Every finding on record at Smith County Health and Rehabilitation

Based on policy review, emergency menu review, observation, and interview, the facility failed to ensure the emergency food supply was completely stocked to accurately reflect the emergency menu. The facility had a census of 84 with 83 residents receiving a meal tray. The findings include: Review of the undated facility policy titled, Emergency Preparedness 2025, revealed .Review your current emergency stock levels to ensure adequate product is on hand. Review of the Emergency Menu Guide for No Electricity, dated 3/2025, revealed .Day 1 Breakfast.Juice.crackers.peanut butter. Day 2 Breakfast.Juice.corn beef hash.Day 3 Breakfast.Juice.crackers.peanut butter .Day 1 Lunch.Beef Stew.cookies.Day 2 Lunch.crackers.cookies. Day 3 Lunch.beets.cookies.Day 1 Dinner.Ravioli.Day 2 Dinner .Sloppy [NAME]. During an observation and interview on 9/16/2025 at 4:04 PM, revealed the Dietary Manager confirmed the facility failed to have emergency food supply stock for the following items: a. juice b. crackers c. peanut butter d. beef stew e. corn beef hash f. beets g. sloppy joe h. ravioli During an interview on 9/17/2025 at 9:57 AM, the Dietary Manager was asked should the emergency food supply be fully stocked. The Dietary Manager stated, .we did not have the items. During an interview on 9/17/2025 at 10:27 AM, the Administrator confirmed the emergency food supply should be fully stocked.

Based on policy review, medical record review, and interview, the facility failed to document indications for medication use for 2 of 5 (Residents #2 and #23) sampled residents reviewed for unnecessary medications. Based on policy review, medical record review, and interview, the facility failed to document indications for medication use for 2 of 5 (Residents #2 and #23) sampled residents reviewed for unnecessary medications. The findings include: 1. Review of the facility policy titled, Medication Orders, dated 2/4/2025, revealed .This facility shall use uniform guidelines for the ordering of medication.Elements of the Medication Order.Diagnosis or indication for use.PRN (as needed orders should also specify the condition, for which they are being administered. Review of the facility policy titled, Use of Psychotropic Medication, dated 6/12/2025, revealed .Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition.A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior.The indication for use of any psychotropic drug will be documented in the medical record. 2. Review of the medical record revealed Resident #2 was admitted [DATE], to the facility with diagnoses including Hemiplegia, Diabetes, Depression, Dementia, Bipolar Disorder, Hypertension, and Anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was not completed due to Resident #2 was severely cognitively impaired. Resident #2 received insulin, antipsychotic, antidepressant, opioid, antiplatelet, hypoglycemic, and anticonvulsant medications. Review of the Physician's Orders dated 12/10/2024, revealed the following medications without an indication for use. a. Aspirin [used to treat heart conditions] .tablet .chewable .81 mg [milligram] .1 .oral .Once A Day . b. Lantus U-100 Insulin [used to treat high blood glucose] .15 Units .subcutaneous [below the skin] .At Bedtime . Review of the Physician's Order dated 7/9/2025, revealed the following medication without an indication for use. Risperidone [used to treat depression] .tablet .1 mg .amount .1.5mg .At bedtime . Review of the Physician's Order dated 8/4/2025, revealed the following medication without an indication for use. MiraLAX [used to treat constipation] .powder .17 gram/dose .17 gram .oral .Once A Day . During an interview on 9/17/2025 at 10:46 AM, the Director of Nursing (DON) confirmed Resident #2's medications did not have an indication for use and confirmed every medication order should have the diagnosis or the reason for use. 3. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Bipolar Disorder, Delusional Disorders, Depression, Anxiety, and Neuropathy. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated Resident #23 was cognitively intact. Resident #23 received antianxiety, antidepressant, anticoagulant, diuretic, and opioid medications. Review of the Physician's Orders dated 5/19/2025, revealed the following medications without an indication for use. a. Ativan [used to treat anxiety].0.5mg.1 tab [tablet].twice a day. b. Remeron [used to treat depression] .15mg .administer 7.5mg with meals .every day. c. Clonidine [used to treat high blood pressure].0.1mg.1 tablet.twice a day . d. Trazodone [used to treat depression].100mg.1 tablet.at bedtime.every day. e. Lipitor [used to treat high cholesterol].40mg.1 tablet.at bedtime.every day. f. Promethazine [used to treat nausea].25mg/ml [milliliter] .1 [ml] .as needed. g. Promethazine.25mg.1 tablet.as needed .every 4 hours. During an interview on 9/16/2025 at 4:18 PM, the DON confirmed Resident #23's medications did not have an indication for use and confirmed that all medications should have a diagnosis or indication for use.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure a report of resident to resident abuse was immediately reported for 2 of 9 sampled resident (Resident #3 and Resident #4) for 2/15/2022 and 3/9/2022. The findings include: Review of the facility's policy titled Abuse, Neglect, and Exploitation, dated 12/2020 revealed, .an immediate investigation is warranted when suspicion of abuse .occur .providing complete and thorough documentation of the investigation .facilty will reporting of all alleged violation to the Administrator, State Agency, Adult Protective Services and to all other required agencies .immediately but not later than 2 hours after the allegation is made . Review of the medical record revealed Resident #3 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Extensive assistance to total assistance of 1 staff member was required for activities of daily living (ADLs) Review of the medical record revealed Resident #4 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarter MDS dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. Supervision to extensive assistance of 1 staff member was required for ADLs. Review of the nursing progress notes dated 2/15/2022 and 3/9/2022 revealed witnessed altercations between Resident #3 and Resident #4. Both altercations were appropriately handled but not reported to the State Agency and other agencies. Observation in the memory unit common area on 5/2/2022 at 8:30 AM revealed Resident #3 and Resident #4 were having breakfast at different tables. 4 staff members were present to assist a total of 10 residents. During an interview on 5/2/2022 at 1:15 PM with the Regional Nurse Consultant and the Administrator confirmed the altercations between Resident #3 and Resident #4 on 2/15/2022 and 3/9/2022 were not reported in a timely manner to the State Agency. They also confirmed this information was disclosed on the Intake Report for complaint TN 121 dated 3/24/2022. During a telephone interview with Registered Nurse (RN) #1 on 5/3/2022 at 9:00 AM revealed she worked on the memory unit on 2/15/2022 and 3/9/2022. She stated she recalled the altercations between Resident #3 and Resident #4 on 2/15/2022 and 3/9/2022 and she did not report them to the Abuse Coordinator. She also confirmed the altercations involving Resident #3 and Resident #4 on 2/15/2022 and 3/9/2022 were not timely reported to the State Agency.

Based on facility policy review, medical record review, and interview, the facility failed to ensure the Responsible Party (RP/Family member/Power of Attorney) for 1 of 9 sampled residents (Resident #1) was notified of changes in Resident #1's condition on 12/27/2021. The finding include: Review of the facility policy titled, Notification of Changes, dated 1/2/2020 revealed, .to ensure the facility promptly informs the resident, consults the resident's physician and notifies consistent with his or her authority the resident's representative when there is a change requiring notification .circumstances requiring notification include .significant change in .resident's physical, mental, or psychosocial condition such as deterioration in health .circumstances that require a need to alter treatment . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 required extensive assistance of 1 to 2 staff members for activities of daily living (ADLs). Review of the nursing progress notes dated 12/27/2021 revealed the RP was not notified of the change in Resident #1's condition and transfer to the hospital. During a telephone interview on 5/2/2022 at 10:50 AM with the RP confirmed she received no telephone call of notification of the decline in status of Resident #1 or her transfer to the hospital on 12/27/2022. During an interview on 5/2/2022 at 11:20 AM with Social Services confirmed no documentation in the medical record of notification of the RP for the change in condition of Resident #1 and transfer to the hospital on 12/27/2022. During an interview on 5/2/2022 at 1:15 PM with the Regional Nurse Consultant and the Administrator confirmed there was no documentation of notification of the RP for the change in condition of Resident #1 and transfer to the hospital on 12/27/2022.

Based on facility policy review, medical record review, and interview, the facility failed to notify the Resident's Representative of a fall for 1 resident (Resident #3) of 3 residents reviewed for falls. The findings included: Review of the undated policy, Falls Management Program Guides, revealed .the responsible party should be notified . Medical record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].FRACTURE OF LUMBOSACRAL SPINE AND PELVIS, REPEATED FALLS, [MEDICAL CONDITIONS] WITHOUT BEHAVIORAL DISTURBANCE, DIFFICULTY IN WALKING, MUSCLE WASTING [MEDICAL CONDITION], GENERALIZED ANXIETY DISORDER, POST-TRAUMATIC STRESS DISORDER, and MAJOR [MEDICAL CONDITION]. Medical record review of the Face Sheet for Resident #3 revealed Family Member #3 was listed as the Contact/Emergency Contact #1. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 had adequate hearing; vision was impaired; her speech was unclear, she usually could make herself understood and usually understood others. She scored a 15 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact. Medical record review revealed the following: On 1/9/2020 at 3:41 PM, of the Health Status Note, written by Licensed Practical Nurse (LPN) #5, revealed .At around 12:50 PM on Thursday (MONTH) 9, 2020, a pt (patient) yelled down the hallway I need a nurse. This nurse came to room and found pt (patient - (Resident #3) lying face down on the floor. there was a fair amount of blood on floor .pt had blood coming from a small laceration above rt (right) eye, and redness to rt cheek . On 1/10/2020, of the Post Fall Review, written by LPN #5, revealed Resident #3 had an unwitnessed fall on 1/9/2020 at 12:50 PM. Further review revealed the .Family/Responsible Party was notified on 1/9/2020 at 2:00 PM and named the specific family member. Further review revealed the specified family member notified was not Family Member #3. Review of the facility investigation included the Supervisor Investigation of Fall form dated 1/9/2020, written by LPN #5, which revealed Resident #3 fell on [DATE] at 12:50 PM, in her room. The form revealed the resident's family member, specifying the relationship to the resident, was notified on 1/9/2020 at 1:15 PM. Further review revealed the family member notified was not family Member #3. Interview with LPN #5 on 2/5/2020 at 8:34 AM, in the conference room revealed the LPN was working at the medicine cart when Resident #3's roommate rolled out of the room in the wheelchair and told the LPN that (Resident #3) needed help. The LPN entered the room and found Resident #3 face down with a little pool of blood under her head. The LPN stated she went to the nursing station and was checking the resident's chart to initiate the notifications when the nursing station telephone rang. The LPN answered the telephone and Resident #3's relative was asking to speak to the resident. The LPN stated she noticed this family members name was listed as an emergency contact and proceeded to inform the individual of the fall and then took the telephone to the resident for the family member to talk with the resident. The LPN stated she saw the name on the list and did not recall if there was a designation of which to notify first. The LPN stated several hours later, (Named Family Member #3) called the facility and 'was yelling at me why didn't I notify her first.' The LPN stated she tried to apologize and explained what had happened regarding the telephone ringing right when she was ready to call and it was Resident #3's family on the telephone and on the emergency contact list. Interview with the Interim Director of Nursing on 2/4/2020 at 3:05 PM, in the conference room confirmed the facility failed to notify the appropriate Family Member, #3. Further interview revealed the Face Sheet used at the time of the 1/9/2020 fall included the name of the the family member which called the facility but there was no evidence of the information in the current medical record or in the fall investigation documentation.

Based on medical record review and staff interview, the facility failed to accurately assess the fall on the Minimum Data Set for 1 (Resident #1) resident of 5 residents reviewed. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].NON-ST ELEVATION [MEDICAL CONDITION] INFARCTION; TYPE 2 DIABETES MELLITUS; MAJOR [MEDICAL CONDITION], RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS; UNSPECIFIED CONVULSIONS, [MEDICAL CONDITIONS] DISORDER, [MEDICAL CONDITION] TYPE; [MEDICAL CONDITION] DISEASE OF NERVOUS SYSTEM, and AGE-RELATED [MEDICAL CONDITION] since 2014 . Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 had clear speech, and usually could make her needs known and usually understood others. The resident scored a 4 on the Brief Interview for Mental Status (BIMS), indicating she was severely cognitively impaired (severely impaired range 0 - 7). She was occasionally incontinent of bowel and bladder. She required limited 1 person assistance for bed mobility, transferring, walking in the room, locomotion on and off the unit, eating and toileting for her activities of daily living (ADL). Resident #1 was assessed as having no falls during the review period. Medical record review of the Nursing Progress Note, written by Licensed Practical Nurse (LPN) #1, dated 12/4/2019 at 7:00 PM, revealed .Resident (#1) was found on the floor of the room across the hall from her own room, (named Certified Nurse Aide (CNA) #1) went down the hall to start her round and saw the resident sitting on her bottom, in the floor, with blood in her hair and on the floor around her, the CNA called for a nurse, this nurse assessed the resident, discovered she had two bleeding wounds, quickly forming lumps, on her head, one on the back, right side, and one on her left side . Review of the facility investigation included the Supervisor Investigation of Fall, written by LPN #1, dated 12/4/2019, revealed Resident #1 had an unwitnessed fall on 12/4/2019 at 7:00 PM, in another resident's room. Further review revealed the resident's head hurt, and she had 2 hematomas to the head and was bleeding. Review of the Resident Event Report Worksheet, written by LPN #1, with the event date and time of 12/4/2019 at 6:55 PM, revealed Resident #1 had an unwitnessed fall with a significant injury while in another resident's room. Further review revealed the resident sustained [REDACTED]. Medical record review of the Quarterly MDS dated [DATE], revealed the MDS did not address the fall with injury which occurred on 12/4/2019. Interview with the Registered Nurse MDS Coordinator on 2/5/2020 at 9:20 AM in the conference room confirmed the MDS dated [DATE] failed to include the fall of 12/4/2019 by Resident #1.

