Every finding on record at Skyline Ridge Nursing & Rehabilitation Center

Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision and intervention to prevent physical abuse for two (#1 and #2) of three residents reviewed for abuse out of three sample residents. Specifically the facility failed to protect Resident #1 from physical abuse by Resident #2.Findings include: I. Facility policy and procedure The Residents Rights and Abuse Prevention policy and procedure manual, revised March 2025, was provided by the nursing home administrator (NHA) on 10/21/25. It read in pertinent part, As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents. Abuse of any kind against residents is strictly prohibited. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse toward a resident can occur as resident-to-resident abuse. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Physical abuse includes, but is not limited to hitting, slapping, biting, punching or kicking. Examples of injuries that could indicate physical abuse include, but are not limited to: facial injuries, including but not limited to, broken or missing teeth, facial fractures, black eye(s), bruising, bleeding or swelling of the mouth or cheeks. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury; or within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. II. Incident of physical abuse of Resident #1 by Resident #2 on 8/13/25 A. Facility investigation The facility's investigation, dated 8/14/25, was provided by the NHA on 10/21/25. The investigation revealed the following: Resident #1 woke up on 8/14/25 with a developing black eye of unknown origin. One of five staff members interviewed witnessed the incident. On 8/13/25 at 6:40 p.m. certified nurse aide (CNA) #1 heard Resident #1 screaming. She went towards Resident #1's voice and found Resident #1 in Resident #2's bedroom. Resident #2 was upset that Resident #1 was in his bed, and was trying to pull Resident #1 out of the bed. Resident #1 had a couple drips of blood coming from her nose. -However, CNA #1 failed to report the incident (see below). On 8/14/25 CNA #2 went to get Resident #1 up for the day and noticed a small amount of dried blood on her blanket and a little bit of dried blood on her nose. CNA #2 immediately notified licensed practical nurse (LPN) #1. Resident #1, who was cognitively impaired, was interviewed and her response was, Someone was punching me and he was not a friend. Resident #2 was interviewed and unable to provide a clear or coherent explanation of the incident. Due to his cognitive impairment, Resident #2 was unable to recall the event. It was determined that he was not of sound mind and unable to meaningfully participate in the interview. CNA #1 was immediately suspended for failing to report the incident at the time it occurred on 8/13/25 and later terminated by the facility. Resident #1 was sent to the emergency room (ER) for further evaluation. Resident #1 received a room change to provide more space and separation from Resident #2. -However, observations during the survey revealed Resident #1's room was located right next door to Resident #2's room (see observations below). The facility investigation identified immediate safety measures to be put in place included the use of a magnetic stop sign added to Resident #2's room, and encouraging Resident #2 to keep his door shut as tolerated. -However, observations during the survey revealed no stop signs was observed on Resident #2's door and Resident #2's bedroom door remained opened and other residents laid in Resident #2's bed (see observations below). The facility's investigation did not identify whether or not the facility substantiated the abuse, however, abuse occurred as Resident #1 stated that someone punched her (which resulted in a bloody nose and a black eye) and Resident #2 was observed trying to remove Resident #1 from his bed. B. Resident #1 (victim) 1. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, mood disturbance, anxiety, dysphagia (difficulty swallowing) and anemia. The 8/16/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of one out of 15. The resident required substantial assistance for activities of daily living (ADL). The MDS assessment revealed the resident exhibited wandering behaviors on one to three days during the assessment look-back period. 2. Record review A health status progress note, dated 8/14/25 at 7:20 a.m. noted Resident #2 had a bruise on her left eye and both CNAs on duty were interviewed. CNA #2 reported getting Resident #2 up in the morning and it was noted that the resident had dry blood on her nostril and a little on her blanket. CNA #2 did not notice bruising. CNA #4 reported Resident #2 was heading out of the dining room and CNA #4 noticed redness under Resident #2's left eye. CNA #4 turned Resident #2 for better lighting and noticed bruising around her left eye and notified the nurse. A long term care follow-up progress note, dated 8/14/25 at 1:37 p.m. revealed Resident #2 was seen by the physician per staff request. Staff stated when they got Resident #2 out of bed in the morning they had noticed a black eye on the resident who had had no recent injuries or falls noted. Upon assessment, purple bruising was noted around the resident's entire left eye orbit and nasal bridge. There was partial purple bruising under the resident's right anterior eye orbit. Facial swelling was noted to the resident's upper nasal root. Ice was applied and a neurological assessment was performed, and the resident's pupils were equal, round and reactive to light (PERRL) and extraocular muscles (EOMs). Due to Resident #2's cognition, she was unable to complete the exam. The nurse spoke with the physician who recommended Resident #2 be evaluated in the emergency room (ER). The after visit ER summary, dated 8/14/25, revealed that Resident #1 was seen in the ER for facial swelling and diagnosed with a contusion (bruise). Resident #1 was discharged back to the facility the same day (8/14/25). An interdisciplinary team (IDT) progress note, dated 8/14/25 at 4:16 p.m. revealed the IDT team met to discuss Resident #2 and the reported incident. Resident #2 was found to have a bruised eye and dried blood on her nose. After investigation, it was discovered that Resident #2 had gotten into another resident's bed and received an injury while the other resident was attempting to remove Resident #2 from their bed. Resident #2 was sent to the ER for evaluation of facial trauma and the results of an Xray and computerized tomography (CT) scan were unremarkable. The resident's representative was notified and followed up with by the DON. Resident #2 was moved to a room closer to the nurses' station. C. Resident #2 (assailant) 1. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the October 2025 CPO, diagnoses included type 2 diabetes mellitus, traumatic subdural hemorrhage, unspecified dementia, psychotic disturbance, mood disturbance and anxiety. The 9/20/25 MDS assessment revealed Resident #2 was severely cognitively impaired with a BIMS score of six out of 15, with continuous disorganized thinking. He was independent with transfers, bathing and toileting. 2. Observations During a continuous observation on 10/21/25, beginning at 12:23 p.m. and ending at 2:07 p.m., the following were observed: At 12:27 p.m. Resident #2's room was observed. Resident #2's room was located right next door to Resident #1's room. There was not a stop sign observed on Resident #2's door and the room door was open. -However per the investigation report dated 8/14/25, the facility implemented a room change to provide more space and separation between Resident #1 and Resident #2 and a stop sign was implemented for Resident #2's door to keep other residents out of Resident #2's room (see investigation above). At 12:55 p.m. an unidentified male resident wandered down the hallway into Resident #2's bedroom and laid down in Resident #2's bed. -No staff member identified that another resident had gone into Resident #2's room and laid down in the resident's bed. At 1:19 p.m. Resident #2 went into his room and discovered the resident in his bed. Resident #2 did not react aggressively and left the room. -However, staff continued to be unaware of the other resident lying in Resident #2's bed. At 1:23 p.m. an unidentified staff member discovered the other resident sleeping in Resident #2's bed. The staff member woke up the other resident and redirected him to his correct room. 3. Record review Review of Resident #2's comprehensive care plan, initiated 3/19/24, care plan documented that Resident #2 had impaired cognitive function and dementia but was able to communicate his needs. He required the care of the secure unit for safety and well-being due to increasing confusion, wandering, and dementia. Interventions included communicating with the resident's family and caregivers regarding the resident's capabilities and needs, closely monitoring when the resident went outside, reporting changes in conditions and behaviors, participating in low stimulation activities, keeping the resident's environment free of hazards, providing pleasant interactions when he was confused and removing and redirecting him from unsafe behavioral confrontations. The 8/14/25 progress note documented Resident #1 had a black eye the morning after an incident of unknown origin. After investigation, the staff found that Resident #1 and Resident #2 were involved in an altercation on 8/13/25 at approximately 6:40 p.m. CNA #1 heard Resident #1 screaming and went to assist the residents, finding Resident #1 on Resident #2's bed. Resident #2 tried to move Resident #1 out of his bed. CNA#1 assisted Resident #1 out of bed and noticed the resident had a nosebleed. The staff notified Resident #1's physician, who ordered a behavioral health evaluation. D. CNA #1 record review Review of the facility's skills fair invoice, dated 8/13/25, revealed that CNA #1 successfully completed the abuse awareness/prevention training provided by the NHA on 8/13/25 (the day the incident between Resident #1 and Resident #2 occurred). -However, despite the training received on 8/13/25, CNA #1 failed to report the incident between Resident #1 and Resident #2 on the evening of 8/13/25. Review of the facility's Dementia workshop education, dated 6/25/25, revealed CNA #1 had successfully completed the training. III. Staff interviews CNA #2 was interviewed on 10/21/25 at 1:45 p.m. CNA #2 said the nurses and the CNAs were both responsible for charting behaviors on the residents. She said CNAs were supposed to notify the nurses of any significant behaviors and the nurse would chart in more detail on the residents' behaviors. CNA #2 said she would attempt to redirect the residents in order to prevent resident abuse. CNA #2 said she would notify the nurse on duty if there was a resident incident and then the nurse would notify the director of nursing (DON) and the NHA. CNA #2 said the NHA gave staff his personal cell phone number on the first day of training so everyone should have the NHA's number in their personal cell phones. CNA #2 said she was not present on the day of the incident between Resident #1 and Resident #2, but she said this was the first time such an incident had occurred between the residents. CNA #2 said the incident was a weird occurrence because Resident #2 walked away when something made him uncomfortable, and he had not hit anybody else in the past. CNA #2 also said she had not seen Resident #2 become upset with anybody because he was good at redirecting himself. CNA #3 was interviewed on 10/21/25 at 2:21 p.m. and said she was aware that Resident #1 frequently got out of her wheelchair to wander because the resident thought she could self transfer. CNA #3 said that to ensure the safety of all the residents, one CNA would stand in the hallway between 2:00 p.m. and 4:00 p.m. to monitor for wandering. CNA #3 said if she encountered a resident-to-resident incident, she would remove one of the residents to get them away from the situation while figuring out what the residents were upset about. CNA #3 said she would then report the incident to the nurse right away. CNA #3 said Resident #1 did not have the ability to recall the incident. Registered nurse (RN) #1 was interviewed on 10/21/25 at 2:00 p.m. RN #1 said CNAs had their own system of charting, but CNAs would report to the nurse any behavioral changes and the nurse would document it. RN #1 said she would contact the DON immediately for resident-to-resident. She said if the incident was physical it would be reported to law enforcement as an assault. RN #1 said that Resident #1 was a target in the secured unit because of her petite size and she frequently bumped into or ran over other residents' feet with her wheelchair. RN #1 said to ensure Resident #1's safety, the resident was provided with constant verbal reminding from staff. RN #1 said she was always aware of Resident #1 being a target and said it was important to anticipate Resident #1's behavior before anything could happen. RN #1 said Resident #1 sometimes just wandered into other residents' rooms, but in a very peaceful way, and that was the only time that Resident #2 hit someone. RN #1 said that in the past, Resident #2 was involved only in verbal altercations due to his short-term memory issues. RN #1 said the staff dispersed residents when they saw someone exhibiting behaviors, prevented residents from going to other people's rooms, and, when arguments began, separated them as quickly as possible. RN #1 said it was easy to redirect Resident #2 when he was agitated, and that calling his son calmed him down. RN #1 said that, at times, Resident #2 allowed others to sleep in his bed. The social services director (SSD) was interviewed on 10/21/25 at 4:26 p.m. and said the process for investigating a resident-to-resident began with interviewing the assailant and the victim. She said if the resident was not interviewable, she interviewed five other residents, five employees and five family members. The SSD once interviews were completed, all the information was given to the NHA to report the incident and file the investigation. The SSD said she completed the reports within 48 hours of the incident. The SSD said she had worked a little with Resident #1 and was aware that Resident #1 wandered a lot and ended up in other residents' rooms and other residents' beds. The SSD said the staff was good about redirecting Resident #1. The SSD said stop signs were used as an intervention in an attempt to deter other residents from going into other residents' rooms. The SSD was unsure if a stop sign was used as an intervention for residents currently. She said she knew that there were stop signs at one point, but the residents kept moving them off the walls so staff stopped using them. The SSD said stop signs should be care planned and the care plans would be completed during an interdisciplinary team meeting (IDT) because someone was actively updating care plans during the IDT meetings. The SSD said room changes would be necessary for roommates, but if the residents involved in an incident were in the same hall, the staff would separate the residents to provide more space between them. The SSD said she was unaware that Resident #1 and Resident #2's rooms were right next to each other. The SSD said Resident #2 was usually okay with other residents laying in his bed and told staff to just let the other residents sleep, but sometimes Resident #2 could become defensive. The DON was interviewed on 10/21/25 at 4:43 p.m. The DON said all staff had been educated to notify her immediately for abuse incidents, and if it was a physical altercation, staff should separate the residents and notify her immediately. The DON said she then checked on the residents involved and talked to the nurse. The DON said she would speak with the SSD and provide the SSD with a list of potentially interviewable staff members who were present at the time of the incident, as well as providing the SSD with any progress notes associated with an incident. The DON said the abuse coordinator was the NHA. The DON said that in cases of resident-to-resident altercations, she reviewed the reports, staff received education, and staff monitored residents frequently. The DON said there were no clinical changes reported to her prior to the altercation between Resident #1 and Resident #2. The DON said she recalled Resident #1 had significant bruising to her face. The DON said neither resident could recall the incident if someone was to ask them about it at this time. The DON said prevention for future altercations was having a CNA monitor the hallway during the high trafficked time between 2:00 p.m. and 4:00 p.m. The DON said the facility had had some new residents placed in the secured unit and there was an adjustment period. The DON said staff was good about performing bed checks to ensure residents were sleeping in the appropriate bed. The DON said the incident with Resident #1 and Resident #2 was a very unusual incident because Resident #2 was usually very protective of female residents. The NHA was interviewed on 10/21/25 at 5:39 p.m. The NHA said the process for handling resident-to-resident abuse was first ensuring the residents' safety and removing or separating them as necessary. He said an assessment was completed to make sure there were no injuries, and the investigation process was initiated. The NHA said he would notify the necessary individuals, such as family members, primary physicians and law enforcement .The NHA said he was the abuse coordinator and his personal cell phone number was given to every new employee on their first day of orientation and his personal cell phone number was also posted at the nurses' station along with the DONs personal cell phone number. The NHA said CNA #1 was no longer employed with the facility.

Based on interviews and record review, the facility failed to employ an infection preventionist (IP) who had completed specialized training in IP and control which had the potential to affect all residents residing in the facility at the time of the survey. Specifically, the facility failed to have a qualified IP involved with the facility's IP and control program. Findings include: I. Facility policy and procedure The Infection Preventionist policy, revised September 2022, was received from the director of nursing (DON) on 1/15/25 at 3:33 p.m. It read in pertinent part, The IP coordinates the development and monitoring of the infection prevention and control program. The IP is professionally trained in nursing or other related fields with at least the following professional training: A nurse must have earned a certificate/diploma or degree in nursing. The IP is qualified by education, training, and has sufficient knowledge to perform the role. The IP remains current with national/state/local guidelines. The IP has the background and ability to fully carry out the requirements of the infection prevention program. The IP has obtained specialized IP training beyond infection prevention or education prior to assuming the role. Evidence of training is provided through a certificate of completion or equivalent documentation. The IP is employed on site and at least part time. The IP is scheduled with enough time to properly implement and monitor the infection prevention program. II. Record review Review of employee records revealed the facility's previous full-time IP resigned and her last day of working in the facility was 10/25/24. II. Staff interviews The DON and the corporate resource nurse (CRN) were interviewed together on 1/16/25 at 4:30 p.m. The DON said the facility's full-time IP had resigned and her last day of working in the facility was 10/25/24. The DON said on 1/8/25, the facility assigned a current staff nurse to the IP position and the new IP did not have a certificate that documented she had completed IP education and training. The DON said she and the CRN worked together to manage the infection prevention program. The DON said she did not have a certificate for the completion of IP training. The CRN said she had completed the IP education modules, however, she was unable to provide a certificate of completion. The CRN said she was a corporate employee and worked at the facility. III. Facility follow up On 1/16/25 at 1:15 p.m. the CRN provided her IP certificate of completion, dated 1/15/25, during the survey. The CRN said she worked from the facility orienting and training the DON and the newly appointed IP, in addition to providing support to other corporate facilities. The CRN said she worked at least half time as the facility's IP. -However, the CRN was unable to provide evidence she had completed the required IP certification training prior to 1/15/25 (during the survey), therefore, the facility did not have a qualified IP in the building from 10/25/24 until 1/15/25.

Based on records review and interviews the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease for seven (#2, #5, #6, #7, #8, #12 and #13) of 14 residents out of 14 sample residents. Specifically, the facility failed to ensure the tracking, offering and administration of the COVID-19 vaccination for Resident #2, Resident #5, Resident #6, Resident #7, Resident #8, Resident #12 and Resident #13. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC), Stay Up to Date with COVID-19 Vaccines, revised on 1/7/25, retrieved on 1/15/25 from https://www.cdc.gov/covid/vaccines/stay-up-to-date.html?s_cid=SEM.GA:PAI:RG_AO_GA_TM_A18_C-CVD-Parents-Brd:covid%20vaccine%20age%20limit:SEM00014&utm_id=SEM.GA:PAI:RG_AO_GA_TM_A18_C-CVD-Parents-Brd:covid%20vaccine%20age%20limit:SEM00014&gad_source=1. It read in pertinent part, Everyone six months and older should get a 2024-2025 COVID-19 vaccine. The COVID-19 vaccine helps protect you from severe illness, hospitalization , and death. It is essential to get your 2024-2025 COVID-19 vaccine if you are 65 and older, are at high risk for severe COVID-19, or have never received a COVID-19 vaccine. Vaccine protection decreases over time, so it is important to get your 2024-2025 COVID-19 vaccine. II. Facility policy and procedure The Vaccination of Residents policy, revised October 2019, was received from the director of nursing (DON) on 1/15/25 at 3:33 p.m. It read in pertinent part, All residents will be offered vaccines that aid in preventing infectious diseases. Prior to receiving vaccinations, the resident or representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. If a vaccine is refused, the refusal shall be documented in the resident's medical record. If the resident receives a vaccine, the following information shall be documented in the resident's medical record: site of administration; date of administration; lot number of the vaccine; expiration date; and, the name of the person administering the vaccine. III. Resident interviews Resident #12 was interviewed on 1/15/25 at 1:27 p.m. Resident #12 said she did not recall if she had been offered the COVID-19 vaccination. Resident #13 was interviewed on 1/15/25 at 1:41 p.m. Resident #13 said she did not recall if she had been offered the COVID-19 vaccination. IV. Record review The DON provided the vaccine roster, dated 3/27/24, on 1/16/25 at 4:30 p.m. The document included hand-handwritten information on the form of Novax, lot 55683MF023, the date 5/31/24, a list of resident names (see interview below). According to the electronic medical record (EMR) of Resident #2, Resident #5, Resident #6, Resident #7, Resident #8 Resident #13 and Resident #13 revealed the EMR's were not up to date with the resident's COVID-19 vaccination status. A review of the EMR revealed the following residents did not have documentation they were offered, administered, or declined the 2024-2025 COVID-19 vaccination. According to a refusal form in Resident #2's EMR, Resident #2 declined the COVID-19 vaccine. The refusal form was undated. There was no evidence in the resident's EMR that the resident had received education regarding the COVID-19 vaccine. Resident #2 tested positive for COVID-19 on 11/27/24. Review of Resident #5's EMR revealed the resident signed a consent form to receive the COVID-19 vaccine. The consent form was undated. There was no evidence in the EMR that Resident #5 was administered the COVID-19 vaccine. Resident #5 tested positive for COVID-19 on 11/27/24. Review of Resident #6's EMR revealed the resident declined the COVID-19 vaccine on 10/1/24. There was no evidence in the EMR that the resident had received education regarding the COVID-19 vaccine. Resident #6 tested positive for COVID-19 on 11/27/24. Resident #7 had a verbal consent form dated 9/30/24 from the resident's representative to receive the COVID-19 vaccination. Review of Resident #7's EMR did not reveal the vaccination was administered. Resident #7 tested positive for COVID-19 on 11/27/24. Review of Resident #8's EMR revealed under the immunization tab, the resident declined the vaccination. There was no evidence in the EMR that the resident received education regarding the COVID-19 vaccine. Resident #8 tested positive for COVID-19 on 11/19/24. Review of Resident #12's EMR did not reveal the COVID-19 vaccine was offered to Resident #12. Resident #12 tested positive for COVID-19 on 11/27/24. There was no evidence Resident #13's EMR the COVID-19 vaccine was offered or declined. Resident #213 tested positive for COVID-19 on 11/19/24. IV. Staff interviews The DON and the corporate resource nurse (CRN) were interviewed together on 1/16/25 at 4:30 p.m. The DON said the infection preventionist resigned on 10/25/24. The DON said herself and the corporate resource nurse (CRN) worked together to manage the infection prevention program. The DON said the residents were offered the seasonal influenza and the COVID-19 vaccines. The DON said the residents signed a consent form to receive or decline the vaccine. The DON said when a resident declined the COVID-19 vaccine, the facility used a declination of COVID-19 vaccination form to document education had been provided to the resident. The DON said that if a vaccine was administered, the nurse documented the vaccine information in the resident's EMR on the immunization tab. The DON said the IP documented vaccines on a resident vaccine roster. The DON said the vaccine roster did not accurately document if a vaccine was administered because it did not include the date of administration, vaccine expiration date, and the name of a staff member as required when a vaccine was administered. The CRN said she reviewed the 3/27/24 vaccine roster and said she could not determine if the vaccines were administered. The CRN said the hand-handwritten information on the form of Novax, lot 55683MF023, 5/31/24, was insufficient to determine if the vaccines were administered on 5/31/24 or if the date was the expiration date or date of vaccine manufacture. The CRN said when a vaccine was administered, documentation should include the date of administration, lot number, expiration date, and location of the vaccine. The DON and the CRN said they could not find documentation of the COVID-19 vaccination being administered or received education as applicable, for Resident #2, Resident #5, Resident #6, Resident #7, Resident #8, Resident #12 and Resident #13.

