Every finding on record at Signature Healthcare of Carrollton Rehab & Wellnes

Based on interview, record review, review of staff training records, and review of the website utilized by the facility for training staff, the facility failed to provide staff training specific to a resident's mental illness diagnoses and behaviors for 1 of 9 sampled residents, Resident (R)1. R1's diagnoses included Borderline Personality Disorder and Schizoaffective Disorder, and the resident exhibited behaviors. However, the facility failed to provide training for staff directly related to R1's mental illness and diagnoses. The findings include: Review of the facility policy titled, Abuse, Neglect and Misappropriation of Property, last revised and reviewed on 09/15/2023, revealed it was the organization's intention to prevent the occurrence of abuse. Review of the policy revealed the facility included training to provide for the protection of the health, welfare, and rights of each resident residing in the facility. Continued review revealed training provided included understanding behavioral symptoms of residents that might increase the risk of abuse and how to respond. Review further revealed the resident behavioral symptoms included aggressive or catastrophic reactions of residents, outbursts or yelling out, and resistance to care. Review of the facility's investigation of an incident on 08/28/2024, revealed R1 became verbally aggressive toward the Housekeeper. Per review, R1 called the Housekeeper a fat, ugly bitch multiple times, which led to the Housekeeper repeating (the words) back to R1. Review further revealed the Housekeeper was removed and was not to return to the premises. Review of the facility's staff training overview for Behavioral Health for Older Adults revealed an overview of the training included the physical decline (of residents), loss of loved ones, and it discussed the most common behavioral disorders, levels of care, and community supports. Continued review revealed the goal of the course was to educate staff in post-acute care on behavioral health in older adults. Review further revealed the course overview did not define specific mental illness or any mental illness, such as R1's diagnoses. Review of the website www.reliasacademy.com training Behavioral Health for Older Adults, utilized by the facility, revealed the training included behavioral health disorders common in older adults. Per review, the behavioral health disorders in the training included Depression, Dementia, Alzheimer's Disease, Suicide, Anxiety, Substance Use Disorder, Bipolar Disorder, Eating Disorders, and Schizophrenia. However, further review revealed Borderline Personality Disorder and Schizoaffective Disorders were not identified as included in the training outline. Review of R1's clinical record revealed the facility admitted the resident on 06/21/2021 and readmitted R1 on 09/30/2021, with diagnoses which included borderline personality disorder, dementia, and schizoaffective disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. Review of R1's comprehensive care plan revealed the facility developed a problem area for behaviors for the resident dated 07/01/2021 and edited 12/09/2024. Review revealed the facility noted R1's behaviors as: being verbally abusive and physically aggressive; refusing care, medications, and psych services; being difficult to redirect; known to yell/cuss and say racial slurs towards staff; and hitting staff. Continued review revealed the facility listed other of R1's behaviors as: attempting to impede the care of others; being destructive to facility property and electronic devices; making unsubstantiated claims and allegations; displaying manipulative behaviors and paranoia; and demanding her care needs be first above other residents. In addition, the facility noted R1 had behaviors of rummaging through others' personal belongings; attempting to rummage through the food carts; and hoarding dishes, linens, food, snacks. Further review of the care plan revealed interventions that included: redirecting and providing education as needed on the benefits and risks of recommended care; two people (present) at all times during care; continuing to offer psychiatric support services; and discussing the behavior with resident if reasonable. Review further revealed other interventions to: intervene as needed to protect the rights and safety of others; divert the resident's attention; remove the resident from a situation as needed; encourage activity; allow the resident to express feelings and provide methods to cope; and re-approach later when she had less agitation. Review of R1's progress notes revealed R1 yelled at staff, cussed staff, and/or called staff names on the following dates: 08/05/2024, 08/07/2024, 08/22/2024, 08/25/2024, 08/28/2024, 09/07/2024, 09/19/2024, 09/23/2024, 10/11/2024, 10/12/2024, 10/13/2024, 10/18/2024, 10/19/2024, 10/22/2024, 11/03/2024, 11/11/2024, 11/19/2024, 11/29/2024, 11/30/2024, 12/02/2024, 12/03/2024, 12/07/2024, 12/08/2024, and 12/09/2024. In interview on 12/12/2024 at 2:42 PM, R1 stated she was calling the federal government and the governor to report staff at the facility. She stated an Adult Protective Services (APS) worker came to speak with her yesterday and the APS worker was going to call the supervisor of the State Survey Agency (SSA) to make her report. R1 spoke of how staff treated her in the facility, calling her names and cussing her. In interview on 12/13/2024 at 9:58 AM, the APS worker stated R1 had a lengthy history with the state. She reported she saw R1 on 12/11/2024, for allegations the resident made against Certified Nurse Aide (CNA) 1 and Licensed Practical Nurse (LPN) 2. In interview on 12/12/2024 at 5:37 PM, LPN 1 stated R1 had diagnoses that caused her to have mental health issues. She further stated R1 got the whole building in an uproar in general, and that was just who she was. In interview on 12/18/2024 at 10:36 AM, the Social Services Director (SSD) stated staff received education for dementia and mental illness when hired, and with yearly competencies (however, review of the facility's training revealed it did not specifically address R1's diagnoses of schizoaffective disorder and borderline personality disorder). The SSD reported staff used R1's care plan interventions when she had behaviors, although they did not prevent the resident's behavior of hitting staff. In interview on 12/18/2024 at 3:16 PM, the Housekeeping District Manager (DM) revealed the housekeepers completed the same trainings the facility staff completed, either in person or online. She stated the housekeepers completed their own training and any general education with the facility. The Housekeeping DM was unsure if facility staff completed training regarding a resident's mental illness. In interview on 12/18/2024 at 6:16 PM, CNA 4 stated she was very familiar with R1, although she did not usually provide care for the resident. She stated R1 called staff names, cussed at staff, and harassed certain staff. CNA 4 stated the facility provided training for working with residents with mental illnesses, such as mental disability or M.R. (mental retardation). In interview on 12/19/2024 at 10:24 AM, the MDS Nurse stated she did not know if any staff received training specific to R1's psychiatric diagnoses (of borderline personality disorder and schizoaffective disorder). She stated the facility had not had a Staff Development Coordinator (SDC) to provide staff education for about two months. The MDS Nurse said facility staff had different learning based on their various roles. She further stated she had not received training related to R1's mental illness diagnoses. In interview on 12/19/2024 at 12:51 PM, the Director of Nursing (DON) stated she was also the current SDC. She said staff had to walk on eggshells with R1 as they did not know how she would react to them. The DON said you could say good morning to R1 and she would cuss you out, or be as nice as can be. She reported each behavior was situational and the majority of R1's behaviors were from the same root cause, her personality disorder. The DON explained R1 targeted specific staff and called staff names and talked derogatively about them. She stated R1 has difficulty interacting appropriately with others and became defensive and angry. Per the DON in interview, the facility did not typically complete resident mental health training for staff as the facility was not a mental health facility. She said staff were trained in dementia and dementia type behaviors when hired and yearly. The DON reported however, staff were not trained on schizoaffective disorder or borderline personality disorder. She said the training the facility provided titled, Behavioral Health for Older Adults was dementia training. The DON stated training in schizoaffective disorder and borderline personality disorder was situational, as everybody's situation was different. She said the purpose of providing training for staff was to help them know how to handle situations or provide care or diversional activities for residents. The DON further stated housekeeping was a different company and she could not answer if they completed the same trainings the facility completed. In interview on 12/19/2024 at 2:22 PM, the Administrator stated R1 did things without being provoked. He said he was aware of R1's mental illness and it was uniquely directed toward staff and visitors and that was just who R1 was. The Administrator reported R1 responded to some staff better than others. He stated R1 hit a CNA and attempted to hit a nurse (on 12/09/2024), and the root cause of those two events had been R1's mental illness. Per the Administrator in interview, staff were trained on R1's mental illnesses in the Behavioral Health for Older Adults training. He stated that the facility's training was a general behavioral training for older adults and R1's diagnoses should be included in the training (however, schizoaffective disorder and borderline personality disorder were not included in the training outlined on the website). The Administrator said the purpose of the trainings was to educate staff on how to manage a resident's behaviors, whether it was mental illness or behavioral, to provide quality of life for residents and person centered care. He further stated the facility was the last stop for many of the residents and the facility wanted to make them as happy and comfortable as possible, and the trainings help in providing that kind of life for the residents.

Based on interview, record review, and review of the facility policy, the facility failed to ensure residents were free from verbal abuse for 1 of 9 sampled residents, Resident (R)1. On 08/28/2024, the Housekeeper cussed at and called R1 names after the resident was verbally aggressive towards the Housekeeper. The findings include: Review of the facility policy titled, Abuse, Neglect and Misappropriation of Property, last reviewed and revised 09/15/2023, revealed it was the organization's intention to prevent abuse and protect the health, welfare, and rights of each resident residing in the facility. Per review, instances of abuse, irrespective of any mental or physical condition, caused harm, pain, or mental anguish. Continued review revealed abuse included verbal abuse, which encompassed use of oral language with any threat, frightening, disparaging or derogatory language to residents or within their hearing distance, regardless of age, ability to comprehend, or disability. Review of the facility policy titled, Resident Rights, last reviewed 09/13/2024, revealed all residents had the right to be treated with respect and dignity, which was to be protected by the facility. Per review, all residents were to be treated in a manner and in an environment that promoted enhancement of quality of life. Review further revealed the facility was to make every effort to support each resident in exercising his/her right to assure the resident was always treated with respect, kindness, and dignity. Review of the facility's investigation for an incident on 08/28/2024, revealed the facility investigated a verbal altercation between the Housekeeper and R1 at 11:30 AM. Per review, the facility removed and suspended the Housekeeper. Review of the Housekeeper's written statement (located in the investigation documentation), dated 08/28/2024 at 4:35 PM, revealed it had been written by the Housekeeper's parent, as the Housekeeper had disabilities; however, was signed by the Housekeeper. Continued review of the Housekeeper's written statement revealed R1 called the Housekeeper a fat, ugly bitch over and over. Further review of the Housekeeper's written statement revealed the Housekeeper finally broke and told R1 to get out of her effing face and she too (R1) was a fat, ugly bitch. Further review of the facility's investigation revealed the facility determined the incident had been a situational, reactionary event without willful intent to harm and the staff member would not return to the premises. Continued review of the facility's investigation documentation, for the incident on 08/28/2024, revealed other staff members' statements. Review of Licensed Practical Nurse (LPN) 1's written statement revealed the nurse heard the Housekeeper yelling at R1 and she told the Housekeeper she could not speak to residents in that manner or that way in the resident area. Review of LPN 3's written statement revealed she heard yelling, which included get out of here you fat bitch and whore. Per review of LPN 3's written statement, LPN 1 asked the Housekeeper if it was her yelling, and the Housekeeper said yes. Further review of LPN 3's statement revealed she (LPN 3) took the Housekeeper's broom and dustpan and escorted the Housekeeper to the timeclock. Review of the clinical record for R1 revealed the facility admitted the resident on 06/21/2021, and readmitted R1 on 09/30/2021, with diagnoses that included dementia, schizoaffective disorder and borderline personality disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R1 with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Review of the comprehensive care plan for R1 revealed the facility developed a behavioral problem area dated 07/01/2021 and edited 06/12/2024. Continued review of R1's behavior care plan revealed the resident's behaviors included being verbally abusive; difficult to redirect; known to yell/cuss at staff; and say racial slurs towards staff. Further review revealed the interventions included to provide a non-confrontational environment for care. In interview on 12/12/2024 at 2:42 PM, R1 stated a housekeeper yelled at her and cussed at her around a month ago. R1 further stated the Administrator fired the housekeeper. In interview on 12/12/2024 at 4:27 PM, the Housekeeper (involved in the incident on 08/24/2024) stated R1 called her a fat ugly bitch and she (the Housekeeper) went off and told R1 to look in the mirror. The Housekeeper stated she said what was noted in her written statement. She further stated the facility wanted her out of the building On 12/12/2024 at 5:37 PM, interview with LPN 1 revealed she had been involved in the situation with R1 and the Housekeeper. She stated she had been at the nurse's station and heard loud yelling and knew it was R1. LPN 1 said she went to where the resident was and intervened with R1. She reported she and another nurse told the Housekeeper she could not speak like that to R1 and asked the Housekeeper to leave the resident area. LPN 1 stated the Housekeeper said, that fucking bitch whore (R1) was not going to talk to her like that. The nurse said R1 called the Housekeeper a fucking bitch, and the housekeeper said no you're a fucking bitch. LPN 1 further stated she escorted the Housekeeper to the timeclock and watched the Housekeeper leave the building. She additionally stated she told R1 it (the incident) would be handled through proper channels. In interview on 12/18/2024 at 3:16 PM, the Housekeeping District Manager (DM) stated R1 made comments to the Housekeeper and when the Housekeeper attempted to walk away, R1 followed her. She stated the Housekeeper then screamed back at the resident. The Housekeeping DM reported the Housekeeper was walked out of the facility after she raised her voice to R1 and was terminated on the spot. She said she spoke with the Housekeeper and informed her R1 was still a patient and she (the Housekeeper) still needed to follow the facility's protocol. The Housekeeping DM further stated there were other things the Housekeeper could have done in that situation. In interview on 12/18/2024 at 12:51 PM, the Director of Nursing (DON) stated R1 started to cuss and yell at the Housekeeper while the Housekeeper was cleaning the resident's room. She said the Housekeeper tried to walk away; however, R1 followed the Housekeeper down the hall. The DON stated the Housekeeper began to talk back to R1, yelling and cussing, and was terminated for the verbal abuse. Interview on 12/18/2024 at 2:22 PM, the Administrator stated R1 did not need to be provoked in her behaviors. He reported LPN 1 heard the incident between R1 and the Housekeeper (on 08/24/2024) and got the Housekeeper immediately out of the building. The Administrator stated the LPN reported the incident to him and the housekeeper was immediately suspended and eventually terminated. He explained R1 had not wanted her room cleaned at the moment; however, the Housekeeper tried to go ahead and clean the room. The Administrator stated R1 followed the Housekeeper in the hall and called the Housekeeper a retard. He further stated the Housekeeper, who had a developmental disability, said R1's words back to the resident.

Based on interview, record review, review of facility policy, and review of a police Uniform Citation, the facility failed to ensure that one (Resident (R) 265) of 65 sampled residents was free from misappropriation of resident property. Licensed Practical Nurse (LPN) 10 took R265's narcotic pain medication without authorization. The findings include: Review of the facility policy titled Controlled Medications, dated 11/13/2023, revealed the policy was to ensure controlled medications are handled, stored, disposed of, and there is record keeping is in place. Added review revealed at each shift change or when keys are rendered, a physical inventory on all controlled medications is conducted by two staff members. Continued review of the guidelines included that a licensed nurse or medication technician with possession of the medication keys is to remain on the facility premises. Added review revealed if staff with the keys are leaving the premises, he or she is to surrender the keys and complete a physical inventory of all controlled substances. Review of R265's face sheet revealed the facility admitted the resident on 05/01/2023 with diagnoses including sepsis, urinary tract infection, and low back pain. Review of R265's order set, dated 06/28/2023, revealed an order for oxycodone -schedule two (narcotic) tablet; 10 milligram (mg) oral, one (1) tablet daily PRN (as needed) at least four hours in between routine pain medication. Added review of the order set revealed the resident also had orders for oxycodone-10 mg, oral one tablet PO (oral) every six hours for pain (at midnight, 06:00 AM, 12:00 PM, and 06:00 PM). Review of a Uniform Citation, dated 07/23/2023 with a violation time of 12:36 PM and time of arrest at 8:30 PM, revealed LPN10 was arrested after she told police on 07/23/2023 at 7:00 PM that she stole five narcotic pills when she first came to work and then another five pills, just before leaving for her extreme pain. Continued review of the Uniform Citation revealed that LPN10 stated she had hidden the empty package (which had previously contained the narcotics), as well as the narcotic count form, inside a diaper in a cardboard box in the trash cart. Review of a typed witness statement by LPN9, sent via e-mail on 09/13/2023 at 1:05 PM, revealed that on the day of the 07/23/2023 incident, LPN10 left the facility and then returned within minutes, stating someone had stolen her purse/wallet. LPN10 asked for LPN9's keys to look in the supply room and when LPN10 exited the supply room, the keys were given back to LPN9. Continued review of the statement revealed that after this, during the medication pass, LPN9 discovered the key that unlocked the medication narcotic box was missing. A master key was ultimately obtained so that the medication pass could continue. However, when LPN9 came to give medications to R265, the nurse found that the resident's oxycodone, as well as the narcotic count sheet for the oxycodone, was missing. Review of a progress note dated 07/23/2023 at 12:29 PM revealed staff explained to R265, whose oxycodone was missing, that a new pain medication supply would be here by the next scheduled dose and if the resident needed pain medication before then, an order would be placed for an emergency kit supply. Review of progress note dated 07/23/2023 at 1:00 PM revealed R265 had no complaints of pain prior to the arrival of the replacement narcotic medication. Further review of the Uniform Citation, dated 07/23/2023, documented that LPN9 stated she allowed LPN10 to use the keys to look for missing personal items. An attempt to reach LPN9 on 04/12/2024 at 4:33 PM for interview was not successful. During interviews with LPN1 at 5:00 PM on 04/12/2024, LPN 3 at 5:10 PM on 04/12/2024, and Kentucky Medication Aide (KMA) 21 at 5:20 PM on 04/12/2024, they stated the facility provided training to include not to give narcotic keys to other staff after the narcotic count had been performed; however, they were unable to state the exact dates of the training. In an interview with the Assistant Director of Nursing (ADON) on 04/11/2024 at 11:15 AM, she stated that on the day of the incident, she received a phone call from LPN9 saying the narcotic key was missing for the South Hall. Per LPN9, when the shift count was performed that day, the narcotic count was correct, and the narcotic key was passed to her from LPN10. She added that LPN9 told her shortly after that, LPN10 exited the building and then returned, saying she left her wallet and requested the keys to unlock the medication room. LPN9 gave LPN10 the keys. LPN10 then returned the keys to LPN9 after looking in the medication room. The ADON continued that it was after this incident that LPN9 discovered the narcotic key was missing when morning medication pass was in process. The ADON stated she came to the facility immediately and, in route, she notified the Administrator. She added when she arrived, she helped search for the key but could not find it and the master key was obtained from the Director of Nursing's (DON) office. During this time, LPN10 texted and requested for her timesheet to be completed and the ADON stated she requested for her to come back to facility and search for the narcotic key. She added that LPN10 did return to the facility and helped search for the narcotic key. The ADON added after LPN10 exited the facility after searching for the narcotic key, the key was found in an area that was previously searched. In an interview with the Director of Nursing (DON) on 04/12/2024 at 4:00 PM, she stated she was on vacation when this incident occurred The DON related that after the arrest, LPN10 was reported to the Kentucky Board of Nursing (KBN). During an interview with the Administrator on 04/12/2024 at 2:55 PM, he stated he was notified of a possible drug diversion by an agency nurse and, upon receiving that information, he came to the facility immediately and began interviewing staff. He stated the facility then made a report to the proper authorities which included the police department. Per the Administrator, the police started their investigation and he confirmed that LPN10 was arrested that night.

