Every finding on record at Smoky Mountain Health and Rehabilitation Center

Based on facility policy review, medical record review, Police Report review, Emergency Medical Services (EMS) records review, hospital records review, personnel files review, the facility's corrective actions review, and interview, the facility failed to avoid a significant medication error for 1 of 4 (Resident #4) residents reviewed for medication compliance. The facility's failure to prevent, timely detect and correct transcription errors contained in the electronic medication administration record (eMAR), resulted in a Morphine overdose (twenty times the prescribed dose) for Resident #4, causing hospitalization and actual Harm to Resident #4. The findings include: Review of the facility policy titled, Administering Medications, dated 4/2019, revealed .Medications are administered in a safe and timely manner as prescribed .medication errors are documented in the medical record .Medication errors include .medications not given accurately/timely .If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident .the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Alcoholic Cirrhosis of Liver with Ascites (abnormal buildup of fluid in the abdomen), Hepatic Encephalopathy (a brain dysfunction caused by liver failure, leading to toxin buildup in the blood that affects mental and physical function), Hepatic (liver) Failure Without Coma, Osteomyelitis of Vertebrae Thoracic Region (infection in the spine), Diabetes Mellitus with Diabetic Polyneuropathy, Chronic Obstructive Pulmonary Disease, Esophageal Varices (enlarged veins in the esophagus) without Bleeding, Hemolytic Anemia (a blood disorder that typically happens when your red blood cells break down or die faster than your body can replace them with new blood cells), Generalized Anxiety Disorder, and Adjustment-Disorder. Review of the physician's order for Resident #4 dated 2/19/2026, revealed an order for liquid morphine sulfate oral solution (narcotic for pain) at 20 milligrams per 5 milliliter (20 mg/5 ml) concentration, give 10 mg (2.5 ml) every 8 hours as needed for pain. Review of the electronic Medication Administration Record (eMAR) for Resident #4 dated 2/19/2026, revealed the physician's orders for the liquid morphine had been incorrectly transcribed onto the eMAR. Continued review revealed the order was transcribed as .Morphine Sulfate Oral Solution 20mg/5ml give10ML [milliliters] [the order was for 10 mg not 10 ml] by mouth every 8 hours as needed for pain management . Further review revealed the incorrect transcription of the Morphine order had not been detected by the nursing staff. Review of the Physician Orders Summary report for Resident #4, revealed the transcription error entered into Resident #4's electronic medical record on 2/19/2026 as noted above, was automatically re-populated to Resident #4's physician's recapitulation orders (physician's order summary report) and eMARS and continued to go un-detected or corrected for the months of 3/2026 and 4/2026. Review of the Narcotic Inventory Tracking Sheet for Resident #4 dated 2/2026, revealed the facility pharmacy dispensed liquid morphine sulfate oral solution in a 30 ml vial, in a concentration of 100 mg/5 ml (equal to 20 mg/ml concentration) to administer 0.5 ml (equal to the prescribed10 mg). Review of the eMARS and the corresponding entries on the Narcotic Inventory Tracking sheet for Resident #4 dated from 2/19/2026 to 3/31/2026, revealed 7 different Licensed Nurses had documented the withdrawal of 0.5 ml of the liquid Morphine (10 mg, the correct Morphine dosage prescribed for Resident #4) from the Narcotic Inventory Tracking sheet, but had signed the eMAR as administering 10 ml (not 10 mg) as noted on the incorrectly transcribed eMAR during 26 documented administrations of liquid Morphine to Resident #4 from 2/20/2026 - 3/31/2026. Review of the nursing notes and Physician's Order Summary reports for Resident #4 dated from 2/2026 to 4/2026, revealed no evidence or documentation the facility nursing staff had detected or corrected the transcription error on the eMAR during that time. Review of the facility's quarterly resident assessment dated [DATE], revealed Resident #4 was cognitively intact. Resident #4 required moderate assistance of 1 or 2 persons for activities of daily living (ADL). Review of the Narcotic Inventory Tracking Sheet for Resident #4, revealed on 4/1/2026, at 11:26 PM, the night shift Licensed Practical Nurse (LPN) A, (a travel nurse contracted to the facility), documented 10 ml (as incorrectly transcribed on the eMAR) was withdrawn and administered to Resident #4 (a dosage of 200 mg, twenty times the prescribed dose). Review of a witness statement dated 4/2/2026, authored by LPN A, revealed .At 23.15 [11:15 PM] .