Based on observations, record review and interviews, the facility failed to ensure the residents' environment remained as free of accidents or hazards as possible to prevent falls for one (#59) of five residents reviewed for falls out of 48 sample residents. Resident #59, who had a history of falling, required the use of a sit-to-stand mechanical lift for transfers. Per staff interviews (see interviews below), the use of the sit-to stand mechanical lift required that two staff members were present during resident transfers. On the night of 7/31/24, Resident #59 was being transferred to bed by a certified nurse aide (CNA). The CNA did not have another staff member present during the transfer and the resident sustained a fall. The CNA alerted the licensed practical nurse (LPN) to the resident's fall and the CNA and the LPN assisted Resident #59 back to her bed. On 8/1/24 Resident #59 was noted to have visible bruising and swelling to her right wrist and the day shift nurse called the physician who requested the resident be transferred to the hospital for further evaluation of her wrist. Resident #59 was diagnosed with a displaced fracture distal right radial metaphysis (a break at the end of the forearm bone near the right wrist) at the hospital. The facility investigated the fall and implemented immediate corrective actions and education to ensure staff were aware that all mechanical lift transfers required the use of two staff members. Although the facility implemented immediate changes in regards to Resident #59's fall with fracture due to the improper transfer with the mechanical lift, observations during the survey (see observations below) revealed the facility continued to have deficient practice in the area of accidents/hazards due to the facility staff failing to ensure fall interventions for Resident #59 were consistently in place. Findings include: I. Facility policy The Fall Risk Assessment policy, revised March 2018, was provided by the nursing home administrator (NHA) on 9/19/24 at 11:33 a.m. It read in pertinent part: The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff and others will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. The Falls Clinical policy, revised September 2012, was provided by the NHA on 9/19/24 at 11:33 a.m. It read in pertinent part: If the interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed if the problem that required the interventions is resolved. II. Resident #59 A. Resident status Resident #59, age greater than 65, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included a fracture to the lower end of the right radius, anxiety disorder, epilepsy, dementia, chronic diastolic (congestive) heart failure, muscle weakness and repeated falls. The 8/14/24 minimum data set (MDS) assessment revealed Resident #59 had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. Resident #59 had an impairment to one of her upper extremities and used a wheelchair. B. Observations On 9/18/24 at 9:49 a.m. Resident #59 was sitting in her wheelchair in her room. The resident's call light was hanging behind her and was out of her reach. At 9:56 a.m. the interim director of nursing (IDON) entered the resident's room and placed the call light within the resident's reach. On 9/19/24 at 9:56 a.m. Resident #59 was asleep in her bed. The bed was in the lowest position, however a fall mat was not on the floor next to the bed. The fall mat was tucked in on the side of the closet. At 10:04 a.m. certified nurse aide (CNA) #2 entered Resident #59's room and placed the fall mat on the floor by the bed as the resident continued to sleep. C. Record review Resident #59 experienced a fall on 8/1/24. The facility failed to use the mechanical lift according to the facility's protocol which resulted in the resident falling to the floor which resulted in a fractured lower end of the right radius. The 8/6/24 interdisciplinary at risk note progress note documented a CNA reported Resident #59 slipped off the bed and onto the floor. She stated she had placed the resident on the bed, moved the lift and saw the resident start to slide. The CNA said the resident leaned to the right, struck the trash can with her right arm and then was able to sit herself up into a sitting position. The progress note documented the root cause of the fall was the resident was not positioned far enough back on the bed. Current interventions were a Call don't fall sign, anticipate the resident's needs, toilet with assistance and proper footwear. New interventions implemented were for the resident to be a full mechanical Hoyer lift with two staff members present during transfers. A physician's note dated 9/6/24 documented Resident #59 had functional impairments with potential high risk for frequent falls. The note documented the resident was on Keppra (a medication used to treat seizures/epilepsy) 500 milligrams (mg) two times per day. The note documented the resident was on fall precautions and staff was to monitor for neurological changes. The note further documented the resident had significant cognitive deficits and was at high risk of falls with physical injury. Resident #59's activities of daily living (ADL) care plan, revised on 9/16/24 (during the survey), revealed the resident had limitations in her ability to perform her ADLs. Interventions included providing extensive assistance with bed mobility, dressing and personal hygiene and transferring the resident with two staff using the medium yellow sling and the Hoyer lift. Resident #59's fall care plan, revised on 8/21/24, revealed the resident was at risk for falls due to a history of falling, decreased mobility, diabetes and hypertension (blood pressure) medications. Interventions included keeping the call light within reach and encouraging the resident to use the call light for assistance, promptly responding to the resident's call light (initiated 8/8/22), low bed and fall mat while in bed (initiated 8/5/24), posting a sign encouraging the resident to call for assistance (initiated 8/5/24) and placing a touch call light within reach (initiated 8/19/24). -However, the facility failed to ensure Resident #59's call light was within reach and the fall mat was on the floor by the resident's bed (see observations above). III. Staff interviews The IDON was interviewed on 9/18/24 at 9:56 a.m. The IDON said Resident #59's call light was supposed to be within reach of the resident. CNA #2 was interviewed on 9/19/24 at 10:04 a.m. CNA #2 said Resident #59 was a fall risk and needed the fall mat on the floor by her bed. CNA #2 said the fall mat was previously on the floor but she said she moved it when she assisted the resident earlier and forgot to put the fall mat back. Corporate consultant (CC) #2 was interviewed on 9/19/24 at 10:45 a.m. CC #2 said on 8/1/24 the day shift registered nurse (RN) noted Resident #59's arm was swollen and tender and the RN obtained a physician's order for an immediate x-ray. CC #2 said an investigation was started because the resident's fall resulted from a CNA transferring the resident with a sit-to-stand lift without a second staff person present. CC #2 said the licensed practical nurse (LPN) from the night of the fall (7/31/24) did not identify any problems or pain with the resident and the resident's representative was not notified right away. CC #2 said the CNA transferred the resident back to bed along with the LPN and the LPN admitted he did not follow the proper steps after a fall. She said the CNA used the sit-to-stand alone and transferred the resident into bed. CC #2 said the CNA notified the LPN the resident fell . CC #2 said the CNA and LPN were suspended pending the facility investigation. CC #2 was interviewed again on 9/19/24 at 11:36 a.m. CC #2 clarified Resident #59 was transferred to the side of her bed and her feet were still on the base of the sit-to-stand when the CNA pulled the lift away from the resident. CC #2 said this was what caused Resident #59 to fall. IV. Facility follow-up The NHA provided follow-up documentation (after the survey) on 9/23/24 at 5:36 p.m. It read in pertinent part: The community self-identified some concerns related to the facility will ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and resident choices. The facility will ensure that the fall management policy is followed per corporate and state regulations. Corrective action: 1. A resident (Resident #59) was sent to the emergency room (ER) for an x-ray due to a change in pain rating, and a swollen wrist and arm. The resident had a fall on 7/31/24. 2. An investigation started immediately upon the radiology report findings. 3. The nurse who failed to document fall assessment, post fall follow up and notification of family was suspended on 8/7/24. 4. Interview with resident, NHA and social worker on 8/6/24. 5. Spoke with resident's daughter on 8/5/24. 6. Notified the medical director (MD) on 8/1/24. 7. CNA suspended pending investigation on 8/5/24. All residents that reside in the facility are at potential risk as every resident has the potential of falling. Facility will review the last 30 days of resident falls to identify any injury that might have occurred and went unreported or unassessed. Facility will review the last two weeks of the 24-hour report to identify any change of condition that was not assessed and followed up on. Issues identified will be addressed at that time. Facility will review residents who require mechanical lift transfers and ensure transfer status is on the residents' care plan. Starting 8/5/24, all nursing staff will be educated by the director of nursing (DON) or designee on ensuring two staff are present for all mechanical lift transfers, the facility fall management and investigation policy, to include safe positioning of resident in a bed, documentation required post fall including assessment and notification of resident after a fall. An attendance sheet will be reconciled with an active staff roster and nursing staff that were unable to attend will be provided with one-on-one re-education. The interdisciplinary team (IDT) will review each business day any concerns from the prior business day and ensure residents who have experienced any change in condition have been appropriately assessed and any follow up has been documented and reported to family and MD. The DON or designee will conduct record reviews post fall to ensure policy and procedures were followed weekly for four weeks, then monthly for two months, then as needed thereafter. DON or designee will observe three random staff utilizing a mechanical list weekly for four weeks, then monthly for two months, then as needed thereafter. Any non-compliance finding will be dealt with immediately. All findings will be tracked and trended and reported to the quality assurance performance improvement (QAPI) committee monthly for three months and then as needed to ensure the plan is implemented, sustained and evaluated for its effectiveness. Date of compliance was 8/9/24.

Based on observations, record review and interviews, the facility failed to ensure one (#34) of three residents out of 50 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Resident #34 was admitted to the facility for long-term care on 6/30/24 with diagnoses of age-related osteoporosis, hypokalemia (low potassium levels in the blood), hypocalcemia (low calcium levels in the blood), hypomagnesemia (low magnesium levels in the blood), cognitive communication deficit and cerebral infarction (stroke). Upon admission, on 6/30/24, the resident weighed 103.4 pounds (lbs). The 7/2/24 nutritional evaluation determined the resident was malnourished. The facility implemented snacks three times a day, however the facility did not have a system in place to monitor the resident's acceptance of the nutritional intervention. The resident's weight continued to decrease. On 9/17/24, Resident #34 weighed 87.5 lbs. Resident #34 had sustained a 15.9 lbs weight loss in three months (15.38%), which was considered a severe weight loss.The facility failed to implement person centered nutritional interventions when the resident's weight continued to decline until the resident sustained severe weight loss. Additionally, the facility failed to provide the resident with adequate assistance during meals and offer the resident meals. Findings include: I. Professional reference Treating Weight Changes in Long-Term Care, published 6/14/22, was retrieved on 9/25/24 from https://dietitiansondemand.com/treating-weight-changes-in-long-term-care/ It read in pertinent part, Any time a nutrition intervention is ordered or discontinued, the nutrition plan of care should reflect the current status of the resident. This helps keep everyone on the same page. A nutrition intervention is only effective when it is implemented. Be sure to communicate any changes to the nutrition plan of care with nursing and other clinical staff. II. Resident #34 A. Resident status Resident #34, age greater than 65, was admitted on [DATE]. According to the September 2024 computerized physician order (CPO), diagnoses included age-related osteoporosis, hypokalemia, hypocalcemia, hypomagnesemia, cognitive communication deficit and cerebral infarction. The 8/22/24 minimum data set (MDS) assessment revealed Resident #34 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment indicated the resident could eat independently. -However, observations revealed the resident had difficulties eating and spilled food on herself and the floor related to her tremors. The 7/4/24 MDS assessment documented the resident was 60 inches tall (five foot) and weighed 102 lbs. It indicated the resident had not had any significant weight gain or weight loss in the last six months. The MDS assessment did not indicate the resident had swallowing difficulties. B. Observations and interviews On 9/16/24 during a continuous observation, from 10:30 a.m. to 11:30 a.m., the following was observed: At 10:50 a.m. Resident #34 was in the dining room. Resident #34 was eating independently. Resident #34 was served french toast, eggs, sausage, bacon and toast. The resident's upper extremities were shaking with tremors. Resident #34 scooped some food on her spoon and as she lifted the spoon to her mouth, her tremors caused the food to fall off the spoon before she got the spoon to her mouth. Resident #34 was not offered assistance during the entire brunch meal. Resident #34 left the dining room at approximately 11:30 a.m. The majority of the residents' food was on the floor. On 9/17/24 during a continuous observation of the dinner meal, beginning at 5:00 p.m. and ending at 5:19 p.m., the following was observed: At 5:00 p.m. Resident #34 was in bed and she received her meal. The resident was served mechanical soft salisbury steak, green beans, mashed potatoes with gravy and peach cobbler. At 5:05 p.m. the resident took two bites of her dinner. She began to cough. At 5:19 p.m. certified nurse aide (CNA) #4 removed Resident #34's tray. Resident #34 had only eaten two bites of her dinner. CNA #4 did not offer an alternative meal option. The resident had her meal for 19 minutes before it was removed and she was not offered assistance to eat. On 9/19/24 at 1:30 p.m. CNA #2 began passing the siesta meal which consisted of two pieces of cheese and three crackers with lemonade. At 1:43 p.m. CNA #2 returned the meal cart to the kitchen. The residents who resided on Resident #34's hallway were not offered the siesta meal, including Resident #34. CNA #2 was interviewed at 1:45 p.m. CNA #2 said she returned the cart with cheese and crackers to the kitchen when all of the residents were served. CNA #2 said she picked up the meal cart at the beginning of the hallway and turned left down the smaller hallway. CNA #2 said she was not aware Resident #34's hallway was not served the siesta meal. At 1:48 p.m. CNA #2 removed the siesta meal cart from the kitchen and served the siesta meal to Resident #34 and the other residents on her hall. The resident took a few bites of the crackers but did not eat the cheese. The resident did not receive any assistance to eat. On 9/19/24 at 6:55 p.m. Resident #34 was lying in bed. She had her head slightly lifted and was eating a shake with a spoon. Resident #34 had spilled the shake on herself. Resident #34 said she needed assistance with eating. CNA #5 was interviewed at 6:57 p.m. CNA #5 said Resident #34 was independent with eating and was able to feed herself. CNA #5 said she was going to check on the resident. C. Record review Resident #34's nutritional care plan, initiated on 7/1/24, revealed the resident was at risk for the inability to maintain her nutrition. Interventions implemented on 7/1/24 included inviting the resident to activities that promoted additional intake, monitoring, documenting and reporting signs or symptoms of dysphagia (swallowing difficulties), monitoring, documenting and reporting signs or symptoms of malnutrition, occupational therapy screening and providing the resident with adaptive equipment for feeding as needed, providing and serving a no added salt diet as ordered per the family's request and recording each meal, the registered dietitian (RD) was to evaluate and make diet change recommendations as needed, speech pathology screening as needed and weighing the resident per facility protocol. Resident #34's activities of daily living (ADL) care plan, revised on 7/29/24, revealed the resident ate food independently. Resident #34's nutrition care plan, revised on 9/3/24, revealed the resident had a Carnation shake (nutritional supplement) added to each meal tray. Resident #34's weights were documented in the resident's electronic medical record (EMR) as follows: -On 6/30/24 Resident #34 weighed 103.4 lbs; -On 7/1/24 Resident #34 weighed 102 lbs; -On 7/10/24 Resident #34 weighed 98.7 lbs; -On 7/16/24 Resident #34 weighed 100.6 lbs; -On 7/23/24 Resident #34 weighed 97.6 lbs; -On 7/30/24 Resident #34 weighed 98.9 lbs; -On 8/1/24 Resident #34 weighed 98.4 lbs; -On 8/13/24 Resident #34 weighed 96.2 lbs; -On 8/20/24 Resident #34 weighed 96.7 lbs; -On 8/27/24 Resident #34 weighed 92.6 lbs; -On 9/2/24 Resident #34 weighed 90.6 lbs; -On 9/10/24 Resident #34 weighed 89.7 lbs; and, -On 9/17/24 Resident #34 weighed 87.5 lbs. -Resident #34 sustained a 7.8 lbs (7.9%) weight loss from 8/1/24 to 9/2/24 in one month, which was considered severe. -Resident #34 lost 15.9 lbs (15.38%) from 6/30/24 to 9/17/24 in three months, which was considered severe. A skilled evaluation note entered in Resident #34's EMR on 6/30/24 revealed the resident was able to orally take in nutrition and hydration. The resident had no symptoms of a swallowing disorder. Difficulty in chewing was documented. The resident was offered assistance with meals which included set up and feeding assistance as needed and nutritional supplements were ordered with meals. The 7/2/24 mini nutritional assessment (MNA) revealed the resident weighed 102 lbs on 7/1/24 and the resident did not have a decreased food intake. The resident was unaware if she had lost any weight in the past three months. The resident was able to get out of her bed or chair but was not eating in the dining room. Resident #34 suffered psychological stress in the past three months and the resident had mild dementia. Resident #34 scored a six out of 14 on the nutritional assessment, which indicated she was malnourished. The 7/2/24 dietary profile revealed the resident was prescribed a no added salt diet, regular food texture and thin liquids. The assessment indicated the resident was not taking nutritional supplements before she was admitted to the facility and was not taking nutritional supplements at the time of the assessment. Resident #34 needed partial assistance during meals. On 7/6/24 Resident #34's diet order was changed to a no added salt diet, regular texture and thin liquids. The 7/9/24 nutrition risk review note revealed the resident was admitted on a regular diet that was changed based on the family's request. Resident #34 was able to eat with set up assistance at meals and her intakes were improving. The nutrition risk review note recommended offering snacks three times a day and weekly weights for four weeks then monthly weights if Resident #34's weight was stable. -Review of the resident's EMR indicated the resident was consuming 0 to 25% of the snacks the majority of the time in the last 30 days. -The task for eating support documented (from 8/21/24 to 9/19/24) revealed the resident required supervision with eating 37 times out of 150 meals, 17 times she required limited assistance out of 150 meals and four times required extensive assistance out of 150 meals. On 7/16/24 Resident #34's diet order changed from a no added salt diet, regular texture and thin liquids to a no added salt diet, mechanical soft texture and nectar thickened liquids. On 8/5/24 Resident #34's diet order changed from a no added salt diet, mechanical soft texture and nectar thickened liquids to a no added salt diet, mechanical soft texture and thin liquids. The 8/28/24 physician note revealed the nurse practitioner (NP) was notified the resident had lost some weight and the nurse thought the resident was feeling depressed. The resident confirmed with the NP that she was depressed and not having much of an appetite. The resident was offered Remeron antidepressant (medication used as an appetite stimulant) and declined. The 9/3/24 weight change note documented the resident had lost 5.2 % of her weight in one month. The resident was offered Remeron by her provider and refused, though the resident also had some depression. The registered dietician (RD) offered a protein shake with each meal and the resident agreed. The RD recommended liberalizing the resident's no added salt diet due to poor intake. The 9/17/24 nutrition note revealed the interdisciplinary team (IDT) notified the staff that the resident needed assistance at meals. The 9/18/24 weight change note revealed the resident lost 9.3% of her weight in one month and a severe weight change was noted. The resident needed more assistance during meals and the resident's EMR indicated needing anywhere from set up assistance to being fully dependent on staff during meals. The RD encouraged the resident to eat her meals in the dining room at the assistance table. The resident agreed to use Remeron for depression and increased appetite. The resident was accepting Carnation supplements 50 percent of the time. The RD encouraged small and frequent meals and ordered MedPass 60 milliliters (ml) three times a day and monitored weights weekly. -A review of the resident's EMR did not include documentation indicating the facility was monitoring the amount the resident was consuming of the Carnation supplement to determine if it was an effective intervention. A review of the September 2024 CPO revealed the resident had the following physician's orders: Carnation Breakfast Essential (nutritional supplement) two times a day, ordered on 9/3/24. Obtain weekly weights due to significant weight loss, ordered on 9/9/24. Mirtazapine (Remeron) seven and a half milligrams (mg) every day for an appetite stimulant, ordered on 9/12/24. TwoCal (nutritional supplement) three times a day, ordered on 9/17/24. III. Staff interviews Registered nurse (RN) #2 was interviewed on 9/18/24 at approximately 4:30 p.m. RN #2 said Resident #34 was able to feed herself, but she required supervision and encouragement. She said at times the resident fed herself better than other days as she had had a decline. The registered dietitian (RD) was interviewed on 9/19/24 at 3:39 p.m. The RD said Resident #34 had a severe weight loss of 9.3% within a month (8/18/24 to 9/18/24). The RD said she started the resident on a protein shake and the resident was offered an appetite stimulant but the resident refused the medication at the time. She said Resident #34 had a diet change which liberalized her previous diet. The RD said Resident #34 was on weekly weights and a TwoCal nutritional supplement in addition to the Carnation shakes she received at meals. The RD said the shake consisted of peanut butter, banana and heavy cream. The RD said if the resident had not eaten her meal, the staff needed to offer an alternative meal. The RD said she spoke to Resident #34 on 9/18/24 and she agreed to have more assistance from staff during her meals. The RD said when she had spoken to the resident, she put out a communication to the interdisciplinary team so they would be aware of the changes. The RD said she sent the changes for Resident #34 on 9/18/24 at 3:29 p.m. from her conversation with the resident that she would like to have assistance with meals. The RD said she also updated Resident #34's kardex. She said Resident #34 was on a mechanical soft texture and was not supposed to receive crackers from the siesta meal. The RD said she relied on the nursing staff to ensure everyone received their meals since the facility offered five meals a day and that residents were not skipped. The interim director of nursing (IDON) was interviewed on 9/19/24 at 4:00 p.m. The IDON said Resident #34 fed herself independently but needed more cueing and assistance. The IDON said the RD was reviewing the resident and Resident #34 was also reviewed in the nutrition at-risk meeting. The dietary manager (DM) was interviewed on 9/19/24 at 4:30 p.m. The DM said the facility provided five meals a day, per the residents' preferences. The five meals included continental breakfast that was served at 7:00 a.m., brunch that was served at 10:30 a.m., siesta that was served at 1:30 p.m., dinner was served at 4:00 p.m. and the nightcap meal was served at 6:30 p.m. The DM said the facility did not have a system in place to track the five meals offered on the facility's meal plan or snacks.

Based on record review and interviews, the facility failed to ensure a discharge summary was in place for four (#236, #84, #85 and #238) of four residents reviewed for discharge out of 50 sample residents. Specifically, the facility failed to ensure discharge summaries were completed and included a recapitulation of the resident's stay. Findings include: I. Resident #236 A. Resident status Resident #236, age greater than 65, was admitted on [DATE] and discharged home on 6/4/24. According to the June 2024 computerized physician orders (CPO), the resident had a diagnosis of aftercare following joint replacement surgery. The 6/12/24 minimum data set (MDS) assessment revealed Resident #236 had a mild cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. B. Record review The discharge summary dated 6/3/24 documented the resident was discharged home with home health services. The facility failed to ensure the discharge summary form was completed in its entirety. The following sections of the discharge summary form were not completed: -Physical and mental functional status including activities of daily living (ADLs); -Continence; -Skin condition; -Vision; -Special treatment and procedures; -Dental; -Nutrition and dental; -Activities pursuit; -Resident needs, strengths and goals; -Resident's customary routine; -Pertinent lab test results; -Rehabilitation follow up or potential; and, -Recapitulation of stay, specifically for activities and rehabilitation. II. Resident #84 A. Resident status Resident #84, age greater than 65, was admitted on [DATE] and discharged home on 1/15/24. According to the January 2024 CPO, diagnoses included sepsis (the body overreacts to an infection or injury), chronic respiratory failure with hypoxia (oxygen does not reach all organs) and acute systolic (congestive) heart failure. The 1/19/24 MDS assessment revealed Resident #84 had a moderate cognitive impairment with a BIMS score of seven out of 15. B. Record review The discharge summary dated 1/15/24 documented the resident was discharged home with outpatient rehabilitation services. The facility failed to ensure the discharge summary form was completed in its entirety. The following sections of the discharge summary form were not completed: -Physical and mental functional status including activities of daily living (ADLs); -Continence; -Skin condition; -Vision; -Special treatment and procedures; -Dental; -Nutrition and dental; -Activities pursuit; -Resident needs, strengths and goals; -Resident's customary routine; -Pertinent lab test results; -Rehabilitation follow up or potential; and, -Recapitulation of stay, specifically for activities and rehabilitation. -Resident #84's discharge summary was started on 1/15/24 and, as of 9/18/24 (the end of the survey), was still in progress. III. Resident #85 A. Resident status Resident #85, age greater than 65, was admitted on [DATE] and discharged to an independent living facility on 8/5/24. According to the August 2024 CPO the resident had a diagnosis of a displaced fracture to the upper end of the right humerus (arm) bone. The 6/19/24 MDS assessment revealed Resident #85 was cognitively intact with a BIMS score of 15 out of 15. B. Record review The discharge summary dated 8/5/24 documented the resident was discharged to an independent living facility with home health services. The facility failed to ensure the discharge summary form was completed in its entirety. The following sections of the discharge summary form were not completed: -Physical and mental functional status including activities of daily living (ADLs); -Continence; -Skin condition; -Vision; -Special treatment and procedures; -Dental; -Nutrition and dental; -Activities pursuit; -Resident needs, strengths and goals; -Resident's customary routine; -Pertinent lab test results; -Rehabilitation follow up or potential; and, -Recapitulation of stay, specifically for activities and rehabilitation. IV. Resident #238 A. Resident status Resident #238, age greater than 65, was admitted on [DATE] and discharged home on 6/17/24. According to the June 2024 CPO, diagnoses included a mechanical loosening of the internal right knee prosthetic joint, chronic pain and dependence on supplemental oxygen. The 6/19/24 MDS assessment revealed Resident #238 was cognitively intact with a BIMS score of 15 out of 15. B. Record review Resident #238's discharge summary was started on 6/17/24 and was still in progress as of 9/18/24 (the end of the survey). -The brief history, nursing summary, dietary summary, activity summary, social services summary and rehabilitation summary sections were not completed. -A review of Resident #238's electronic medical record (EMR) failed to reveal that a nursing summary with the recapitulation of the resident's stay was completed upon the resident's discharge from the facility. V. Staff interviews The interim director of nursing (IDON) and corporate consultant (CC) #1 were interviewed together on 6/19/24 at 2:29 p.m. The IDON said the social service director opened the discharge summary form in the residents' EMR and informed the interdisciplinary team (IDT) to complete their designated portions. She said the discharge summary was to be completed on the resident's day of discharge. She said the discharge summary, the medication list and any pertinent information was provided to the family or the receiving facility at the time of discharge. The IDON reviewed the discharge summaries for Resident #236, #84, #85 and #238 and said the discharge summary forms were not completed thoroughly. She said the forms were missing pertinent information. CC #1 reviewed the discharge summaries for Resident #236, #84, #85 and #238. She said the facility was using the wrong discharge summary form. She said the facility was using the post discharge plan of care rather than the correct discharge summary form. CC #1 said the facility had not identified that there were concerns with residents' discharge summaries.