Based on facility policy review, medical record review, and interview, the facility failed to conduct a thorough investigation of falls for 2 (Resident #1 and #3) residents of 3 residents reviewed with falls. The findings included: Review of the undated policy, Falls Management Program Guides, revealed the corporation strived to maintain a hazard free environment, mitigate fall risk factors and the implementation of preventative measures. The definition of a fall was considered to be .an unintentional coming to rest on the ground, floor, or the lower level, but not as a result of an overwhelming external force .when a resident is found on the floor, a fall is considered to have occurred . The Procedure included the fall risk assessment as part of the admission, quarterly and when a fall occurred, the identified risk factors should have been evaluated for the contribution they may have to the resident's likelihood of falling and the care plan interventions should have been implemented that addressed the resident's risk factors. Further review revealed if the event the resident fell .the attending nurse shall complete a post fall assessment .includes an investigation of the circumstances surrounding the fall to determine the cause of the episode, a reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT to evaluate thoroughness of the investigation and the appropriateness of the interventions .nursing staff will observe and document continued resident response and effectiveness of interventions for 72 hours . Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].NON-ST ELEVATION [MEDICAL CONDITION] INFARCTION; TYPE 2 DIABETES MELLITUS; MAJOR [MEDICAL CONDITION], RECURRENT, SEVERE WITH PSYCHOTIC SYMPTOMS; UNSPECIFIED CONVULSIONS; [MEDICAL CONDITION]; [MEDICAL CONDITION]; [MEDICAL CONDITION] DISORDER, [MEDICAL CONDITION] TYPE; [MEDICAL CONDITION] DISEASE OF NERVOUS SYSTEM, and AGE-RELATED [MEDICAL CONDITION] since 2014 . Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 had adequate hearing and vision with no devices; had clear speech, and usually could make her needs known and usually understood others. The resident scored a 4 on the Brief Interview for Mental Status (BIMS), indicating she was severely cognitively impaired (severely impaired range 0 - 7). She did not have a change in mental status and exhibited no [MEDICAL CONDITION] or behaviors during the review period. She did exhibit inattentiveness which did fluctuate. She exhibited alteration in sleep and depression/feeling down for 12 - 14 days of the review period. She exhibited a change in energy for 7 - 12 days of the review period. She exhibited a change in appetite and concentration for 2 - 6 days of the review period. She was occasionally incontinent of bowel and bladder. She required limited 1 person assistance for bed mobility, transferring, walking in the room, locomotion on and off the unit, eating and toileting for her activities of daily living (ADL). Resident #1 was assessed as having no falls during the review period. Medical record review of the care plan updated in 10/28/2019, revealed Resident #1 was at risk for falls related to she required assistance with ADLs at times, received [MEDICAL CONDITION] medication, and had Actual Falls. The interventions included .Encourage resident to request assistance in ambulating, Fall Intervention: Keep personal items within reach, activities that minimize the potential for falls while providing diversion and distraction upon her visitors departure, Make sure shower chair is locked on both sides, Provide non-skid footwear as tolerated, and Therapy to provide resident with a reacher device (long handled device with pinchers on one end to grasp items) . Medical record review of the Morse Fall Scale form dated 10/29/2019, revealed Resident #1 was at a moderate risk for falls with a score of 40. Medical record review of the Nursing Progress Note, written by Licensed Practical Nurse (LPN) #1, dated 12/4/2019 at 7:00 PM, revealed .Resident (#1) was found on the floor of the room across the hall from her own room, (named CNA #1) went down the hall to start her round and saw the resident sitting on her bottom, in the floor, with blood in her hair and on the floor around her, the CNA called for a nurse, this nurse assessed the resident, discovered she had two bleeding wounds, quickly forming lumps, on her head, one on the back, right side, and one on her left side, pressure was applied with a cold towel, the other nurse called for an ambulance, which arrived and transported the resident to (named hospital) . Review of the facility investigation of the undated, Staffs 10 Questions at the Time of a Resident Fall, written by LPN #1, revealed Resident #1's head hurt, .What were you trying to do when you fell ? Walking .Position of resident when they fell ? Near wheelchair. How far from surface where they? Next to surface. What were position of their arms and legs? Arms in lap, legs in front of her .Apparel resident was wearing? Night gown .Shoes, Socks (non-skid) . Review of the facility investigation included the Supervisor Investigation of Fall, written by LPN #1, dated 12/4/2019, revealed Resident #1 had an unwitnessed fall on 12/4/2019 at 7:00 PM, in another resident's room. She possibly fell from the wheelchair, unknown. The resident's head hurt, and she had 2 hematomas to the head and was bleeding. The Immediate Intervention was to apply pressure to the wounds. The resident had not had a previous fall. CNA #1 found the resident. The resident was sent to the emergency room and neurological checks were started after the resident returned from the hospital. The physician and family were notified. Review of the Resident Event Report Worksheet, written by LPN #1, with the event date and time of 12/4/2019 at 6:55 PM, revealed the physician and family were notified. The assigned staff to Resident #1 were CNA #1 and LPN #1. The resident had an unwitnessed fall with a significant injury while in another resident's room and was found on the floor. The circumstances were unknown. The resident sustained [REDACTED]. Review of the POS [REDACTED]. Vital Signs were - Temperature 98.4; Pulse 71; Respiration 16; and Blood Pressure 147/99. The resident was found on the floor of another resident's room and she didn't know what happened, says 'I just fell .' Fall review location: in another resident's room; location prior to fall: wheelchair; Activity at time of the fall? Unknown. Footwear/device at time of fall: shoes. There were no environmental factors identified. The immediate prevention put in place was to encourage resident to ask for assistance with ADL's. Medical record review for the Morse Fall Scale form revealed there was no form for the fall on 12/4/2019 for Resident #1. Review of the undated written statement by CNA # 1 revealed .Went down 300 hall to start my round I saw (named Resident #1) on the floor with blood around her. I immediately called for help. (Named LPN #6) and (named LPN #1) came down and we grabbed towels and applied pressure. (Named LPN #6) went and called 911 and got all the paperwork together. We took her vitals and assessed her. The paramedics showed up and picked her up . Medical record review of the potential resident witnesses to the fall of Resident #1 on 12/4/2019, revealed Resident #4's Quarterly MDS dated [DATE], showed she had a BIMS of 9, indicating she was moderately cognitively impaired (moderately range 8 - 12). She had minimal difficulty hearing, adequate vision, had clear speech and could usually make herself understood and usually understood others. The investigation failed to include an interview of what the resident potentially saw and/or heard during the fall. Medical record review of potential resident witness to the fall of Resident #1 on 12/4/2019, revealed Resident #5's Annual MDS dated [DATE], showed she had a BIMS of 12, indicating she was moderately cognitively impaired. She had adequate hearing and vision, clear speech, and could make herself understood and understood others. Resident #5 had another MDS dated [DATE], which showed her BIMS was 13, indicating she was cognitively intact (intact range 13 - 15) and the other data was the same as the 9/15/2019 MDS. The investigation failed to include an interview of what the resident potentially saw and/or heard during the fall. Further review of the investigation revealed the failure to identify the room where the fall took place, failure to identify the 2 residents in the room of the fall, and failure to obtain an interview from the residents potentially witnessing the fall, if feasible, or have data to show the 2 residents where not capable of providing information. The investigation did not include a diagram of the room layout and the resident's position at the time of the fall. The investigation included 1 witness statement, by CNA #1, who named another staff member, (named LPN #6) was present in the room. There was no statement in the investigation from LPN #6. The investigation did not include a root cause. Interview with the Interim Director of Nursing (IDON) on 2/4/2020 at 8:00 AM, in the conference room stated some areas of the Post Fall Review form addressed the fall risks assessment addressed in the Falls Management Program Guidelines policy. The IDON read the Post Fall Review dated 12/4/2019 and confirmed it did not include the fall risk assessment. Further interview at 9:10 AM confirmed the investigation did not include the statement by the staff named (LPN #6) in CNA #1's statement, did not indicate when Resident #1 was last seen by staff and what she was doing, did not include how Resident #1 got into room of the fall, did not specify the room where the fall occurred, and did not identify the 2 residents who were potential witnesses and if the 2 residents were capable of providing a statement. The IDON confirmed the investigation was not complete. The IDON confirmed the Fall Risk Assessment should have been completed as part of the investigation. Medical record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED].FRACTURE OF LUMBOSACRAL SPINE AND PELVIS, REPEATED FALLS, HYPERTENSION, CHRONIC PAIN, [MEDICAL CONDITION], TYPE 2 DIABETES MELLITUS, [MEDICAL CONDITIONS] WITHOUT BEHAVIORAL DISTURBANCE, DIFFICULTY IN WALKING, MUSCLE WASTING AND ATROPHY, RETENTION OF URINE, [MEDICAL CONDITIONS], GENERALIZED ANXIETY DISORDER, POST-TRAUMATIC STRESS DISORDER, MAJOR [MEDICAL CONDITION], and ANXIETY DISORDER . Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 had adequate hearing; vision was impaired; her speech was unclear, she usually could make herself understood and usually understood others. She scored a 15 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact. She had no changes in mental status, no [MEDICAL CONDITION], no [MEDICAL CONDITION] or any behaviors during the review period. The resident exhibited feeling down/depressed and a change in appetite over the past 12-14 days; a change in energy for 7-11 days, and a change in sleep and feeling bad about herself/let others down over the past 2-6 days of the review period. The resident required total 1 person assistance for bathing; extensive 2 plus (+) person assistance with bed mobility; extensive 1 person assistance with transferring, dressing, hygiene, and with toilet use. She required supervision of 1 person with locomotion on and off the unit. She resident was always incontinent of bowel and bladder. The resident had not had falls after the last MDS. Medical record review revealed the following: On 1/8/2020, of the Morse Fall Scale revealed Resident #3 score 55, indicating the resident was at high risk for falls. On 1/9/2020 at 3:41 PM, of the Health Status Note, written by Licensed Practical Nurse (LPN) #5 revealed .At around 12:50 PM on Thursday (MONTH) 9, 2020, a pt (patient) yelled down the hallway I need a nurse. This nurse came to room and found pt (Resident #3) lying face down on the floor. there was a fair amount of blood on floor with pt's glasses on floor in front of her. called another nurse into room, assessed pt then turned her over on her back, pt had blood coming from a small laceration above rt (right) eye, and redness to rt cheek. Pt was A&O x (alert and oriented times) 4, able to tell us what happened, denied any pain at this time. Picked her up and placed her back into her wheelchair. pt stated I was sitting on side of my bed, bent over to plug in my cell phone, and fell over. v/s (vital signs) (Blood Pressure (BP)) 134/78, (Respiration (R)) 18, (Pulse (P)) 80, O2 97% (percent) on room air. at this time bleeding to her head had stopped, contacted wound care nurse to asses for treatment, spoke to (named Nurse Practitioner). Had pt apply ice to right side of face/eye area. Will continue to monitor, continue on neuro checks per protocol. Call light within reach . Review of the facility investigation included the Supervisor Investigation of Fall form dated 1/9/2020, written by LPN #5, which revealed Resident #3 fell on [DATE] at 12:50 PM, in her room while bending forward trying to plug cell phone in. The roommate found the resident. The resident had an injury of a laceration above the right eye, was not sent to the emergency room , neurochecks were initiated and the physician and resident's (family member) were notified. The facility intervention was to attach the phone cord to the bedrail for easy access and the intervention was placed on the care plan. Review of the facility investigation included the undated Staff's 10 Questions at the Time of a Resident Fall form which revealed the resident stated she was 'Okay', that she was face down next to a surface and the environment was clean, dry, had no spills and the area was uncluttered. The resident was wearing pants, shirt, shoes and socks. The assistive device used was a wheelchair and she was wearing her glasses. Review of the facility investigation included the Resident Event Report Worksheet form dated 1/9/2020, written by LPN #5, revealed the date and time of the unwitnessed fall by Resident #3 was 1/9/2020 at 12:50 PM, which had occurred in Resident #3's room. The resident sustained [REDACTED]. The resident had a laceration to the right eyebrow/temple area and a red cheek. The factors related to the fall was she was reaching. The resident had no pain and the physician and family were notified. Medical record review of Resident #3's roommate, at the time of the 1/9/2020 fall, Quarterly MDS dated [DATE], revealed a BIMS score of 11, indicating she was (upper range) moderately cognitively impaired (Moderate range: 8 - 12). She had moderate difficulty with hearing, she had adequate vision and wore lenses. Medical record review of the Neurological Record form dated 1/9/2020 at 1:00 PM through 9:30 PM, and on 1/10/2020 at 1:30 AM through 5:30 AM, revealed Resident #3's results were within normal range. Medical record review of the Health Status Note dated 1/10/2020 at 9:00 AM, revealed .Nurse was called to room by (named Family Member #3). (Named Family Member #3) insisted on resident being sent to hospital for a CT (Computerized [NAME]ography) Scan due to S/P (status [REDACTED]. Noted to have bruise to right shoulder. Skin tear above right eye. No bleeding or swelling noted to site. (Named) NP (Nurse Practitioner) was called, received new orders to transport to (named hospital) for CT scan. Will continue to monitor . Interview with LPN #5 on 2/5/2020 at 8:34 AM, in the conference room revealed the LPN was working at the medicine cart when Resident #3's roommate rolled out of the room in the wheelchair and told the LPN that (Resident #3) needed help. The LPN entered the room and found Resident #3 face down with a little pool of blood under her head. The LPN called for help from other nurse. The LPN could not recall the name of the nurse helping her. The LPN reviewed her written report and confirmed she failed to write the name of the nurse on the report. The LPN stated once the other nurse was available, they assessed the resident. The LPN stated she notified the NP who was in the facility and the LPN recalled the NP went to assess the resident. The NP saw the resident, the vital signs and neurochecks were normal, the resident had complained of a sore head, but not pain, and the NP did not order a discharge to the hospital. Interview with the NP on 2/5/2020 at 9:35 AM, in the conference room revealed the NP had seen Resident #3 earlier in the day, prior to the fall on 1/9/2020. The NP stated she was notified of the fall, went to assess the resident, noted the neurocheck was normal so far, and the resident was not complaining of pain. The NP stated her intent was to continue monitoring the vital signs and neurochecks and to assess the resident for abnormalities. The NP stated the resident returned to the facility on [DATE] and she then wrote her note dated on 1/13/2020. Further review of the investigation revealed no written statements from the staff involved in the response, LPN #5, another unnamed nurse, the assigned CNA, the NP; failed to include what the resident was doing and last known location, prior to the fall; no statement from the resident; no statement from the roommate alerting staff of the fall; no diagram of the resident's room and the of the resident as found at the time of the fall, a complete set of the neurochecks, and no root cause analysis. Medical record review revealed the following: On 1/14/2020 at 10:48 AM, of the Infection Note revealed .Review of (Resident #3's) S/Sx (signs/symptoms) of infection completed using McGeer's Criteria. diagnosed infection: uti (urinary tract infection) Medication Order: [MEDICATION NAME]. Care plan revised as indicated . On 1/20/2020 at 3:20 PM, of the Health Status Note, written by LPN #3, revealed .Nurse was called to resident's room by therapy. Resident was sitting in floor on her bottom at the foot of her bed, with her back leaned up against heater. When asked resident what she was doing she said, I stood up and I was trying to reach my cell phone and I fell over. No complaints of pain voiced. No injuries noted. Intervention: Signage to be used to remind resident to ask for assistance. (Named NP) was notified. (Named Family Member #3) was notified .(Named Director of Nursing) was notified. Will continue to monitor . On 1/21/2020 at 8:53 AM, of the Health Status Note revealed the .IDT met to discuss resident's fall from (1/20/2020). Resident fell while in her room. Intervention is to provide resident with a sign to ask for staff assist . Review of the facility investigation included the Supervisor Investigation of Fall, written by LPN #3, dated 1/20/2020, revealed Resident #3 fell on Monday, 1/20/2020 at 2:30 PM, in her room when she stood up from the wheelchair and was reaching for the cell phone and fell out of the wheelchair. The therapist found the resident on the floor. The resident had no injuries or complaint of pain. The facility's immediate intervention was to assist the resident up from the floor, with 2 staff assisting, back into the wheelchair. The recent had had recent falls and the facility started neurochecks. The physician and (Family Member #3) were notified. The intervention was signage. Review of the facility investigation included the undated, Staff's 10 Questions at the Time of a Resident Fall form, written by LPN #3, revealed Resident #3 stated she was okay, and had stood up to reach for her cell phone. The resident's position after the fall was described as sitting on her bottom with her back against the heater with her legs straight out and her arms in her lap. The environment was described as clean, dry, and uncluttered with good visibility. The resident was wearing shoes and socks with proper fitting clothing. There was no one in the area when the resident fell . Review of the facility investigation included the Resident Event Report Worksheet form, written by LPN #3, dated 1/20/2020, which revealed Resident #3 had a fall in her room while reaching which resulted in no significant injury. Further review revealed LPN #2 and CNA #2 were assigned to the resident. Interview with CNA #2 on 2/4/2020 at 1:07 PM, in the conference room revealed the CNA had been assigned to the resident but she had not witnessed the fall on 1/20/2020. CNA #2 stated she had been informed of the fall by a therapist. The therapist was working with another resident in the hallway and had walked past Resident #3's room when she saw Resident #3 on the floor. The CNA stated when she entered the room the resident was seated on her bottom with her back to the heater/air conditioner, her left side was next to the window wall, her right side was on the bed side, and her legs were straight out in front of her. The CNA asked the resident to wait to get a nurse to check her over. The CNA stated LPN #4 came to the room because LPN #2, assigned to the resident, was not available. LPN #4 assessed the resident and no injury was noted and 'we got the resident into the wheelchair.' Interview with LPN #3 on 2/4/2020 at 1:34 PM, in the conference room revealed the assigned nurse, LPN #2, had gone to lunch and she had responded to CNA #2's request to help with Resident #3. The LPN did not recall a therapist being involved. LPN #3 stated LPN #4 helped her get the resident off the floor. LPN #3 stated she called the NP and Family Member #3 regarding the fall. Interview with LPN #4 on 2/4/2020 at 1:57 PM, in the conference room revealed a therapist had walked down the hall and had said something to LPN #3, then .LPN #3 yelled for me . When LPN #4 got into Resident #3's room the resident was seated on the floor with her back to the heater/air conditioner. LPN #4 stated she and LPN #3 assessed the resident, got her up into her wheelchair, and obtained vital signs. Interview with LPN #2 on 2/4/2020 at 2:55 PM, in the conference room revealed the LPN was assigned to Resident #3 on 1/20/2020. The LPN stated .a therapist got LPN #3 in the hall, then LPN #3 or CNA #2, or someone, got me. The resident was on her buttocks with her back to the heater/air conditioner and her legs were in front of her . when the LPN got into the room. The LPN stated the resident was assessed for pain and injury, while she was on the floor, and she was okay. LPN #2 stated LPN #3 was in the room with LPN #2 but LPN #2 had no recall of LPN #4 being present. LPN #2 stated this LPN notified the NP and Family Member #3 of the fall. Further review of the investigation revealed no written statements by CNA #2, LPN #2, LPN #3, LPN #4, the NP, or the therapist seeing Resident #3 on the floor. The investigation provided failed to identify all the staff involved and failed to identify the therapist. There was no diagram of the resident's room and of the resident as found at the time of the fall, and no root cause analysis. The investigation did not include the potential of the UTI contributing to the fall. Interview with the Interim Director of Nursing on 2/4/2020 at 3:05 PM, in the conference room confirmed the facility failed .to obtain interviews from staff, the therapist, anyone involved with the fall. I understand what you're saying. The information isn't there and the investigation isn't complete .

