 at 10:40 AM, the LVN stated the loose pills in the cart were a result of the cards coming loose or missing the cups when pills were being popped out of the cards. The LVN stated she knew the importance of keeping the medication carts and treatment carts locked when not in use. In an interview on 08/17/23 at 10:55 AM, the DON stated she believed the loose pills were related to accidental puncture of the cards as well as excessive inventory in the medication cart storage areas. The DON also stated the reason the treatment cart was open was because the nurse responsible for that cart was busy with a resident admission and it was an oversight. The DON stated all nurses know the medication carts and treatment carts must be always locked when not in use. Review of the facility policy titled Storage of Medications revised April 2019, reads in part: Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure: Holding temperatures for 8 dishes were taken of the meal prior to serving; Food was labeled and dated so they could be thrown out when appropriate; Food in the walk-in refrigerator was sealed to prevent contamination and was left open to air. These deficient practices could affect residents who received meals prepared from the kitchen at risk for food borne illness and cross contamination. Findings included: Observation beginning [DATE] between 10:15 AM and 10:45 AM of the facility's only kitchen revealed: The walk-in refrigerator had: macaroni salad dated [DATE]; A bag of cheese dated ,d+[DATE] but open to air; A pan of pears labeled as expired ,d+[DATE]; A pan of guacamole that was completely brown. The FSS stated As much as I love guacamole, I wouldn't eat it A baking sheet of bacon dated ,d+[DATE] but open to air - The FSS agreed it was open to air. The dishwashing area had a particle board backing on the wall that was bubbled up indicating it was porous and not sanitizable from water exposure. The dishwasher was rusted. Cook C stated the dishwasher was new. Observation on [DATE] between 11:35 AM and 12:46 PM of the noon meal preparation and meal service revealed: Cook C made the regular, mechanical soft, and puree meals and placed them in a pan. At 12:14 PM she began to serve the meal. She did not take the holding temperature of the regular protein, the mechanical soft protein, either kind of pureed protein (pudding thick or regular puree). She did not take the holding temperature of the BBQ beans - regular, the pudding thick puree or the regular puree. She did not take the temperature of the regular potato salad. (For a total of 8 of 9 dishes not having their holding temperature taken). Interview on [DATE] at 1:51 PM, Cook C stated she usually worked as the cook in the facility and had since ,d+[DATE]. Cook C stated she took temperatures of the food prior to putting it on the steam table. She stated she did not take temperatures of the puree food because she was thinking it would be the same as the food on the steam table but when she thought about it said, it would be because of the water. She said she did not take holding temperatures of the noon meal. Cook C stated the particle board on the back of the dirty dish area was bubbled and up and was hard enough to get clean She stated it had been that way since the facility got the new dishwasher in ,d+[DATE] or ,d+[DATE]. Interview on [DATE] at 1:29 PM, the FSS said she was responsible for ensuring that temperatures of the food were taken. She stated Cook C missed the temperature on the potato salad. The FSS stated the food that was open to air and/or out of date was not normal practice. She said the food was checked daily. The FSS said that on [DATE] she was getting ready for care plans and did not make it into the refrigerator to check the dates. The FSS said the board on the back of the wall was not particle board and it was supposed to be sanitizable but did say if it's bubbling up at the edges it needs to be replaced. Interview and observation on [DATE] at 01:57 PM, the Administrator was informed of the kitchen findings and shown the dirty dish area with the rusted dishwasher and the back wall. He was showed the dishwasher and back wall over dish area. He said ok to the back wall. The Administrator said the facility just replaced the dishwasher but did state the facility's water was very hard, so they used a lot of salt in the water softener. Review of the facility's policy and procedure on Food receiving and Storage, undated, documented: Foods shall be received and stored in a manner that complies with safe food handling practices. Food Services/designee will maintain clean food storage areas at all times. All foods stored in the refrigerator or freezer will be covered, labeled and dated with an open date and a use by date. Food that has been served to residents without temperature controls will be discarded if not eaten within two hours.

Based on observations, interviews and record review it was determined the facility failed to ensure medications were discarded when expired and dated when opened for 2 of 2 medication rooms reviewed for pharmacy services in that: The east hall medication room refrigerator had a [MEDICATION(S)] vial that was not dated when opened. The west hall medication room refrigerator had a [MEDICATION(S)] vial that was expired. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. Findings included: During an observation and interview on 07/13/22 at 04:20 PM, an inspection of the facility east side medication room was conducted with LVN A present. There was a small refrigerator that contained several medications to include a 1 ml [MEDICATION(S)] vial that had been opened but not dated. LVN A said she would have to dispose of that vial as it did not have an open date on it. LVN A said she was not aware of the vial not being dated. During an observation and interview on 07/13/22 at 04:38 PM, an inspection of the facility west side medication room was conducted with LVN B present. There was a small refrigerator that contained several medications to include a 1 ml [MEDICATION(S)] vial that had been opened and dated 06/07/22. LVN B said the vial was expired as it had been over 30 days since it was opened. LVN B said she was aware of the [MEDICATION(S)] only being good for 30 days after being opened and had just now noticed it was expired. LVN B said she would dispose of the vial and said that it was their responsibility to keep up with removing the expired medications from the medication room. During an interview on 07/14/22 at 02:10 PM, the DON said it was everyone's responsibility to keep up with the medications in the medication rooms to include removing expired meds. The DON said there was no one person assigned to keep up with inspecting the medication rooms. The DON said the issue occurred because there was no one assigned to inspect the medication room for expired medications or medications that were not dated when opened. The DON said expired and none dated [MEDICATION(S)] solutions could lead to false positives and staff not aware as to when a none dated vial was expected to expire. During an interview on 07/14/22 at 02:24 PM, the Administrator said it was every nursing staff's responsibility to remove medications that had expired or had not been dated when opened from the medication room. The Administrator said he believed the failure occurred because there was no one specifically assigned to keep up with removing the expired or none dated medications from the medication room. The Administrator said expired or none dated [MEDICATION(S)] solutions could lead to false test results. Record review of the [MEDICATION(S)] vial manufacturers instructional pamphlet dated April 2016, indicated in part: Storage - A vial of [MEDICATION(S)] which has been entered and in use for 30 days should be discarded. Record review of the facility's policy titled Storage of medications and dated April 2019 indicated in part: The facility stores all drugs and biologicals in a safe, secure and orderly manner. Discontinued, outdated or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for four (Resident #5, #11, #28 and #33) of 40 residents reviewed for accommodations of needs. Staff failed to attend to Residents' #5, #11, #28 and #33 needs in a timely matter when they used their call light to call staff for assistance. This failure could place residents at risk for needs going unmet, decreased quality of life, self-worth, and dignity. Findings included: Resident #11 Record review of Resident #11's admission record dated 05/05/2021 indicated she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was [AGE] years of age. Record review of Resident #11's MDS dated [DATE] indicated in part: BIMS = 13 indicating resident was cognitively intact. Record review of Resident #11's care plan revised on 06/19/2020 indicated in part: Focus: The resident has an ADL self-care performance deficit r/t Activity Intolerance, SOB. Goal: Declines in ADLs will be addressed promptly. Interventions/Tasks: DRESSING: The resident requires x1 staff assist. TOILET USE: The resident is able to call for assist, she uses a BSC her choice to transfer and pull pants on and off. During an interview on 05/04/21 at 11:27 AM Resident #11 said at times when she used the call light button to get assistance, the staff would enter her room and tell her they would be back to assist her. Resident #11 said the staff would cancel her light or turn it off and leave without attending to her need. Resident #11 said the staff would at times come back to help her or they would forget because they would not come back at all. Resident #11 said at times she would press her call light a second time since they did not come back and again, the staff would come in and cancel her light a second time. Resident #11 said the staff would tell her that they were busy at the time and reason they could not attend to her at that time. Resident #11 said this would upset her because she felt the staff was ignoring her and not attending to her needs timely. Resident #33 Record review of Resident #33's admission record dated 05/05/2021 indicated he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was [AGE] years of age. Record review of Resident #33's MDS dated [DATE] indicated in part: BIMS = 13 indicating resident was cognitively intact. Bladder and Bowel: Bowel and urinary Continence, Always incontinent. Record review of Resident #33's care plan revised on 08/27/2020 indicated in part: Focus: The resident has an ADL self-care performance deficit r/t Disease Process Debility , [CONDITION(S)] disease and arthritis. Goal: The resident will improve current level of function in strength and mobility through the review date. Interventions/Tasks: Res requests to wear brief at night while in bed. The resident needs x 1-2 staff for dressing. The resident needs x1-2 staff for toilet use. Resident is able to use call light and let staff know when she needs to toilet. During an observation and interview on 05/05/2021 at 2:09 PM Resident #33 was seen laying in his bed calling for help and his call light was not on. Resident #33 said he needed his brief changed and had being asking for it to be changed. Resident #33 said his call light was on but LVN C had come into his room and told him they would attend to him later and cancelled the call light and then left. Resident #33 was asked to turn on the call light again. Resident #33's call light was on and CNA B came in and cancelled the call light and told the resident she would come back later. CNA B was gone for 12 minutes and then came back to attend to the resident. During an interview on 05/05/2021 at 2:28 PM LVN C said as far as she knew it was fine to cancel a resident's call light without first attending to their need. LVN C said she would cancel the call light and then go and tell someone to attend to them. LVN C said if she did not cancel the call light how could she tell when another call light came on, LVN C said she could only visually see 2 call lights from the nurse's station so how would she be able to see if the other call lights were on. LVN C said she had cancelled Resident #33's call light and told him that the aides would eventually attend to him. LVN C was made aware of the resident's complaining about the staff cancelling their call lights and not returning to attend them. During an interview on 05/05/2021 at 2:34 PM. The DON sa,d if a call light was on staff were expected to answer it timely like within approximately 10 minutes. The DON said if they cannot assist the resident at that time then let the resident know they'll be back and they should return within 5 minutes. The DON said they liked for the staff to cancel the light as the beeping sound would over stimulate some of the residents. The DON said LVN C could have changed Resident #33's brief instead of asking someone to assist him. Resident #5 During an interview on 05/05/2021 at 4:12 PM Resident #5 said she would use her call light to call for assistance. Resident #5 said staff would at times come into her room and cancel her light and tell her they would come back but at times they would not. Resident #5 said her roommate Resident #28 would also call for help and she had seen staff come in and cancel her light and tell her they would come back later. Record review of Resident #5's admission record dated 05/05/2021 indicated she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was [AGE] years of age. Record review of Resident #5's MDS dated [DATE] indicated in part: BIMS = 06 indicating resident had severe impairment. Record review of Resident #5's care plan revised on 11/14/2020 indicated in part: Focus: The resident is at risk for falls r/t Gait/balance problems, back and leg pain. Goal: The resident will not sustain serious injury through the review date. Interventions/Tasks: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. During an interview on 05/06/2021 at 9:18 AM CNA B said if a resident's call light was on, she would go and see what they needed. CNA B said if it was something she could do; she would do it right away if not she would tell the resident she would be back. CNA B said she would cancel the call light and come back later. CNA B said that they could not do that anymore as they had been in-serviced yesterday on no longer cancelling the call light until they had attended to the resident's needs. CNA B said she was not aware Resident #33 had called for assistance before she went into his room and canceled his call light for a second time. CNA B said no one had told her that Resident #33 was asking to be changed. Resident #28 Record review of Resident #28's admission record dated 05/05/2021 indicated she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was [AGE] years of age. Record review of Resident #28's MDS dated [DATE] indicated in part: BIMS = 15 indicating resident was cognitively intact. Record review of Resident #28's care plan revised on 08/27/2020 indicated in part: Focus: The resident has an ADL self-care performance deficit r/t Disease Process Debility , [CONDITION(S)] disease and arthritis. Goal: The resident will improve current level of function in strength and mobility through the review date. Interventions/Tasks: Res requests to wear brief at night while in bed. The resident needs x 1-2 staff for dressing. The resident needs x1-2 staff for toilet use. Resident is able to use call light and let staff know when she needs to toilet. During an interview on 05/06/21 at 11:48 AM Resident #28 said at times when she called for help by using her call light the staff would enter her room and tell her they were busy helping someone else that required more assistance and would be back later. Resident #28 said the staff would then cancel her light and leave the room. Resident #28 said the staff would then take like another 15 minutes to return and help her or sometimes forget to come back. Resident #28 said she knew it was like 15 minutes because she had a clock on the wall of her room and that was how she knew approximately how long it took them. Resident #28 said the staff would cancel her light so it would not be buzzing or the call light be on which was located right outside her room. Resident #28 said she would get frustrated when the staff canceled her call light and would not attend to her at that time. During an interview on 05/07/21 at 10:20 AM the Administrator said they were going to work on a new policy regarding how staff answered the call lights and also conduct follow ups regarding the new policy. Record review of the facility's policy titled Call lights accessibility and timely response and dated 11/2017 indicated in part: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. Record review of the facility's policy titled Policy on answering call lights and dated 5-5-2021 indicated in part: Amendment to policy - staff will now answer call light and instead of turning off call light they will leave the light on until the residents needs have been met. All staff are responsible for answering call lights. If the resident has a request that can be completed by one staff member complete the task and cancel the call light. If the task requires 2 staff members DO NOT turn off the light until the residents' needs have been met.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #31) of two residents reviewed for incontinent care and for 5 ( Cook D, DA E, DA F, DA G and Cook H) of 10 kitchen staff in that; CNA A failed to change her gloves once they became contaminated during incontinent care for Resident #31. Dietary staff Cook D, DA E, DA F, DA G and Cook H failed to appropriately wear their face masks while in the facility kitchen. These failures could place resident's risk for cross contamination and the spread of infection. Finding included: Record review of Resident #31's admission record dated 05/05/2021 indicated she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was [AGE] years of age. Record review of Resident #31's MDS dated [DATE] indicated in part: Cognitive Skills for Daily Decision Making was severely impaired. Bladder and Bowel. Bowel and urinary Continence. Always incontinent. Record review of Resident #31's care plan revised on 02/13/2020 indicated in part: Focus: The resident has an ADL self-care performance deficit r/t Alzheimer's. Goal: The resident will maintain current level of function in ADL's through the review date. Declines will be addressed promptly . Interventions/Tasks: TOILET USE: assisted x1-2 staff, resident is incontinent of bowel and bladder. During an observation on 05/04/21 at 04:20 PM CNA A performed incontinent care for Resident #31. CNA A donned gloves and proceeded to wipe the resident's peri-area with a wet washcloth. The resident had voided. CNA A turned the resident on her side and wiped the resident's bottom with a wet washcloth. While still wearing the same gloves, CNA A placed a clean brief and the mechanical lift sling on the resident. During an interview on 05/06/21 at 10:52 AM CNA A said when she performed incontinent care, she would wash her hands, glove up and use a washcloth to clean the peri-area from front to back. CNA A said the washcloth was considered dirty so it was placed in a bag to be taken to the laundry. CNA A said she would then change her gloves because she was done with the dirty part of the incontinent care. CNA A said she would remove the gloves because they were considered contaminated at that time so she would not want to touch any of the clean items with the dirty gloves. The CNA said the DON and the ADON would do competency tests where they would check them off on incontinent care. CNA A said she became nervous during the incontinent care she performed for Resident #31 and forgot to change her gloves once they became contaminated. During an interview on 05/06/21 at 02:16 PM the ADON said she had conducted competency checks regarding incontinent care with the CNAs. The ADON said they also conducted in-services or watched them perform tasks such as handwashing and incontinent care. The ADON said when staff performed peri-care with a wash cloth, that washcloth was now considered contaminated and was placed in a bag. The ADON said the reason the staff had to change their gloves before they applied a clean brief was because those gloves could be contaminated. The ADON said staff were expected to change their gloves because if not then everything else they touched with those gloves was being contaminated. The ADON was made aware of the incontinent care observation and she said the aide should have changed her gloves once they became contaminated. During an interview on 05/06/21 at 03:12 PM the DON was made aware of the incontinent care observation. The DON said the aide should have changed her gloves once she went from dirty to clean. The DON said they had an in-service last month on incontinent care and washing hands. The DON said they did not have a specific policy that indicated the CNA's had to change their gloves once they became contaminated. The DON said they would train the staff by instructing them to change their gloves once they became contaminated and don clean gloves before proceeding to the clean part of the task. During an interview on 05/07/21 at 10:15 AM the Administrator was made aware of the incontinent care observation. The Administrator said he agreed with the DON response that the aide should have changed her gloves once they became contaminated. Record review of the facility's in-service titled Skill 21 - provides perineal care (peri-care) for female dated 04/23/2021 indicated in part: Puts on clean gloves before washing perineal area. Washes genital area, moving from front to back, while using a clean area of the washcloth for each stroke. Removes and disposes of gloves (without contaminating self) into waste container and washes hands. MASK (KITCHEN) During an observation on 5/04/21 at 10:31 AM revealed DA E and DA F in the kitchen with their mask below their noses (not covering their nose and mouth). Cook D also had her mask completely below her chin (leaving her nose and mouth exposed). During an observation on 05/05/21 at 10:11 AM revealed Cook D with no mask on. Observation and interview on 05/05/21 between 11:12 AM and 12:24 PM revealed: Cook D with a surgical mask on below her chin leaving her nose and mouth exposed. While pulling the food out of the oven she took the mask off. DA E had her mask on but left her nose exposed through the entire observation. The FSS also came into the kitchen to observe; the beginning of the observation, the FSS pulled her mask away from her face, laughed and said, so, are you tired of these masks yet? She placed the mask back on her face under her nose and every comment she made after that she would pull the mask away from her face leaving her mouth exposed. Cook D left the kitchen area to wash her hands and DA F yelled across the kitchen [Cook D] you need a mask on! Cook D yelled back, [DA F] I don't like you no more! Cook D returned to the kitchen area with a surgical mask on inside out. At 11:45 AM Cook D began preparing the puree meals and complained to the surveyor the kitchen was hot while pulling her mask below her chin. The mask stayed below her chin for the rest of the observation. At 12:05 PM Cook H entered the kitchen with a mask on but it was below her nose. She prepared food and altered diets to assist Cook D. During an observation on 5/06/21 at 9:07 AM revealed DA E in the kitchen with the mask below her chin exposing her face. Cook D was not wearing a mask. During an interview on 5/06/21 at 2:46 PM the Administrator said all facility staff were expected to don a mask as soon as they walk in the door. He said the expectation was the staff wear surgical masks unless there was a Covid-19-positive resident in the facility then all staff were expected to wear a N-95. He said the only part of the facility it was acceptable to not be wearing a mask was the employee break room or in an office if the person was by themselves and the door was shut. The Administrator stated that was the facility's policy. He said that the facility had weekly QA meetings and it had been discussed so all the staff were aware they needed to be wearing a mask. He was unable to find the policy in the Covid-19 policy manual and left to have the DON find it. He returned with the policy and stated it was updated 10/16/20 The Administrator stated for a mask to be effective the nose and mouth must be covered. The Administrator was informed that there were multiple dietary staff members observed without their mask on. The Administrator stated he was frequently in and out of the kitchen are and usually the dietary staff were compliant with mask use. He stated he did not know why there were so many dietary staff were not wearing their mask in the kitchen and he did not know when it started becoming the kitchen's practice. During an interview on 5/06/21 at 3:10 PM the FSS stated all of the staff were tired of wearing the masks but she was aware they needed to be wearing one at all times. She acknowledged she pulled her mask away from her face and stated it was to keep her glasses from fogging up and to get a breath of fresh air. She pulled the mask away from her face at that time. The FSS asked if the inadequate mask use had been observed facility-wide or just the kitchen. She was informed it was observed it primarily in the kitchen. The FSS said she guessed the kitchen staff felt since they were away from the residents that the ones who had been vaccinated felt they were a little more protected. The FSS stated she smoked and the mask made her feel muffled or smothered and the person she was speaking too could not see her. She acknowledged she saw Cook D not wearing a mask and had sent DA F to tell Cook D to put one on. The FSS stated she guess she set the example for the staff's mask use. Review of the facility's policy and procedure on Transmission Based Precautions and Covid-19, updated 10/16/2020 documented all employees will don appropriate masks prior to entrance into facility.

Based on observation, interview, and record review, the facility failed to ensure that nurse aides were able to demonstrate competency in the provision of skills and techniques necessary to care for one (Resident #31) of two residents reviewed for incontinent care in that; CNA A failed to change her gloves once they became contaminated during incontinent care for Resident #31. This failure has the potential to affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills competencies to provide care that is safe and capable of minimizing exposure to communicable diseases and infections. The findings were: Record review of Resident #31's admission record dated 05/05/2021 indicated she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was [AGE] years of age. Record review of Resident #31's MDS dated [DATE] indicated in part: Cognitive Skills for Daily Decision Making was severely impaired. Bladder and Bowel. Bowel and urinary Continence. Always incontinent. Record review of Resident #31's care plan revised on 02/13/2020 indicated in part: Focus: The resident has an ADL self-care performance deficit r/t Alzheimer's. Goal: The resident will maintain current level of function in ADL's through the review date. Declines will be addressed promptly . Interventions/Tasks: TOILET USE: assisted x1-2 staff, resident is incontinent of bowel and bladder. During an observation on 05/04/21 at 04:20 PM CNA A performed incontinent care for Resident #31. CNA A donned gloves and proceeded to wipe the resident's peri-area with a wet washcloth. The resident had voided. CNA A turned the resident on her side and wiped the resident's bottom with a wet washcloth. While still wearing the same gloves, CNA A placed a clean brief and the mechanical lift sling on the resident. During an interview on 05/06/21 at 10:52 AM CNA A said when she performed incontinent care, she would wash her hands, glove up and use a washcloth to clean the peri-area from front to back. CNA A said the washcloth was considered dirty so it was placed in a bag to be taken to the laundry. CNA A said she would then change her gloves because she was done with the dirty part of the incontinent care. CNA A said she would remove the gloves because they were considered contaminated at that time so she would not want to touch any of the clean items with the dirty gloves. The CNA said the DON and the ADON would do competency tests where they would check them off on incontinent care. CNA A said she became nervous during the incontinent care she performed for Resident #31 and forgot to change her gloves once they became contaminated. During an interview on 05/06/21 at 02:16 PM the ADON said she had conducted competency checks regarding incontinent care with the CNAs. The ADON said they also conducted in-services or watched them perform tasks such as handwashing and incontinent care. The ADON said when staff performed peri-care with a washcloth, that washcloth was now considered contaminated and was placed in a bag. The ADON said the reason the staff had to change their gloves before they applied a clean brief was because those gloves could be contaminated. The ADON said staff were expected to change their gloves because if not then everything else they touched with those gloves was being contaminated. The ADON was made aware of the incontinent care observation and she said the aide should have changed her gloves once they became contaminated. During an interview on 05/06/21 at 03:12 PM the DON was made aware of the incontinent care observation. The DON said the aide should have changed her gloves once she went from dirty to clean. The DON said they had an in-service last month on incontinent care and washing hands. The DON said they did not have a specific policy that indicated the CNA's had to change their gloves once they became contaminated. The DON said they would train the staff by instructing them to change their gloves once they became contaminated and don clean gloves before proceeding to the clean part of the task. During an interview on 05/07/21 at 10:15 AM the Administrator was made aware of the incontinent care observation. The Administrator said he agreed with the DON response that the aide should have changed her gloves once they became contaminated. Record review of the facility's in-service titled Skill 21 - provides perineal care (peri-care) for female dated 04/23/2021 indicated in part: Puts on clean gloves before washing perineal area. Washes genital area, moving from front to back, while using a clean area of the washcloth for each stroke. Removes and disposes of gloves (without contaminating self) into waste container and washes hands. Record review of the facility's undated document titled Job description for certified Nursing Assistant indicated in part: Provides direct care to residents as directed by licensed nurses; most duties involve assisting residents with activities of daily living but some also include nursing care. Essential duties and responsibilities: Be alert and active in supporting facility's commitment to safe practices, infection control and respect for resident's rights. Assist residents in activities of daily living, such as bathing, dressing and undressing; using the toilet; mouth care and moving about.