Based on observation, interview, record review, and facility policy/procedure, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for one (Resident (R) 51) of 49 sampled residents. Staff entered R51's room, which was designated as a contact precaution room, without first donning proper Personal Protective Equipment (PPE). The findings include: Review of the facility's policy, titled Infection Control, with an effective date of 01/23/2024, revealed the intention of the policy was to help prevent and manage the transmission of diseases and infections. Added review of the policy revealed the objectives were to establish guidelines for implementing Isolation Precautions, including Standard and Transmission-Based Precautions. Review of the facility's signage for contact precautions (procedure to be used) revealed providers and staff must put on gloves and gown before room entry and discard the PPE before exiting the room. Review of R51's face sheet revealed the resident was admitted on [DATE] with diagnoses including candidiasis of the skin and nail. Review of R51's order set, dated 12/30/2023, revealed an order for contact precautions. Review of R51's Comprehensive Care Plan (CCP), dated 01/12/2024 with revision date of 04/09/2024, revealed the resident had a problem identified as being on ongoing contact isolation related to candidiasis auris, a species of fungus that grows as yeast. Review of interventions included staff were to use PPE as indicated. On 04/10/2024 at 8:15 AM, observation revealed signage for contact isolation on R51's door. Review of the contact isolation signage revealed it documented that staff were to don PPE, including gloves and a gown, prior to entering the room. An isolation cart containing PPE was available for use. Kentucky Medication Aide (KMA)1 failed to don the required PPE prior to entering R51's room, carrying medications in a medication cup. During interview at this time, KMA1 stated staff was told by nursing that if they were just walking in the room to hand pills, they did not need to gown up. In an additional interview with KMA1 on 04/11/2024 at 3:30 PM, she stated she has worked at facility since June of 2023 and her job tasks include passing medications to residents. KMA1 stated she had been given wrong instructions by nurses about not needing PPE when entering the room. KMA1 noted that she had training for contact isolation and knew better, and she should have donned PPE. During an interview with the Infection Preventionist (IP) on 04/11/2024 at 1:30 PM, she stated she is also the facility's Director of Nursing (DON). She stated she performs infection control trainings yearly and in-services as needed, adding the last training was in 12/2023. She added in the trainings she performs skill checkoffs with staff which included donning/doffing proper PPE for different isolation, adding re-education was given if needed. The IP/DON stated that random audits were performed on infection control procedures, but she did not keep evidence of the audits. During an interview with the Administrator on 04/12/2024 at 2:55 PM, he stated that staff had been educated on contact isolation, and education is an ongoing process in facility.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide sufficient nursing staff in order to implement supervision to ensure resident's safety for one (1) of thirty-seven (37) sampled residents (Resident #60). Resident #60 sustained a fall, on 02/04/2020 at 4:15 AM, when the facility-scheduled staff included one (1) nurse and one (1) aide for the North Unit Hall with a census of thirty-one (31) residents, who required care and supervision. The findings include: The facility did not provide a Staff or Staffing Policy upon request. Review of the facility's policy, Safety and Supervision of Resident, reviewed 05/31/18, revealed the facility ensured the safety and well-being of the resident with routine checks on residents. Routine checks involved staff to physical enter the resident's room to determine the residents' needs. The policy identified needs included the change of condition, sleep status, toileting assistance, and possible concerns identified by the resident. The facility addressed resident safety needs on an individualized basis. Furthermore, the implementation of resident interventions, which reduced the risk of an accident, included assigned responsibility to carry out the interventions. In order to monitor the facility's effectiveness for safety, the facility completed a through evaluation of the facility's interventions. Review of the facility's policy, Falls, revised 11/06/19, revealed the facility provided residents with assistance and supervision to reduce the possibility of a resident fall. All falls, which occurred in the facility, required monthly review from the Quality Assurance Performance Improvement (QAPI) Committee, which reviewed and determined the course of action required for the identified trend. Review of the facility's policy titled, Aspects of Care, undated, revealed the facility's clinical care services' responsibilities included implementation of care to prevent complications and maintain residents' safety. The Director of Nursing's (DON) responsibility included to ensure residents received the implementation of their identified care on a twenty-four (24) hour basis. Review of the facility's policy titled, Dementia Care, reviewed 07/11/18, revealed care for residents with cognitive impairment included to maintain a safe environment. Review of the Facility Assessment document, dated 2020, revealed the facility assessed the staffing requirements for each resident on each unit to ensure the facility provided sufficient staff for the assessed need(s) of all residents. The facility assessed that adequate staff for the shift hours of 7:00 PM to 7:00 AM, was two (2) nurses and two (2) aides. Review of the Facility Schedule, dated 02/03/2020, revealed for the 7:00 PM to 7:00 AM shift, after 12:00 AM on 02/04/2020, the staffing only included one (1) aide and one (1) nurse. The census for the North Unit Hall included thirty-one (31) residents. Resident #60 resided on the North Unit Hall. Review of Resident #60's clinical record revealed the facility admitted the resident, on 01/09/19, with diagnoses, which included Dementia, Muscle Weakness, and History of falls. Review of the facility's Quarterly Minimum Data Set (MDS) Assessment for Resident #60, dated 01/23/2020, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15), indicating the resident was severely cognitively impaired. Further review revealed the facility assessed Resident #60 to be unsteady and required extensive one (1) person assist. In addition, review of the MDS revealed the facility also assessed Resident #60 as always incontinent of bowel and bladder. Review of Resident #60's history revealed the resident had a fall, at home, on 01/05/19 and sustained a [MEDICAL CONDITION] and pubis. Further review of Resident #60's clinical record revealed the facility care planned the resident for the risk of falls. Further review revealed the facility identified fall risk factors that included the resident's age, incontinence, unsteady gate, altered awareness, and need for assistance. The fall interventions, initiated on 07/08/19, included to assist with ambulation, report falls to provider and family, when in wheelchair place in a common area, refer to therapy, and encourage activity participation to increase strength. Continued review of the fall care plan revealed to further prevent a fall, the facility included to have the call light within reach, to rise in a slow manner, and rest before a transfer, to keep the area free of clutter, and glare free light. Interview with Certified Nursing Assistant (CNA) #8, on 03/05/2020 at 3:37 PM, revealed the facility scheduled one (1) aide and one (1) nurse after midnight for each unit of the facility. The CNA stated she took care of thirty (30) residents with one nurse after midnight. She stated the facility has scheduled this level of staff since her employment with the facility. Further interview revealed on the night of Resident #60's fall, the nurse required assistance for another resident's dressing change; therefore, she and the nurse provided care in the other resident's room. The CNA stated while in the room with the nurse, they both heard a resident's cry for help, she left the room, and discovered Resident #60 on the floor. She stated the resident cried out and stated that his/her arm was broken. The CNA stated when the facility scheduled two (2) staff for the unit, the Director of Nursing (DON) expected the nurse to work with the aide to meet the needs of all residents, which included up to thirty-three (33) residents. Interview with Licensed Practical Nurse (LPN) #3, on 03/05/2020 at 2:17 PM, revealed she worked with one CNA on 02/04/2020 after midnight, when Resident #60 experienced the fall at 4:15 AM. The LPN stated, the facility's routine schedule included one (1) nurse, and (1) one CNA to provide resident care on the unit after midnight. LPN #3 stated on the night of the fall, a resident on the unit required her and the aide to complete a wound dressing change, and they both were in the room with the door closed. Continued interview revealed the facility expected the aide and nurse to work together to meet the needs of the residents. However, when care required two (2) staff to be in a room it left the residents alone on the floor. LPN #3 stated staff supervised and checked on the residents when they passed the doors and looked into the rooms. The LPN further stated the lights used for observation of residents included the hallway light, not the resident's room lighting. She stated Resident #60 fell on to the floor while she and the aide provided care behind a closed door. The LPN stated staff's responsibilities included to ensure to keep residents safe. Interview with the Director of Nursing (DON), on 03/05/2020 at 4:07 PM, revealed staffing after 11:00 PM included one (1) aide and one (1) nurse for each unit and remarked the staffing level was a skeleton crew. The DON stated the nurse's and aide's responsibilities after 11:00 PM included all care needs of up to thirty-three (33) residents on the unit. The DON stated residents who required more than one staff to assist with care would have to wait until the second staff became available. During continued interview with the DON, she stated the facility expected the nurses to assist the aides after 11:00 PM. The DON stated the nurses helped the aides when the nurses' time allowed. She further stated, she did not interview staff scheduled 11:00 PM on 02/03/2020 to 7:00 AM on 02/04/2020, and she was unaware of the specifics of the fall. The DON stated she was not aware the staff was in another resident's room behind closed doors when the fall occurred. She stated the facility's responsibilities included to provide the residents' care needs at all times. Interview with the Administrator, on 03/05/2020 at 5:52 PM, revealed the facility's routine included to staff night shift per unit with one (1) nurse and one (1) aide for each unit. He stated the facility expected staff to work together to maintain a safe environment and to meet the care needs of residents. He stated the level of care of Resident #60 as independent. He stated the resident ambulated without calling staff for assistance and the facility concluded this as the reason for the resident's fall with injury. However, the facility assessed Resident #60 to be unsteady and required extensive one (1) person assist and he/she was always incontinent of bowel and bladder. He further stated he had not been aware of the unavailability of the scheduled staff because of another resident's need for both staff to be in a room for treatment.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide adequate supervision, complete a thorough investigation to determine the root cause, and develop effective interventions to prevent further falls for one (1) of thirty-seven (37) sampled residents (Resident #60). Resident #60, who had a history of [REDACTED]. When Resident #60 experienced the fall, the only nurse and aide assigned to his/her care were in another resident's room providing wound care. At the time of the fall, thirty-one (31) residents resided on Resident #60's unit, with the one (1) nurse and one (1) aide to provide resident care. Resident #60's fall resulted in transfer of the resident to the hospital emergency room (ER). The ER diagnosed the resident with a right shoulder fracture, with constant unrelieved pain. Additionally, the Director of Nursing's (DON's) fall investigation failed to include interviews with all staff present at the time of the fall to assist in determining the root cause of the fall. The DON also failed to ensure the revision of Resident #60's fall care plan to include necessary and appropriate interventions. In addition, the DON failed to document accurate information related to Resident #60's fall on the facility's investigation when finalized. The findings include: Review of the facility's policy titled, Falls, revised 11/06/2019, revealed the facility minimized the risk of falls, and fall related injuries with staff's assistance and supervision. Per policy review, the facility completed residents' fall risk assessment quarterly, with a change of condition, and included interventions appropriate to the resident. Further review revealed the facility's Interdisciplinary Team (IDT) was to determine the root cause of residents' falls as part of the investigation with initiation of new interventions for the resident. Review of the facility's policy titled, Accidents and Incidents Investigating Reporting, revised 11/06/2019, revealed the facility's investigation of incidents included documentation of the investigation performed. Review of the facility's policy titled, Pain Management, revised 11/06/2019, revealed the facility's commitment for residents' pain control included attaining and maintaining the highest reasonable level of pain control for the resident's well-being. Review of the facility's policy titled, Aspects of Care, undated, revealed clinical care services' responsibilities included implementation of specific measures to prevent complications and maintain a resident's safety. The policy review revealed the goal of clinical services was to maintain the resident's well-being and ensure quality of life. Review of the Facility Assessment document, dated 2020, revealed the facility accepted cognitively impaired residents, including residents with Dementia. Per review of the document, the facility assessed its staffing needs for its resident units to ensure staffing was sufficient. Further review revealed the Assessment document included the staffing for the facility's night shift, 7:00 PM to 7:00 AM, was to be two (2) nurses and two (2) aides. Review of the Facility Schedule document, dated 02/03/2020, revealed the facility scheduled for the 7:00 PM to 7:00 AM, night shift staff, after 12:00 AM on 02/04/2020, only one (1) aide and one (1) nurse providing care for the thirty-one (31) residents residing on Resident #60's unit. Review of Resident #60's clinical record revealed the facility admitted the resident, on 01/09/19, with the [DIAGNOSES REDACTED]. Review of the facility's Quarterly Minimum Data Set (MDS) Assessment for Resident #60, dated 01/23/2020, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15), indicating he/she was severely cognitively impaired and not considered interviewable. Further review revealed the facility assessed Resident #60 as unsteady and to require extensive one (1) person assist. In addition, review of the MDS revealed the facility also assessed Resident #60 as always incontinent of bowel and bladder, and without pain. Review of the facility's Fall Risk Assessment document for Resident #60, dated 10/23/19, revealed the facility utilized the John Hopkins Fall Risk Assessment Tool for its assessment. The document revealed a score greater than thirteen (13) was indicative of being a high risk for falls. Continued review revealed the facility assessed Resident #60 to have a total score of twenty-one (21), making the resident a high risk for falls. Further review revealed the facility identified risk factors for Resident #60, which included a previous fall within six (6) months, incontinence, and use of a high-risk medication (anti-depressant). In addition, review revealed other risk factors, which placed Resident #60 at high risk for falls included 1.) If the resident required assistance; 2.) needed supervision with transfer and ambulation, 3.) if he/she had an unsteady gait, and 4.) if he/she had an altered awareness. Review of the John Hopkins Fall Risk Assessment tool, dated 2007, revealed the tool instructions for high-risk for falls category residents included: residents with a known history of falls before admission; during admission; or after a readmission. Further review revealed the total score of the assessment determined a resident's level of risk for falls. The score categories included six (6) to thirteen (13) as moderate risk, and higher than thirteen (13) denoted the resident was at high risk for falls. Review of the facility's Fall Risk Assessment for Resident #60, dated 01/24/2020, revealed the facility assessed the resident as a moderate risk for falls with a score of ten (10), even though he/she had a history falls. Further review revealed staff identified the risk factors for Resident #60 included: the resident's age, incontinence, unsteady gait, altered awareness, and need for assistance with ambulation. Review of the Nurse's Note, dated 02/04/2020 at 4:15 AM, revealed Licensed Practical Nurse (LPN) #3 documented Resident #60 was found lying on the floor, clutching his/her right shoulder, and telling staff his/her shoulder was broken. Per review, the LPN observed Resident #60's shoulder looked displaced, with a bump under the shoulder skin. Continued review revealed staff concluded Resident #60 had broken his/her right shoulder based on the observation. The Note stated Resident #60 cried out in pain while lying on the floor and continually guarded his/her shoulder with the left arm. Review of the Note revealed the LPN noted that she was unable to complete a bilateral upper extremity assessment on Resident #60 due to the resident's pain. Further review revealed the LPN had Emergency Medical Technicians (EMT's), who were present in the facility at that time, transport Resident #60 immediately to the hospital ER. In addition, review revealed the LPN notified the Physician prior to the EMT's transporting Resident #60 to obtain an order to do so immediately. Review of the Hospital Admission ER records, dated 02/04/2020 at 6:00 AM, revealed the ER Physician had ordered an x-ray of Resident #60's right shoulder. Review revealed the x-ray was completed, and the results noted fractures located in Resident #60's right shoulder area. Continued review revealed Resident #60 was diagnosed with [REDACTED]. Per review, at 11:11 AM, the Physician/Provider noted Resident #60 was to return to the facility after completion of the surgery. Further review revealed Resident #60 was to use a cradle sling at all times, and was to have the application of ice to his/her right shoulder. Continued review revealed the recommendation for Resident #60 to have [MEDICATION NAME] (narcotic pain medication) or [MEDICATION NAME] (narcotic pain medications) was ordered for his/her pain control. Review of the Nurse's Note, dated 02/04/2020 at 4:15 PM, revealed Resident #60 returned to the facility with a cradle sling in place to his/her right arm. Interview with LPN #3, on 03/05/2020 at 2:17 PM, revealed staff completed a full assessment after Resident #60 sustained the fall, with the exception of being able to assess the resident's left and right shoulder and arms due to the severe pain he/she was experiencing. She stated her observations during her assessment revealed Resident #60's right shoulder was clearly broken. Further interview revealed with observation of the resident's intense pain she had not attempted assessment of the resident's bilateral arms to check for Range of Motion (ROM), as she had not wanted to cause further harm or pain. Review of the facility's Event Report document, revealed staff had completed the event evaluation for Resident #60's fall sustained on 02/04/2020. Continued review of the document revealed the event evaluation was closed on paper on 02/07/2020, and completely closed out on 02/12/2020. Review of the Event Report evaluation notes revealed they included the information regarding the evaluation of Resident #60 in the hospital ER. Further review revealed the ER evaluation of Resident #60 was noted as no major injury for the resident and his/her pain associated with the event (fall) was noted as resolved. Observation, on 03/01/2020 at 10:39 AM, revealed Resident #60's shoulder sling was bunched up above his/her shoulder around the resident's mouth, and his/her call bell was lying at his/her right knee, inaccessible due the fractured right shoulder. Continued observation at 2:42 PM, revealed Resident #60's shoulder sling was loose and once again, bunched up around the resident's neck. In addition, Resident #60's call bell was still located on his/her right side and inaccessible to the resident. Further review of the Fall Risk Assessments for Resident #60 revealed the facility re-assessed the resident's fall risk, on 02/05/2020 at 5:23 PM, after the fall sustained on 02/04/2020. Further review revealed the facility continued assessing the resident as a moderate risk for falls, even though he/she had a history of [REDACTED]. Review of the facility's Quarterly MDS Assessment for Resident #60, dated 02/11/2020, seven (7) days after his/her fall on 02/04/2020, revealed the facility assessed the resident to now require two (2) person assist with all transfers and toileting. Further review of the MDS revealed the facility assessed the resident to now have frequent pain, with a pain intensity score of eight (8) on a scale of zero (0) to ten (10), indicating severe pain. Review of Resident #60's Physician order [REDACTED]. Per review, the Physician ordered [MEDICATION NAME] scheduled every six (6) hours for pain for Resident #60, as recommended. Review of Resident's 60's Medication Administration Record [REDACTED]. Per review, nursing staff documented Resident #60's pain level ranged from moderate to severe. Continued review of the MAR indicated [REDACTED]. In addition, review revealed nursing staff had administered Resident #60's scheduled [MEDICATION NAME] every six (6) hours with no missed doses. Further review revealed prior to the fall on 02/04/2020, Resident #60's physician's orders [REDACTED]. However, further review of Resident #60's MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED] Further review of Resident #60's Comprehensive Care Plan revealed no documented evidence of the revision of the care plan after the resident's fall to implement additional interventions related to his/her care needs post fall. In addition, review revealed no documented evidence the care plan was revised to include Resident #60's use of [MEDICATION NAME] pain medications, the change in his/her Tylenol order, or for the use of the shoulder sling. Observation, on 03/02/2020 at 9:46 AM, revealed Resident #60 was in a wheelchair and was being transported back to his/her room after therapy by the Rehabilitation (Rehab) Manager. Continued observation revealed the Rehab Manager parked Resident #60 in his/her wheelchair at the room door entryway. Observation revealed the Rehab Manager educated staff on how to properly place Resident #60's sling on his/her right shoulder/arm area. Per observation, the Rehab Manager explained to Resident #60 he/she had completed therapy for strengthening, and told the resident someone would be in to put him/her to bed. Continued observation revealed Resident #60 told the Rehab Manager his/her arm hurt. Observation revealed the Rehab Manager informed Resident #60 he/she received scheduled pain medications, and the Rehab Manager left the resident's room. Further observation revealed Resident #60 was grimacing, holding his/her right shoulder/arm area, and attempting to shift himself/herself in the wheelchair. Observation further revealed nursing staff passed Resident #60, without addressing the resident or his/her observed grimaces of pain. In addition, observation revealed Resident #60 remained sitting up in the wheelchair, grimacing, for eleven (11) minutes after the Rehab Manager left him/her, until 9:58 AM, when CNA #10 wheeled the resident to the activity room. Additional observation, on 03/02/2020 at 2:45 PM, revealed Resident #60 lying on his/her bed, and not observed in the lowest height position. Observation further revealed Resident #60's call bell was clipped to the cord on the wall, out of reach and inaccessible to the resident. Interview with Licensed Practical Nurse (LPN) #1, on 03/02/2020 at 1:10 PM, revealed the Rehab Manager had not reported Resident #60's complaints of pain that morning to her. She stated Resident #60's pain relief regimen included scheduled pain medication