Based on facility policy review, facility documentation review, medical record review and interview the facility failed to ensure 1 (Resident #43) of 13 residents reviewed on the secured unit was free from physical restraints when a staff member placed chairs around Resident #43's bed which resulted in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was informed of the Immediate Jeopardy (IJ) on 9/24/19 at 3:05 PM in his office. F604 was cited at a scope and severity of J. The facility was cited F604-J which is Substandard Quality of Care. An extended survey was conducted from 9/24/19 to 9/25/19. The Immediate Jeopardy was effective from 9/18/19 through 9/24/19. An acceptable Allegation of Compliance (AOC), which removed the immediacy of the jeopardy was received on 9/25/19 at 2:10 PM and corrective actions were validated onsite by the surveyors on 9/25/19. The findings include: Facility policy review, Abuse, revised 11/28/17, revealed .Verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, and neglect of the resident as well as mistreatment, injuries of unknown source, exploitation, and misappropriation of resident property are strictly prohibited .This includes, but is not limited to, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms . Facility policy review, Use of Restraints, revised 2007, revealed .Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully .Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience or for the prevention of falls . Medical record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #43's Admission Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Continued review revealed the resident exhibited physical, verbal, and other behavioral symptoms. Further review revealed the resident rejected care. Continued review revealed the resident required extensive assist of 1 person with walking in room and corridor. Further review revealed the resident required no restraints. Continued review revealed the resident received Occupational Therapy Services and Physical Therapy Services. Review of the facility investigation dated 9/18/19 revealed an allegation of Resident #43 being restrained by 4 chairs surrounding her bed on 9/18/19. Continue review revealed the facility substantiated the allegation. Review of Resident #43's nursing Progress Notes dated 7/25/19 revealed .ambulates very short distances with walker . Review of Resident #43's Nurse Practitioner Progress Note dated 9/17/19 revealed .She walked some with family and staff assistance to the restroom . Review of Resident #43's Progress Note dated 9/18/19 at 8:30 AM by the Social Worker revealed .Resident was found with 2 chairs up against each side of her bed this morning by tech [Certified Nursing Assistant] . Review of Resident #43's Progress Note dated 9/18/19 at 9:45 AM by the Director of Nursing (DON) revealed .A CNA [Certified Nursing Assistant] notified the ADON [Assistant Director of Nursing] that upon entering the residents room she saw three regular chairs and a wheelchair setting around the residents bed enabling resident to get out of bed . Interview with the DON on 9/26/19 at 12:45 PM in the conference room when asked to clarify the progress note for Resident #43 dated 9/18/19 revealed, I documented enabling the resident to get out of bed but I meant to document preventing the resident from getting out of bed. Interview with CNA #2 on 9/23/19 at 2:42 PM in the Harmony Unit dining room when asked concerning the allegation of restraints for Resident #43 revealed, When I went into [named Resident #43] room she had chairs all around her bed; 2 chairs on each side of the bed, one being her wheelchair. She was trying to sit up in the bed. I immediately removed the chairs and got her out of bed into her wheelchair and reported the chairs being around her bed to the nurse. Interview with the Social Worker on 9/23/19 at 2:56 PM in the Harmony Unit dining room confirmed the incident involving a restraint for Resident #43 was reported to the ADON and the Administrator. Telephone interview with CNA #1 on 9/23/19 at 4:04 PM when asked about the incident with Resident #43 revealed, After [named Resident #43] was in bed she was trying to get up so I offered to get her up and she said no and if I tried to get her out of bed she would knock my head off; we had another resident running a high fever and I gave that resident a shower and after I got finished, [named Resident #43] was still trying to get out of bed so I put the chairs around her bed. Continued interview confirmed, I know it was barricading her, but I was afraid she would fall and get hurt; I knew it was a restraint but I was trying to keep her safe. Continued interview revealed, I had forgotten about the chairs; I was notified later that day the day shift staff found the chairs around her bed. Telephone Interview with Resident #43's daughter on 9/25/19 at 3:22 PM revealed when the resident was at home she would get out of bed and walk to the bathroom, living room and the kitchen. Interview with the DON and the Administrator on 9/23/19 at 3:10 PM in the DON's office confirmed the incident in which Resident #43 was restrained in her bed was substantiated. The facility's failure to ensure Resident #43 was free of physical restraints resulted in Immediate Jeopardy. The surveyors verified the AOC by: 1. The chairs were removed from around Resident #43's bed on 9/18/19. The surveyors interviewed staff and confirmed the chairs were removed. 2. CNA #1 was suspended immediately. Skin assessments were completed on 100% of the residents residing in the secure unit. The surveyors reviewed the skin assessments provided on the residents residing in the secure unit. The surveyors observed residents in the secure unit with no restraints noted. On 9/25/19 the facility's Staff Development Coordinator, Assistant Director of Nursing and the Minimum Data Set Coordinator interviewed staff regarding the use of non-standard (not approved) fall interventions on or near a resident. The surveyors reviewed staff interviews. 3. All facility personnel were in-serviced on Abuse and Resident Rights by the facility Staff Development Coordinator beginning on 9/18/19 and completed on 9/20/19. The Surveyors reviewed in-service sign in sheets and interviewed staff on each shift. The surveyors also reviewed CNA #1's personnel file which revealed CNA #1 received training on abuse/neglect and resident rights on 2/13/19. Continued review revealed a complete and thorough investigation was finished on 9/18/19 resulting in termination of Certified Nursing Assistant #1. The noncompliance of F604 continues at a scope of D level for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on facility policy review, facility documentation review, medical record review, observation and interview the facility failed to ensure 1 (Resident #43) of 13 residents reviewed on the secured unit was free from accident hazards related to chairs being placed around the resident's bed and placed the resident in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was informed of the Immediate Jeopardy (IJ) on 9/24/19 at 3:05 PM in his office. F689 was cited at a scope and severity of J. The facility was cited F689-J which is Substandard Quality of Care. An extended survey was conducted from 9/24/19 to 9/25/19. The Immediate Jeopardy was effective from 9/18/19 through 9/24/19. An acceptable Allegation of Compliance (AOC), which removed the immediacy of the jeopardy was received on 9/25/19 at 2:10 PM and corrective actions were validated onsite by the surveyors on 9/25/19. The findings include: Facility policy review, Hazardous Areas, Devices and Equipment, revised July 2017, revealed .All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible . Medical record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Dementia with Behavioral Disturbance, Anxiety Disorder, Major Depressive Disorder and Difficulty in Walking. Review of Resident #43's Admission Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Continued review revealed the resident exhibited physical, verbal, and other behavioral symptoms. Further review revealed the resident rejected care. Continued review revealed the resident required extensive assist of 1 person with walking in room and corridor. Further review revealed the resident required no restraints. Continued review revealed the resident received Occupational Therapy Services and Physical Therapy Services. Review of Resident #43's Comprehensive Care Plan dated 7/25/19 revealed .at risk for falls r/t [related to] gait/balance problems . Review of the facility investigation dated 9/18/19 revealed a facility substantiated allegation of Resident #43 being restrained when Certified Nursing Assistant (CNA) #1 placed 4 chairs around her bed on 9/18/19. Review of Resident #43's nursing Progress Notes dated 7/25/19 revealed .ambulates very short distances with walker . Review of Resident #43's nursing Progress Notes dated 8/6/19 revealed .Uses reclining chair when up out of bed due to safety/fall risk . Review of Resident #43's nursing Progress Notes dated 8/15/19 revealed .Resident was agitated and anxious pulling picc [peripherally inserted central catheter] line, trying to slide out of bed and between rails . Medical record review of Resident #43 Physical Therapy Discharge Summary dated 8/8/19 revealed .Progress varies day to day depending on cognitive level .When patient is alert can ambulate with rollator walker up to 50 [feet] with CGA [contact guard assist] [Therapist has one or two hands on the residents body to help with balance but provides no other assistance to perform the functional task] . Review of Resident #43's nursing Progress Notes dated 8/20/19 revealed .Several attempts to stand up out of geri chair [reclining chair]. Unable to redirect resident due to her confusion . Review of Resident #43's nursing Progress Notes dated 8/27/19 revealed .several attempts to lay down in bed have been detained due to the resident trying to climb over chair/bed . Review of Resident #43's Nurse Practitioner Progress Note dated 9/17/19 revealed .She walked some with family and staff assistance to the restroom . Review of Resident #43's Progress Note dated 9/18/19 at 8:30 AM by the Social Worker revealed .Resident was found with 2 chairs up against each side of her bed this morning by tech [Certified Nursing Assistant] . Observation of Resident #43 on 9/23/19 at 9:06 AM and 10:46 AM revealed the resident lying in bed with 2 half side rails in the up position and 4 regular chairs and a wheelchair were in the room but not near the bed; 1 regular chair at the resident's left bedside, 2 regular chairs at the end of the bed by the closet, and 1 regular chair at Resident #43's roommate's right bedside and the resident's wheelchair and rollator walker at the end of Resident #43's bed. Interview with Certified Nursing Assistant (CNA) #2 on 9/23/19 at 2:42 PM in the Harmony Unit dining room when asked concerning the allegation of restraints for Resident #43 revealed, When I went into [named Resident #43] room she had chairs all around her bed; 2 chairs on each side of the bed, one being her wheelchair; She was trying to sit up in the bed. Continued interview revealed, I immediately removed the chairs and got her up out of bed into her wheelchair. Interview with Registered Nurse (RN) #1 on 9/23/19 at 2:51 PM in the Harmony Unit dining room when asked concerning the incident on 9/18/19 with Resident #43 revealed, [named CNA #2 and #3] reported [named Resident #43] had 4 chairs around her bed, her wheelchair and 3 other chairs. Interview with the Assistant Director of Nursing (ADON) on 9/23/19 at 3:04 PM in the Harmony Unit dining room when asked about the incident involving Resident #43 revealed, I came over to check on the nurse during morning rounds; It was reported to me by [CNA #2] [named Resident #43] was in the bed with chairs around her bed, keeping her in the bed. Telephone interview with CNA #1 on 9/24/19 at 5:49 PM revealed, That night when I walked into [named Resident #43] room she was laying cross ways of the bed, her head on one side of the bed and her feet hanging off the other side of the bed. She was climbing out of bed. Continued interview revealed, I assisted her back to bed at that time (10:30 PM - 11:00 PM); She kept trying to get out of the bed, approximately 10 times, before I placed the chairs around her bed (around 2:00 AM). Interview with Licensed Practical Nurse (LPN) #1 on 9/24/19 at 6:26 PM in the Harmony unit shower room revealed, [named Resident #43] has a history of climbing out of bed. Continued interview revealed, She was moved to a room closer to the nurses station related to past attempts of climbing out of bed. Continued interview revealed, We normally put a chair outside of her door and chart so we can keep an eye on her because she hangs her legs over the side of the bed. Continued interview revealed She even hangs her legs on the rails likes she's climbing. Continued interview revealed, She [named Resident #43] pulls the rails to position her body so she can dangle her legs over the side of the bed. Continued interview LPN #1 demonstrated to the surveyors Resident #43's frantic flailing and climbing motions. Interview with the Physical Therapy Assistant (PTA) on 9/25/19 at 11:19 AM in the therapy room revealed, She has the ability to move her legs when she wants to; Her therapy depends on her cognition. Telephone Interview with Resident #43's daughter on 9/25/19 at 3:22 PM revealed the resident was able to get out of the bed and ambulate independently from room to room at home. Interview with the Director of Nursing (DON) and the Administrator on 9/23/19 at 3:10 PM in the DON's office confirmed the incident in which Resident # 43 was restrained in her bed was substantiated. The facility's failure to ensure Resident #43 was free from accident hazards placed the resident in Immediate Jeopardy. The surveyors verified the AOC by: 1. The chairs were removed from around Resident #43's bed on 9/18/19. The surveyors interviewed staff and confirmed the chairs were removed. 2. CNA #1 was suspended immediately. Skin assessments were completed on 100% of the residents residing in the secure unit. The surveyors reviewed the skin assessments provided on the residents residing in the secure unit. The surveyors observed residents in the secure unit with no restraints noted. On 9/25/19 the facility's Staff Development Coordinator, Assistant Director of Nursing and the Minimum Data Set Coordinator interviewed staff regarding the use of non-standard (not approved) fall interventions on or near a resident. The surveyors reviewed staff interviews. 3. All facility personnel were in-serviced on Abuse and Resident Rights by the facility Staff Development Coordinator beginning on 9/18/19 and completed on 9/20/19. The Surveyors reviewed in-service sign in sheets and interviewed staff on each shift. The surveyors also reviewed Certified Nursing Assistant (CNA) #1's personnel file which revealed CNA #1 received training on abuse/neglect and resident rights on 2/13/19. Continued review revealed a complete and thorough investigation was finished on 9/18/19 resulting in termination of Certified Nursing Assistant #1. The noncompliance of F689 continues at a scope of D level for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on facility policy review, facility documentation review, medical record review, observation and interview the facility failed to maintain resident rights for 1 (Resident #43) of 13 residents reviewed on the secured unit related to a physical restraint when a staff member placed chairs around Resident #43's bed which resulted in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was informed of the Immediate Jeopardy (IJ) on 9/24/19 at 3:05 PM in his office. F550 was cited at a scope and severity of J. The facility was cited F550-J which is Substandard Quality of Care. An extended survey was conducted from 9/24/19 to 9/25/19. The Immediate Jeopardy was effective from 9/18/19 through 9/24/19. An acceptable Allegation of Compliance (AOC), which removed the immediacy of the jeopardy was received on 9/25/19 at 2:10 PM and corrective actions were validated onsite by the surveyors on 9/25/19. The findings include: Facility policy review, Your Rights and Protections as a Nursing Home Resident, undated, revealed .Be Free from Restraints .Nursing homes can't use physical restraints or chemical restraints to discipline you for the staff's own convenience . Facility policy review, Use of Restraints, revised 2007, revealed .Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully .Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience or for the prevention of falls . Medical record review revealed Resident #43 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #43's Admission Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Continued review revealed the resident required extensive assist of 1 person for walking in room and in corridor. Further review revealed the resident did not require restraints. Review of the facility investigation dated 9/18/19 revealed an allegation of Resident #43 being restrained by 4 chairs surrounding her bed on 9/18/19. Review of Resident #43's Progress Note dated 9/18/19 at 8:30 AM by the Social Worker revealed .Resident was found with 2 chairs up against each side of her bed this morning by tech[certified Nursing Assistant] . Observation of Resident #43 on 9/23/19 at 9:06 AM and 10:46 AM revealed the resident lying in bed with 2 half side rails in the up position and 4 regular chairs and a wheelchair in the room but not near the bed; 1 regular chair at the resident's left bedside, 2 regular chairs at the end of the bed by the closet, and 1 regular chair at Resident #43's roommate's right bedside and the resident's wheelchair and rollator walker [a walker with a seat and wheels designed to help people with disabilities move safely] at the end of Resident #43's bed. Interview with Certified Nursing Assistant (CNA) #2 on 9/23/19 at 2:42 PM in the Harmony Unit dining room when asked concerning the allegation of restraints for Resident #43 revealed, When I went into [named Resident #43] room she had chairs all around her bed; 2 chairs on each side of the bed, one being her wheelchair. She was trying to sit up in the bed. Interview with the Assistant Director of Nursing (ADON) on 9/23/19 at 3:04 PM in the Harmony Unit dining room when asked about the incident involving Resident #43 revealed, I came over to check on the nurse during morning rounds; It was reported to me by the CNA [named CNA #2] [named Resident #43] was in the bed with chairs around her bed, keeping her in the bed. Telephone interview with CNA #1 on 9/23/19 at 4:04 PM when asked about the incident with Resident #43 revealed, After [named Resident #43] was in bed she was trying to get up so I offered to get her up and she said no and if I tried to get her out of bed she would knock my head off; we had another resident running a high fever and I gave that resident a shower and after I got finished, [named Resident #43] was still trying to get out of the bed, so I put the chairs around her bed. Continued interview confirmed, I know it was barricading her, but I was afraid she would fall and get hurt; I knew it was a restraint but I was trying to keep her safe. Continued interview revealed, I had forgotten about the chairs; I was notified later that day the day shift staff found the chairs around her bed. Interview with the Director of Nursing (DON) and the Administrator on 9/23/19 at 3:10 PM in the DON's office confirmed the incident involving a restraint for Resident #43 was substantiated. The facility's failure to maintain Resident #43's rights resulted in IJ. The surveyors verified the AOC by: 1. The chairs were removed from around Resident #43's bed on 9/18/19. The surveyors interviewed staff and confirmed the chairs were removed. 2. CNA #1 was suspended immediately. Skin assessments were completed on 100% of the residents residing in the secure unit. The surveyors reviewed the skin assessments provided on the residents residing in the secure unit. The surveyors observed residents in the secure unit with no restraints noted. On 9/25/19 the facility's Staff Development Coordinator, Assistant Director of Nursing and the Minimum Data Set Coordinator interviewed staff regarding the use of non-standard(not approved) fall interventions on or near a resident. The surveyors reviewed staff interviews. 3. All facility personnel were in-serviced on Abuse and Resident Rights by the facility Staff Development Coordinator beginning on 9/18/19 and completed on 9/20/19. The Surveyors reviewed in-service sign in sheets and interviewed staff on each shift. The surveyors also reviewed the personnel file of CNA #1 which revealed she received training on abuse/neglect and resident rights on 2/13/19. Continued review revealed a complete and thorough investigation was finished on 9/18/19 resulting termination of Certified Nursing Assistant #1. The noncompliance of F550 continues at a scope of D level for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.