Based on interview and record review, the facility failed to ensure the interdisciplinary team determined self- administration of medication was safe for 1of 1 resident reviewed for medication self-administration. (Resident # 29). The facility failed to ensure the IDT assess, reassess, and care plan Resident #29's ability to safely administer OTC eye drops. This failure could place one resident who self-administered medications at risk of not receiving their medication as ordered. Findings included: Review of Resident #29's Admission Record dated 08/02/19 indicated she was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #29's MDS assessment dated [DATE] scored 12 on the BIMS portion, indicating she had moderate cognitive impairment. She required supervision with ADLs, except for some assistance with bathing. She was ambulatory with a walker. She was continent of bowel and bladder. She recieved scheduled pain medication. She recieved anticoagulant medication. Review of Resident #29's undated care plan did not include self-administration of medication. Review of Resident #29's Order Summary Report active as of 07/25/29 included Eye Drops Solution 0.05% (Tetrahydrozoline HCl) Instill 1 drop in both eyes three times a day for redness may keep at bedside. Review of Resident #29's Assessment for Self-Administration of Medications dated 02/19/16 indicated the resident could correctly administer eye drops according to proper procedure and was approved to self-administer. The assessment did not include the name of the eye drops, or whether they were OTC or prescription. The assessment was signed by an LVN on 02/19/16. There were no Interdisciplinary Team signatures and the attending physician listed on the assessment was no longer Resident #29's attending physician. Review of Resident #29's (MONTH) 2019 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. In an interview with the DON on 08/02/19 at 11:00 AM she said Resident #29 complains of dry, itchy eyes, and preferes to self-administer the OTC eye drops. She keeps the eye drops in her room. She said there was no other Assessment for Self-Administration of Medications done on Resident #29 since 02/19/16. In an interview with the DON on 08/02/19 at 11:30 AM she said she just now reevaluated Resident #29 and she remains able to self-administer the eye drops, and would update the order. Review of facility policy, Self-Administration of Medications dated 12/2016, included the following, in part: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. 13. The staff and practitioner will periodically (for example, during quarterly MDS reviews) reevaluate a resident's ability to continue to self-administer medications.

Based on interview and record review the facility failed to ensure that 1 of 1 resident (Resident #22) reviewed for respiratory care was provided such care, consistent with professional standards of practice. The facility failed to administer Flutter valve therapy as ordered by the physician for an unknown period of time. This deficient practice placed one resident at risk of respiratory complications and decline in health. Findings included: Review of Resident #22's Admission Record, dated 08/02/19, indicated she was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #22's MDS assessment dated [DATE] indicated she had a BIMS score of 6, meaning she had moderately severe cognitive impairment. She required supervision for dressing, eating, toileting, and personal hygiene. She required limited assistance for ambulation. Review of Resident #22's undated care plan included oxygen therapy related to hypoxemia. Interventions included continuous oxygen and use of Flutter valve QID. Review of Resident #22's Order Summary Report dated 08/02/19 included an order to Use Flutter valve 4x daily for [MEDICATION NAME] related to Hypoxemia with start date of 06/04/19. The following information was accessed on 08/08/19 at: https://www.respiratorytherapyzone.com/acapella-flutter-valve A flutter valve is a handheld device used as a type (of) breathing therapy. It helps to clear mucus from the lungs as well as make the breathing easier and more comfortable . This device loosens the secretions in your lungs and helps you to cough them up. The acapella causes both airway vibrations and positive expiratory pressure (PEP) therapy, so it essentially provides dual therapy. Review of Resident #22's nurses' notes included the following, in part: 06/28/19 - Flutter valve lost, used balloon . 06/30/19 - Using balloon, flutter valve lost . 07/13/19 - Using balloon, flutter valve lost . 07/20/19 - Waiting for family to bring flutter valve from home. In an interview with LVN A on 07/31/19 at 3:35 PM she said she doesn't know when Resident #22's Flutter valve went missing or when they found it or got a new one. She said she did not use a balloon for the resident's breathing exercises. In an interview with the DON on 08/01/19 at 3:55 PM she said Resident #22's daughter provided the Flutter valve. She lives in (another city) and came to visit this summer and brought another Flutter valve. The DON said she did not know if Resident #22's physician was made aware that the Flutter valve was missing. The DON said the facility did not have a policy that addressed the facility providing respiratory therapy devices.

Based on observation, interview and record review, the facility failed to ensure each resident was free from neglect for two (Resident #9 and Resident #28) of 3 residents reviewed for neglect. On 07/21/18 the facility failed to supervise and prevent Resident #9 from exiting the facility through a side door secured with a key pad into 102-degree heat. Resident #9 exited the building without staff knowledge or supervision to an outside courtyard, and then exited the court yard through a latched gate. Resident #9 was seen outside of the secure areas of the building by facility staff, but she did not alert other staff of Resident #9's location until approximately 15 minutes later. Resident #9's body temperature was elevated and required interventions to help cool her body temperature. On 06/10/18 and 06/27/18 the facility failed to supervise and prevent Resident #28, a resident identified as an elopement risk, from leaving the facility unsupervised. On 06/10/18 Resident #28 exited the building and walked across the street to an apartment complex. While attempting to navigate stairs at the apartment complex Resident #28 fell , causing bruising and skin tears. On 06/27/18 Resident #28 again left the building unsupervised. She was found walking down the road and had to be picked up in staff's vehicle. An Immediate Jeopardy situation was identified on 8/29/18. The Immediate Jeopardy was removed on 8/31/18. The facility remained out of compliance at a level of potential for more than minimal harm with a scope identified as pattern due to the facility's need to review elopement policy and training of all staff and monitor the plan of removal. This failure could affect all three residents who are able to ambulate and at risk for elopement resulting in accidents and possible injuries. Findings included: Resident #9's face sheet dated 08/29/18 revealed she was a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's wander guard care plan dated 05/05/17 on 08/28/18 at 9:30 A.M. states the following: Wander guard in place as a means of communication for resident to let staff know when she goes outside due to fall risk. Check for function and placement every shift. Let resident know she can go out when she wants, the alarm does not mean for her to come back in it is only for her to let staff know she is outside. Timer provided for staff to use or timer on personal phones may be used to keep track of how long residents have been outside and when to check on her. Resident is only allowed to be outside without supervision in the smoking area courtyard. Record review of Resident #9's undated care plan revealed the following: Resident #9 had impaired cognitive function/dementia or impaired thought process related to Alzheimer's and Dementia (revised 09/29/15) Resident #9 had impaired vision function related to [MEDICATION NAME] degeneration. (revised 09/29/15) Resident #9 is at risk for falls related to vision/hearing problems, gait/balance problems (revised 04/25/18) Interventions: Wander guard is placed as a means of communication for resident to let staff know when she goes outside due to fall risk Resident #9's MDS (minimum data sheet) dated 06/21/18 revealed Resident #9 vision was highly impaired, had a BIMS (brief interview for mental status) of 7 indicating she was moderately cognitively impaired, and required limited assistance of one person for transfer. Record review of Resident #9's nurses notes written by LVN C dated 07/21/18 at 5:29 P.M. revealed the following: Resident (#9) was brought to the nurse's desk earlier by kitchen staff who said she was by the back freezer outside the kitchen. Staff member said she had seen her in the yard when she went to the store. She said when I came back she (Resident #9) was by the freezer. 'I brought her to you all because I knew she was hot .' Resident said she got lost and couldn't remember how to get back in. Resident temperature (body temperature) was 99.4 degrees Fahrenheit, given water and tepid washcloth to cool her off. Resident #9 offered ice cream or other cool snacks. Educated staff that if resident wants to go outside, she may go out the back lobby (smoking area) where the gate is locked and has a clear concrete path. The resident is a wandering risk with very poor vision. If she goes out (east lobby fenced area), she can open the gate an get out easily area with key pad) .she must be accompanied by staff. During an observation on 08/28/18 at 10:30 A.M. Resident #9 had a wander guard on her right ankle and was sitting in a wheel chair. During an observation on 08/29/18 at 2:30 P.M. the door Resident #9 exit out of revealed the door code was posted on the door both inside and outside the door. During an interview on 08/29/18 at 3:15 P.M. with LVN C she said Resident #9 had poor vision and could not get back into the facility. She does go outside, and residents have a right to go outside and is part of her activities. She said on that day 07/21/18 she was let outside, but we do not know who let her out. When she goes out we have someone to go out with her. She said we do not know who let her out on that day (07/21/18) and no one was outside with her. She said Resident #9 can stand and may have opened the gate to go out when she was found by the kitchen located outside of the building. During an interview on 08/29/18 at 1:45 P.M. with the Cook said on 07/21/18, she was going to the store to get some things for the evening meal. She said when she left she saw Resident #9 in the courtyard by herself. She said she was gone about 15 minutes and when she returned to the facility Resident #9 was standing by the walk-in freezer located outside of the building near the kitchen. She said it was hot outside and she took Resident #9 to the nurses to get her checked out. During a review of actual weather temperature reported on the website www.accuweather.com/em/us stated the temperature was 102 degrees Fahrenheit on 07/21/18 at the facility's location. During an interview on 08/29/8 at 9:40 A.M. with Resident #9 she said she was outside by herself, on 07/21/18 but could not remember how she got by the kitchen. During an interview on 08/29/18 at 9:00 A.M. with the Administrator he said we are doing in-servicing regarding Resident #9. We are making sure if Resident #9 goes outside to be sure to go to the enclosed area where the smokers go and check on her frequently. We are also updating her care plan today. He said an incident report was not generated or reported because Resident #9 was not injured. During an interview on 08/29/18 at 11:40 A.M. with the DON she said if a resident goes out the (east side courtyard enclosed fence area with keypad, where Resident #9 exited) someone goes out with them. During an interview on 08/29/18 at 5:00 P.M. with Resident #9's Physician said he was not aware Resident #9 was found outside on 07/21/18 and the facility had to take interventions to cool off Resident #9 after being outside unsupervised. He said he felt she would be unsafe outside and unsupervised. During an interview on 08/30/18 at 10:20 A.M. with DON she said resident have a right to go outside, going outside was part of Resident #9's activities. She said the way residents are monitored is if they go outside the nurses set a timer on their telephones and check on them. She said they do not have a log when they go outside. She said Resident #9 may have been outside 15 to 30 minutes there was no way to know. According to the U.S. Department of Health and Human Services' National Institute on Aging (NIA) too much heat is not safe for anyone and is even riskier if you are older or have health problems. According to the NIA it is important to get relief from heat quickly and that being hot for too long can cause several illnesses. The NIA indicated, Older people can have a tough time dealing with heat and humidity. The temperature inside or outside does not have to reach 100°F (38°C) to put them at risk for a heat-related illness. https://www.nia.nih.gov/health/hot-weather-safety-older-adults (accessed on 09/13/18) According to the Centers for Disease Control and Prevention (CDC) People aged [AGE] years or older are more prone to heat-related health problems. The CDC recommends older adults stay in air-conditioned buildings as much as possible. https://www.cdc.gov/disasters/extremeheat/older-adults-heat.html (accessed on 09/13/18) Resident #28 Review of Resident #28's face sheet dated 08/29/18 at 1:25 P.M. revealed she was a [AGE] year-old-female admitted on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #28's MDS dated [DATE] revealed she needed extensive assistance with two staff members for all of her needs, had hallucinations, and delusion and a BIMS of three indicating she was severely cognitively impaired. Record review of Resident #28's care plan dated plan revealed the following: Resident is an elopement risk and wanderer related to disoriented to place, history of attempts to leave facility unattended. (initiated 06/11/18) Resident has learned that if she leans on the locked doors long enough even if the alarm goes off they will open. (06/11/18) Interventions: Scheduled staff assigned to front office doors and resident though (MONTH) (YEAR) (initiated 06/11/18) Record review of the Accident/Incident report dated 06/10/18 revealed the following: Falls: Across street at apartment complex step up onto sidewalk. Resident: Was ambulating. Was Resident Injured: Yes, skin tear and bruises to arms and knees Review of nurse's notes dated 06/10/at 2:24 P.M. revealed the following: Resident went out West Side Lobby door exit. Laundry Aide B witnessed Resident #28 fall at apartment complex steps. Laundry Aide B state that the resident missed as step and rolled to her right side. Staff went immediately to the resident to assess .Skin tear noted to right elbow and right pinky finger. Physician, DON and Administrator was notified of fall. During an interview on 08/30/18 at 1:33 P.M. with Laundry Aide B she said on 06/10/18 she was delivering napkins to the dining room and she heard the door alarm down the hall where the offices are. I went down the hall the where the west side door exit was and saw Resident #28 at the Housing Authority apartments inside their gate. Laundry Aide B said Resident #28 fell on the steps at an apartment across from the facility. She said when I got to Resident #28 I saw a apartment resident and asked her to call the nursing home to help me get Resident #28 back to the facility because I forgot my telephone. Laundry Aide B said when she left the west side exit she left the alarm on and she saw Dietary Aide looking out the door and she said I told her to get help. The dietary aide got three nurses to come over with a wheel chair and we took Resident #28 back to the facility. Record review of Incidents/Accidents dated 06/27/18 at 6:15 P.M. revealed the following: Resident (Resident #28) was witnessed at the Housing Authority heading toward the highway. Laundry staff (Laundry Aide A) saw Resident #28 and immediately responded to her and called the facility. Resident #28 was picked up in LVN E's pickup and brought back to the facility. No adverse effects, injuries or falls noted. During an interview on 08/30/18 at 9:30 A.M. with Laundry Aide A she said on 06/27/18 she was picking up laundry when she hears the door alarm going crazy on the west side exit and saw Resident #28 going to the Housing Authority I told her to come back and she got mad and kept walking. I called the facility and told them to help me get Resident #28 back. Laundry Aide A said LVN E came in her pick up and Resident #28 got in her truck and LVN E brought her back to the facility. During an interview on 08/30/18 at 3:45 PM. With LVN E she said Resident #28 had eloped on 06/27/18 and Laundry Aide A was trying to get her back in the facility. She said Resident #28 was combative and we could not convince her to go back to the facility. She said she got her truck and Resident #28 got in the truck with her and she took Resident #28 back to the facility. LVN E said she did not hear the alarm and that has always been a problem. Record review of the facility's policy and procedure dated (MONTH) (YEAR) titled Abuse Prevention Program revealed the following: .3 Develop and implement policy and procedure to aid our facility in prevention abuse, neglect, or mistreatment of [REDACTED]. Review of facility's undated policy and procedure titled Wander- guards Policy and Procedure revealed: 4. The resident's care plan will be updated to reflect that the resident is potentially an elopement risk or at risk for other safety issues. Record review of facility's policy and procedure dated (MONTH) 2007 titled Elopements revealed the following: 3. When a departing individual return to the facility, the Director of Nursing Services or Charge Nurse shall: .b. Notify the Attending Physician; .d. Complete and file Report of Incident/Accident An Immediate Jeopardy was identified on 8/29/18 at 3:15 P.M. The Administrator and DON were informed, and a Plan of Removal was requested at that time. The Plan of Removal dated 8/30/18 and accepted on 8/31/18 at 4:00 P.M., indicated the following: Criterion 1: What corrective action will be taken for those residents found to have been affected by the deficient practice? Residents with cognitive impairment who are at risk for elopement were immediately assessed, without negative findings by the nursing staff. Educated staff members that resident will only go outside with supervision. (8/29/18) The code for egress doors will be removed for safety purpose. (8/30/18) Criterion 2: How other residents with the potential to be affected by the same deficient practice will be identified? Three residents with cognitive impairment at risk for elopement had the potential to be affected by the alleged deficient practice. Criterion 3: What measures will be put into place or systematic changes will be made to ensure that the deficient practice does not occur? Staff was immediately re-educated on neglect, elopement, adequate supervision, for cognitively impaired residents at risk for elopement, heat exhaustion, and hydration, staff was also educated on the designated outdoor sitting area where residents with cognitive impairment who are at risk for elopement will sit, as a resident request activity, with adequate supervision with a staff member present. Current and new residents and their representatives will be notified of the designated outdoor sitting area. This will be completed by the end of business 8/30/18. Staff members that do not sign off on the re-education will not be allowed to work until they have reviewed and signed the sign-in sheet. Develop a policy and procedure for Wander guard system. (8/30/18 A staff member will maintain direct line of sight of the front of the facility, by staffing the west nurses' station, hall or lobby on al shifts. (8/29/18) Criterion 4: How the corrective actions will be monitored to ensure the deficient practice is being corrected and will not occur? The Administrator, DON, or assigned designee will make unannounced surveillance rounds on all shifts monitoring exit doors, adequate supervision and any potential risk for elopement. Employees will be educated in the orientation process on neglect, elopement, adequate supervision for cognitively impaired residents at risk for elopement heat exhaustion, hydration and resident designated outdoor siting area (8/30/18) Administrator, DON, or assigned designee will report abnormal findings to the management team, and the Quality Assurance Committee for three months or until the committee deems it no longer is necessary. Continue monitoring of the elopement policy will be ongoing to meet the needs of the resident. Criterion 5: When corrective action will be completed? Correction date: End of business 8/30/18 (1 day after IJ announced) Review of the undated policy titled Wander guards Policy and Procedure revealed the following: Policy statement The facility will strive to prevent unsafe individuals from wandering while still maintaining the least restrictive living environment for residents that are deemed at risk for possible elopement. Policy Interpretation and implementation 1. Upon admission the resident will be screened for possible elopement risks using assigned elopement form in admission packet. 2. A consent is place in the admission packet that allows staff to receive consent from responsible party or designated resident representative to place a wander guard if deemed necessary. 3. Once the consent is received the bracelet will be applied to an area of the body which as wrist or ankle. 4. The resident's care plan will be updated to reflect that the resident is potentially an elopement risk or for other safety issues. 5. Th nursing staff will include routine monitoring of the wander guard each shift onto the treatment order sheet (TARS). 6. Any device needing to be changed will be changed immediately, any abnormal findings will be reported to the Administrator, DON, or assigned designee. 7. The resident will be reviewed on a quarterly basis or as needed to determine if they are still at risk for elopement and this will be documented in the medical record. 8. When a resident has become a risk for elopement based on a resident elopement risk assessment, staff will notify resident and/or resident representative for consent to place a wander guard. Monitoring interviews with the following staff on 8/30/18 revealed staff were aware of wandering/elopement risk residents and wander guard/elopement policies and procedures. 2:10 PM- CNA H Monitoring West side exit 2:45 PM- LVN D E MDS Coordinator 3:00 PM- DON 3:05 PM- LVN I Monitor West side exit 3:15 PM- CNA J Works Zone I, II, III, IV 3:25 PM - Dietary Aide 3:30 PM - Dietary Manager 3:35 PM - CMA K Dispense medications to Zone I, II, III, IV 3:50 PM - LVN E Evening shift nurse supervisor 4:00 PM - LVN L Night shift nurse supervisor Record review of the Wander book and physician orders [REDACTED]. Record review of provided documentation dated 8/30/18, indicated the facility audited all residents in the facility for the following: Elopement risk wander guard orders, diagnosis, BIMS score, behavior monitoring, information in elopement book (if at risk), MDS coding, and care plan. Record review of provided in-service documentation dated 8/30/18 indicated staff signed off on being in-serviced regarding Elopement Policies and Procedures, wander guard/elopement book, wander guard elopement documentation, wander guard function checks, wander guard expiration and placement checks, abuse/neglect policy, reporting change of condition, signs of increased wandering/elopement risk, updating care plans, and accountability of residents through shift. Review of a list of residents provided by the DON on 8/30/18 indicated 3 residents were at risk for elopement/wandering. Record review of the Wander book and physician orders [REDACTED]. Record review of provided documentation dated 8/30/18, indicated the facility audited all residents in the facility for the following: Elopement risk wander guard orders, diagnosis, BIMS score, behavior monitoring, information in elopement book (if at risk), MDS coding, and care plan. Record review of provided in-service documentation dated 8/30/18 indicated staff signed off on being in-serviced regarding Elopement Policies and Procedures, wander guard/elopement book, wander guard elopement documentation, wander guard function checks, wander guard expiration and placement checks, abuse/neglect policy, reporting change of condition, signs of increased wandering/elopement risk, updating care plans, and accountability of residents through shift. While the Immediate Jeopardy was removed on 8/31/18 at 4:00 P.M. (Administrator notified), the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and at a scope of pattern because the facility was still monitoring the Plan of Removal. Review of a list of residents provided by the DON on 8/30/18 indicated 3 residents were at risk for elopement.