Based on record review and interviews, the facility failed to maintain medical records on each resident that were accurately documented for four (#72, #34, #33 and #237) of 13 residents out of 50 sample residents. Specifically, the facility failed to have an effective process in place to ensure residents' directives for cardiopulmonary resuscitation status (CPR) were maintained accurately and nursing staff was aware of where to find the information in the event of a medical emergency. Findings include: I. Professional reference [NAME] Advantage for Basic Nursing Thinking, Doing and Caring Third edition (2022), Philadelphia, PA by F. A. [NAME] Company, retrieved on [DATE], pg. 977, read in pertinent part: You must know the terminology used by your healthcare organization and pay careful attention to agency policies and advanced directives so you are prepared if a patient suffers a cardiopulmonary arrest. II. Admission Agreement The Admission Agreement, unrevised, was provided by the nursing home administrator on [DATE] at 1:57 p.m. It read in pertinent part: Unless directed otherwise in a written and valid advanced directive document (such as a do not resuscitate order), the community is authorized to provide or arrange for any emergency medical treatment deemed necessary for the resident. If the resident has any advance directives, a copy must be provided to the community at admission. If any advance directives are amended or changed while a resident of the community, copies must be provided to the community. III. Resident #72 A. Resident status Resident #72, age greater than 65, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included acute respiratory failure with hypoxia (not enough oxygen throughout the body), acute kidney failure, acute systolic (congestive) heart failure and heart failure. The [DATE] minimum data set (MDS) assessment revealed Resident #72 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. B. Record review Resident #72's Medical Orders For the Scope of Treatment (MOST) form, signed on [DATE], revealed the resident wished to receive CPR. Resident #72's most recent MOST form, signed on [DATE], revealed the resident did not want to receive CPR and wished to be a do-not-resuscitate (DNR). Resident #72's advanced directives care plan, revised on [DATE], revealed Resident #72 was a full code (receive CPR). -The facility failed to update the resident's care plan to accurately reflect the resident's wishes when he wished to be a DNR (no CPR) on [DATE]. Review of the [DATE] CPO revealed Resident #72 had a physician's order indicating the resident was a DNR code status (no CPR), ordered [DATE]. -However, Resident #72 was documented on the CPR list page in the narcotics book as wishing to receive CPR, although his MOST form and physician's order indicated he was to be a DNR. IV. Resident # 34 A. Resident status Resident #34, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included age-related osteoporosis, hypokalemia, hypocalcemia, hypomagnesemia, cognitive communication deficit and cerebral infarction. The [DATE] MDS assessment revealed Resident #34 was cognitively intact with a BIMS score of 15 out of 15. B. Record review Resident #34's most recent MOST form, signed on [DATE], revealed the resident's representative wanted the resident to receive CPR. Resident #34's advanced directives care plan, revised [DATE], revealed Resident #34 was a full code (receive CPR). Review of the [DATE] CPO revealed Resident #34 had a physician's order indicating she was a CPR full code status, ordered [DATE]. -However, Resident #34 was not listed on the CPR list page in the narcotics book as wishing to receive CPR. V. Resident #33 A. Resident status Resident #33, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included Alzheimer's disease, depression and heart failure. The [DATE] MDS assessment revealed Resident #33 was unable to complete the BIMS assessment due to rarely being understood. The staff assessment for mental status revealed Resident #33 had short-term and long-term memory problems. B. Record review Resident #33's most recent MOST form, signed on [DATE], revealed the resident's representative wanted the resident to be a DNR (no CPR). Resident #33's advanced directives care plan, revised [DATE], revealed the resident was a DNR based on his new MOST form signed on [DATE]. Review of the [DATE] CPO revealed Resident #33 had a physician's order indicating the resident was a DNR code status (no CPR). -However, Resident #33 was documented on the CPR list page in the narcotics book as wishing to receive CPR, although his MOST form and physician's order indicated he was to be a DNR. VI. Resident #237 A. Resident status Resident #237, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included a fracture of the right femur (leg bone), heart disease and diabetes. The [DATE] MDS assessment was not completed for Resident #237's BIMS score. B. Record review Resident #237's most recent MOST form, signed on [DATE], revealed the resident wished to receive CPR. -Resident #237's advanced directives care plan was not completed as of [DATE] (the end of the survey). Review of the [DATE] CPO revealed Resident #237 had a physician's order indicating the resident was a CPR full code status. -However, Resident #237 was not listed on the CPR list page in the narcotics book as wishing to receive CPR. VII. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 12:30 p.m. LPN #1 said when a resident was unresponsive and she needed to find out the resident's code status, the facility had a page in the narcotics book which indicated which residents were to receive CPR. -LPN #1 opened the narcotics book and said the page indicating which residents were to receive CPR was last updated on [DATE]. LPN #1 said the page in the narcotics book which indicated which residents were to receive CPR was the only resource nurses used to determine if a resident should be given CPR. Registered nurse (RN) #2 was interviewed on [DATE] at 12:45 p.m. RN #2 said the list of residents who were to receive CPR was kept on a page in the narcotics books. RN #2 said she was able to check the resident's electronic medical chart (EMR) if she was unsure about the CPR list in the narcotics book, but she said the narcotics book was the CPR list resource for the nurses. The interim director of nursing (IDON) was interviewed on [DATE] at 6:00 p.m. The IDON said the admitting nurse obtained the resident's order for the code status. The IDON said the physician or nurse practitioner talked to the residents about their wishes for CPR status. The IDON said the CPR list page in the narcotics books was not the proper way for staff to check a resident's code status. The IDON said the facility had a MOST form book at the nurses' stations that contained the MOST forms for all residents and the MOST form book was the resource nurses were to use to check residents' CPR code statuses. The IDON said she provided training to the nurses on [DATE] (during the survey) because the nurses were using the CPR list page in the narcotics books instead of the MOST form books. The IDON said she was going to audit all of the MOST forms to ensure the forms matched the physician's orders and the residents' wishes.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development of infection and transmission of diseases. Specifically, the facility failed to: -Ensure facility staff offered appropriate hand hygiene to residents before meals; and, -Ensure laundry staff handled clean laundry in a sanitary manner. Findings include: I. Failure to provide hand hygiene to residents A. Facility policy The Handwashing/Hand Hygiene policy, revised October 2023, was received from the nursing home administrator (NHA) on 9/16/24 at 1:57 p.m. The policy read in pertinent part, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors. Hand hygiene is provided and supplies are readily accessible and convenient for staff to encourage compliance with hand hygiene policies. Alcohol-based hand rub dispensers are placed in areas of high visibility and consistent with workflow throughout the facility. Residents are encouraged to practice hand hygiene. B. Observations On 9/17/24 at 4:20 p.m. the main dining room was observed during the evening meal. The residents' meal trays had a warm green wet cloth which was placed on the tray. The resident's who were able to use the green cloth independently sanitized their hands prior to eating. -However, the residents who were not independent in their self care were not assisted with sanitizing their hands prior to eating their meal. -Resident #4 was not assisted with hand hygiene prior to eating her meal. She was observed picking at her cake with her fingers. On 9/18/24 at 10:49 a.m. the main dining room was observed during the brunch meal. The residents' meal trays had a warm green wet cloth which was placed on the tray. The resident's who were able to use the cloth did wipe their hands. However, the residents who were not independent in their self care, were not assisted to wash their hands prior to eating their meal. On 9/18/24 at 4:35 p.m. the main dining room was passing the meal trays. The trays had a warm green wet cloth which was placed on the tray. The resident's who were able to use the green cloth independently sanitized their hands prior to eating. -However, the residents who were not independent in their self care were not assisted with sanitizing their hands prior to eating their meal. -Resident #59 self-propelled her wheelchair into the dining room. An unidentified certified nurse aide (CNA) assisted her with her wheelchair to the dining room table. -The CNA did not offer Resident #59 assistance with sanitizing her hands. Resident #59 received her meal at approximately 4:45 p.m. She received a finger food diet. The Salisbury steak was placed in a bun. The resident picked up the food with her unsanitized hands and began eating. C. Staff interviews The infection preventionist (IP) and corporate consultant #1 (CC) were interviewed together on 9/19/24 at 12:30 p.m. The IP said the residents were offered hand hygiene in the dining room before meals. The IP said the dietary staff were expected to place washcloths pre-moistened with warm water in a bucket in the dining room. As residents were ready to eat their meals, she said a staff member retrieved a clean, pre-moistened washcloth and offered it to the residents for hand hygiene. The IP said hand hygiene was essential to reduce hand-to-mouth disease transmission. CC #1 said the facility should offer the residents a sani-wipe, an individually wrapped hand-sanitizing wipe. CC #1 said she would work with the IP to ensure the residents were provided with hand hygiene before their meals. II. Failure to handle clean laundry in a sanitary manner A. Facility policy The Laundry and Bedding, Soiled policy, revised September 2022, was received from the NHA on 9/19/24 at 7:38 p.m. The policy read in pertinent part, Soiled laundry/bedding shall be handled, transported and processed according to best practice for infection prevention. All used laundry is handled as potentially contaminated using standard precautions. Contaminated laundry is bagged or contained at the point of collection. Staff handle soiled textiles with minimum agitation to avoid the contamination of air, surfaces, and persons. Contaminated linen and laundry is not held close to the body or squeezed during transportation. Clean linen is protected from dust and soiling during transport and storage to ensure cleanliness. B. Observation On 9/18/24 at approximately 11:00 a.m. the laundry aide (LA) was delivering clean clothing to residents' rooms. She held the clean personal laundry next to her uniform. She had several hangers and went into multiple rooms holding the clothes directly against her uniform. C. Staff interviews The LA was interviewed on 9/18/24 at approximately 11:15 a.m. The LA said she had a cart that she was supposed to use to transport residents' clean clothing, however, she said it was easier for her to deliver the clothes by holding them instead of placing them on the cart. She said she did not know she should not hold the clean clothes against her uniform. The IP was interviewed on 9/19/24 at 12:30 p.m. The IP said staff should not transport clean laundry by holding the laundry against their bodies. The IP said if the laundry was clean, holding the laundry against the body could cause the laundry to become contaminated by any pathogens on the employees' clothing. She said if the laundry was soiled and came into contact with the employees' clothing, the employees' clothing would be a possible source for spreading pathogens.

Based on interviews and record review, the facility failed to ensure two (#38 and #74) of 10 residents reviewed for abuse out of 50 sample residents were kept free from physical abuse. Specifically, the facility failed to: -Prevent a physical altercation between Resident #239 and Resident #38; and, -Prevent a physical altercation between Resident #74 and Resident #70. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, revised September 2022, was provided by the nursing home administrator (NHA) on 9/16/24 at 1:57 p.m. The policy read in pertinent part, All reports of resident abuse are reported to local, state, and federal agencies. If resident abuse is suspected, the suspicion must be reported to the administrator and other officials according to state law. The administrator immediately (within two hours of an allegation of abuse) reports the suspicion to the state licensing agency responsible for surveying/licensing the facility and law enforcement officials. Upon receiving allegations of abuse the administrator is responsible for determining what actions are needed for the protection of residents. All allegations are thoroughly investigated. The administrator initiates investigations. Investigations may be assigned to an individual trained to review, investigate, and report abuse allegations. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. II. Altercation on 1/1/24 between Resident #239 and Resident #38 A. Facility investigation The 1/1/24 progress note documented Resident #239 hit Resident #38 and was aggressive with staff as they attempted to redirect him. The altercation was unwitnessed by staff, and staff became aware of the occurrence when Resident #38 walked to the dining room on the unit, bleeding from his head. The progress note documented Resident #239 was aggressive with staff as they attempted to redirect him away from Resident #38. The progress note documented the nurse immediately assessed both residents, contacted the provider, and transferred both residents to the hospital for evaluation. Resident #239 returned to the facility on [DATE] and Resident #38 returned to the facility on [DATE]. B. Resident #239 1. Resident status Resident #239, age greater than 65, was admitted on [DATE], discharged to the hospital on 1/1/24 and readmitted to the facility on [DATE]. He was discharged from the hospital on 1/4/24 and went home with his spouse. According to the January 2024 computerized physician's orders (CPO), diagnoses included unspecified Alzheimer's disease and dementia without behavioral disturbance. Resident #239 resided in the memory care unit of the facility for wandering and elopement attempts. The 1/4/24 minimum data set (MDS) assessment documented the brief interview for mental status (BIMS) was not completed because the resident was sometimes not understood. The staff assessment for mental status documented the resident had short and long-term memory problems and was severely impaired in daily decision-making. Resident #239 had physical and verbal behavioral symptoms directed towards others for one to three days during the assessment period. Resident #239 put others at significant risk for physical injury and disrupted care and the living environment for one to three days during the assessment period. The MDS assessment documented Resident #239 rejected evaluation or care for one to three days during the assessment period and wandered and intruded significantly on the privacy of others. 2. Record review The care plan, initiated on 1/1/24, identified Resident #239's severe cognitive loss, which could relate to physically and verbally aggressive behaviors. Interventions included staff not engaging in a power struggle with the resident, calling the resident's wife as needed, giving the resident space when he became angry and keeping the resident in line of sight for safety. A nurse progress note, dated 1/1/24 at 9:09 p.m., documented Resident #239 hit Resident #38 and was aggressive with staff after he hit Resident #38. The physician was contacted and ordered Resident #239 to be transferred to the hospital for evaluation. C. Resident #38 1. Resident status Resident #38, age greater than 65, was admitted on [DATE] and discharged on [DATE] to another long-term facility. According to the September 2024 CPO, diagnoses included dementia with behavioral disturbance and hypertension. Resident #38 resided in the memory care unit of the facility. The 8/26/24 MDS assessment documented the BIMS assessment was not completed because he was rarely understood. The staff assessment for mental status documented the resident had short and long-term memory problems. Resident #38 knew the location of his room and was moderately impaired with daily decision-making. Resident #38 had physical and verbal behavioral symptoms directed toward others for one to three days during the assessment period. Other behavioral symptoms were not directed toward others for 4 to 6 days during the assessment period. He put others at significant risk for physical injury and disrupted care and the living environment for one to three days during the assessment period. Resident #38 rejected evaluation or care for one to three days during the assessment period. Resident #38 was independent with eating, oral hygiene, toileting hygiene, dressing, putting on and taking off footwear and personal hygiene, bed mobility, transfers in and out of bed, and ambulation. He required staff supervision for showers and shower transfers. He used a wheelchair for mobility. 2. Record review The care plan, initiated on 11/27/23, identified Resident #38 as needing a memory care unit for increased wandering, confusion, and dementia. Interventions included keeping the resident's environment free of hazards, having pleasant interactions when the resident was confused, and removing and redirecting the resident from unsafe behavioral confrontations. The care plan, initiated on 1/3/24, identified the resident had a behavior of agitation with verbally and physically abusive behavior toward staff and others and was hard to redirect. Interventions included placing a stop sign banner on the door entry, keeping the resident in line of sight when agitated, keeping the resident safe from others due to unpredictable and impulsive moods and behaviors and social services would look for appropriate placement for Resident #38. The care plan, initiated on 3/29/24, identified Resident #38 as becoming agitated and wanting to leave. He was obsessive about his wife. Interventions included encouraging safe boundaries and space with his wife when he was agitated, taking a walk, separating him from his wife and keeping the resident in line of sight. A progress note, dated 1/1/24 at 9:25 p.m., documented Resident #38 was sitting in the dining room with blood on his hand and neck and covered with a towel. The resident had a laceration and bruise on his head, neck and left ear. The physician was contacted and ordered Resident #38 to be sent to the hospital for evaluation. The physician was contacted and ordered Resident #38 to be sent to the hospital for evaluation. He returned to the facility on [DATE]. D. Staff interview The NHA was interviewed on 9/19/24 at 4:25 p.m. The NHA said the facility immediately separated the residents and each resident was placed on one-on-one staff monitoring until they were both sent to the hospital for evaluation. The NHA said Resident #239 was a new resident to the facility on [DATE]. He said the interdisciplinary team (IDT) reviewed the status of each resident on the unit and determined Resident #239 and Resident #38 would be a safe trial for room sharing prior to the incident. The NHA said Resident #38 tended to obsess only about his wife, who also resided in the memory care unit. The NHA said the facility was told prior to Resident #249's admission to the facility that he was not violent. He said Resident #38 obsessed over his spouse, another resident in the facility, and did not have issues with other males in the memory care unit. The NHA said staff responded to the altercation appropriately and had each resident was on one-to-one supervision after the incident until the physician was contacted. The NHA said when Resident #239 returned to the facility from the hospital, he had another occurrence of aggressive behavior with staff members. The NHA said Resident #239 was transported back to the hospital and discharged to his home with his spouse from the hospital. III. Altercation on 8/31/24 between Resident #74 and Resident #70 A. Facility investigation On 8/31/24, Resident #70 slapped Resident #74, her spouse, with force while he assisted her with her clothing. A facility volunteer observed the altercation. The volunteer reported after the altercation, the residents were separated immediately by staff. The volunteer reported the occurrence to facility staff on 9/1/24, which was reported to state and local authorities on 9/3/24. -Cross reference F609 for failure to report an allegation of abuse timely. The facility initiated an investigation on 9/3/24 and interviewed 15 staff members, residents and family members. No concerns about Residents #70 and #74 were reported. The family reported the behavior between the two residents was a long-term dynamic and agreed to have the couple continue to share a room at the facility. B. Resident #74 1. Resident status Resident #74, age greater than 65, was admitted on [DATE]. According to the September 2024 CPO, diagnoses included unspecified lack of normal physiological development in childhood, hypertension and diabetes. The 4/7/24 MDS assessment documented Resident #74 had severe cognitive impairment with a BIMS score of four out of 15. Resident #74 was independent with eating, hygiene, dressing, putting on and taking off footwear, bed mobility, transfers in and out of bed and ambulation. 2. Record review A progress note, dated 9/3/24 at 2:05 p.m., documented Resident #74's altercation with his spouse, Resident #70. The progress note documented Resident #70 hit Resident #74 on his arm while he attempted to assist her with changing her shirt. The progress note documented a nurse completed a skin assessment and there were no marks or abrasions apparent on Resident #74. The provider was notified and ordered to monitor Resident #74 for 72 hours. C. Resident #70 1. Resident status Resident #70, age greater than 65, was admitted on [DATE]. According to the September 2024 CPO, diagnoses included unspecified dementia without behavioral disturbance, difficulty walking and diabetes. The 3/17/24 MDS assessment documented Resident #70 had severe cognitive impairment with a BIMS score of three out of 15. Resident #70 was independent with eating and bed mobility. She required partial/moderate assistance from staff for hygiene, showers, dressing, bed mobility, and transfers. Resident #70 used a manual wheelchair and was dependent on staff for locomotion. Resident #70 had no previous behavioral episodes. 2. Record review A progress note, dated 9/3/24 at 9:01 a.m., documented the staff reported to the provider that Resident #70 was in an altercation with Resident #74. The provider evaluated Resident #70 and gave no new orders. D. Staff interview The NHA was interviewed on 9/19/24 at 4:25 p.m. The NHA said the altercation was reported late to the State Survey and Certification Agency because the volunteer thought the window for reporting abuse was 48 hours. The NHA said the facility began an investigation on 9/1/24 when the altercation was reported by the volunteer. The NHA said a facility volunteer was responsible for reporting abuse in the same manner and time frames as facility staff. He said the volunteer received education on immediate reporting. The NHA said the provider evaluated Resident #70 and found no injuries. The NHA said the family was notified about the altercation and agreed to let the couple continue to reside in the same room. The NHA said neither resident had behavior events before the 8/31/24 altercation.

Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints for one (#62) of one resident reviewed out of 50 sample residents. Specifically, the facility failed to ensure a physician's order was obtained, a safety risk assessment was completed and alternative interventions were attempted for the use of Resident #62's bed alarm. Findings include: I. Resident #62 A. Resident status Resident #62, age 85, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease and glaucoma (an eye disease that causes vision loss). The 8/4/24 minimum data set (MDS) assessment documented the resident's brief interview for mental status (BIMS) score could not be determined because the resident could not communicate. The resident was dependent on staff for assistance for showering and personal hygiene, dressing, eating, moving in bed and transfers. B. Observations On 9/18/24 at 9:36 a.m., Resident #62's bed was observed. There was a bed alarm hooked over the head of the bed. The alarm was a box shape with a magnet attached to the front. The magnet was attached to a string that was approximately three feet long. C. Record review The care plan, revised 8/8/24, revealed Resident #62 used a voice alarm and helmet to prevent injury from falls. Pertinent interventions included ensuring the device was properly applied, evaluating the resident for adverse consequences of the alarm, including fear, anxiety, agitation related to the alarm sound, decreased mobility, sleep disturbances, and infringement of freedom. On 9/19/24 (during the survey), a physician's order was placed for a tab alarm to alert staff to the resident's needs. -A review of Resident #62's electronic medical record (EMR) did not reveal there was a safety risk assessment evaluation document that showed alternative treatments were attempted and justified the reasons for the alarm. D. Staff interviews The interim director of nursing (IDON) was interviewed on 9/18/24 at 11:50 a.m. The IDON said the facility used tab alarms for residents who were at risk for transferring without staff assistance, falling out of their chairs. The IDON said the tab alarm was not considered a restraint because when the device was attached to the resident, the resident was able to move and reposition freely. The IDON said the device did not restrict the resident from moving around in the facility and was activated only when the resident put too much tension on the cord. The IDON said a physician's order was not required to use the tab alarm. She said when a resident was identified as a candidate for using the alarm, the interdisciplinary team (IDT) reviewed the resident status and if recommended, consent was obtained from the resident or family, and the device was attached to the chair and resident. The IDON said when restraint devices were used, the facility did not monitor for removal until quarterly care conferences. Registered nurse (RN) #3 was interviewed on 9/18/24 at 1:04 p.m. RN #3 said Resident #62 had a bed alarm that was used at night. RN #3 said the bed alarm had a box with a magnet and the magnet was attached by a string to the resident's clothes. She said if the magnet fell off because the resident moved too far, the alarm sounded. Certified nurse aide (CNA) #3 was interviewed on 9/18/24 at 1:28 p.m. CNA #3 said she thought Resident #62 was the only resident at the facility with a bed alarm. She said the string was clipped to the resident's underwear. She said the alarm was sensitive, so even if he rolled over, the alarm would sound. She said the alarm beeped and had a man's voice that asked him to please sit down until someone could help him. CNA #3 said the bed alarm helped prevent more falls. RN #4 was interviewed on 9/19/24 at 7:34 p.m. RN #4 said Resident #62's bed alarm had been utilized since April 2024. He said it helped prevent falls. RN #4 said the staff heard the alarm from the nurse's station. He said if the alarm sounded, he went into the resident's room and assessed him. RN #4 said most of the time he had rolled just far enough for the string to pull off the magnet. He said most of the time, the resident was still asleep when that happened. He said sometimes the resident looked back up at him and then he fell back asleep. RN #4 said the staff tried a lot of other fall interventions before implementing the bed alarm.

Based on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#74) of ten residents reviewed for abuse out of 50 sample residents. Specifically, the facility failed to report an allegation of resident to resident physical abuse to the local police or the State Agency within 24 hours of the altercation. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, revised September 2022, was provided by the nursing home administrator (NHA) on 9/16/24 at 1:57 p.m. The policy read in pertinent part, All reports of resident abuse are reported to local, state, and federal agencies. If resident abuse is suspected, the suspicion must be reported to the administrator and other officials according to state law. The administrator immediately (within two hours of an allegation of abuse) reports the suspicion to the state licensing agency responsible for surveying/licensing the facility and law enforcement officials. II. Incident of physical abuse between Resident #70 and #74 The facility investigation notes documented on 8/31/24, Resident #70 slapped Resident #74, her spouse, with force while he assisted her with her clothing. A facility volunteer observed the altercation and separated the residents. The volunteer reported the occurrence to facility staff on 9/1/24. The facility failed to report the allegation of abuse to state and local authorities until 9/3/24, two days after the incident was reported to the facility by the volunteer. III. Staff interviews The NHA was interviewed on 9/19/24 at 4:25 p.m. The NHA said the altercation was reported late to the State Survey and Certification Agency because the volunteer thought the window for reporting abuse was 48 hours. The NHA said the facility began an investigation when the altercation was reported on 9/1/24. The NHA said a facility volunteer was responsible for reporting abuse in the manner and time frames as facility staff. He said the volunteer received education on immediate reporting.

Based on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADL) for one (#4) of four residents reviewed out of 50 sample residents. Specifically, the facility failed to provide Resident #4 with encouragement and cueing at meals to ensure the resident received adequate nutritional intake. Findings include: A. Resident status Resident #4, age greater than 65, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included dementia, mood disturbance and anxiety. According to the 9/16/24 minimum data set (MDS) assessment, Resident #4 had significant cognitive impairment and was unable to complete the brief interview for mental status (BIMS) assessment. The resident had both short and long term memory problems. She had severely impaired decision making. She required supervision and touching assistance with eating. The assessment documented the resident did not have rejections of care. B. Observations On 9/17/24 during a continuous observation of the dinner meal, beginning at 4:20 p.m. and ending at 4:39 p.m., the following was observed: At 4:20 p.m. Resident #4 was in the dining room. She had her meal in front of her. She was not eating. At 4:27 p.m. the resident continued to sit in the dining room with her meal in front of her. She was picking at her cake with her fingers. She had not received any cueing or encouragement to eat from staff. At 4:34 p.m. she continued sitting at the dining room table. She had not eaten any of her meal. At 4:36 p.m. certified nurse aide (CNA) #1 entered the dining room and asked Resident #4 if she was eating. The resident did not respond. CNA #1 asked the resident if she was finished eating. Resident #4 nodded her head slightly and CNA #1 removed her dinner meal from the table. She had eaten less than 10 percent (%) of her meal. -CNA #1 failed to provide cueing or encouragement to eat to Resident #4. -CNA #1 failed to offer Resident #4 an alternative when she did not eat the meal that was in front of her. At 4:39 p.m. the resident continued to sit at the dining room table after CNA #1 had removed her meal On 9/18/24, during a continuous observation of the brunch meal, beginning at 10:49 a.m. and ending at 11:16 a.m., the following was observed: At 10:49 a.m. Resident #4 received her meal of a waffle, sausage link, a bowl of fruit loops and a shake. A CNA cut up the resident's waffle and left the table. At 11:00 a.m. the resident was not eating. She was drinking the shake, but she had only eaten a couple of bites of the waffle. Resident #4 piled her silverware and drinks onto her plate. -Staff did not offer assistance or encouragement to eat to the resident. At 11:06 a.m. the resident's family member came in and sat with her and talked. At 11:13 a.m. the resident's family member asked the resident if she was done eating and pushed the tray away. -Staff did not observe the resident's plate to see if she had eaten and staff did not offer encouragement to eat to the resident. At 11:16 a.m. the resident was assisted out of the dining room by her family member. -Staff did not observe what the resident had eaten and did not stop her from leaving the dining room. Resident #4 had only eaten bites of her waffle and half of the shake. On 9/18/24 during a continuous observation of the dinner meal, beginning at 4:35 p.m. and ending at 4:55 p.m., the following was observed: At 4:35 p.m. Resident #4 was in the dining room awaiting her meal. At 4:38 p.m. the resident received her meal of salisbury steak, broccoli and mashed potatoes and gravy. At 4:45 p.m. the resident continued sitting at the table with her meal in front of her. -Staff did not offer assistance or encouragement to eat to the resident. At 4:50 p.m. the resident continued to sit at the dining room table without eating her meal. -Staff did not offer assistance or encouragement to eat to the resident. At 4:55 p.m. an unidentified CNA asked the resident if she was ready. The resident did not respond and the CNA pushed her tray away. Resident #4 had not eaten any of her meal. -The unidentified CNA failed to provide cueing or encouragement to eat to Resident #4. -The CNA failed to offer Resident #4 an alternative when she did not eat the meal that was in front of her. C. Record review Review of Resident #4's nutrition care plan, revised 6/19/24, revealed the resident was at risk for inability to maintain nutrition. Pertinent interventions included fair intakes at meals and monitoring and encouraging adequate intake at meals. D. Staff interviews CNA #6 was interviewed on 9/19/24 at 1:58 p.m. CNA #6 said Resident #4 was dependent on staff for all activities of daily living, however, she said she was able to feed herself. She said the resident required supervision and cueing while eating. CNA #6 said at times Resident #4 would yell that she did not need help, however, she said she needed to receive the cueing if she was not eating and alternatives should be offered to the resident. The registered dietitian (RD) was interviewed on 9/19/24 at 3:39 p.m. The RD said Resident #4 was able to feed herself. She said if the resident was not eating, staff was to provide her with encouragement. She said the resident should be offered an alternative if she did not eat her meal. The interim director of nursing (IDON) was interviewed on 9/19/24 at approximately 3:30 p.m. The IDON said Resident #4 was able to feed herself, however, she said at times the resident got upset if she was assisted. The IDON said if the resident was not eating, the staff needed to provide encouragement to her.