Based on facility policy review, medical record review, observation and interview, the facility failed to serve food in a safe and sanitary manner for 2 of 16 residents (#28 and #60) observed during the breakfast meal. The findings include: Review of the facility policy Dining Standards revised 11/2017 revealed .staff uses utensils, deli tissues, dispensing equipment or single use gloves to avoid bare hand contact of ready to eat foods . Medical record review revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 required supervision with assistance of 1 person for eating. Observation on 9/24/18 at 8:00 AM in Resident #28's room revealed Certified Nurse Aide (CNA) #1 was setting up breakfast for the resident. Further observation revealed CNA #1 picked up the resident's biscuit with her bare hand, cut the biscuit in half lengthwise using a butter knife, then picked up the sausage with her bare hand and placed it between the two biscuit halves and placed it back on the plate. Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS assessment dated [DATE] revealed Resident #60 required supervision with meal setup only. Observation on 9/24/18 at 7:55 AM in Resident #60's room revealed CNA #1 was setting up breakfast for the resident. Further observation revealed CNA #1 picked up the resident's biscuit with her bare hand, cut the biscuit in half lengthwise using a butter knife, then picked up the bacon with her bare hand and placed it between the biscuit halves and put it back on the plate. Interview with CNA #1 on 9/24/18 at 8:01 AM in Resident #28's room confirmed she needed to put gloves on before touching the resident's food. Interview with the Director of Nursing (DON) on 9/25/18 at 8:22 AM in front of her office confirmed the staff needed to wear gloves when touching the resident's food.