[Resident #4] asked for pain medication. On looking up her medication orders, she has a PRN [as needed] order for morphine 10 ml every 8 hrs [hours]. I [LPN A] gave her [Resident #4] 10 ml as per the order in the system [electronic medical record]. Throughout the night, the patient [Resident #4] was sleeping and she did not have or show any signs of respiratory distress. At 0620 [6:20 AM] .the dayshift nurse [LPN B] came and while we were about to do shift-change report, the dayshift nurse saw the empty bottle of morphine and asked me what happened to the morphine. I [LPN A] told her [LPN B] that there was 10 ml in there [the bottle] and I gave it to the patient [Resident #4]. She [LPN B] said that is a medication error because she is not supposed to get 10ml at once. I [LPN A] told her that, that's what the medication order says (Give 10ml by mouth every 8 hours as needed for pain management). She later when [went] to the patient's [Resident #4's] room, checked her vitals and level of consciousness. The patient was not responding to commands, she had a pulse and was breathing. 911 responders were called, they assessed the patient and gave her Naloxone/Narcan .antidote for opioid medication and they also gave her supplemental oxygen using an ambu bag [a hand-held medical tool used to push air into the lungs of patients who are not breathing or are struggling to breathe adequately] .They [EMS] later took her to hospital .When the EMT [Emergency Medical Technician] were headed out [out of the facility with Resident #4] .one of the EMT Staff came by the nurse's cart and I [LPN A] was there with the dayshift nurse [LPN B] .EMT asked us more questions about the medication [morphine] and what she [Resident #4] was given. [LPN B] told him [EMT] that the patient [Resident #4] was given 10ml which is what is in the order [physician's order] but she mentioned that the order is supposed to read 0.5 ml not 10 ml. I [LPN A] told the EMT that I read the order and gave 10ml as per the order. When I [LPN A] said that [LPN B] said 'Well, the order says 10ml but you should have used your nursing judgment to tell that the order is wrong' . Review of the nursing notes and witness statement for Resident #4 dated 4/2/2026 at 8:07 AM, authored by the oncoming day shift nurse (LPN B), revealed on 4/2/2026 at .around 0620 [6:20 AM] I [LPN B] .went to med [medication] cart to take report and count [narcotic reconciliation count with the off going nurse [LPN A] when I [LPN B] noticed .empty bottle of morphine sitting on the cart that I recalled had 10.5 ML in it last night around 18:40 [6:40 PM] when I had counted with oncoming night nurse [LPN A] .I asked the night shift nurse [LPN A] what happened to the medication .she stated that she gave it [administered to Resident #4] and order was for 10ML .went in to look at patient [Resident #4].was gray and ashen in color, shallow breathing .confirmed she had .pulse .eyes noted to be pinpoint .was not responding verbally or to painful stimuli .BP [blood pressure] 106/54 HR [heart rate] 81 .I [LPN B] asked the night nurse [LPN A] when she gave medication .stated at around midnight .but she had not signed it out [at midnight] because she could not find the paper [the narcotic log]. The paper was in the narc [narcotic] book .I asked her [LPN A] if she had checked on her [Resident #4] and she said no .06:32 [6:32 AM] I asked my hall partner .to call 911 .A police officer showed up [arrived] at 0640 [6:40 AM] .He [Police Officer] administered one dose of Narcan [a narcotic antagonist drug used to reverse opioid overdose] [Resident #4 had an order for Narcan but the facility staff did not administer.] .EMS arrived and after explaining situation.they [Paramedics, Emergency Medical Technicians (EMTs)] administered 4mg Narcan intranasally [given through the nose] .EMS .moved her [Resident #4] from bed to the stretcher and she was taken to the hospital .Upon looking into computer the order did say give 10 MLs and was overlooked until now . Review of a police report for Resident #4 dated 4/2/2026, revealed the local police arrived at the facility at 6:33 AM. Continued review revealed, .I [Police Officer] was dispatched to [the facility] in reference to an overdose .Upon my arrival I was taken to room [Resident #4s room] .where one of the staff members told me the lady identified to be [Resident #4] was given 200mg of Morphine.She was found at approximately 0620 [6:20 AM] in her condition .I administered Narcan in the left nostril .I checked for a pulse and was able to locate a pulse in the left arm. Her breathing was shallow and troubled .EMS arrived shortly after and began giving her oxygen. The paramedic administered a second Narcan .A few minutes later [Resident #4] started coming back to breathing normal and her eyes were reactive .was transported to [local hospital] for further evaluation and treatment .I spoke with the nurse who identified herself [LPN A] .She told me that the documentation she was sent on their system was to give 10ML .That converted to 200mg of Morphine administered orally . Review of EMS records for Resident #4 dated 4/2/2026, revealed EMS was dispatched to the facility at 6:33 AM and arrived on scene at 6:35 AM. EMS personnel took control of Resident #4 at 6:37 AM. EMS departed the facility to a local hospital with Resident #4 at 6:49 AM and arrived to the hospital emergency department (ED) at 7:03 AM. Resident #4 was transferred to the care of hospital staff at 7:53 AM. Continued review of the EMS record revealed, .Nurse stated the .patient [Resident #4] was given 200mg Morphine by medication order mistake .Entering the room .pt [patient] [Resident #4] was found lying in her bed .There was not painful or verbal stimuli from the pt .The pt was given 15 L [liters] 02 [oxygen].