administered every six (6) hours, at 6:00 AM, 12:00 PM, 6:00 PM, and 12:00 AM. Per interview however, Resident #60 did not have as needed (PRN) pain medications ordered for any breakthrough pain. She further stated she did not receive notification on 3/04/2020 after completion of therapy of complaints of pain by the resident. Therefore, she did not provide Resident #60 with non-medicated nursing interventions to alleviate his/her pain during the morning hours of her shift. Observation, on 03/03/2020 at 9:47 AM, revealed Resident #60 was lying on the bed with the call bell placed to the right side of the bed, near his/her fractured right shoulder and inaccessible to him/her. Continued observation at 3:30 PM, revealed Resident #60 remained in bed with the call bell off the bed, and again inaccessible to the resident. Interview with CNA #10, on 03/03/20 at 2:40 PM, revealed staff were to review the aide care binder for interventions to provide for fall risk residents. Further interview revealed interventions for fall risk residents included things like: making sure the resident's call light was within reach for his/her use at all times; making increased and frequent rounds; offering assistance as needed; and reminding the resident to call for assistance. Interview with Family #1, on 03/04/2020 at 11:39 AM, revealed Resident #60 was alert; however, always confused. The family member stated Resident #60 had fallen at home and while at the facility. Per interview, Resident #60's roommate called for assistance for the resident because he/she did not understand how to use the call bell. According to Family #1, when visiting they had observed Resident #60's arm sling loose and up around the resident's neck. The family member stated Resident #60 complained of pain at every visit, and always appeared to be pain while the family was there. Continued interview revealed Resident #60 was always incontinent of bowel and bladder; unsteady when standing; unable to walk; and used a wheelchair for locomotion. The family member stated when they visited Resident #60 staff never entered the room to check on the resident. Additionally, Family #1 stated it upset the family to have Resident #60 experiencing so much pain with the broken shoulder. Interview with CNA #8, on 03/05/2020 at 3:37 PM, revealed the scheduled staff for night shift after midnight, included only one (1) CNA and one (1) nurse for each of the facility's units. She stated Resident #60 required staff to check on him/her every two (2) hours due to being incontinent and not using the toilet. Continued interview revealed staff performed scheduled rounds every two (2) hours, which included documenting the care provided during rounds in the computer. CNA #8 stated Resident #60 required at least one (1) person assist for all of his/her care needs and transfers. Per interview, on 02/04/2020 LPN #3 needed assistance with another resident to complete wound care. The CNA stated when she assisted LPN #3 in another resident's room, Resident #60 sustained the fall. Interview revealed she had heard a resident yell for help while she was assisting LPN #3 in the other resident's room. Per CNA #8, when she left LPN #3, she found Resident #60 on the floor in his/her room, lying on his/her back, and crying out with complaints of arm pain. She stated Resident #60 was saying he/she had broken his/her arm. Further interview revealed the facility really didn't have any fall interventions in place for Resident #60 before the fall. CNA #8 further stated LPN #3 updated Resident #60's care plan immediately after the fall to have staff offer or take the resident to the toilet every two (2) hours during their rounds. In addition, she stated the facility's Nursing Administration had not interviewed her or asked her for a written statement regarding the circumstances of Resident #60's fall on 02/04/2020. Review of Resident #60's Point of Care (POC) CNA documentation, for 02/03/2020 at 11:07 PM, revealed CNA #5 had documented an episode of the resident being incontinent of bladder and bowel. Continued review revealed staff documented Resident #60 required total assistance with all care. Further review revealed no documented evidence of entries by CNA #5 or other staff after 11:07 PM on 02/03/2020, to the time the resident sustained [REDACTED]. Interview, on 03/05/2020 at 2:17 PM with LPN #3, revealed CNA #8 worked with her on 02/04/2020, when Resident #60 experienced the fall at 4:15 AM. She stated the EMS (Emergency Medical System) transported Resident #60 to the ER approximately fifteen (15) minutes after the fall. Per the LPN, after midnight the facility only scheduled one (1) nurse and (1) one CNA to provide resident care on the units. LPN #3 stated staff were to put eyes on residents, by checking them every two (2) hours at night for incontinence, and reposition them as needed. LPN #3 stated put eyes, meant as staff walked the hall they looked into the rooms as they passed to observe the residents well-being. She stated the aides responsibilities included documenting on the residents after the every two (2) hour rounds were completed. Continued interview with LPN #3 on 03/05/2020, at 2:17 PM revealed she had required CNA #8's assistance with repositioning one (1) of the other residents on her unit in order to complete that resident's ordered treatment. Per LPN #3, on 02/04/2020, as CNA #8 was assisting her with repositioning the other resident in his/her room, they heard another resident yell for help. According to LPN #3, when CNA #8 left the room to see who needed help, the CNAfound Resident #60 lying on the floor by the bed in his/her room. LPN #3 stated CNA #8 observed Resident #60 holding onto his/her right shoulder. The LPN stated when she entered Resident #60's room, she found the resident in the same position as CNA #8 had found him/her. Per the LPN, Resident #60 was crying and stating his/her, shoulder was broken. Interview revealed upon assessment the resident's right shoulder appeared displaced under the skin. LPN #3 revealed she completed her assessment of Resident #60, SHOULD BE #60?? and notified emergency services. She stated Resident #60 slept throughout the night after staff placed him/her in bed and resident never attempted to self-transfer out of his/her bed since she worked at the facility. Per LPN #3, the Unit Manager (UM), and DON came to the unit later in the morning on 02/04/2020, and she reported the events of Resident #60's fall to them. According to the LPN, after providing that information, no one from the facility's administration staff had requested any further information or other documentation related to the resident's fall from her. During the interview with LPN #3, she stated Resident #60 stated, after the fall, that he/she had gotten up to attempt to go to the bathroom. She stated she initiated a new intervention for Resident #60, after the resident was transferred to the ER, for staff to perform every two (2) hour checks of Resident #60, and offer to toilet the resident if he/she was not wet. Per LPN #3, her reasoning for initiating the new intervention to offer to toilet Resident #60 if he/she was dry, was due to the resident telling staff he/she had been trying to go to the bathroom when the fall occurred. However, she stated the resident never previously requested to be toileted. The LPN stated the facility always scheduled minimal staff on night shift, and other facility staff called night shift the skeleton crew. Per LPN #3, approximately thirty (30) residents resided on the same unit as Resident #60, and she had to assist the one (1) aide, when she had time to do so, with performing the every two (2) hour rounds on her assigned residents. LPN #3 further revealed she also checked on the residents when she walked up and down the hallways of her unit during her shift. She stated staff kept residents' room lights off in their rooms at night, and used the hallway lights to observe the residents with their doors open. According to the LPN, the facility educated staff on fall prevention and the education included: staff checking on residents often; providing every two (2) hour check and change rounds; ensuring beds were in the lowest position; and to ensure residents' call bells were within reach at all times. She further stated the risk of injury and pain occurred anytime a resident sustained [REDACTED]. Review of the Fall Investigation document, dated 02/04/2020 at 4:15 AM, revealed the description of the event noted Resident #60 had attempted to self-transfer from his/her bed to the bathroom without assistance. Review revealed the interventions marked as in place at the time of the fall included the resident's call light being within reach and adequate light. Continued review revealed the contributing factors to the fall included muscle weakness for Resident #60. Further review revealed the root cause was determined to have been that Resident #60 needed assistance with transfers. In addition, the immediate interventions initiated by LPN #3 included staff to check on Resident #60 every two (2) to three (3) hours to check and change him/her if incontinent, and if dry to offer to toilet the resident. Interview with the Assistant Director of Nursing (ADON) #1, on 03/05/2020 at 1:12 PM, revealed the facility's policy for resident care and services included staff to check residents every two (2) hours, and toilet or change the resident's brief during the checks. She stated the facility expected the aides to chart every two (2) hours on residents who required care assistance. Continued interview at 3:02 PM revealed, the facility monitored fall risk residents by having staff perform room rounds every two (2) hours, and she monitored staff to ensure completion of resident care interventions through her daily walking rounds. According to the ADON, she also reviewed residents' care plans, which she carried with her during her walking rounds to assist with her monitoring of staff. Per interview, staff reported off to each other at shift change regarding residents who were a fall risk and/or used an alarm, and reported off to oncoming staff the last intervention initiated for the resident. The ADON stated Resident #60 required one (1) person assistance with all his/her care needs. She stated Resident #60's night routine usually included going to bed and staying in bed until the next morning when staff assisted him/her with getting up out of bed. She stated it was unusual that the resident had attempted to go to the bathroom on 02/04/2020. According to the ADON, per facility policy, any resident fall required an investigation be performed, and was to include interviewing all staff present at the time of the fall. Further interview revealed the completed fall investigation included review of the resident's chart for medications, Nursing Notes, and care documentation as part of the complete fall investigation. In addition, she stated the facility implemented immediate interventions for a resident after a fall, and additional interventions if needed after the IDT's review of the fall. She further stated her expectations were for nursing staff to complete all resident care and document the care as required. Interview with the Director of Nursing (DON), on 03/05/2020 at 4:07 PM, revealed the facility monitored a resident's risk for falls, which included any status changes occurring in the resident. She stated an appropriate intervention for residents with Dementia would include reminding the resident to use the call bell to request assistance. (However, per interview with Resident #60's family member, the resident could not use a call bell to request assistance.) Per interview, after Resident #60 sustained the fall, in order to prevent further falls, the nurse initiated an intervention to check and change Resident #60 every two (2) hours, and toilet him/her if needed at that time. The DON stated she initiated the fall investigation, and interviewed the nurse on duty as part of her investigation. She stated she had not asked the nurse about the events, which occurred prior to the resident's fall. According to the DON however, she was aware of where staff were located on the unit when Resident #60 sustained the fall on 02/04/2020. Continued interview revealed she had not interviewed the CNA working with LPN #3, at the time of Resident #60's fall. The DON stated she had not requested the LPN and CNA submit a written summary of the events occurring before Resident #60's fall on 02/04/2020. Continued interview with the DON, on 03/05/2020 at 4:07 PM, revealed the LPN and CNA had reported that Resident #60 told them he/she was attempting to go to the bathroom when the fall occurred. Per the DON, the LPN initiated an immediate intervention post fall for Resident #60 for every two (2) hours rounds to check for incontinence, and if the resident was found dry to assist him/her to the toilet. Continued interview revealed the facility's standard of care for residents with Dementia, included providing toileting assistance with the every two (2) hour rounds performed, and staff to document the care soon after completion of the rounds. She stated she had not reviewed CNA #8's documentation to see if it had been completed the night and early morning hours before Resident #60's fall. The DON stated the lack of documentation by the CNA prior to Resident #60's fall on 02/04/2020, meant the facility had nothing to show that the resident's care was provided as required. She stated staff should ensure Resident #60's call bell position included within reach of the resident's left hand. Per the DON however, the ability of a resident, with dementia, to know what a call bell was and how to use it depended on the resident's state of mind, and he/she might not have the ability to use the call bell. The DON stated she did not know the reason Resident #60's fall risk evaluations had determined the resident to be a moderate fall risk before and after the fall on 02/04/2020. Further interview revealed she also was not aware of why the fall risk evaluation completed on 10/23/2019, had determined Resident #60 to be a high fall risk at that time. During the interview, on 03/05/2020 at 4:07 PM, with the DON, the State Surveyor reviewed the facility's Fall Investigation Event Report, dated 02/04/2020, with the DON, who had completed it. The DON acknowledged she had documented and completed the facility's Fall Investigation Event Report. She also acknowledged she had noted on the Fall Investigation Event Report document, there was adequate lighting at the time of Resident #60's fall, and she had additionally noted the resident's call light was within reach at the time of the fall. Continued interview with the DON revealed she was unaware of what light illuminated Resident #60's room the night the resident fell (02/04/2020). She stated the lighting might have come from the light in the resident's bathroom. According to the DON, the Fall Investigation Event Report had the following items not checked for the resident: impaired safety awareness; assist with transfers; and reminders for the resident to call for assistance. She stated she should have checked the areas as they applied to Resident #60's care needs. Continued interview with the DON revealed she had closed the Fall Investigation Event Report, and completed all the documentation on 02/07/2020. The DON stated in her conclusion, documented on the Fall Investigation Event Report, she noted Resident #60 had received: an evaluation in the ER; he/she had no major injury; and his/her pain was resolved. She stated she had also documented the fall prevention program as not initiated on the Fall Investigation Event Report. Per the DON, she had documented incorrect information on the facility's Fall Investigation Event Report, which she realized she now needed to go back and correct to ensure the accurate information was included. The DON further stated the IDT met after a resident's fall to review the events of the fall, and determine whether the immediate intervention initiated after the fall was adequate or not. She stated the facility's DON's and IDT's responsibilities included to complete a thorough investigation of a resident's fall, and determine the reason the fall had occurred. Additionally, she stated the facility's administrative staff had not reviewed the completed fall investigation regarding Resident #60's fall on 02/04/2020. Interview with the DON, on 03/05/2020 at 4:07 PM, revealed the facility's staffing for night shift included one (1) aide and one (1) nurse for each unit after 11:00 PM and remarked that the staffing level was a skeleton crew. The DON stated that the residents who required two (2) person assist for their care needs on night shift might have to wait depending on the (TRUNCATED)

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure it honored a decision of care made by a resident's legal representative or Power of Attorney (POA) for one (1) of thirty-seven (37) sampled residents (Resident #46). Review of previous admissions to the facility for Resident #46, revealed the facility had documented the resident's legal representative. Interview revealed the resident's significant other had provided the facility with a copy of Resident #46's POA documentation. Record review and interviews revealed, on 01/24/2020, the POA notified the facility of Resident #46's need to use a respiratory mask which assisted with the resident's respiratory efforts at night. The POA made multiple requests to allow the use of the mask for the resident's respiratory care needs. However, the facility failed to honor the POA's request and told the POA it was in contradiction of the Physician's admission orders [REDACTED] The findings include: Review of the facility's policy titled, Advance Directive (AD) Procedure, revised 02/06/19, revealed the facility was to make an effort to obtain a written copy of the AD if it was notified, and it included provision of a POA for a resident. In addition, the facility was not to place conditions of the provision of care, on any individual whether or not the resident had completed an AD. Review of the facility's policy titled, Resident Rights, revised 08/16/18, revealed the facility ensured all residents were treated with respect and dignity. In addition, the policy revealed the facility's resident rights included making medical care decisions, which encompassed refusals. Review of the POA documentation for Resident #46, dated 05/09/17, revealed the resident had given his/her significant other the ability to make decisions when the resident did not have the capacity to make medical and financial decisions. Review of Resident #46's Discharge Summary, dated 11/23/19, revealed a a pre-assessment document which noted the resident used a mask, for respiratory support at night, called a Bilevel Positive Airway Pressure ([MEDICAL CONDITION]) or Continuous Positive Airway Pressure ([MEDICAL CONDITION]). Review of Resident #46 clinical record revealed the facility admitted the resident on 01/24/2020, with [DIAGNOSES REDACTED]. Review of the Facility Pre- Assessment Admission Form for Resident #46, dated 01/23/2020, revealed a check mark for the answer of Yes for respiratory mask, use of a [MEDICAL CONDITION] under the [MEDICAL CONDITION] section of the form. Review of the facility's Nursing Admission Assessment, dated 01/24/2020 at 12:09 PM, revealed Resident #46's medical history included the use of a mask for respiratory support when asleep. Continued review revealed the information regarding the mask use had been obtained from a family member. Review of the facility's Admission Minimum Data Set (MDS) Assessment, dated 01/31/2020, revealed the facility assessed the resident as impaired with decision making. Review of Licensed Practical Nurse (LPN) #1's Nursing Note, documented as a late entry on 01/27/2020 at 1:49 AM, revealed on 01/25/2020, staff had observed Resident #46's POA remove the resident's nasal oxygen from him/her, and place a respiratory mask on the resident. Continued review revealed staff attempted to remove the respiratory mask and replace it with the nasal oxygen, with the POA objecting to this being done. Further review revealed staff notified the Director of Nursing (DON) and received instructions to call the police if the POA continued to attempt to replace the nasal oxygen with the respiratory mask. In addition, staff also notified the Physician, who stated the representative had the right to remove it if they wanted to use the respiratory mask. Review of the Nurse's Note, dated 01/25/2020 at 01:15 PM, revealed documented LPN #1 entered the note on 01/46/2020 at 10:14 AM, and documented the POA notified staff the resident needed the mask and she wanted the resident to use the mask. Interview with Family Member #2, Resident #46's POA, on 03/01/2020 at 12:13 PM, revealed the resident needed the respiratory mask when sleeping as he/she stopped breathing at times. The POA stated Resident #46 had used the respiratory mask for over twenty (20) years. Per interview, the POA stated she had provided the facility paperwork for the POA documentation during the resident's previous admission to the facility. The POA stated she had made multiple requests of staff for Resident #46 to use the respiratory mask in order for the resident to be able to rest. Further interview revealed staff told her (the POA) multiple times the facility would call the police if she continued to attempt to apply the respiratory mask on Resident #46. An additional interview with Family Member #2/POA, on 03/03/20 at 2:56 PM, revealed when the facility did not allow Resident #46 to use the respiratory mask as the POA requested it had made her feel terrible. Per interview, the POA stated she had cared for Resident #46 for many years and the facility's refusal to listen to her and allow the resident to use the respiratory mask made her feel like garbage and ignorant. Continued interview revealed when the facility staff threatened to call the police if she continued to apply the respiratory mask on Resident #46, the staff's gruff and authoritative manner made her feel as though she had no choice in the care the resident received. The POA stated it felt as though Resident #46's care was controlled only by the facility. Further interview revealed the POA had a right to decide on the care Resident #46 received as the resident's POA. Interview with LPN #1, on 03/05/2020 at 9:34 AM, revealed the LPN knew if a resident was unable to make decisions regarding their care and they had a POA, the POA made the decisions regarding the resident's care. An additional interview with LPN #1, on 03/05/2020 at 3:30 PM, revealed Resident #46's POA made the choices or decisions regarding care for the resident now, as he/she was unable to make the decisions himself/herself. According to LPN #1, the rights of the resident to make decisions carried over to the POA when the resident could not make or verbalize his/her own decisions. She stated the POA wanted and requested the use of the respiratory mask for Resident #46. Continued interview revealed however, the resident required oxygen and the respiratory mask did not have oxygen. The LPN stated therefore, staff felt the POA had interfered with the doctor's order for oxygen. Further interview revealed, after being notified of the issue by staff, the doctor ordered the facility to obtain a respiratory mask with oxygen, and did not know why the resident did not have the unit at the bedside already. Interview with LPN #4, on 03/05/2020 at 10:21 AM, revealed the reason for a resident to have a POA was for the POA to represent the resident to ensure his/her care continued when he/she became unable to make decisions regarding their care. Per interview, a resident's POA's rights included the same rights of the resident with any decision regarding care, and this required staff to honor and respect the POA's decisions. LPN #4 stated the POA, as a resident's representative, knew the care needs of the resident, and wanted the best for the resident. She stated that decisions made affected a resident's outcome and the POA/family's emotional well being. Further interview revealed Resident #46's POA told her it was very upsetting to have been told the police would be called if she continued to place the respiratory mask on the resident. In addition, LPN #4 stated the POA told her after years of marriage to Resident #46, it upset her not to have a say in the resident's care. She further stated staff usually documented resident care issues when residents or families did not agree on the facility's care choices. Interview with the Director of Nursing (DON), on 03/05/2020 at 4:07 PM, revealed when a resident became unable to make a medical decision for care or for their care needs, then the POA made those decisions for the resident. She stated Resident #46's POA had interfered with Resident #46's medical orders when she removed the nasal oxygen, placed the respiratory mask on the resident. According to the DON, the POA continued to interfere with the nurses when they attempted to replace Resident #46's oxygen, which was why she had directed staff to call the police if the POA continued not to follow the doctor's orders. However, further interview revealed, the DON stated the POA's rights included making medical decisions for Resident #46 to ensure the resident's rights were upheld regarding making decisions or refusing care. Interview with the Administrator, on 03/05/2020 at 5:52 PM, revealed the facility's audits had not identified concerns or issues with the rights of the families and/or POAs to make decisions for care for residents unable to make those decisions. He stated the facility could not make its own orders for resident care as that was up to the doctor. Further interview reveled Resident #46 required oxygen, and the resident's oxygen levels dropped if oxygen was not provided.