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to protect a resident's right to be free from misappropriation of property for 1 resident (#3) of 10 residents reviewed. The findings included: Review of facility policy, Drug Diversion, POL 602.23, revised 11/28/17, revealed .Oncoming and off-going nurses complete a shift to shift count on medication cards or containers containing controlled substance medication; controlled substance medication sheets; controlled substance medications in Emergency Kits when the kit had been opened .Nurses report any discrepancies in controlled substance medication counts to the Director of Nursing Service immediately .Facility management should investigate and make every reasonable effort to reconcile reported discrepancies .Investigation includes but may not be limited to interviews, medical record review, observation of facility practices related to handling of controlled substances, evaluation if loss is associated or attributed to specific individual(s), time period, unique situation or random, and identify any potential negative impact on resident's condition or safety .If potential criminal activity is suspected notify the Administrator, pharmacy manager, and consultant pharmacist at once .Educate staff on current procedures and implement interventions if needed .Document corrective action taken .Analyze findings from any discrepancy events or substantiated thefts or diversions as part of Performance Improvement . Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Physician's admission orders [REDACTED]. Continued review revealed Resident #3 brought a bottle of [MEDICATION NAME] from home. Facility investigation review revealed on 1/30/18 it was discovered 5 pills were missing from the bottle the resident brought in from home. Continued review revealed an investigation was conducted including staff interviews as well as police involvement. Further review revealed one nurse confessed she had taken the pills. Continued review revealed the nurse was terminated and the resident was reimbursed for the missing pills. Review of facility investigation revealed an interview with Registered Nurse (RN) #1 on 1/30/18 who stated she was speaking with the off-going Supervisor about the new admission (Resident #3). Continued review revealed RN #1 stated Resident #3 came in with 20 [MEDICATION NAME] pills but the Supervisor stated the resident had come in with 25 pills because she had counted them. Further review revealed both nurses went to the Narcotic box; counted the pills in the bottle; and arrived at a count of 20 pills. Continued review revealed RN #1 reviewed the narcotic sheet and it was labeled with 20 pills so she called the Administrator. Review of facility investigation revealed an interview with Licensed Practical Nurse (LPN) #2 on 1/30/18 revealed she was asked if she was the one who inventoried the pills of Resident #3 he brought from home and she said she was. Continued investigation revealed LPN #2 stated she counted 20 pills and stated LPN #1 had counted with her. Further investigation revealed LPN #2 was told the pills were counted previously and there were 25 pills but LPN #2 did not know how that was possible. Review of facility investigation revealed an interview with RN #2 who stated she counted 25 pills of [MEDICATION NAME] 10/325 mg which belonged to Resident #3. Review of facility investigation revealed an interview with LPN #1 on 2/1/18, who stated LPN #2 walked over to her chair at the nurses' station and said they had to count narcotics for the new admission. Continued review revealed LPN #1 was in the process of putting the new admission medications into the computer so pharmacy would deliver them. Further interview revealed LPN #1 saw LPN #2 with the bottle of pills but never actually saw her pour them out or physically see her count them but heard her count to 20 twice. Continued interview revealed LPN #1 never touched the pills nor did she physically see the pills. Further review revealed at this point both nurses were suspended pending the outcome of the investigation. Review of facility investigation revealed on 2/1/18 the police called the Administrator to say LPN #2 was requesting to speak with her at the police station. Continued interview revealed LPN #2 said she had done it and when asked what she had done she responded I took those pills and I'm sorry. What happens from here? Further review revealed the Administrator told LPN #2 was terminated and she would be reported to the Board of Nursing. Continued interview revealed LPN #2 was asked if she had taken any other pills and she responded This was the only time I've ever done that; I don't know what I was thinking. Review of facility investigation revealed Resident #3's personal physician as well as the Medical Director were informed of the diversion. Continued review revealed Resident #3 was informed of the situation and the facility reimbursed him for the medication. Facility investigation revealed all nurses were re-educated on narcotic counts with both nurses observing the medications and the count sheets when doing change of shift counts as well as both nurses observing and counting together when a resident brings medications from home. Interview with the DON and Administrator on 3/7/18 at 1:15 PM in the conference room revealed neither was in the facility when the diversion occurred. Review of the employee records of LPN #1 and LPN #2 revealed no previous disciplinary action for either of them.

Based on review of facility policy, medical record review, and interview, the facility failed to update the Care Plan with interventions for 3 residents (#7, #6, #4) of 7 residents reviewed. The facility's failure to identify risk and update the care plan with approporiate interventions resulted in falls with injuries (HARM) for resident #7,#6, #4. The findings included: Review of facility policy, Accidents and Supervision to Prevent Accidents (dated: 4/28/2011), revealed .The center provides an environment that is free from accident hazards .Implementation of interventions to reduce hazard(s) and risk(s) .Monitors to verify interventions are in place .Evaluates interventions at designated interval for effectiveness .Modifies and/or replaces ineffective interventions when necessary . Medical record review revealed Resident #7 admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #7 had a Brief Interview Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Further review revealed the resident required extensive assistance with transfers and Activities of Daily Living (ADL) and had no impairment of the upper and lower extremities. The resident was occasionally incontinent of the bowel and bladder. Medical record review of a Progress Note dated 9/5/17 revealed Resident #7 had a fall with no injury to occur on 9/5/17 and 9/9/17. Review of the Care Plan initiated on 8/7/17 for Resident #7 revealed it was not updated after the fall occurred on 9/5/17, 9/9/17, 9/17/17, and only revised on 10/24/17. Medical record review of a Post Fall Investigation dated 9/17/17 revealed the resident was .heard resident yelling .went to room and the resident was sitting on the floor on the L (left) side of the bed .was sitting on her botttom with her leg bent at the knee under her. When the resident tried to straighten it out she yelled and there was a popping noise . Continued review revealed the resident was transferred to the hospital and admitted for a Nondisplaced Midcervical Fracture of Right Femur. Interview with LPN #9 on 10/26/17 at 9:20 AM in the conference room revealed the nurse was to update the Care Plan with interventions after each fall. LPN #9 confirmed she failed to update the Care Plan after Resident #7 fell on [DATE] and another fall occurred on 9/17/17. Interview with the Administrator on 10/26/17 at 10:52 AM in the Social Services office revealed the Care Plans were to be updated with interventions after every fall by the nurse. After review of the Care Plan, the Administrator confirmed the facility failed to update the Care Plan with interventions after Resident #7 had a fall with injury (HARM) on 9/17/17. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30-day Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 had severe cognitive impairment with short and long term memory problems. The resident required extensive assistance with bed mobility, transfers, dressing, personal hygiene, eating and toileting and required total dependence for bathing. Continued review revealed Resident #6 was always incontinent of bowel and bladder, had bilateral impairment of both upper and lower extremities and utilized a wheelchair for mobility. Upon admission pt (patient) was identified as falls risk as evidenced by admission Care Plan. Medical record review of Progress Notes dated 8/27/17 and 9/6/17 revealed Resident #6 had falls to occur on these dates. Further review revealed Resident #6 received an injury as a result of the 9/6/17 fall when found on floor. Continued review of a Progress Note dated 9/7/17 revealed .family says he's been c/o (complaining of) left side discomfort . Medical record review of a Radiology Report dated 9/7/17 revealed .Conclusion: Acute right lateral ninth rib fracture . Medical record review of the Care Plan for Resident #6 revealed it was not updated or revised with new interventions after the falls occurred on 8/27/17 and 9/6/17. Interview with Licensed Practical Nurse (LPN) #9 on 10/26/17 at 9:20 AM in the conference room revealed after each fall the nurse was required to update the Care Plan with interventions. LPN #9 confirmed she failed to update the Care Plan with an appropriate intervention after Resident #6 fell on [DATE]. Interview with Administrator on 10/26/17 at 10:52 AM in the Social Services office revealed the Care Plan was to be updated with interventions after every fall by the nurse. After review of the Care Plan, the Administrator confirmed the facility failed to update the Care Plan with interventions after Resident #6 had falls to occur on 8/27/17 and 9/6/17. Medical record review of the Care Plan for Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quartely MDS dated [DATE] revealed the resident has a BMS score of 7 (severe impairment). The Resident was extensive assist with 1 person for transfer, extensive assist with 1 person for transfer, dressing and personal hygeine, independent with ambulationwith wheelchair, set up only, limited assist with 1 person for eating and total dependence with 1 person for bathing. The residnet had impairment on one side for upper and lower extremities and frequesntly incontinent of bowel and bladder. Medical record review of a fall investigation dated 9/17/17 revealed Resident was trying to get in to bed without assist (resident knows to ask for help) and sat on the floor beside the bed. Denies injury at this time .Neuro checks and 30 minute checks started .no injuries noted . Review of a Progress Note dated 9/18/17 revealed the Physician ordered a Tibia/Fibula x-ray. Review of the results of the x-ray dated 9/19/17 revealed an abnormal x-ray and orders to consult with an Orthopedic Medical record review of the Care Plan for Resident #4 revealed the facility failed to update the Care Plan after the 9/17/17 fall. Interview on 10/26/17 with the Administrator at 9:33 AM in her office revealed the facility failed to update the Care Plan after the 9/17/17 fall. The Administrator confirmed the facility failed to update the Care Plan with interventions after falls. Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 7 (severe impairment). The resident required extensive assistance with 1 person for transfer, dressing and personal hygiene, independent with ambulation with wheelchair, set up only, limited assist with 1 person for eating and total dependence with 1 person for bathing. The resident had unilateral impairment on one side of upper and lower extremities and frequently incontinent of bowel and bladder. Medical record review of a fall investigation dated 9/17/17 revealed Resident was trying to get in to bed without assist (resident knows to ask for help) and sat on the floor beside the bed. Denies injury at this time .Neuro checks and 30 minute checks started .no injuries noted . Review of Progress Notes dated 9/18/17 revealed the resident with a Tibula/Fibula fracture and placement of a cast. Medical record review of the Care Plan for Resident #4 revealed the facility failed to update the Care Plan after the 9/17/17 fall. Interview with the Administrator on 10/26/17 at 9:33 AM in her office confirmed the facility failed to update the Care Plan after the 9/17/17 fall.

Based on review of facility policy, medical record review, and interview, the facility failed to maintain an environment free from accidents for 3 residents (#7,#6, #4) of 7 residents reviewed. The facility's failure to recognize fall risk and identify interventions for three residents (#7, #6, #4) resulted in falls with injury (HARM). The findings included: Review of facility policy, Accidents and Supervision to Prevent Accidents, dated 4/28/2011 revealed .The center provides an environment that is free from accidents hazards .Implementation of interventions to reduce hazard(s) and risk(s) .Monitors to verify interventions are in place .Evaluates interventions at designated interval for effectiveness .Modifies and/or replaces ineffective interventions when necessary . Medical record review revealed Resident #7 admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS (Minimum Data Set) dated 10/10/17 revealed Resident #7 had a Brief Interview Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Further review revealed the resident required extensive assistance with transfers and Activities of Daily Living (ADL) and had no impairment of the upper and lower extremities. The resident was occasionally incontinent of the bowel and bladder. Medical record review of a Progress Note dated 9/5/17 revealed Resident #7 had a fall with no injury to occur on 9/5/17 and 9/9/17. Review of the Care Plan initiated on 8/7/17 for Resident #7 revealed it was not updated after the fall occurred on 9/5/17, 9/9/17, 9/17/17, and only revised on 10/24/17. Medical record review of a Post Fall Investigation dated 9/17/17 revealed .heard resident yelling .went to room and the resident was sitting on the floor on the L (left) side of the bed .was sitting on her botttom with her leg bent at the knee under her. When the resident tried to straighten it out she yelled and there was a popping noise . Continued review revealed the resident was transferred to the hospital and admitted for a Nondisplaced Midcervical Fracture of Right Femur. Interview with LPN (Licensed Practical Nurse) #9 on 10/26/17 at 9:20 AM in the conference room revealed the nurse was to update the Care Plan with interventions after each fall. LPN #9 confirmed she failed to update the Care Plan after Resident #7 fell on [DATE] and another fall occurred on 9/17/17. Interview with the Administrator on 10/26/17 at 10:52 AM in the Social Services office revealed the Care Plans were to be updated with interventions after every fall by the nurse. After review of the Care Plan, the Administrator confirmed the facility failed to update the Care Plan with interventions after Resident #7 had a fall with injury (HARM) on 9/17/17. Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30-day MDS dated [DATE] revealed Resident #6 had severe cognitive impairment with short and long term memory problems. The resident required extensive assistance with bed mobility, transfers, dressing, personal hygiene, eating and toileting and required total dependence for bathing. Continued review revealed Resident #6 was always incontinent of bowel and bladder, had bilateral impairment of both upper and lower extremities and utilized a wheelchair for mobility. Medical record review revealed Resident #6 had falls to occur on 8/11/17, 8/12/17, 8/13/17 and 8/14/17. Continued review revealed the following interventions were put in place after the falls occurred: .encourage to participate in activities .Strips to be placed to floor on each side of bed .encourage resident to toilet upon rising, before meals and after meals, and before bed .assist resident to common area .apply dysum pad to w/c (wheelchair) when arising to w/c . Medical record review of a Progress Note dated 8/27/17 revealed Resident #6 had a witnessed fall to occur as he was attempting to get up from the wheelchair. Review of the Care Plan revealed no intervention was put in place after the fall occurred on 8/27/17. Medical record review of a Progress Note dated 9/6/17 revealed Resident #6 had an unwitnessed fall to occur. Resident #6 was found by staff .sitting on his bottom beside of the end of the bed with his legs outstretched and his hands to his side. The residents pants were slightly pulled down as if the resident was trying to go to the restroom and his diaper was wet . Continued review of a Progress Note dated 9/7/17 revealed .MD (Medical Doctor) notified that Pt (patient) is now c/o (complaining of) discomfort in the left ribcage area. Pt grimaces with pain when area is palpated. Received order for x-ray . Medical record review of a Radiology Report dated 9/7/17 revealed .Conclusion: Acute right lateral ninth rib fracture . Review of the Care Plan revealed no intervention was put in place after the fall occurred on 8/27/17. Interview with LPN #9 on 10/26/17 at 9:20 AM in the conference room revealed after each fall the nurse was required to update the Care Plan with interventions. LPN #9 confirmed she failed to update the Care Plan with an appropriate intervention after Resident #6 fell on [DATE]. Interview with the Administrator on 10/26/17 at 10:52 AM in the Social Services office revealed the Care Plan was to be updated with interventions after every fall by the nurse. After review of the Care Plan, the Administrator confirmed the facility failed to maintain an environment free from accidents for Resident #6 who had a fall to occur on 9/6/17 which resulted in a fracture of the rib (HARM). Medical record review revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quartely MDS dated [DATE] revealed the resident has a BIMS score of 7 (severe impairment). The Resident was extensive assist with 1 person for transfer, extensive assist with 1 person for transfer, dressing and personal hygeine, independent with ambulationwith wheelchair, set up only, limited assist with 1 person for eating and total dependence with 1 person for bathing. The residnet had impairment on one side for upper and lower extremities and frequesntly incontinent of bowel and bladder. Medical record review of a fall investigation dated 9/17/17 revealed Resident was trying to get in to bed without assist (resident knows to ask for help) and sat on the floor beside the bed. Denies injury at this time .Neuro checks and 30 minute checks started .no injuries noted . Review of a Progress Note dated 9/18/17 revealed Called mobile with x-ray order. Review of the Progress Notes dated 9/20/17 revealed .Received resident Tibia/Fibula x-ray report on 9/19/17 at 1800 (6:00 PM). Noted abnormal x-ray .Notified NP (Nurse Practitioner) via phone .of x-ray results. Received the following new MD (Medical Doctor) orders. 1. consult with (orthopedic) . Review of a Progress Note dated 9/21/17 revealed MD applied cast at this time to right lower extremeity. MD wants to follow up with an x-ray on Monday 9/25/17 to check placement with new cast. MD wants to follow up in four weeks to change cast on 11/19/17. Family made aware . Medical record review of the Care Plan for Resident #4 revealed the facility failed to update the Care Plan after the 9/17/17 fall and place new interventions in place to prevent falls. Interview on 10/26/17 with the Administrator at 9:33 AM in her office revealed the facility failed to update the Care Plan after the 9/17/17 fall.