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents, for two (Resident #9 and Resident #28) of 3 residents reviewed for elopement risk. On 07/21/18 the facility failed to supervise and prevent Resident #9 from exiting the facility through a side door secured with a key pad into 102-degree heat. Resident #9 exited the building without staff knowledge or supervision to an outside courtyard, and then exited the court yard through a latched gate. Resident #9 was seen outside of the secure areas of the building by facility staff, but she did not alert other staff of Resident #9's location until approximately 15 minutes later. Resident #9's body temperature was elevated and required interventions to help cool her body temperature. On 06/10/18 and 06/27/18 the facility failed to supervise and prevent Resident #28, a resident identified as an elopement risk, from leaving the facility unsupervised. On 06/10/18 Resident #28 exited the building and walked across the street to an apartment complex. While attempting to navigate stairs at the apartment complex Resident #28 fell , causing bruising and skin tears. On 06/27/18 Resident #28 again left the building unsupervised. She was found walking down the road and had to be picked up in staff's vehicle. An Immediate Jeopardy situation was identified on 8/29/18. The Immediate Jeopardy was removed on 8/31/18. The facility remained out of compliance at a level of potential for more than minimal harm with a scope identified as pattern due to the facility's need to review elopement policy and training of all staff and monitor the plan of removal. This failure could affect all three residents who are able to ambulate and at risk for elopement resulting in accidents and possible injuries. Findings included: Resident #9's face sheet dated 08/29/18 revealed she was a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's wander guard care plan dated 05/05/17 on 08/28/18 at 9:30 A.M. states the following: Wander guard in place as a means of communication for resident to let staff know when she goes outside due to fall risk. Check for function and placement every shift. Let resident know she can go out when she wants, the alarm does not mean for her to come back in it is only for her to let staff know she is outside. Timer provided for staff to use or timer on personal phones may be used to keep track of how long residents have been outside and when to check on her. Resident is only allowed to be outside without supervision in the smoking area courtyard. Record review of Resident #9's undated care plan revealed the following: Resident #9 had impaired cognitive function/dementia or impaired thought process related to Alzheimer's and Dementia (revised 09/29/15) Resident #9 had impaired vision function related to [MEDICATION NAME] degeneration. (revised 09/29/15) Resident #9 is at risk for falls related to vision/hearing problems, gait/balance problems (revised 04/25/18) Interventions: Wander guard is placed as a means of communication for resident to let staff know when she goes outside due to fall risk Resident #9's MDS (minimum data sheet) dated 06/21/18 revealed Resident #9 vision was highly impaired, had a BIMS (brief interview for mental status) of 7 indicating she was moderately cognitively impaired, and required limited assistance of one person for transfer. Record review of Resident #9's nurses notes written by LVN C dated 07/21/18 at 5:29 P.M. revealed the following: Resident (#9) was brought to the nurse's desk earlier by kitchen staff who said she was by the back freezer outside the kitchen. Staff member said she had seen her in the yard when she went to the store. She said when I came back she (Resident #9) was by the freezer. 'I brought her to you all because I knew she was hot .' Resident said she got lost and couldn't remember how to get back in. Resident temperature (body temperature) was 99.4 degrees Fahrenheit, given water and tepid washcloth to cool her off. Resident #9 offered ice cream or other cool snacks. Educated staff that if resident wants to go outside, she may go out the back lobby (smoking area) where the gate is locked and has a clear concrete path. The resident is a wandering risk with very poor vision. If she goes out (east lobby fenced area), she can open the gate an get out easily area with key pad) .she must be accompanied by staff. During an observation on 08/28/18 at 10:30 A.M. Resident #9 had a wander guard on her right ankle and was sitting in a wheel chair. During an observation on 08/29/18 at 2:30 P.M. the door Resident #9 exit out of revealed the door code was posted on the door both inside and outside the door. During an interview on 08/29/18 at 3:15 P.M. with LVN C she said Resident #9 had poor vision and could not get back into the facility. She does go outside, and residents have a right to go outside and is part of her activities. She said on that day 07/21/18 she was let outside, but we do not know who let her out. When she goes out we have someone to go out with her. She said we do not know who let her out on that day (07/21/18) and no one was outside with her. She said Resident #9 can stand and may have opened the gate to go out when she was found by the kitchen located outside of the building. During an interview on 08/29/18 at 1:45 P.M. with the Cook said on 07/21/18, she was going to the store to get some things for the evening meal. She said when she left she saw Resident #9 in the courtyard by herself. She said she was gone about 15 minutes and when she returned to the facility Resident #9 was standing by the walk-in freezer located outside of the building near the kitchen. She said it was hot outside and she took Resident #9 to the nurses to get her checked out. During a review of actual weather temperature reported on the website www.accuweather.com/em/us stated the temperature was 102 degrees Fahrenheit on 07/21/18 at the facility's location. During an interview on 08/29/8 at 9:40 A.M. with Resident #9 she said she was outside by herself, on 07/21/18 but could not remember how she got by the kitchen. During an interview on 08/29/18 at 9:00 A.M. with the Administrator he said we are doing in-servicing regarding Resident #9. We are making sure if Resident #9 goes outside to be sure to go to the enclosed area where the smokers go and check on her frequently. We are also updating her care plan today. He said an incident report was not generated or reported because Resident #9 was not injured. During an interview on 08/29/18 at 11:40 A.M. with the DON she said if a resident goes out the (east side courtyard enclosed fence area with keypad, where Resident #9 exited) someone goes out with them. During an interview on 08/29/18 at 5:00 P.M. with Resident #9's Physician said he was not aware Resident #9 was found outside on 07/21/18 and the facility had to take interventions to cool off Resident #9 after being outside unsupervised. He said he felt she would be unsafe outside and unsupervised. During an interview on 08/30/18 at 10:20 A.M. with DON she said resident have a right to go outside, going outside was part of Resident #9's activities. She said the way residents are monitored is if they go outside the nurses set a timer on their telephones and check on them. She said they do not have a log when they go outside. She said Resident #9 may have been outside 15 to 30 minutes there was no way to know. According to the U.S. Department of Health and Human Services' National Institute on Aging (NIA) too much heat is not safe for anyone and is even riskier if you are older or have health problems. According to the NIA it is important to get relief from heat quickly and that being hot for too long can cause several illnesses. The NIA indicated, Older people can have a tough time dealing with heat and humidity. The temperature inside or outside does not have to reach 100°F (38°C) to put them at risk for a heat-related illness. https://www.nia.nih.gov/health/hot-weather-safety-older-adults (accessed on 09/13/18) According to the Centers for Disease Control and Prevention (CDC) People aged [AGE] years or older are more prone to heat-related health problems. The CDC recommends older adults stay in air-conditioned buildings as much as possible. https://www.cdc.gov/disasters/extremeheat/older-adults-heat.html (accessed on 09/13/18) Resident #28 Review of Resident #28's face sheet dated 08/29/18 at 1:25 P.M. revealed she was a [AGE] year-old-female admitted on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #28's MDS dated [DATE] revealed she needed extensive assistance with two staff members for all of her needs, had hallucinations, and delusion and a BIMS of three indicating she was severely cognitively impaired. Record review of Resident #28's care plan dated plan revealed the following: Resident is an elopement risk and wanderer related to disoriented to place, history of attempts to leave facility unattended. (initiated 06/11/18) Resident has learned that if she leans on the locked doors long enough even if the alarm goes off they will open. (06/11/18) Interventions: Scheduled staff assigned to front office doors and resident though (MONTH) (YEAR) (initiated 06/11/18) Record review of the Accident/Incident report dated 06/10/18 revealed the following: Falls: Across street at apartment complex step up onto sidewalk. Resident: Was ambulating. Was Resident Injured: Yes, skin tear and bruises to arms and knees Review of nurse's notes dated 06/10/at 2:24 P.M. revealed the following: Resident went out West Side Lobby door exit. Laundry Aide B witnessed Resident #28 fall at apartment complex steps. Laundry Aide B state that the resident missed as step and rolled to her right side. Staff went immediately to the resident to assess .Skin tear noted to right elbow and right pinky finger. Physician, DON and Administrator was notified of fall. During an interview on 08/30/18 at 1:33 P.M. with Laundry Aide B she said on 06/10/18 she was delivering napkins to the dining room and she heard the door alarm down the hall where the offices are. I went down the hall the where the west side door exit was and saw Resident #28 at the Housing Authority apartments inside their gate. Laundry Aide B said Resident #28 fell on the steps at an apartment across from the facility. She said when I got to Resident #28 I saw a apartment resident and asked her to call the nursing home to help me get Resident #28 back to the facility because I forgot my telephone. Laundry Aide B said when she left the west side exit she left the alarm on and she saw Dietary Aide looking out the door and she said I told her to get help. The dietary aide got three nurses to come over with a wheel chair and we took Resident #28 back to the facility. Record review of Incidents/Accidents dated 06/27/18 at 6:15 P.M. revealed the following: Resident (Resident #28) was witnessed at the Housing Authority heading toward the highway. Laundry staff (Laundry Aide A) saw Resident #28 and immediately responded to her and called the facility. Resident #28 was picked up in LVN E's pickup and brought back to the facility. No adverse effects, injuries or falls noted. During an interview on 08/30/18 at 9:30 A.M. with Laundry Aide A she said on 06/27/18 she was picking up laundry when she hears the door alarm going crazy on the west side exit and saw Resident #28 going to the Housing Authority I told her to come back and she got mad and kept walking. I called the facility and told them to help me get Resident #28 back. Laundry Aide A said LVN E came in her pick up and Resident #28 got in her truck and LVN E brought her back to the facility. During an interview on 08/30/18 at 3:45 PM. With LVN E she said Resident #28 had eloped on 06/27/18 and Laundry Aide A was trying to get her back in the facility. She said Resident #28 was combative and we could not convince her to go back to the facility. She said she got her truck and Resident #28 got in the truck with her and she took Resident #28 back to the facility. LVN E said she did not hear the alarm and that has always been a problem. Review of facility's undated policy and procedure titled Wander- guards Policy and Procedure revealed: 4. The resident's care plan will be updated to reflect that the resident is potentially an elopement risk or at risk for other safety issues. Record review of facility's policy and procedure dated (MONTH) 2007 titled Elopements revealed the following: 3. When a departing individual return to the facility, the Director of Nursing Services or Charge Nurse shall: .b. Notify the Attending Physician; .d. Complete and file Report of Incident/Accident An Immediate Jeopardy was identified on 8/29/18 at 3:15 P.M. The Administrator and DON were informed, and a Plan of Removal was requested at that time. The Plan of Removal dated 8/30/18 and accepted on 8/31/18 at 4:00 P.M., indicated the following: Criterion 1: What corrective action will be taken for those residents found to have been affected by the deficient practice? Residents with cognitive impairment who are at risk for elopement were immediately assessed, without negative findings by the nursing staff. Educated staff members that resident will only go outside with supervision. (8/29/18) The code for egress doors will be removed for safety purpose. (8/30/18) Criterion 2: How other residents with the potential to be affected by the same deficient practice will be identified? Three residents with cognitive impairment at risk for elopement had the potential to be affected by the alleged deficient practice. Criterion 3: What measures will be put into place or systematic changes will be made to ensure that the deficient practice does not occur? Staff was immediately re-educated on neglect, elopement, adequate supervision, for cognitively impaired residents at risk for elopement, heat exhaustion, and hydration, staff was also educated on the designated outdoor sitting area where residents with cognitive impairment who are at risk for elopement will sit, as a resident request activity, with adequate supervision with a staff member present. Current and new residents and their representatives will be notified of the designated outdoor sitting area. This will be completed by the end of business 8/30/18. Staff members that do not sign off on the re-education will not be allowed to work until they have reviewed and signed the sign-in sheet. Develop a policy and procedure for Wander guard system. (8/30/18 A staff member will maintain direct line of sight of the front of the facility, by staffing the west nurses' station, hall or lobby on al shifts. (8/29/18) Criterion 4: How the corrective actions will be monitored to ensure the deficient practice is being corrected and will not occur? The Administrator, DON, or assigned designee will make unannounced surveillance rounds on all shifts monitoring exit doors, adequate supervision and any potential risk for elopement. Employees will be educated in the orientation process on neglect, elopement, adequate supervision for cognitively impaired residents at risk for elopement heat exhaustion, hydration and resident designated outdoor siting area (8/30/18) Administrator, DON, or assigned designee will report abnormal findings to the management team, and the Quality Assurance Committee for three months or until the committee deems it no longer is necessary. Continue monitoring of the elopement policy will be ongoing to meet the needs of the resident. Criterion 5: When corrective action will be completed? Correction date: End of business 8/30/18 (1 day after IJ announced) Review of the undated policy titled Wander guards Policy and Procedure revealed the following: Policy statement The facility will strive to prevent unsafe individuals from wandering while still maintaining the least restrictive living environment for residents that are deemed at risk for possible elopement. Policy Interpretation and implementation 1. Upon admission the resident will be screened for possible elopement risks using assigned elopement form in admission packet. 2. A consent is place in the admission packet that allows staff to receive consent from responsible party or designated resident representative to place a wander guard if deemed necessary. 3. Once the consent is received the bracelet will be applied to an area of the body which as wrist or ankle. 4. The resident's care plan will be updated to reflect that the resident is potentially an elopement risk or for other safety issues. 5. Th nursing staff will include routine monitoring of the wander guard each shift onto the treatment order sheet (TARS). 6. Any device needing to be changed will be changed immediately, any abnormal findings will be reported to the Administrator, DON, or assigned designee. 7. The resident will be reviewed on a quarterly basis or as needed to determine if they are still at risk for elopement and this will be documented in the medical record. 8. When a resident has become a risk for elopement based on a resident elopement risk assessment, staff will notify resident and/or resident representative for consent to place a wander guard. Monitoring interviews with the following staff on 8/30/18 revealed staff were aware of wandering/elopement risk residents and wander guard/elopement policies and procedures. 2:10 PM- CNA H Monitoring West side exit 2:45 PM- LVN D E MDS Coordinator 3:00 PM- DON 3:05 PM- LVN I Monitor West side exit 3:15 PM- CNA J Works Zone I, II, III, IV 3:25 PM - Dietary Aide 3:30 PM - Dietary Manager 3:35 PM - CMA K Dispense medications to Zone I, II, III, IV 3:50 PM - LVN E Evening shift nurse supervisor 4:00 PM - LVN L Night shift nurse supervisor Record review of the Wander book and physician orders [REDACTED]. Record review of provided documentation dated 8/30/18, indicated the facility audited all residents in the facility for the following: Elopement risk wander guard orders, diagnosis, BIMS score, behavior monitoring, information in elopement book (if at risk), MDS coding, and care plan. Record review of provided in-service documentation dated 8/30/18 indicated staff signed off on being in-serviced regarding Elopement Policies and Procedures, wander guard/elopement book, wander guard elopement documentation, wander guard function checks, wander guard expiration and placement checks, abuse/neglect policy, reporting change of condition, signs of increased wandering/elopement risk, updating care plans, and accountability of residents through shift. Review of a list of residents provided by the DON on 8/30/18 indicated 3 residents were at risk for elopement/wandering. Record review of the Wander book and physician orders [REDACTED]. Record review of provided documentation dated 8/30/18, indicated the facility audited all residents in the facility for the following: Elopement risk wander guard orders, diagnosis, BIMS score, behavior monitoring, information in elopement book (if at risk), MDS coding, and care plan. Record review of provided in-service documentation dated 8/30/18 indicated staff signed off on being in-serviced regarding Elopement Policies and Procedures, wander guard/elopement book, wander guard elopement documentation, wander guard function checks, wander guard expiration and placement checks, abuse/neglect policy, reporting change of condition, signs of increased wandering/elopement risk, updating care plans, and accountability of residents through shift. While the Immediate Jeopardy was removed on 8/31/18 at 4:00 P.M. (Administrator notified), the facility remained out of compliance at the severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and at a scope of pattern because the facility was still monitoring the Plan of Removal. Review of a list of residents provided by the DON on 8/30/18 indicated 3 residents were at risk for elopement.

Based on observation, record review and interview the facility failed to implement its written policy and procedures that prohibit neglect. This failure affected 2 residents (Resident #1 and Resident #3) of 5 residents sampled for neglect. The facility failures were evidenced by: 1.) Failed to provide adequate supervision to prevent Resident #1 from falling. 2.) CNA ' A ' transferred Resident #1 to his wheelchair after a fall. 3.) CNA ' A ' failed to report Resident #1 ' s fall to the charge nurse. 4.) Failed to investigate fractures of unknown origin for Resident #1 and #3, when X-ray results determined Resident #1 had a left [MEDICAL CONDITION] and determined Resident #3 had a fractured left thumb. 5.) Created a risk for elopement for wandering for Resident #3 when propping open the doors to the locked Alzheimer's unit. 6.) Failed to provide adequate supervision of Resident #3 while outside in the courtyard of the locked Alzheimer's unit resulting in unwitnessed falls and a fracture of unknown origin to her left thumb. These facility failures could affect all of the 9 residents who reside on the locked Alzheimer's unit, by placing all 9 residents at risk for further injury from unwitnessed falls due to inadequate supervision, by placing all 9 residents at risk for abuse/neglect by not investigating injury of unknown origin, and by placing wandering residents at risk of elopement. These failures resulted in Immediate Jeopardy which was identified on 1/12/11. While the Immediate Jeopardy was removed on 1/14/11, the facility remained out of compliance at a level of a pattern of actual harm. Although these facility failures affected Resident #1 and #3, all 9 residents who lived on the secured Alzheimer's Unit could have been affected. Findings included: Review of the facility ' s Provider Investigation Report dated 12/29/10 at 2:44 p.m. revealed; Administrator (ADM) was in the facility about 11:00 a.m. on 12/29/10. The ADM stated he was reviewing the tapes to the security cameras due to recently having computer programmers in the facility and was monitoring to make sure the cameras were working properly. He stated at random he had picked the Alzheimer's unit on 12/25/10 to review. He stated that during his review of the tapes at " around 3:00 p.m. " he observed Resident #1 stand up from his wheelchair and fall to the floor on his left side," apparently hitting his head on another chair. " He stated he had observed CNA ' A ' who had been sitting at the desk in the lobby, walk over to Resident #1 and pick him up and place him back into his wheelchair. He stated after CNA ' A ' had placed Resident #1 back into his wheelchair, CNA ' A ' went back to the desk and left Resident #1 in the lobby in his wheelchair. He stated he further observed " about 30 minutes later " , RN ' A ' was making rounds on the unit and noticed Resident #1 crying and asked him if he was hurting. The ADM stated, " He must have said yes and then she told LVN ' A ' , who gave Resident #1 a pain pill of some kind." He stated during the time period observed " no nurse assessed Resident #1 " and " Both nurses reported they were not aware of Resident #1 falling." He stated he had shown the tape to the DON and ADON (Assistant Director of Nurses) and began the Provider Investigation Report and notified the local Sheriff 's dept. The ADM statement revealed at 1:30 p.m. on 12/29/10, he, the DON, and the ADON had interviewed CNA ' A ' who denied knowing Resident #1 had fallen and denied anything out of the ordinary had happened on 12/25/10. Review of the security camera video tape dated 12/25/10 from 2:45 p.m. through 3:44 p.m. revealed the following: (Note: There was no audio to this video) The video begins at 2:45 p.m. on 12/25/10; Resident #1 was alone with no supervision and seen standing up from his wheelchair in the lobby of the Alzheimer's unit. Resident #2 was observed coming from the patio area and speaking to Resident #1. At 2:46 p.m. CNA ' A ' , was observed to come from the hallway and sit at the desk, after a few minutes he laid his head down on the desk. At 2:51 p.m. Resident #1 was observed attempting to stand up from his wheelchair and sitting back down. At 2:52 p.m. Resident #1 was seen attempting to stand up from his wheelchair and sitting back down. At 2:56 p.m. Resident #1 was observed to completely stand up from his wheelchair, revealing his pressure alarm in the seat of his wheelchair, Resident #1 sat back down. At 2:57 p.m. Resident #1 was observed to stand up from his wheelchair for approximately 1 minute, as he attempted to sit back down he lost his footing and fell to the floor on his left side, striking his head on a chair in the lobby. At 2:58 p.m. CNA ' A ' was observed getting up from the desk and walking over towards Resident #1's wheelchair, moving it closer to Resident #1. CNA ' A ' was observed putting Resident #1 's right shoe back on his foot, pulling Resident #1 up to a seated position on the floor, and then moving behind Resident #1 and lifting him up and placing him back in his wheelchair. CNA ' A ' was observed to stand with Resident #1 for a short time then CNA ' A ' was observed to walk down the hallway, leaving Resident #1 sitting in his wheelchair, alone in the lobby of the Alzheimer's unit. At 3:00 p.m. CNA ' A ' was observed to walk out from the hallway accompanied by Resident #2. It appeared CNA ' A ' was directing Resident #2 to sit on the couch in the lobby. Resident #2, did not sit on the couch, but instead walked over to Resident #1. Resident #2 was observed to console by patting Resident #1 . Resident #2's hands were shaking and his attentions are more focused towards Resident #1.) At 3:02 p.m. CNA ' A ' was observed to direct Resident #2 to sit on the couch again, Resident #2 was observed to walk into the hallway. At 3:07 p.m. CNA ' A ' was observed to touch a button on the call light system and walk down the hallway, leaving Resident #1 unsupervised. At 3:08 p.m. Resident #1 was observed standing up from his wheelchair and sitting back down. At 3:10 p.m. Resident #1 was observed standing up from his wheelchair and sitting back down. (Note Resident #1 was left unsupervised for 4 minutes). At 3:11 p.m. CNA ' A ' was observed coming back from the hallway and sitting at the desk. CNA ' A ' laid his head on the desk face down. At 3: 14 p.m. CNA ' A ' was observed to get up from the desk and go back down the hallway leaving Resident #1 unsupervised. At 3:15 p.m. HSKP was observed on the unit, Resident #2 was observed to talk to her. At 3:17 p.m. HSKP was observed speaking to Resident #1, Resident #2 was standing at her side. At 3: 22 p.m. Resident #2 was observed with a female visitor (the facility identified as Resident #2 ' s granddaughter); Resident #2 was observed to walk her over to Resident #1. Resident #2 and visitor were observed to leave the lobby. No staff was observed in the area. At 3:23 p.m. Resident #1 was observed attempting to stand up from his wheelchair and sitting back down. At 3:25 p.m. Resident #2 was observed picking up the call light system and pulling it towards Resident #1. At 3:26 p.m. Resident #2 was observed pushing Resident #1 's wheelchair towards one of the lobby chairs. The HSKP was observed speaking to Resident #1 and Resident #2. RN ' A ' was observed walking from the hallway. HSKP is talking to RN ' A ' and was observed motioning to her right side and pointing towards Resident #1's left side. At 3:28 p.m. RN ' A ' was observed to walk down the hallway away from Resident #1 leaving him unsupervised. At 3:32 p.m. Resident #1 was observed attempting to stand up from his wheelchair and sitting back down.