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure to develop s resident-centered Comprehensive Care Plan (CCP) which accurately reflected care to meet the medical, physical and mental needs to prevent a fall for one (1) of thirty-seven (37) sampled residents (Resident #60). Resident #60 fell on [DATE] at 4:15 AM, which resulted in a fracture to the resident's right shoulder. The findings include: Review of the facility's policy titled, Comprehensive Care Plan, revised 07/19/18, revealed staff's assessments of the resident reflected the needs of the resident and presented the guide to complete an individualized care plan for residents. Review revealed the resident's care plan included the identified risks and problems which the facility developed the care plan. Review of the policy revealed the resident's interventions addressed the identified problems. Further review revealed the facility was to revise residents' care plans as necessary and to reflect changes in a resident's condition. The facility identified the risk of falls for Resident #60, on 07/08/19. Review of the facility's policy titled, Falls, revised 11/06/19, revealed the facility-assessed residents on admission, quarterly, and as needed for the risk of a fall. The goal included to minimize the risk of resident falls and related injuries. Continued review revealed the facility developed fall interventions for the individual resident to decrease the risks for the areas identified. The facility developed a fall's call plan, on 07/08/19, with the indication of Dementia as one of the factors for the resident's fall risk. Review of the facility's policy titled, Aspects of Care, undated, revealed the facility's clinical care services responsibilities included implementation of specific measures to prevent complications and maintain a resident's safety, which included falls. Review of Resident #60's clinical record revealed the facility admitted the resident, on 01/09/19, with diagnoses, which included Dementia, Muscle Weakness, and the History of falls. Review of Resident #60's Admission Minimum Data Set (MDS) Assessment, dated 01/09/19, revealed the facility assessed the resident with a history of falls, as the resident had a fall which resulted in a fracture one month prior to admission. The resident used a walker or wheelchair for mobility and required transfers with an extensive two (2) person assist which included bed mobility, and toilet use. Further review revealed the facility assessed the resident's cognition with the Brief Interview for Mental Status (BIMS) assessment and scored the resident as a five (5) out of fifteen (15), which indicated the resident had severe cognitive impairment. However, the facility's initial care plan did not include falls or fall risk as a problem after completion of the MDS assessment, which included the documented history of a fall with fracture, cognition, and the extent of assistance for care needs. Continued review revealed, on 07/23/19, the facility completed a Quarterly MDS assessment and identified one (1) fall after admission. The resident continued to have severe cognitive impairment with an assessment score of zero (0). Further review revealed the resident's admission assessment included the resident's fall before admission, which resulted in a fracture. Record review revealed the facility initiated a fall's care plan on 07/08/19. The facility initiated the care plan for the resident six (6) months after admission, even though the facility assessed the resident to have severe cognitive impairment, extensive assist needs, and history of falls before admission. Review of Resident #60's fall's care plan revealed the facility initiated the care plan on 07/08/19. The fall interventions included to assist with ambulation, report fall to provider and family, when in wheelchair place in a common area, refer to therapy, and encourage activity participation to increase strength. Continued review of the fall care plan revealed to further prevent a fall, the interventions included to have the call light within reach, to rise in a slow manner, and rest before a transfer, to keep the area free of clutter, and glare free light. Further review revealed on 08/12/19, the facility added the interventions to use the call light to request help prior to transfer, to observe the resident's use of adaptive devices, teach the resident safety to reduce the fall risk and what to do if a fall occurred. However, the facility's assessments identified the resident with severe cognitive impairment, and extensive assist with all care needs, and he/she did not walk. The facility failed to ensure the interventions reflected the resident's cognitive impairment and functional ability. Review of Resident #60's Quarterly Fall Risk Assessment, dated 01/24/2020, revealed the facility identified risk factors as age (3 points), incontinence (2 points), unsteady gate (2 points), and an altered awareness of environment (1 point) as risk factors. Further review revealed a score of ten (10) which indicated a moderate risk for falls. However, record review revealed the resident's history included falls before admission (5 points) and the use of an antidepressant, which the side effect included sedation or increased confusion (3 points). The assessment form instructions included to choose all areas which applied to the resident's mobility, which included transfer assistance and unsteady gait (4 total points), an altered awareness of environment and lack of understanding of physical and cognitive limitations (5 total points). With these risk factors included, the resident's score would have been twenty-two (22). In addition, the assessment's written instruction noted if the resident's history included a fall, the assessment stopped at the high-risk level of evaluation. According to the instructions, the resident's score would indicate the resident to be in the high category for the risk of falls. Further review of Resident #60's Quarterly MDS Assessment, dated 01/23/2020, revealed the facility assessed the resident as an extensive two (2) person assist with transfers, bed mobility, and toileting. The resident required one (1) person extensive assist with toilet use and hygiene. The resident required incontinent care at all times. Furthermore, the resident required one (1) person assist for transfers because of balance issues; and, the resident did not walk and used a walker or wheelchair. The facility assessed the resident's cognition as four (4) out of fifteen (15), which determined the resident remained at the level of a severely cognitive impaired resident. Review of Resident #60's Progress Note, dated 02/04/2020 at 4:15 PM, revealed the resident fell at the end of the bed on his/her back and was found on the floor. Further review revealed staff heard a cry, while they were in another room. Resident #60's fall which resulted in fractures to two areas of his/her right shoulder. Continued record review revealed the hospital determined the resident was not a candidate for repair of the fracture due to the resident's age and frail condition. Observation of Resident #60 on 03/01/2020 at 10:39 AM, revealed the resident's call bell was on the resident's right side by his/her hip while in bed. Observation at 2:42 PM revealed the call bell was on the resident's right side on his/her lap. However, the resident's fracture to the right shoulder resulted in his/her arm immobilized in a sling and he/she was unable to access the call bell for assistance. Staff's placement of the call bell and the resident's cognitive ability, did not allow the resident to use the call light for assistance, as care planned. Interview with Family #1, on 03/04/2020 at 11:39 AM, revealed Resident #60 remained confused since he/she came to the facility. The family stated Resident #60 fell at home, which caused the resident's admission to the facility. Family Member #1 stated the resident had a fell in the facility after the admission to the facility. Continued interview with the family revealed Resident #60's roommate activated the call bell or called for assistance for the resident because he/she did not understand how to use the call bell. The family described the resident's overall needs as incontinent of bowel at all times, unsteady, and unable to walk. The family stated the resident used a wheelchair for locomotion after staff assisted him/her to stand and turn. During further interview, the family stated the resident complained of pain from the fall with every visit. The family stated the facility should have known the resident could fall because the resident fell frequently at home which required him/her to come and live at the facility. He further stated he/she wanted the resident to be safe and the main reason he/she kept the resident at the facility. Interview with CNA #10, on 03/03/20 at 2:40 PM, revealed staff were to review the aide care binder for interventions for resident care. However, the binder did not identify the resident's level of fall risk. She stated the use of a call bell to call for assistance was a normal intervention. However, she stated residents with memory issues did not remember to use the call bell or, not to get up without help because they were confused. Interview with CNA #8, on 03/05/2020 at 3:37 PM, revealed resident care plans provided the care and level of care needs for the aides and nurses. She stated that the residents required specific interventions for their level of care and ability. CNA #8 stated Resident #60 required full assist with all needs except to feed himself/herself, but he/she required supervisor with meals. She further stated when residents required care in all areas, she considered the resident a higher risk for a fall. Further interview revealed CNA #8 worked the day, the resident fell in the early am and broke his/her arm. She stated she and the nurse found the resident on the floor after hearing an unidentified cry on the unit. Interview with Licensed Practical Nurse (LPN) #3, on 03/05/2020 at 2:17 PM, revealed Resident #60's care included transfer and toileting assistance. She stated the resident had not had a fall in the facility before 02/04/2020. LPN #3 stated all residents required a care plan that included the needs of the resident's level of care. She stated Resident #60's care plan included to use the call bell for help and the cause of the resident's fall. LPN #3 stated the resident did not call or wait for help. However, LPN #3 stated the resident's [DIAGNOSES REDACTED]. The LPN stated the resident's memory came and went depending on the day. She stated the care plan process was initiated at admission, which included the reason for the admission as well as the identified care areas. LPN #3 stated, Resident #60's care plan reflected appropriate interventions for the resident's fall risk before and after his/her fall. She stated the facility initiated the fall's care plan after a fall, although the resident's admission history included a fall. The LPN stated Resident #60's CCP did not include specific interventions for falls to meet the need of the resident, who has Dementia; and the facility assessed to have severe cognitive impairment; and, extensive assist with all care needs. Review of the clinical record revealed the facility did not initiate an individualized CCP to reflect the resident's needs. Interview with the Minimum Data Set (MDS) Coordinator, on 03/05/ at 3:53 PM, revealed the facility completed a CCP with review of all clinical information at admission, with interviews, and observations of the resident. She stated the initial CCP reflected the resident's history, admission, and current needs to complete care and maintain the resident's safety in the facility. She stated staff followed care plans to meet the resident's needs. She further stated any resident whose admission included a fall prior to admission required the start of a care plan for falls. The MDS Coordinator further stated the facility expected the care plans to reflect the resident's care needs. However, the resident's care plan did not reflect the initiation of a fall's care plan upon admission. Interview on 03/05/2020 at 1:12 PM and 3:02 PM, with Assistant Director of Nursing (ADON) #1, revealed the facility's process on admission included numerous areas of assessments to initiate the resident's CCP. She stated any known history of a resident's fall risk meant the facility initiated the fall's risk on the admission CCP. The ADON stated the residents' care plans reflected the needs of the residents and she expected staff to follow all interventions. In addition, she stated she did not complete audits of the residents' care plans to determine if the interventions were appropriate for the resident's needs. She stated if the resident's CCP did not meet the need of the resident, then the resident would not receive the care required and put the resident at risk. Interview on 03/05/2020 at 4:07 PM, with the Director of Nursing (DON), revealed the facility-implemented interventions, which the assessor individualized to the resident. She stated she expected staff to follow the initial care plan and report needs to change interventions to reflect the resident. The DON stated the facility initiated and continued an adequate plan of care for Resident #60's risk of falls, before the 02/04/2020 fall and after the fall. She stated the nurses or ADON's completed the fall risk assessments and she did not know why the resident's fall assessments before and after the resident's fall scored into the moderate fall risk. Further interview with the DON revealed the fall on 02/04/2020, had been the resident's first fall while in the facility. The DON stated she rounded on residents on the units to evaluate if the care plans reflected the resident's need; and Resident #60's care plan reflected his/her required needs. However, after review of the resident's record of previous falls, fall risk assessments, and cognition assessments, with the State Survey Agency, the DON stated the resident's cognition might play a factor. She stated education of the resident to use the call bell for staff assistance; to teach the resident safety, and what to do in case of a fall might not be appropriate. She stated the resident's cognition came and went so some days the interventions may not be appropriate In addition, she stated her expectations included staff to implement the interventions in place, and notify her if the interventions required revisions. She stated the facility's responsibility included to ensure the resident's care plan reflected interventions to support the resident's care needs and safety. However, Resident #60's initial care plan did not reflect a fall risk focus related to his/her severe cognition and the [DIAGNOSES REDACTED]. In addition, the facility initiated a care plan focus for falls after the resident fell , on 07/08/2019, six (6) months after admission, which the interventions did not meet the individual cognitive level to prevent falls, as the facility assessed the resident to have poor short-term memory. Interview on 03/05/2020 at 5:52 PM with the Administrator, revealed the facility had self-identified issues with residents' care plans previously. He stated the identified issues included the lack of individualized interventions for residents' care plans. The Administrator stated the facility's responsibility included to ensure fall care plans and care plans in general met the need of the resident and were effective for the residents. He stated the IDT met to discuss new residents and the MDS Coordinator attended the meeting. Continued interview revealed the IDT team did not identify issues with Resident #60's care plan after the resident's fall. The Administrator stated Resident #60 was independent with most of his/her care needs, and transferred out of bed on 02/04/2020 without requested assistance from staff, as the staff previously educated and reminded the resident to do. However, record review revealed the facility assessed the resident to require the extensive assistance with care needs related to Dementia.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to revise a resident's plan of care with interventions to prevent further falls for one (1) of thirty-seven (37) sampled residents (Resident #60). The findings include: Review of the facility's policy titled, Comprehensive Care Plan, revised 07/19/18, revealed the facility was to revise residents' care plans as necessary and to reflect changes in a resident's condition. Review of the facility's policy titled, Falls, revised 11/06/19, revealed the facility-completed residents' fall risk assessments quarterly and with a change of condition. The facility revised the care plan with necessary and appropriate interventions for the resident. Further review revealed the facility's Interdisciplinary Team (IDT) determined the root cause of a resident's fall and would initiate new interventions for the resident. Review of the facility's policy titled, Aspects of Care, undated, revealed the facility's clinical care services implemented specific interventions to maintain a resident's safety. Review of the John(NAME)Fall Risk Assessment tool, dated 2007, revealed the tool assisted facilities with the assessment of a resident's risk for a fall. The tool noted a resident would remain a high risk for falls when the history included a fall before or after facility admission. The facility used the assessment to review and revise the resident's care plan. Review of Resident #60's clinical record revealed the facility admitted the resident, on 01/09/19, with the diagnoses, of Dementia, Muscle Weakness, and the history of falls. Review of hospital discharge records revealed the resident's admission to the hospital included a fall at home on 01/03/19, which resulted in the [MEDICAL CONDITION] bone. Review of Resident #60's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility noted under Section J, one (1) fall since admission to the facility. Review of Resident #60's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with the Brief Interview for Mental Status (BIMS) with a score of four (4) out of fifteen (15), which indicated the resident had severe cognitive impairment. Further review revealed the facility assessed Resident #60's functional status as an extensive one-person assist transfer due to unsteadiness and incontinent at all times. Review of the resident's care plan revealed the facility did not make revision changes to the fall care plan with new interventions to prevent falls. Review of the facility's Quarterly Fall Risk Assessment for Resident #60, dated 01/24/2020, revealed the facility assessed him/her as a moderate risk for falls with a score of ten (10). Review of Resident #60's assessment completed by the facility revealed risk factors that included age, incontinence, unsteady gait, altered awareness, and the need for assistance with ambulation. The clinical record indicated an admission with a fall and a fall in the facility, which would indicate a high risk for a fall. The resident's care plan did not include a revision for individualized interventions for the identified high fall risk. Review of Resident #60's fall care plan, initiated 07/08/19, revealed the facility initiated a care plan for falls. The fall interventions included to assist with ambulation, report fall to provider and family, when in wheelchair place in a common area, refer to therapy, and encourage activity participation to increase strength. Continued review of the fall care plan revealed to further prevent a fall, the facility included to have the call light within reach, to rise in a slow manner, and rest before a transfer, to keep the area free of clutter, and glare free light. Further review revealed on 08/12/19, the facility added the interventions to use the call light to request help prior to transfer, to observe the resident's use of adaptive devices, teach the resident safety to reduce fall risk and what to do if a fall occurred. However, the facility's assessments identified the resident with severe cognitive impairment, and extensive assist with all care needs, and he/she did not walk. The interventions, the facility care planned did not reflect the resident's cognitive impairment and functional ability for the resident's fall risk. Interview with Licensed Practical Nurse (LPN) #3, on 03/05/2020 at 2:17 PM, revealed Resident #60 fell on [DATE] when he/she attempted to go to the bathroom alone. She stated staff did not know the resident had gotten up out of bed until they found him/her on the floor with a broken shoulder. She stated the facility determined the resident did not request assistance as the reason for the fall. She stated the resident's [DIAGNOSES REDACTED]. LPN #3 stated the resident's memory effected his/her ability to remember safety, or how to use the call bell. She stated the clinical team determined the revision to the care plan after review of the investigation. However, she stated the facility did not notify her of any revised interventions for the resident to prevent falls. She stated if the resident got up out of bed, unless someone was nearby or in the room, staff would not know the resident was trying to get up out of bed. She stated the care plan should reflect the needs of the resident. LPN #3 stated the facility did not revise the care plan to address the resident's new fall with appropriate intervention for the resident's cognition, the use of his/her right arm, which increased the resident's unsteady balance, or the transfer of the resident without staff's knowledge's with appropriate interventions to prevent a fall. Interview with Certified Nurse Aide (CNA) #8, on 03/05/2020 at 3:37 PM, revealed the resident had a fell on the floor on 02/04/2020 when he/she attempted to go to the bathroom without staff assistance. She stated the resident did not toilet or ambulate by himself/herself and this attempt to the bathroom was the first time the resident attempted. CNA #8 stated she did not know the resident got up out of bed until she heard a resident cry out. She stated the resident broke his/her arm when he/she fell . She stated Resident #60 required full assist with except to feed him/herself. CNA #8 stated the resident did not have fall prevention interventions on his/her care plan and, she did not receive report of revisions to the care plan to address the resident's fall. Interview with Family #1, on 03/04/2020 at 11:39 AM, revealed Resident #60 fell at home, which caused the resident's admission to the facility. The family member stated the resident also fell in the facility after the admission. Continued interview with Family Member #1 revealed Resident #60's roommate activated the call bell or called, and/or assisted the resident because of his/her confusion, and Dementia. Further interview revealed the resident did not understand how to use the call bell. The family member stated the resident did not walk and used a wheelchair for locomotion around the facility. Family Member #1 stated the resident was unable to stand and turn without help. The family member stated the facility should have known the resident could fall again because the resident fell at home and fell again in the facility. He further stated he/she wanted the resident to be safe at the facility. Family Member #1 further stated the facility requested permission to use an alarm for the bed, which he observed on the resident's bed. However, it was the last time he saw the use of the bed alarm and he did not know of any other way they decided to know if the resident got out of bed. Review of Resident #60's Fall Risk Assessment, dated 02/05/2020, revealed the facility assessed the fall risk level after the resident's fall with a fracture. The facility assessed the resident with the score of thirteen (13) which indicated the resident remained a moderate fall risk. The assessment instructions indicated the resident was a high fall risk and not a moderate risk of fall. However, the facility did not revise the care plan to reflect the known risks and place interventions to address the risks to prevent falls. The facility failed to follow its policy to revise the care plan. Continued review of Resident #60's fall care plan, initiated 07/08/19, revealed the care plan revision did not reflect the date of the resident's fall and the type of the injury. In addition, the facility assessed Resident #60 with severe cognitive impairment for short-term memory and the facility did not revise the care plan to address the resident's fall, or to address the level of severe cognition with interventions for the level of impairment to prevent further falls, as they should have per policy. Interview with the Assistant Director of Nursing (ADON) #1, on 03/05/2020 at 3:02 PM, revealed the facility's process was for the Director of Nursing (DON) to review residents' care plans, during the investigation, and make revisions necessary to prevent falls. She stated the clinical team recommended revisions to the care plan, with incidents and change of condition; and, with review of the investigation to determine the root cause of the fall. She stated care plan revisions included specific and individual interventions identified by the clinical team to prevent another fall for a resident. Interview on 03/05/2020 at 4:07 PM, with the Director of Nursing (DON), revealed staff revised residents' care plans after a fall with new interventions to prevent further falls. She stated the facility rounded every two hours for check and change Resident #60, as a revision to prevent further falls. She stated the facility determined the resident fell because he/she did not ask for assistance up out of bed to toilet. The DON stated Dementia caused memory issues and the resident's [DIAGNOSES REDACTED]. The DON stated the facility's interventions for Resident 60, whose [DIAGNOSES REDACTED]. She stated those interventions for this resident were not appropriate. She stated the facility's responsibilities included to ensure the residents were safe in the facility, which included revisions to the care plan with interventions appropriate to the resident's condition and needs. Interview on 03/05/2020 at 5:52 PM with the Administrator, revealed the facility had self-identified issues with residents' care plans. He stated the facility-identified issues included that the residents' care plans needed to have individualized interventions and to ensure the care plan interventions reflected the specific needs and effective.