Based on facility policy, observation, and interview, the facility failed to follow infection control protocol for glucometer cleaning on 1 of 4 observations and facility failed to prevent cross contamination of medications, and medication cup on 1 of 25 opportunities observed. The findings included: Review of the facility policy dated 8/31/12, Cleaning Diagnostic Equipment In-Between Patients, revealed the procedure is to .clean outside of patient equipment .If no manufacturer's instructions clean with a 10% (percent) bleach solution moistened wipes in-between each patient and as needed .Allow contact with bleach solution for 1 minute .Follow with a cloth dampened with water to remove residual bleach . Further review of facility policy, General Dose Preparation and Medication Administration, Assistance or Observation revealed .The community staff should not touch the medication when opening a bottle or unit dose package . Observation of Licensed Practical Nurse (LPN) #2 on 10/23/17 at 7:40 PM on the 700 Hall at the medication cart revealed LPN #2 cleaning the glucometer without gloves and using an alcohol prep pad. LPN #2 had not used glucometer to check blood glucose level, and when asked by the surveyor how she should clean the glucometer stated .she would find out .and not use the glucometer until she found out how to clean it. Interview with LPN #2 on 10/23/17 at 7:45 PM on the 700 Hall at the medication cart revealed when asked if she knew the policy for cleaning the glucometers she said .No I don't . Interview with the Director of Nursing (DON) on 10/23/17 at 8:00 PM on the 700 Hall at the medication cart confirmed the facility failed to follow infection control protocol and cleaning of the glucometer. Observation of the Medication Pass on 10/25/17 at 7:30 AM on the 500 Hall revealed LPN #3 with 2 capsules and 1 tablet lying on top of medication cart surface. LPN #3 picked up the tablet with her ungloved hand and placed the tablet in the medication pouch to be crushed.Further observation revealed LPN #3 then picked up the 2 capsules with her ungloved hand off the medication cart, opened them and placed the contents into the medication pouch to be crushed. Observation of the Medication Pass on 10/25/17 at 7:30 AM on the 500 Hall revealed LPN #3 placed her ungloved finger into the top of the medication cup, then placed the medication into the cup. Interview with LPN #3 on 10/25/17 at 7:30 AM on 500 Hall confirmed .she should not touch medications with her ungloved hands, let medications come into contact with uncleaned surfaces, or touch other objects with gloved hands and then touch medication . Interview with the Director of Nursing (DON) on 10/25/17 at 3:15 PM in her office confirmed .nursing should not touch medication or the inside of medication cups with their hands or with gloves which have been used to touch other surfaces . The DON confirmed the facility failed to follow facility policy for infection control protocol.

Based on review of law enforcement arrest report, facility policy, medical record review, facility investigation and interview, the facility failed to ensure 1 resident (#15) of 15 reviewed was free from misappropriation of property. The findings included: Review of facility policy, Abuse, dated 10/20/16 revealed .misappropriation of patient property are strictly prohibited . Medical record review revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE]. Further review of the Minimum (MDS) data set [DATE] revealed Resident #15 had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Review of a facility investigation dated 10/14/17 revealed Resident #15 reported a missing $60 gift card. Further review of a written statement by Licensed Practical Nurse (LPN) #6 dated 10/15/17 revealed .(Resident #15) stated that she had a $60.00 gift card stolen from her pink wristlet change purse .(Resident #15) also stated that tech (certified nurse aide) who took the card came to her room on the night of 10/14/17 after hearing that she reported a gift card stolen and tech stated 'Really (Resident #15), you borrow money off of me for weeks and then pay me back with a gift card and then report it stolen.' (Resident #15) stated she never borrowed money from the tech and she would never borrow money from a tech . Continued review of a written statement by Resident #15's sister on 10/16/17 revealed a $50 gift card was purchased on 9/19/17 and given to the resident on the same day. The resident's sister also reported the gift card had been used twice on 10/12/17 at a local store. Review of a law enforcement arrest report dated 10/14/17 revealed .We proceeded to speak with (Resident #15) who advised that she had a visa gift card missing from her change purse and presumed it had been stolen. She further advised the gift card was valued at $60.00. (Resident #15's sister) checked with the visa customer service and found that the card had been used .visa had records indicating that a total of 49.47 had been spent .A check of (local store) video footage .shows a white female making a purchase with the card number provided .A good photo (photograph) was printed and taken to the charge nurse .who recognized the lady as one of the night shift nurses .she (Certified Nurse Assistant (CNA) #7) has admitted to using the card as witnessed on video but claims she paid (Resident #15) cash for the card. To verify this statement I called (Resident #15) and she absolutely denies this ever happened .(CNA #7) showed obvious intent to deprive the owner of certain property without her effective consent. (CNA #7) was placed under arrest . Review of a written statement given to law enforcement by CNA #7 dated 10/14/17 revealed .I (CNA #7) worked on Wednesday night 10/11/12 - 10/12/12 on (the) 700 hall. (Resident #15) asked me if I would give her cash for her prepaid debit card bc (because) it wasn't a cash back card and no one would take her card and get anything for her. I told her I only had sixty dollars and she said it had fifty something on there so I gave her three twenty dollar bills and she gave me the card . Interview with the Administrator on 10/24/17 at 2:20 PM in the conference room revealed the facility investigation was neither substantiated nor unsubstantiated because she was unable to get a statement from CNA #7 and Resident #15 was reluctant to give a detailed statement. The Administrator confirmed CNA #7 was terminated due to the misappropriation of property.

Based on review of facility policy, medical record review, resident observation and interview, the facility failed to ensure residents are free of any significant medication errors for 1 resident (#12) of 13 reviewed for medications with parameters. The findings included: Review of facility policy (undated), Suggested Medication Administration, Assistance or Observation Procedures, revealed .Resident Right's and Dignity must be preserved during medication administration/observation . Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Physicians Order Sheet (POS) revealed an order dated 3/7/17 .[MEDICATION NAME] (Antihypertensive) 100 mg (milligram) give 1 tablet by mouth 1 time a day at 7:00 AM [MEDICAL CONDITION](Hypertension). Hold if pulse is 60 or below . Continued review of the POS revealed a second order for [MEDICATION NAME] 200 mg, give 1 tablet 1 time a day at 8:00pm for HTN, re written on 5/24/17 to include, hold if pulse is 60 or below . Medical record review of the Medication Administration Record (MAR) revealed Resident #12 received [MEDICATION NAME] 100 mg 7:AM dose and 200mg PM dose on the following dates with the pulse documented at 60 or below. 4/2/17 pulse 54, medication documented as administered. 4/9/17 pulse 60, medication documented as administered. 4/28/17 pulse 60, medication documented as administered. 6/8/17 pulse 60, medication documented as administered. 6/24/17 pulse 60, medication documented as administered. 7/22/17 pulse 60, medication documented as administered. 7/26/17 pulse 60, medication documented as administered. 7/31/17 pulse 60, medication documented as administered. 8/1/17 pulse 56, medication documented as administered. 8/2/17 pulse 60, medication documented as administered. 8/15/17 pulse 56, medication documented as administered. 8/16/17 pulse 60, medication documented as administered. 9/17/17 pulse 60, medication documented as administered. 10/15/17 pulse 60, medication documented as administered. Resident observation on 10/23/17 at 12:35 PM revealed Resident #12 sitting at bedside, call light in reach, well-groomed and dressed appropriately, conversing with roommate. Further observation on 10/23/17 at 7:45 PM revealed Resident #12 sitting at bedside conversing on the telephone. Interview with Licensed Practical Nurse #2 on 10/23/17 at 7:45 PM on the 700 hall revealed .when the pulse check of Resident #12 is 60 or below the nurse was to hold the medication . Interview with the Nurse Practitioner on 10/24/17 at 11:30 AM in the conference room revealed she .expected the nurses to follow the parameters .and was .concerned .the resident had received [MEDICATION NAME] with heart rate 60 or below .The Nurse Practitioner reviewed the MAR and confirmed the medication was given with a pulse check of 60 and below . Interview with the Medical Director on 10/24/17 at 11:10 AM on the 800 hallway revealed that he .expects the nurses to follow parameters and not to administer [MEDICATION NAME] to (Resident #12) if pulse is 60 or below. Interview with the Director of Nursing (DON) on 10/25/17 at 3:15 PM in her office confirmed .the [MEDICATION NAME] was given to (Resident #12) with pulse documented at 60 and below . The DON confirmed the facility failed to prevent a significant medication error for Resident #12.

Based on review of facility policy, observation, and interview, the facility failed to properly label, date, and/or discard 3 multi-dose vials of insulin according to facility policy on 1 of 4 medication carts reviewed. The findings included: Review of facility policy dated 8/31/12, Medication package insert, Medication Storage, Storage and Expiration Dating of Medications, Biologicals, Syringes and needles, revealed .facility should ensure that medications and biologicals (1) have an expired date on the label; (2) have been retained longer than manufacturers guidelines; or,(3) have been contaminated or deteriorated , are stored separate from other medications until destroyed or returned to the pharmacy .Facility should destroy or return all discontinued, outdated/expired medications or biologicals in accordance with pharmacy return/destruction guidelines and other applicable law . Review of package insert for Novolin R insulin storage revealed instructions to .throw away the vial 42 days after it is taken out of the refrigerator if it is unopened . Observation of Licensed Practical Nurse (LPN) #2 during medication pass on 10/23/17 at 7:30 PM on the 700 Hall revealed 1 vial of Novolin R Insulin multi-dose vial, date opened 8/31/17. Continued observation revealed LPN #2 drew up 2 units of Insulin for Resident #16 from the vial to be administered and placed the syringe on the top of the medication cart. The surveyor advised LPN #2 the vial was expired and LPN #2 immediately discarded the syringe. Further observation of the medication cart revealed a bottle of novolin R insulin multi dose- vial opened, half full, and undated, received from the pharmacy 9/16/17, 1 vial of novalin N insulin multi-dose vial opened, undated and received from the pharmacy on 10/04/17. Interview with LPN #2 accompanied by the Director of Nursing (DON) on 10/23/17 at 8:00 PM at the 700 hall medication cart confirmed .the vial of R Insulin was expired .and the 1 vial of novolin N insulin and 1 vial of novolin R insulin were opened and undated . Interview with the DON on 10/25/17 at 3:15 PM in her office revealed the nurses are expected to label and date insulin medications when opened, discard expired medication, and check for expiration dates before administering medications. The DON confirmed the facility failed to properly label, discard and/or store medication.

Based on observation and interview, the facility's dietary department failed to maintain food preparation equipment in a sanitary manner and failed to maintain storage equipment in a sanitary manner. The findings included: Observation on 8/1/17 beginning at 1:53 PM, with the Certified Dietary Manager (CDM) present, revealed the facility failed to maintain the following food preparation equipment in a sanitary manner: 1. The can opener base had sticky blackened debris covering the exterior side of the slot of the can opener with an accumulation of sticky blackened debris dripping down the exterior sides of the slot. The interior of the can opener slot had a heavy accumulation of blackened sticky debris present. The can opener blade had an accumulation of sticky brown debris present. 2. The interior perimeter of the two convection oven doors had an accumulation of brown and black debris present. 3. The air vent in the hood had blackened debris on the vent fins. There was hanging blackened debris on the air vent fins positioned over the 6 burner range top and food was in preparation in the 2 pots on the burners. 4. The mixer was covered with a plastic bag. The mixer had white powdery residue on the beater arm, white dried splattered debris on the underside of the beater arm, and an accumulation of dried sticky brown debris on the table top in contact with the mixer feet. Interview with the CDM on 8/1/17 beginning at 1:53 PM in the dietary department revealed the plastic covered equipment meant the equipment was clean and ready to use. Further interview confirmed the facility failed to maintain the food preparation equipment in a sanitary manner. Observation on 8/2/17 from 9:03 AM to 9:13 AM, with the CDM present, revealed the dish machine was in operation with dietary staff storing dome lids and insulated bases onto the storage/drying racks. Further observation revealed the dome lid and base storage/drying racks were rusted and sticky with brown debris. Further observation of the dry goods store room revealed the can rack had an accumulation of dried debris on the rungs and the 4 food storage racks were sticky with brown debris. Interview with the CDM on 8/2/17 beginning at 9:03 AM in the dietary department confirmed the facility failed to maintain the storage equipment in a sanitary manner.