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was not greater than five percent (%). Specifically, the facility's medication error rate was 7.69% or two errors out of 26 opportunities for error. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), Elsevier, St. Louis Missouri, pp. 606-607, was retrieved on 9/24/24, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, the right route, the right time, the right documentation and the right indication. II. Facility policy and procedure The Medication Administration Times policy was provided by the nursing home administrator (NHA) on 9/16/24 at 1:57 p.m. It read in pertinent part, Med pass times: 7:00 a.m.-11:00 a.m. 11:00 a.m. -3:00 p.m. 3:00 p.m.-11:00 p.m. 4:00 p.m.-9:00 p.m. 12:00 a.m. -3:00 a.m. III. Observations On 9/19/24 at 11:39 a.m. registered nurse (RN) #1 was preparing and administering medications to Resident #49. The orders included: -Aspirin EC (enteric coated) delayed release 81 milligrams (mg), one tablet by mouth one time a day for heart health. Scheduled for 7:00 a.m. to 11:00 a.m. -Lisinopril 10 mg, 0.5 tablet by mouth one time a day for hypertension. Scheduled for 7:00 a.m. to 11:00 a.m. -RN #1 gave the two medications at 11:39 a.m. (39 minutes after the allowed administration time). D. Staff interviews RN #1 was interviewed on 9/19/24 at 11:39 a.m. RN #1 said a few of the residents on the unit were having a hard day and he had to re-approach one of them later to see if they would take their medications, which slowed down the medication administration. The interim director of nursing (IDON) and the NHA were interviewed together on 9/19/24 at approximately 3:30 p.m. The IDON and the NHA said they were surprised that the medications were given late. The IDON said that RN #1 spent a lot of time with the residents and the residents loved him.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored in one of two medication refrigerators. Specifically, the facility failed to: -Ensure the medication refrigerator was locked when left unattended; and, -Ensure controlled medications were locked in a double locked area inside the medication refrigerator. Findings include: I. Professional reference According to Treas, L.S., [NAME], et.al. (2022) [NAME] Advantage for Basic Nursing (3 ed.), p. 1975, was retrieved on 9/25/24, Controlled substances must be double locked stored in locked drawers within a second locked area. According to the United States Drug Enforcement Administration (DEA) (4/10/18), was retrieved on 9/25/24 from https://www.dea.gov/drug-information/drug-scheduling. Lorazepam (Ativan) is a Schedule IV controlled substance. II. Observations On 9/16/24 at 9:26 a.m., the padlock on the Pine Ridge medication refrigerator behind the nurse's station was unlocked. The nurse's station was a U-shaped desk with two small entrances on each end. Behind the desk, were shelves lining the walls, and a medication refrigerator on the left-sided counter. The nurse's station was not locked. On 9/19/24 at 9:33 a.m. the padlock on the Pine Ridge medication refrigerator was unlocked. At 10:05 a.m. the padlock on the Pine Ridge medication refrigerator was unlocked. At 10:25 a.m. the padlock on the Pine Ridge medication refrigerator was unlocked and there were multiple doses of insulin and there were eye drops. There was a black lock box inside the refrigerator with a chain attaching it to the refrigerator shelf. There were no nurses in the vicinity. There were two non-facility employees from a hospice agency within a few feet of the refrigerator doing paperwork, and three residents in wheelchairs sitting just outside the nurse's station. At 10:36 a.m. registered nurse (RN) #2 locked the Pine Ridge medication refrigerator. III. Staff interviews RN #2 was interviewed on 9/19/24 at 1:30 p.m. RN #2 said she did not know the code for the lock that was on the outside of the refrigerator. She said the lock on the medication box inside the fridge was difficult to open. The NHA was interviewed on 9/19/24 at approximately 3:30 p.m. The NHA said the staff had reported difficulty opening the locks and that may have been why the refrigerator was unlocked. The NHA said he had not addressed the concerns regarding the staff having difficulty opening the locks on the medication refrigerator. IV. Facility follow-up On 9/20/24 at 10:26 a.m. (after the survey exit) the NHA provided pictures of a sign that was posted on the outside of all of the medication refrigerator doors that said, in pertinent part, Both the outside and inside locks have to be locked in order to be compliant.

Based on interviews and record review, the facility failed to ensure two (#65 and #77) out of 44 sample residents were kept free from abuse. Specifically, the facility: -Failed to prevent two resident-to-resident altercations between Resident #65 and #64; and, -Failed to prevent a resident-to-resident altercation between Resident #65 and #77. Findings include: I. Facility policy and procedure The Abuse and Neglect policy, revised March 2018, was provided by the director of nursing (DON) on 5/15/23 at 11:21 a.m., included in part, Abuse is defined as 'the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or anguish.' Willful means' the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.' II. Altercation on 5/7/23 A. Record review for Resident #64 A progress note from Resident #64's record dated 5/7/23 at 8:54 p.m. included, Certified nurse aide (CNA) called for staff to come to pt's (patient's, Resident #64's) room. CNA was redirecting another resident (Resident #65) that had entered Resident #64's room. Once CNA got (sic) Resident #65 to sit in the wheelchair and taking her out of the room, Resident #64 came towards staff and Resident #65 at which time Resident #64 slapped Resident #65 across her face. B. Record review for Resident #65 A progress note from Resident #65's record dated 5/7/23 at 9:00 p.m. included, CNA called staff to Resident #64's room. Resident #65 had wandered into Resident #64's room. The CNA went to get a wheelchair for Resident #65 and while the CNA was attempting to get Resident #65 to sit in the wheelchair, Resident #64 approached this CNA and Resident #65. CNA tried to redirect Resident #64 and reassure him she was taking Resident #65 out of his room, Resident #64 slapped Resident #65 in the face as the CNA attempted to take Resident #65 out of the room, Resident #64 continued to try and grab at this resident. CNA was able to separate both residents. Registered nurse (RN) assessed Resident #65 with no injuries found. The interdisciplinary team (IDT) note dated 5/8/23 at 8:58 a.m. noted, Observe whereabouts when resident (#65) near room. Stop sign replaced back to door frame. The progress note dated 5/8/23 at 10:29 a.m. included, No injuries noted to Resident #65 from being slapped in the face by (sic) Resident #64. The facility unsubstantiated alleged abuse. -However, the abuse should have been substantiated with Resident #64 slapping Resident #65. III. Altercation #1 on 5/14/23 A. Record review for Resident #64 The progress note dated 5/14/23 at 6:38 p.m. included, CNA reported that she heard Resident #64 yelling 'Hey get out of here'. CNA ran to room from dining room and saw Resident #65 next to Resident #64's bed and bedside table. Resident #64 noted with his hand connecting to Resident #65's right side of face. Resident #65 had removed the stop sign from doorway previously as CNA reported it, they were not in place (the room) at time of incident. The IDT note dated 5/17/23 at 9:47 a.m. noted, IDT review of behaviors and interventions not being effective. Will move to the general population today to (room number). The hall was quiet and will not have residents wandering in his room or agitating him. Wanderguard will be placed on him, as he does have delusions and feels he needs to leave at times. Son and doctor will be informed. B. Record review for Resident #65 The progress note dated 5/14/23 at 7:14 p.m. included, CNA reported that she heard Resident #64 yelling, 'Hey get out of here.' CNA ran to the room from the dining room and saw Resident #65 next to Resident #64's bed and bedside table. Resident #65 noted with Resident #64's hand connecting to Resident #65's right side of face. Resident #65 not fearful of others. Pleasant after incident walking around and / or sitting in dining room playing with activities gadgets. The progress note dated 5/14/23 at 9:49 p.m. noted, Resident #65 not fearful of others. Pleasant and smiling in the dining room after the incident. Engaging in activities things at dining room table. The facility unsubstantiated alleged abuse. -However, the abuse should have been substantiated with Resident #64 slapping Resident #65. IV. Altercation #2 on 5/14/23 A. Record review for Resident #65 The progress noted dated 5/14/23 at 7:14 p.m. included, CNA reported that Resident #65 was walking around in dining room touching things and went to grab Resident #77s drink. Resident #77 held her drink and told Resident #65 to stop touching her drinks. Resident #65 got upset that Resident #77 wouldn't let her have the drink and then Resident #65 slapped Resident #77 in her face open handed. B. Record review for Resident #77 The progress noted dated 5/14/23 at 7:19 p.m. included, CNA reported Resident #65 was walking around in the dining room touching things and went to grab Resident #77's drink. Resident #77 held her drink and told Resident #65 to stop touching her drinks. Resident #65 got upset that Resident #77 would not let her have the drink and Resident #65 slapped Resident #77 in her face open handed. The progress note dated 5/14/23 at 7:30 p.m. noted, Resident #77 not fearful of others after the incident. Resident was in dining room socializing with others. She did not isolate self from others after incident. Pt happy and smiling with staff. Voiced no pain. The facility unsubstantiated alleged abuse. -However, the abuse should have been substantiated with Resident #65 slapping Resident #77. V. Resident #64 A. Resident status Resident #64, over the age of 90, was admitted on [DATE]. According to the May 2023 computerized physicians orders (CPO), diagnoses included dementia and hypertension. The 4/8/23 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of three out of 15. He displayed the identified behaviors of physical behavioral symptoms directed toward others once, and verbal behavioral symptoms directed toward others twice during the assessment period. B. Record review The care plan, initiated 4/11/22 and revised on 5/10/22, identified he had an increased potential for alteration in mood and behavior related to a history of depression as evidenced by he did not like others to enter his room and he can become combative. Interventions included: -Keep Resident #64 a safe distance from residents he may seem to be irritable with or has a history of not getting along with. -Put a STOP banner across the door to deter other residents from wandering into his room. Staff will monitor and ensure others are not trying to remove or enter his room unknowingly. -The care plan was not updated after the 5/14/23 altercation. VI. Resident #65 A. Resident status Resident #65, age 76, was admitted on [DATE]. According to the May 2023 CPO, diagnoses included Alzheimer's disease and dementia. The 3/25/23 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of zero out of 15. She displayed the identified behaviors of physical behavioral symptoms directed toward others twice, and verbal behavioral symptoms directed toward others twice during the assessment period. B. Record review The care plan, initiated 7/24/22 and revised on 3/6/23, included that the resident was dependent on staff for meeting emotional, intellectual, physical, spiritual and social needs related to cognitive deficits as evidenced by the resident becoming aggressive toward staff and other residents. She will do her own thing and may become agitated when directed toward other things. Interventions include: -All staff to converse with resident while providing cares. The care plan, initiated 10/20/22 and revised on 12/29/22, identified behaviors as evidenced by there are days the resident may become physically and verbally aggressive/inappropriate towards staff and others due to poor impulse control secondary to dementia. Interventions include: -The resident can become physically aggressive towards others usually due to poor impulse control. -The resident can become verbally aggressive at times. -If the resident becomes agitated, intervene before she escalates, redirect her, engage calmly in conversation. If she continues, direct staff to walk calmly away, keeping her safe and approach later. -The resident's care plan was not updated after the altercations on 5/7/23 and 5/14/23. VII. Resident #77 A. Resident status Resident #77, age 88, was admitted on [DATE]. According to the May 2023 CPO, diagnoses included dementia and anxiety. The 3/7/23 minimum data set (MDS) assessment revealed the resident's cognitive status was severely impaired with a brief interview for mental status (BIMS) score of three out of 15. She displayed the identified behaviors of physical behavioral symptoms directed toward others once, verbal behavioral symptoms directed toward others once, and other behavioral symptoms not directed toward others once during the assessment period. B. Record review The care plan, initiated 4/8/23, identified behaviors as evidenced by there are days the resident may become physically and verbally aggressive/inappropriate towards staff and others due to poor impulse control secondary to dementia. Interventions include: -The resident can become physically aggressive towards others usually due to poor impulse control. -The resident can become verbally aggressive at times. -If the resident becomes agitated, intervene before she escalates, redirect her, engage calmly in conversation. If she continues, direct staff to walk calmly away, keeping her safe and approach later. -The resident's care plan was not updated after the 5/14/23 altercation. VIII. Interviews CNA #1 was interviewed on 5/17/23 at 9:21 a.m. She said Resident #64 wanted to leave the unit on several occasions. She said when he did that, she redirected him and engaged with him. She said he could be aggressive and strike out at staff and other residents. She said he did not like other people in his room or walking in front of his room door. She said when he became aggressive toward others, she would remove the other resident from the area, talk calmly to him, and redirect him. She said when there was an altercation, she reported it to the on call nurse and the social services (SS) department. She said Resident #64's normal behavior included sitting at a table in the dining room. Licensed practical nurse (LPN) #1 was interviewed on 5/17/23 at 9:30 a.m. She said Resident #64 had aggressive behaviors when someone would enter his room or stand in his doorway. She said he could be difficult to redirect and he became angry easily. She said if there was a resident to resident altercation she removed the residents from each other and would check for injuries. She would call the on-call nurse and let SS staff know there was an altercation. She said she would start an incident report and notify the family and medical provider. She said at that point the SS staff took over the investigation. The social services director (SSD) was interviewed on 5/17/23 at 10:24 a.m. She said Resident #64's biggest challenge was keeping people out of his room and away from his doorway. She said the IDT team reviewed the incidents and had implemented a stop sign in front of the door, but after a while the stop sign irritated him. She said the facility was going to try to move Resident #64 out of the memory care on a quiet hall with less wandering residents and see how he did. She said Resident #65 was difficult to redirect and often became more agitated, but she would respond sometimes to one-on-one talks and some activities. She said every resident had the right to live free from abuse. She said the IDT team would meet and discuss every resident to resident altercation and at that time would re-evaluate the interventions. The DON was interviewed on 5/17/23 at 1:10 p.m. She said if staff saw/discovered a resident to resident altercation, the staff would separate the residents and check for injuries. She wanted the staff to notify the medical provider, the family, the SSD and herself. She said the altercations were reviewed in the IDT team meeting. CNA #1 was interviewed again on 5/18/23 at 9:25 a.m. She said Resident #65 had behaviors that included hitting, scratching, biting, pinching, spitting and throwing water on people. She said Resident #64 liked to take things from other people and would become upset when anyone tried to take the items back. She said redirection worked well and gave her something else to do. Registered nurse (RN) #4 was interviewed on 5/18/23 at 9:45 a.m. She said Resident #65 had behaviors that included hitting, kicking, pinching, scratching during cares and spitting. She said her triggers varied, but were more frequent when she tried to take something that was not hers and staff tried to intervene. Staff tried to redirect her with activities, gadgets and talking which sometimes worked and sometimes giving her space. If any resident was involved in an altercation, the staff separated the residents, assessed for harm, and notified the family, medical provider and the SS staff to complete the investigation.

Based on interviews and record review, the facility failed to report resident to resident altercations for three (#65, #64 and #77) out of 44 sample residents. Specifically, the facility: -Failed to report two resident-to-resident altercations between Resident #65 and #64; and, -Failed to report a resident-to-resident altercation between Resident #65 and #77. Findings include: I. Facility policy and procedure The Abuse Investigation and Reporting policy, revised July 2017, was provided by the director of human services (HR) on 5/18/23 at 10:47 a.m., included in part, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately, but not later than: -Two hours if the alleged violation involves abuse or has resulted in serious bodily injury; or -Twenty-four hours if the alleged violation does not involve abuse and has not resulted in serious bodily injury. II. Altercations The facility failed to report three resident to resident altercations: one on 5/7/23, and two on 5/14/23. Cross-reference 600 abuse. The resident to resident altercation on 5/7/23 noted, CNA (certified nurse aide) called staff to Resident #64's room. Resident #65 had wandered into Resident #64's room. The CNA went to get a wheelchair for Resident #65 and while the CNA was attempting to get Resident #65 to sit in the wheelchair, Resident #64 approached this CNA and Resident #65. CNA tried to redirect Resident #64 and reassure him she was taking Resident #65 out of his room, Resident #64 slapped Resident #65 in the face as the CNA attempted to take Resident #65 out of the room, Resident #64 continued to try and grab at this resident. CNA was able to separate both residents. Registered nurse (RN) assessed Resident #65 with no injuries found. The resident to resident altercation #1 on 5/14/23 noted, CNA reported that she heard Resident #64 yelling 'Hey get out of here'. CNA ran to room from dining room and saw Resident #65 next to Resident #64's bed and bedside table. Resident #64 noted with his hand connecting to Resident #65's right side of face. Resident #65 had removed the stop sign from doorway previously as CNA reported it, they were not in place (the room) at time of incident. The resident to resident altercation #2 on 5/14/23 noted, CNA reported that Resident #65 was walking around in dining room touching things and went to grab Resident #77's drink. Resident #77 held her drink and told Resident #65 to stop touching her drink. Resident #65 got upset that Resident #77 wouldn't let her have the drink and then Resident #65 slapped Resident #77 on her face open handed. III. Interviews The social services director (SSD), who was the abuse officer, was interviewed on 5/17/23 at 10:24 a.m. She said she was following the State Agency reporting requirements and was not aware they were different from the Federal requirements. She said the residents involved in the altercations resided on the memory care unit and often would forget the altercation right after. She said due to the dementia diagnosis there would be no willful intent. She did not agree the altercations were reportable. She said she tried to enter the incidents to the State Agency reporting portal and she would hit a wall and not be allowed to input further. She said she had received correspondence from the State Agency that the incidents did not meet the State occurrence criteria for reporting. The director of nursing (DON) was interviewed on 5/17/23 at 1:30 p.m. She said the incidents had been reported, but the facility had hit a wall when reporting to the State Agency portal and could not continue. She said the State Agency had sent communications back to the facility that the incidents did not meet the reporting criteria. She said the facility would reach out for more information. -However, according to Federal guidelines, all allegations of abuse and/or abuse that did not involve serious bodily harm need to be reported to the State Agency within 24 hours.

Based on record review and interviews, the facility failed to ensure licensed nurses were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to ensure nursing staff had completed competencies in the past 12 months prior to providing skilled services as described in the plan of care for two out of three registered nurses (RN) and two of six certified nurse aides (CNA) reviewed for competencies. Findings include: I. Resident census and conditions According to the resident census and conditions provided by the director of nursing (DON) on [DATE] at 10:50 a.m., the facility had: -Four residents with an indwelling catheter, and, -Residents who needed the assistance of one to two staff: 58 with bathing, 56 with dressing, 57 with transferring, 62 with toilet use and 39 with eating. II. Record review RN #4, RN #6, CNA #5 and CNA #7 did not have competencies completed for identified conditions in the facility, specifically catheter care and activities of daily living (ADLs). III. Interviews The director of nursing was interviewed on [DATE] at 1:30 p.m. She said she did not know the competencies of some of the nursing staff had expired. She said it was important to ensure the skills of staff performing cares for the safety of the residents. She said going forward the facility would complete competencies annually. The assistant director of nursing (ADON) was interviewed on [DATE] at 9:30 a.m. She said CNA #5 had not had a skills competency completed since [DATE]. She said RN #4, RN #6 and CNA #7 had not completed annual skill competencies. She said the facility had performed random hand washing check offs, but had not completed a completed skill competency assessment on staff. She said going forward she would ensure staff had annual competencies completed. The HR director communicated by electronic mail on [DATE] at 11:54 a.m. It documented he could not locate current competencies for RN #4, RN #6 and CNA #7.