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to provide necessary equipment to assist with respiratory function while the resident slept for one (1) of thirty-seven (37) sampled residents (Resident #46). The resident's representative notified the facility at admission, on 01/24/2020, of Resident #46's need for a respiratory support machine called a [MEDICAL CONDITION] (Bi-Level Positive Airway Pressure) and mask for a known chronic medical condition upon admission. On, 01/26/2020, after staff notified the resident's physician over the concern of the family's removal of oxygen and placement of the mask brought from home, the provider verbalized to order a [MEDICAL CONDITION] unit with the ability to provide Oxygen. However, the facility never ordered the machine for the resident. The findings include: Review of the Power of Attorney (POA) document for Resident #46, dated 05/09/2017, revealed Resident #46 had given his/her significant other (spouse) the ability to make medical decisions for him/her when he/she was unable to have the decisional capacity to make those decisions. Review of the contract agency's Respiratory Service Agreement, dated 08/05/2016, revealed the agency provided respiratory equipment and services for the facility, including [MEDICAL CONDITION] and [MEDICAL CONDITION] (Continuous Positive Airway Pressure) units for resident use. Review of the Facility Assessment, dated 2020, revealed the facility's provision of care requirement for residents included providing [MEDICAL CONDITION] and [MEDICAL CONDITION] machines as needed, ensuring sufficient staff to meet the care requirement, and to have the respiratory equipment available from the contracted company. Review of Resident #46's clinical record revealed the facility admitted the resident on 01/24/2020 with diagnoses, which included [MEDICAL CONDITIONS], Dilated [DIAGNOSES REDACTED], and [MEDICAL CONDITION]. Further review revealed Resident #46 was previously admitted to the facility on [DATE]. Review of Resident #46's Transition Care/Discharge Summary, dated 11/23/2019 revealed the pre-assessment data noted the resident's treatments included using a [MEDICAL CONDITION]/[MEDICAL CONDITION] with oxygen. Review of Resident #46's Pre-Assessment, dated 01/23/2020, revealed [MEDICAL CONDITION] marked Yes under the [MEDICAL CONDITION] section. Review of the Nursing Admission Assessment, dated 01/24/2020 at 12:09 PM, revealed Resident #46's medical history included difficulty sleeping, shortness of breath when flat in bed, and shortness of breath when he/she woke up. Further review revealed Resident #46 used a [MEDICAL CONDITION] when asleep. Review of the facility's Admission Minimum Data Set (MDS) Assessment for Resident #46 dated 01/31/2020, revealed the facility assessed the resident as moderately impaired with decision making and required supervision. The assessment revealed Resident #46 experienced shortness of breath with exertion, at rest, and when lying flat. Further review revealed under Section O: Special Treatments, Procedures, and Programs, the facility did not include Resident #46 required a non-invasive mechanical ventilator or [MEDICAL CONDITION]. Review of the late entry Nurse's Note dated 01/27/2020 at 1:27 AM, revealed Licensed Practical Nurse (LPN) #5 entered a late entry Nurse's Note. The entry included that she had notified the doctor on 01/25/2020 that the resident's family member removed the resident's oxygen nasal cannula, and replaced it with his/her [MEDICAL CONDITION] mask, which the family brought from home for use. The Note stated the doctor had given a verbal order to obtain a new Continuous Positive Airway Pressure ([MEDICAL CONDITION]) which accommodated oxygen hookup. Continued review revealed LPN #5 reported to the doctor the POA's continued attempts to remove Resident #46's nasal cannula oxygen. Review revealed LPN #5 informed the doctor the removal of the oxygen resulted in decreased oxygen saturation levels for the resident. The nurse noted she requested to send Resident #46 to hospital emergency room (ER) if the family continued removing the resident's oxygen nasal cannula, and placed the [MEDICAL CONDITION] on him/her. Further review revealed the doctor declined the nurse's request and informed her, The wife has a right to remove it if she wants. Review of the facility's North Station 24 Hour Report document, dated 01/25/2020, revealed the remark and change of condition section contained no documented evidence of placement of the [MEDICAL CONDITION] on Resident #46 by the POA. Further review of the Report revealed no documented evidence to include concerns of use of oxygen versus [MEDICAL CONDITION] use. Review of a Nurse's Note, dated 01/25/2020 at 1:15 PM, revealed LPN #1 documented she had written the Note on 01/46/2020 at 10:14 AM. Review revealed LPN #1 documented on 01/25/2020, she entered Resident #46's room to find the resident had a [MEDICAL CONDITION] in use, and not his/her ordered oxygen in place. Continued review revealed the LPN removed the [MEDICAL CONDITION] from Resident #46, and replaced it with the nasal cannula oxygen. Per review, the LPN provided education for the family regarding the reason for the oxygen. Further review revealed LPN #1 documented Resident #46's POA stated that after forty (40) years of marriage, he/she knew the resident's needs, and informed staff he/she needed the [MEDICAL CONDITION] for sleeping. Review of the Nurse's Note, dated 01/26/2020 at 8:28 PM, revealed the nurse's shift assessment determined the resident's alert status as lethargic. The POA requested use of [MEDICAL CONDITION] for the lethargic condition. The nurse notified the doctor of the change of condition with the POA's request to use the [MEDICAL CONDITION]. The nurse noted the doctor was okay with the request to use the [MEDICAL CONDITION]. Review of the North Station 24 Hour Report, dated 01/26/2020, revealed no documented evidence staff included Resident #46's change of condition, nor of the doctor's approval of the use of the [MEDICAL CONDITION] for the resident. Further review revealed no medical order for the use of [REDACTED] Review of the Nurse's Note, dated 01/31/2020 at 1:15 PM, revealed the Director of Nursing (DON) documented an Inter-Departmental Team (IDT) review of Resident #46's admission information. Review revealed the IDT's documentation included an observation of Resident #46, and noted the resident's decline from his/her previous admission to the facility. In addition, review revealed the documentation noted Resident #46's POA was involved with the resident's care. Observations, on 03/01/2020 through 03/05/2020, revealed the contract agency's respiratory equipment in Resident #46's room, which included observation of a suction machine and an oxygen concentrator. Interview with Family #2, Resident #46's POA, on 03/01/2020 at 12:13 PM, revealed the resident had used a [MEDICAL CONDITION] machine for over twenty (20) years. Per the POA, she had notified the facility's staff on the resident's admission to the facility of his/her use of the [MEDICAL CONDITION]. The POA stated Resident #46 used the [MEDICAL CONDITION] during his/her previous admission to the facility. According to the POA, the hospitalists at the hospital instructed him/her (the POA) to bring the [MEDICAL CONDITION] machine to the facility for the resident's use after admission. Continued interview revealed the POA had spoken to staff on multiple occasions, after the resident's current admission, of the resident's need to use the [MEDICAL CONDITION] for sleep and rest. The POA further stated staff had repeatedly informed her the facility would call the police if she continued with her attempts to apply the [MEDICAL CONDITION] on the resident, and remove the resident's nasal cannula oxygen. Further interview revealed therefore, the POA had taken Resident #46's [MEDICAL CONDITION] machine home. Interview with the facility's Central Supply Clerk (CSC), on 03/05/2020 at 8:41 AM, revealed the facility provided [MEDICAL CONDITION] or [MEDICAL CONDITION] respiratory equipment for residents as needed. She stated she ordered the units through the company the facility contracted. Per interview, staff notified her verbally if a resident had an order for [REDACTED].#46's need for a [MEDICAL CONDITION] or [MEDICAL CONDITION] respiratory unit, which had the capability for use of oxygen with the unit for the resident's use. Interview with LPN #1, on 03/05/2020 at 9:34 AM, revealed she provided care for Resident #46 routinely, and on 01/25/2020. She stated the POA had visited and removed the resident's oxygen nasal cannula and attempted to place a [MEDICAL CONDITION] on him/her. She stated the POA explained that Resident #46 required the use of the [MEDICAL CONDITION] unit. LPN #1 stated Resident #46 had arrived at the facility with doctor's orders for the use of oxygen; however, there was no order for use of a [MEDICAL CONDITION]. Per LPN #1, she was aware staff had obtained an order for [REDACTED].#46's [MEDICAL CONDITION] unit. She stated the reason a resident used a [MEDICAL CONDITION] unit was to keep them from having periods of not breathing while they were asleep. Further interview revealed if a resident did not have their [MEDICAL CONDITION] and stopped breathing the result could be death. In addition, she stated the responsibility of the assigned nurse who received the order included to ensure the facility acquired the [MEDICAL CONDITION] or [MEDICAL CONDITION] unit for the resident. Interview with LPN 4, on 03/05/2020 at 10:21 AM, revealed the facility had previously admitted Resident #46 for provision of care, and during that admission, he/she had used the [MEDICAL CONDITION] unit for sleeping. She stated the nurse who took the telephone order from the Physician was responsible for the order and needed to complete the input of the order immediately, which ensured the availability of the respiratory unit. Per LPN #4, the facility's responsibility included to ensure the resident received the [MEDICAL CONDITION] unit for his/her use. Further interview revealed residents' who did not receive his/her [MEDICAL CONDITION] could experience impaired sleep, which could lead to a negative change in the resident's condition. Interview with Registered Nurse (RN) #5, on 03/05/2020 at 3:30 PM, revealed she assisted LPN #1 on 01/25/2020, when the POA had removed Resident #46's oxygen nasal cannula. She stated she called the doctor regarding staff's concern of the POA's removal of the oxygen to place the [MEDICAL CONDITION] mask on Resident #46. Per RN #5, the Physician ordered Resident #46 a new [MEDICAL CONDITION] unit; however, she could not remember if she completed the order or notified the CSC for the new [MEDICAL CONDITION] unit. She stated the facility assigned her to the South Hall on 01/25/2020 and the North Hall included Resident #46's assigned room. Further interview with RN #5 revealed the staff member who received the order included the responsibility to enter the order into the facility's electronic system followed with entry of a nurses' note. Staff's responsibility included to place new orders onto the facility's 24 Hour Report form to notify the DON of the new order. In addition, she stated the facility expected staff to complete the process of verbal orders when received. RN #5 stated the facility failed to order the medical equipment because completion of the verbal order process did not occur. RN #5 further revealed long-term negative effects, such as, heart failure, could occur if a resident required the [MEDICAL CONDITION]. However, she stated the North Unit assigned LPN #1 for the resident and did feel responsible to follow through with the order. Interview with the Assistant Director of Nursing (ADON), on 03/05/2020 at 3:02 PM revealed her expectations of staff included to place physician's orders [REDACTED]. She stated the process included entering the verbal order into the computer; place the order on the facility's 24 Hour Report form, and document the order in the Nurse's Note. She stated she had no knowledge of the doctor's order for Resident #46's respiratory unit to include the ability to have oxygen administered via the unit. She stated the [MEDICAL CONDITION] machine would allow Resident #46 to rest properly and therefore, not be tired. The ADON stated the facility had not completed the physician's orders [REDACTED]. In addition, she stated she expected all nurses to follow through to ensure the resident received the ordered medical device. Interview with the Director of Nursing (DON), on 03/05/2020 at 4:07 PM, revealed the facility's CSC ordered all equipment for residents; however, the ADON, DON, and Administrator were able to order as well. She stated she expected nursing staff to follow through to completion when they received a physician's orders [REDACTED]. Report Sheet. She stated the best practice for clinical staff included entry of the physician's orders [REDACTED]. In addition, she stated the facility's responsibility included to ensure Resident #46 received the respiratory equipment ordered by the Physician. Interview with the Administrator, on 03/05/2020 at 5:52 PM, revealed facility staff did not previously identify a family with a request of the use of respiratory equipment for apnea or, of an order to obtain equipment to meet the need of oxygen with the use of [MEDICAL CONDITION] for a resident. He stated facility staff identified the resident without his/her ordered respiratory equipment when the Surveyor (State Survey Agency) interviewed staff in the facility. He stated the facility failed to follow the physician's orders [REDACTED].

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide adequate supervision and assistance to three (3) of eighteen (18) sampled residents, Resident #4, #26, and #62 to prevent accidents. Record review revealed Resident #4 was confused, had a history of [REDACTED]. Review of a facility Investigation revealed Resident #4 had taken self to the bathroom on 01/28/19 at 1:13 AM, and also return from the bathroom unassisted, lost his/her balance, fell and hit his/her head on the wall. The facility transferred the resident to the hospital, where he/she received four (4) staples for a three (3) centimeter laceration to the back of the head. Further review of the Summary of Investigative Findings and Conclusions revealed Resident #4 got up out of bed, went to the bathroom and on the way back fell hitting his/her head on the wall. The immediate action put in place to prevent another fall was to encourage the resident to use his/her call light and to wait for assistance. Additional interventions put in place after the fall was a therapy referral, for staff to ensure night light was on, and the use of non-skid socks. Continued review of the facility's Conclusions revealed no evidence the facility identified staff did not provide Resident #4 the required assessed assistance of one (1) with toileting or that he/she needed additional interventions related to increased toileting opportunities, a toileting schedule, or increased supervision to prevent another fall. Resident #26 was left unsupervised in the hall in his/her wheelchair and leaned forward and fell on his/her forehead sustaining a baseball size hematoma. Resident #62 utilized a seatbelt while in the wheelchair to prevent him/her from sliding out of the chair; however, observation revealed the seatbelt was fastened but laid loose across the resident's lap. The findings include: Review of the facility's policy, Safety and Supervision of Resident, dated 05/31/18, revealed staff would make routine resident and environmental checks to ensure the safety and well-being of residents. Implementing interventions to reduce accident risks and hazards included communicating specific interventions to all relevant staff; assigning responsibility for carrying out the interventions; provide training as necessary; and ensure staff implemented and documented interventions. Monitoring for effectiveness included ensuring correct and consistent implementation of the interventions. 1. Observation of Resident #4, on 02/05/19 at 2:41 PM, revealed the resident was in his/her bathroom without staff assistance, got up from the toilet and went back to bed by himself/herself. Observation of Resident #4, on 02/07/19 at 10:01 AM, revealed the resident in bed, partially covered, with non-skid socks on both feet. The socks were on upside down, as the anti-skid strips were on the top of the feet. Review of Resident #4's clinical record revealed the facility readmitted the resident on 01/25/19, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #4 required supervision and the assistance of one (1) staff with transfers between surfaces and toileting, and limited assistance of one (1) staff for personal hygiene. The facility determined the resident was not interviewable with a Brief Interview for Mental Status (BIMS) score of three (3) of fifteen (15). Review of an Occupational Therapy Evaluation and Plan of Treatment, dated 01/26/19, revealed the resident was hospitalized [DATE] to 01/25/19 and referred to therapy due to new onset of decrease in strength, decrease in functional mobility, decrease in transfers, and increased need for assistance from others. Review of Resident #4's Fall Risk Evaluation, dated 01/26/19, revealed the facility assessed the resident with a fall risk score of twenty-two (22) and determined the resident was at risk for falls, as a score of ten (10) or higher put a resident at risk for falls. Review of the Care Plan for Resident #4, dated 07/11/18, revealed the resident was at risk for falls with interventions for a wheelchair for long distances, assist of one (1) staff with gait belt and walker for ambulation, assist to the bathroom upon his/her request, and non-skid socks in bed as he/she would allow. Interview with the MDS Coordinator, on 02/08/19 at 4:22 PM, revealed Resident #4 was scheduled for bathroom assistance every two (2) to three (3) hours; however, he/she got up on his/her own without assistance and did not use the call light all the time. However, review of Resident #4's Nursing Progress Note, dated 01/28/19, revealed the resident fell on his/her way back from the bathroom unassisted, was sent out to the hospital and received four (4) staples to the back of his/her head. In addition, the resident was on antibiotic therapy at the time for Pneumonia. Review of a facility Investigation, dated 01/28/19, revealed Resident #4 had taken self to the bathroom on 01/28/19 at 1:13 AM, and returned from the bathroom unassisted, lost his/her balance, and hit his/her head on wall. The facility transferred the resident to the hospital where he/she received four (4) staples for a three (3) centimeter laceration to the back of the head. The investigation documentation revealed the contributing factors to the fall were a history of falls, lower extremity weakness, and the resident resisted assistance and forgot to ask for help. Further review revealed the Overall Summary of Investigative Findings and Conclusions stated the resident got up out of bed and went to the bathroom and on the way back fell hitting his/her head on the wall. The immediate actions put in place to prevent another fall was to encourage the resident to use his/her call light and wait for assistance. Additional interventions put in place after the fall was a therapy referral, for staff to ensure a night light was on, and for the resident to use non-skid socks. The Summary continued to state the facility implemented both immediate and preventative interventions of resident assessment after the fall, transfer to the hospital for laceration treatment, and for staff to encourage the resident to use call light and wait for assistance. However, continued review revealed no evidence the facility identified Resident #4 needed interventions related to increased toileting opportunities, a toileting schedule, or increased supervision to prevent another fall. In addition, the Summary stated no actions were implemented for any other resident that might be identified at risk, education or competencies were not provided to staff to address any issues, and not applicable was placed next to describe the identified/ongoing Quality Assessment/Process Improvement plan. Interview with Certified Nursing Assistant (CNA) #9, on 02/08/19 at 9:56 AM, revealed Resident #4 had good and bad days with ambulation and got assistance from staff with going to and from the bathroom. She stated the resident was incontinent at night. The CNA stated the resident thought he/she could do everything on his/her own but the resident was confused and was not reliable to use the call light. Interview with CNA #8, on 02/08/19 at 9:53 AM, revealed she checked on Resident #4 about every two (2) to three (3) hours. She stated the resident was not reliable to use the call light. She stated if the non-skid socks were not on right, they would not help to prevent a fall. Interview with CNA #10, on 02/08/19 at 3:27 PM, revealed she knew Resident #4 needed help with going back and forth to the bathroom and was checked every two (2) hours. She stated the resident could make choices on some days but not on others. According to CNA #10, Resident #4 knew what a call light was but had no understanding he/she needed to push it to get help. The CNA stated the resident was an assist of one (1) staff, which meant he/she required assistance with transfers from the bed to the toilet. She further stated CNAs should ensure the resident had their non-skid socks on correctly. Interview with Licensed Practical Nurse (LPN) #2, on 02/08/19 at 3:11 PM, revealed Resident #4 was not aware of his/her surroundings or of safety issues and needed assistance from staff. She stated CNAs should know the resident did not understand to use his/her call light to go to the bathroom. The LPN stated the resident did not have a toileting schedule and it was hard to know when she/he needed to use the bathroom. She further stated it was nursing staff's responsibility to assist a resident to make sure the resident was kept safe. Interview, on 02/08/19 at 10:14 AM, with Unit Manager (UM) #2 revealed the facility determined the root cause of the resident's fall was Resident #4 ambulated without assistance, lost his/her balance, and fell and hit his/her head on the wall. However, she stated staff should assist Resident #4 to the bathroom because he/she required the assistance of one (1) with toileting and transfers. UM #2 stated staff would frequently find the resident had toileted himself/herself without assistance. She stated more frequent checks and offering toileting after meals would be additional fall prevention interventions for safety. Interview, on 02/07/19 at 2:41 PM, with the Staff Development (SD) revealed she oriented CNAs and provided instructions on direct care. She stated for cognitively impaired residents, CNAs used a gait belt for transfers, asked impaired residents if they needed to use the bathroom, and kept residents as safe as possible. The SD stated nursing staff was to check at least every two (2) hours on those residents, or if the resident was a fall risk, more frequently. She stated non-skid socks were effective if residents could ask for assistance, otherwise she deemed them ineffective and a more effective intervention was to keep the bed in a low position and check on them more frequently. The SD stated if a resident did not know what a call light was there for, then it was not an effective intervention. Interview, on 02/08/19 at 4:49 PM, with UM #1 revealed she was part of the Interdisciplinary team, which reviewed incidents, attempted to find the root cause of the incidents, and made sure interventions were on the care plan. She stated the team determined the root cause of Resident #4's fall was that the resident went to the bathroom on his/ her own to try to retain his/her independence and did not call for help. She stated CNAs were to assist the resident to the bathroom due to the assessed need of one (1) to assist with toileting and because the resident could not do so independently. She further stated a root cause analysis was done to prevent future falls; however, she stated non-skid socks would only be helpful if the resident was alert and would not prevent the resident from getting up and falling. 