Based on facility policy review, medical record review, and interview, the facility failed to prevent misappropriation of medications for 1 resident (#79) of 7 residents reviewed for abuse. The findings included: Review of facility policy, Abuse, released 10/20/16, revealed .Verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and neglect of the patient as well as mistreatment, injuries of unknown source, and misappropriation of patient property are strictly prohibited .Misappropriation is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent . Review of facility policy, Drug Diversion, released 6/1/16, revealed .Oncoming and offgoing nurses complete a shift to shift count on medication cards or containers containing controlled substance medication; controlled substance medication sheets; controlled substance medications in E-kits (Emergency medications) when the E-kit has been opened .Nurses report any discrepancy in controlled substance medication counts to the Director of Nursing Service (DNS) immediately .Facility management should investigate and make every reasonable effort to reconcile reported discrepancies. Investigation included interview, medical record reviews, observation of facility practices related to handling of controlled substances; evaluate if loss is associated with or attributed to specific individuals; identify any potential negative impact on patient's condition or safety .Notify the Executive Director, pharmacy manager, and consultant pharmacist immediately .Potential theft of controlled substance is reportable to the local law enforcement agency, appropriate professional licensing board; and state agency . Medical record review revealed Resident #79 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the physician's orders [REDACTED].#79 was ordered [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 7.5/325 mg (milligrams) 1 tablet QID (four times daily). Review of the Pharmacy Delivery Invoice revealed 30 tablets of [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 mg were delivered to the facility on [DATE] and signed for by the two nurses on duty. Review of the facility investigation revealed: 1/3/17 -card of 7.5/325 mg [MEDICATION NAME] and its narcotic sheet missing -all medication carts were checked -pharmacy was called to verify delivery 1/4/17 - complete MAR (Medication Administration Records) to cart audits were done on on all carts - pharmacy was requested to do a complete audit of delivery - part of the December narcotic shift-to-shift tracking log was also missing - interviews were completed with licensed nurses who had access to the carts - Executive Director and corporate office were notified 1/5/17 - inservices for licensed nurses on counts and drug diversion were held - police were notified - suspect nurse was terminated - suspect nurse did not show for her shift 1/4/17 at 6:00 PM - 6:30 AM nor any subsequent shifts - suspect was unable to be reached by telephone The DNS interviewed all nurses who had access to the medication cart during the period of the diversion including Licensed Practical Nurses (LPN) #5, #6, #7, #8, #9 and Registered Nurse (RN #1). Questions asked included did they count; how many medication cards did they see; did they see the card count sheet; who received the drug delivery; and what was done with the drugs after delivery. Review of the Root Cause Analysis Summary revealed the delivery of the [MEDICATION NAME] on 12/31/16. On 1/3/17 the supervisor was doing a verification of narcotics when she noted a card of [MEDICATION NAME] and its narcotic sign sheet were missing. The narcotics were signed in on delivery by 2 licensed nurses and delivered to medication carts to be locked in the narcotic drawer. The carts were kept locked and only the nurse working that hall has the key to the cart. The cards were logged onto the card count sheet. When cards were taken out of the cart they were logged on the card count sheet and nurses signed for them. Reports from pharmacy were sent to the DNS to verify narcotic deliveries and the presence of narcotics. Narcotics were delivered; accepted; and stored correctly. The nurse signed on the narcotic sheet/card count sheet as 29 vs 30 as it should have been. The nurse was made aware of the missing drug and she began to question fell ow nurses as to how it was found out. The suspected nurse became a no call no show for scheduled shifts. The suspected nurse was unable to be reached by telephone and did not return calls. The facility was unable to say definitively she was guilty but she had keys to the cart and access to the narcotics. Resident #79 had multiple cards of drugs in the cart and by changing the card count sheet with next day being a new month, the count would be correct. Interview with the DNS, on 8/2/17 at 9:25 AM in her office confirmed a card of 30 tablets of [MEDICATION NAME] as well as the accompanying sign out sheet were missing and unable to be located. The DNS also confirmed the accused nurse refused to return telephone calls so was unable to be interviewed

Based on review of facility policy, medical record review, review of the facility investigation, corrective action plan and interview, the facility failed to ensure a transfer with a mechanical lift was provided with 2 persons and the appropriate size lift sling for one Resident (#2) of 6 residents reviewed for falls, of 10 residents reviewed. The facility's noncompliance resulted in a fall and fracture of the 10th thoracic vertebrae (Harm). The findings included: Review of facility policy, Mechanical Lift (Sling Lift), dated 8/31/14 revealed .A patient lift team consists of at least two employees working together to perform transfers, repositioning, or lifting tasks on high risk patients .using a lift team, position the patient and apply the sling .one staff member guides the patient and one staff member maneuvers the lift . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired, dependent for transfers and all activities of daily living. Review of the care plan revealed .transfers with mechanical lift . Review of the Certified Nursing Assistant (CNA) Kardex revealed . lift sling medium . Review of the facility investigation dated 4/5/16 at 11:10 AM revealed CNA #1 attempted to transfer Resident #2 from the bed with a mechanical lift and a size small lift sling without assistance, resulting in a fall and subsequent oblique fracture of the resident's 10th thoracic vertebrae confirmed by X-rays and Computer Assisted Tomography (CAT scan). Continued review of the investigation, facility policy, and the CNA Kardex revealed Resident #2 required transfer with mechanical lift and assistance of 2 persons using a medium sized lift sling. Interview with Registered Nurse (RN) #1 on 5/2/16 at 3:55 PM, in the conference room revealed RN #1 was the House Supervisor at the time of Resident #2's fall and responded to calls for assistance from CNA #1 from inside the resident's room. Continued interview revealed RN #1 stated she observed the resident in the floor, supine, with her back across the legs of the mechanical lift and her head near the crossbar of the lift and was informed by the CNA the resident had fallen from the sling. Continued interview revealed RN #1 stated she questioned CNA #1 as to why she had attempted to transfer the resident alone and if the CNA was aware facility policy required two persons assistance with all mechanical lift transfers and the CNA responded she was aware of the policy and had not followed it. Continued interview revealed RN #1 stated she also observed the lift was equipped with a small size sling and was aware the resident required a medium sized sling and questioned CNA #1 as to why she used the wrong sized sling and the CNA responded, there wasn't one. Interview with CNA #2 on 5/2/16 at 4:00 PM, in the conference room revealed CNA #2 had also responded to the incident and witnessed the exchange between CNA #1 and RN #1 and confirmed CNA #1 had stated to the nurse she knew the facility policy required 2 persons assistance with all mechanical lift transfers and confirmed CNA #1 stated she was aware the resident required a medium size sling and chose to use a small size sling instead. Interview with the Director of Nursing (DON) on 5/3/16 at 3:14 PM, in the conference room confirmed CNA #1 had attempted to transfer Resident #2 with a mechanical lift alone and without assistance from another qualified staff member and the wrong size sling resulting in a fall from the mechanical lift to the floor and a fracture of the resident's 10th Thoracic Vertebrae (Harm) for Resident #2. The facility's corrective action plan included the following: On 4/5/16 the facility did the following: 1. Ad Hoc Quality Assurance (QA) meeting included Medical Director and review of the facility mechanical lift policy and the resident's care plan, medical record and Kardex completed on 4/5/16 at 11:45 AM. CNA #1 suspended pending investigation of incident. The QA team formulated a QA plan with target dates for completion. 2. In-service training for all floor nurses and CNAs on duty at the time of fall related to mechanical lift policy with emphasis on two persons required at all times and use of proper sling sizes was initiated on 4/5/16 at 11:45 AM. On 4/6/16 the facility did the following: 3. Mandatory in-service training of all employees on all shifts initiated on the facility mechanical lift use policy and sling size use. Audits of all sling inventories and mechanical lifts was initiated on 4/6/16. On 4/7/16 the facility did the following: 4. Completed audits of all mechanical lifts and sling systems in use facility wide. No irregularities noted. Audits of all residents with mechanical lifts in use for accurate sling sizes per body weights per lift manufacturer recommendations was completed. No irregularities were noted. All CNA Kardexes with lift sling size highlighted and documented in same location on Kardex were completed. 5. Second mandatory in-service training to all facility staff related to location of the sling size documentation in the same location and highlighting of sling size prominently on any updated Kardexes was completed. On 4/8 to 4/11/16 the facility did the following: 6. Root Cause Analysis of the incident was completed. CNA #1 was terminated on 4/8/16. Observations of mechanical lift and sling use for all dependent residents by the DON and Assistant Director of Nursing (ADON) on all shifts facility wide including spot audits of all Kardexes for accuracy and additional reviews and interviews of all staff related to mechanical lift policy was completed on 4/8 to 4/11/16. Mandatory in-service for all clinical staff with the findings of root cause analysis were reviewed and completed on 4/11/16. On 4/12/16 the facility did the following: 7. Findings of Root Cause Analysis and Corrective Action Plan Interventions were reviewed with Administrator. The findings were forwarded to Quality Assurance Committee (QA) for full review in the May 2016 QA meeting. Weekly audits of mechanical lift use and Kardexes were initiated. The first weekly audit was completed by DON with no irregularities noted and full compliance was achieved. The State Agency was notified of incident on 4/12/16. On 4/13 to 4/26/16 the facility did the following: 8. Additional weekly audits of all mechanical lifts and sling use facility wide were completed on 4/19/16 and 4/26/16 and no additional deficient practices were noted. Audits included observations of mechanical lift use and random audits of CNA Kardex documentation on dependent residents by the ADON and DON on all shifts. Weekly audits are ongoing. The surveyors verified the facility's corrective actions onsite during the complaint survey as follows: 1. Observations of mechanical lift use on dependent residents including Resident #2 were completed on both shifts 5/2/16 to 5/4/16. 2. Audits of all CNA Kardexes on all units in the facility revealed all mechanical lift use and sling size documentation was uniform and consistent with manufacturer recommendations, sling sizes were highlighted and documentation was prominently displayed on the first page of the CNA Kardex in the same location. 3. Observations of all mechanical lifts in the facility between 5/2-5/4/16 revealed all lifts were well maintained and in good repair. Additional observations of the sling inventory were completed and sufficient numbers of slings were present in all sizes required and all slings were in good repair. All lift slings of various sizes were readily available for use on all units of the facility on all shifts. 4. Interviews with 7 certified Nursing Assistants (CNAs #2, #3, #4, #5, #6, #7, #8), 3 Registered Nurses (RNs # 1, #2, #3), and 5 Licensed Practical Nurses (LPN #1, #2, #3, #4, #5) revealed all were fully aware of the facility mechanical lift policy, location of all lift slings in the facility, aware of how to appropriately fit residents to sling size based on body weight, aware of the location of sling size documentation on the CNA Kardex, and where to find the most recent weights in the written and electronic medical records for residents who clinicians suspected may need adjustments in sling sizes based on body changes. All staff interviewed were aware of the facility corrective action plan and QA team Root Cause Analysis findings and verified the facility had provided mandatory in-service training related to the incident that involved Resident #2's fall and injury. 5. Interviews with 2 residents and 3 family members of cognitively impaired persons revealed no concerns with staffing levels, abuse or neglect, transfers, mechanical lift use, or resident safety in the facility. 6. Review of the incident and grievance logs for one year revealed no similar incidents involving mechanical lift use and falls were present. 7. Interviews with the Administrator, DON, ADON, and members of the Quality Assurance Team including the MDS coordinator and Social Services Director confirmed the incident was reviewed in an Ad Hoc QA meeting and findings shared with the QA team as noted in the corrective action plan and routine audits of mechanical lift use were ongoing at the time of the complaint investigation. 8. Medical record reviews and reviews of facility fall investigations were completed for 5 additional residents (Residents #4, #5, #6, #7, #8) who had sustained falls in the facility and no deficient practices were identified. The harm existed from 4/5/16 to 4/26/16. The Harm was removed on 4/27/16. The facility's corrective action plan that removed the Harm at F-280- G and F-323 G was received and corrective actions validated onsite by the surveyor on 5/3-4/16. The harm (G) was cited as past noncompliance for F-280 and F-323 and the facility is not required to submit a plan of correction for those tags.