(Note: CNA ' A ' left Resident #1 unsupervised for 18 minutes) CNA ' A ' was observed to come from the hallway, HSKP was observed to speak to CNA ' A ' and make hand motions towards her side. CNA ' A ' was observed to walk towards the desk, stop and fix the cord to the call light system, then sit down and place his head on the desk. At 3:37 p.m. LVN ' A ' was observed to come into the lobby area from the hallway. She approached Resident #1 and gave him a medication and water. At 3:42 p.m. Resident #1 was observed attempting to stand up from his wheelchair and sitting back down, while CNA ' A ' was sitting at the desk. (Note: CNA ' A ' is observed to get up from his seat at the desk to redirect Resident #2 who was attempting to push Resident #1's wheelchair, after he had pushed him approximately 4 feet.) At 3:44 p.m. RN ' A ' was observed coming from the hallway and speaking to CNA ' A ' , and RN ' A ' was observed to reach up and put her hand to CNA 'A's cheek. Resident #1 Review of Resident #1's Record of admitted d 1/11/11 at 12:40 p.m. revealed Resident #1 was admitted on [DATE] and readmitted on [DATE]. He was [AGE] years old at the time of this investigation. Review of Resident #1's consolidated physician orders [REDACTED]. Included in Resident #1's consolidated physician orders [REDACTED]. and Moniotr for signs and symptoms of [MEDICAL CONDITION] every shift dated 12/02/10. Review of Resident #1's History and Physical dated 12/26/10 revealed, Resident #1 had been admitted to the hospital with [REDACTED]. Past Surgical History included: [MEDICATION NAME] surgery (11/26/10), Orchiectomy, Ventriculoperitoneal shunt, and Open reduction and internal fixation of right hip. Review of Resident #1 ' s Functional Assessment for Persons with Alzheimer ' s Disease dated 11/9/10 revealed the facility had identified Resident #1 ' s orientation as unable to identify place or misidentifies place; disoriented to day/month/season/year; usually knows immediate family but misidentifies extended family members/friends. Resident #1 ' s motor skills were identified as difficulty making complex decisions. Resident #1 ' s attention, memory and cognitive functioning was identified as distractible; severe short term memory deficit, long term memory somewhat impaired; fixations; possessive with belongings; territorial; sleep disturbances; has catastrophic reactions; unprovoked aggression; resists care; misidentifies objects/use. Review of Resident #1 ' s Care Plan dated 12/2/10 revealed the facility had identified Resident #1 as having Self Care Deficit in the following areas: Transferring and Ambulation: Problem / Need related to: Dementia, Alzheimer ' s, resulting in two staff assist. Goals were identified as: Resident will be free of complications secondary to requiring staff assistance, Resident will maintain intact skin, Resident will have normal bowel patterns and absence of [MEDICAL CONDITION], and Resident will maintain a positive self image. Interventions: Knock on door before entering room. Call resident by name and identify yourself by name. Resident uses wheelchair. Review of Resident #1's Nurses Notes dated 12/26/10 at 7:50 a.m. revealed the CNA (unidentified) had reported Resident#1 had pain and [MEDICAL CONDITION] to his left foot and received PRN pain medication. Review of Resident #1's Nurses Notes dated 12/26/10 at 9:10 a.m. revealed Hospice was informed of Resident#1's pain and [MEDICAL CONDITION] to his left foot. Review of Resident #1's Nurses Notes dated 12/26/10 at 1:05 p.m. revealed, " [MEDICAL CONDITION] continues to the top of the left foot, elevation ineffective. Resident ' s left outer upper thigh is now swollen. Painful to touch. " Review of Resident #1's Nurses Notes dated 12/26/10 at 1:15 p.m. revealed Hospice was called and the facility was awaiting return call. Review of Resident #1's Nurses Notes dated 12/26/10 at 2:15 p.m. revealed Hospice nurse had arrived to assess Resident #1. Resident #1 ' s left leg was " exhibiting outward rotation with pain when moved. " Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 2:00 p.m. revealed, Hospice nurse had assessed Resident #1 and found him to have mild +1 [MEDICAL CONDITION] to his left foot, +2 [MEDICAL CONDITION] to his upper left thigh, and his left leg was abducted. New Orders per Hospice: X-ray of left hip. Review of Resident #1' s Nurses Notes dated 12/26/10 at 3:40 p.m. revealed Mobile Imaging had arrived to do X-ray of Resident #1 ' s left hip. Review of Resident #1's X-ray Report dated 12/26/10 received by the facility at 5:25 p.m. revealed, Findings: Acute Left Comminuted Intertrochanteric Fracture with Mild Displacement. (Note: Comminuted Fracture is a fracture in which the bone is broken, splintered or crushed into a number of pieces.) Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 5:40 p.m. revealed results from X-ray had been received with the Diagnosis: [REDACTED]. Review of Resident #1's Nurses Notes dated 12/26/10 at 5:55 p.m. revealed physician orders [REDACTED]. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 6:40 p.m. revealed Resident #1 was transferred to the hospital via ambulance. D.O.N (Director of Nurses) and Resident #1 ' s physician were notified of transfer. Review of the facility 's statement from CNA ' A ' dated 12/29/10, regarding Resident #1 's fall on 12/25/10 revealed, CNA ' A ' had been working on the locked Alzheimer ' s unit when about 3:00 p.m. Resident #1 fell to the floor. He stated he proceeded to help Resident #1 into his chair, and " without thinking " did not report Resident #1 ' s fall to the nurse. CNA ' A ' stated he had not been feeling well that day and he felt his head was " in a blur " . He stated the only medications he had taken were Pepto Bismol, and Tylenol Cold and Flu. In an interview on 1/10/11 at 1:30 p.m. with the DON she revealed, she was very surprised at what she had observed on the video regarding Resident #1 ' s fall. She stated CNA ' A ' had been a hard worker until recently and she would have never suspected the observed behaviors out of him. She stated he had only had a couple of performance issues requiring any counseling, one being he had " walked off the job " , and the other not wearing the proper work attire. She stated, " This has all caught me completely off guard, and has been very upsetting to everyone involved. " In an observation on 1/10/11 at 1:45 p.m. revealed Resident #1 resting in his bed with his eyes closed. His room is minimally decorated, bed alarm observed. During an interview on 1/10/11 at 2:00 p.m. with ADM revealed, CNA ' A ' had been terminated as of 12/30/10 due to picking up Resident #1 when he fell , and not reporting a fall to the nurse. ADM stated he had made DADS a copy of the security camera video and he would like to show this surveyor several things on the video. The video was observed in the ADM office with DON and ADON. During an interview on 1/10/11 at 2:30 p.m. with one of the facility housekeeper ' s (HSKP) revealed when she arrived to the Alzheimer's unit lobby on 12/25/10 were she observed Resident #1 was sitting in his wheelchair crying. She stated she asked him in Spanish why he was crying, and he had replied to her in Spanish he was crying because his left leg and side hurt. She stated she talked to Resident #1 for a few minutes and she notified the nurse. She also stated she felt CNA ' A ' was " very sick that day and had a red face. " During an interview on 1/10/11 at 2:58 p.m. with ADM stated, no investigation of abuse or neglect had been done following receiving the X-ray results of Resident #1 ' s revealing a left [MEDICAL CONDITION] on 12/26/10. He stated he was not aware of Resident #1 ' s fall until 12/29/10, when he watched the video and had begun his investigation at that time. During an interview on 1/10/11 at 2:58 p.m. with the DON, she stated she had done a " verbal investigation " . The DON stated she had attempted to investigate Resident #1's left [MEDICAL CONDITION], but after reading the X-ray results had assumed Resident #1 ' s fracture was " pathological " due to the results stating he had [MEDICAL CONDITION]. She stated she asked the CNA ' s and the nurses if Resident #1 had fallen, or if they had any knowledge of how he might have injured his hip and no one was aware of any incidents. She stated the investigation began on 12/29/10 after observing the fall on the security tape. The DON stated she would look through all of her personal notes to see if she had documented any of her investigation into Resident #1's X-ray results received on 12/26/10 with the finding of left [MEDICAL CONDITION]. During an interview on 1/10/11 at 3:20 p.m. with CNA ' C ' , she revealed she had worked with CNA ' A ' before and she felt he had been " a hard worker and took good care of the residents. " She stated she had not ever been aware of CNA ' A ' being abusive or neglectful of the residents. She stated CNA ' A ' had been ill recently with a " stomach virus ". During an interview on 1/11/11 at 10:00 a.m. with Hospice RN she stated she had been notified originally regarding Resident #1 having [MEDICAL CONDITION] to his left foot on 12/26/10. She stated upon assessment of Resident #1 she had determined he had [MEDICAL CONDITION] to his left foot and left thigh and had ordered an X-ray. She stated Resident #1 was asleep during the majority of her assessment and did not show signs of being in a large amount of pain. She stated she had not notified by the facility of any falls or incidents regarding Resident #1. During an interview on 1/11/11 at 10:15 a.m. with RN ' A ' she revealed CNA ' A ' had not notified her of Resident #1 ' s fall on 12/25/10. She stated she had noticed while doing her rounds on the Alzheimer ' s unit, Resident #1 appeared to be in pain. She stated she could " see it in his eyes " . She stated Resident #1 had complaints of leg pain and she had informed LVN ' A ' to administer medications to alleviate his pain. RN ' A ' stated she had assisted CNA ' A ' with transferring Resident #1 to his bed to help him to be more comfortable, she stated while doing so she had assessed Resident #1 ' s pain, but had not done a head to toe assessment and had not observed anything abnormal regarding Resident #1. During an interview on 1/11/11 at 10:45 a.m. with DON, she stated after she had investigated and did not find any explanation of Resident #1 ' s left [MEDICAL CONDITION], she had assumed it was pathological. She stated she knew that she should not have " assumed " anything and should have investigated more diligently. She stated she could not locate any documentation of her investigation. During an interview on 1/11/11 at 10:45 a.m. with ADM, he stated, " Even if the DON had investigated Resident #1's left [MEDICAL CONDITION] results, it doesn't mean we would know exactly what happened. It could have happened while he moved in the bed. " The ADM stated, " The incident was not apparent until the video was observed on 12/29/10. He stated despite the facility not knowing how Resident #1 ' s hip was fractured, there was no formal investigation until the video had been observed on 12/29/10. During an interview on 1/11/11 at 11:32 a.m. with CNA ' A ' via telephone revealed CNA ' A ' requested to speak " face to face " and did not feel comfortable speaking about the situation over the phone. Arrangements were made with CNA ' A ' to meet him at a local fast food restaurant at 4:30 p.m. on 1/11/11. During an interview on 1/11/11 at 11:45 a.m. with ADON revealed she had been notified of CNA ' A ' being ill at approximately 3:00 p.m. on 12/25/10 and she began searching for another CNA to go in and replace him. She stated she had contacted CNA ' E ' , who agreed to replace CNA ' A ' at 5:00 p.m. on 12/25/10. During an interview on 1/11/11 at 2:10 p.m. with LVN ' C ' revealed she had worked the 10-6 shift on 12/25/10. She stated Resident #1 had slept all night and had made no complaints of pain. During an interview on 1/11/11 at 2:20 p.m. with LVN ' B ' revealed she felt CNA ' A ' was a " good CNA " . She stated she was very shocked when she saw the video of the Resident #1 falling. She stated she felt CNA ' A ' was not his " normal self " , he had recently had a baby, he had recently had " the flu " , and he " should have called in sick if he felt like he had it again. " She stated she had never seen CNA ' A ' being anything but caring towards the residents, and generally went above and beyond his job duties. In an interview on 1/11/11 at 2:30 p.m. with CNA ' F ' revealed she had been originally scheduled to work with CNA ' A ' on the Alzheimer ' s Unit for the 2-10 shift on 12/25/10. She stated when she arrived she could tell CNA ' A ' was not feeling well, his face was " flushed " and he was " very quiet " which was unlike his usual demeanor. She stated she was notified due to being " short staffed " ; she would need to go and work on the East wing. (Note: This action left CNA 'A' alone on the locked Alzheimer's unit to monitor residents.) During an interview on 1/11/11 at 3:00 p.m. with LVN ' A ' she revealed she was aware when CNA ' A ' arrived to clock in he was sick. She stated he had a " stomach virus " for the second time. She stated she and RN ' A ' immediately started to find another staff to come in and replace CNA ' A ' . LVN ' A ' stated she had no knowledge of Resident #1 ' s fall on 12/25/10, and CNA ' A ' had not mentioned any abnormal happenings on the Alzheimer ' s unit with any residents on 12/25/10. She stated RN ' A ' had informed her about Resident #1 ' s pain and she had medicated him per physician orders. She stated Resident #1 is " hard to assess " due to his cognitive level and he frequently has complaints of pain and cannot verbalize where his pain is located. She stated the nurses have to often attempt to determine if Resident #1 is in pain by non-verbal cues such as grimacing. She stated she was able to determine Resident #1 was having left leg pain, but had not done a full assessment. In an interview on 1/11/11 at 4:30 p.m. with CNA ' A ' he revealed on 12/25/10 at approximately 10:00 a.m. he stated he had called and left a message on the ADON ' s cell phone informing her that he was ill with vomiting and diarrhea and needed to be taken off the schedule. He stated he did not receive a call back and went into to work his scheduled 2-10 shift even though he was feeling ill. CNA ' A ' stated he had notified LVN ' A ' when he arrived at work of his vomiting and diarrhea and she had informed him they would try and find someone to replace him. He stated CNA ' F ' was also scheduled on the Alzheimer ' s Unit for 2-10 shift on 12/25/10 and RN ' A ' had reassigned her to the East Wing due to other staff calling in sick that shift. He stated when he arrived to the unit he was responsible for caring for 8 residents and 1 more resident was due back from a pass later in the shift. He stated he was back and forth to the restroom with vomiting and diarrhea while he was on duty. He stated before 3:00 p.m. he was sitting at the desk when Resident #1 stood up from his wheelchair. He stated he had redirected Resident #1 to sit back down and when Resident #1 had attempted to sit back down he had somehow " lost his footing " and he had fallen to the floor. He stated he went and moved the wheelchair due to Resident #1 ' s leg being on the foot rest and then " immediately " attempted to care for Resident #1. CNA ' A ' stated Resident #1 had requested CNA ' A ' to assist him up from the floor. He stated he did not see any bruising or injury and he helped Resident #1 back up into his wheelchair. CNA ' A ' stated he used the speaker (intercom system) to notify LVN ' A ' of Resident #1 ' s fall, but wasn't sure she had heard him. He stated he had talked with HSKP in the hallway and she had informed him, Resident #1 had complaints of his left leg hurting. CNA ' A ' stated at approximately 3:00 p.m. he had gone to the unit doors to " double check " if LVN ' A ' had heard him and had discussed Resident #1 ' s fall with her. He stated a few minutes later RN ' A ' came to the unit and talked with Resident #1, then LVN ' A ' came onto the unit and gave Resident #1 a pain pill. He stated he was not sure if the nurses assessed Resident #1 or not, due to having to answer call lights for other residents on the unit. CNA ' A ' stated CNA ' E ' arrived to replace him around 6:00 p.m. and he had informed her of Resident #1 ' s fall and complaints of pain to his left leg. CNA ' A ' stated he knew the one thing he had done wrong was to move Resident #1 after he had fallen due to the nurses needing to assess him for injury. CNA ' A ' stated he was not aware of any specific interventions to keep Resident #1 from falling with the exception of telling Resident #1 to sit back down. CNA ' A ' stated, Resident #1 ' s wheelchair alarm was sounding when Resident #1 attempted to stand up from his wheelchair. He stated, " The alarm went off 3 or 4 times and I would tell him to sit down and he would sit down. " CNA ' A ' stated he was not aware if Resident #1 had hit his head during the fall and if Resident #1 had hit his head, he would have gone and informed the nurse. In an interview on 1/12/11 at 1:40 p.m. with CNA ' G ', she stated that there have been many times when she has had to work on the Alzheimer ' s Unit alone. She stated the bathroom for the staff is located off the unit, therefore if a staff person is working on the unit alone, they have to wait until someone can come sit on the unit to monitor the residents or if it ' s late and most of the residents are in bed, " we just prop one of the doors open " . In an interview on 1/12/11 at 1:10 p.m. the Administrator said all the only staff that were in-serviced was listed on the Provider Investigation Report and no other staff had been in-serviced. In an interview on 1/12/11 at 1:32 p.m. the ADON said she was on call 24/7 for the facility staffing. She said CNA ' A ' reported to work at 1:45 p.m. and she received a call from RN ' A ' at 3:00 p.m. regarding CNA ' A ' being sick with the stomach bug. She said CNA ' A ' was able to go home at 5:15 p.m. She said the policy regarding staffing for the locked dementia unit was two CNA ' s in the morning, 2 in the afternoon and 1 at night. She said on 12/25/10 on the 2:00 p.m. to 10 p.m. shift the facility had 1 RN, 2 LVN ' s, 4 CNA ' s and a medication aide from 4:00 p.m. to 8:00 p.m. She said, for example, if the unit had only one CNA and a resident needed incontinent care the other residents would be unattended while the CNA was assisting the resident. On 1/12/11 at 2:25 p.m. the Administrator and DON were notified of IJ and substandard quality of care. In an interview on 1/12/11 at 2:58 p.m. LVN ' A ' said CNA ' A ' arrived at work on 12/25/10 for his 2-10 shift . She said he appeared pale and felt warm to the touch. She said he reported he had the stomach bug and had an episode of diarrhea when he arrived at the facility for his shift. She said she asked him if he wanted some Tylenol and he told her he did not want any because he would not be able to keep it down. She said the RN called the ADON to report CNA ' A ' was ill when he arrived for his shift but the ADON did not return the call until 3:00 p.m. She said CNA ' A ' was on the schedule for the locked dementia unit so they just stayed with the schedule and tried to find him a replacement. She said there was no bathroom on the locked dementia unit and the staff would have to leave the unit to go to the bathroom. She said she was not sure if CNA ' A ' had to the leave the unit that day but usually if there was just one staff person on the unit the staff would prop the locked door open and go to the bathroom in the main building. She said the staff prop the door open a lot at night because there is just one staff member on the unit. She said the staff tries not to leave the door propped open too much due to the wandering residents. She said a lot of the time on the 2:00 p.m. to 10:00 p.m. shift there was just one aide on the Alzheimer ' s unit. She said on 12/25/10 on the 2:00 p.m. to 10:00 p.m. shift there was 1 RN, 2 LVN ' s, 4 CNA ' s and a medication aide came in at 4:00 p.m. She said a replacement was found for CNA ' A ' and he was able to go home at 5:15 p.m. During an interview on 1/12/11 at 3:30 p.m. the Administrator, DON and ADON said they were not aware the staff was leaving the locked door to the Alzheimer ' s unit propped open. The DON said the staff did not leave the door open when administration was in the building and the staff had been told not to prop the door open. During an interview on 1/13/11 at 10:35 a.m. the DON said if an investigation had been done on an incident, it would be on a piece of paper stapled to the Incident/Accident form. She said she did not have a system for conducting investigations. During a telephone interview on 1/13/11 at 2:36 p.m. LVN ' B ' said there was only one CNA for the locked dementia unit on the 2:00 p.m. to 10:00 p.m. shift about 50% of the time. She said the facility had difficulty staffing the unit. She said the staff propped the door to the Alzheimer ' s unit open some on the afternoon and night shift but more on the night shift. During an interview on 1/13/11 at 3:15 p.m. RN ' B ' , who worked the 2:00 p.m. to 10:00 p.m. shift, said the aides propped the door open on the locked Alzheimer ' s unit at times. She said when she worked the aide would prop the door open, leave the unit and she would watch the unit from the nurse ' s station outside the locked doors. She said from that position she could not see the unit lobby area or patio but she could see down the main hall. Review of Resident #1 ' s Fall Risk assessment dated [DATE] revealed Resident #1 scored a total of 25. The assessment instructions revealed a score of higher than 10 or greater should be considered at HIGH RISK for potential falls and a prevention protocol should be initiated immediately and documented on the care plan. Review of facility ' s Incident and Accident report dated 10/17/10 at 2:30 a.m. revealed Resident #1 was up walking in his room without his walker. Resident #1 was witnessed to fall and sit on his buttocks in the middle of the floor. Resident #1 was alert and had no apparent injury. Additional comments and steps to be taken to prevent a recurrence: Encourage Resident to use his walker when he gets up. DON signature was dated 10/18/10. ADM signature was dated 10/20/10. Medical Director signature was dated 11/02/10. Review of facility ' s Incident and Accident report dated10/25/10 at 6:25 p.m. revealed Resident #1 was found on the floor in the sitting area in front of his wheelchair. Wheels on wheelchair were unlocked. Resident #1 ' s level of consciousness was alert. Additional comments and steps to be taken to prevent a recurrence: Lock Wheelchair. DON signature was dated 10/21/10. ADM signature was dated 10/22/10. Medical Director signature was dated 11/02/10. Review of Resident #1 's Care Plan dated 12/17/10 revealed Resident #1 had a fall resulting in minor injury resulting in a faint red mark to the middle of his back, described as fading. Strengths to draw on were listed as: Resident appears free of infection. Goals: will resume usual activities without further incident. Involved areas will resolve without complications. Interventions: Crani-checks for 48 hours (precautionary). Vital Signs per Neurological check protocol, Continue interventions on the at-risk plan. No further interventions were found. Review of Resident #1 ' s Minimum (MDS) data set [DATE] revealed Resident #1 was identified as having short and long term memory problems, he was sometimes understood and sometimes understands. Resident #1 was identified as being moderately impaired for cognitive skills for daily decision making. Res

Based on observation, interview and record review the facility failed to ensure that injuries of unknown origin involving 3 of 5 reviewed for neglect, Resident ' s (#1, #3 and #4) were thoroughly investigated to rule out mistreatment, abuse and neglect, and reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility failed to: 1.) Thoroughly investigate and report if required, falls involving a. The facility receiived x-ray results on 12/26/10 determining Resident #1 had sustained a left [MEDICAL CONDITION] and failed to investigate; b. The facility received x-ray results on 12/15/10 determining Resident #3 had sustained a left thumb fracture and failed to investigate; c. The facility failed to investigate Resident #4's unwitnessed fall requiring transfer to the emergency room . These failures resulted in an Immediate Jeopardy which was identified on 1/12/10. While the Immediate Jeopardy was removed on 1/14/10, the facility remained out of compliance at a level of a pattern of actual harm. These failures resulted in incident/falls involving Resident #1and #3 which resulted in injury, and Resident #4 having pain; not being fully investigated and resulted in the lack of corrective measures being implemented. These failures could affect any of the 9 residents who reside on the facility ' s Alzheimer ' s Unit and could result in abuse and neglect occurring undetected in the facility. Findings included: Review of the facility ' s Provider Investigation Report dated 12/29/10 at 2:44 p.m. revealed; Administrator (ADM) was in the facility about 11:00 a.m. on 12/29/10. The ADM stated he was reviewing the tapes to the security cameras due to recently having computer programmers in the facility and was monitoring to make sure the cameras were working properly. He stated at random he had picked the Alzheimer ' s unit on 12/25/10 to review. He stated that during his review of the tapes at " around 3:00 p.m. " he observed Resident #1 stand up from his wheelchair and fall to the floor on his left side, " apparently hitting his head on another chair. " He stated he had observed CNA ' A ' who had been sitting at the desk in the lobby, walk over to Resident #1 and pick him up and place him back into his wheelchair. He stated after CNA ' A ' had placed Resident #1 back into his wheelchair, CNA ' A ' had went back to the desk and left Resident #1 in the lobby in his wheelchair. He stated he had further observed " about 30 minutes later " , RN ' A ' was making rounds on the unit and noticed Resident #1 crying and asked him if he was hurting. The ADM states, " He must have said yes and then she told LVN ' A ' , who gave Resident #1 a pain pill of some kind. " He stated during the time period observed " no nurse assessed Resident #1 " and " Both nurses report that they were not aware of Resident #1 falling. " He stated he had shown the tape to the DON and ADON (Assistant Director of Nurses) and began the Provider Investigation Report and notified the local Sheriff ' s dept. The ADM statement revealed at 1:30 p.m. on 12/29/10, he, the DON, and the ADON had interviewed CNA ' A ' who denied knowing Resident #1 had fallen and denied anything out of the ordinary had happened on 12/25/10. Review of security camera video tape dated 12/25/10 from 2:45 p.m. through 3:44 p.m. revealed the following: (Note: There was no audio to this video) The video begins at 2:45 p.m. on 12/25/10; Resident #1 is alone with no supervision and seen standing up from his wheelchair in the lobby of the Alzheimer's unit. Resident #2 is observed coming from the patio area and speaking to Resident #1. At 2:46 p.m. CNA ' A ' , was observed to come from the hallway and sit at the desk, after a few minutes he lays his head down on the desk. At 2:51 p.m. Resident #1 is observed attempting to stand up from his wheelchair and sitting back down. At 2:52 p.m. Resident #1 is seen attempting to stand up from his wheelchair and sitting back down. At 2:56 p.m. Resident #1 is observed to completely stand up from his wheelchair, revealing his pressure alarm in the seat of his wheelchair, Resident #1 sat back down. At 2:57 p.m. Resident #1 is observed to stand up from his wheelchair for approximately 1 minute, as he attempts to sit back down he looses his footing and falls to the floor on his left side, striking his head on a chair in the lobby. At 2:58 p.m. CNA ' A ' is observed getting up from the desk and walking over towards Resident #1's wheelchair, moving it closer to Resident #1. CNA ' A ' is observed putting Resident #1 's right shoe back on his foot, pulling Resident #1 up to a seated position on the floor, and then moving behind Resident #1 and lifting him up and placing him back in his wheelchair. CNA ' A ' is observed to stand with Resident #1 for a short time then CNA ' A ' is observed to walk down the hallway, leaving Resident #1 sitting in his wheelchair, alone in the lobby of the Alzheimer ' s unit. At 3:00 p.m. CNA ' A ' was observed to walk out from the hallway accompanied by Resident #2. It appears CNA ' A ' was directing Resident #2 to sit on the couch in the lobby. Resident #2, does not sit on the couch, but instead walks over to Resident #1. (Resident #2 appears very anxious, his hands are shaking.) At 3:02 p.m. CNA ' A ' was observed to direct Resident #2 to sit on the couch again, Resident #2 is observed to walk into the hallway. At 3:07 p.m. CNA ' A ' was observed to touch a button on the Call Light System and walk down the hallway, leaving Resident #1 unsupervised. At 3:08 p.m. Resident #1 was observed standing up from his wheelchair and sitting back down. At 3:10 p.m. Resident #1 is observed standing up from his wheelchair and sitting back down. (Note Resident #1 was left unsupervised for 4 minutes).At 3:11 p.m. CNA ' A ' was observed coming back from the hallway and sitting at the desk. CNA ' A ' lays his head on the desk face down. At 3: 14 p.m. CNA ' A ' was observed to get up from the desk and go back down the hallway leaving Resident #1 unsupervised. At 3:15 p.m. HSKP is observed on the unit, Resident #2 is observed to talk to her. At 3:17 p.m. HSKP is observed speaking to Resident #1, Resident #2 is standing at her side. At 3: 22 p.m. Resident #2 is observed with a female visitor (the facility identified as Resident #2 ' s granddaughter); Resident #2 is observed to walk her over to Resident #1.Resident #2 and visitor were observed to leave the lobby. No staff was observed in the area. At 3:23 p.m. Resident #1 is observed attempting to stand up from his wheelchair and sitting back down. At 3:25 p.m. Resident #2 is observed picking up the Call Light System and pulling it towards Resident #1. At 3:26 p.m. Resident #2 is observed pushing Resident #1 ' s wheelchair towards one of the lobby chairs. The HSKP is observed speaking to Resident #1 and Resident #2. RN ' A ' is observed walking from the hallway. HSKP is talking to RN ' A ' and was observed motioning to her side and pointing towards Resident #1. At 3:28 p.m. RN ' A ' is observed to walk down the hallway away from Resident #1 leaving hi unsupervised. At 3:32 p.m. Resident #1 is observed attempting to stand up from his wheelchair and sitting back down.