2. Review of Resident #26's clinical record revealed the facility readmitted the resident on 11/14/18, with [DIAGNOSES REDACTED]. Review of the Admission MDS, dated [DATE], revealed the facility assessed Resident #26 was totally dependent on two (2) staff for transfers between surfaces in his/her room and toilet use. The resident required extensive assistance of one (1) staff for locomotion on the unit. The facility assessed Resident #4 was not interviewable with a BIMS score of zero (0) of fifteen (15). Review of Resident #26's Fall Risk Evaluation, dated 12/13/18, revealed the facility assessed the resident with a score of eighteen (18) and determined the resident was at risk for falls, as a score of ten (10) or higher put a resident at risk for falls. Review of the Care Plan for Resident #26, dated 11/29/18, revealed the resident was at risk for falls and dependent on staff for all Activities of Daily Living (ADL) care. Interventions included a mechanical lift with two (2) staff for transfers, assistance for locomotion as needed, check and change every two (2) to three (3) hours and as needed, wheelchair for all locomotion, and provide all ADL care to ensure daily needs were met. Review of a facility Investigation, dated 12/12/18, revealed Resident #26 fell on [DATE] at 10:15 PM. Resident #26 was sitting in his/her wheelchair in the hallway outside his/her room waiting for staff to put him/her to bed. CNAs witnessed the resident lean forward and slide out of the wheelchair, landing toward his/her left side with his/her forehead taking the brunt of the fall. A hematoma developed and a small area of skin allowed blood to ooze. The Investigation stated the contributing factors for the fall were a history of falls, lower extremity weakness, and resident confusion. The new nursing interventions were for therapy to evaluate the resident for positioning, foot pedal placement, lowering the wheelchair seat, and use of a Dycem (non-slip material). Further review of the facility Investigation revealed interventions in place prior to the fall were a positioning device in the wheelchair, appropriate footwear, and Physical, Occupational, and Speech Therapy evaluations. The Overall Summary of Investigative Findings and Conclusions was marked not applicable. Continued review of the Summary revealed the facility did not identify Resident #26 needed increased supervision while in his/her wheelchair when sleepy to prevent another fall. In addition, the Summary stated no actions were implemented for any other resident that might be identified at risk, education or competencies were not provided to staff to address any issues, and not applicable was placed next to describe the identified/ongoing Quality Assessment/Process Improvement plan. Review of the Hospital Discharge Summary for Resident #26, dated 12/12/18, revealed the resident was treated for [REDACTED]. Interview with CNA #10, on 02/08/19 at 3:37 PM, revealed after she gave Resident #26 an evening snack, she pushed him/her near his/her room and answered the call light in the room next door. When she turned around, she stated Resident #26 was bending down to pick at his/her pants and fell forward, out of the chair. The CNA stated the resident was not supervised while she went to answer a call light, and if she had not left the resident unattended, he/she would not have fallen. Interview with LPN #5, on 02/08/19 at 3:55 PM, revealed Resident #26 was a fall risk and when the resident was sleepy, he/she would lean over in his/her wheelchair, which could cause the resident to fall. She stated she was on duty when Resident #26 fell and prior to the fall, a CNA was about to put Resident #26 to bed; however, the CNA left the resident unattended to answer the call light in the room next door and the resident fell to the floor. She stated the CNA should have taken the resident straight to his/her room and not answered the call light. Even if the resident would have been in the CNA or nurse's view, they should not have left the resident alone. LPN #5 stated to prevent another similar fall, more frequent supervision was needed of Resident #26. Interview with UM #2, on 02/08/19 at 5:17 PM, revealed Resident #26 was tired and nursing staff was supposed to take him/her to bed. However, CNA #10 went to answer a call light in the room next to Resident #26's room and parked the resident in his/her wheelchair in the hall and left the resident unsupervised. The UM stated another staff should have answered the call light so staff was with the resident at all times. She further stated since the resident fell there was no supervision of Resident #26. The Director of Nursing was unavailable for interview during the survey. Interview, on 02/08/19 at 6:20 PM, with the Administrator revealed finding the root cause of a fall was done to find out why a resident fell , the reason he/she had not asked for help, and to put interventions in place that had a positive impact. He stated it was important for nursing staff to put the right interventions in place and be attentive to resident needs in order to prevent falls. 3. Review of the clinical record revealed the facility readmitted Resident #62 on 05/03/18, with [DIAGNOSES REDACTED]. Review of Occupational Therapy (OT) Notes, signed 08/03/18, revealed the resident was a fall risk and required constant supervision. Short-term goals included assessment to obtain the most appropriate assistive positioning device to promote midline positioning for increased comfort, safety, and quality of life when up in wheelchair. Review of Resident #62's Care Plan, revised 12/12/18, revealed the resident was at risk for falls with an intervention to place an alarming safety seatbelt when the resident was seated in the wheelchair. Observations, on 02/06/19 at 9:30 AM and 10:19 AM, revealed Resident #62 sitting in his/her wheelchair with the seatbelt ends clasped together; however, the seatbelt was loose and laid across the thighs of the resident, opposed to fitting snugly, against the resident's waist. Interview with CNA #8, on 02/08/19 at 9:31 AM, revealed the seatbelt prevented Resident #62 from sliding out of the wheelchair and should be snug but not tight, and should be positioned at or near the abdomen to prevent the resident from falling out of the wheelchair. CNA #8 stated Resident #62 moved around the unit in the wheelchair and could slide out of the wheelchair, as she had observed the resident lean over the side of the wheelchair. She stated a loose seatbelt allowed a resident to fall and become injured. Interview with CNA #9, on 02/08/19 at 9:56 AM, revealed the facility utilized a seatbelt for Resident #62 when he/she was in the wheelchair to prevent the resident from falling. CNA #9 stated it was not appropriate for a seatbelt not to be snug. Interview with CNA #3, on 02/08/19 at 3:20 PM, revealed proper positioning for a seatbelt was around a resident's waist to prevent the resident from falling from a chair. CNA #3 stated a loose seatbelt might allow a resident to slide down, easily come out of a chair, obtain an injury, and choke if the belt ended up around a resident's neck. Interview with the Occupational Therapy Assistant (OTA), on 02/08/19 at 10:47 AM, revealed a properly fitted seatbelt should be snug to prevent a resident from sliding out of a wheelchair. The OTA stated an improperly fitted seatbelt could cause the resident to fall out of the wheelchair, obtain an injury such as broken bones, skin tears, which could result in pain. Interview with LPN #3, on 02/08/19 at 9:07 AM, revealed the facility utilized a seatbelt for Resident #62 to aid in positioning and resident safety. The LPN stated the seatbelt should be snug, but not tight, across the resident's lap. LPN #3 stated a loose seatbelt made it easier for the resident to slide out of the wheelchair. Interview with UM #1, on 02/08/19 at 5:26 PM, revealed staff considered Resident #62 a fall risk and placed a seatbelt on the resident for poor positioning. RN #2 stated the seatbelt should be positioned properly, not on the resident's lap, to prevent the resident from sliding down, sustain an injury, or strangulation. Interview with the Administrator, on 02/08/19 at 6:16 PM, revealed staff should correctly position seatbelts to prevent falls.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to revise the care plan for two (2) of eighteen (18) sampled residents, Resident #26 and #42. Resident #26 was left unsupervised in the hall in his/her wheelchair and leaned forward and fell on his/her forehead sustaining a baseball size hematoma. After the fall, staff was instructed to put the resident to bed when tired; however, it was not added to the plan of care. Observations of Resident #42 revealed the resident experienced hallucinations. The resident's care plan had interventions to monitor the resident's behavior; however, did not provide staff steps with what to do when the resident displayed the behaviors. The findings include: Review of the facility's policy, Care Planning-Interdisciplinary Team, dated [DATE], revealed the team was responsible to develop an individualized, comprehensive care plan for each resident that included goals and objectives to reach the highest obtainable level of independence. 1. Review of Resident #26's clinical record revealed the facility readmitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #26 was totally dependent on two (2) staff for transfers between surfaces in his/her room and toilet use. The resident required extensive assistance of one (1) staff for locomotion. The facility assessed Resident #4 was not interviewable with a BIMS score of zero (0) of fifteen (15). Review of the Care Plan for Resident #26, dated [DATE], revealed the resident was at risk for falls and dependent on staff for all Activities of Daily Living (ADL) care. Interventions included a mechanical lift with two (2) staff for transfers, assistance for locomotion as needed, check and change every two (2) to three (3) hours and as needed, wheelchair for all locomotion, and provide all ADL care to ensure daily needs were met. Review of a facility Investigation, dated [DATE], revealed Resident #26 fell on [DATE] at 10:15 PM. Resident #26 was sitting in his/her wheelchair in the hallway outside his/her room waiting for staff to put him/her to bed. Certified Nursing Assistants (CNA) witnessed the resident lean forward and slide out of the wheelchair, landing toward his/her left side with his/her forehead taking the brunt of the fall. A hematoma developed and a small area of skin allowed blood to ooze. Review of the Hospital Discharge Summary for Resident #26, dated [DATE], revealed the resident was treated for [REDACTED]. Interview, on [DATE] at 3:37 PM, with CNA #10 revealed she was present when Resident #26 fell and stated after she gave the resident an evening snack, she pushed the resident near his/her room and answered the call light in the room next door. When she came out she saw Resident #26 bending down to pick at his/her pants and he/she fell forward and hit his/her head on the floor. The CNA stated she left the resident unattended and if she had not, he/she would not have fallen. Interview, on [DATE] at 3:55 PM, with Licensed Practical Nurse (LPN) #8 revealed Resident #26 needed more supervision when he/she was in the wheelchair and sleepy. However, she did not know if this was on the care plan. She stated the CNA was getting ready to put Resident #26 to bed, stopped to answer the call light in the next room, left the resident unattended and the resident fell to the floor. She stated the CNA should have taken the resident straight to his/her room and not answered the call light, or left the resident alone. Interview, on [DATE] at 5:17 PM, with Unit Manager (UM) #2 revealed Resident #26 was tired and nursing staff was about to take him/her to bed but CNA #10 instead answered a call light in the next door room, and parked the resident in his/her wheelchair in the hall. The UM stated the CNA should have stayed with the resident, because the resident required increased supervision when in his/her wheelchair and tired. She stated after the fall staff were instructed to put the resident to bed when tired; however, she was not sure if this intervention was added to the plan of care. Interview, on [DATE] at 6:20 PM, with the Administrator revealed care plans were only effective if they were revised to ensure the safety of residents. 2. Review of Resident #42's clinical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #42's Quarterly MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of twelve (12) of fifteen (15) and determined the resident interviewable. Review of the Psychiatric Mental Health Nurse Practitioner Notes, dated [DATE], revealed Resident #42 reported a man came into his/her room and raped him/her. He/she reported he/she was married to the man that had sex with him/her and he/she was a different person. The resident reported he/she had a bad week because his/her parents had just died . Resident #42 denied being scared. Review of the Resident #42's Care Plan, dated [DATE], revealed the resident received daily [MEDICAL CONDITION] medications for the [DIAGNOSES REDACTED]. Interview with and observation of Resident #42, on [DATE] at 1:15 PM, revealed the resident in bed, spoke of a person trying to kill him/her, and rats being placed inside of him/her. Upon surveyor intervention, the Unit Manager and Social Services Director approached resident. Interview with CNA #10, on [DATE] at 3:55 PM, revealed she cared for Resident #42 and was aware of allegations he/she had made. She stated Resident #42 alleged his/her spouse raped him/her, and his/her male friend put rats inside of him/her. She stated there were multiple allegations made by this resident. Interview with UM #1, on [DATE] at 4:20 PM, revealed Resident #42 made allegations of sexual behaviors, and rats placed inside of him/her. She stated staff was aware and two (2) staff was to provide care to him/her. Upon review of the care plan for behaviors, she stated the monitoring and observation interventions did not provide direction as to what the next step was for the staff to know who to report the information to, how to direct the resident care, and the care plan did not have follow through to meet the resident's psychiatric needs. Interview with the MDS Coordinator, on [DATE] at 4:34 PM, revealed she developed the comprehensive care plans, and updated as indicated, as well as reviewed and updated during the clinical meetings. She was familiar with Resident #42 and stated the care plan was updated on [DATE], by the Social Services Director and UM #1. Continued review of the care plan, dated [DATE], revealed the resident had sexually explicit thought/conversations related to being impregnated by rats/spouse putting rats inside, and thoughts of being raped, feeling of spouse wanting to murder the resident, and the Iraqi People were out to get him/her. Upon further review of the interventions added, they included if the resident reported any pest/rodent concerns, staff was to report to Plant Ops for pest control. The Director of Nursing was not available for interview during the survey.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to follow the care plan for two (2) of eighteen (18) sampled residents, Resident #4 and #62. Resident #4 was care planned to have staff assistance for toileting; however, the resident did not receive assistance with toileting and sustained a fall with injury. Resident #62 was care planned to have a seatbelt on while in the wheelchair to prevent falls; however, observations revealed the seatbelt was not in the proper position. The findings include: Review of the facility's policy, Care Planning-Interdisciplinary Team, 06/01/15, revealed the team was responsible to develop an individualized, comprehensive care plan for each resident that included goals and objectives to reach the highest obtainable level of independence. 1. Observation, on 02/05/19 at 2:41 PM, of Resident #4 revealed the resident was in his/her bathroom, got up from the toilet, and went back to bed by himself/herself. Observation, on 02/07/19 at 10:01 AM, of Resident #4 revealed the resident had non-skid socks on both feet with the anti-skid strips on the top of the feet. Review of Resident #4's clinical record revealed the facility readmitted the resident on 01/25/19, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #4 required supervision and the assistance of one (1) staff with transfers between surfaces and toileting. The facility determined the resident was not interviewable with a Brief Interview for Mental Status (BIMS) score of three (3) of fifteen (15). Interview with the MDS Coordinator, on 02/08/19 at 4:22 PM, revealed Resident #4 was scheduled for bathroom assistance every two (2) to three (3) hours; however, he/she got up frequently on his/her own without assistance and did not use the call light all the time. Review of the Care Plan for Resident #4, dated 07/11/18, revealed the resident was at risk for falls with interventions for a wheelchair for long distances, assist of one (1) staff with gait belt and walker for ambulation, assist to the bathroom upon his/her request, non-skid socks in bed as he/she would allow. On 01/28/19 the facility added interventions for the resident to wear non-skid socks, refer the resident to therapy and ensure the night light was on. Review of a facility Investigation, dated 01/28/19, revealed Resident #4 fell on [DATE] at 1:13 AM when coming back from bathroom alone and lost his/her balance and hit his/her head on wall. The facility transferred the resident to the hospital where he/she received four (4) staples to the back of his/her, and sent back to the facility. Interview, on 02/08/19 at 9:56 AM, with Certified Nursing Assistant (CNA) #9 revealed the resident was confused and not reliable to use the call light. She stated due to the resident's confusion he/she thought he/she could do tasks on his//her own without assistance. CNA #9 stated the care plan directed them to toilet the resident every two (2) to three (3) hours. However, she stated staff could not stop Resident #4 from going to the bathroom unassisted. Interview, on 02/08/19 at 9:53 AM, with CNA #8 revealed she checked on Resident #4 about every two (2) to three (3) hours. She stated the resident could use the call light but was not reliable to use the call light. She stated when the resident's non-skid socks were on with the anti-strips on top of his/her feet, they would not help prevent falls. Interview, on 02/08/19 at 3:27 PM, with CNA #10 revealed she knew Resident #4 needed help with going back and forth to the bathroom and he/she was a two (2) hour check. She stated the resident required the assist of one (1) staff to transfer from the bed to the toilet. She further stated CNAs needed to check if residents had their non-skid socks on correctly. Interview, on 02/08/19 at 3:11 PM, with Licensed Practical Nurse (LPN) #2 revealed Resident #4 was not aware of his/her surroundings or of his/her safety issues and received assistance from staff for transfers to and from the toilet. She stated the CNAs should know Resident #4 did not understand the use of his/her call light to go to the bathroom. The LPN stated CNAs checked on the resident on two (2) hour rounds; however, she stated the resident did not have a toileting schedule and it was hard to know when she/he needed to use the bathroom. Interview, on 02/08/19 at 4:22 PM, with the MDS Coordinator revealed Resident #4's CNA care plan instructed CNAs to toilet him/her every two (2) to three (3) hours; however, Resident #4 got up on her own without assistance and could not reliably use the call light all the time. She stated she thought nursing staff had followed the care plan because staff could not check on the resident continuously. Interview, on 02/07/19 at 2:41 PM, with Staff Development (SD) revealed non-skid socks were only effective if a resident could ask for assistance; however, other than that she deemed them ineffective. The SD stated a more effective intervention for cognitively impaired residents who were a fall risk was to keep the bed in a low position and check on them more frequently. Interview, on 02/08/19 at 10:14 AM, with Unit Manager (UM) #2 revealed Resident #4 was not supposed use the bathroom independently but did so all the time. The UM stated the resident required the assistance of one (1) staff for transfers and was to receive assistance to go to the bathroom; however, staff did not know the resident had already gone to the toilet or that he/she was up and/or on his/her way back to the bed. The UM stated CNAs checked on residents about every two (2) hours; however, the resident needed checked more frequently and after meals. Interview, on 02/08/19 at 4:49 PM, with UM #1 revealed the Interdisciplinary team reviewed the incidents and made sure interventions were on the care plan. The UM stated CNAs were to assist the resident to the bathroom because he/she was an assist of one (1) for transfers and not able to do it independently. 2. Review of the clinical record for Resident #62 revealed the facility readmitted him/her on 05/03/18, with [DIAGNOSES REDACTED]. Review of Resident #62's Care Plan, revised 12/12/18, revealed the resident was at risk for falls with interventions to place an alarming safety seatbelt when the resident was seated in the wheelchair. Observations, on 02/06/19 at 9:30 AM and 10:19 AM, revealed Resident #62 sitting in his/her wheelchair with a safety seatbelt on; however, the seatbelt laid loose across the resident's thighs instead of snugly, against the resident's waist to prevent the resident from sliding out of the chair. Interview with CNA #3, on 02/08/19 at 3:20 PM, revealed the facility listed the seatbelt on the care plan for Resident #62 but staff did not implement appropriately because the belt should be around the resident's waist to prevent him/her from falling out of the chair. Interview with LPN #3, on 02/08/19 at 9:07 AM, revealed the facility included a seatbelt as an intervention for Resident #62 for the resident's safety; however the seatbelt should be snug across the resident's lap to keep the resident from sliding out of the chair. Interview with Registered Nurse (RN) #2, on 02/08/19 at 5:26 PM revealed the care plan for Resident #62 included a seatbelt because of the resident's poor positioning, leaning, and jerking, and the resident's potential for falls. Interview with the Administrator, on 02/08/19 at 6:16 PM, revealed if interventions on resident care plans were not implemented, then they were not effective. The Administrator stated the facility educated staff to follow care plans to ensure the safety of residents and reduce the risk of injury.

Based on interview and review of Certified Nursing Assistant (CNA) personnel files, it was determined the facility failed to complete annual performance reviews for six (6) of six (6) CNA files reviewed. The facility failed to conduct annual performance reviews for CNA #1, #2, #3, #4, #5, and #6. The findings included: Review of the facility's CNA Job Description, dated (MONTH) 2011, revealed the CNA performed direct resident care duties and assisted with promoting a [MEDICATION NAME] physical and psychosocial environment for the residents. Review of CNA #1, #2, #3, #4, #5, and #6's personnel files revealed the facility had not conducted an annual performance review. Interview with the Staff Development Coordinator, on 02/07/19 at 3:58 PM, revealed she was new to the position and her role currently included the orientation program for new hires. She stated the performance reviews would improve the CNAs' job performances. The Director of Nursing was not available for interview. Interview with the Administrator and Unit Manager (UM) #2, on 02/08/19 at 6:15 PM, revealed the Administrator was not aware the CNAs did not have the required annual performance reviews. The UM and Administrator stated annual performance reviews were not completed, as it was not their practice.