[15 L/per minute (15 l/m)] .Narcan 4mg L [left] nostril by law enforcement PTA [prior to arrival] .4mg R [right nostril] by EMS upon arrival After securing the pt in the ambulance .Pt was transferred to 3L O2 by NC [nasal cannula] .Vitals were continuously monitored .Became more responsive to verbal and painful stimuli . Review of Hospital Records for Resident #4 dated 4/2/2026, revealed .[Resident #4] presents to emergency department who was a resident at [the facility] here in rehab and evidently.midnight.was given her routine pain mediation [Morphine Sulfate] however after investigation .had discovered.she had received 200mg .[Resident #4] had been drowsy, had Hypo ventilatory [low respiratory rate] episodes .was given Narcan at the nursing home with some improvement in her condition .Patient arrives in emergency department.continues to be very somnolent [demonstrates a clear and observable pattern of impaired wakefulness, drowsiness] but.arousable and will respond to questioning but immediately goes back to sleep .Was placed on a Narcan drip which did improve her overall mentation [mental activity or mental state] . Review of the Hospital admission History and Physical for Resident #4 dated 4/2/2026 at 10:33 AM (3 hours and 30 minutes after arrival to the ED), revealed .When I [physician] came into the room daughter and sister were in the room .Patient was awake and alert .she was oriented to hospital .she did know city name .thought the year was 2025 .She did know the month .She followed commands appropriately .She was alert .I held the Narcan drip while I was in the room .She did not become somnolent while I was there .Her only complaint to me was abdominal pain, predominantly right sided or suprapubic [refers to the area of the lower abdomen located just above the pubic bone] . Continued review revealed Resident #4 was admitted to the hospital for additional observation with admission diagnoses including Toxic Metabolic Encephalopathy, Opiate Overdose, Cirrhosis, Acute Kidney Injury, Diabetes, Chronic Pain, Malnutrition, Macrocytic Anemia, Hyponatremia, Osteomyelitis of the Thoracic Spine, Altered Mental Status and Ovarian Cancer. Resident #4 was discharged back to the facility for continued care on 4/3/2026. Review of the personnel files for LPN A and LPN B revealed both were contracted travel nurses, licensed in good standing in Tennessee or Compact States and eligible to work in Tennessee. During an interview on 7/16/2026 at 2:45 PM, Resident #4's responsible party (RP) stated she had been informed by facility administration of the causes of Resident #4's accidental overdose of morphine identified in the facility investigation and the facility responses to the incident. The RP stated she had also spoken with local police, hospital and EMS personnel in regard to the incident, and was aware the alleged perpetrators involved in the incident were referred to professional boards afterwards. During an interview on 7/16/2026 at 4:20 PM, the facility Nurse Practitioner (NP) and the Medical Director stated they were involved in the QAPI committee responses to the incident and had been regularly advised of findings of the ongoing monitoring by the facility DON and Consultant Pharmacist. The NP stated further analysis of the incident by the facility medical staff which was shared with selected Quality Assurance (QA) committee members concluded the fact Resident #4 had been regularly taking opioids for an extended period at the time of the incident, likely prevented more serious outcomes had the resident been opioid naive. The NP confirmed the facility quality assurance team considered the medication error significant in nature and harmful to Resident #4 at the time of occurrence. During review of the facility investigation materials, witness statements corrective actions and interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 7/15/2026 at 3:55 PM, the ADON stated she was the person responsible for the transcription error noted in the electronic health records including the eMAR. The ADON stated the facility investigation determined the error occurred due to multiple factors which included alignment of medication order texts contained in the facility electronic record keeping system which listed MG, ML, and MG/ML in a listing sequence in a drop-down menu used to generate electronic physician orders and by accident clicked the incorrect text on the listing. The ADON stated she failed to detect the error at the time it occurred likely due to multi-tasking while transcribing Resident #4's orders into the electronic record keeping system. The DON confirmed the facility had failed to detect the transcription error when it occurred, and the facility did not double check all new orders transcribed using a 2-person verification system to ensure accuracy prior to orders being entered into the electronic record keeping system. The DON also confirmed the facility investigation also identified multiple personnel had failed to correct the transcription error noted on the eMARS which was signed as administered to Resident #4 with successive doses yet withdrew correct dosages of Morphine for Resident #4 for administration which led to a discrepancy in the documentation. The DON confirmed