Based on review of facility policy, medical record review, review of the facility investigation, review of the facility corrective action plan, and interview, the facility failed to follow the care plan to ensure a transfer with a mechanical lift was provided with the assistance of 2 persons and the appropriate size lift sling for one Resident (#2) of 6 residents with reviewed for falls of 10 residents reviewed. The facility's noncompliance resulted in a fall with a [MEDICAL CONDITION] vertebrae (Harm). The findings included: Review of facility policy, Mechanical Lift (Sling Lift), dated 8/31/14 revealed .A patient lift team consists of at least two employees .identify patient .require a mechanical lift to transfer .include in evaluation correct lift .sling brand .model .size .validate the sling is the correct size .validate that patient falls in the slings minimum and maximum weight range for the sling . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired and dependent for transfers and all activities of daily living. Review of the care plan revealed .transfers with mechanical lift . Review of the Certified Nursing Assistant (CNA) Kardex revealed . lift sling medium . Review of the facility investigation dated 4/5/16 at 11:10 AM revealed CNA #1 attempted to transfer Resident #2 from the bed with a mechanical lift and a size small lift sling without assistance, resulting in a fall and subsequent oblique [MEDICAL CONDITION]'s 10th [MEDICATION NAME] vertebrae confirmed by X-rays and Computer Assisted Tomography (CAT scan). Continued review of the investigation, facility policy, and the CNA Kardex revealed Resident #2 required transfer with mechanical lift with the assistance of 2 persons using a medium sized lift sling. Interview with Registered Nurse (RN) #1 on 5/2/16 at 3:55 PM, in the conference room revealed RN #1 was the House Supervisor at the time of Resident #2's fall and responded to calls for assistance from CNA #1 from inside the resident's room. Continued interview revealed RN #1 stated she observed the resident in the floor, supine, with her back across the legs of the mechanical lift and her head near the crossbar of the lift and was informed by the CNA the resident had fallen from the sling. Continued interview revealed RN #1 stated she questioned CNA #1 as to why she had attempted to transfer the resident alone and if the CNA was aware facility policy required two persons assistance with all mechanical lift transfers and the CNA responded she was aware of the policy and had not followed it. Continued interview revealed RN #1 stated she also observed the lift was equipped with a small size sling and was aware the resident required a medium sized sling and questioned CNA #1 as to why she used the wrong sized sling and the CNA responded, there wasn't one. Interview with CNA #2 on 5/2/16 at 4:00 PM, in the conference room revealed CNA #2 had also responded to the incident and witnessed the exchange between CNA #1 and RN #1 and confirmed CNA #1 had stated to the nurse she knew the facility policy required 2 persons assistance with all mechanical lift transfers and confirmed CNA #1 stated she was aware the resident required a medium sized sling and chose to use a small sized sling instead. Continued interview revealed CNA #2 reported there were multiple medium size slings available on the unit at the time the fall occurred and CNA #1 had not requested her assistance with the transfer. Interview with the Director of Nursing (DON) on 5/3/16 at 3:14 PM, in the conference room confirmed the CNA had failed to follow facility policy for mechanical lifts for a 2 person transfer and failed to follow the the care plan and CNA Kardex for the use of the proper sized lift sling to transfer the resident, resulting in a fall with a [MEDICAL CONDITION] vertebrae (Harm) for Resident #2. The facility's corrective action plan included the following: On 4/5/16 the facility did the following: 1. Ad Hoc Quality Assurance (QA) meeting included Medical Director and review of the facility mechanical lift policy and the resident's care plan, medical record and Kardex completed on 4/5/16 at 11:45 AM. CNA #1 suspended pending investigation of incident. The QA team formulated a QA plan with target dates for completion. 2. In-service training for all floor nurses and CNAs on duty at the time of fall related to mechanical lift policy with emphasis on two persons required at all times and use of proper sling sizes was initiated on 4/5/16 at 11:45 AM. On 4/6/16 the facility did the following: 3. Mandatory in-service training of all employees on all shifts initiated on the facility mechanical lift use policy and sling size use. Audits of all sling inventories and mechanical lifts was initiated on 4/6/16. On 4/7/16 the facility did the following: 4. Completed audits of all mechanical lifts and sling systems in use facility wide. No irregularities noted. Audits of all residents with mechanical lifts in use for accurate sling sizes per body weights per lift manufacturer recommendations was completed. No irregularities were noted. All CNA Kardexes with lift sling size highlighted and documented in same location on Kardex were completed. 5. Second mandatory in-service training to all facility staff related to location of the sling size documentation in the same location and highlighting of sling size prominently on any updated Kardexes was completed. On 4/8 to 4/11/16 the facility did the following: 6. Root Cause Analysis of the incident was completed. CNA #1 was terminated on 4/8/16. Observations of mechanical lift and sling use for all dependent residents by the DON and Assistant Director of Nursing (ADON) on all shifts facility wide including spot audits of all Kardexes for accuracy and additional reviews and interviews of all staff related to mechanical lift policy was completed on 4/8 to 4/11/16. Mandatory in-service for all clinical staff with the findings of root cause analysis were reviewed and completed on 4/11/16. On 4/12/16 the facility did the following: 7. Findings of Root Cause Analysis and Corrective Action Plan Interventions were reviewed with Administrator. The findings were forwarded to Quality Assurance Committee (QA) for full review in the May 2016 QA meeting. Weekly audits of mechanical lift use and Kardexes were initiated. The first weekly audit was completed by DON with no irregularities noted and full compliance was achieved. The State Agency was notified of the incident on 4/12/16. On 4/13 to 4/26/16 the facility did the following: 8. Additional weekly audits of all mechanical lifts and sling use facility wide were completed on 4/19/16 and 4/26/16 and no additional deficient practices were noted. Audits included observations of mechanical lift use and random audits of CNA Kardex documentation on dependent residents by the ADON and DON on all shifts. Weekly audits are ongoing. The surveyors verified the facility's corrective actions onsite during the complaint survey as follows: 1. Observations of mechanical lift use on dependent residents including Resident #2 were completed on both shifts 5/2/16 to 5/4/16. 2. Audits of all CNA Kardexes on all units in the facility revealed all mechanical lift use and sling size documentation was uniform and consistent with manufacturer recommendations, sling sizes were highlighted and documentation was prominently displayed on the first page of the CNA Kardex in the same location. 3. Observations of all mechanical lifts in the facility between 5/2-5/4/16 revealed all lifts were well maintained and in good repair. Additional observations of the sling inventory were completed and sufficient numbers of slings were present in all sizes required and all slings were in good repair. All lift slings of various sizes were readily available for use on all units of the facility on all shifts. 4. Interviews with 7 certified Nursing Assistants (CNAs #2, #3, #4, #5, #6, #7, #8), 3 Registered Nurses (RNs # 1, #2, #3), and 5 Licensed Practical Nurses (LPN #1, #2, #3, #4, #5) revealed all were fully aware of the facility mechanical lift policy, location of all lift slings in the facility, aware of how to appropriately fit residents to sling size based on body weight, aware of the location of sling size documentation on the CNA Kardex, and where to find the most recent weights in the written and electronic medical records for residents who clinicians suspected may need adjustments in sling sizes based on body changes. All staff interviewed were aware of the facility corrective action plan and QA team Root Cause Analysis findings and verified the facility had provided mandatory in-service training related to the incident that involved Resident #2's fall and injury. 5. Interviews with 2 residents and 3 family members of cognitively impaired persons revealed no concerns with staffing levels, abuse or neglect, transfers, mechanical lift use, or resident safety in the facility. 6. Review of the incident and grievance logs for one year revealed no similar incidents involving mechanical lift use and falls were present. 7. Interviews with the Administrator, DON, ADON, and members of the Quality Assurance Team including the MDS coordinator and Social Services Director confirmed the incident was reviewed in an Ad Hoc QA meeting and findings shared with the QA team as noted in the corrective action plan and routine audits of mechanical lift use were ongoing at the time of the complaint investigation. 8. Medical record reviews and reviews of facility fall investigations were completed for 5 additional residents (Residents #4, #5, #6, #7, #8) who had sustained falls in the facility and no deficient practices were identified. The harm existed from 4/5/16 to 4/26/16. The Harm was removed on 4/27/16. The facility's corrective action plan that removed the Harm at F-280 G and F-323 G was received and corrective actions validated onsite by the surveyors on 5/3-4/16. The harm was cited as past noncompliance for F-280 and F-323 and the facility is not required to submit a plan of correction for those tags.

Based on medical record review, review of a facility investigation, observation, and interview, the facility failed to provide supervision and/or ensure safety devices were in place for two residents (#1 and #5) of eleven residents reviewed. The facility's failure resulted in harm to resident #1. The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident was severely impaired cognitively; required two people for transfer; required extensive assistance with Activities of Daily Living (ADLs); was fed; and was incontinent of bowel and bladder. Medical record review of a nurse's note dated August 24, 2010, revealed "Called to room by CNA (Certified Nursing Assistant). Resident on floor on left side, facing away from window. Laceration to center of forehead. Blood pressure 220/119. Pressure alarm sounding." Continued medical record review revealed the resident was transferred to the hospital for evaluation and treatment. Medical record review of a hospital discharge summary dated August 26, 2010, revealed the resident suffered a "C1 (first cervical vertebra) impaction fracture with mild displacement of left lateral mass." Continued medical record review of the hospital discharge summary revealed "...did not feel (resident) was a candidate for any further treatment in terms of...fracture...did feel it would be best to keep (resident) in a collar as best (resident) can tolerate...however, if the collar did become uncomfortable or started to cause pressure sores, it could be discontinued with the understanding that (resident) could wind up with a catastrophic spinal cord injury..." Medical record review revealed the resident was readmitted to the facility on [DATE]. Review of the facility investigation dated August 24, 2010, revealed an untimed interview with CNA #1 on August 24, 2010, "went into the room to get tray, resident's chair was reclined all the way back when I left room." Continued review revealed an untimed interview with the Activities Director dated August 26, 2010, which stated "Passed room I noted ... was facing window with chair reclined." Further review revealed an untimed interview with CNA #2 dated August 24, 2010, which stated, "Brought resident out of dining room and took to room. Picked up tray and chair was reclined all the way back." Continued review revealed an untimed interview with the Registered Nurse dated August 24, 2010, who stated "Resident was lying on floor beside air conditioner on left side. Head turned on left side. Area 6"-9" blood pooled around head, face. Right hand laying flat in it. Turned resident on back. Left upper sleeve was soaked with blood. Cut blouse off and had large area that skin was all gone. All bleeding areas cleaned and wrapped." Further review revealed an untimed interview with the Maintenance Director dated August 24, 2010, who stated "Chair was in proper working order." Observation of the resident on October 4, 2010, at 1:10 p.m., revealed the resident lying in bed on a pressure-relieving mattress on the back with a soft cervical collar in place. Continued observation revealed the resident did not respond to verbal comments. Observation of the resident on October 5, 2010, at 11:30 a.m., revealed the resident in bed with the head of the bed raised and the sitter beginning to feed lunch. Further observation revealed the resident was eating a puree diet and was able to utter some comments about lunch. Interview with the Director of Nursing (DON) on October 5, 2010, at 3:50 p.m., in the Wound Care Nurse's office, revealed prior to the accident, the resident would "whip (resident) legs over the side of the geri chair. The resident was kept out at the nursing station so (resident) could look around and staff could keep an eye on the resident. The (resident's) daughter had said if (resident) got too noisy in the dining room, just to take (resident) to room and let (resident) look out window...that usually calms for a while..." Further interview with the DON revealed on August 24, 2010, "the resident was particularly rambunctious (noisy, yelling out) in the dining room so the CNA took the resident to the resident's room to look out the window (not the nurse's station where the resident could be observed). Further interview with the DON revealed the Maintenance Director walked past the resident's room and noted the resident to be on the floor. Interview with the DON and Administrator on October 6, 2010, at 5:00 p.m., in the Administrator's office, revealed the resident was able to throw legs over the side of the geri chair but was unable to stand. Continued interview confirmed the resident was left alone in the room and the resident was not supervised or observed by staff resulting in a fall from the gerichair requiring hospitialization for a cervical fracture. Resident #5 was initially admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. edical record review of the MDS dated [DATE], revealed the resident had short and long term memory deficits; required assistance with ADLs; was occasionally incontinent of bowel and frequently incontinent of bladder; was independent with eating. Medical record review of a nursing note dated September 5, 2010, revealed "...sitting on floor six feet from w/c (wheelchair). Shut alarm off. Got out of w/c. Feet tangled when turned around." Continued medical record review of a nursing note dated September 9, 2010, revealed "Sitting on floor in front of w/c leaning into seat. Was trying to scoot back in w/c and chair rolled. Alarm in place on w/c." Medical record review of a nursing note dated September 10, 2010, revealed "Sit on floor of bathroom. Was trying to get to bathroom but lost balance and fell . No shoes or socks. Pressure alarm to be placed in bed and chair." Medical record review of a nursing note dated September 19, 2010, revealed "Sit on bathroom floor near toilet. 'I got up to go to bathroom and missed toilet.' BM (bowel movement) on floor. Pressure alarm in place. Unplugged and turned off alarm." edcial record review of a nursing note dated September 22, 2010, revealed "Lying on floor in hallway. Was trying to walk and fell . Alarm box on w/c, not bed." Interview with the DON on October 5, 2010, at 2:30 p.m., in the Wound Care Nurse's office, revealed the resident "goes through spells without falls then starts again. The resident gets belligerent and says 'I can do this.'" Continued interview with the DON revealed the DON was unaware how long it had been since Physical Therapy worked with the resident. Further interview with the DON confirmed the resident turned off or removed alarms so the alarms could not alert staff of unassisted transfers by the resident resulting in frequent falls. COMPLAINT #