(Note: CNA ' A ' left Resident #1 unsupervised for 18 minutes) CNA ' A ' is observed to come from the hallway, HSKP is observed to speak to CNA ' A ' and make hand motions towards her side. CNA ' A ' is observed to walk towards the desk, stop and fix the cord to the Call Light System, then sit down and place his head on the desk. At 3:37 p.m. LVN ' A ' was observed to come into the lobby area from the hallway. She approached Resident #1 and gave him a medication and water. At 3:42 p.m. Resident #1 was observed attempting to stand up from his wheelchair and sitting back down, while CNA ' A ' is sitting at the desk. (Note: CNA ' A ' is observed to get up from his seat at the desk to redirect Resident #2 who was attempting to push Resident #1 ' s wheelchair, after he had pushed him approximately 4 feet.) At 3:44 p.m. RN ' A ' was observed coming from the hallway and speaking to CNA ' A ' , and RN ' A ' is observed to reach up and put her hand to his cheek. Resident #1 Review of Resident #1 ' s Record of admitted d 1/11/11 at 12:40 p.m. revealed Resident #1 was admitted on [DATE] and readmitted on [DATE]. He was [AGE] years old at the time of this investigation. Review of Resident #1 ' s consolidated physician orders [REDACTED]. Review of Resident #1 ' s History and Physical dated 12/26/10 revealed, Resident #1 had been admitted to the hospital with [REDACTED]. Past Surgical History included: [MEDICATION NAME] surgery (11/26/10), Orchiectomy, Ventriculoperitoneal shunt, and Open reduction and internal fixation of right hip. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 7:50 a.m. revealed the CNA (unidentified) had reported Resident#1 had pain and [MEDICAL CONDITION] to his left foot and received PRN pain medication. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 9:10 a.m. revealed Hospice was informed of Resident#1 ' s pain and [MEDICAL CONDITION] to his left foot. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 1:05 p.m. revealed, " [MEDICAL CONDITION] continues to the top of the left foot, elevation ineffective. Resident ' s left outer upper thigh is now swollen. Painful to touch. " Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 1:15 p.m. revealed Hospice was called and the facility was awaiting return call. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 2:15 p.m. revealed Hospice nurse had arrived to assess Resident #1. Resident #1 ' s left leg was " exhibiting outward rotation with pain when moved. " Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 2:00 p.m. revealed, Hospice nurse had assessed Resident #1 and found him to have mild +1 [MEDICAL CONDITION] to his left foot, +2 [MEDICAL CONDITION] to his upper left thigh, and his left leg was abducted. New Orders per Hospice: X-ray of left hip. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 3:40 p.m. revealed Mobile Imaging had arrived to do X-ray of Resident #1 ' s left hip. Review of Resident #1 ' s X-ray Report dated 12/26/10 received by the facility at 5:25 p.m. revealed, Findings: There is a left comminuted intertrochanteric fracture with mild displacement. Femoral head is in alignment within the acetabular fossa. The pubic rami are unremarkable. Impression: Acute Left Comminuted Intertrochanteric Fracture with Mild Displacement. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 5:40 p.m. revealed results from X-ray had been received with the Diagnosis: [REDACTED]. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 5:55 p.m. revealed physician orders [REDACTED]. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 6:40 p.m. revealed Resident #1 was transferred to the hospital via ambulance. D.O.N (Director of Nurses) and Resident #1 ' s physician were notified of transfer. Review of the facility 's statement from CNA ' A ' dated 12/29/10 regarding Resident #1's fall on 12/25/10 revealed, CNA ' A ' had been working on the locked Alzheimer 's unit when about 3:00 p.m. Resident #1 fell to the floor. He stated he proceeded to help Resident #1 into his chair, and " without thinking " did not report Resident #1 ' s fall to the nurse. CNA ' A ' stated he had not been feeling well that day and he felt his head was " in a blur " . He stated the only medications he had taken were Pepto Bismol, and Tylenol Cold and Flu. In an interview on 1/10/11 at 1:30 p.m. with the DON she revealed, she was very surprised at what she had observed on the video regarding Resident #1 ' s fall. She stated CNA ' A ' had been a hard worker until recently and she would have never suspected the observed behaviors out of him. She stated he had only had a couple of performance issues requiring any counseling, one being he had " walked off the job " , and the other not wearing the proper work attire. She stated, " This has all caught me completely off guard, and has been very upsetting to everyone involved. " In an observation on 1/10/11 at 1:45 p.m. revealed Resident #1 resting in his bed with his eyes closed. His room is minimally decorated, bed alarm observed. During an interview on 1/10/11 at 2:00 p.m. with ADM revealed, CNA ' A ' had been terminated as of 12/30/10 due to picking up Resident #1 when he fell , and not reporting a fall to the nurse. ADM stated he had made DADS a copy of the security camera video and he would like to show this surveyor several things on the video. The video was observed in the ADM office with DON and ADON. During an interview on 1/10/11 at 2:30 p.m. with one of the facility housekeeper 's (HSKP) revealed when she arrived to the Alzheimer's unit lobby to clean her observed Resident #1 was sitting in his wheelchair crying. She stated she asked him in Spanish why he was crying, and he had replied to her in Spanish he was crying because his left leg and side hurt. She stated she talked to Resident #1 for a few minutes and she notified the nurse. She also stated she felt CNA ' A ' was " very sick that day and had a red face. " During an interview on 1/10/11 at 2:58 p.m. with ADM stated, no investigation of abuse or neglect had been done following receiving the X-ray results of Resident #1 ' s revealing a left [MEDICAL CONDITION] on 12/26/10. He stated he was not aware of Resident #1 ' s fall until 12/29/10, when he watched the video and had begun his investigation at that time. During an interview on 1/10/11 at 2:58 p.m. with the DON, she stated she had done a " verbal investigation " . The DON stated she had attempted to investigate Resident #1's left [MEDICAL CONDITION], but after reading the X-ray results had assumed Resident #1's fracture was " pathological " due to the results stating he had [MEDICAL CONDITION]. She stated she asked the CNA ' s and the nurses if Resident #1 had fallen, or if they had any knowledge of how he might have injured his hip and no one was aware of any incidents. She stated the investigation began on 12/29/10 after observing the fall on the security tape. The DON stated she would look through all of her personal notes to see if she had documented any of her investigation into Resident #1's X-ray results received on 12/26/10 with the finding of left [MEDICAL CONDITION]. During an interview on 1/10/11 at 3:20 p.m. with CNA ' C ' , she revealed she had worked with CNA ' A ' before and she felt he had been " a hard worker and took good care of the residents. " She stated she had not ever been aware of CNA ' A ' being abusive or neglectful of the residents. She stated CNA ' A ' had been ill recently with a " stomach virus ". During an interview on 1/11/11 at 10:00 a.m. with Hospice RN she stated she had been notified originally regarding Resident #1 having [MEDICAL CONDITION] to his left foot on 12/26/10. She stated upon assessment of Resident #1 she had determined he had [MEDICAL CONDITION] to his left foot and left thigh and had ordered an X-ray. She stated Resident #1 was asleep during the majority of her assessment and did not show signs of being in a large amount of pain. She stated she had not notified by the facility of any falls or incidents regarding Resident #1. During an interview on 1/11/11 at 10:15 a.m. with RN ' A ' she revealed CNA ' A ' had not notified her of Resident #1 ' s fall on 12/25/10. She stated she had noticed while doing her rounds on the Alzheimer 's unit, Resident #1 appeared to be in pain. She stated she could " see it in his eyes " . She stated Resident #1 had complaints of leg pain and she had informed LVN ' A ' to administer medications to alleviate his pain. RN ' A ' stated she had assisted CNA ' A ' with transferring Resident #1 to his bed to help him to be more comfortable, she stated while doing so she had assessed Resident #1 ' s pain, but had not done a head to toe assessment and had not observed anything abnormal regarding Resident #1. During an interview on 1/11/11 at 10:45 a.m. with DON, she stated after she had investigated and did not find any explanation of Resident #1 's left [MEDICAL CONDITION], she had assumed it was pathological. She stated she knew that she should not have " assumed " anything and should have investigated more diligently. She stated she could not locate any documentation of her investigation. During an interview on 1/11/11 at 10:45 a.m. with ADM, he stated, " Even if the DON had investigated Resident #1's left [MEDICAL CONDITION] results, it doesn't mean we would know exactly what happened. It could have happened while he moved in the bed. " The ADM stated, " The incident was not apparent until the video was observed on 12/29/10. He stated despite the facility not knowing how Resident #1 ' s hip was fractured, there was no formal investigation until the video had been observed on 12/29/10. During an interview on 1/11/11 at 11:32 a.m. with CNA ' A ' via telephone revealed CNA ' A ' requested to speak " face to face " and did not feel comfortable speaking about the situation over the phone. Arrangements were made with CNA ' A ' to meet him at a local fast food restaurant at 4:30 p.m. on 1/11/11. During an interview on 1/11/11 at 11:45 a.m. with ADON revealed she had been notified of CNA ' A ' being ill at approximately 3:00 p.m. on 12/25/10 and she began searching for another CNA to go in and replace him. She stated she had contacted CNA ' E ' , who agreed to replace CNA ' A ' at 5:00 p.m. on 12/25/10. During an interview on 1/11/11 at 2:10 p.m. with LVN ' C ' revealed she had worked the 10-6 shift on 12/25/10. She stated Resident #1 had slept all night and had made no complaints of pain. During an interview on 1/11/11 at 2:20 p.m. with LVN ' B ' revealed she felt CNA ' A ' was a " good CNA " . She stated she was very shocked when she saw the video of the Resident #1 falling. She stated she felt CNA ' A ' was not his " normal self " , he had recently had a baby, he had recently had " the flu " , and he " should have called in sick if he felt like he had it again. " She stated she had never seen CNA ' A ' being anything but caring towards the residents, and generally went above and beyond his job duties. In an interview on 1/11/11 at 2:30 p.m. with CNA ' F ' revealed she had been originally scheduled to work with CNA ' A ' on the Alzheimer ' s Unit for the 2-10 shift on 12/25/10. She stated when she arrived she could tell CNA ' A ' was not feeling well, his face was " flushed " and he was " very quiet " which was unlike his usual demeanor. She stated she was notified due to being " short staffed " ; she would need to go and work on the East wing. During an interview on 1/11/11 at 3:00 p.m. with LVN ' A ' she revealed she was aware when CNA ' A ' arrived to clock in he was sick. She stated he had a " stomach virus " for the second time. She stated she and RN ' A ' immediately started to find another staff to come in and replace CNA ' A ' . LVN ' A ' stated she had no knowledge of Resident #1 ' s fall on 12/25/10, and CNA ' A ' had not mentioned any abnormal happenings on the Alzheimer ' s unit with any residents on 12/25/10. She stated RN ' A ' had informed her about Resident #1 ' s pain and she had medicated him per physician orders. She stated Resident #1 is " hard to assess " due to his cognitive level and he frequently has complaints of pain and cannot verbalize where his pain is located. She stated the nurses have to often attempt to determine if Resident #1 is in pain by non-verbal cues such as grimacing. She stated she was able to determine Resident #1 was having left leg pain, but had not done a full assessment. In an interview on 1/11/11 at 4:30 p.m. with CNA ' A ' he revealed on 12/25/10 at approximately 10:00 a.m. he stated he had called and left a message on the ADON ' s cell phone informing her that he was ill with vomiting and diarrhea and needed to be taken off the schedule. He stated he did not receive a call back and went into to work his scheduled 2-10 shift even though he was feeling ill. CNA ' A ' stated he had notified LVN ' A ' when he arrived at work of his vomiting and diarrhea and she had informed him they would try and find someone to replace him. He stated CNA ' F ' was also scheduled on the Alzheimer ' s Unit for 2-10 shift on 12/25/10 and RN ' A ' had reassigned her to the East Wing due to other staff calling in sick that shift. He stated when he arrived to the unit he was responsible for caring for 8 residents and 1 more resident was due back form a pass later in the shift. He stated he was back and forth to the restroom with vomiting and diarrhea while he was on duty. He stated before 3:00 p.m. he was sitting at the desk when Resident #1 stood up from his wheelchair. He stated he had redirected Resident #1 to sit back down and when Resident #1 had attempted to sit back down he had somehow " lost his footing " and he had fallen to the floor. He stated he went and moved the wheelchair due to Resident #1 ' s leg being on the foot rest and then " immediately " attempted to care for Resident #1. CNA ' A ' stated Resident #1 had requested CNA ' A ' to assist him up from the floor. He stated he did not see any bruising or injury and he helped Resident #1 back up into his wheelchair. CNA ' A ' stated he used the speaker (intercom system) to notify LVN ' A ' of Resident #1 ' s fall, but wasn't sure she had heard him. He stated he had talked with HSKP in the hallway and she had informed him, Resident #1 had complaints of his left leg hurting. CNA ' A ' stated at approximately 3:00 p.m. he had gone to the unit doors to " double check " if LVN ' A ' had heard him and had discussed Resident #1 ' s fall with her. He stated a few minutes later RN ' A ' came to the unit and talked with Resident #1, then LVN ' A ' came onto the unit and gave Resident #1 a pain pill. He stated he was not sure if the nurses assessed Resident #1 or not, due to having to answer call lights for other residents on the unit. CNA ' A ' stated CNA ' E ' arrived to replace him around 6:00 p.m. and he had informed her of Resident #1 ' s fall and complaints of pain to his left leg. CNA ' A ' stated he knew the one thing he had done wrong was to move Resident #1 after he had fallen due to the nurses needing to assess him for injury. CNA ' A ' stated he was not aware of any specific interventions to keep Resident #1 from falling with the exception of telling Resident #1 to sit back down. CNA ' A ' stated, Resident #1 ' s wheelchair alarm was sounding when Resident #1 attempted to stand up from his wheelchair. He stated, " The alarm went off 3 or 4 times and I would tell him to sit down and he would sit down. " CNA ' A ' stated he was not aware if Resident #1 had hit his head during the fall. He stated he was not aware of Resident #1 hitting his head during the fall and if Resident #1 had hit his head, he would have gone and informed the nurse. In an interview on 1/12/11 at 1:40 p.m. with CNA ' G ', she stated that there have been many times when she has had to work on the Alzheimer ' s Unit alone. She stated the bathroom for the staff is located off the unit, therefore if a staff person is working on the unit alone, they have to wait until someone can come sit on the unit to monitor the residents or if it ' s late and most of the residents are in bed, " we just prop one of the doors open " . In an interview on 1/12/11 at 1:10 p.m. the Administrator said all the only staff that were in-serviced was listed on the Provider Investigation Report and no other staff had been in-serviced. In an interview on 1/12/11 at 1:32 p.m. the ADON said she was on call 24/7 for the facility staffing. She said CNA ' A ' reported to work at 1:45 p.m. and she received a call from RN ' A ' at 3:00 p.m. regarding CNA ' A ' being sick with the stomach bug. She said CNA ' A ' was able to go home at 5:15 p.m. She said the policy regarding staffing for the locked dementia unit was two CNA ' s in the morning, 2 in the afternoon and 1 at night. She said on 12/25/10 on the 2:00 p.m. to 10 p.m. shift the facility had 1 RN, 2 LVN ' s, 4 CNA ' s and a medication aide from 4:00 p.m. to 8:00 p.m. She said, for example, if the unit had only one CNA and a resident needed incontinent care the other residents would be unattended while the CNA was assisting the resident. On 1/12/11 at 2:25 p.m. the Administrator and DON were notified of IJ and substandard quality of care. In an interview on 1/12/11 at 2:58 p.m. LVN ' A ' said CNA ' A ' arrived at work on 12/25/10 for his 2-10 shift . She said he appeared pale and felt warm to the touch. She said he reported he had the stomach bug and had an episode of diarrhea when he arrived at the facility for his shift. She said she asked him if he wanted some Tylenol and he told her he did not want any because he would not be able to keep it down. She said the RN called the ADON to report CNA ' A ' was ill when he arrived for his shift but the ADON did not return the call until 3:00 p.m. She said CNA ' A ' was on the schedule for the locked dementia unit so they just stayed with the schedule and tried to find him a replacement. She said there was no bathroom on the locked dementia unit and the staff would have to leave the unit to go to the bathroom. She said she was not sure if CNA ' A ' had to the leave the unit that day but usually if there was just one staff person on the unit the staff would prop the locked door open and go to the bathroom in the main building. She said the staff prop the door open a lot at night because there is just one staff member on the unit. She said the staff tries not to leave the door propped open too much due to the wandering residents. She said a lot of the time on the 2:00 p.m. to 10:00 p.m. shift there was just one aide on the Alzheimer ' s unit. She said on 12/25/10 on the 2:00 p.m. to 10:00 p.m. shift there was 1 RN, 2 LVN ' s, 4 CNA ' s and a medication aide came in at 4:00 p.m. She said a replacement was found for CNA ' A ' and he was able to go home at 5:15 p.m. During an interview on 1/12/11 at 3:30 p.m. the Administrator, DON and ADON said they were not aware the staff was leaving the locked door to the Alzheimer ' s unit propped open. The DON said the staff did not leave the door open when administration was in the building and the staff had been told not to prop the door open. During an interview on 1/13/11 at 10:35 a.m. the DON said if an investigation had been done on an incident, it would be on a piece of paper stapled to the Incident/Accident form. She said she did not have a system for conducting investigations. During a telephone interview on 1/13/11 at 2:36 p.m. LVN ' B ' said there was only one CNA for the locked dementia unit on the 2:00 p.m. to 10:00 p.m. shift about 50% of the time. She said the facility had difficulty staffing the unit. She said the staff propped the door to the Alzheimer ' s unit open some on the afternoon and night shift but more on the night shift. During an interview on 1/13/11 at 3:15 p.m. RN ' B ' , who worked the 2:00 p.m. to 10:00 p.m. shift, said the aides propped the door open on the locked Alzheimer ' s unit at times. She said when she worked the aide would prop the door open, leave the unit and she would watch the unit from the nurse ' s station outside the locked doors. She said from that position she could not see the unit lobby area or patio but she could see down the main hall. Review of Resident #1 ' s Functional Assessment for Persons with Alzheimer ' s Disease dated 11/9/10 revealed the facility had identified Resident #1 ' s orientation as unable to identify place or misidentifies place; disoriented to day/month/season/year; usually knows immediate family but misidentifies extended family members/friends. Resident #1 ' s motor skills were identified as difficulty making complex decisions. Resident #1 ' s attention, memory and cognitive functioning was identified as distractible; severe short term memory deficit, long term memory somewhat impaired; fixations; possessive with belongings; territorial; sleep disturbances; has catastrophic reactions; unprovoked aggression; resists care; misidentifies objects/use. Review of Resident #1 ' s Care Plan dated 12/2/10 revealed the facility had identified Resident #1 as having Self Care Deficit in the following areas: Transferring and Ambulation: Problem / Need related to: Dementia, Alzheimer ' s, resulting in two staff assist. Goals were identified as: Resident will be free of complications secondary to requiring staff assistance, Resident will maintain intact skin, Resident will have normal bowel patterns and absence of [MEDICAL CONDITION], and Resident will maintain a positive self image. Interventions: Knock on door before entering room. Call resident by name and identify yourself by name. Resident uses wheelchair. Review of Resident #1 ' s Fall Risk assessment dated [DATE] revealed Resident #1 scored a total of 25. The assessment instructions revealed a score of higher than 10 or greater should be considered at HIGH RISK for potential falls and a prevention protocol should be initiated immediately and documented on the care plan. Review of Resident #1 ' s Care Plan dated 12/17/10 revealed Resident #1 had a fall resulting in minor injury resulting in a faint red mark to the middle of his back, described as fading. Strengths to draw on were listed as: Resident appears free of infection. Goals: will resume usual activities without further incident. Involved areas will resolve without complications. Interventions: Crani-checks for 48 hours (precautionary). Vital Signs per Neurological check protocol, Continue interventions on the at-risk plan. No further interventions were found. Review of Resident #1 ' s Minimum (MDS) data set [DATE] revealed Resident #1 was identified as having short and long term memory problems, he was sometimes understood and sometimes understands. Resident #1 was identified as being moderately impaired for cognitive skills for daily decision making. Resident #1 was identified as having; little interest or pleasure in doing things; trouble falling or staying asleep, or sleeping to much; fell ing tired or having little energy; trouble concentrating on things such as the newspaper or watching television for 7-11 days ( half or more of the days) of the 14 days assessed. Resident #1 was identified as feeling or appearing down, depressed, or hopeless and moving or speaking so slowly that other people have noticed or the opposite- being so fidgety or restless that he/she has been moving around a lot more than usual for 12-14 days ( nearly every day) of the 14 days assessed. Resident #1 ' s balance during transfers was identified as; not steady, only able to stabilize with human assistance for sections: moving from seated to standing positions and surface to surface transfer. Resident #1 was identified as Total dependence/ Two + person physical assist for; bed mobility, transfers, dressing, and toilet use. Resident #1 was identified as Total dependence/ One person physical assist for; locomotion on unit, eating, and personal hygiene. Resident #1 was incontinent of bowel and bladder. Resident #3 Review of Resident #3 ' s Record of Admission (date could not be read) revealed the female resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was currently [AGE] years old. Review of Resident #3 '

Based on observations, interviews and record reviews, the facility failed to implement written policies and procedures for the prevention, identification, investigation, and reporting of abuse and/or neglect, for 3 (Resident #1, #3, and #4) of 5 residents reviewed for abuse/neglect as evidenced by: 1.) The facility failed to implement its written policy failing to investigate incidents/accidents regarding Resident #1, #3, and #4 following unwitnessed falls. a. The facility recieived x-ray results on 12/26/10 determining Resident #1 had sustained a left [MEDICAL CONDITION] and failed to investigate; b. The facility recieved x-ray results on 12/15/10 determining Resident #3 had sustained a left thumb fracture and failed to investigate; c. The facility failed to investigate Resident #4's unwitnessed fall requiring transfer to the emergency room . These failures resulted in an Immediate Jeopardy which was identified on 1/12/10. While the Immediate Jeopardy was removed on 1/14/10, the facility remained out of compliance at a level of a pattern of actual harm. These failures could affect any of the 9 residents who reside on the facility' s Alzheimer' s Unit by placing them at risk of having incidents/accidents that are not fully investigated and could result in abuse and neglect occurring undetected in the facility. Findings included: Review of the facility ' s Nursing Services Policy and Procedure Manual; Accidents and Incidents- Investigating and Reporting dated 4/2010 revealed the following: Policy Statement: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. Policy Interpretation and Implementation: The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The following data, as applicable, shall be included on the Report of Incident/Accident form: The date and time the accident or incident took place; The nature of the injury/illness (e.g. bruise, fall, nausea, etc.); The circumstances surrounding the accident or incident; where the accident or incident took place; The names of witnesses and their accounts of the accident or incident; The injured person ' s account of the accident or incident; The time the injured person ' s attending physician was notified, as well as the time the physician responded and his or her instructions; The date /time the injured person ' s family was notified and by whom; The condition of the injured person, including vital signs; The disposition of the injured(i.e., transferred to hospital, put to bed, sent home, returned to work, etc.); Any corrective actions taken; Follow-up information; Other pertinent data as necessary or required; and The signature and title of the person complete. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing within 24 hours of the incident or accident. The Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence. Review of the facility ' s Unusual Occurrence and Abuse Prevention Policy (no documented date) revealed the following: It is the responsibility of any persons having contact with a resident to report any unusual occurrences. The facility will not condone any form of resident abuse or neglect. To aid in the prevention, all personnel are to report any signs and symptoms of abuse and neglect, unexplained injury or any other unusual occurrences to their charge nurse, director of nursing or administrator, "immediately " upon discovery. To ensure the safety of the resident has not been jeopardized, an investigation of all reported occurrences will be conducted by the administrator, director of nursing or any other individuals appointed by the administrator. Unusual occurrences shall include but not be limited to: A bruise, cut, fall of unknown origin; Allegations from anyone of abuse, neglect or sexual misconduct; Complaint from a resident or family member or visitor; Resident to Resident abuse; possible theft or misappropriation of resident property; and unusual change in medical condition. The Administrator has the overall responsibility for coordination and implementation of the facility ' s Unusual Occurrence and Abuse Prevention program policies and procedures. Should a resident be observed and reported with any of the conditions cited in this policy, the Charge Nurse must complete an accident/incident form, document such information ' s into the resident ' s clinical record and start an investigation. The Administrator and Director of Nurses shall be notified and upon reviewing the report forms completed by the Charge Nurse will determine if further investigation is needed. Neglect is defined as a failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Abuse is defined as the willful infliction of injury; unreasonable confinement; intimidation; punishment with resulting physical harm, pain or mental anguish; deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychological well-being. Recognizing Signs and Symptoms of Abuse and Neglect: Signs of Actual Physical Abuse: welts or bruises; abrasions or lacerations; fractures, dislocations or sprains of questionable origin. Signs of Actual Physical Neglect: Inadequate provision of care; caregiver indifferent to resident ' s personal care or needs, left alone but needs supervision. Signs and Symptoms of Psychological Abuse/Neglect: Inconsistent injury explanation. Accidents/Incidents: All accidents/incidents involving residents must be reported to the Director of Nursing and the Administrator and will be investigated by management. An " Incident/Accident Form " must be completed on the shift in which the accident/incident occurred. A copy of the report is to be provided to the Administrator within 24 hours of such incident. This form does not become a part of the resident ' s clinical record but is filed with the Quality Assurance Committee for review and analysis. The facility ' s abuse/intervention program includes, but is not limited to the following: Assessing, Care planning, and monitoring of residents with needs and behaviors that may lead to conflict or neglect; Striving to maintain adequate staffing on all shifts to ensure that the needs of each resident are met; and encouraging all personnel, residents, family members, visitors, etc., to report any signs or suspected incidents of abuse to facility management immediately. Review of the facility ' s Provider Investigation Report dated 12/29/10 at 2:44 p.m. revealed; Administrator (ADM) was in the facility about 11:00 a.m. on 12/29/10. The ADM stated he was reviewing the tapes to the security cameras due to recently having computer programmers in the facility and was monitoring to make sure the cameras were working properly. He stated at random he had picked the Alzheimer ' s unit on 12/25/10 to review. He stated that during his review of the tapes at " around 3:00 p.m. " he observed Resident #1 stand up from his wheelchair and fall to the floor on his left side, " apparently hitting his head on another chair. " He stated he had observed CNA ' A ' who had been sitting at the desk in the lobby, walk over to Resident #1 and pick him up and place him back into his wheelchair. He stated after CNA ' A ' had placed Resident #1 back into his wheelchair, CNA ' A ' had went back to the desk and left Resident #1 in the lobby in his wheelchair. He stated he had further observed " about 30 minutes later " , RN ' A ' was making rounds on the unit and noticed Resident #1 crying and asked him if he was hurting. The ADM states, " He must have said yes and then she told LVN ' A ' , who gave Resident #1 a pain pill of some kind. " He stated during the time period observed " no nurse assessed Resident #1 " and " Both nurses report that they were not aware of Resident #1 falling. " He stated he had shown the tape to the DON and ADON (Assistant Director of Nurses) and began the Provider Investigation Report and notified the local Sheriff ' s dept. The ADM statement revealed at 1:30 p.m. on 12/29/10, he, the DON, and the ADON had interviewed CNA ' A ' who denied knowing Resident #1 had fallen and denied anything out of the ordinary had happened on 12/25/10. Review of security camera video tape dated 12/25/10 from 2:45 p.m. through 3:44 p.m. revealed the following: (Note: There was no audio to this video) The video begins at 2:45 p.m. on 12/25/10; Resident #1 is alone with no supervision and seen standing up from his wheelchair in the lobby of the Alzheimer's unit. Resident #2 is observed coming from the patio area and speaking to Resident #1. At 2:46 p.m. CNA ' A ' , was observed to come from the hallway and sit at the desk, after a few minutes he lays his head down on the desk. At 2:51 p.m. Resident #1 is observed attempting to stand up from his wheelchair and sitting back down. At 2:52 p.m. Resident #1 is seen attempting to stand up from his wheelchair and sitting back down. At 2:56 p.m. Resident #1 is observed to completely stand up from his wheelchair, revealing his pressure alarm in the seat of his wheelchair, Resident #1 sat back down. At 2:57 p.m. Resident #1 is observed to stand up from his wheelchair for approximately 1 minute, as he attempts to sit back down he looses his footing and falls to the floor on his left side, striking his head on a chair in the lobby. At 2:58 p.m. CNA ' A ' is observed getting up from the desk and walking over towards Resident #1's wheelchair, moving it closer to Resident #1. CNA ' A ' is observed putting Resident #1 's right shoe back on his foot, pulling Resident #1 up to a seated position on the floor, and then moving behind Resident #1 and lifting him up and placing him back in his wheelchair. CNA ' A ' is observed to stand with Resident #1 for a short time then CNA ' A ' is observed to walk down the hallway, leaving Resident #1 sitting in his wheelchair, alone in the lobby of the Alzheimer ' s unit. At 3:00 p.m. CNA ' A ' was observed to walk out from the hallway accompanied by Resident #2. It appears CNA ' A ' was directing Resident #2 to sit on the couch in the lobby. Resident #2, does not sit on the couch, but instead walks over to Resident #1. (Resident #2 appears very anxious, his hands are shaking.) At 3:02 p.m. CNA ' A ' was observed to direct Resident #2 to sit on the couch again, Resident #2 is observed to walk into the hallway. At 3:07 p.m. CNA ' A ' was observed to touch a button on the Call Light System and walk down the hallway, leaving Resident #1 unsupervised. At 3:08 p.m. Resident #1 was observed standing up from his wheelchair and sitting back down. At 3:10 p.m. Resident #1 is observed standing up from his wheelchair and sitting back down. (Note Resident #1 was left unsupervised for 4 minutes).At 3:11 p.m. CNA ' A ' was observed coming back from the hallway and sitting at the desk. CNA ' A ' lays his head on the desk face down. At 3: 14 p.m. CNA ' A ' was observed to get up from the desk and go back down the hallway leaving Resident #1 unsupervised. At 3:15 p.m. HSKP is observed on the unit, Resident #2 is observed to talk to her. At 3:17 p.m. HSKP is observed speaking to Resident #1, Resident #2 is standing at her side. At 3: 22 p.m. Resident #2 is observed with a female visitor (the facility identified as Resident #2 ' s granddaughter); Resident #2 is observed to walk her over to Resident #1.Resident #2 and visitor were observed to leave the lobby. No staff was observed in the area. At 3:23 p.m. Resident #1 is observed attempting to stand up from his wheelchair and sitting back down. At 3:25 p.m. Resident #2 is observed picking up the Call Light System and pulling it towards Resident #1. At 3:26 p.m. Resident #2 is observed pushing Resident #1 ' s wheelchair towards one of the lobby chairs. The HSKP is observed speaking to Resident #1 and Resident #2. RN ' A ' is observed walking from the hallway. HSKP is talking to RN ' A ' and was observed motioning to her side and pointing towards Resident #1. At 3:28 p.m. RN ' A ' is observed to walk down the hallway away from Resident #1 leaving hi unsupervised. At 3:32 p.m. Resident #1 is observed attempting to stand up from his wheelchair and sitting back down.(Note: CNA ' A ' left Resident #1 unsupervised for 18 minutes) CNA ' A ' is observed to come from the hallway, HSKP is observed to speak to CNA ' A ' and make hand motions towards her side. CNA ' A ' is observed to walk towards the desk, stop and fix the cord to the Call Light System, then sit down and place his head on the desk. At 3:37 p.m. LVN ' A ' was observed to come into the lobby area from the hallway. She approached Resident #1 and gave him a medication and water. At 3:42 p.m. Resident #1 was observed attempting to stand up from his wheelchair and sitting back down, while CNA ' A ' is sitting at the desk. (Note: CNA ' A ' is observed to get up from his seat at the desk to redirect Resident #2 who was attempting to push Resident #1 ' s wheelchair, after he had pushed him approximately 4 feet.) At 3:44 p.m. RN ' A ' was observed coming from the hallway and speaking to CNA ' A ' , and RN ' A ' is observed to reach up and put her hand to his cheek. Resident #1 Review of Resident #1 ' s Record of admitted d 1/11/11 at 12:40 p.m. revealed Resident #1 was admitted on [DATE] and readmitted on [DATE]. He was [AGE] years old at the time of this investigation. Review of Resident #1 ' s consolidated physician orders [REDACTED]. Review of Resident #1 ' s History and Physical dated 12/26/10 revealed, Resident #1 had been admitted to the hospital with [REDACTED]. Past Surgical History included: [MEDICATION NAME] surgery (11/26/10), Orchiectomy, Ventriculoperitoneal shunt, and Open reduction and internal fixation of right hip. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 7:50 a.m. revealed the CNA (unidentified) had reported Resident#1 had pain and [MEDICAL CONDITION] to his left foot and received PRN pain medication. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 9:10 a.m. revealed Hospice was informed of Resident#1 ' s pain and [MEDICAL CONDITION] to his left foot. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 1:05 p.m. revealed, " [MEDICAL CONDITION] continues to the top of the left foot, elevation ineffective. Resident ' s left outer upper thigh is now swollen. Painful to touch. " Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 1:15 p.m. revealed Hospice was called and the facility was awaiting return call. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 2:15 p.m. revealed Hospice nurse had arrived to assess Resident #1. Resident #1 ' s left leg was " exhibiting outward rotation with pain when moved. " Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 2:00 p.m. revealed, Hospice nurse had assessed Resident #1 and found him to have mild +1 [MEDICAL CONDITION] to his left foot, +2 [MEDICAL CONDITION] to his upper left thigh, and his left leg was abducted. New Orders per Hospice: X-ray of left hip. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 3:40 p.m. revealed Mobile Imaging had arrived to do X-ray of Resident #1 ' s left hip. Review of Resident #1 ' s X-ray Report dated 12/26/10 received by the facility at 5:25 p.m. revealed, Findings: There is a left comminuted intertrochanteric fracture with mild displacement. Femoral head is in alignment within the acetabular fossa. The pubic rami are unremarkable. Impression: Acute Left Comminuted Intertrochanteric Fracture with Mild Displacement. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 5:40 p.m. revealed results from X-ray had been received with the Diagnosis: [REDACTED]. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 5:55 p.m. revealed physician orders [REDACTED]. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 6:40 p.m. revealed Resident #1 was transferred to the hospital via ambulance. D.O.N (Director of Nurses) and Resident #1 ' s physician were notified of transfer. Review of the facility 's statement from CNA ' A ' dated 12/29/10 regarding Resident #1's fall on 12/25/10 revealed, CNA ' A ' had been working on the locked Alzheimer 's unit when about 3:00 p.m. Resident #1 fell to the floor. He stated he proceeded to help Resident #1 into his chair, and " without thinking " did not report Resident #1 ' s fall to the nurse. CNA ' A ' stated he had not been feeling well that day and he felt his head was " in a blur " . He stated the only medications he had taken were Pepto Bismol, and Tylenol Cold and Flu. In an interview on 1/10/11 at 1:30 p.m. with the DON she revealed, she was very surprised at what she had observed on the video regarding Resident #1 ' s fall. She stated CNA ' A ' had been a hard worker until recently and she would have never suspected the observed behaviors out of him. She stated he had only had a couple of performance issues requiring any counseling, one being he had " walked off the job " , and the other not wearing the proper work attire. She stated, " This has all caught me completely off guard, and has been very upsetting to everyone involved. " In an observation on 1/10/11 at 1:45 p.m. revealed Resident #1 resting in his bed with his eyes closed. His room is minimally decorated, bed alarm observed. During an interview on 1/10/11 at 2:00 p.m. with ADM revealed, CNA ' A ' had been terminated as of 12/30/10 due to picking up Resident #1 when he fell , and not reporting a fall to the nurse. ADM stated he had made DADS a copy of the security camera video and he would like to show this surveyor several things on the video. The video was observed in the ADM office with DON and ADON. During an interview on 1/10/11 at 2:30 p.m. with one of the facility housekeeper 's (HSKP) revealed when she arrived to the Alzheimer's unit lobby to clean her observed Resident #1 was sitting in his wheelchair crying. She stated she asked him in Spanish why he was crying, and he had replied to her in Spanish he was crying because his left leg and side hurt. She stated she talked to Resident #1 for a few minutes and she notified the nurse. She also stated she felt CNA ' A ' was " very sick that day and had a red face. " During an interview on 1/10/11 at 2:58 p.m. with ADM stated, no investigation of abuse or neglect had been done following receiving the X-ray results of Resident #1 ' s revealing a left [MEDICAL CONDITION] on 12/26/10. He stated he was not aware of Resident #1 ' s fall until 12/29/10, when he watched the video and had begun his investigation at that time. During an interview on 1/10/11 at 2:58 p.m. with the DON, she stated she had done a " verbal investigation " . The DON stated she had attempted to investigate Resident #1's left [MEDICAL CONDITION], but after reading the X-ray results had assumed Resident #1's fracture was " pathological " due to the results stating he had [MEDICAL CONDITION]. She stated she asked the CNA ' s and the nurses if Resident #1 had fallen, or if they had any knowledge of how he might have injured his hip and no one was aware of any incidents. She stated the investigation began on 12/29/10 after observing the fall on the security tape. The DON stated she would look through all of her personal notes to see if she had documented any of her investigation into Resident #1's X-ray results received on 12/26/10 with the finding of left [MEDICAL CONDITION]. During an interview on 1/10/11 at 3:20 p.m. with CNA ' C ' , she revealed she had worked with CNA ' A ' before and she felt he had been " a hard worker and took good care of the residents. " She stated she had not ever been aware of CNA ' A ' being abusive or neglectful of the residents. She stated CNA ' A ' had been ill recently with a " stomach virus ". During an interview on 1/11/11 at 10:00 a.m. with Hospice RN she stated she had been notified originally regarding Resident #1 having [MEDICAL CONDITION] to his left foot on 12/26/10. She stated upon assessment of Resident #1 she had determined he had [MEDICAL CONDITION] to his left foot and left thigh and had ordered an X-ray. She stated Resident #1 was asleep during the majority of her assessment and did not show signs of being in a large amount of pain. She stated she had not notified by the facility of any falls or incidents regarding Resident #1. During an interview on 1/11/11 at 10:15 a.m. with RN ' A ' she revealed CNA ' A ' had not notified her of Resident #1 ' s fall on 12/25/10. She stated she had noticed while doing her rounds on the Alzheimer 's unit, Resident #1 appeared to be in pain. She stated she could " see it in his eyes " . She stated Resident #1 had complaints of leg pain and she had informed LVN ' A ' to administer medications to alleviate his pain. RN ' A ' stated she had assisted CNA ' A ' with transferring Resident #1 to his bed to help him to be more comfortable, she stated while doing so she had assessed Resident #1 ' s pain, but had not done a head to toe assessment and had not observed anything abnormal regarding Resident #1. During an interview on 1/11/11 at 10:45 a.m. with DON, she stated after she had investigated and did not find any explanation of Resident #1 's left [MEDICAL CONDITION], she had assumed it was pathological. She stated she knew that she should not have " assumed " anything and should have investigated more diligently. She stated she could not locate any documentation of her investigation. During an interview on 1/11/11 at 10:45 a.m. with ADM, he stated, " Even if the DON had investigated Resident #1's left [MEDICAL CONDITION] results, it doesn't mean we would know exactly what happened. It could have happened while he moved in the bed. " The ADM stated, " The incident was not apparent until the video was observed on 12/29/10. He stated despite the facility not knowing how Resident #1 ' s hip was fractured, there was no formal investigation until the video had been observed on 12/29/10. During an interview on 1/11/11 at 11:32 a.m. with CNA ' A ' via telephone revealed CNA ' A ' requested to speak " face to face " and did not feel comfortable speaking about the situation over the phone. Arrangements were made with CNA ' A ' to meet him at a local fast food restaurant at 4:30 p.m. on 1/11/11. During an interview on 1/11/11 at 11:45 a.m. with ADON revealed she had been notified of CNA ' A ' being ill at approximately 3:00 p.m. on 12/25/10 and she began searching for another CNA to go in and replace him. She stated she had contacted CNA ' E ' , who agreed to replace CNA ' A ' at 5:00 p.m. on 12/25/10. During an interview on 1/11/11 at 2:10 p.m. with LVN ' C ' revealed she had worked the 10-6 shift on 12/25/10. She stated Resident #1 had slept all night and had made no complaints of pain. During an interview on 1/11/11 at 2:20 p.m. with LVN ' B ' revealed she felt CNA ' A ' was a " good CNA " . She stated she was very shocked when she saw the video of the Resident #1 falling. She stated she felt CNA ' A ' was not his " normal self " , he had recently had a baby, he had recently had " the flu " , and he " should have called in sick if he felt like he had it again. " She stated she had never seen CNA ' A ' being anything but caring towards the residents, and generally went above and beyond his job duties. In an interview on 1/11/11 at 2:30 p.m. with CNA ' F ' revealed she had been originally scheduled to work with CNA ' A ' on the Alzheimer ' s Unit for the 2-10 shift on 12/25/10. She stated when she arrived she could tell CNA ' A ' was not feeling well, his face was " flushed " and he was " very quiet " which was unlike his usual demeanor. She stated she was notified due to being " short staffed " ; she would need to go and work on the East wing. During an interview on 1/11/11 at 3:00 p.m. with LVN ' A ' she revealed she was aware when CNA ' A ' arrived to clock in he was sick. She stated he had a " stomach virus " for the second time. She stated she and RN ' A ' immediately started to find another staff to come in and replace CNA ' A ' . LVN ' A ' stated she had no knowledge of Resident #1 ' s fall on 12/25/10, and CNA ' A ' had not mentioned any abnormal happenings on the Alzheimer ' s unit with any residents on 12/25/10. She stated RN ' A ' had informed her about Resident #1 ' s pain and she had medicated him per physician orders. She stated Resident #1 is " hard to assess " due to his cognitive level and he frequently has complaints of pain and cannot verbalize where his pain is located. She stated the nurses have to often attempt to determine if Resident #1 is in pain by non-verbal cues such as grimacing. She stated she was able to determine Resident #1 was having left leg pain, but had not done a full assessment. In an interview on 1/11/11 at 4:30 p.m. with CNA ' A ' he revealed on 12/25/10 at approximately 10:00 a.m. he stated he had called and left a message on the ADON ' s cell phone informing her that he was ill with vomiting and diarrhea and needed to be taken off the schedule. He stated he did not receive a call back and went into to work his scheduled 2-10 shift even though he was feeling ill. CNA ' A ' stated he had notified LVN ' A ' when he arrived at work of his vomiting and diarrhea and she had informed him they would try and find someone to replace him. He stated CNA ' F ' was also scheduled on the Alzheimer ' s Unit for 2-10 shift on 12/25/10 and RN ' A ' had reassigned her to the East Wing due to other staff calling in sick that shift. He stated when he arrived to the unit he was responsible for caring for 8 residents and 1 more resident was due back form a pass later in the shift. He stated he was back and forth to the restroom with vomiting and diarrhea while he was on duty. He stated before 3:00 p.m. he was sitting at the desk when Resident #1 stood up from his wheelchair. He stated he had redirected Resident #1 to sit back down and when Resident #1 had attempted to sit back down he had somehow " lost his footing " and he had fallen to the floor. He stated he went and moved the wheelchair due to Resident #1 ' s leg being on the foot rest and then " immediately " attempted to care for Resident #1. CNA ' A ' stated Resident #1 had requested CNA ' A ' to assist him up from the floor. He stated he did not see any bruising or injury and he helped Resident #1 back up into his wheelchair. CNA ' A ' stated he used the speaker (intercom system) to notify LVN ' A ' of Resident #1 ' s fall, but wasn't sure she had heard him. He stated he had talked with HSKP in the hallway and she had informed him, Resident #1 had complaints of his left leg hurting. CNA ' A ' stated at approximately 3:00 p.m. he had gone to the unit doors to " double check " if LVN ' A ' had heard him and had discussed Resident #1 ' s fall with her. He stated a few minutes later RN ' A ' came to the unit and talked with Resident #1, then LVN ' A ' came onto the unit and gave Resident #1 a pain pill. He stated he was not sure if the nurses assessed Resident #1 or not, due to having to answer call lights for other residents on the unit. CNA ' A ' stated CNA ' E ' arrived to replace him around 6:00 p.m. and he had informed her of Resident #1 ' s fall and complaints of pain to his left leg. CNA ' A ' stated he knew the one thing he had done wrong was to move Resident #1 after he had fallen due to the nurses needing to assess him for injury. CNA ' A ' stated he was not aware of any specific interventions to keep Resident #1 from falling with the exception of telling Resident #1 to sit back down. CNA ' A ' stated, Resident #1 ' s wheelchair alarm was sounding when Resident #1 attempted to stand up from his wheelchair. He stated, " The alarm went off 3 or 4 times and I would tell him to sit down and he would sit down. " CNA ' A ' stated he was not aware if Resident #1 had hit his head during the fall. He stated he was not aware of Resident #1 hitting his head during the fall and if Resident #1 had hit his head, he would have gone and informed the nurse. In an interview on 1/12/11 at 1:40 p.m. with CNA ' G ', she stated that there have been many times when she has had to work on the Alzheimer ' s Unit alone. She stated the bathroom for the staff is located off the unit, therefore if a staff person is working on the unit alone, they have to wait until someone can come sit on the unit to monitor the residents or if it ' s late and most of the residents are in bed, " we just prop one of the doors open " . In an interview on 1/12/11 at 1:10 p.m. the Administrator said all the only staff that were in-serviced was listed on the Provider Investigation Report and no other staff had been in-serviced. In an interview on 1/12/11 at 1:32 p.m. the ADON said she was on call 24/7 for the facility staffing. She said CNA ' A ' reported to work at 1:45 p.m. and she received a call from RN ' A ' at 3:00 p.m. regarding CNA ' A ' being sick with the stomach bug. She said CNA ' A ' was able to go home at 5:15 p.m. She said the policy regarding staffing for the locked dementia unit was two CNA ' s in the morning, 2 in the afternoon and 1 at night. She said on 12/25/10 on the 2:00 p.m. to 10 p.m. shift the facility had 1 RN, 2 LVN ' s, 4 CNA ' s and a medication aide from 4:00 p.m. to 8:00 p.m. She said, for example, if the unit had only one CNA and a resident needed incontinent care the other residents would be unattended while the CNA was assisting the resident. On 1/12/11 at 2:25 p.m. the Administrator and DON were notified of IJ and substandard quality of care. In an interview on 1/12/11 at 2:58 p.m. LVN ' A ' said CNA ' A ' arrived at work on 12/25/10 for his 2-10 shift . She said he appeared pale and felt warm to the touch. She said he reported he had the stomach bug and had an episode of diarrhea when he arrived at the facility for his shift. She said she asked him if he wanted some Tylenol and he told her he did not want any because he would not be able to keep it down. She said the RN called the ADON to report CNA ' A ' was ill when he arrived for his shift but the ADON did not return the call until 3:00 p.m. She said CNA ' A ' was on the schedule for the locked dementia unit so they just stayed with the schedule and tried to find him a replacement. She said there was no bathroom on the locked dementia unit and the staff would have to leave the unit to go to the bathroom. She said she was not sure if CNA ' A ' had to the leave the unit that day but usually if there was just one staff person on the unit the staff would prop the locked door open and go to the bathroom in the main building. She said the staff prop the door open a lot at night because there is just one staff member on the unit. She said the staff tries not to leave the door propped open too much due to the wandering residents. She said a lot of the time on the 2:00 p.m. to 10:00 p.m. shift there was just one aide on the Alzheimer ' s unit. She said on 12/25/10 on the 2:00 p.m. to 10:00 p.m. shift there was 1 RN, 2 LVN ' s, 4 CNA ' s and a medication aide came in at 4:00 p.m. She said a replacement was found for CNA ' A ' and he was able to go home at 5:15 p.m. During an interview on 1/12/11 at 3:30 p.m. the Administrator, DON and ADON said they were not aware the staff was leaving the locked door to the Alzheimer ' s unit propped open. The DON said the staff did not leave the doo