Based on observation and interview, it was determined the facility failed to ensure supplies were not expired and available for use in one (1) of two (2) medication rooms, the South Medication Room. In addition, the facility stored the Emergency Drug Kit (EDK) and the pharmacy medication tote on the soiled floor in the North Medication Room. The findings include: The facility did not provide a policy for medication room storage. Observation of the North Medication Room, on [DATE] at 2:38 PM, with Licensed Practical Nurse (LPN) #2, revealed the EDK and the pharmacy tote were on the floor in medication room. The floor and the corners were soiled with loose, fluffy grey particles. Interview with LPN #2, on [DATE] at 2:38 PM, during the observation, revealed the floor was dirty and the loose grey particles needed to be cleaned out. She stated housekeeping would clean out the room if requested and it looked like the room had not been cleaned in a long time. During the interview, the facility's Regional Consulting Nurse pointed to the medication room as she walked by and advised the LPN standing in the nurses' station that the medication room needed to be cleaned, while she pointed to the floor. Observation of the South Medication Room, on [DATE] at 2:59 PM, with LPN #6, revealed it contained expired supplies that were available for staff use on the residents. The expired items included an Intravenous (IV) Start Kit with an expiration date of [DATE], a Suction Catheter Kit, 14 FR, with an expiration date of (MONTH) (YEAR), two (2) Para Pack collection containers with expiration dates of (MONTH) (YEAR) and (MONTH) (YEAR), and two (2) Vacuette collection tubes with expiration dates of [DATE] and [DATE]. Interview with LPN #6, on [DATE] at 2:59 PM, during the observation, revealed if staff used the expired collection tubes and containers for testing, they could potentially cause an inaccurate test result. She stated staff should review the expiration dates before use, but the supplies were available for staff use. The Director of Nursing was not available for interview during the survey. Interview with Unit Manager (UM) #2, on [DATE] at 6:15 PM, revealed all expired items should be removed and not available for staff use, as expired items had the potential to provide inaccurate laboratory results if used. Other expired items might be an infection control concern, as they might not have maintained sterility. The UM stated the facility checked medication rooms for expired items and she was not sure how the items were missed, or when the last time the rooms were checked for expired items as she did not conduct the checks. The UM stated the EDK and pharmacy tote should not be stored on the floor; however, that was where they were kept on a routine basis.

Based on interview, record review, and review of a facility investigation, it was determined the facility failed to ensure controlled drugs were accounted for, for one (1) of three sampled residents, Resident #120. Record review and interview revealed Resident #120's pain medication, [MEDICATION NAME], went missing and could not be accounted for. The findings include: Review of the facility's policy, Controlled Medications and Drug Diversion, revised 07/24/18, revealed medications included in the Drug Enforcement Administration (DEA) classification as controlled substances were subject to special handling, storage, disposal, and recordkeeping within the facility in accordance with federal, state, and other applicable laws and regulations. Two (2) staff members would be required to witness and attest to the wasting of a controlled substance. The two (2) staff members would sign on the Narcotic Administration Record and the reason for wasting the medication would be documented on the back of the form. Review of a facility Investigation revealed on 11/23/18, the facility discovered eighty-three (83) [MEDICATION NAME] tablets for Resident #120 were missing and unaccounted for. The facility determined the facility's system for counting and managing controlled substances, and accepting or releasing medication carts, had not been followed. Review of a Police Report, dated 11/23/18, revealed the facility reported eighty-three (83) missing [MEDICATION NAME] tablets. Interview with the Administrator, on 02/07/19 at 10:45 AM, revealed the facility had a drug diversion identified and reported. He stated the prior Interim Director of Nursing (IDON) completed the investigation. Interview with the prior IDON, on 02/08/19 at 4:52 PM, via telephone, revealed during the 11/22/18 shift change at 7:00 PM, Registered Nurse (RN) #1 (off-going nurse) and Licensed Practical Nurse (LPN) #2 (on-coming nurse) were completing their narcotic counts when they identified one (1) of Resident #120's three (3) [MEDICATION NAME] cards was missing two (2) pills. She stated the [MEDICATION NAME] pills were signed out as wasted by LPN #7 without a second nurse to sign the waste as witnessed. RN #1 reported to her Resident #120 had been discharged from the facility. The IDON stated when she went in on 11/23/18 to waste all the resident's [MEDICATION NAME], she identified all three (3) medication cards were missing along with the narcotic sheets. She stated RN #1 confirmed she had placed them in the cart along with the narcotics sheets when she discharged the resident. She stated she interviewed the nurses assigned to that medication cart and all the nurses returned for interviews and submitted to drug screens, except LPN #7. LPN #7 never returned the phone calls and never returned to work at any point after the IDON identified the missing narcotics. She stated upon investigation, she identified staff were not following the shift protocol for narcotic counts at change of shift. She stated one nurse left without completing shift change narcotic count, and another nurse did not visualize the complete narcotic cards in the drawer when counting to verify all the pills were in the cards. In addition, LPN #7 did not have a second nurse witness the wasted two (2) pills. She stated the nurses were not counting the narcotic sheets, either, only the cards. The investigation revealed LPN #7 was the last nurse to work that cart. She stated she had never had any reports prior to this concern regarding narcotic counts. Interview with Unit Manager (UM) #1, on 02/08/19 at 5:54 PM, revealed when the diversion of narcotics was identified, she assisted with the audits. She stated she audited the narcotic sheets, matched each new sheet for each narcotic received. The UM stated the facility's on-coming nurses and the off-going nurses were supposed to complete the narcotic counts at shift change. Once the narcotics were reconciled with the narcotic count, then the narcotic key was handed from the off-going nurse to the on-coming nurse. Per interview, the facility identified narcotic medication diversion had occurred with the medications; however, was not able to identify by whom.

Based on interview, facility policy review, and review of the facility's Certified Nursing Assistant (CNA) annual in-service training hours, it was determined the facility failed to ensure CNAs completed a minimum of twelve (12) hours of in-services annually for two (2) of six (6) CNAs, CNA #1 and #6. The findings include: Review of the facility's policy, In-Service Training, dated 01/01/08, revealed stakeholders were required to attend the scheduled in-service training classes. Stakeholders were required to complete a minimum of twelve (12) hours. Review of the facility's Staff Development Coordinator (SDC) job description, updated (MONTH) 2011, revealed the SDC was to develop and implement job skills training, in-service education as required by regulations, and employee health monitoring for the nursing department employees. The essential duties and responsibilities included work cooperatively with the Administrator, Human Resources, and the Director of Nursing in assessing educational needs and plan programs to meet those needs and regulatory requirements. The SDC ensured all employees completed hours of required training during the required time period, and coordinated and tracked all in-services regarding mandatory topics. Review of CNA #1's annual in-service record revealed her date of hire was 10/26/16. The CNA completed 4.2 hours of in-services 10/26/17 through 10/26/18. CNA #1 remained on the current work schedule. Review of CNA #6's annual in-service record revealed her date of hire was 07/01/15. The CNA completed 2.25 hours of in-services 07/01/17 through 07/01/18. CNA #6 remained on the current work schedule. Interview with the SDC, on 02/07/19 at 3:58 PM, revealed she was new to the position and was not able to provide the in-service hours for CNA #1 and #6 from last year. Further interview on 02/08/19 at 9:15 AM, revealed the CNA in-service hours provided further education for the safety of the residents, and staff themselves, and improved their job performances. She stated there were multiple ways for staff to obtain their CNA hours but staff did not have opportunities during their shift to complete the education; however, they could complete the training from home. The Director of Nursing was not available for interview during the survey. Interview with the Administrator and Unit Manager #2, on 02/08/19 at 6:15 PM, revealed due to the changes with various SDC positions, the facility was not able to confirm what CNA education was completed. The Administrator stated he was not aware staff was not current with their CNA hours.

Based on observation and interview, it was determined the facility failed to post nurse staffing information in a prominent location for four (4) of four (4) days of the survey, 02/05/19, 02/06/19, 02/07/19, and 02/08/19. In addition, the posting did not have all the required information listed. The findings included: The facility did not provide a policy for staff posting information. Observation of the facility's Daily Staffing Form, on 02/05/19, 02/06/19, 02/07/19, and 02/08/19, revealed it was located on the South Hall near the staff entrance and time clock, off from the main portion of the South Hall. In addition, none of the forms had the resident census listed. Review of the facility's Daily Staffing Forms, dated 02/01/19, 02/02/19, 02/03/19, and 02/04/19, revealed the resident census was not listed for any of the dates. Interview with the Staff Scheduler, on 02/08/19 at 10:10 AM, revealed she completed the Daily Staffing Form and posted it once daily, which included day shift and night shift. She stated the posting location was in the short hall near the time clock, which was the entrance the staff frequently used but was not routinely used by families or visitors for the residents on the North Hall and up front. She stated people could see the posting if they came down the hall; however, it was not visible to the families, residents, staff, or visitors not on the South Hall, or if they did not know where it was located. Interview with the Administrator and Unit Manager (UM) #2, on 02/08/19 at 6:15 PM, revealed the Daily Staffing Form was posted on the South Hall near the time clock and not all staff, families, visitors, or residents utilized that particular entrance/exit. They stated the families, visitors, and residents for the North Hall probably did not know the posting was located there, and the posting was not in a prominent location for everyone to see.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure residents' medications were administered in accordance with professional standards of care for one (1) of seventeen (17) sampled residents, Resident #22. Interview and record review revealed staff left medications at the bedside for Resident #22 to consume without staff present. The findings include: Review of the facility's policy, Medication Administration General Guidelines, dated May 2016, revealed medications were to be administered at the time the medication was prepared. The resident was to be observed to ensure the dose was completely ingested and all medications were to be documented of the administration after the medication was consumed. Observation of medication administration with Licensed Practical Nurse (LPN) #2, on 12/07/17 at 9:22 AM, revealed the LPN administered medication to Resident #27. The resident told the nurse he/she was surprised the nurse waited for the medication to be consumed as nurses usually left the medication at the bedside all the time and would leave the room without watching the resident consume the medications. Review of the clinical record of Resident #27 revealed the facility assessed the resident on 09/28/17, with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) and determined the resident interviewable. Interview with Resident #27, on 12/08/17 at 3:50 PM, revealed the nurses usually left his/her medication at the bedside and did not watched him/her consume the medication. Review of Resident #22's BIMS, dated 09/21/17, revealed the facility assessed the resident with a score of fifteen (15) out of a fifteen (15) and determined the resident interviewable. Review of Physician order [REDACTED]. Review of Physicians Orders, dated 09/04/17, revealed [MEDICATION NAME]/APAP 10/325 mg, one (1) tablet by mouth three (3) times a day and every four (4) hours as needed for pain. Review of Resident #22's Controlled Drug Record revealed on 09/10/17 at 10:00 PM, staff signed out [MEDICATION NAME] 5 mg and [MEDICATION NAME]/APAP 10/325 mg. Review of the Nursing Progress Notes for Resident #22, dated 09/10/17 at 10:26 PM, revealed the nurse documented she placed the medications on the bedside table. The nurse noted Resident #22 spoke for twenty (20) minutes prior to leaving the room. The nurse returned to Resident #22's room after a Certified Nursing Assistant stated Resident #22 complained he/she had not received scheduled pain medication. The nurse documented she returned to Resident #22's room and told the resident he/she had received the pain tablet as the medication was still in the cup she had prepared and separated. The nurse further noted the resident could not state the medications were not given because the medications were still present in the cup placed on the resident's table. Interview with Resident #22, on 12/08/17 at 4:15 PM, revealed the night registered Nurse (RN) had left pills in a clear medication cup on the bedside table during medication pass. Resident #22 stated the RN put the medication cup on the table, walked out of the room, and did not observe him/her ingesting the medication, which occurred frequently with his/her regular medication and with the pain medication and nerve medication he/she received at night. Interview with Licensed Practical Nurse (LPN) #4, on 12/08/17 at 2:21 PM, revealed medications were not to be left at the residents' bedside. LPN #4 stated nurses were to observe the resident consume all medications brought to the resident. LPN #4 stated there were no residents the facility had assessed as able to self-administer medications. Interview with LPN #3, on 12/08/17 at 4:05 PM, revealed staff was never to leave medications at the bedside table for the resident to consume later. LPN #3 stated medications were to be observed consumed by the resident and then documented on the Medication Administration Record as administered. LPN #3 further stated medications found at the bedside were to be reported to the Director of Nursing (DON) immediately. Interview with the Unit Manager, on 12/08/17 at 4:30 PM, revealed staff was not to leave medication at the resident bedside for any reason. The Unit Manager stated medications could be hoarded and other residents could take the medications that were not prescribed for them. The Unit Manager stated if residents did not receive their pain medication, their pain would not be controlled. The Unit Manager stated medications left at the bedside put everyone at risk. Interview with the DON, on 12/08/17 at 4:30 PM, revealed she had conducted observations of medication pass with staff. The DON stated she expected staff to observe all residents consume prescribed medication and to document after the observation that the medications had been consumed. The DON stated it was the standard of care that all staff members watch the resident consume all medications. The DON further stated she was concerned to learn reported medications were left at the resident's bedside due to possible hoarding issues and safety to other residents, because it was poor practice and she did not expect any nurse in the facility to leave medications unattended. Interview with the Administrator, on 12/08/17 at 4:45 PM, revealed he assured safe medication pass in the facility with frequent communication with the DON concerning observations and issues that were found and how the DON handled and followed up with the findings. He stated the DON and Pharmacist Consultant had not revealed issues related to medication administration. He further stated he relied on the DON to ensure the residents were receiving all medications in a safe and proper manner.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure proper hand hygiene practices were adhered to during meal service as evidenced by a staff person touching themselves and other contaminated items without washing and/or sanitizing their hands. The findings include: Review of the facility's policy, Serving Resident Food-Resource, dated 06/01/15, revealed employees must wash their hands before serving the next resident if there was contact with soiled dishes, clothing, or resident's personal effects. Observation in the kitchen during the lunch meal, on 10/12/16 at 11:31 AM, revealed Licensed Practical Nurse (LPN) #1 was in the kitchen waiting at the steam table for the Cook to plate the food. LPN #1 placed her thumb on the inside of her shirt and brought the shirt up to her face and wiped her right eye twice, then released her shirt. She then repeated the process and wiped her eye two (2) more times. Without performing hand hygiene, LPN #1 took a tray with three (3) resident lunch plates on it into the dining room and served the residents. LPN #1 then touched the television, retrieved and used an ink pen from her pocket, and removed a dirty plate from a resident. Without performing hand hygiene, LPN #1 picked up and delivered a dessert plate to a resident. Additionally, LPN #1 retrieved two (2) dirty plates from two (2) residents and without performing hand hygiene, delivered a dessert plate to a different resident Interview with LPN #1, on 10/13/16 at 11:19 AM, revealed she served the residents their meals during lunch and supper. LPN #1 stated after she wiped her eyes, she should have performed hand hygiene, but forgot. LPN #1 also stated she should have performed hand hygiene after she touched a resident's dirty dish to prevent cross-contamination, but she could not remember if had performed hand hygiene each time. LPN #1 stated the facility did not train her on cross-contamination, but it was common sense to perform hand hygiene after touching her eyes and residents' dirty dishes. LPN #1 further stated a resident could become ill from her failure to perform hand hygiene. Interview with the Certified Nursing Aid/Restorative Aid (CNA/RA), on 10/13/16 at 11:30 AM, revealed when she served residents their plates, she performed hand hygiene after each time she handled dirty dishes, touch herself, or touched a resident. The CNA/RA stated hand hygiene prevented cross-contamination and the risk of residents becoming ill. The CNA/RA stated the facility's Staffing Coordinator trained her on cross-contamination and infection control six (6) months ago. Interview with CNA #3, on 10/13/16 at 11:31 AM, revealed the purpose of hand hygiene was to prevent the spread of infection. CNA #3 stated staff performed hand hygiene when delivering plates between residents and after removing a dirty plate from a resident. CNA #3 stated a staff member's failure to perform hand hygiene when delivering plates to residents increased the risk of infection to residents. Additionally, CNA #3 stated staff was trained on hand hygiene annually and the training included when and how to perform hand hygiene. Interview with the Dietary Director, on 10/13/16 at 2:22 PM, revealed she trained on performing hand hygiene during meal services, which included after they touch dirty dishes, themselves, or other residents. The Dietary Director stated when hands were exposed to unclean surfaces, including staff body parts, they became contaminated. The Dietary Director also stated serving residents with contaminated hands could cause resident to become ill. According to the Dietary Director, she trained staff on cross-contamination every six (6) months and reminded staff daily to utilize proper hand hygiene techniques. Interview with the Administrator, on 10/13/16 at 4:00 PM, revealed staff should adhere to the facility's policies and procedures regarding cross-contamination and hand hygiene while serving residents' meals to prevent the spread of possible infections to the residents.