due to these failures to detect, correct the transcription errors, and to follow established standards of practice related to medication administration (the rights of medication administration) by multiple nursing employees, Resident #4 had received a substantial overdose of Morphine on 4/2/2026, which resulted in harm to Resident #4. During an interview on 7/30/2026 between 3:50 PM and 4:17 PM, the facility Consultant Pharmacist (CP) stated on 4/2/2026 she was contacted by the facility Regional Director of Clinical Operations and notified of the serious medication error on Resident #4. The CP stated a transcription error had occurred which led to Resident #4's overdose. The CP stated, the facility eMAR and Pharmacy Systems were not directly linked for controlled substance prescriptions, therefore the pharmacy had no means to detect the eMAR transcription error made by facility staff at the time it occurred, and the error itself occurred in between scheduled onsite visits by the consulting pharmacy. The CP further stated in her professional judgement the serious morphine overdose administered to Resident #4, was due to a transcription error on the eMAR, which went undetected or unaddressed by the facility until 4/2/206, and occurred when the nurse of record administered the drug as incorrectly documented on the eMAR, despite the correct dosage being noted on the narcotic order printed on the reconciliation sheets.

Based on review of facility policy, medical record review, review of the facility incident logs, review of facility fall investigations, emergency medical services (EMS), police records, police body camera (cam) footage, hospital records , observations, and interviews, the facility failed to provide supervision to prevent recurrent falls, review and revise the Care Plan, and implement fall interventions for 1 Resident (Resident #1) of 7 residents reviewed for falls. Resident #1, a severely cognitively impaired resident with a history of 6 falls since he admitted to the facility on [DATE], fell on [DATE] and staff were unaware he had fallen until they were notified by police officers who responded to a call for a welfare check. Resident #1 was unable to reach facility staff and called a friend to ask for help. The friend notified law enforcement after he called the facility 10-12 times with no answer. The facility failed to review and revise the Care Plan and implement an intervention following the fall on 2/17/2024. On 2/27/2024, 10 days later, Resident #1 fell again and sustained a hip fracture. The facility's failure placed Resident #1 in an Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to resident) when he fell on [DATE] and sustained a hip fracture. The Facility Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Regional [NAME] President were notified of the IJ on 4/2/2024 at 8:00 PM, in the conference room. The facility was cited Immediate Jeopardy at F-689 at a scope and severity of J which is substandard quality of care. The IJ began on 2/17/2024 and continued through 4/3/2024. The IJ ended on 4/4/2024 and was removed on site. An acceptable Removal Plan which removed the immediacy was provided by the facility 4/4/2024. Noncompliance continues at F-689 at a scope and severity of D. The corrective actions were validated on site by the surveyor on 4/5/2024 for F-689 . The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility's undated policy titled Fall Prevention Program, showed .When any resident experiences a fall, the facility will .assess the resident .complete an incident report .review the resident's care plan and update as indicated . Review of the facility policy titled, Falls, revised 11/8/2022, revealed .The intent of this requirement is to ensure the facility provides .supervision .to each resident to prevent avoidable accidents . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses including Pain in Thoracic Spine, Difficulty Walking, Severe Malnutrition, Chronic Obstructive Pulmonary Disease, Dementia, with Behavioral Disturbances, Atrial Fibrillation, Long Term Use of Anticoagulants, and Acute and Chronic Respiratory Failure with Hypoxia. Review of the admission fall risk assessment dated [DATE] showed Resident #1 was considered at a high risk for falls. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 had a Brief Interview for Mental Status Score (BIMS) of 7 out of 15 which indicated Resident #1 had severe cognitive impairment. Resident #1 required substantial to maximum assistance of 1 or 2 staff members for all activities of daily living. Review of the facility incident logs dated 1/1/2024 to 3/27/2024, showed the facility documented Resident #1 fell on [DATE], 1/29/2024, 2/14/2024, 2/16/2024, and 2/27/224. Continued review showed a fall which occurred on 2/17/2024 had not been documented on the incident log. Review of the care plan for Resident #1 dated 1/22/2024, showed .Fall Prevention Care Plan .Resident has had actual falls including with injury .at risk for additional falls related to weakness, poor safety awareness and impaired cognition . Continued review of the care plan showed the facility implemented the interventions after falls as follows: 1/23/2024 (no injury noted) .Keep frequently used items in reach . 