Based on record review, observations and interviews, the facility failed to ensure three (#33, #22 and #29) of five residents were free from unnecessary psychotropic medications out of 44 sample residents. Specifically, the facility failed to: -Monitor targeted behaviors, side effects, and provide non-pharmacological interventions for psychotropic medications for Resident #33, #22 and #29; and, -Ensure a risk/benefit statement or a gradual dose reduction was completed for psychotropic medications for Resident #33 and Resident #22. Findings include: I. Facility policy and procedure The Psychotropic Medication policy, dated July 2022, was provided by the director of nursing (DON) on 5/16/23 at 2:46 p.m. It revealed in pertinent part, Psychotropic medication management includes: Indications for use, dose, duration, adequate monitoring for efficacy and adverse consequences, and preventing, identifying and responding to adverse consequences. Considerations for the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify causes. Residents on psychotropic medications receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, in an effort to discontinue these medications. II. Resident #33 A. Resident status Resident #33, age 86, was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the diagnoses included mild cognitive impairment, depressive episodes and unspecified dementia. The 3/21/23 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview of mental status (BIMS) score of eleven out of 15. No behaviors were identified for the resident. B. Resident interview Resident #33 was interviewed on 5/15/23 at 9:43 a.m. She stated she preferred to stay in her room, she used to go to the activities but the activities were repetitive. She denied depression and said she had become accustomed to living in the facility. C. Record review The mood care plan, revised on 10/13/21, revealed the resident was taking an antidepressant medication related to depression. Interventions indicated to monitor and document adverse reactions and to monitor and document changes in behavior/mood/cognition. -The care plan failed to reveal non-pharmacological interventions. The May 2023 CPO revealed the following physician orders for psychotropic medications: -Sertraline (Zoloft) 100 MG (milligrams)- give one tablet by mouth twice a day for depressive episodes- ordered 9/20/21. -No decreases in dose were located in discontinued and completed orders. -The CPO failed to reveal an order for side effect monitoring for the Sertraline. A review of the physician visit notes revealed in pertinent part: The 12/21/22 visit note documented the resident was negative for anxiety, depression, hallucinations and suicidal ideations. The 2/2/23 visit note documented the resident was negative for anxiety, depression, hallucinations and suicidal ideations. The 4/6/23 visit note documented the resident was negative for anxiety, depression, hallucinations and suicidal ideations. A depression assessment dated [DATE] revealed the resident had a score of three indicating the absence of a depressive disorder. The patient health questionnaire-9 (PHQ-9) for depression dated 3/21/23 revealed the resident had a score of two indicating the absence of a depressive disorder. The behavior monitoring task for the certified nurse aide (CNA) dated 4/19/23 to 5/18/23 failed to reveal signs and symptoms of depression. The psychoactive medication quarterly evaluation dated 12/9/22 revealed the Sertraline 100 MG was reviewed. The behavior warranting the use of the medication was loss of independence. -The rest of the evaluation was incomplete. The psychoactive medication quarterly evaluation dated 1/20/23 revealed the Sertraline 100 MG was reviewed. The behavior warranting the use of the medication was loss of independence. -There were no changes or recommendations indicated. The psychoactive medication quarterly evaluation dated 4/14/23 revealed the Sertraline 100 MG was reviewed. The behavior warranting the use of the medication was loss of independence with activities. A risk/benefit was recommended 1/24/23 according to the evaluation. -No risk/benefit statements for the depression medication were located in the resident's medical record. Progress notes dated 12/6/22 to 5/17/23 revealed: -No progress notes were located documenting depressive symptoms or behaviors. -No progress notes were located documenting a risk/benefit had been provided by the physician or a gradual dose reduction of the Sertraline had been discussed. III. Resident #22 A. Resident status Resident #22, age 83, was admitted on [DATE]. According to the May 2023 CPO, the diagnoses included altered mental status, Alzheimer's disease and other specified eating disorders. The 4/8/23 MDS assessment revealed the resident had moderately cognitive impairment with a BIMS score of eight out of 15. No behaviors were identified for the resident. B. Observations The resident was observed in bed in her room on 5/15/23 at 10:02 a.m. with no Plexiglas (hard plastic) sheet present on the wall next to bed (see care plan below). An observation of the resident's room on 5/16/23 at 10:10 a.m. revealed no Plexiglas sheet was present on the wall next to bed. An observation of the resident's room on 5/17/23 at 11:06 a.m. revealed no Plexiglas sheet was present on the wall next to bed. C. Record review The behavior care plan, revised on 7/24/2020, revealed the resident had behaviors of pulling paint off the wall and eating it. Interventions indicated to place a Plexiglas sheet on the wall beside the resident's bed. The mood care plan, revised on 10/13/21, revealed the resident was taking an antidepressant medication for the behavior of eating paint chips and washcloths. Interventions indicated to educate the resident/family/caregivers about risk, benefits, and the side effects of the antidepressant drugs being given, monitor and document adverse reactions and to monitor and document changes in behavior/mood/cognition. According to the mood care plan, the antidepressant was reviewed on 5/14/2020, 8/10/2020, 11/9/2020, 2/8/21, 5/10/21, 8/11/21, 11/17/21, 2/9/22, 8/26/22 and 11/11/22 with no changes to the medication. -The care plan failed to reveal non-pharmacological interventions. The May 2023 CPO revealed the following physician orders for psychotropic medications: -Sertraline (Zoloft) 50 MG- give one tablet by mouth three times a day for PICA (eating disorder)- ordered 2/1/2020. -No decreases in dose were located in discontinued and completed orders. Monitor behavior: PICA. I have an alteration in behavior. I will often pull the paint off the wall and eat it.-ordered 5/16/23 (during survey). -There were no interventions listed with monitoring of the behavior. -The CPO failed to reveal side effect monitoring for the Sertraline. A review of the physician visit notes revealed in pertinent part: The 12/9/22 visit note documented a gradual dose reduction was deferred and a risk/benefit was issued 3/22. No behaviors indicated. The 2/5/23 visit note documented a gradual dose reduction was deferred and a risk/benefit was issued 3/22. No behaviors indicated. The 3/5/23 visit note documented a gradual dose reduction was deferred and a risk/benefit was issued 3/22. No behaviors indicated. The behavior monitoring task for the CNA dated 4/19/23 to 5/18/23 revealed there was not a behavior of eating paint or washcloths listed to monitor for. The psychoactive medication quarterly evaluation dated 11/11/22 revealed the Sertraline 150 MG was reviewed. The behavior warranting the use of the medication was eating non-food items. The comment section documented a risk/benefit 3/6/22 but did not indicate if it had been completed. The psychoactive medication quarterly evaluation dated 2/10/23 revealed the Sertraline 150 MG was reviewed. The behavior warranting the use of the medication was picking at the wall or eating what she was able to pick off. A risk/benefit was requested. The psychoactive medication quarterly evaluation dated 5/12/23 revealed the resident's Sertraline 150 MG was reviewed. The behavior warranting the use of the medication was PICA. According to the evaluation, a risk/benefit was due. -No risk/benefit statements for the depression medication were located in the resident's medical record. Progress notes dated 6/10/22 to 5/17/23 revealed: Social services note dated 6/10/22 revealed the resident remained on Sertraline for PICA related behaviors. The resident was stable and her behaviors had improved. Social services note dated 8/26/22 revealed an increase in the Sertraline was requested related to the resident continuing to have behaviors. -The note did not indicate what behaviors. Social services note dated 1/20/23 revealed the resident would wander into other resident's rooms and take snacks or drinks but was easily redirected and reminded to be respectful of boundaries. Social services note dated 2/10/23 revealed a risk/benefit would be requested. Social services note dated 4/12/23 revealed the resident would wander into other resident's rooms and take snacks or drinks but is easily redirected and reminded to be respectful of boundaries. Social services note dated 5/12/23 revealed a risk/benefit had been requested. -No progress notes were located documenting a gradual dose reduction of the Sertraline had been discussed. -No progress notes were located documenting behaviors. IV. Staff interviews CNA #8 was interviewed on 5/15/23 at 9:43 a.m. The CNA stated Resident #22 picked paint off of the wall in her room next to her bed but the CNA had not observed the behavior. Registered nurse (RN) #2 was interviewed on 5/15/23 at 12:30 p.m. Resident #22 had behaviors of picking paint off of the wall. She had never seen her eat paint. The staff tried to keep her out of her room as much as possible and not too close to walls. The resident had a Plexiglas sheet on her wall so she could not pick the paint, but she had not displayed that behavior since March 2023. RN #2 said the nurses completed behavior tracking on the resident's medication administration record (MAR) but the RN did not find any behaviors on Resident #22's MAR. The CNA tracked behaviors in the resident's tasks but she did not have behaviors of eating non-food items on the tasks. RN #2 said Resident #33 did not have any behaviors and her depression had improved in the last three months. RN #2 said if a resident had behaviors, the nurses would report the behaviors to the social worker. The only psychotropic medications the nurses tracked in the MAR were antipsychotics and the nurses did not track side effects for any psychotropic medications. Licensed practical nurse (LPN) #4 was interviewed on 5/15/23 at 12:45 p.m. She said she took care of Resident #22 before the resident moved to her new room in March 2023. She said Resident #22 had not eaten paint off of the wall since November 2022. CNA #9 was interviewed on 5/16/23 at 1:36 p.m. The CNA stated the CNAs document behaviors in the tasks. The facility management did not communicate to the CNAs what a resident's target behaviors were. The CNA said Resident #33 had no behaviors. The CNA said Resident #22 used to wander the facility and eat paint off the walls but had not done this behavior since moving to her new room in March 2023. The interventions were to stop her and redirect her to an activity. The social services director (SSD) was interviewed on 5/16/23 at 1:46 p.m. The facility had a monthly meeting to review residents who were on psychotropic medications. The meeting included the medical director, pharmacist, DON, MDS coordinator and the SSD. During this meeting, the risk/benefits, gradual dose reductions and behaviors were reviewed to determine if a resident would continue with medications. The pharmacist determined when a gradual dose reduction or risk/benefit was appropriate. If there were no progress notes for 90 days, a gradual dose reduction would be recommended. If there were no documented behaviors for 90 days, the medication would be reduced or discontinued. The SSD did not know where the risk/benefit statements, behavior tracking or gradual dose reductions were in the resident's medical records. Residents had behavior tracking if they were taking psychotropic medications or displaying behaviors. The SSD said antidepressants were only tracked with the quarterly PHQ-9 scores and the facility staff and managers were not consistent with documenting behaviors; the staff usually gave reports of behaviors verbally to her. The SSD did not document these verbal reports in the resident's medical record. The SSD stated Resident #33 took antidepressants for depression related to her loss of independence. She did not think Resident #33 had gradual dose reductions because she continued to be depressed. The only non-pharmacological intervention for Resident #33 was counseling but she often did not want to attend. The SSD stated Resident #22 took antidepressants for a picking disorder but the SSD said she never saw the resident picking non-food items and eating them. Resident #22 used to have a Plexiglas sheet on her wall to prevent her from picking the paint off the wall but the SSD did not know if the Plexiglas was still on her wall since she moved rooms in March 2023. The SSD said she did not know what the plan was for the Plexiglas sheet. RN #5 was interviewed on 5/17/23 at 11:08 a.m. He stated Resident #33 had no behavioral issues and had not shown signs or symptoms of depression. He stated Resident #22 had no behavioral issues. She had not picked paint and eaten it in a long time. She sometimes would pick up items off the floor or go into other resident's rooms and take things. He would allow her to go into the linen closet and take washcloths as a non-pharmacological intervention because it satisfied her behavior. He said nurses were to document behaviors and side effects in the MAR. For a behavior or side effect to be included on the MAR to track there needed to be a physician order. All psychotropics need tracking for behaviors and side effects. He was unable to locate orders or tracking for behaviors and side effects in Resident #33 or Resident #22's medical records. The SSD was interviewed again on 5/17/23 at 1:55 p.m. She was not aware Resident #33 had low PHQ-9 scores for the last five months. She said the PHQ-9 score was not always accurate and the management team would discuss behaviors reported to them when considering continuing a medication. She acknowledged the verbal reports given to her by staff were not corroborated by documentation. The DON and MDS coordinator were interviewed on 5/17/23 at 2:31 p.m. The DON stated target behaviors were identified through staff communication but not tracked in the MAR. Behaviors on the tasks were generic for each resident and not personalized. If a resident was stable for a three month period, this would trigger a gradual dose reduction to be considered for the psychotropic medication. Non-pharmacological interventions were in the resident's care plan or the CNA tasks. According to the MDS coordinator, it was important to track non-pharmacological interventions because the facility should try non-pharmacological interventions before psychotropic medications. The DON stated she had identified the facility was not tracking behaviors and side effects for psychotropic medications. She said an audit of the resident records would be started to add behavior tracking and side effects for all residents on psychotropic medications. 40960 V. Resident #29 A. Resident status Resident #29, age 90, was admitted on [DATE]. According to the May 2023 CPO, the diagnoses included post-traumatic stress disorder (PTSD), specified depressive episodes, unspecified psychosis not due to a substance or known physiological condition, cognitive communication deficit and anxiety disorder. The 3/15/23 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS of 12 out of 15. He required limited assistance with most of his activities of daily living (ADLs). He had no delusions or hallucinations. He had no behaviors and did not reject care. He received an antidepressant and an antipsychotic daily. B. Observations Resident #29 was observed intermittently in his room throughout each day of the survey on the following dates and times: -5/15/23 at 1:12 p.m. sitting in his wheelchair in his room; -5/16/23 at 11:37 a.m. sleeping in his recliner; -5/17/23 at 11:21 a.m. sleeping in his recliner; and, -5/17/23 at 12:48 p.m. sleeping in his recliner. C. Record review Physician orders -1/21/21 Fluphenazine (antipsychotic medication) 0.5 milligrams (mg) daily. -2/3/21 discontinue Fluphenazine and start Aripiprazole (antipsychotic medication) 10 mg daily. -2/15/21 increase Aripiprazole to 15 mg daily. -2/24/21 discontinue Aripiprazole and started Risperidone (antipsychotic medication) 1 mg twice daily. -5/17/23 increase Risperdone to 1 mg three times a day. The May 2023 CPO showed the resident had the following medication prescribed for behaviors: -Risperidone 1 mg (milligram) two times a day for psychosis. The start date was 2/24/21. -The Risperidone was increased to 1 mg three times a day on 5/17/23. -Sertraline (antidepressant) 50 mg give two tablets one time a day for depression. The start date was 3/11/23. -The CPO did not identify the specific diagnoses for the use of the antipsychotic medication. Care Plans The antipsychotic care plan, initiated 11/17/21, revealed Resident #29 was at increased risk for complications of an antipsychotic medication. Interventions included: -Administer medications as ordered by the physician. -Monitor for side effects and effectiveness. -Attempt non-drug approaches to assist to redirect behaviors. -Discuss with physician and family re ongoing need for use of the medication. -Review behaviors/interventions and alternative therapies attempted and their effectiveness as per facility policy. -Monitor/document/report as needed reactions of psychotropic medications: unsteady gait, tardive dyskinesia, shuffling gait, rigid muscles, shaking, frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps, nausea, vomiting, and behavioral symptoms not usual to the person. -Monitor/record occurrence of target behavior symptoms (hallucinations). The antidepressant care plan, initiated 8/8/21, revealed Resident #29 was at increased risk for adverse reactions related to using antidepressant medications. Interventions included: -Administer medications as ordered by the physician. -Monitor for side effects and effectiveness. -Attempt non-drug approaches to assist to redirect my behaviors as appropriate. -My behaviors are exhibited by verbal statements of depression related to loss of independence. Progress notes The 5/2/23 behavior note revealed the resident was having multiple hallucinations. He was in his doorway talking about dogs, cats, and his ex wife falling out of bed. He was very disoriented and had an unsteady gait. He was given multiple redirections with minimal success. The 5/16/23 health status note at 9:19 a.m. revealed the resident was having hallucinations and delusions. The resident was seeing people in his room that had been dead for years. He thought he had to go to court and was getting thrown out of the facility. The resident was reassured and the physician was notified. The 5/16/23 health status note at 12:59 a.m. revealed the resident was having hallucinations. The resident thought a kitten was dead in his room. The physician was notified. The 5/17/23 health status note revealed an increase in Risperidone to 1 mg three times a day per physician. -The facility failed to track behaviors, side effects and non-pharmacological interventions prior to the start of his antipsychotic medication. -The facility failed to update his pre-admission screening resident review (PASRR) level I with the new diagnoses of psychosis and the start of an antipsychotic medication (cross-reference F644). D. Staff interviews CNA #3 was interviewed on 5/17/23 at 1:18 p.m. She said she had only seen Resident #29 have hallucinations during the night. She said he knew when he was hallucinating and would ask staff to just go along with the hallucination. She said he was easily redirected and compliant with care. RN #2 was interviewed on 5/17/23 at 1:48 p.m. She said Resident #29 still was having hallucinations and his delusions changed daily. She said his Risperidone medication was increased related to severe hallucinations and delusions. She said he did not have tracking for behaviors, side effects or non-pharmacological interventions. However, they were going to start tracking for him. She said at the time of survey they had no system in place. The SSD was interviewed on 5/17/23 at 1:53 p.m. She said Resident #29 had hallucinations and delusions that were destressing to him. She said the facility should be tracking the residents' behaviors, side effects and non-pharmacological interventions that were tried. The DON was interviewed on 5/17/23 at 3:30 p.m. She said non-pharmacological interventions were documented on the care plan. However, she said Resident #29 did not have any non-pharmacological interventions in place.

Based on observations, record review, and staff interviews, the facility failed to ensure one (#48) of four residents reviewed were free from physical restraints out of 44 sample residents. Specifically, the facility failed to provide rationale, justification, and a consent for placing a wander guard on Resident #48 to restrict her movements in and around her environment. Findings include: I. Facility policy and procedure The Wandering and Elopement policy, revised March 2019, was provided by the director of nursing (DON) on 5/18/23 at 1:30 p.m. It read in pertinent part: The facility would identify residents who were at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The care plan would include strategies and interventions to maintain the residents' safety. II. Resident #48 A. Resident status Resident #48, age 81, was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the diagnoses included fracture of the left femur (hip), depression, unsteadiness of feet and Alzheimer's disease. The 4/1/23 minimum data set (MDS) assessment revealed, the resident was not assessed for the brief interview for mental status score (BIMS). She had short and long term memory problems, and her cognitive skills for daily decision making were severely impaired. She wandered four to six days out of the seven day look back period. She required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. She had impairment to one side of her lower extremity. She used a walker and a wheelchair. A wander/elopement alarm was used daily. B. Observations Resident #48 was observed on 5/15/23 at 10:17 a.m. participating in the exercise activity in the main lobby. On 5/16/23 at 10:15 a.m. the resident was participating in the exercise activity in the main lobby. At 11:33 a.m. the resident was eating in the dining room. At 12:23 p.m. the resident was still sitting in the dining room watching people. She had a wander guard on her right ankle. At 12:26 p.m. the resident propelled herself out of the dining room down the hallway towards the nurses station. She sat at the nurses station, by the door, and looked outside. On 5/17/23 at 11:24 am. the resident was propelling herself in her wheelchair down the hallway. At 2:24 p.m. propelling her wheelchair to the nurses station. She sat and watched the birds outside through the door. On 5/18/23 at 11:45 a.m. the resident was propelling herself to the front door and spoke with the receptionist. After speaking with the receptionist, she turned herself around and propelled into the main lobby and watched the birds. -No exit seeking behaviors were observed during the observations. III. Record review A. Physician orders The physician order dated 3/28/23 documented a wander guard to the left ankle and evening nurse to check battery every evening. However, the guard was on her right ankle. B. Assessment The wandering risk assessment dated [DATE] revealed the resident had a moderate elopement risk score of 5: 0-3=low risk, 4-7=at risk to wander, and 8-above=high risk to wander. -However, she had no reported episodes of wandering or attempts to leave the facility. C. Care plan The wanderguard care plan, initiated 4/10/23, revealed the resident became confused at times and was at increased risk for elopement and wandering related to disorientation of place. The interventions included: wanderguard order obtained, wander guard battery to be checked every evening by the afternoon nurse and wander guard was placed on the right ankle. -There was no wander guard consent provided or in the resident's medical record. IV. Staff interviews Registered nurse (RN) #2 was interviewed on 5/16/23 at 2:22 p.m. She said when a resident was admitted the facility monitored them for exit seeking behaviors. She said if the facility identified exit seeking behaviors, the MDS coordinator would do an assessment and then call the physician for an order. She said a consent must be signed and she verified there was no consent for the wander guard in Resident #48's record. She said Resident #48 wandered the hallways and went into other resident rooms, but she had never seen her try to leave the facility or exit seek. The MDS coordinator was interviewed on 5/16/23 at 2:35 p.m. She said when a resident was admitted , a wander guard would be placed on a resident if the family had concerns with wandering or exit seeking or if they scored high on the elopement assessment. She said she would then get a physician order and have the family sign a consent. She said the facility would monitor the resident for two weeks to a month and reassess the need for the wander guard. She said if there were no exit seeking behaviors, the wander guard would be discontinued and removed. She said Resident #48's wander guard should have been discontinued since she had no exit seeking behaviors. The social services director (SSD) was interviewed on 5/16/23 at 2:53 p.m. She said the MDS coordinator was responsible for obtaining a physician order and a signed consent for the wander guard. She said wander guards were used with residents who had exit seeking behaviors and wandering without a purpose. She said a consent should be signed for all restraints. She said if the resident showed no signs of exit seeking, the wander guard should be removed. She said Resident #48 had no exit seeking behaviors and her wander guard should have been removed. The DON was interviewed on 5/17/23 at 2:31 p.m. She said all residents with a wander guard should have a consent in place and meet the criteria of wander seeking. She said the resident should be reassessed quarterly for the continued need.

Based on record review and staff interviews, the facility failed to coordinate assessments with the pre-admission screening resident review (PASRR) program for one (#29) of 44 sample residents. Specifically, the facility failed to notify the PASRR program that the resident had started on an antipsychotic medication and had a new diagnosis of psychosis. Findings include: I. Facility policy and procedure The Admission Criteria policy and procedure, revised March 2019, was provided by the social services director (SSD) on 5/18/23 at 8:59 a.m. It read in pertinent part: -All new admissions and readmissions were screened for mental disorders, intellectual disabilities or related disorders per the PASRR process; -The social worker was responsible for making referrals to the appropriate state-designated authority; -Upon completion of a Level II evaluation the state PASRR representative determined if the individual had a physical or mental condition, what specialized or rehabilitation services he or she needed, and whether placement in the facility was appropriate. II. Resident #29 A. Resident status Resident #29, age 90, was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the diagnoses included post-traumatic stress disorder (PTSD), specified depressive episodes, unspecified psychosis not due to a substance or known physiological condition, cognitive communication deficit and anxiety disorder. The 3/15/23 minimum data set (MDS) assessment revealed, the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) of 12 out of 15. He required limited assistance with most of his activities of daily living (ADLs). He had no delusions or hallucinations. He had no behaviors and did not reject care. He received an antidepressant and an antipsychotic daily. III. Record review A. Physician's order -1/21/21 Fluphenazine (antipsychotic medication) 0.5 milligrams (mg) daily. -2/3/21 discontinue Fluphenazine and start Aripiprazole (antipsychotic medication) 10 mg daily. -2/15/21 increase Aripiprazole to 15 mg daily. -2/24/21 discontinue Aripiprazole and started Risperidone (antipsychotic medication) 1 mg twice daily for diagnosis of psychosis. -5/17/23 increase Risperdone to 1 mg three times a day. B. Care plans The PTSD care plan, initiated 2/2/21, revealed Resident #29 had a diagnosis of PTSD and indicated he felt numb or detached from people, activities and surroundings due to a traumatic experience in his life. Interventions included: -Resident #29 refused counseling or psych consult for PTSD; -Keep resident safe during moments of delusions or hallucinations; and, -Report changes in mood or behaviors. The hallucinations care plan, initiated 2/1/21, revealed Resident #29 had been having audio and visual hallucinations. The interventions included: -Administer medications as ordered; -Anticipate and meet the residents needs; -Monitor episodes and attempt to determine underlying etiology/cause; and, -Reassure and validate as needed. -There was no care plan in the resident's medical record related to PASRR. C. PASRR The PASRR level 1 screening was completed in September 2019 which revealed a diagnosis of mild depression, a diagnosis of Alzhiemers/dementia and it noted the resident received Sertraline (antidepressant medication) 50 mg by mouth daily. -It did not identify his diagnosis of PTSD. -It was unclear why the resident was given the diagnosis of psychosis nor why he required the antipsychotic medication (cross-reference F758 for unnecessary medication). -The facility failed to provide the PASRR program with the resident's new diagnosis and start of an antipsychotic medication. IV. Staff interviews The social services director (SSD) was interviewed on 5/17/23 at 1:53 p.m. She said Resident #29 had hallucinations and delusions which were distressing to him. She said he had been having delusions and hallucinations for quite awhile. She said his primary care physician (PCP) gave the psychosis diagnosis. She said she did not know she was still required to report a change in a medication category or with the new diagnosis. She said a PASRR level I should be updated when there were worsening symptoms and she probably should have updated his PASRR. The director of nurses (DON) was interviewed on 5/17/23 at 3:30 p.m. She said she believed an update to the PASRR program for a level I assessment should have been done to determine if a level II was required. She said Resident #29 would benefit from a correct PASRR assessment with an accurate diagnosis, non-medication interventions and justification for the medication.