Based on interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to have an effective system to ensure the provision of adequate supervision to prevent accidents for one (1) of eight (8) sampled residents (Resident #1). The facility failed to ensure staff followed guidelines to assess a resident's risk for elopement. On 10/18/13 at approximately 2:54 PM, the facility admitted Resident #1 with [DIAGNOSES REDACTED]. An Initial Admission Skilled Nursing Observation, dated 10/18/13 at 3:20 PM, revealed Licensed Practical Nurse (LPN) #1 had documented "received in report resident wanders". However, an Elopement Risk Assessment, completed by LPN #1, failed to identify the resident to be at risk for elopement even though the resident triggered for an elopement risk based on the assessment guidelines. Further review of the assessment revealed LPN #1 failed to provide a rationale for not identifying the resident as an elopement risk per the instructions on the assessment form. Interview with LPN #1 revealed she felt some of the questions were not fair on the Elopement Risk Assessment and that staff needed to promote resident freedom. Per interview, LPN #1 used her own judgment when assessing the resident's elopement risk, and chose not to implement interventions for increased supervision, which may include applying a Code Alert device per the facility's policy. Interview with Registered Nurse (RN) #1 revealed Resident #1 wandered throughout the night; following and staying by RN #1's side. On 10/19/13 at 8:15 AM, approximately seventeen (17) hours and fifteen (15) minutes after admission, Resident #1 exited through the front door of the main lobby of the facility without staff knowledge, and was discovered at a neighboring home, half a block from the facility, wanting to enter the residence. The resident was returned to the facility by local law enforcement on 10/19/13 at approximately 9:00 AM, after the facility was informed by a neighbor that the resident was in police custody. Further interview with LPN #1 revealed even after Resident #1 had successfully eloped from the facility, she stood by her assessment and if she had to do it again, she would not place a Code Alert on the resident because in her judgment, the resident was not exit seeking and not having behaviors. The facility's failure to provide adequate supervision placed residents at risk for elopement in a situation that was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 10/24/13 and was found to exist on 10/19/13. The facility was notified of the Immediate Jeopardy on 10/24/13. The facility provided a credible Allegation of Compliance (AOC) on 10/25/13. The State Survey Agency verified Immediate Jeopardy was removed on 10/26/13 as alleged, prior to exit on 10/30/13 which lowered the scope and severity to a "D" while the facility's Quality Assurance Committee monitors the effectiveness of implemented action plans to achieve and maintain compliance. The findings include: Review of the facility's policy titled Elopement, dated 01/01/09, revealed residents would be assessed upon admission/readmission, between day three (3) and day seven (7), between day thirty (30) and forty-five (45), quarterly and with significant change in activity of daily living (ADL) function or cognitive function using the Elopement Risk Assessment. The policy also revealed any resident identified at risk of elopement would have a plan developed to eliminate or reduce the risk of elopement. The plan may include frequent visual checks, use of 1-on-1 services, bed alarms, motion detectors at doorway, activity programs and Code Alert bracelet or wandering monitoring system. The facility would maintain a list of all residents identified at risk for elopement and be kept at the reception area and in each Medication Administration Record (MAR). The policy did not specifically state whether the nurse had the autonomy to deviate from the policy or the elopement risk assessment form. Review of the Elopement Risk assessment sheet, revised 12/08, revealed five (5) questions, and each question was to be answered with a yes or a no. Questions: 1. Is the resident physically able to leave the facility on his/her own, with or without assistive devices? If no, disregard remaining questions. 2. Is the resident a new admission (less than three days)? 3. Does the resident exhibit periods of confusion? 4. Does the resident have a history of leaving the facility or home (actual or reported)? 5. Does the resident exhibit periods of pacing, agitation or wandering? Further review of the Elopement Risk Assessment, revealed if two (2) or more answers were a yes, this would indicate a possible risk for elopement. If the resident had two (2) or more yes answers and was determined to not be at risk, staff was to provide the rationale for not identifying the resident as an elopement risk. However, the assessment did not provide guidelines/criteria as to when a resident who triggered at risk would not be identified an elopement risk. Review of the facility's Initial Report, dated 10/21/13 and signed by the Administrator, revealed Resident #1 was admitted the afternoon of 10/18/13 and assessed by Licensed Practical Nurse (LPN) #1 utilizing the Elopement Risk assessment. However, the LPN assessed the resident as not at risk for elopement. On 10/19/13, eighteen (18) hours after admission, the resident was found walking from the facility in the neighbor's yard. Resident #1 was returned to the facility by the Sheriff's Department. The staff then implemented an intervention for Resident #1 of immediate application of a code alert device and staff monitoring 1-on-1. The Post Event Investigation, dated 10/24/13 and signed by the Administrator, detailed that "LPN #1 failed to appropriately assess a new resident and follow policy and procedure". The Post Event Investigation identified the resident triggered in four (4) of five (5) elopement questions, but no Code Alert was applied. Review of the nurses notes, dated 10/18/13 at 3:20 PM, revealed an Initial Admission Skilled Nursing Observation on which LPN #1 had documented "received in report resident wanders" under the mood and behavior; chronic behavior notes section. A nurses note dated 10/19/13 at 8:30 AM, revealed the facility spoke with the POA regarding transfer to the hospital psych unit and the POA requested to speak with the MD (Medical Doctor) first. A nurses note, dated 10/19/13 at 8:40 AM, revealed the resident disappeared after breakfast; went to a residence next door; and, knocked on their door. The person from that home transported the resident to the police station. Per the nurses note, on 10/19/13 at 8:40 AM, that person then came to the facility and asked if a resident was missing, and that was when it was discovered Resident #1 had "escaped". The Police station was called and the Police escorted Resident #1 back to the facility. Further review of the nurses notes revealed an entry dated, 10/19/13 at 6:45 PM and titled a summary of the day, which stated the resident displayed behaviors of agitation, going in and out of resident rooms, following staff during medication pass, and was not easily redirected. The resident was subsequently transferred to the hospital for evaluation at 9:05 PM on 10/19/13, and was admitted on [DATE]. Interview with the Police Officer, on 10/23/13 at 3:23 PM, revealed on 10/19/13 Resident #1 was found at a neighbor's house, banging on the door (about a block away from the facility). The Police Officer stated Resident #1 was "disoriented and medically intact". The Police Officer stated he asked Resident #1 who, where and what questions, but Resident #1 did not have a clue. The Police Officer stated he decided to transport Resident #1 to the Hospital (which was two (2) minutes from the facility) to ensure Resident #1 was not suffering from a stroke. The Police Officer stated he could not relay time frames as he did not complete a report. Interview with Weekend House Supervisor, on 10/23/13 at 3:40 PM, revealed she was not familiar with Resident #1, but on the morning of 10/19/13 a gentleman (neighbor) came in and stated he took a gray haired person to the police station. The Weekend House Supervisor stated she then began a head count and a staff member informed her Resident #1 was missing. The Weekend House Supervisor then called the Police Department and the Police Officer brought Resident #1 back to the facility. Resident #1 was assessed with [REDACTED]. Further interview with the Police Officer, on 10/23/13 at 3:23 PM, revealed it was raining that day and Resident #1's jogging suit was found to be damp. Review of weather report from the National Weather Service recorded the weather conditions in Carrollton, Kentucky on 10/19/13 as having precipitation with a low of thirty-seven (37) degrees Fahrenheit and a high of fifty-two (52) degrees Fahrenheit. Interview with Certified Nursing Assistant (CNA) #1, on 10/23/13 at 1:50 PM, revealed when Resident #1 came back into the facility, Resident #1's clothes had to be changed because it was raining and then staff put a code alert device on him/her. CNA #1 stated Resident #1 was upset because he/she was in the facility. Further interview with the Weekend House Supervisor, on 10/23/13 at 3:40 PM, revealed she began her investigation and made phone calls to the family, Director of Nursing and the Administrator. She interviewed the nursing staff to see who saw Resident #1 last and they stated at breakfast. She stated LPN #1 was working that morning and she interviewed LPN #1 to see why she did not place a code alert device on Resident #1. LPN #1 stated she did not place a code alert device on Resident #1 because he/she was not showing any signs of wandering at the time of the initial Elopement Risk assessment. The Weekend House Supervisor stated LPN #1 should have placed a code alert device on Resident #1 because on Resident #1's elopement assessment there were two (2) or more questions answered with a yes. Review of Resident #1's Elopement Assessment, dated 10/18/13, revealed LPN #1 assessed Resident #1 to being physically able to leave the facility on his/her own; was a new admission (less than three (3) days); had periods of confusion; and, exhibited periods of pacing, agitation or wandering. The Elopement Assessment instructions stated two (2) or more yes answers indicated the resident was a possible risk for elopement, and Resident #1 triggered "yes" on four (4) of five (5) elopement questions. However, LPN #1 failed to identify Resident #1 at risk for elopement and failed to provide a rationale, per the instructions, as to why the resident was not an elopement risk. Therefore, no interventions were implemented for Resident #1 at the time of the assessment per the facility's policy related to elopement. Further review of the assessment revealed LPN #1 documented staff was to observe and document the resident's behaviors in the nursing notes and update the plan and assessment as needed. Interview with LPN #1, on 10/24/13 at 9:03 AM, revealed she remembered obtaining report from the Hospital about Resident #1 on 10/18/13 at approximately 12:49 PM. LPN #1 stated she was informed that Resident #1 was combative with family and liked to be busy doing things, like cleaning tables. Per interview, there was no information about the resident wandering or leaving home; even though the Initial Admission Skilled Nursing Observation, dated 10/18/13 by LPN #1, stated "received in report resident wanders". LPN #1 stated when Resident #1 was admitted to the facility, the resident sat in the foyer and did not appear to be exit seeking and at risk for elopement. LPN #1 stated when she received report from the night shift nurse, Registered Nurse (RN) #1 on the morning of 10/19/13, RN #1 reported Resident #1 did not sleep and followed the nurse all night. However, LPN #1 stated she did not place a Code Alert on Resident #1, because Resident #1 was not exhibiting any behaviors or exit seeking the morning of 10/19/13 and the resident was sitting in the dining room, drinking coffee at approximately 8:15 AM. LPN #1 further stated she felt some of the questions were not fair on the Elopement Risk assessment and that staff needed to promote resident freedom. Continued interview revealed even though the resident triggered "yes" to four (4) of five (5) questions on the assessment and had successfully eloped from the facility, the LPN stood by her assessment and if she had to do it again she would not place a Code Alert on the resident because the resident was not exit seeking and not having behaviors. Interview with Registered Nurse (RN) #1, on 10/24/13 at 8:21 AM, revealed she worked with Resident #1 the night of his/her admission. Resident #1 was observed to be sweet, no wandering or exiting behaviors were observed. RN #1 stated she did not feel Resident #1 was an elopement risk that was why she did not put a code alert device on Resident #1. However, RN #1 stated Resident #1 followed her the whole night, while she did med pass, and stayed by her side. RN #1 stated Resident #1 did not wander away from her. RN #1 stated she was aware Resident #1's Elopement Risk Assessment had four (4) of five (5) questions marked as a yes and that she was to monitor the resident's behavior. RN #1 stated Resident #1 probably should have been provided a code alert device. Interview with LPN #3, on 10/30/13 at 2:28 PM, revealed she would put a code alert on a resident if the Elopement Risk Assessment had four (4) of the five (5) questions answered yes and also because the resident was a new admission, could be confused and may want to go home. Interview with RN #2, on 10/30/13 at 2:18 PM, revealed if a resident triggered "yes" on four (4) of five (5) questions on the Elopement Risk Assessment, she would have placed a code alert on the resident because of the nature of the questions and also because the resident had Dementia and was in a new place. Interview with the North Unit Manager RN #3, on 10/30/13 at 2:50 PM, revealed if four (4) of the five (5) elopement risk assessment questions were marked yes, the resident should be considered high risk for elopement. The North Unit Manager stated she would expect the nursing staff to put a code alert device on a resident who was determined high risk. Further interview with LPN #1 revealed the Elopement policy did not give the nurses the authority to not follow the policy, but the Elopement policy gave the nurses the opportunity to use their judgment when assessing the resident for behaviors. LPN #1 stated through training, she was educated to monitor the behaviors of residents, otherwise every resident who was admitted would have to have a code alert in place because the first two questions of the Elopement assessment would most likely be a yes answer. LPN #1 stated she was educated on the Elopement Policy and assessment upon hire, on 09/07/11, and annually by the Staff Development Coordinator. Interview with LPN #8, on 11/22/13 at 10:37 AM, revealed she received training on the Elopement Assessment and the Elopement Policy. LPN #8 stated the Staff Development Coordinator completed the training. LPN #8 stated if two (2) of the five (5) questions on the Elopement Assessment were answered yes, she would have placed a Code Alert on the resident for safety. LPN #8 stated the Elopement Policy does not give nursing staff the authority to not follow the policy, but nurses must utilize their judgment. Interview with the Staff Development Coordinator, on 11/22/13 at 10:46 AM, revealed she completed the education of staff upon hire and annually. The education of the Elopement policy and assessment were also provided upon hire and annually to staff as well. The Staff Development Coordinator stated she provided an Elopement Policy and Assessment education back in March of 2013, in which she stated was a refresher course for the nursing staff. She further stated she educated the nursing staff to use their nursing judgment if a resident had two questions marked yes on the Elopement Assessment form and to also monitor the resident's behavior. The nurses must utilize the Elopement policy and their judgment. The nursing staff do not have the authority to not utilize the Elopement policy or assessment forms. Interview with the Director of Nursing (DON), on 10/24/13 at 9:44 AM, revealed she knew Resident #1 was going to need a code alert device from the pre-admission screening that stated the resident was confused and ambulatory. However, she did not inform any nursing staff at that time because the resident was not in the building. The DON stated the nurse could pick and choose which interventions to use if the resident was determined to be at risk for elopement per the policy. The policy did not inform the nurse when to put on a code alert device, but lists it as an intervention. The DON stated she felt the Elopement Risk Assessment form was not confusing and felt the questions were very clear. The DON stated she became concerned when she reviewed Resident #1's admission assessments and saw that Resident #1's elopement assessment had four (4) questions answered yes. The DON stated she asked LPN #1 why she did not put a code alert device on Resident #1 and LPN #1 responded Resident #1 was calm and not exit seeking and in her nursing judgment she felt the resident was not at risk. The DON stated she felt there was a problem with the assessment and LPN #1 should have placed a code alert device on Resident #1. Interview with the Administrator, on 10/24/13 at 11:03 AM, revealed through meetings with the DON he found the error occurred with the elopement assessment completed by LPN #1 and the poor judgment that was made by LPN #1. Resident #1 should have had a code alert device on, which would have prevented Resident #1 from exiting the building. The Administrator further stated the QA Committee determined the LPN used poor judgment in the assessment. The assessment was a corporate policy and if there was a gray area the nurses could use their judgment with a good rationale. Per interview, the assessment was not appropriate, even if the resident did not leave the building, because there were four (4) triggers for the resident; however, the policy did not say if four (4) were answered yes there had to be a Code Alert applied to the resident. Interview with the Administrator further revealed the Elopement policy did not give the nurse the latitude to not follow the policy and there was no nursing judgment outside of following the policy. Interview with the Maintenance Director, on 10/23/13 at 10:45 AM, revealed the front doors stayed opened between the hours of six (6) AM and six (6) PM every day and were equipped with a code alert system. The Maintenance Director stated when a resident with a code alert device on, walked up within six (6) feet of the front door, an alarm would sound to alert staff. Review of the acceptable Allegation of Compliance (AOC), dated 10/25/13, revealed the facility took the following actions: 1. Resident #1 was returned to the facility by the Police Officer and was assessed on 10/19/13 and found no injury was sustained. Resident #1 was placed on 1-on-1 supervision until transfer to the hospital that evening due to an escalation in behaviors. The Care Plan for Resident #1 was updated on 10/19/13 identifying elopement risk and application of a new code alert device. 2. The Weekend House Supervisor conducted a head count immediately when it was learned of the elopement on 10/19/13 and all residents were safe and accounted for. The Supervising Nurse checked all thirteen (13) code alert transmitters and found them in place and working properly on 10/19/13. The DON re-checked all devices for placement and proper functioning and checked all code alert transmitters to ensure all were within expiration dates on 10/21/13. In addition, on 10/21/13, the DON and Quality Assurance Nurse reviewed all code alert transmitter check documentation to ensure all were performed in accordance with policy and procedures. 3. The DON completed an audit on 10/21/13, to confirm all residents at risk for elopement had physician orders [REDACTED]. 4. The Weekend House Supervisor checked all doors for proper functioning on 10/19/13 and found all were working properly. The Maintenance Director re-checked to ensure all exit doors were properly functioning and changed access codes for each key pad on 10/21/13. 5. The Administrator reviewed the results of the resident audits, transmitter and door audits, and physician order, TAR and care planning audits to ensure all charts were audited and no more residents were identified at risk and that all systems were working properly on 10/21/13 6. All floor nurses, supervisors, administrative nurses and Social Services Directors were re-educated by the Weekend House Supervisor on 10/20/13 and by the DON and Staff Development Coordinator on 10/21/13 on elopement policy and procedures, the assessment process and the implementation of interventions. 7. All other staff in the facility were re-educated by the Staff Development Coordinator on the elopement policy and procedures on 10/24/13 and 10/25/13. 8. The Elopement Assessment form was amended on 10/22/13 by the Administrator, DON and QA Nurse, to require two (2) nurses to assess all at-risk residents upon admission or re-admission to verify accurate assessment and appropriate interventions were in place. 9. The Maintenance Director changed the door lock down times to 4:30 PM to 8:00 AM, Monday through Friday and all doors were locked down twenty-four (24) hours a day on Saturday and Sunday on 10/24/13. During Business hours Monday through Friday a staff member would monitor the front door. 10. Social Services would update the elopement binder immediately when a change in cognitive status required elopement precautions, and would review the binder weekly for accuracy. 11. The Administrator developed a QA agenda and schedule in conjunction with the Director of Nursing and Nurse Consultant. Initial QA meeting was held on 10/21/13, with meetings on 10/22/13 and 10/24/13, then weekly from that date. The Medical Director attended QA on 10/24/13 and will attend not less than monthly thereafter. The State Survey Agency (SSA) validated the AOC on 10/30/13 as follows: 1. Review of the initial care plan revealed it had been updated on 10/19/13 to identify the resident as an elopement risk and the 1-to-1 checks for Resident #1 revealed they were completed and dated until the resident's discharge to the hospital on [DATE]. Review of the nurses' notes confirmed the assessment of the resident. 2. Interview with the Weekend House Supervisor, on 10/23/13 at 3:40 PM, revealed she had conducted a head count to ensure all residents were safe. The Weekend House Supervisor also checked the thirteen (13) residents who were identified as elopement risks to ensure transmitters were in place and functioning properly on 10/19/13. Interview with the DON and Quality Assurance (QA) Nurse, on 10/30/13 at 4:00 PM, revealed on 10/21/13, the DON and QA Nurse checked all devices for placement and functioning. 3. Review of five (5) if eight (8) residents at risk for elopement, revealed Residents #1, #3, #4, #6 and #7 had physician orders [REDACTED]. Interview with the DON, on 10/30/13 at 4:00 PM, revealed she had checked the physician orders, TARs and care plans on 10/21/13. 4. Interview with the Weekend House Supervisor, on 10/23/13 at 3:40 PM, revealed all six (6) doors were functioning appropriately on 10/19/13. Record Review of the log book, for the door checks revealed the doors were functioning properly on 10/18/13 and the doors were rechecked and functioning properly on 10/22/13. Interview with the Assistant Maintenance Director, on 10/30/13 at 2:20 PM, revealed he checked the doors weekly and assisted the Maintenance Director with changing the access codes for each key pad on 10/21/13. Observation of all six (6) doors, on 10/22/13 at 3:20 PM, revealed five (5) doors had to utilize a key pad to exit and the front door was open to residents to come and go without a key pad. Observation of a resident walking up to the front door, with a code alert bracelet on, on 10/23/13 at 10:50 AM, revealed the front door functioned properly. 5. Record review for Resident #1, #2, #3, #4, #5, #6, #7 and #8, found elopement assessments were completed and assessed per policy and procedure. Review of the auditing tools dated 10/21/13 utilized by the Administrator revealed the transmitter and door audits were completed, physician orders [REDACTED]. 6. Interview with LPN #3, on 10/30/13 at 2:28 PM, revealed she was in-serviced on the elopement policy and elopement assessment, on 10/20/13 by the Weekend House Supervisor. Interview with Registered Nurse (RN) #2, on 10/30/13 at 2:18 PM, revealed she was educated on the elopement policy and assessment, on 10/20/13 by the Weekend House Supervisor . RN #2 stated two nurses were to now sign the elopement assessment to ensure proper decision was made for the resident. Interview with the Weekend House Supervisor, on 10/23/13 at 3:40 PM, revealed she started the education on the elopement policy and elopement assessment on Sunday 10/20/13 and the Staff Development Nurse finished the education. Record Review of the In-service training dated 10/20/13 through 10/25/13 revealed the subject was elopement education on the elopement policy and assessment. Interview with the Staff Development Coordinator, on 10/30/13 at 3:22 PM, revealed she educated nursing staff on the elopement policy and elopement assessment on 10/21/13. 7. All other staff in the facility was re-educated on elopement policy and procedures on 10/24/13 and 10/25/13. Interview with CNA #8, on 10/30/13 at 2:42 PM, revealed she was educated about what to do when the door alarms and how to keep residents safe when an elopement has occurred. CNA #8 stated she was educated by Staff Development on 10/25/13. Interview with Housekeeper, on 10/30/13 at 2:02 PM, revealed she was in-serviced by the Staff Development Coordinator, on 10/25/13, on what to do when the alarm sounded at the door and who to inform if a resident was observed to leave the building. Interview with the Bookkeeper, on 10/30/13 at 3:16 PM, revealed she was in-serviced by the Staff Development Coordinator on what to do when the alarm sounded at the doors and who to report to when a resident was trying to leave the building. Interview with the Staff Development Coordinator, on 10/30/13 at 3:22 PM, revealed she educated everyone in the building by 10/25/13. Record review of the signatures for the training between the days of 10/20/13 through 10/25/13 revealed all staff were in-serviced. 8. Record review of the elopement assessment, revealed there was a space added for two nurses to sign that the elopement assessment was completed accurately. Interview with RN #2, on 10/30/13 at 2:18 PM, revealed two nurses were to now sign the elopement assessment and if the resident was identified to not be at risk for elopement the nurses must give a rationale as to why. 9. Interview with the Administrator, on 10/24/13 at 11:03 AM, revealed on 10/24/13 he had the Maintenance Director change the locks on the front door, to be closed between the hours of 4:30 PM to 8:00 AM. The front door was also set to be locked for twenty-four (24) hours on the weekend. Interview with the Weekend House Supervisor on Saturday 10/26/13 at 3:20 PM, revealed the front doors were locked and someone was present at the front desk to ensure no resident could get out without supervision. 10. Interview with the Social Services Director, on 10/24/13 at 2:35 PM, revealed she completed the elopement binder. She finds out about changes in the morning meeting and changes the binder accordingly. The Social Services Director stated she changed the binder daily as needed. The State Survey Agency reviewed the elopement binder that revealed all thirteen (13) residents were included with updated information. 11. Review of the QA binder revealed there were QA meetings on 10/21/13, 10/22/13 and 10/24/13. The Medical Director attended on 10/24/13. Interview with the Medical Director, on 10/30/13 at 3:50 PM, revealed he was notified of the elopement on 10/19/13. The Medical Director stated he attended a QA meeting on 10/24/13 and would attend weekly there after and had no concerns.