Based on observations, interviews, and record reviews the facility failed to provide adequate supervision and assistance devices to prevent accidents for 3 Residents (#1, #3 and #4) of 5 residents sampled for falls as evidenced by: 1.) failure to determine the possible causes of falls, assess fall and safety risks, and implement fall prevention strategies for Resident #1. Resident #1 was identified by the facility to be cognitively impaired, had a history of [REDACTED]. 2.) failure to determine the possible causes of falls, assess fall and safety risks, and implement fall prevention strategies for Resident #3, who was cognitively impaired, had a history of [REDACTED]. 3.) failure to determine the possible causes of falls, assess fall and safety risks, and implement fall prevention strategies for Resident #4, who was cognitively impaired and had a history of [REDACTED]. 4.) failure to supervise the 3 residents ( #1, #3, and #4) identified as high risk for falls on the secured Alzheimer's unit. These failures resulted in an Immediate Jeopardy which was identified on 1/12/11. While the Immediate Jeopardy was removed 1/14/10, the facility remained out of compliance at a level of a pattern for actual harm. These failures could result in a continuance of accidents and injuries to any of the 9 residents who reside on the Alzheimer ' s Unit. Findings included: Resident #1 Review of Resident #1's Record of admitted d 1/11/11 at 12:40 p.m. revealed Resident #1 was admitted on [DATE] and readmitted on [DATE]. He was [AGE] years old at the time of this investigation. Review of Resident #1's consolidated physician orders [REDACTED]. Review of facility's Incident and Accident report dated 10/17/10 at 2:30 a.m. revealed Resident #1 was up walking in his room without his walker. Resident #1 was witnessed to fall and sit on his buttocks in the middle of the floor. Resident #1 was alert and had no apparent injury. Additional comments and steps to be taken to prevent a recurrence: Encourage Resident to use his walker when he gets up. DON signature on the incident report was dated 10/18/10. ADM signature was dated 10/20/10. Medical Director signature was dated 11/02/10 indicating they were aware of the resident's fall. Review of facility ' s Incident and Accident report dated10/25/10 at 6:25 p.m. revealed Resident #1 was found on the floor in the sitting area in front of his wheelchair. Wheels on wheelchair were unlocked. Resident #1 ' s level of consciousness was alert. Additional comments and steps to be taken to prevent a recurrence: Lock Wheelchair. DON signature was dated 10/21/10. ADM signature was dated 10/22/10. Medical Director signature was dated 11/02/10. Review of Resident #1 ' s Functional Assessment for Persons with Alzheimer ' s Disease dated 11/9/10 revealed the facility had identified Resident #1 ' s orientation as unable to identify place or misidentifies place; disoriented to day/month/season/year; usually knows immediate family but misidentifies extended family members/friends. Resident #1 ' s motor skills were identified as difficulty making complex decisions. Resident #1 ' s attention, memory and cognitive functioning was identified as distractible; severe short term memory deficit, long term memory somewhat impaired; fixations; possessive with belongings; territorial; sleep disturbances; has catastrophic reactions; unprovoked aggression; resists care; misidentifies objects/use. Review of Resident #1 ' s Care Plan dated 12/2/10 revealed the facility had identified Resident #1 as having Self Care Deficit in the following areas: Transferring and Ambulation: Problem / Need related to: Dementia, Alzheimer ' s, resulting in two staff assist. Goals were identified as: Resident will be free of complications secondary to requiring staff assistance, Resident will maintain intact skin, Resident will have normal bowel patterns and absence of thrombophlebitis, and Resident will maintain a positive self image. Interventions: Knock on door before entering room. Call resident by name and identify yourself by name. Resident uses wheelchair. There were no interventions in this care plan addressing the resident's fall risks. Review of Resident #1 ' s Fall Risk assessment dated [DATE] revealed Resident #1 scored a total of 25. The assessment instructions revealed a score of higher than 10 or greater should be considered at HIGH RISK for potential falls and a prevention protocol should be initiated immediately and documented on the care plan. Review of Resident #1 ' s Care Plan dated 12/17/10 revealed Resident #1 had a fall resulting in minor injury resulting in a faint red mark to the middle of his back, described as fading. Strengths to draw on were listed as: Resident appears free of infection. Goals: will resume usual activities without further incident. Involved areas will resolve without complications. Interventions: Crani-checks for 48 hours (precautionary). Vital Signs per Neurological check protocol, Continue interventions on the at-risk plan. No further safety interventions were documented. Review of Resident #1 ' s Minimum (MDS) data set [DATE] revealed Resident #1 was identified as having short and long term memory problems, he was sometimes understood and sometimes understands. Resident #1 was identified as being moderately impaired for cognitive skills for daily decision making. Resident #1 was identified as having; little interest or pleasure in doing things; trouble falling or staying asleep, or sleeping to much; fell ing tired or having little energy; trouble concentrating on things such as the newspaper or watching television for 7-11 days ( half or more of the days) of the 14 days assessed. Resident #1 was identified as feeling or appearing down, depressed, or hopeless and moving or speaking so slowly that other people have noticed or the opposite- being so fidgety or restless that he/she has been moving around a lot more than usual for 12-14 days ( nearly every day) of the 14 days assessed. Resident #1 ' s balance during transfers was identified as; not steady, only able to stabilize with human assistance for sections: moving from seated to standing positions and surface to surface transfer. Resident #1 was identified as Total dependence/ Two + person physical assist for; bed mobility, transfers, dressing, and toilet use. Resident #1 was identified as Total dependence/ One person physical assist for; locomotion on unit, eating, and personal hygiene. Resident #1 was incontinent of bowel and bladder. Review of Resident #1's Nurses Notes, there was no documentation for 12/25/10. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 7:50 a.m. revealed the CNA (unidentified) had reported Resident#1 had pain and edema to his left foot and received PRN pain medication. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 9:10 a.m. revealed Hospice was informed of Resident#1 ' s pain and edema to his left foot. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 1:05 p.m. revealed, " Edema continues to the top of the left foot, elevation ineffective. Resident ' s left outer upper thigh is now swollen. "Painful to touch. " Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 1:15 p.m. revealed Hospice was called and the facility was awaiting return call. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 2:15 p.m. revealed Hospice nurse had arrived to assess Resident #1. Resident #1 ' s left leg was " exhibiting outward rotation with pain when moved. " Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 2:00 p.m. revealed, Hospice nurse had assessed Resident #1 and found him to have mild +1 pitting edema to his left foot, +2 pitting edema to his upper left thigh, and his left leg was abducted. New Orders per Hospice: X-ray of left hip. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 3:40 p.m. revealed Mobile Imaging had arrived to do X-ray of Resident #1 ' s left hip. Review of Resident #1 ' s X-ray Report dated 12/26/10 received by the facility at 5:25 p.m. revealed, Findings: There is a left comminuted intertrochanteric fracture with mild displacement. Femoral head is in alignment within the acetabular fossa. The pubic rami are unremarkable. Impression: Acute Left Comminuted Intertrochanteric Fracture with Mild Displacement. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 5:40 p.m. revealed results from X-ray had been received with the Diagnosis: [REDACTED]. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 5:55 p.m. revealed physician orders [REDACTED]. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 6:40 p.m. revealed Resident #1 was transferred to the hospital via ambulance. D.O.N (Director of Nurses) and Resident #1 ' s physician were notified of transfer. Review of Resident #1 ' s History and Physical dated 12/26/10 revealed, Resident #1 had been admitted to the hospital with [REDACTED]. Past Surgical History included: Thoracic surgery (11/26/10), Orchiectomy, Ventriculoperitoneal shunt, and Open reduction and internal fixation of right hip. Review of the facility ' s Provider Investigation Report dated 12/29/10 at 2:44 p.m. revealed; Administrator (ADM) was in the facility about 11:00 a.m. on 12/29/10. The ADM stated he was reviewing the tapes to the security cameras due to recently having computer programmers in the facility and was monitoring to make sure the cameras were working properly. He stated at random he had picked the Alzheimer ' s unit on 12/25/10 to review. He stated that during his review of the tapes at " around 3:00 p.m. " he observed Resident #1 stand up from his wheelchair and fall to the floor on his left side, " apparently hitting his head on another chair. " He stated he had observed CNA ' A ' who had been sitting at the desk in the lobby, walk over to Resident #1 and pick him up and place him back into his wheelchair. He stated after CNA ' A ' had placed Resident #1 back into his wheelchair, CNA ' A ' had went back to the desk and left Resident #1 in the lobby in his wheelchair. He stated he had further observed " about 30 minutes later " , RN ' A ' was making rounds on the unit and noticed Resident #1 crying and asked him if he was hurting. The ADM states, " He must have said yes and then she told LVN ' A ' , who gave Resident #1 a pain pill of some kind. " He stated during the time period observed " no nurse assessed Resident #1 " and " Both nurses report that they were not aware of Resident #1 falling. " He stated he had shown the tape to the DON and ADON (Assistant Director of Nurses) and began the Provider Investigation Report and notified the local Sheriff ' s dept. The ADM statement revealed at 1:30 p.m. on 12/29/10, he, the DON, and the ADON had interviewed CNA ' A ' who denied knowing Resident #1 had fallen and denied anything out of the ordinary had happened on 12/25/10. In an interview on 1/10/11 at 2:00 p.m. with ADM revealed, CNA 'A' had been terminated as of 12/30/10 due to picking up Resident #1 when he fell , and not reporting the fall to the charge nurse. The ADM stated he made DADS a copy of the security camera video. Review of the security camera video tape of the Alzheimer's unit lobby dated 12/25/10 from 2:45 p.m. through 3:44 p.m. revealed the following: The video begins at 2:45 p.m. 1.) Resident #1 was observed to stand up from his wheelchair and sit back down, he was observed to be alone in the lobby of the Alzheimer's unit. At 2:46 p.m. CNA 'A' appears on in the lobby and takes a seat at the desk, were he laid his head on the desk. While CNA 'A' was sitting at the desk, Resident #1 stood up from his wheelchair at: 2:51 p.m., 2:52 p.m, 2:53 p.m., 2:56 p.m., And 2:57 p.m. when Resident #1 fell to the floor on his left side and hit his head on a lobby chair. CNA'A' was observed to move Resident #1's wheelchair, assist him to a seated position, then pick him up and place him in his wheelchair. At 2:59 p.m. CNA 'A' was observed walking down the hallway, leaving Resident #1 alone in the lobby. At 3:00 p.m. CNA 'A' was observed walking on to the lobby area were he stayed until 3:02 p.m. when he walked back down the hallway leaving Resident #1 alone in the lobby. At 3:08 p.m. and 3:10 p.m. Resident #1 was observed to stand up from his wheelchair and sit back down. CNA 'A' was observed to come back from the hallway into the lobby area from 3:11 p.m. (Resident #1 was unsupervised for 9 minutes) through 3:14 p.m. when he walked back down the hallway leaving Resident #1 unsupervised. At 3:23 p.m. Resident #1 was observed to stand up from his wheelchair and sit back down. From 3:26 p.m. through 3:28 p.m. RN 'A' is observed in the lobby of the unit (No assessment was observed).At 3:32 p.m. Resident #1 was observed to stand up from his wheelchair and sit back down. ( He was unsupervised for 18 minutes.) At 3:32 p.m. CNA 'A' returned to the desk in the lobby of the Alzheimer's unit and laid his head down on the desk. At 3:37 p.m. LVN 'A' appears from the hallway and gave Resident #1 a pill and water.( No assessment observed)At 3:42 p.m. Resident #1 was observed to stand up from his wheelchair and sit back down. Review of the facility ' s statement from CNA ' A ' dated 12/29/10 regarding Resident #1 ' s fall on 12/25/10 revealed, CNA ' A ' dated 12/29/10 had been working on the locked Alzheimer ' s unit when about 3:00 p.m. Resident #1 fell to the floor. He stated he proceeded to help Resident #1 up into his chair, and " without thinking " did not report Resident #1 ' s fall to the nurse. CNA ' A ' stated he had not been feeling well that day and he felt his head was " in a blur " . He stated the only medications he had taken were Pepto Bismol, and Tylenol Cold and Flu. In an interview on 1/10/11 at 1:30 p.m. the DON revealed, she was very surprised at what she had observed on the video regarding Resident #1 ' s fall. She stated CNA ' A ' had been a hard worker until recently and she would have never suspected the observed behaviors out of him. She stated he had only had a couple of performance issues requiring any counseling, one being he had " walked off the job " , and the other not wearing the proper work attire. She stated, " This has all caught me completely off guard, and has been very upsetting to everyone involved. " In an observation on 1/10/11 at 1:45 p.m. revealed Resident #1 resting in his bed with his eyes closed. His room is minimally decorated, bed alarm observed. In an interview on 1/10/11 at 2:00 p.m. with ADM revealed, CNA ' A ' had been terminated as of 12/30/10 due to picking up Resident #1 when he fell , and not reporting a fall to the nurse. In an interview on 1/10/11 at 2:30 p.m. with one of the facility housekeeper ' s (HSKP) revealed when she arrived to the Alzheimer ' s unit lobby to clean and she observed Resident #1 was sitting in his wheelchair crying. She stated she asked him in Spanish why he was crying, and he had replied to her in Spanish he was crying because his left leg and side hurt. She stated she talked to him for a few minutes and she notified the nurse. She stated she felt CNA ' A ' " very sick that day with a red face. " In an interview on 1/11/11 at 10:00 a.m. with Hospice RN she stated she had been notified originally regarding Resident #1 having edema to his left foot. She stated upon assessment of Resident #1 she had determined he had edema to his left foot and left thigh and had ordered an X-ray. She stated Resident #1 was asleep during the majority of her assessment and did not show signs of being in a large amount of pain. She stated she had not been notified of any falls or incidents regarding Resident #1. In an interview on 1/11/11 at 11:45 a.m. with ADON revealed she had been notified of CNA ' A ' being ill at approximately 3:00 p.m. on 12/25/10 and she began searching for another CNA to go in and replace him. She stated she had contacted CNA ' E ' , who agreed to replace CNA ' A ' at 5:00 p.m. on 12/25/10. In an interview on 1/11/11 at 2:20 p.m. with LVN ' B ' stated she was very shocked when she saw the video of the Resident #1 falling. She stated she felt CNA ' A ' was not his " normal self " , he had recently had a baby, he had recently had " the flu " , and he " should have called in sick if he felt like he had it again. " In an interview on 1/11/11 at 2:30 p.m. with CNA ' F ' revealed she had been originally scheduled to work with CNA ' A ' on the Alzheimer ' s Unit for the 2-10 shift on 12/25/10. She stated when she arrived she could tell CNA ' A ' was not feeling well, his face was " flushed " and he was " very quiet " which was unlike his usual demeanor. She stated she was notified due to being " short staffed " ; she would need to go and work on the East wing. In an interview on 1/11/11 at 3:00 p.m. with LVN ' A ' revealed she was aware when CNA ' A ' arrived to clock in he was sick. She stated he had a " stomach virus " for the second time. She stated she and RN ' A ' immediately started to find another staff to come in and replace CNA ' A ' . LVN ' A ' stated she had no knowledge of Resident #1 ' s fall on 12/25/10, and CNA ' A ' had not mentioned any abnormal happenings on the Alzheimer ' s unit with any residents on 12/25/10. She stated RN ' A ' had informed her about Resident #1 ' s pain and she had medicated him per physician orders. She stated Resident #1 is " hard to assess " due to his cognitive level and he frequently has complaints of pain and cannot verbalize where his pain is located. She stated the nurses have to often attempt to determine if Resident #1 is in pain by non-verbal cues such as grimacing. She stated Resident #1 was able to determine he was having left leg pain. However she had not done a full assessment. In an interview on 1/11/11 at 4:30 p.m. with CNA ' A ' revealed on 12/25/10 at approximately 10:00 a.m. he stated he had called and left a message on the ADON ' s cell phone informing her that he was ill with vomiting and diarrhea and needed to be taken off the schedule. He stated he did not receive a call back and went into to work even though he was feeling ill. CNA ' A ' stated he had notified LVN ' A ' when he arrived at work of his vomiting and diarrhea and she had informed him they would try and find someone to replace him. He stated CNA ' F ' was also scheduled on the Alzheimer ' s Unit for 2-10 shift on 12/25/10 and RN ' A ' had reassigned her to the East Wing due to other staff calling in sick that shift. He stated when he arrived to the unit he was responsible for caring for 8 residents and 1 more resident was due back form a pass later in the shift. He stated he was back and forth to the restroom with vomiting and diarrhea while he was on duty. He stated before 3:00 p.m. he was sitting at the desk when Resident #1 stood up from his wheelchair. He stated he had redirected Resident #1 to sit back down and when Resident #1 had attempted to sit back down he had somehow " lost his footing " and he had fallen to the floor. He stated he went and moved the wheelchair due to Resident #1 ' s leg being on the foot rest and then " immediately " attempted to care for Resident #1. CNA ' A ' stated Resident #1 requested CNA ' A ' to assist him up from the floor. CNA 'A' stated he did not see any bruising or injury so he helped Resident #1 back up into his wheelchair. CNA ' A ' stated he used the speaker (intercom system) to notify LVN ' A ' of Resident #1 ' s fall, but wasn ' t sure she had heard him. He stated he had talked with HSKP in the hallway and she had informed him, Resident #1 had complaints of his left leg hurting. CNA ' A ' stated at approximately 3:00 p.m. he had gone to the unit doors to " double check " if LVN ' A ' had heard him and had discussed Resident #1 ' s fall with her. He stated a few minutes later RN ' A ' came to the unit and talked with Resident #1, then LVN ' A ' came onto the unit and gave Resident #1 a pain pill. He stated he was not sure if the nurses assessed Resident #1 or not, due to having to answer call lights for other residents on the unit. CNA ' A ' stated CNA ' E ' arrived to replace him around 6:00 p.m. and he had informed her of Resident #1 ' s fall and complaints of pain to his left leg. CNA ' A ' stated he knew the one thing he had done wrong was to move Resident #1 after he had fallen because the nurses needed to assess him for injury. CNA 'A' stated he was not aware of any specific interventions for fall risks with the exception of telling Resident #1 to sit back down. CNA ' A ' said Resident #1 ' s wheelchair alarm was sounding when Resident #1 attempted to stand up from his wheelchair. He stated, " Yes, it went off 3 or 4 times and I would tell him to sit down and he would sit down. " CNA 'A' stated he was not aware of Resident #1 hitting his head during the fall and if Resident #1 had hit his head, he would have gone and informed the nurse. In an interview on 1/12/11 at 1:40 p.m. with CNA ' G ' revealed she had seen the video of Resident #1 ' s fall and was shocked. She stated there had been many times when she worked on the Alzheimer ' s Unit alone. She stated the bathroom for the staff is located off the unit, therefore if a staff person is working on the unit alone, they have to wait until someone can come sit on the unit to monitor the residents or if it ' s late and most of the residents are in bed, " we just prop one of the doors open " . A review of Secure Universal Alarm Personal safety Product Manufacture Instructions received from DON on 1/12/11 revealed the following: CAUTION! This product is not a restraint. It will not prevent a resident from getting out of their bed or chair. This product is designed as a monitor, alerting staff when the resident has risen from their bed or chair. This product is to be used in conjunction with a total fall prevention program. Resident #3 Review of Resident #3 ' s Record of Admission (date could not be read) revealed the female resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was currently [AGE] years old. Review of Resident #3 ' s annual MDS dated [DATE] revealed the resident had short-term and long-term memory problems. The resident was severely impaired for decision making. The resident had signs and symptoms of delirium which included inattention and disorganized thinking. The resident had daily behavioral symptoms that were not directed toward others and wandering. The resident was totally dependent of one staff person for dressing, toilet use and personal hygiene. The resident required extensive assistance of one person for bathing. The resident was independent for ambulation and all other activities of daily living. The resident did not use any mobility devices. The resident was always incontinent of bladder and bowel. The resident had not had any falls since the prior assessment. Review of Resident #3 ' s Fall Risk Evaluation dated 12/10/10 revealed the resident scored a 24 (total score of 10 or above represented a high fall risk). Review of Resident #3 ' s Incident/Accident Reports revealed on 10/27/10 at 1:45 p.m. the resident was observed to be sitting on her buttocks outside in the yard on the unit. The resident was assessed to have no apparent injuries and neurological checks were initiated. The incident was unwitnessed. There was no further investigation to rule out possible abuse or neglect. --on 10/27/10 at 6:30 p.m. the resident was observed sitting outside partway on the grassy area and the sidewalk. The resident was sitting on her buttocks and another un-named resident was standing beside her. The resident was assessed to have no apparent injuries and the neurological checks were continued. The incident was unwitnessed. The report noted the staff was to keep the resident in their line of sight to prevent a recurrence of the incident. There was no further investigation regarding the incident. Review of Resident #3 ' s Nurse ' s Notes dated 10/27/10 revealed no additional information regarding the incident at 1:45 p.m. At 6:30 p.m. the nurse instructed the CNA ' s to keep the resident in their line of sight. At 7:30 p.m. the resident ' s spouse was informed of the incidents and stated the resident liked to sit on the ground and work in her garden at home. There was no further investigation regarding the incident. --on 10/28/10 at 3:45 p.m. the resident had mottled reddish and blue bruising developing on her left hip and buttock. The bruising was noted to be scattered over a 4 inch x 5 inch area. --on 10/29/10 at 9:00 a.m. a large purple bruise 6.5 cm x 5 cm was observed on the resident ' s left outer thigh and a 3.5 cm x 2 cm bruise lighter in color than the bruise to the resident ' s thigh was observed on the resident ' s left shoulder. At 7:30 p.m. bruising was noted to the resident ' s upper left arm and shoulder. The bruising was scattered and purplish red in color. The bruising was 4 inches in length and scattered over a 2 to 3 inch area. The bruising on the resident ' s left hip and buttock was darker purple and bluer than the day before and remained scattered. --on 10/30/10 at 10:00 a.m. a bruise was observed on the posterior aspect of the resident ' s right arm on her bicep area. The bruise was approximately 5 cm across and was dark purple like the other bruises. At 6:45 p.m. a pale blue 2 inch x 1 inch bruise was noted to the resident ' s right rib cage and a small 1 inch pale blue bruise was noted laterally on the resident ' s right breast. --on 10/31/10 at 9:00 p.m. the staff reported to the nurse the resident had been carrying straight back chairs under her arms and dragging them up and down the sidewalk outside, which the nurse thought might account for some of the resident ' s bruising. --on 11/01/10 at 12:30 p.m. the physician was notified of the resident ' s bruising. Orders were received to monitor the bruising every shift and report any major changes or additional findings, the CNA ' s were to report any instability in the resident ' s gait and lab work was ordered. The nurse documented she had spoken to the staff (on the unit) at length regarding reporting any changes in the resident ' s skin or gait and all the staff verbalized understanding. --on 11/02/10 at 4:30 p.m. the physician assessed the resident ' s bruising. No new orders were written. Review of Resident #3 ' s Incident/Accident Reports revealed on 11/25/10 at 7:30 a.m. the resident was observed in a sitting position outside the unit. The resident was holding her knees with her arms. Visible swelling was noted to the left side of the resident ' s face. No other injuries were apparent. The staff applied ice to the resident ' s face and began neurological checks. The incident was unwitnessed. The report documented the staff could not monitor the resident at all times and could not keep the resident from going outside. There was no further investigation to rule out possible abuse or neglect. Review of Resident #3 ' s Nurse ' s Notes dated 11/25/10 revealed a CNA went out to the unit yard to bring the resident in for breakfast and observed the resident on the ground. There was no further investigation regarding the incident. -- on 11/26/10 at 5:00 p.m. the resident had reddish gray bruising on the back of her left hand, bluish gray bruising was noted to the left side of the resident ' s face and jaw line with reddish bruising under the resident ' s left eye. Review of Resident #3 ' s Incident/Accident Reports revealed on 12/09/10 at 11:00 a.m. the resident was outside ambulating on the sidewalk and stepped off the walk, lost her balance and fell to the ground. The resident was assessed to have no apparent injuries and neurological checks were initiated. The incident was witnessed by a CNA. The report noted a CNA was to be at the resident ' s side when she was outside to prevent a recurrence of the incident. Review of Resident #3 ' s Incident/Accident Reports revealed on 12/14/10 at 3:15 p.m. the resident was observed sitting on the sidewalk beside an overturned patio chair. The resident had some " pebbling " abrasions to her left forehead and chin. Neurological checks were initiated. The incident was unwitnessed. The report noted the staff was to continue to monitor the resident closely for changes in her gait. There was no further investigation to rule out possible abuse or neglect. Review of Resident #3 ' s Nurse ' s Notes dated 12/14/10 revealed no additional information regarding the incident or further investigation but at 6:15 p.m. the resident ' s thumb began swelling and an x-ray was ordered. Review of Resident #3 ' s Final X-Ray Report dated 12/15/10 revealed the resident had a possible fractured left thumb. In a telephone interview on 1/13/11 at 2:36 p.m. LVN ' B ' said the fenced patio on the unit was open 24/7 and the door to the patio did not alarm. She said the residents could not be seen from the unit if they were on the patio. She said the unit was hard for one CNA to provide supervision if a resident was going in and out the patio door. An observation on 1/13/11 at 3:05 p.m. revealed Resident #3 was in her room. The resident was ambulatory. In an interview on 1/13/11 at 3:05 p.m. CNA ' B ' said Resident #3 went outside on the patio a lot and it was tough to work the unit with just one CNA to watch all the residents. An observation on 1/13/11 at 3:20 p.m. the door to the patio area was observed to be unlocked. The door did not have a keypad and did not alarm. A wanderguard system was observed on the door. The patio area was observed to be about 50 ft x 25 ft fenced in area. The patio had a concrete walk way around it with a grassy area in the center. Approximately 22 feet of the patio was covered and could be seen from the door to the unit but the rest of the patio are could not be seen. The patio area was not monitored by a camera and the staff would have to go outside to observe the residents. In an interview on 1/13/11 at 3:55 p.m. Rehab Aide ' A ' and the AD ( Activity Director) said the wanderguard system on the unit was not utilized. In an interview on 1/13/11 at 4:20 p.m. the ADON said the door to the patio was always unlocked and the wanderguard system was not utilized because the sound of the alarm constantly going off would agitate the other residents. She said there was not a camera outside on the patio. She said Resident #3 had an unwitnessed fall and fractured her thumb on 12/14/10. In an interview on 1/13/11 at 4:35 p.m. the DON said the outside door to the court yard on the unit was open all the time and it did not alarm. She said she did not complete an investigation on any of Resident #3 ' s unwitnessed falls and she was not aware the incident and accident report dated 12/09/10 documented one staff member should be with the resident when she was outside. Please note all the above Incident/Accident Reports were signed by the nurse preparing the report, the DON, Medical Director and Administrator. Review of Resident #3 ' s Care Plans revealed the resident ' s Fall Risk Care Plan dated 10/13/10 was updated on 11/01/10, 11/25/10, 12/03/10, 12/09/10 and 12/14/10 to reflect the resid