Based on record review, observations and interviews, the facility failed to ensure four (#15, #16, #49, and #2) of five residents received adequate supervision to prevent accidents out of 40 sample residents reviewed. Specifically, the facility failed to develop and implement a person-centered care plan that identified the resident's fall risk and put effective interventions into place to reduce falls and prevent injury for Resident #15, #16 and #49. Resident #15 was identified as a fall risk within the comprehensive care plan. The facility failed to identify the resident's patterns throughout the day and put personalized and effective interventions into place to prevent falls. The fall risk care plan was put into place on 1/4/18 which identified the resident as a fall risk. On 6/25/21, Resident #15 fell in her room and sustained a fracture to the right clavicle, fracture to the right maxillary sinus, subdural hematoma (blood on the brain) and had stitches around her right eye requiring hospital treatment. The facility put a room camera in her room with a monitor at the nursing station and a low bed with a safety mat. After the initial fall and major injury, the resident fell an additional six times, one with another major injury on 9/6/21, a distal radius fracture (two forearm bones on the thumb side) and ulna fracture (forearm bone on the pinky finger side). Resident #16, who was a documented fall risk upon admission to the facility, fell on [DATE] and sustained a distal clavicle fracture. The facility failed to put person-centered approaches in place to prevent falls and subsequent major injury. Resident #49 was documented to be at an increased risk for falls. The resident sustained two falls within two days. The facility failed to put any person centered approaches in place to prevent additional falls. Furthermore, the facility failed to update each resident's plan of care with person-centered approaches and evaluate interventions already in place for effectiveness to prevent further falls and injuries. In addition, the facility failed to ensure Resident #2's bed was in a safe position. Findings include: I. Facility policy and procedure The Fall Management policy and procedure, undated, was provided by the nursing home administrator (NHA) on 3/17/22 at 7:00 p.m. It revealed, in pertinent part, A careful review and analysis of the possible contributing factors with or without injuries is completed using the QAPI (quality assurance and performance improvement) post fall investigation form. The director of nursing (DON), or designee, analyzes the results for trends and patterns in the resident's falls to use as a basis for implementation of process improvement. The resident's attending physician reviews individual cases with multiple falls, to modify interventions as indicated. II. Resident #15 A. Resident status Resident #15, age 92, was admitted on [DATE] and readmitted [DATE]. According to the March 2022 computerized physician orders (CPO), the diagnoses included dementia without behavioral disturbance, [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting the right dominant side, displaced fracture of the shaft of the right clavicle (6/25/21), and muscle wasting. The 1/29/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. She required extensive assistance of one person with bed mobility, transfers, dressing, toileting and personal hygiene. She required limited assistance of one person for walking in the room and corridor. It indicated the resident had one fall since her admission or prior assessment with no injury. B. Observations During a continuous observation on 3/16/22 beginning at 9:30 a.m. and ended at 12:30 p.m. the following was observed: -At 9:30 a.m. Resident #15 was observed sitting in her wheelchair in her room. She was in front of her night stand going through the drawers. She said she was leaving and needed to pack her room. She said he needed boxes. -At 10:21 a.m. the activity staff member entered the resident's room. He provided the daily chronicle to the resident and then exited the resident's room. -At 10:46 a.m. the resident wheeled herself down the hallway from the dining room to the nursing station. She asked licensed practical nurse (LPN) #1 if her dad was there. The nurse told her no and the resident wheeled herself down the hallway and into her room. LPN #1 continued to sit at the nursing station and typing on the computer. A video monitor system was added after the resident's fall on 6/25/21 to monitor the resident's movement, in which the camera was located on a table in the room pointed at her bed. She did not look at the video monitors at the nursing station. The sound on the monitor indicated it was on mute. There was no other way for the staff to be notified if the resident had movement other than the monitor located at the nursing station. -At 10:48 a.m. Resident #15 returned to the nursing station and asked for the phone. LPN #1 told her to wait for a few minutes. Resident #15 asked if she could reach for the phone. LPN #1 said no. A few minutes later, LPN #1 handed the resident the phone. The resident asked for the nurse to assist her with the phone number and the nurse asked her to wait while she answered a phone call. A few minutes later, LPN #1 asked the resident for the phone number. RN #2 did not turn the portable phone on, but pushed the numbers. She told the resident the phone was not working. The director of nursing (DON) arrived and asked the resident if she could take her down to the dining room. Resident #15 said she wanted to make a phone call. The DON told the resident she could make a phone call after the resident ate in the dining room. The DON then wheeled the resident to the dining room. -At 11:13 a.m. Resident #15 returned to the nursing station and asked to use the phone. LPN #1 told the resident the phone was not working and to come back in 30 minutes. The resident wheeled herself back to her room. LPN #1 continued to type at the computer. She did not look at the video monitors while she was sitting at the nursing station. -At 11:19 a.m. the resident returned to the nursing station looking for boxes. -At 11:23 a.m. the resident returned to her room. -At 11:30 a.m. a certified nurse aide (CNA) entered the nursing station. She did not look at the video monitors. -At 11:35 a.m. the CNA left the nursing station. -At 11:40 a.m. the resident returned to the nursing station and began asking multiple staff members for boxes. She was observed asking four staff members for a box. Each staff member told her they did not have any boxes and did not know where to go to find one. C. Record review The cognitive loss care plan, initiated on 2/25/2020 and revised on 5/11/2020, documented the resident had cognitive loss related to dementia and age related decline. It indicated the resident had severe cognitive and memory loss with delusions at times, was often reassured but quickly forgets. The interventions included: the family consoles with her, remind the resident that her family has taken her cane and crutches homes, reassure and reorient the resident as needed and write notes to remind the resident of the things she perseverates on as a reminder. The activities of daily living (ADL) care plan, initiated 10/12/18 and revised on 6/2/21, documented the resident had limitations in her ability to perform ADLs with decreased independence with mobility related to a cerebral vascular accident ([CONDITION(S)]). The interventions included: use the bars on the bed to assist with positioning. The activity care plan, initiated on 5/21/2020 and revised on 1/17/22, documented the resident enjoyed visiting with her family, friends, Bingo, exercise programs, bible study, going on walks with the facility staff outdoors and daily fun packs. The interventions included to provide the daily chronicle, provide the monthly activity calendar, invite the resident to activities such as bingo and exercise group and offer snacks from the snack cart. The fall risk care plan, initiated on 1/4/18 and revised on 5/19/21, revealed the resident was at risk for falls related to the diagnosis of unspecified open-angle [CONDITION(S)], essential hypertension, cerebral infarction and asthma. It indicated the resident was on medications that could increase the resident's risk of falls and she required assistance with ADLs. The interventions included: the resident did not remember to ask for assistance with mobility, keep the resident's room door open, added a room monitor, obtain anti-rollbacks for the wheelchair, increased staff monitoring for 72 hours, request lab work, encourage fluids, anticipate the resident's needs, be sure the resident's all light is in place and encourage the resident to use it, educate the resident and family about safety reminders and what to do if a fall occurs, and follow the facility fall protocol. The 2/23/22 fall risk assessment documented the resident had a history of one to two falls within the previous 90 days, was easily distracted, had periods of altered perception or awareness of surroundings, episodes of disorganized speech, periods of restlessness, periods of lethargy, mental function varied over the course of the day and wandered. It indicated the resident had moderately impaired limited vision but could identify objects, did not have steady balance and was only able to stabilize with physical assistance. The resident scored a 19, which indicated the resident was a fall risk and interventions should have been promptly put into place. 1. Fall incident on 6/25/21 The 6/25/21 change of condition progress note documented the resident was found on the floor, yelling for help at approximately 5:30 a.m. The resident was found on the right side with blood coming from her head. The resident complained of right shoulder pain. The resident was sent to the hospital for further evaluation and treatment. -At 9:30 a.m. the resident's son called the facility and informed the nurse the resident had sustained a right clavicle fracture and had to get stitches around her right eye. -At 10:12 p.m. the resident returned from the hospital with a diagnosis of a fracture to the right clavicle, fracture to the right maxillary sinus and a subdural hematoma. The 6/25/21 fall investigation documented the resident was found on the floor on the right side of the hallway with the wheelchair tipped over. The resident had blood coming from her forehead, complaint of pain to the right knee, had impaired range of motion to the clavicle and a laceration above the eyebrow. The nursing staff used a lift to get the resident off the ground and place her into her bed. The resident was sent to the hospital for further evaluation. The interventions included increasing staff observation, placing a room monitor in the resident's room during sleeping hours and placing the call light by the resident's bed. The 6/26/21 nursing progress note documented Resident #15 remained unaware of her safety needs. The nurse found the resident standing next to her bed and ambulating to the door. The nurse documented that she provided a friendly reminder to the resident. The 6/28/21 nursing progress note documented the resident's bed was in the low position with a landing strip in place and staff monitored the resident's movement with a camera monitor. -This intervention was not noted on the fall risk care plan. 2. Fall incident on 9/6/21 The 9/6/21 nursing progress note documented at 9:00 p.m. the resident was found on the floor in the bedroom. The resident sustained a compound fracture to the left wrist and was sent to the hospital for further evaluation and treatment. The 9/7/21 interdisciplinary team (IDT) note documenting the fall was reviewed by the IDT. The IDT recommended increasing the monitoring of the resident for 72 hours and re-evaluating the resident upon her return from the hospital. The 9/6/21 fall investigation documented the resident was found on the floor in her room. Upon assessment, the resident had a compound fracture to the left wrist and was sent to the emergency room . It indicated the resident would be reassessed when she returned from the hospital. -It did not include any interventions to prevent further falls or injuries. The 9/8/21 nursing progress note documented the resident returned to the facility from the hospital with a diagnosis of a distal radius fracture (two forearm bones on the thumb side) and ulna fracture (forearm bone on the pinky finger side). It indicated to continue to monitor the resident, place the call light within reach and put the bed in the low position with the fall mat in place. -These interventions were put into place following the resident's fall with a major injury on 6/26/21. The fall risk care plan was not updated and did not document any new interventions or the re-evaluation of the interventions that were in place to determine their effectiveness. 3. Fall incident on 12/2/21 The 12/3/21 IDT progress note documented the resident had a fall in her room. She sustained a skin tear to the right forearm. It indicated the resident did not remember to request for assistance with mobility. The interventions included to increase monitoring of the resident for 72 hours, keep the resident's door open and continue with the room monitor in place. The 12/2/21 fall investigation documented the resident was found on the floor in her room. The resident sustained a skin tear to the right forearm and the right elbow. The interventions included monitoring the resident for 72 hours following the fall. The fall risk care plan documented the circumstances of the fall including the skin tear to the right forearm sustained by the resident. It indicated to increase staff monitoring for 72 hours and keep the resident's door open. -It did not document any further interventions put into place to prevent the resident from continued falls. -The facility failed to re-evaluate the interventions in place to ensure effectiveness to prevent the resident's continued falls and injuries. 4. Fall incident on 12/17/21 The 12/17/21 fall investigation documented while attempting to transfer herself from the toilet to the wheelchair, the resident fell to the ground. The breaks were not locked on the resident's wheelchair. The intervention included adding an antilock brake to the resident's wheelchair. -There was no further documentation of the incident in the resident's medical record. The fall risk care plan was updated to include the anti-rollback brakes for the resident's wheelchair. 5. Fall incident on 2/1/22 The 2/1/22 fall investigation documented the CNA reported the resident was found sitting on the floor next to her bed. She was attempting to grab a picture off the wall and fell down. -There were no noted interventions identified in the fall investigation. The fall risk care plan was updated with the circumstances of the fall. -It did not include any additional interventions. -There was no further documentation of the incident in the resident's medical record. 6. Fall incident on 2/23/22 The 2/23/22 change of condition progress note documented the resident was found sitting on the floor on the safety mat with the bed in the low position. The resident sustained a skin tear on the right hand. It indicated there were no recommendations at this time. The 2/23/22 fall investigation documented the resident was found on the floor next to her bed. The resident sustained a skin tear to the right hand. She said she was trying to go to the bathroom, but her knees wouldn't let me. -There were no noted interventions identified in the fall investigation. The 2/23/22 IDT progress note documented interventions were in place and reduced the potential for injury. The fall risk care plan documented the circumstances of the fall and to increase staff monitoring for 72 hours. -It did not document any additional interventions or the re-evaluation of the current interventions to determine their effectiveness. C. Staff interviews CNA #3 was interviewed on 3/17/22 at 11:34 a.m. She said if a resident was found on the floor, she said she would call for the nurse or another CNA. She said she would stay with the resident while the nurse assessed the resident. She said Resident #15 was very confused. She said the resident went to the staff and asked for boxes so she could leave. She said the resident would ask for the phone to call her son or her parents. She said the resident had worked with the resident for many years. She said the resident required assistance with all activities of daily living. She said the resident would try and take herself to the bathroom, or transfer herself from the bed to her wheelchair, but would lose her balance and fall. She said the resident was considered a high fall risk. She said the resident had fallen a lot in the past. She said the staff would try to redirect the resident throughout the day. She said the resident had a camera in her room with the monitor located at the nursing station. She said she was busy most of the day and was not able to check the monitor. She said whoever was at the nursing station should keep watch over the monitors. She said the monitor was to help watch the resident to ensure she did not fall. She said the monitor had been in place for a long time. She said the resident had fallen a few times since the monitor was put in place. She said the resident was not on a low bed. She said she was unsure of any fall interventions in place for the resident other than the video monitor. She said fall interventions were not included on the tasks in the point of care (POC) electronic charting system. LPN #1 was interviewed on 3/17/22 at 11:45 a.m. She said when a resident fell , the nurse should assess the resident for injuries. She said the nurse will complete the risk management form, the fall risk assessment and notify the resident's family and the physician. She said the nurse should determine what immediate interventions should be put into place. She said the IDT reviewed the falls and updated the resident's care plan. She said Resident #15 was a high fall risk. She said the resident had fallen and sustained a few fractures in the past six months. She said she had fallen a lot. She said the staff tried to redirect the resident throughout the day. She said the resident was confused and required assistance with transfers and other ADLs. She said the resident would forget to ask for assistance. She said the video monitor was used to keep an eye on the resident. She said whoever was at the nursing station should keep an eye on the monitors. She said she did not always have time to sit at the nursing station and watch the monitors. She confirmed the sound was on mute on all of the video monitors. She said the resident's bed should be in the low position when she was in the bed with a safety mat on the floor. She said the staff tried to keep the resident out of her room because that was where she often fell . She said the resident would often come to the nursing station to ask to use the phone. She said sometimes they helped the resident call her family and the other times they told her the phone was broken and redirected her down the hallway. The DON was interviewed on 3/17/22 at 12:52 p.m. She said each fall was reviewed by the IDT. She said the IDT discussed the circumstances around each fall, put interventions into place and updated the care plan each morning. She said all interventions should be re-evaluated quarterly to determine if they were effective and after each fall. She said all fall interventions should be included on the CNA tasks. She said Resident #15 was considered a high fall risk. She confirmed Resident #15's care plan had not been updated or interventions re-evaluated for effectiveness prior to the resident's fall on 6/25/21. She said after the fall on 6/25/21, the facility placed a camera with a monitor at the nursing station to be able to monitor the resident at night and increased staff observations of the resident. She said the nurse at the nursing station should check the monitors regularly while sitting at the desk. She said the staff observations were not at a specified interval and not documented in the resident's medical record. She said monitoring was usually for 72 hours and was a community standard with any change of condition. She said the resident's care plan was not updated to include interventions following the fall on 9/6/21, 12/3/21, 2/1/22 and 2/23/22. She confirmed fall interventions were not documented on the CNA tasks for the resident. She said that there was a pattern to the resident's falls. She said almost all of the falls occurred in the resident's room. She said the monitor was not effective if she continued to fall in her room. The DON and the clinical consultant were interviewed on 3/17/22 at 2:33 p.m. The clinical consultant said after each fall, the facility monitored the resident for 72 hours, did lab work and encouraged fluids. She said monitoring for 72 hours after a change of condition was a community standard. The clinical consultant said doing lab work showed the facility provided personalized interventions because it was the resident's labs that were being drawn and reviewed. She said offering fluids was considered a person-centered intervention because it was the staff encouraging fluids. She confirmed there were no documented interventions other than the lab work, 72 hour monitoring, and the encouragement of fluids for the 9/6/21, 12/2/21, 2/1/22 and 2/23/22 falls. She said the personalization of the resident's care was indicated in the activity care plan. She said the facility staff provided the resident things to do throughout the day to distract the resident, address her needs and keep her from falling (however, the resident sustained six falls in eight months with two falls causing major injuries). She said they provide her with activity items at the nursing station. -However, based on observations, LPN #1 did not provide the resident with assistance when she asked to call her family. LPN #1 told the resident the phone was not working and to come back later. The resident left the nursing station and went back to her room. LPN #1 did not offer the resident any activities or redirection. Multiple staff members did not provide the resident with an alternate activity when she asked for boxes, in fact they told her they did not have any and walked away from the resident. Multiple staff members were observed at the nursing station and did not look at the camera monitors. III. Resident #16 A. Resident status Resident #16, age 96, was admitted on [DATE]. According to the March 2022 CPO, the diagnoses included Alzheimer's disease, muscle wasting, unsteadiness on feet and non-displaced fracture of the lateral end of the left clavicle. The 1/29/22 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. She required extensive assistance of one person with bed mobility, transfers, dressing, toileting and personal hygiene. It indicated the resident had sustained a fall with a major injury since the previous assessment period. B. Record review The ADL care plan, initiated on 5/21/21 and revised on 6/1/21, revealed the resident had limitations in the ability to perform ADLs related to Alzheimer's disease. The interventions included: the resident requiring assistance with bed mobility, dressing, personal hygiene, transfers and eating. The fall risk care plan, initiated on 5/21/21 and revised on 5/31/21, documented the resident was at risk for falls related to poor safety awareness, a diagnosis of Alzheimer's disease and balance problems. The interventions included: educate the resident and family about safety reminders and what to do if a fall occurs, increase staff monitoring, obtain a therapy referral as ordered by the physician, ensure the resident is wearing appropriate footwear and clothing, ensure the walker and call light are within reach, remind the resident to use the call light for assistance and provide a safe environment free of clutter. The 5/21/21 admission fall risk assessment documented the resident was a high fall risk with a history of falls in the previous six months. It indicated the resident was weak and overestimated or forgot her limits. The 6/1/21 plan of care progress note documented the resident was admitted to the facility. The resident was at an increased fall risk related to poor safety awareness with a diagnosis of Alzheimer's disease and balance problems. -The facility failed to ensure person-centered interventions were put into place upon the resident's admission to the facility, for which it was identified the resident was a high fall risk. The facility did not update the plan of care since the resident's admission to the facility to ensure effective interventions were in place to prevent sustained injuries from a fall. 1. Fall incident on 12/30/21 The 12/30/21 nursing progress note documented the resident was found on the floor by the foot of the bed on the right side at 12:40 p.m. The resident was assisted back to bed and assessed by the registered nurse (RN). The RN documented the resident did not sustain an injury. -Approximately an hour later, the resident was brought to the nursing station complaining of left shoulder pain. The resident's daughter was present and insisted the resident be sent to the hospital for an x-ray. The physician ordered for the resident to be sent to the hospital for an evaluation. -The resident returned from the hospital at approximately 5:05 p.m. with a diagnosis of a distal clavicle fracture caused by the fall. The 12/30/21 fall investigation documented the resident was found lying on the floor at the foot of the bed on the right side. The resident was unable to give a description of what happened. The facility identified impaired memory, confusion and weakness as predisposing factors to the fall. -It did not include any interventions that were documented on the care plan upon the resident's admission to the facility. -Following the fall, the facility failed to put any interventions into place, other than increasing staff monitoring with no documentation in the resident's medical record as to how often the staff monitoring would occur. The facility failed to ensure interventions were in place since the resident's admission to prevent the fall and subsequent fracture. C. Staff interviews CNA #4 was interviewed on 3/17/22 at 11:40 a.m. She said Resident #16 was very confused and was considered a high fall risk. She said the resident required staff hands on assistance for all ADLs. She said the resident was able to transfer herself, but was not safe to do so. She said the resident did not usually use the call light. LPN #1 was interviewed on 3/17/22 at 11:46 a.m. She said Resident #16 was not considered a high fall risk. She said the resident was easy and took a long time to wake up. She said she required assistance with ADLs. She said she was not sure if there were any fall interventions in place for Resident #16. IV. Resident #49 A. Resident status Resident #49, age 64, was admitted on [DATE] and readmitted on [DATE]. According to the March 2022 CPO, the diagnoses included muscle weakness, dementia without behavioral disturbance, cognitive communication deficit, difficulty walking and lack of coordination. The 2/10/22 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of six out of 15. She required extensive assistance of one person with bed mobility, transfers, dressing, toileting and personal hygiene. It indicated the resident did not have a fall since the prior assessment. B. Record review The ADL care plan, initiated and revised on 5/19/21, documented the resident had limitations in the resident's ability to perform ADLs related to weakness, cognitive decline and decreased mobility. The resident required extensive assistance of one person with bathing, bed mobility, dressing, personal hygiene, transfers and toileting. The interventions included: encouraging the resident to use the call bell for assistance. The activity care plan, initiated on 10/21/2020 and revised on 10/25/2020, revealed the resident was at risk for social isolation related to limited mobility in the community during the COVID-19 pandemic. The interventions included: the staff would provide support and encouragement through the one on one visits, staff would provide independent programs and supplies in the resident's room, staff would provide a monthly activities calendar and review the resident's areas of interest, provide and encourage the resident's use of social media, and encourage the resident's participation in the programs of preference that have been adapted to the new service delivery formats related to COVID-19 restrictions. The fall risk care plan, initiated on 10/29/2020 and revised on 8/17/21, revealed the resident was at an increased risk for falls related to dementia, [CONDITION(S)] and use of oxygen. The interventions included: educate the resident about safety reminders and what to do if a fall occurs, obtain a therapy referral as ordered by the physician, ensure the resident wore the appropriate footwear and clothing, ensure the call light is within reach, provide a safe environment free of clutter and remind the resident to use the call light for assistance. -The fall risk care plan was last updated with an intervention on 9/3/21. 1. Fall incident on 1/28/22 The 1/28/22 change of condition progress note documented the resident had sustained a fall. It indicated the resident was weak from a urinary tract infection ([CONDITION(S)]). It did not contain any other details of the fall. The interventions section was documented as not applicable. The fall risk care plan indicated the resident was found sitting on the floor, next to the bed, with stockings on her feet. It did not include interventions. This was added to the care plan on 2/3/22. 2. Fall incident on 1/29/22 The 1/29/22 change of condition progress note documented sustained another fall. The resident was found sitting on the floor next to her bed. She said she attempted to go to the bathroom and slid off the bed and onto the ground. It indicated the staff would provide friendly reminders to call for assistance. It did not include any effective interventions. C. Staff interviews CNA #4 was interviewed on 3/17/22 at 11:40 a.m. She said Resident #49 required limited assistance with her ADLs. She said the resident was unable to transfer on her own. She said the resident would get up on her own, but was not safe. She said the resident was a high fall risk but did not know of any fall interventions in place. LPN #1 was interviewed on 3/17/22 at 11:46 a.m. She said Resident #49 had a history of falls but had not fallen recently. She said she did not consider the resident a high fall risk. She said Resident #49 required assistance with ADLs. She said she was not aware of any fall interventions in place for Resident #49. V. Resident #2 A. Resident status Resident #2, age 81, was admitted on [DATE]. According to the March 2022 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbance, depressive disorder, type 2 diabetes, hypertension and COVID-19. The 12/25/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of fo[TRUNCATED]

Based on record review and staff interviews, the facility failed to ensure proper safety measures were in place to prevent accidents. The facility failed to ensure one (#2) of four sampled residents was assessed for the use of resident equipment in the resident's room (specifically, an electric recliner), and that the recliner was properly evaluated after a fall from the recliner. Specifically, the facility failed to prevent a resident from falling out of an electric recliner, resulting in abnormal neurological vital signs, ultimately requiring the resident to need immediate medical attention. The findings include: Facility Protocol on Fall Management and Investigation Program (in pertinent part): -To utilize all reasonable efforts to provide a system to review the resident's risk potential for falls and provide a proactive program of supervision, assistive devices and interventions to manage and minimize falls and identify resident's continued needs. -All residents are considered to be at risk for falls on admission until all review processes are completed and reviewed. -A fall care plan will be developed within 8 hours of admission, readmission or change in status addressing potential risk factors for all residents. -A PT (physical therapy) screening will be requested upon admission. -Post fall: if a head injury is present or suspected, the resident will be monitored, including vital signs, pupil reactions, nausea/vomiting: every 15 minutes x 4, then every 2 hours x 3, then every shift x 3. Determine if resident requires urgent care. -A careful review and analysis of the possible contributing factors to the fall with or without injuries will be completed Resident Status Resident #2, age 72, was admitted to the facility on [DATE]. According to the facility face sheet, the resident's [DIAGNOSES REDACTED]. The 1/30/15 hospital "Patient Transfer Summary," indicated the resident was alert and oriented x 1 with clear speech. The resident was also noted to be a high fall risk, required total assistance, the use of a Hoyer lift, and was noted as having left side flaccid. The Hospital History and Physical (prior to admission to the skilled nursing facility) revealed resident #2 was originally admitted to the hospital for a subdural hematoma after falling backwards and hitting his head on concrete. The resident had left-sided paralysis and developed a deep vein thrombosis. A head CT (Computed Tomography) Scan indicated the resident had a large subdural hematoma along the falx and the blood was revealed to be resolving. The resident was placed on Coumadin and discharged to the skilled nursing facility on 1/30/15 for care and therapy. The Hospital General Discharge Instructions completed on 1/29/15, documented the resident had "blood clots in left lower extremity at this time, was on Coumadin (blood thinner) with an INR (international ratio) of 1.9, and Lovenox (blood thinner). The instructions included to watch for any bleeding of the nose or gums, to avoid falls, and to avoid bumping your head." The 1/30/15 Admission Physician order [REDACTED]. - Coumadin 4 mg daily, -Lovenox 90 mg subQ (subcutaneously) every 12 hours, and -PT (Physical Therapy) Clarifications: Skilled PT to evaluate and treat 5 x week x 12 weeks for stroke rehabilitation, bed mobility, sitting balance, and transfers. Admission Data Collection Tool (revealed in pertinent part): This was completed by the admitting registered nurse (RN) upon admission on 1/30/15 at 12:30 p.m. and read, the resident was transferring from the hospital, his level of consciousness was described as alert, and his's-pupils were described as the left and right were equal and reactive. The data included the resident had a history of [REDACTED]. He was non-ambulatory, needed physical assistance for activities of daily living, dressing, grooming, eating, transfer, toilet use, bed mobility, and bathing options, was limited on the left side in range of motion, impaired gait and a history of falls with injury in the last 60 days. Physical Therapy (PT) Daily Treatment Notes completed upon admission on 1/30/15 revealed the following: -The resident was seen for initial evaluation today. To see PT 5 x week x 12 weeks for neuro rehabilitation. -The resident was seen for sitting balance at edge of bed. Facilitation for sitting and use of right upper extremities for support. The resident required maximum assist to sit with feet flat. The resident required maximum assist of therapist for supine to sit and sit to supine. Minimal assist by pt to bring right lower extremities up onto bed. -Was discharged before therapy could continue. -No documentation of a recliner (in room) being evaluated for safety needs. Nurse Notes (in pertinent part): On 1/30/15 at 1600 (4 p.m.)-Fairly alert. Pleasant and cooperative. Left side is flaccid. Assist of two with transfers. Max assist with adls (activities of daily living). Boots worn for pressure relief and prevention of foot drop. Denies pain or discomfort. On 1/30/15 at 2000 (8 p.m.)-Is alert and oriented x 1 this p.m. He stated, "I am going home. I have my pickup truck out in the front." He keeps swinging his feet out of bed so the bed is in the lowest position along with a fall mat. Continues to be max assist. On 1/31/15 at 2000 (8 p.m.)-Resident was sitting in his recliner. Nursing staff walked by and observed him laying face down on the floor. He has a laceration on the left eye that was cleansed and steri-stripped with three steri-strips. He has an opened cut on his right knee. Neuros, the pupils on the right side were 3 cm and sluggish, left side was 3 cm and non-reactive. He was slightly confused. He had an ice pack on his left eye and it started to bruise. No other injuries noted at this time. Fall mat is in place. Bed was in low position. Family notified. MD (medical doctor) notified/ADON (Assistant Director of Nursing) notified. He was lying in his bed at that time. Family was back in facility and at bedside. Recliner repositioned and electric recliner moved to the other side of room. Left pupil is non-reactive at this time. He was here s/p (status [REDACTED]. Head of bed was up 30 degree. Vital signs were wnl (within normal limits) at that time. Tab alarm at that time. On 2/1/15 at 0200 (2 a.m.) -Made 1st round at 2305 (11:05 p.m.) on 1/31/15. Resident was resting in bed. When asked how his pain was, resident stated he had none at this time. Check left eye and steri-strips. Strips were in place. Left eye lid very purple and very swollen. Rechecked resident again at 2330 (11:30 p.m.). Resident appeared to be resting peacefully. No change in left eye steri-strips. Rechecked resident again at 0000 (midnight) hours. Resident had removed bipap machine, which this writer had helped him put on at 2330. Asked resident if he wanted it back on. Resident stated not now, it hurt his eye. Resident turned to left side. This writer asked if resident wanted pain med, he stated no not now, appeared to be sleepy. At 0010 (12:10 a.m.) staff CNA (certified nurse aide) had gone to resident room to get resident vital signs. CNA called this writer to room. Noted resident had removed steri-strips and had large pool of blood on the bed under his head. Had a continuous stream of blood running from left eye lid. Staff found steri-strips in resident right hand. This writer applied pressure to eyelid and asked CNA to call RN to please come and assess resident condition. Explained to RN what had appeared to have happened. RN also attempted to reduce bleeding from left eye lid, non-effect. RN decided to send the resident to the ER (emergency room ) to evaluate and treat his eye. Order to transport. Facility Failures I. On 2/2/15 at 1:55 p.m., the Fall Committee reviewed the incident from 1/31/15 at 7:30 p.m. Documentation included a fall mat was in place, the bed was in low position and a tab alarm was placed on the resident. The Fall Committee noted that fall preventions were in place. However, it failed to document and evaluate the actual cause of the fall - a fall from the recliner. This was not noted in the Fall Committee notes. II. An Incident Report Form dated 1/31/15, indicated the resident was sitting in a recliner and attempted to get out of the recliner and the recliner was tipped forward. The resident was found face down on the floor. Left eye approximate 4 cm and was steri-stripped. Right knee had cut unopened. Un-witnessed fall. Final outcome/Disposition: Low bed, mat, tab alarm. The incident report indicated the resident fell from the electric recliner and sustained injuries. However, the documented outcomes (see above) failed to address the use of the recliner as a potential concern and the cause for the fall. III. The Neuro-Signs Flow Sheet was reviewed and documented the following: -Started on 1/31/15 at 1930 (7:30 p.m.) -Done 1/31/15 at 1930-right pupil was sluggish, left pupil was non-reactive -Done 1/31/15 at 1945-right pupil was sluggish, left pupil was non-reactive -Done 1/31/15 at 2000-right pupil was sluggish, left pupil was non-reactive -Done 1/31/15 at 2015-right pupil was sluggish, left pupil was non-reactive -On 1/31/15 at 2215-not done -Done 1/31/15 at 2415-right pupil was sluggish, left pupil was non-reactive -No more neuros done. Resident sent out to emergency room -The Initial Admission Data Collection completed on 1/30/15 by the admitting RN (see above) indicated the resident's pupils were equal and reactive. The pupils documented on the Neuro-Signs Flow Sheet indicated a significant change in condition. However, no documentation of this observation was noted in the nurse notes, and it was not documented as being provided to the physician in a timely fashion according to the facility policy on Fall Management. Care Plans (in pertinent part): -Alteration in skin integrity related to wound laceration to left eye. Noted to be steri-stripped. Cleanse with wound cleanser. No date or additional information documented. -Low/Moderate/High risk for falls according to the fall risk review tool, but does not distinguish fall risk level. Goal: I will have less occurrences of falls if possible weekly. Approaches: call light usable and within reach; bed in lowest position; keep room free from clutter; equipment needs of-moved remote control chair to other side of room 1/31/15; floor mat by my bed; all staff are informed of my fall risk; follow up fall intervention, clip alarm attached to head of bed and resident gown 1/31/15; fall mat place 1/31/15. The fall care plan was noted as being reviewed on 2/2/15, after the resident had already been discharged . Hospital Records-Post Fall: -Seen at Emergency Department on 2/1/15 at 0232 (2:32 a.m.). Patient fell at nursing home at 1930 (7:30 p.m.) hours last night. Sustained less than 1 cm laceration. Patient on blood thinners. -Tonight at 7:30 again he fell forward out of the chair and struck his face and head. He had a laceration and it was dressed with steri-strips. -He has some edema around his left eyelid and small laceration lateral to his left eye. -Tenderness around left orbit but no crepitance. -The radiologist reported acute hemorrhage in the left temporal horn of the left occipital horn, which was new since previous CT. The subdural hematoma appeared subacute and had decreased in volume. He does have mild [DIAGNOSES REDACTED], which was new. -He also had fractures of his left inferior orbital wall and lateral wall of the orbital wall; he also had fracture of anterior wall and lateral wall of the left maxillary sinus with opacification of the sinus. Was a fracture of the zygoma on the left. -Primary impression: acute intracranial hemorrhage -Additional impression: fracture, facial bones -CT head without contrast was on done on 2/1/15 at 0358 (3:58 a.m.) Documentation included: Comparison to CT on 12/29/14: left tripod fractures. Persistent [DIAGNOSES REDACTED] without change. Previous large parafalcine subdural hematoma now evolving. There was a little bit of blood or blood products in the left temporal horn. This could be a little residual hemorrhage from before but it looked new. Possibly a little bit of new subdural blood seen along the tentorium. Probable thin subacute subdural hematoma over the left frontal lobe measuring about 3 mm in thickness. New moderately large parietal white matter parenchymal hematoma. Interviews: On 5/1/15 at 10:40 a.m., physical therapy assistant (PTA #1) said recliners were often not in the facility rooms when new residents came in on admission. Because of that, the resident would not be assessed for the safe use of the different recliner types upon admission. On 5/1/15 at 10:43 a.m., the PTA #2 stated that resident #2 was a maximum assistance and was not able to stand up on admission. The PTA #2 stated that it was possible that the electric recliner was placed in the resident's room later, to aid the staff in getting the resident up and down. The PTA #2 said that because the recliners were often not seen in the resident rooms during the initial therapy assessment, they would not assess the safety needs of the residents until therapy began at a later time. The therapy assistant stated that she had heard that the resident's family member had handed the electric remote to the resident, but could not be certain. On 5/1/15 at 12:50 p.m., a registered nurse (RN #1) stated if a resident falls and they are not sure if they hit their head or not, they will do neurological checks every 15 minutes for an hour, then every 2 hours for 3 times, and then each shift for an additional 72 hours. The RN stated she would always compare the vitals and pupils to prior falls or what she knows the standard to be. She stated if she saw something that looked off, such as nonreactive pupils, she would contact the doctor and note it in the nurses' notes. The RN added if a resident came into the facility and had an initial fall, and she was not aware of what the resident's baseline was, she would call the doctor as soon as she saw the first abnormal vitals response, because she would want the doctor to know if that was acceptable or not. On 5/1/15 at 1:40 p.m., PTA #2 said resident #2 was evaluated for physical therapy on the date of admission, but did not remember the recliner being in the room. The PTA added that if she was evaluating for transfers or other activities of daily living needs that could be potentially affected by the use of different types of recliners, she would note and document it. The PTA stated the therapy department "often finds" residents do not have appropriate types of recliners in their rooms, and they will ask maintenance to move them. This was a continuing problem. The PTA said due to time constraints, the therapy staff often ends up doing most of the moving of the recliners around the facility to try to place the appropriate ones in each room. The PTA confirmed therapy had addressed the concern of residents having inappropriate recliners in their rooms, which were safety hazards. The PTA stated the Nursing Home Administrator (NHA) and Director of Nursing (DON) had been told this was a problem and it needed to be a higher priority. The PTA said the NHA and DON had told therapy to evaluate the residents on a case by case basis, which the PTA said was very hard to do. The PTA said the therapy department had just assessed a female resident who had recently fallen out of her recliner twice, and was found by therapy to be using the wrong type of recliner. Unfortunately, this evaluation occurred after the falls, not before. The PTA said that therapy staff often had to change recliners for residents. The PTA stated a nurse for resident #2 had told the therapy department that the resident had requested the recliner, after therapy had already assessed him. The nurse also told the therapy assistant that a family member had left the resident with the use of the electronic remote. However, the resident had not been assessed for the use of an electric recliner, and the family had not yet been educated on this. The PTA said that if a staff member placed any type of recliner into a resident room, the therapy department would want to be informed so a safety assessment could be done, which often does not happen. On 5/1/15 at 2:05 p.m., a certified nurse aide (CNA #1) stated when a resident was receiving therapy; they often requested the use of a recliner. The CNA stated they will go and find one and place it in the resident's room. The CNA confirmed the decision to place a recliner in the resident room was often based upon whether or not the aides thought the resident would be ok with the use of a recliner. "We don't usually have therapy or nursing look at the appropriateness, we just do it if we think it will be good for them." The CNA stated they had recliners that were electric and some that had handle pulls. The CNA said, however, that the therapy department will sometimes help determine the type of recliner to use if available, or the families will often bring in one from home. The CNA said if the resident was very confused, they would not like to give them an electric recliner "because they can manipulate the switch." But the aide stated that if the family wanted the resident to have the electric one they will "let them have it." The aide stated they had found a resident in their room that was unsafe, and had raised the electric lift recliner too high. Because the resident had not been assessed, the CNA stated, "I unplugged it to keep her safe because I don't know if she would have tried to get out and face plant." The CNA said they were not aware of any facility process in place that helped to ensure residents were assessed for appropriateness of recliner use. The CNA added, "It can be rude to tell family that something they bring in isn't appropriate." On 5/1/15 at 2:15 p.m., CNA #2 stated if a resident did not know how to use the electronic controls for a recliner, they would not let the resident have the remote. The CNA said that the aides consider the state of mind of the resident to figure out if they should give them the remote or not. The CNA said if a family brought in an electric recliner for someone who was not appropriate, "We would have to tell them no. I think that's what we would do." The CNA said they would not give the resident the remote. The aide was not aware of any facility practice to ensure residents were evaluated for safe use of recliners. The CNA confirmed therapy does get involved with the needs of the recliner and sometimes have to find different sizes for the residents. The aide stated they were not aware of any education for the use of recliners. On 5/1/15 at 2:33 p.m., a licensed practical nurse (LPN #1) stated if they were evaluating a resident's neurological exams after a fall, they would look to see if the pupils were equal and reactive, how well the focus, and the vitals. The LPN stated it was basic protocol. The LPN said as long as they have two initial checks, they can skip one during mealtime. However, the LPN said that they would only ever skip once, and as soon as the resident came back from the meal they would do the next set of vitals right away. The LPN confirmed that when a resident was initially admitted , the nurse would do the cognition, range of motion, and all other data collection. The LPN stated when resident #2 was admitted , there was no recliner in the resident's room and perhaps "maintenance put one in there." The LPN confirmed there was no assessment done to determine if the resident would be safe with the use of an electric recliner, and that they would not have placed one in the resident's room until an assessment had been done. The LPN said that when a new resident was admitted they would do 15-30 minute checks, because they are not familiar with how the resident will behave. The LPN said the nurses took the same approach for any resident that falls and hits their head. The LPN stated it can be hard to read the history and physical records for a new resident, and therefore do not always know what the resident's baseline would be. If the resident then falls, it can be difficult to know the changes that are seen in a resident. The LPN stated that if there were changes in the resident's neurological assessments in comparison to the initial documentation from admission, "I would have called the doctor" or the ambulance directly in order to get the resident sent out. The LPN added the fall investigation should show that the resident fell out of the electric recliner, not the bed. "I would never have let the resident have access to that remote." The LPN stated staff did not discuss or have education about the safety of resident's recliner use after the incident. On 5/1/15 at 3:14 p.m., CNA #3 stated she had worked the day that resident #2 was admitted to the facility. The aide stated the resident was in and out of alertness and cognition, and that "he would know what was going on and then the next minute he would have no idea what was going on." The CNA stated the resident had a private room with a bed, table, and an electric recliner. The aide stated the resident had the electric recliner in the room on admission. The aide did not know if the resident received any assessment or evaluation on admission for the safety of the electric recliner, and stated the resident had been admitted earlier in the day. The aide stated the resident had spent the first day mostly in bed, and on the second day had been in his wheelchair. The CNA stated on the resident's second day of admission, the family requested the resident be placed into the electric recliner for the first time to relax. The CNA said the resident was a full lift, so the aide and a nurse assisted the resident into the recliner by using the Hoyer lift. "He was still in and out with cognition. It changed minute to minute." The CNA said the resident's family stayed in the room for awhile, and the aide would keep checking on the resident. The CNA stated the resident requested to use the bathroom, so they got the urinal for the resident. "He asked to raise the recliner so he could use it and I didn't want him to fall. He told me it was ok because he could do it and be okay. I raised it, but he couldn't go to the bathroom. I lowered him and put the remote in the side pocket on the bottom side of the recliner." The CNA said that around bedtime the resident told the aide that he was okay and wanted to continue to watch television. The aide stated they went to go help another resident across the hall, when an aide came and told her that resident #2 had fallen on the floor. "It was right after I had left his room." The CNA said that the resident was laying on the floor and other staff were present. "The nurse was in there cleaning up blood. The aides were getting him a pillow and getting him comfortable, getting the vital kit. The recliner was in high position. I don't know if he did it or the other staff did it". The CNA confirmed the resident had a gash on his eyebrow. The aide said that vitals were taken and first aid was provided. The aide said that they assisted the resident to bed. The resident stated he had a headache and his eye hurt, so the aide said the resident was given ice for the eye. The CNA said the resident was on 15 minute checks, and after the 3rd or 4th check, she noticed blood pooling around the inner eye, bleeding from around the steri-strips. The aide said the nurse did the neurological checks, and the resident said his head hurt. The aide confirmed the resident had been sent to the hospital. The aide stated that they were not sure who at the facility decided whether or not a resident should or should not have a recliner in their room. The aide said that they would not have placed the resident in the electric recliner if they thought he should not be in it. "There was no reason for me to believe he would fall out of the chair." However, the aide also stated, "But I didn't give him the remote, because I knew his alertness and knew he sometimes would think he could stand when he couldn't." On 5/1/15 at 3:37 p.m., RN #1 stated as a general rule the nurse will call the physician and the family within an hour after an incident. However, the RN stated if the incident occurred in the middle of the night some families preferred the staff to wait and call in the morning. The RN stated they would still fax the physician to let them know, and if it was serious, then they would call sooner. On 5/1/15 at 3:44 p.m., the Director of Nursing (DON) was interviewed. The DON stated a lot of the residents in the facility bring in their own recliners from home, and that it was not uncommon. The DON confirmed as far as she was aware, there was no facility policy to evaluate the safe use of the different types of recliners for the residents. The DON stated she recalled seeing resident #2 when he was admitted and recalled the resident had a low bed and landing strips on the floor, but could not recall if there was a recliner in the room. The DON stated he was discharged before she saw him again. The DON said, "We never would have put a recliner in there if we thought he would have fallen."

Based on observations, interviews and record reviews, the facility failed to ensure the highest practicable level of well being was maintained for three (#115, #37, #75) of 37 sample residents. Specifically the facility failed to: -Identify, assess, and monitor and manage resident #75's pain. The resident experienced pain at elevated levels that was not addressed, as well as immobility, incontinence and skin breakdown. Cross-reference F314 (pressure ulcers). -Conduct thorough assessment and monitoring of injuries following un-witnessed falls for resident #115. -Identify and monitor skin tears for resident #37. Cross-reference F314 (pressure ulcers) and F323 (accident hazards) The findings include: 1. Resident #75 Resident #75, age 88, was admitted to the facility on [DATE]. According to the Computerized Physician order [REDACTED]. According to the admission MDS, dated [DATE], the resident's was coded with no pain on admission. a. Fall 2/16/13 Nurses' notes on 2/16/13 at 0915 (9:15 a.m.) read, "Resident was found on floor by CNA (certified nurse aide). Resident reports that she fell backwards onto the floor. She has a 10/10 pain to her posterior right hip. She is only able to bend her right knee slightly with pain. Area is extremely tender to touch. She also reports slight pain to her right elbow posteriorly. She appears to be forming a bruise on her posterior right elbow. Physician ordered a hip x-ray. (There were no further nurses' notes 2/16/13.) Interview with LPN, 3/14/13 at 8:30 a.m., revealed the resident fell while ambulating; she got tangled up in the oxygen tubing. Record review revealed the x-rays completed 2/17/13 revealed no [MEDICAL CONDITION], but [MEDICAL CONDITION]; specifically right superior and inferior pubic rami. b. Resident status [REDACTED]. Following the fall on 2/16/13, review of nurses' notes revealed the resident remained in bed, complaining of pain and was incontinent. A pressure ulcer was identified 2/21/13. Review of nurses' notes (NN), the facility "Pain Assessment" form (where PRN medications are documented) and the resident's medication administration record revealed: 2/16/13: See NN above; the resident complained of pain 10/10. Review of the "Pain Assessment" form revealed no pain medications were administered 2/16/13. 2/17/13: NN at 1600 (4 p.m.), "continue(s) to have pain in the area of her right hip." At 1745 (5:45 p.m.) "...Pain increases with movement..." "Resting in bed." Review of the facility "Pain Assessment" form revealed at this time, the resident complained of pain at a level "8" and was medicated with Tylenol 325 mg. (Her pain, when rechecked, was reduced to a level "4.") NN - A late entry (3/18/13) for 2/17/13 at 0700 (7 a.m.)...resident refusing to go to bathroom. "resting peacefully." NN - Another late entry (3/18/13) for 2/17/13 "resident checked at 11:00 a.m." in bed, ate her brunch in bed. 2/18/13: NN at 1250 (12:50 p.m.), "has preferred to remain in bed this shift." At 2200 (10 p.m.), "remains in bed." A review of the facility "Pain Assessment" form at "08" revealed the resident complained of right hip pain at level "4." Documentation read, "does not want to move." The resident was medicated with [MEDICATION NAME] 5/325. (Pain reduced to "0") 2/19/13: NN at 0415 (4:15 a.m.), "resident has remained in bed all shift. Has been incontinent of urine 2 all bed checks." NN at 1110 (11:10 a.m.) "resident prefers to remain in bed without moving, being incontinent...medicated for pain." NN at 1705 (5:05 p.m.), "has c/o (complaint of) pain with any position change of 7/10..." Review of the "Pain Assessment" form for 2/19/13 revealed at 4:00 a.m., "pelvis pain," at level "8," crying out when turning" [MEDICATION NAME] administered with relief at level "2," resting in bed. Another entry at 8 a.m. read, "pelvis pain" with a pain rating of "6." [MEDICATION NAME] was administered with relief" ("0" pain level), resident was in "bed." 2/20/13: NN at 04:30 (4:30 a.m.) "Res has rested peacefully through this shift. Remains incontinent of urine." The "Pain Assessment" form documented at 830 (8:30 a.m.), documented hip/back pain "7" [MEDICATION NAME] 5/325 given. 2/21/13: NN revealed documentation of a pressure ulcer on the resident's coccyx. Review of the MAR revealed [MEDICATION NAME] 5/325 was given 2 times - no time documented per MAR. (There was no documentation on the "Pain Assessment" form for 2/21/13.) c. Failure to Ensure Pain was Adequately Managed According to the resident's care plan for 'pelvis fracture,' dated 2/17/13, staff was to observe for signs and symptoms of pain and medicate as needed. Review of the resident's orders and Medication Administration Record (MAR) revealed the following orders for pain management following the resident's fall 2/16/13: -Tylenol 325 mg PO Q 4 hours PRN Pain or increase temp and Tylenol 650 mg supp PR Q 4 hours PRN pain or increase temp. Written on Medication Administration Record (MAR) but not on order sheet. Tylenol was "stopped" 2/17/13 following the telephone order (TO) below. -TO written on 2/17/13 at 2000 (8 p.m.) for [MEDICATION NAME] ([MEDICATION NAME] APAP 5/325) 1 tab orally every 4 hours PRN (as needed) for pain to address fractures. (1) Review of the resident's MAR and "Pain Assessment" form (for documentation of PRN medications) revealed that following the resident's fall, the pain medication was given as follows: Review of the resident's MAR and "Pain Assessment" for February revealed: -2/16/13 no pain medications administered although, see above, the resident reported pain at a level 10 out of 10. -2/17/13 one dose of PRN Tylenol 325 mg was given no time indicated per MAR. Per "Pain Assessment," Tylenol was given at 5:45 p.m. (A late entry dated 3/16/13 at 0700 (7 a.m.) for 2/17/13 - 07:00 indicated the resident also received Tylenol that morning. The late entry read in pertinent part, "This nurse took res Tylenol 325 mg, res would not scale her pain, just stated it only hurts when I move.") -2/18/13 one dose of [MEDICATION NAME] 5/325 was provided no time was indicated per MAR. Per "Pain Assessment," [MEDICATION NAME] was given at 8 a.m. -2/19/13 [MEDICATION NAME] 5/325 was provided at 3 different times, time was not indicated per MAR. Per "Pain Assessment," [MEDICATION NAME] was given at 8 a.m. and 4 a.m. NN indicated the resident also was medicated at 11 a.m. and 5:05 p.m. -2/20/13 [MEDICATION NAME] 5/325 was given one time no time indicated per MAR. Per "Pain Assessment" form, at 8:30 a.m. [MEDICATION NAME] was provided for pain of "7". -2/21/13 [MEDICATION NAME] 5/325 was given 2 times (time not documented) per MAR. No documentation on the "Pain Assessment" form. (2) During this time, facility assessments and therapy documentation revealed the resident was frequently experiencing pain. In addition to the above NN and "Pain Assessments" documenting complaints of pain, additional assessments by the facility documented the resident's pain. Specifically: -Review of the resident's 2/28/13 significant change MDS (see above) revealed the resident was coded as having pain frequently and the pain had made it hard for her to sleep at night. She had limited day-to-day activities because of pain. She rated her pain at 6 out of 0-10 scale (10 being the worst). -Review of the "Resident Pain Review Tool," completed 2/27/13 documented in pertinent part, that the resident had "persistent or frequent pain the last two weeks." The resident described her pain as "it just hurts," and rated her pain at a level 5, indicating 0-3 level was acceptable. Although the resident was documented as saying that the present treatment controls her pain "most of the time," she also indicated that the pain affects sleep, physical activity, mood, concentration and relationship with others." -Review of Physical Therapy Daily Treatment Notes revealed on 2/21/13, "Pt required mod asst x 2 for sit to stand and standing balance, cried out in pain with standing." On 2/22/13, "Pt required max assist ... pt cried out with pain with bed mobility." Review of the resident's care plan for 'pelvic fracture' and review of medication orders included no directive to medicate the resident prior to therapy. (3) In an interview with the Director of Nurses (DON) on 3/18/13 at 2:50 p.m., the DON stated she had done her own "self-facility identification and action plan" after identifying the nurses' note stating 10/10 pain and no documentation of pain medications. However, the DON identification and action plan was initiated during survey. The action plan was started on Friday 3/15/13 and the DON conducted her interviews over the weekend. d. Failure to Ensure Resident's Pain was Timely Assessed In an interview with the DON, on 3/19/13 at 12:29 p.m., the DON stated staff use the "Resident Pain Review Tool," quarterly, change of condition, admission and PRN to evaluate pain. Although the resident had a change of condition 2/16/13, record review revealed a "Resident Pain Review Tool" was not completed for resident #75 until 2/27/13 (see above). This was over a week following the resident's change of condition. e. Staff Interview In an interview, on 3/18/13 at 11:50 a.m., with a registered nurse (RN), she stated, "(The resident) doesn't hurt unless you move her. Lying perfectly still was her way to cope with pain." In an interview, on 3/18/13 at approximately 11:55 a.m., the licensed practical nurse who routinely cared for the resident said the resident screamed or yelled in the beginning (after her fall) while providing cares. She stated, "I think (her pain) is minimal now." She said when she asked the resident about her pain today, the resident said, "I don't know," but indicated she was comfortable. She further stated, "I can never get a number (pain level) out of her. We decided since she was smiling and comfortable that (we) would rate her pain as "0/10." In an interview, on 3/18/13 at 1:40 p.m., with the Physical Therapist who was currently working with the resident, the therapist stated, "(Resident #75) was hurting especially when we initially picked her up (2/22/13)...Now it not her hip (hurting), but her bottom bothering her." (Cross-reference F314; pressure ulcers) f. Observations On 3/13/13 at 3:12 p.m., the resident was observed in her room in bed. The resident complained of her bottom hurting. On 3/14/13 at 8:55 a.m., when asked if she had pain, the resident said, "I did this morning but it's not bad now." 2. Resident #115 Resident #115, age 79, was admitted to the facility on [DATE]. The 3/2013 Computerized physician's orders [REDACTED]. The list of [DIAGNOSES REDACTED]. According to the 2/10/13 admission Minimum Data Set (MDS), resident #115 had adequate uncorrected vision and adequate vision with the use of corrective lenses. Resident #115 had unclear speech, was sometimes understood by others and usually understood others. -Resident #115 had severe cognitive impairment as evidenced by a Brief Interview Mental Status exam score of 6/15. -Resident #115 required limited assistance with bed mobility, locomotion on and off the unit and required supervision with eating. Resident #115 required extensive assistance with transfers, dressing, toileting, personal hygiene and required physical assistance with bathing. -The resident was not coded as having a fracture related to a fall in the six months prior to admission. The resident was not coded to have any skin injuries such as skin tears at the time of admission. a. Resident Status on Admission On 3/14/13 and 3/18/13, the clinical record for resident #115 was reviewed. The 1/23/13 hospital admission records showed that resident #115 was admitted after [MEDICAL CONDITION] in the restroom at his group home. Resident #115 was noted to have experienced a fall, the sound of which alerted group home staff to the resident's sudden illness. The admission record from the hospital assessed the resident's skin as "Cool and dry, without rash or lesion." emergency room records showed the resident's skin to be "warm, dry, no rashes, no petechiae" and musculoskeletal system as, "Extremities are symmetrical, full range of motion." The 1/29/13 admission "Data Collection Tool" indicated that wound(s) were present. The Data Collection Tool form directed the completion of an "Initial Wound Evaluation Form;" however, an Initial Wound Evaluation Form was not identified in the clinical record. The 1/29/13 "Documentation of Actual Altered Skin Integrity" form was reviewed. The form showed the resident had "4+" [MEDICAL CONDITION] to the bilateral lower extremities. The injury diagram did not evidence any areas of bruising to either arm. A Daily Skilled Nursing Notes completed by the night shift nurse for resident #115 revealed, on 2/2/13 at 1:00 a.m., the resident was found sitting in the middle of the bedroom floor as the result of an unwitnessed fall. A 2/2/13 fall investigation showed that resident #115 had an injury to the left wrist. b. Status Following 2/2/13 Fall Record Review and Interview revealed pain, swelling and bruising following the resident's fall 2/2/13. Specifically: Review of the Daily Skilled Nursing Notes completed, on 2/2/13 revealed at 1:00 p.m., the resident complained of pain to the left wrist with some bruising to the area noted. The physician was notified of the fall with possible injury. At 1:57 p.m., resident #115 complained of pain to the left wrist and elbow of 5/10 related to the earlier fall. The resident received Tylenol for the pain. A bruise to the top of the left hand and wrist were noted. At 2:30 p.m., the family was notified of fall "with left wrist and elbow sore." The note indicated that nursing would continue to monitor the injury. The therapy notes were reviewed. The therapy notes revealed, in pertinent part that: -2/2/13 at 12:59 p.m., ice was applied to the left hand during therapy. -2/4/13 at 3:00 p.m., resident was complaining of left arm pain, which was relayed to the nurse. -2/8/13 at 4:49 p.m., compression gloves were order for [MEDICAL CONDITION] in hands. -2/13/13 at 11:14 a.m., resident had difficulty dressing due to pain in left upper extremity. Medication Administration Record for 2/13 showed that resident #115 received 500 milligrams of as needed Tylenol once on 2/2/13. Interview with the Physical Therapist (PT) and Physical Therapy Assistant (PTA) responsible for resident #115's therapy care on 3/19/13 at 12:30 p.m., revealed both the PT and the PTA had worked with resident #115 from the time of his admission through his discharge from therapy. The PT and PTA stated the resident had no visible injuries to the left hand at admission. The PT stated that resident #115 did not complain of left hand or arm pain when they first worked with him after admission to the facility. The PT stated she recalled resident #115 began having bruising and swelling with complaints of discomfort to the left extremity around the early part of February. The PT stated that the Occupational Therapist (OT) ordered an [MEDICATION NAME] glove for resident #115's hand to combat the swelling. The PT reviewed the clinical record for resident #115. The PT noted that the OT's notes showed resident #115 complained of pain to the left hand/arm on 2/4/13. The PT stated that therapy informed the nurse of the bruising to the left hand that they noted on 2/4/13. The PT noted that the OT's documentation showed that pain and swelling were noted to the left hand on 2/5/13 and 2/7/13. The PT stated that the notes showed OT reported the pain and swelling to nursing for follow-up. The PT stated therapies discovered noticeable yellowing and discoloration of resident #115's arm on 2/12/13 when they working with him. The PT stated that the OT went to get the nurse because resident #115 had bruising up his left arm and his left hand was swollen and painful. c. Failure to conduct thorough assessment and monitoring of injuries following un-witnessed fall for resident #115 after 2/2/13. Specifically: (1) Review of the "Documentation of Actual Altered Skin Integrity" form completed by the unit nurse revealed entries for 2/5/13, 2/12/13, and 2/19/13. These entries did not reference any bruising or swelling of the resident's left wrist. -The 2/5/13 entry noted facial rash/redness and a healing abrasion above the left eye but did not note bruising to the hands or arms. -The 2/12/13 entry indicated no new skin issues were present. The rash to the face was noted to be healing. No indication of bruising to the arms or hands was noted. -The 2/19/13 entry indicated the resident had a hematoma above the right eye and resolving bruising to the left upper extremity. The Daily Skilled Nursing Notes completed after 2/2/13 did not reference any bruising or swelling of the resident's left wrist. -2/3/13 at 4:00 a.m., resident #115 denied pain related to his fall. No assessment of the bruising or swelling to the left hand was noted. -2/3/13 at 9:00 p.m., resident #115 denied pain related to his fall. No assessment of the bruising or swelling to the left hand was noted. -2/4/13 at 4:00 a.m., old bruising to both arms was noted. -2/5/13 at 3:30 a.m., resident was noted to have been found sitting on the floor of his room by his bed at 2:45 a.m. No injuries or pain were noted. -Nursing notes from 2/6/13, 2/7/13, 2/8/13 indicated there were no signs or symptoms of injury from the resident's falls, even though he had bruising to the left hand and wrist noted as a result of the fall on 2/2/13 (see above). The resident's skin was documented to be "intact" on these dates. -2/12/13 at 3:15 p.m., resident was noted to have "Left hand has bruising up the arm. No known origin for the bruising." The resident was examined by his physician. -2/13/13 at 3:56 p.m., the x-ray of resident #115's wrist showed the resident had an undisplaced [MEDICAL CONDITION] metacarpal. The plan to treat fracture was a splint and a referral to an orthopedic physician. d. Staff Interviews On 3/19/13 at 12:50 p.m., the wound nurse at the facility was asked to review the resident's chart. The wound nurse reviewed Alteration of Actual Skin Integrity document and stated that according to the document, resident #115 did not have any bruising to his left arm or his right arm documented at admission. On 3/19/13 at 12:29 p.m., the Health Information Director (HID) stated the 1/29/13 Initial Wound Assessment Form did not appear to be completed as it was not present in the clinical records maintained by the facility. However, the HID said the Alteration of Actual Skin Integrity form in the clinical record documented no bruising to resident #115's hands or arms at the time of admission. -The HID stated that she was responsible for keeping fall investigations. The HID reviewed the 2/2/13 fall sustained by resident #115. The HID stated that resident #115 was noted to have an injury to the left wrist sustained during the 2/2/13 fall. The HID stated that resident #115 complained of pain to the left wrist and that bruising was noted. -The HID was asked to furnish any other purged or unfilled portions of resident #115's chart. At the time of survey exit and during the post survey grace period, no additional information related to assessments after the 2/2/13 fall or the Initial Wound Evaluation Form were furnished by the facility. On 3/19/13 at 1:45 p.m., the Director of Nursing (DON) was interviewed regarding resident #115's stay at the facility and assessments completed after resident #115's falls. -The DON reviewed the clinical record and said a [MEDICAL CONDITION] hand was not part of resident #115's admitting diagnoses. The DON stated that injuries to skin at the time of resident #115's admission included a rash on the face, an abrasion to the forehead, cracked dry skin on the feet, an old scar on the shins and [MEDICAL CONDITION]. The DON stated no bruising to the left or to the right hands or arms were noted at the time of resident #115's admission. The DON stated she would expect nursing staff to document bruising, when it was present. -The DON stated the resident had falls on 2/2/13 at 12:15 a.m., 2/5/13 at 2:45 a.m., 2/16/13 at 2:30 a.m., and 3/8/13 at 4:00 p.m. The DON reviewed the 2/2/13 nurses' notes and the 2/2/13 fall investigation and corresponding incident report. The DON stated that the 2/2/13 nurses' note at 1:00 a.m. noted that resident #115 complained of left wrist pain and that bruising was noted. DON stated that later, on 2/2/13 the 1:57 p.m., note showed the resident complained of pain that was a 5/10 to the left wrist and elbow. The DON stated the fall investigation showed resident #115 fell on his left side on 2/2/13, injuring his left wrist. -The DON stated continued assessment of injury after falls would be found in the neuro checks and the nurses' notes. The DON reviewed the nurses' notes and neuro checks from 2/3/13 to 2/12/13, for assessment of injury to resident #115's left arm and hand. The DON stated that beginning on 2/3/13, resident #115's skin was documented as being intact and no documentation was present related to re-assessment of injured left wrist. -The DON stated that resident #115 was discovered to have additional injuries to the left hand and arm on 2/12/13 according to the 3:15 p.m. nurses' note. The DON stated the nurses' note said resident #115 had a fall landing on his left side. The DON stated the nurses' note indicated there was no known origin for the bruising on resident #115's left arm. The DON stated that an x-ray showed that resident #115 had an acute undisplaced fracture to his fourth metacarpal which was treated with a splint to the left hand. On 3/19/13 at 4:41 p.m., the primary physician for resident #115 was interviewed regarding resident #115's fractured left hand. The physician said the resident had multiple falls prior to the discovery of the broken hand. The physician stated he became aware of the broken hand when he was asked to examine the resident after bruising and swelling to the left arm and hand were identified. -The physician stated visitors from the resident's group home had reported resident #115 sustained a fall in the course of his [MEDICAL CONDITION]. The physician acknowledged that resident #115 also experienced multiple falls after admission to the facility. -The physician acknowledged that in the absence of an x-ray, it was not possible to determine which fall resulted in the fractured left hand. The physician stated that the nursing department should have assessed for injuries and monitored, noted injuries after each fall. 3. Resident #37 Resident #37, [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A significant change MDS assessment, dated 12/6/12, revealed the resident needed limited/extensive assistance and required physical assistance of 1-2 persons with all activities of daily living (ADLs) except eating, for which the resident needed set up only. Her Brief Interview for Mental Status (BIMS) was coded 6 of 15 which indicated severe cognitive impairment. a. Observation On 3/11/13 at 1:25 p.m., the resident was observed in her room sitting with her legs extended on her recliner. The observation revealed the resident had three visible skin tears; one skin tear was on her right upper arm, one on left forearm and and another on her left shin. The skin tears were dressed with steri strips, open to air. b. Record Review The resident's care plan (CP), updated 3/7/13, revealed the resident was treated with an antibiotic for bacteremia as of 2/20/13. She had some falls in past quarter, and she had a skin tear to right arm on 2/28/13. On 3/13/13 a new problem was added to the CP as "alternation in skin integrity r/t fragile skin with frequent skin tears." The March Computerized Physician order [REDACTED]. Review of the resident's skin checks located on Treatment Administration Record (TAR) revealed the resident's skin was checked on 2/5/13. There was a plus sign (+) which indicated skin issue, and the back of the TAR had a note indicating that staff identified skin tear on the resident's right forearm. The other three weeks in February were marked negative (-) on the TAR which indicated there were no skin problems. However: -The nurses notes (NN), dated 2/23/13 at 4:30 a.m., read, "resident up at 4:00 a.m. to (BR) bathroom and noted small V-shaped skin tear outer left (LT) lower leg," The skin assessment completed by Licensed Practical Nurse (LPN) on 2/26/13 (three days later) documented that there were no skin issues according to the LPN documentation. -The NN notes on 2/28/13 revealed the resident had a skin tear to right upper arm about 2 cm long. At 7:15 a.m., the resident's daughter was notified about resident's injury, "skin tear and abrasion which was on left side on her back near to the shoulder." The March TAR revealed a skin check was done by the LPN on 3/5/13. She did not identify any skin problems; however, the NN on 3/1/13 at 7:00 a.m., three days earlier, revealed the staff noted the resident had bruising from top of left buttock up the left side and back to shoulder area. On 3/12/13 the same LPN's initials were found on the TAR and only one skin tear was identified on resident's left elbow. However, on 3/10/13 and 3/12/13, NN revealed the resident had two more skin tears (one on her arm and on the elbow), dressed with steri-strips. Interviews: On 3/13/13 at approximately 1:35 p.m., the LPN/wound nurse (WN), identified as the nurse whose initials were found on TARs on the dates when the skin checks were done for resident #37, was interviewed. -She stated that she was very busy with her work load as a wound nurse and sometimes she did not do very thorough skin checks. -On 3/12/13, one day after observation of three visible skin tears (see above), the LPN/WN stated she did not check the resident's skin, she just remembered the resident had a recent skin tear on her left elbow which she documented on the back of the TAR. She added the skin checks should be done weekly from head to toe and all abnormalities should be properly documented, communicated to the other team members and monitored until healed. On 3/13/13 at approximately 3:30 p.m., the DON was informed of the above findings. On 3/14/13 at 11:30 a.m., the DON presented evidence that all the skin tears were properly investigated; however, the skin checks did not reflect any of the injuries. She added the LPN/WN was educated and the proper skin check for resident #37 was done that morning and the copy of documentation was provided. The DON agreed any skin injury should be noted on the TARs and monitored for signs and symptoms of infection or other complications until healed.