Based on observations, interviews, and record reviews, the Administrator, DON and Weekend Supervisor RN, failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well being for 3 ( Resident #1, #3, and #4) of 5 residents reviews for falls as evidenced by: The Weekend Supervisor RN (RN 'A') failed to: 1.) appropriately delegate responsibilities to CNA's when she reassigned a CNA originally scheduled to work on the Alzheimer's Unit to the East wing, knowingly leaving a CNA who was ill/impaired to manage the care of the residents on the Alzheimer's unit alone. The DON failed to: 1.) implement the facility 's policies and procedures of investigating injuries of unknown origin to rule out possible abuse and/or neglect when she became aware of Resident #1's X-ray results determining he had a fractured left hip and Resident #3's X-ray results determining she had a fractured left thumb , of unknown origin. 2.) supervise nurse's aides and to ensure adequate supervision was provided to residents at all times. 3.) review, revise, and implement care planning strategies to prevent falls for Residents #1 and #3 who were at risk for falls and had significant falls with injuries. The ADM failed to: 1.) monitor and supervise the responsibilities of the DON to ensure the DON carried out her responsibilities to direct nursing care to the facility residents. 2.) implement the facility's abuse and neglect policies to ensure the investigation of injuries of unknown origin and report those injuries to the state authority. 3.) ensure the secured Alzheimer's unit was kept appropriately staffed. On 12/25/10 the facility had only one CNA, who was identified by nursing supervisor as being ill to monitor residents. These failures resulted in an Immediate Jeopardy which was identified on 1/12/11. While the Immediate Jeopardy was removed 1/14/11, the facility remained out of compliance at a level of potential a pattern of actual harm, due to the facility's need to monitor and evaluate the effectiveness of the corrective actions. These failures have the potential to result in continued resident accidents that could cause serious harm or death to any of the 9 residents whom reside on the Alzheimer's unit and could result in reduced quality of care in other aspects of resident care. Findings included: Review of the facility ' s Provider Investigation Report dated 12/29/10 at 2:44 p.m. revealed; Administrator (ADM) was in the facility about 11:00 a.m. on 12/29/10. The ADM stated he was reviewing the tapes to the security cameras due to recently having computer programmers in the facility and was monitoring to make sure the cameras were working properly. He stated at random he had picked the Alzheimer's unit on 12/25/10 to review. He stated that during his review of the tapes at " around 3:00 p.m. " he observed Resident #1 stand up from his wheelchair and fall to the floor on his left side," apparently hitting his head on another chair. " He stated he had observed CNA ' A ' who had been sitting at the desk in the lobby, walk over to Resident #1 and pick him up and place him back into his wheelchair. He stated after CNA ' A ' had placed Resident #1 back into his wheelchair, CNA ' A ' went back to the desk and left Resident #1 in the lobby in his wheelchair. He stated he further observed " about 30 minutes later " , RN ' A ' was making rounds on the unit and noticed Resident #1 crying and asked him if he was hurting. The ADM stated, " He must have said yes and then she told LVN ' A ' , who gave Resident #1 a pain pill of some kind." He stated during the time period observed " no nurse assessed Resident #1 " and " Both nurses reported they were not aware of Resident #1 falling." He stated he had shown the tape to the DON and ADON (Assistant Director of Nurses) and began the Provider Investigation Report and notified the local Sheriff 's dept. The ADM statement revealed at 1:30 p.m. on 12/29/10, he, the DON, and the ADON had interviewed CNA ' A ' who denied knowing Resident #1 had fallen and denied anything out of the ordinary had happened on 12/25/10. Review of the security camera video tape dated 12/25/10 from 2:45 p.m. through 3:44 p.m. revealed the following: (Note: There was no audio to this video) The video begins at 2:45 p.m. on 12/25/10; Resident #1 was alone with no supervision and seen standing up from his wheelchair in the lobby of the Alzheimer's unit. Resident #2 was observed coming from the patio area and speaking to Resident #1. At 2:46 p.m. CNA ' A ' , was observed to come from the hallway and sit at the desk, after a few minutes he laid his head down on the desk. At 2:51 p.m. Resident #1 was observed attempting to stand up from his wheelchair and sitting back down. At 2:52 p.m. Resident #1 was seen attempting to stand up from his wheelchair and sitting back down. At 2:56 p.m. Resident #1 was observed to completely stand up from his wheelchair, revealing his pressure alarm in the seat of his wheelchair, Resident #1 sat back down. At 2:57 p.m. Resident #1 was observed to stand up from his wheelchair for approximately 1 minute, as he attempted to sit back down he lost his footing and fell to the floor on his left side, striking his head on a chair in the lobby. At 2:58 p.m. CNA ' A ' was observed getting up from the desk and walking over towards Resident #1's wheelchair, moving it closer to Resident #1. CNA ' A ' was observed putting Resident #1 's right shoe back on his foot, pulling Resident #1 up to a seated position on the floor, and then moving behind Resident #1 and lifting him up and placing him back in his wheelchair. CNA ' A ' was observed to stand with Resident #1 for a short time then CNA ' A ' was observed to walk down the hallway, leaving Resident #1 sitting in his wheelchair, alone in the lobby of the Alzheimer ' s unit. At 3:00 p.m. CNA ' A ' was observed to walk out from the hallway accompanied by Resident #2. It appeared CNA ' A ' was directing Resident #2 to sit on the couch in the lobby. Resident #2, did not sit on the couch, but instead walked over to Resident #1. (Resident #2 appeared very anxious. Resident #2 appeared to attempt to console Resident #1. Resident #2's hands were shaking and he appeared to be concerned for Resident #1.) At 3:02 p.m. CNA ' A ' was observed to direct Resident #2 to sit on the couch again, Resident #2 was observed to walk into the hallway. At 3:07 p.m. CNA ' A ' was observed to touch a button on the call light system and walk down the hallway, leaving Resident #1 unsupervised. At 3:08 p.m. Resident #1 was observed standing up from his wheelchair and sitting back down. At 3:10 p.m. Resident #1 was observed standing up from his wheelchair and sitting back down. (Note Resident #1 was left unsupervised for 4 minutes). At 3:11 p.m. CNA ' A ' was observed coming back from the hallway and sitting at the desk. CNA ' A ' laid his head on the desk face down. At 3: 14 p.m. CNA ' A ' was observed to get up from the desk and go back down the hallway leaving Resident #1 unsupervised. At 3:15 p.m. HSKP was observed on the unit, Resident #2 was observed to talk to her. At 3:17 p.m. HSKP was observed speaking to Resident #1, Resident #2 was standing at her side. At 3: 22 p.m. Resident #2 was observed with a female visitor (the facility identified as Resident #2 ' s granddaughter); Resident #2 was observed to walk her over to Resident #1. Resident #2 and visitor were observed to leave the lobby. No staff was observed in the area. At 3:23 p.m. Resident #1 was observed attempting to stand up from his wheelchair and sitting back down. At 3:25 p.m. Resident #2 was observed picking up the call light system and pulling it towards Resident #1. At 3:26 p.m. Resident #2 was observed pushing Resident #1 's wheelchair towards one of the lobby chairs. The HSKP was observed speaking to Resident #1 and Resident #2. RN ' A ' was observed walking from the hallway. HSKP is talking to RN ' A ' and was observed motioning to her right side and pointing towards Resident #1's left side. At 3:28 p.m. RN ' A ' was observed to walk down the hallway away from Resident #1 leaving him unsupervised. At 3:32 p.m. Resident #1 was observed attempting to stand up from his wheelchair and sitting back down.(Note: CNA ' A ' left Resident #1 unsupervised for 18 minutes) CNA ' A ' was observed to come from the hallway, HSKP was observed to speak to CNA ' A ' and make hand motions towards her side. CNA ' A ' was observed to walk towards the desk, stop and fix the cord to the call light system, then sit down and place his head on the desk. At 3:37 p.m. LVN ' A ' was observed to come into the lobby area from the hallway. She approached Resident #1 and gave him a medication and water. At 3:42 p.m. Resident #1 was observed attempting to stand up from his wheelchair and sitting back down, while CNA ' A ' was sitting at the desk. (Note: CNA ' A ' is observed to get up from his seat at the desk to redirect Resident #2 who was attempting to push Resident #1's wheelchair, after he had pushed him approximately 4 feet.) At 3:44 p.m. RN ' A ' was observed coming from the hallway and speaking to CNA ' A ' , and RN ' A ' was observed to reach up and put her hand to his cheek. Resident #1 Review of Resident #1's Record of admitted d 1/11/11 at 12:40 p.m. revealed Resident #1 was admitted on [DATE] and readmitted on [DATE]. He was [AGE] years old at the time of this investigation. Review of Resident #1's consolidated physician orders [REDACTED]. Review of Resident #1's History and Physical dated 12/26/10 revealed, Resident #1 had been admitted to the hospital with [REDACTED]. Past Surgical History included: [MEDICATION NAME] surgery (11/26/10), Orchiectomy, Ventriculoperitoneal shunt, and Open reduction and internal fixation of right hip. Review of Resident #1's Nurses Notes dated 12/26/10 at 7:50 a.m. revealed the CNA (unidentified) had reported Resident#1 had pain and [MEDICAL CONDITION] to his left foot and received PRN pain medication. Review of Resident #1's Nurses Notes dated 12/26/10 at 9:10 a.m. revealed Hospice was informed of Resident#1's pain and [MEDICAL CONDITION] to his left foot. Review of Resident #1's Nurses Notes dated 12/26/10 at 1:05 p.m. revealed, " [MEDICAL CONDITION] continues to the top of the left foot, elevation ineffective. Resident ' s left outer upper thigh is now swollen. Painful to touch. " Review of Resident #1's Nurses Notes dated 12/26/10 at 1:15 p.m. revealed Hospice was called and the facility was awaiting return call. Review of Resident #1's Nurses Notes dated 12/26/10 at 2:15 p.m. revealed Hospice nurse had arrived to assess Resident #1. Resident #1 ' s left leg was " exhibiting outward rotation with pain when moved. " Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 2:00 p.m. revealed, Hospice nurse had assessed Resident #1 and found him to have mild +1 [MEDICAL CONDITION] to his left foot, +2 [MEDICAL CONDITION] to his upper left thigh, and his left leg was abducted. New Orders per Hospice: X-ray of left hip. Review of Resident #1' s Nurses Notes dated 12/26/10 at 3:40 p.m. revealed Mobile Imaging had arrived to do X-ray of Resident #1 ' s left hip. Review of Resident #1's X-ray Report dated 12/26/10 received by the facility at 5:25 p.m. revealed, Findings: There is a left comminuted intertrochanteric fracture with mild displacement. Femoral head is in alignment within the acetabular fossa. The pubic rami are unremarkable. Impression: Acute Left Comminuted Intertrochanteric Fracture with Mild Displacement. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 5:40 p.m. revealed results from X-ray had been received with the Diagnosis: [REDACTED]. Review of Resident #1's Nurses Notes dated 12/26/10 at 5:55 p.m. revealed physician orders [REDACTED]. Review of Resident #1 ' s Nurses Notes dated 12/26/10 at 6:40 p.m. revealed Resident #1 was transferred to the hospital via ambulance. D.O.N (Director of Nurses) and Resident #1 ' s physician were notified of transfer. Review of the facility 's statement from CNA ' A ' regarding Resident #1 's fall on 12/25/10 revealed, CNA ' A ' had been working on the locked Alzheimer ' s unit when about 3:00 p.m. Resident #1 fell to the floor. He stated he proceeded to help Resident #1 into his chair, and " without thinking " did not report Resident #1 ' s fall to the nurse. CNA ' A ' stated he had not been feeling well that day and he felt his head was " in a blur " . He stated the only medications he had taken were Pepto Bismol, and Tylenol Cold and Flu. In an interview on 1/10/11 at 1:30 p.m. with the DON she revealed, she was very surprised at what she had observed on the video regarding Resident #1 ' s fall. She stated CNA ' A ' had been a hard worker until recently and she would have never suspected the observed behaviors out of him. She stated he had only had a couple of performance issues requiring any counseling, one being he had " walked off the job " , and the other not wearing the proper work attire. She stated, " This has all caught me completely off guard, and has been very upsetting to everyone involved. " In an observation on 1/10/11 at 1:45 p.m. revealed Resident #1 resting in his bed with his eyes closed. His room is minimally decorated, bed alarm observed. During an interview on 1/10/11 at 2:00 p.m. with ADM revealed, CNA ' A ' had been terminated as of 12/30/10 due to picking up Resident #1 when he fell , and not reporting a fall to the nurse. ADM stated he had made DADS a copy of the security camera video and he would like to show this surveyor several things on the video. The video was observed in the ADM office with DON and ADON. During an interview on 1/10/11 at 2:30 p.m. with one of the facility housekeeper ' s (HSKP) revealed when she arrived to the Alzheimer's unit lobby to clean her observed Resident #1 was sitting in his wheelchair crying. She stated she asked him in Spanish why he was crying, and he had replied to her in Spanish he was crying because his left leg and side hurt. She stated she talked to Resident #1 for a few minutes and she notified the nurse. She also stated she felt CNA ' A ' was " very sick that day and had a red face. " During an interview on 1/10/11 at 2:58 p.m. with ADM stated, no investigation of abuse or neglect had been done following receiving the X-ray results of Resident #1 ' s revealing a left [MEDICAL CONDITION] on 12/26/10. He stated he was not aware of Resident #1 ' s fall until 12/29/10, when he watched the video and had begun his investigation at that time. During an interview on 1/10/11 at 2:58 p.m. with the DON, she stated she had done a " verbal investigation " . The DON stated she had attempted to investigate Resident #1's left [MEDICAL CONDITION], but after reading the X-ray results had assumed Resident #1 ' s fracture was " pathological " due to the results stating he had [MEDICAL CONDITION]. She stated she asked the CNA ' s and the nurses if Resident #1 had fallen, or if they had any knowledge of how he might have injured his hip and no one was aware of any incidents. She stated the investigation began on 12/29/10 after observing the fall on the security tape. The DON stated she would look through all of her personal notes to see if she had documented any of her investigation into Resident #1's X-ray results received on 12/26/10 with the finding of left [MEDICAL CONDITION]. During an interview on 1/10/11 at 3:20 p.m. with CNA ' C ' , she revealed she had worked with CNA ' A ' before and she felt he had been " a hard worker and took good care of the residents. " She stated she had not ever been aware of CNA ' A ' being abusive or neglectful of the residents. She stated CNA ' A ' had been ill recently with a " stomach virus ". During an interview on 1/11/11 at 10:00 a.m. with Hospice RN she stated she had been notified originally regarding Resident #1 having [MEDICAL CONDITION] to his left foot on 12/26/10. She stated upon assessment of Resident #1 she had determined he had [MEDICAL CONDITION] to his left foot and left thigh and had ordered an X-ray. She stated Resident #1 was asleep during the majority of her assessment and did not show signs of being in a large amount of pain. She stated she had not notified by the facility of any falls or incidents regarding Resident #1. During an interview on 1/11/11 at 10:15 a.m. with RN ' A ' she revealed CNA ' A ' had not notified her of Resident #1 ' s fall on 12/25/10. She stated she had noticed while doing her rounds on the Alzheimer ' s unit, Resident #1 appeared to be in pain. She stated she could " see it in his eyes " . She stated Resident #1 had complaints of leg pain and she had informed LVN ' A ' to administer medications to alleviate his pain. RN ' A ' stated she had assisted CNA ' A ' with transferring Resident #1 to his bed to help him to be more comfortable, she stated while doing so she had assessed Resident #1 ' s pain, but had not done a head to toe assessment and had not observed anything abnormal regarding Resident #1. During an interview on 1/11/11 at 10:45 a.m. with DON, she stated after she had investigated and did not find any explanation of Resident #1 ' s left [MEDICAL CONDITION], she had assumed it was pathological. She stated she knew that she should not have " assumed " anything and should have investigated more diligently. She stated she could not locate any documentation of her investigation. During an interview on 1/11/11 at 10:45 a.m. with ADM, he stated, " Even if the DON had investigated Resident #1's left [MEDICAL CONDITION] results, it doesn't mean we would know exactly what happened. It could have happened while he moved in the bed. " The ADM stated, " The incident was not apparent until the video was observed on 12/29/10. He stated despite the facility not knowing how Resident #1 ' s hip was fractured, there was no formal investigation until the video had been observed on 12/29/10. During an interview on 1/11/11 at 11:45 a.m. with ADON revealed she had been notified of CNA ' A ' being ill at approximately 3:00 p.m. on 12/25/10 and she began searching for another CNA to go in and replace him. She stated she had contacted CNA ' E ' , who agreed to replace CNA ' A ' at 5:00 p.m. on 12/25/10. During an interview on 1/11/11 at 2:10 p.m. with LVN ' C ' revealed she had worked the 10-6 shift on 12/25/10. She stated Resident #1 had slept all night and had made no complaints of pain. During an interview on 1/11/11 at 2:20 p.m. with LVN ' B ' revealed she felt CNA ' A ' was a " good CNA " . She stated she was very shocked when she saw the video of the Resident #1 falling. She stated she felt CNA ' A ' was not his " normal self " , he had recently had a baby, he had recently had " the flu " , and he " should have called in sick if he felt like he had it again. " She stated she had never seen CNA ' A ' being anything but caring towards the residents, and generally went above and beyond his job duties. In an interview on 1/11/11 at 2:30 p.m. with CNA ' F ' revealed she had been originally scheduled to work with CNA ' A ' on the Alzheimer ' s Unit for the 2-10 shift on 12/25/10. She stated when she arrived she could tell CNA ' A ' was not feeling well, his face was " flushed " and he was " very quiet " which was unlike his usual demeanor. She stated she was notified due to being " short staffed " ; she would need to go and work on the East wing. During an interview on 1/11/11 at 3:00 p.m. with LVN ' A ' she revealed she was aware when CNA ' A ' arrived to clock in he was sick. She stated he had a " stomach virus " for the second time. She stated she and RN ' A ' immediately started to find another staff to come in and replace CNA ' A ' . LVN ' A ' stated she had no knowledge of Resident #1 ' s fall on 12/25/10, and CNA ' A ' had not mentioned any abnormal happenings on the Alzheimer ' s unit with any residents on 12/25/10. She stated RN ' A ' had informed her about Resident #1 ' s pain and she had medicated him per physician orders. She stated Resident #1 is " hard to assess " due to his cognitive level and he frequently has complaints of pain and cannot verbalize where his pain is located. She stated the nurses have to often attempt to determine if Resident #1 is in pain by non-verbal cues such as grimacing. She stated she was able to determine Resident #1 was having left leg pain, but had not done a full assessment. In an interview on 1/11/11 at 4:30 p.m. with CNA ' A ' he revealed on 12/25/10 at approximately 10:00 a.m. he stated he had called and left a message on the ADON ' s cell phone informing her that he was ill with vomiting and diarrhea and needed to be taken off the schedule. He stated he did not receive a call back and went into to work his scheduled 2-10 shift even though he was feeling ill. CNA ' A ' stated he had notified LVN ' A ' when he arrived at work of his vomiting and diarrhea and she had informed him they would try and find someone to replace him. He stated CNA ' F ' was also scheduled on the Alzheimer ' s Unit for 2-10 shift on 12/25/10 and RN ' A ' had reassigned her to the East Wing due to other staff calling in sick that shift. He stated when he arrived to the unit he was responsible for caring for 8 residents and 1 more resident was due back form a pass later in the shift. He stated he was back and forth to the restroom with vomiting and diarrhea while he was on duty. He stated before 3:00 p.m. he was sitting at the desk when Resident #1 stood up from his wheelchair. He stated he had redirected Resident #1 to sit back down and when Resident #1 had attempted to sit back down he had somehow " lost his footing " and he had fallen to the floor. He stated he went and moved the wheelchair due to Resident #1 ' s leg being on the foot rest and then " immediately " attempted to care for Resident #1. CNA ' A ' stated Resident #1 had requested CNA ' A ' to assist him up from the floor. He stated he did not see any bruising or injury and he helped Resident #1 back up into his wheelchair. CNA ' A ' stated he used the speaker (intercom system) to notify LVN ' A ' of Resident #1 ' s fall, but wasn't sure she had heard him. He stated he had talked with HSKP in the hallway and she had informed him, Resident #1 had complaints of his left leg hurting. CNA ' A ' stated at approximately 3:00 p.m. he had gone to the unit doors to " double check " if LVN ' A ' had heard him and had discussed Resident #1 ' s fall with her. He stated a few minutes later RN ' A ' came to the unit and talked with Resident #1, then LVN ' A ' came onto the unit and gave Resident #1 a pain pill. He stated he was not sure if the nurses assessed Resident #1 or not, due to having to answer call lights for other residents on the unit. CNA ' A ' stated CNA ' E ' arrived to replace him around 6:00 p.m. and he had informed her of Resident #1 ' s fall and complaints of pain to his left leg. CNA ' A ' stated he knew the one thing he had done wrong was to move Resident #1 after he had fallen due to the nurses needing to assess him for injury. CNA ' A ' stated he was not aware of any specific interventions to keep Resident #1 from falling with the exception of telling Resident #1 to sit back down. CNA ' A ' stated, Resident #1 ' s wheelchair alarm was sounding when Resident #1 attempted to stand up from his wheelchair. He stated, " The alarm went off 3 or 4 times and I would tell him to sit down and he would sit down. " CNA ' A ' stated he was not aware if Resident #1 had hit his head during the fall. He stated he was not aware of Resident #1 hitting his head during the fall and if Resident #1 had hit his head, he would have gone and informed the nurse. In an interview on 1/12/11 at 1:40 p.m. with CNA ' G ', she stated that there have been many times when she has had to work on the Alzheimer ' s Unit alone. She stated the bathroom for the staff is located off the unit, therefore if a staff person is working on the unit alone, they have to wait until someone can come sit on the unit to monitor the residents or if it ' s late and most of the residents are in bed, " we just prop one of the doors open " . In an interview on 1/12/11 at 1:10 p.m. the Administrator said all the only staff that were in-serviced was listed on the Provider Investigation Report and no other staff had been in-serviced. In an interview on 1/12/11 at 1:32 p.m. the ADON said she was on call 24/7 for the facility staffing. She said CNA ' A ' reported to work at 1:45 p.m. and she received a call from RN ' A ' at 3:00 p.m. regarding CNA ' A ' being sick with the stomach bug. She said CNA ' A ' was able to go home at 5:15 p.m. She said the policy regarding staffing for the locked dementia unit was two CNA ' s in the morning, 2 in the afternoon and 1 at night. She said on 12/25/10 on the 2:00 p.m. to 10 p.m. shift the facility had 1 RN, 2 LVN ' s, 4 CNA ' s and a medication aide from 4:00 p.m. to 8:00 p.m. She said, for example, if the unit had only one CNA and a resident needed incontinent care the other residents would be unattended while the CNA was assisting the resident. On 1/12/11 at 2:25 p.m. the Administrator and DON were notified of IJ and substandard quality of care. In an interview on 1/12/11 at 2:58 p.m. LVN ' A ' said CNA ' A ' arrived at work on 12/25/10 for his 2-10 shift . She said he appeared pale and felt warm to the touch. She said he reported he had the stomach bug and had an episode of diarrhea when he arrived at the facility for his shift. She said she asked him if he wanted some Tylenol and he told her he did not want any because he would not be able to keep it down. She said the RN called the ADON to report CNA ' A ' was ill when he arrived for his shift but the ADON did not return the call until 3:00 p.m. She said CNA ' A ' was on the schedule for the locked dementia unit so they just stayed with the schedule and tried to find him a replacement. She said there was no bathroom on the locked dementia unit and the staff would have to leave the unit to go to the bathroom. She said she was not sure if CNA ' A ' had to the leave the unit that day but usually if there was just one staff person on the unit the staff would prop the locked door open and go to the bathroom in the main building. She said the staff prop the door open a lot at night because there is just one staff member on the unit. She said the staff tries not to leave the door propped open too much due to the wandering residents. She said a lot of the time on the 2:00 p.m. to 10:00 p.m. shift there was just one aide on the Alzheimer ' s unit. She said on 12/25/10 on the 2:00 p.m. to 10:00 p.m. shift there was 1 RN, 2 LVN ' s, 4 CNA ' s and a medication aide came in at 4:00 p.m. She said a replacement was found for CNA ' A ' and he was able to go home at 5:15 p.m. During an interview on 1/12/11 at 3:30 p.m. the Administrator, DON and ADON said they were not aware the staff was leaving the locked door to the Alzheimer ' s unit propped open. The DON said the staff did not leave the door open when administration was in the building and the staff had been told not to prop the door open. During an interview on 1/13/11 at 10:35 a.m. the DON said if an investigation had been done on an incident, it would be on a piece of paper stapled to the Incident/Accident form. She said she did not have a system for conducting investigations. During a telephone interview on 1/13/11 at 2:36 p.m. LVN ' B ' said there was only one CNA for the locked dementia unit on the 2:00 p.m. to 10:00 p.m. shift about 50% of the time. She said the facility had difficulty staffing the unit. She said the staff propped the door to the Alzheimer ' s unit open some on the afternoon and night shift but more on the night shift. During an interview on 1/13/11 at 3:15 p.m. RN ' B ' , who worked the 2:00 p.m. to 10:00 p.m. shift, said the aides propped the door open on the locked Alzheimer ' s unit at times. She said when she worked the aide would prop the door open, leave the unit and she would watch the unit from the nurse ' s station outside the locked doors. She said from that position she could not see the unit lobby area or patio but she could see down the main hall. Review of Resident #1 ' s Functional Assessment for Persons with Alzheimer ' s Disease dated 11/9/10 revealed the facility had identified Resident #1 ' s orientation as unable to identify place or misidentifies place; disoriented to day/month/season/year; usually knows immediate family but misidentifies extended family members/friends. Resident #1 ' s motor skills were identified as difficulty making complex decisions. Resident #1 ' s attention, memory and cognitive functioning was identified as distractible; severe short term memory deficit, long term memory somewhat impaired; fixations; possessive with belongings; territorial; sleep disturbances; has catastrophic reactions; unprovoked aggression; resists care; misidentifies objects/use. Review of Resident #1 ' s Care Plan dated 12/2/10 revealed the facility had identified Resident #1 as having Self Care Deficit in the following areas: Transferring and Ambulation: Problem / Need related to: Dementia, Alzheimer ' s, resulting in two staff assist. Goals were identified as: Resident will be free of complications secondary to requiring staff assistance, Resident will maintain intact skin, Resident will have normal bowel patterns and absence of [MEDICAL CONDITION], and Resident will maintain a positive self image. Interventions: Knock on door before entering room. Call resident by name and identify yourself by name. Resident uses wheelchair. Review of Resident #1 ' s Fall Risk assessment dated [DATE] revealed Resident #1 scored a total of 25. The assessment instructions revealed a score of higher than 10 or greater should be considered at HIGH RISK for potential falls and a prevention protocol should be initiated immediately and documented on the care plan. Review of facility ' s Incident and Accident report dated 10/17/10 at 2:30 a.m. revealed Resident #1 was up walking in his room without his walker. Resident #1 was witnessed to fall and sit on his buttocks in the middle of the floor. Resident #1 was alert and had no apparent injury. Additional comments and steps to be taken to prevent a recurrence: Encourage Resident to use his walker when he gets up. DON signature was dated 10/18/10. ADM signature was dated 10/20/10. Medical Director signature was dated 11/02/10. Review of facility ' s Incident and Accident report dated10/25/10 at 6:25 p.m. revealed Resident #1 was found on the floor in the sitting area in front of his wheelchair. Wheels on wheelchair were unlocked. Resident #1 ' s level of consciousness was alert. Additional comments and steps to be taken to prevent a recurrence: Lock Wheelchair. DON signature was dated 10/21/10. ADM signature was dated 10/22/10. Medical Director signature was dated 11/02/10. Review of Resident #1 's Care Plan dated 12/17/10 revealed Resident #1 had a fall resulting in minor injury resulting in a faint red mark to the middle of his back, described as fading. Strengths to draw on were listed as: Resident appears free of infection. Goals: will resume usual activities without further incident. Involved areas will resolve without complications. Interventions: Crani-checks for 48 hours (precautionary). Vital Signs per Neurological check protocol, Continue interventions on the at-risk plan. No further interventions were found. Review of Resident #1 ' s Minimum (MDS) data set [DATE] revealed Resident #1 was identified as having short an