Based on observations, interviews and record reviews, the facility failed to ensure the resident environment was as free from accident hazards as possible and that one (#115) of 37 sample residents received adequate supervision to prevent accidents. Specifically the facility failed to: -Thoroughly investigate, assess and develop individualized measures to prevent falls for resident #115. The resident fell several times and was sent to the hospital after a fall with head injury. -Ensure that chemicals were stored appropriately. -Ensure that repairs were made to keep surfaces free of skin tear hazards. -Ensure resident rooms were free from non-approved outlet extenders. The findings include: I. Falls A. Facility Expectations According to the facility's "Fall Prevention Program" policy dated 9/4/12, "Patients are assessed/reassessed for fall risk using the Modified Morse Fall Risk Assessment at the following times: i. Upon admission to the facility ii. At the time of transfer from unit to another within the facility iii. Following any significant change of status (as applicable) iv. Following a fall v. During morning meeting, team meeting and/or informal interdisciplinary meetings (as applicable) " On 3/19/13 at 9:05 a.m., the facility-select members of the Quality Assurance Committee were interviewed regarding how the facility managed resident falls. The Nursing Home Administrator (NHA) and the Health Information Director (HID) were present. -According to the HID, the fall committee will review the circumstance of a resident's fall at their weekly meetings three times a week. The HID stated that residents with two falls in 30 days have a leaf placed on their door to alert staff to fall risk. -The HID stated that the fall committee looked at all aspects of care before making a recommendation related to falls. The HID stated medications, past history, activities to occupy the resident and family input are all considered in developing fall prevention strategies for a resident with falls. B. Resident #115 Resident #115, age 79, was admitted to the facility on [DATE] from the hospital. The 3/2013 Computerized physician's orders [REDACTED]. The list of [DIAGNOSES REDACTED]. 1. Recent History The 1/23/13 hospital admission records showed that resident #115 was admitted to the hospital after cardiac arrest in the restroom at his group home. Resident #115 was noted to have experienced a fall, the sound of which alerted group home staff to the resident's sudden illness. On 3/19/13 at 12:30 p.m., the Physical Therapist (PT) and Physical Therapy Assistant (PTA) responsible for resident #115's therapy care were interviewed. The PT stated that prior to his recent cardiac arrest and subsequent resuscitation, resident #115 was ambulatory without the use of a walker. The PT stated that resident #115 was independent with his activities of daily living and was ambulatory prior to his cardiac episode. The PT reported that caregivers at resident #115's group home reported resident #115 did chores and helped with meals. 2. Status on Admission According to the 2/10/13 admission Minimum Data Set: -Resident #115 had adequate uncorrected vision and adequate vision with the use of corrective lenses. Resident #115 had unclear speech, was sometimes understood by others and usually understood others. Resident #115 had severe cognitive impairment as evidenced by a Brief Interview Mental Status exam score of 6/15. -Resident #115 required limited assistance with bed mobility, locomotion on and off the unit and required supervision for eating. Resident #115 required extensive assistance with transfers, dressing, toileting, personal hygiene and required physical assistance with bathing. -Resident #115 was not on a toileting program for bowel or bladder. The resident was not coded to have had a fall any time in the month prior to admission (but see hospital report above). The resident was not coded as having a fracture related to a fall in the six months prior to admission. The MDS did not show the resident had any falls since his admission (but see below). 3. Observations On 3/12/13 at 9:09 a.m., resident #115 was observed sitting in his wheelchair in his room. The call light was on his bed, out of reach. Resident #115 was observed to have a large, raised hematoma to the right forehead. The hematoma was approximately two and one half centimeters in diameter and two centimeters in raised depth from his forehead. The hematoma was scabbed and bleeding slightly. Faint bruising was noted around the resident's right eye. The resident was observed to have difficulty attempting to roll his chair backwards toward his bed as the landing mat remained in place on the floor next to his bed. The resident was not wearing glasses. The room had a linoleum tile floor. No leaf was in place on the door to denote that the resident was a high fall risk (see facility expectations above). On 3/12/13 at 3:50 p.m., resident #115 was observed seated in his room in his wheelchair. The resident was wearing tennis shoes. The hematoma on resident #115's head continued to be noticeable at an approximate height of two centimeters and a diameter of two and one half centimeters. The hematoma was observed to be bleeding. Resident #115 was not wearing his glasses and his oxygen cannula was positioned so that one of the two prongs was not directing oxygen into his nose. No leaf was in place on the door to denote that the resident was a high fall risk. 4. Falls since Admission On 3/11/13 at 3:46 p.m., the unit nurse for resident #115 was interviewed. The unit nurse stated that resident #115 had several falls with the most recent being a fall in the dining room on 3/8/13. The nurse stated the fall was not witnessed and resulted in a cut to the pre-existing hematoma from a previous fall. The nurse stated the resident was sent to the hospital after the fall. The clinical record for the resident was reviewed throughout the survey from 3/12/13 through 3/19/13. The review of the clinical record and other pertinent resident documents revealed the following documentation regarding resident falls and the facility's response: a. 2/2/13 The Medicare Daily Skilled Nursing Notes (DSNN) documented on 2/2/13 at 1:00 a.m., the resident was found on the floor. He complained of left wrist pain and bruises to the same were noted. Resident was attempting to ambulate to the bathroom at the time of the fall. The facility fall investigation documented 2/2/13 at 12:15 a.m., resident #115 fell in his room while attempting to go to the bathroom. No footwear was noted to be in place at the time of the fall. The resident had injured his left wrist in the fall. The facility developed a fall care plan 2/4/13. Interventions included: -Assess nutritional status. -Assist as needed with toileting, transfers and ambulation. -Complete therapy screens as needed for change in Activities of Daily Living, wheelchair position or increased falls. -If fall occurs treat as needed. Notify family and physician. Fall to be reviewed by fall committee and their recommendations incorporated into the care plan. -Keep call light in reach and answer light promptly. -Keep room clutter free. -Meet physical needs like hunger, thirst and toileting. -Monitor for changes in function and cognition. -Provide adequate hydration. b. 2/5/13 The DSNN documented 2/5/13 at 3:30 a.m., that the resident was found sitting on the floor. No complaint of injury. The fall investigation documented on 2/5/13 at 2:45 a.m., resident #115 was found on the floor of his room. He was unable to communicate what happened. The resident was noted to have poor safety awareness and a lack of comprehension of his new physical limitations. No injuries were noted from this fall. The resident was not wearing footwear at the time of his fall. The recommended intervention was a low bed with a landing mat. The DSNN documented 2/8/13, untimed, that the Fall committee would add a nightlight, low bed and a landing mat as fall prevention approaches after the 2/5/13 fall. Review of the resident's 2/4/13 fall care plan revealed handwritten entries to this care plan that included encourage to use call light, nightlight in bathroom, low bed and landing strip and move to room in higher traffic area for increased visualization of the resident On 2/11/13, another fall risk care plan was initiated. This care plan included all of the interventions in the original care plan. However, the handwritten interventions (see above), interventions recommended by the Fall committee 2/8/13, were not carried over to this care plan. c. 2/16/13 The DSNN documented on 2/16/13 at 2:30 a.m., the resident was found down in his room with blood dripping from his head. Tylenol was given for head pain. The resident was assessed for other injuries. The facility fall investigation read that on 2/16/13 at 2:45 a.m., resident #115 was found on the floor of his room. The resident sustained [REDACTED]. (Cross-reference F309 for details on pain and swelling from wrist fracture.) Recommendations to prevent future falls were not captured on the fall investigation as the fall investigation was incomplete. However, further review of the DSNN revealed a note on 2/17/13 that the resident was moved from room #63 to room #37. d. 3/8/13 The fall investigation dated 3/8/13 at 4:00 p.m., documented resident #115 was found on the floor in the dining room. The resident had hit his head causing a laceration to the hematoma from the 2/16/13 fall. Resident #115 was sent to the hospital as a result of this fall. The rest of the fall investigation form, including fall prevention recommendations and analysis of the fall was not completed. Review of the resident's 2/11/13 Fall Risk care plan revealed an intervention, "Restorative to work six times weekly for ambulation," was added on 3/11/13. 5. Failures in Facility Response to Resident's Fall Risk and Repeat Falls a. Record review revealed no assessment of the resident's fall risk on admission, or after significant changes (wrist fracture, head injury) and falls. The Director of Nurses, during an interview 3/19/13 at 1:45 p.m., stated that a fall risk assessment was not completed for resident #115 and that no such assessment was in resident #115's clinical record. b. Record review revealed no thorough investigation to determine why the resident was falling and what specific need he was attempting to address when he fell . -Record review revealed no assessment of the resident's toileting needs though the voiding pattern attached to the bladder assessment form was filled out. The DON during an interview on 3/19/13 at 1:45 p.m., reviewed the clinical record for assessment of the resident related to his needs for toileting. The DON agreed that a toileting needs assessment was not completed for resident #115. The DON stated that only the bladder voiding pattern was conducted and the remainder of the assessment was incomplete. The DON stated that resident #115's assessment of nighttime voiding needs was not conducted. The DON stated the bladder/toileting assessment should have been completed. -Review of the resident's Medication Administration Record (MAR) for 2/2013 revealed that the resident was experiencing pain. Cross-reference F309; he complained of wrist pain and was diagnosed with [REDACTED]. Resident #115 was noted to have received an as needed dose of Tylenol for wrist pain three times prior to his second fall 2/16/13. From 2/16/13 (fall with hematoma) to 2/28/13, resident #115 had 16 instances of pain with pain noted on all three shifts. Resident #115's reported pain levels ranged from 4 to 8 and from 2/16/13 through 2/28/13, resident #115 received 13 doses of as needed Tylenol and four doses of as needed morphine sulfate for pain in his head and on his right side. c. Interview revealed interventions on the resident's Fall Risk care plan were not specifically tailored to the resident's cognitive and functional abilities. On 3/19/13 at 12:30 p.m., the Physical Therapist (PT) and Physical Therapy Assistant (PTA) responsible for resident #115's therapy care were interviewed. -The PT stated that resident #115 had poor balance and poor safety awareness. The PT stated resident #115's ability to detect and compensate for his change in physical ability after the cardiac arrest was impacted by a combination of [DIAGNOSES REDACTED] and his life-long developmental delay. The PT stated resident #115 did not demonstrate awareness of his new physical deficits. -The PT and PTA stated that resident #115 was mostly non-verbal, stating one or maybe two words at a time. The PT and PTA stated that resident #115 was not cooperative with therapies for most of the course of his treatment. -The PT stated that the therapy department did repeated education with resident #115 regarding safety awareness. The PT expressed doubt at resident #115's ability to retain the imparted educational information. The PT stated resident #115 seemed to do better with concepts when they were his idea. The DON, during an interview on 3/19/13 at 1:45 p.m., reviewed the two fall prevention care plans in the clinical record for the fall care plan for resident #115 and was asked to comment on which of the approaches were on the care plans were individually developed for resident #115 based on his fall history. -The DON pointed out the handwritten approach to move resident #115 to a higher traffic room. The DON was not able to explain keeping a call light in place and promptly answering it was an effective, resident specific approach for resident #115 who had severe cognitive impairment and developmental delay. -The DON agreed the care plan did not specifically list interventions related to resident #115's nighttime toileting needs, more frequent monitoring of the resident by staff in the overnight hours or footwear use at night. d. Interview revealed fall investigations were not thorough and/or complete On 3/19/13 at 1:45 p.m., the DON was interviewed regarding the falls, fall investigations and fall prevention interventions implemented for resident #115. The DON reviewed the nurses' notes and fall investigations and reported the following: -After reviewing the 2/2/13 fall investigation, the DON stated that resident #115 had a fall on 2/2/13 at 12:15 a.m. The DON stated that the resident was found down on the floor with an injury to the left wrist. The DON noted that the report showed that resident #115 was not wearing footwear at the time he got out of bed to use the bathroom. The DON stated no fall interventions were put in place at that time because the resident was new to the facility, was adjusting and was receiving therapy. -The DON reviewed the 2/5/13 fall investigation for resident #115 and noted that the resident fell at 2:45 a.m. while walking in his room without footwear. The DON stated that the resident had been toileted at 2:15 a.m. and was continent at the toileting. The DON noted that a low bed and landing mat were implemented upon completion of the investigation. The DON stated that the low bed and landing mat were selected because they wanted there to be a reduced distance to the ground and a soft surface if the resident fell from bed; the low bed was not implemented to keep resident #115 from arising. The DON was unable to point to anything in the incident report or the fall investigation that suggested that resident #115 had fallen from the bed on 2/5/13. -The DON stated that resident #115 fell on [DATE], however, see above; there was no documentation of a fall investigation. The DON called to the HID to request the fall investigation and incident report for the 2/12/13 fall. The HID was unable to locate this investigation. No follow-up assessments were identified in the nurses' notes related to a fall on 2/12/13. The DON stated that a fall investigation should have been completed for a fall. -The DON reviewed the 2/16/13 post fall investigation and stated that resident #115 was found down in his room. The DON reported the resident was bleeding from the head and was noted to have a hematoma to his right forehead. The DON noted that two previous falls and a left wrist fracture at the time of this fall. (Cross reference to F309 regarding resident #115's fractured left wrist.) The DON stated that hematoma observed on his forehead on 3/12/13 (see above observations) was the injury that the resident received from this fall. The DON stated that resident #115 was ambulating in his room with no footwear in place at the time of the unwitnessed fall. The DON stated the remainder of the post fall investigation form, where follow-up measures, evaluation of the fall and new interventions are documented, was not completed. The DON stated resident #115 experienced pain from the fall on 2/16/13. The DON, after reviewing the medication administration records from 2/16/13 forward, noted that resident #115 received as needed Tylenol everyday from 2/16 through 2/26 for complaint of headache. The DON stated the resident had received Tylenol as needed three times total prior to the 2/16/13 fall. The DON noted that after the 2/16/13 fall, resident #115 was moved from #63 which was a room at the end of a side hallway to room #37, nearer to the nurses' station with more foot traffic in the center hallway. DON explained that the resident could not be moved earlier due to a lack of more suitable room availability. -The DON reviewed the 3/8/13 fall investigation. The DON stated the resident fell at 4:00 p.m., in the dining room while ambulating. The DON stated the resident struck his right forehead, opening a laceration on the hematoma on the forehead. The DON stated the resident was sent to the hospital where he was admitted . The DON stated the resident was placed on a restorative program for strengthening after this fall. II. Environmental Hazards A. Chemical Storage On 3/11/13 at 1:58 p.m. and again on 3/13/13 at 4:48 p.m., observations of room #28 revealed an eight ounce aerosol can of Glade Water Crisp air freshener stored in the basket of the walker in the bathroom. The label of the can was observed to have warnings directing to keep the chemical out of reach of children. On 3/19/13 at 10:26 a.m., room #28 was observed in the presence of the DON. The DON stated that the resident should not have a chemical stored in an unsecure manner in her room. The DON pointed to the "Keep Out of Reach of Children" warning as evidence that it was not safe to keep this chemical out in the resident's room. The DON was observed to remove the aerosol air freshener and give it to a staff member for secure storage. B. Hazardous Surfaces 1. Memory Lane Dining Room On 3/11/13 at 3:30 p.m. and again on 3/13/13 at 3:39 p.m., the dining area in the Memory Lane secure unit was observed. There was unfinished sink and sink surround project in the main dining room. Edges of the glass tiling were noted to be sharp. Screws were observed to be sticking out of the unfinished wood supports, at shin-height, that were used to establish the sink area. On 3/14/13 at 2:00 p.m., the Director of Maintenance (DM) was asked to observe the glass tiling in the dining room. The DM agreed that there were sharp edges to the glass tiles. On 3/18/13 at 6:58 p.m., the dining room was observed in the presence of the DON. The DON agreed the shin-height screws that were not flush with the wood framing presented a skin tear hazard. 2. Room #24 On 3/12/13 at 10:21 a.m. and again on 3/13/13 at 4:57 p.m., room #24 was observed to have damaged wood on the inside of the bathroom door. The wood felt splintered to the touch. On 3/19/13 at 10:31 a.m., room #24 was observed in the presence of the DON, DM, and the Housekeeping Supervisor (HS). The DON stated the door's splintered texture was a skin tear and splinter hazard. 3. Room #27 On 3/12/13 at 10:53 a.m. and again on 3/13/13 at 4:54 p.m., the A side of the room was observed to have numerous personal items stored in stacks on the floor at the head of the bed. On 3/19/13 at 10:21 a.m., the A side of the room was observed in the presence of the DON, DM and the HS. The DON, DM and HS agreed that the resident on the A side of the room had stacked numerous personal items on the floor at the head of the bed. The DON stated they were aware of the resident's propensity to stack personal items on the floor. The DON stated the items stored on the floor presented a trip hazard for the resident who was ambulatory. The DON stated the facility had not explored alternatives to get the personal items up from the floor. C. Non-approved Outlet Extender On 3/11/13 at 1:28 p.m. and again on 3/13/13 at 4:56 p.m., the outlet in the bathroom of room #025 was observed. Room #025 was observed to have a three outlet extender plugged into the outlet at the sink. On 3/19/13 at 10:32 a.m., the outlet in the bathroom of #025 was observed in the presence of the DON, DM and the HS. The DM stated the three outlet extender that was applied to the outlet in the bathroom was not acceptable because it was not the surge protector style outlet permitted by the facility. The DM was observed to remove the three outlet expander from the socket.