1/29/2024 (skin tear left elbow, reddened area to chin, treatment administered) .offer rest period between lunch and dinner as resident will accept . 2/15/2024 (no injury noted) .offer toileting before dinner as resident will accept . 2/16/2024 (dislodged indwelling urinary catheter, skin tear to right thumb/hand, skin tears to right shin, transferred to hospital) . fall mats at bedside . 2/17/2024 No documentation a fall occurred; no new fall interventions were implemented. 2/27/2024 Resident #1 had a fall sustaining a right hip fracture and was transported to the hospital. 3/5/2024 .Have resident in high traffic areas while up in wheelchair . Review of the nursing notes for 2/16/2024, showed .[Resident #1] observed in the floor of the hallway yelling for help .blood noted on ground from his RLL [right lower leg] and right hand .Resident laying with head against the door to his room and legs out in the hallway .catheter bag [indwelling urinary catheter] still attached to bed .Resident stated I fell and I don't know what happened .cleaned and bandaged skin tears .[indwelling urinary catheter] reattached to catheter bag called EMS to transport to ER [emergency room ] for evaluation due to head injury on blood thinners [anticoagulants] . Review of the EMS records for Resident #1 dated 2/16/2024, showed .Injury to hand [primary] .falls .2/16/2024 .dispatched to scene .on arrival received report from nurse .patient found on floor .concerned for head injury .patient on blood thinners .pulled out [indwelling urinary catheter] at some point today .but they [facility staff] reinserted one .pt [patient] found in bed on arrival .has skin tear to LT [left shin] .thumb .bleeding controlled .placed on cot via [by way of] draw sheet .transported [to the hospital emergency room ] . Review of the hospital records dated 2/16/2024 showed Resident #1 was treated in the ER for skin tears to the thumb and shins. Resident #1 underwent neuroimaging [Computed tomography or CT Scan] which revealed no evidence of acute head injury or spinal injuries. Resident #1 was diagnosed with a severe Urinary Tract Infection (UTI) and fall related injuries. The indwelling urinary catheter was replaced in the emergency room . The resident returned to the nursing home with diagnoses of Fall from Standing, Multiple Skin Tears, a Complicated UTI with orders for antibiotics to treat the UTI, fall prevention instructions and wound care instructions. Review of the care plan revised 2/16/2024, showed Resident #1 had a new fall intervention for a floor fall mat at the bedside. Review of the Police Department Preliminary Investigative Report dated 2/17/2024, showed at 7:23 PM, a friend of Resident #1 called 911 and asked for a welfare check on Resident #1. The 911 caller stated Resident #1 had called him from the facility and informed the caller he had fallen to the floor, was on his back, and his calls for help [of the facility staff] had gone unanswered. Police officers arrived to the facility at 7:25 PM.Upon arrival officers made contact with [Resident #1] [at 7:30 PM] in room [Resident #1's room] in his bed .[Resident #1] stated he had not seen a nurse in over an hour and a half and that he did fall a while before officers got there .pushed his emergency button but no one came to help him .while officers were on the scene we did not see any nurses throughout the rehab .[Resident #1] was bleeding all over both of his arms, his legs, and possibly his back .There was blood in his bed, on the floor from his bed to the heating and air unit, all over the heating and air unit itself, across the floor to the doorway and on the wall and door .[Resident #1] requested an ambulance and wanted to go to the hospital .he was transported .by .[ambulance] to [hospital] .Just before the ambulance arrive to the rehab, a couple of nurses finally arrived and stated they did not know anything about [Resident #1] falling or bleeding everywhere. The nurses wanted to clean up [Resident #1's] wounds and the room before the ambulance arrived, and .[Officer #1 and Officer #2] .both told the nurses to leave things the way they were so paramedics could see the injuries . Review of police body cam footage of the incident, time stamped and dated 2/17/2024, showed both police officers who responded to the 911 call activated body cams immediately upon entering the facility lobby at 7:30 PM (the police officers had knowledge of the key access code of the locked keyless entry pad to the front lobby doors). Body cam footage from both officers showed no staff members were visible anywhere in the facility as they walked to Resident #1's room from the front lobby and made initial contact with the resident at 7:30 PM. Resident #1 was observed in his bed which was at normal height (approximately between thigh and hip high and not lowered as documented in the nursing notes) when the police officers arrived. Resident #1 was observed on the camera stating to the officers he had fallen and wished to be taken to a hospital. EMS was summoned by radio by the police officers at 7:34 PM. Officer #1 left Resident #1's room at 7:35 PM, walked back to the lobby to await the ambulance and no facility staff were visible anywhere in the facility. Officer #1's footage showed she awaited the ambulance in the front lobby and was not approached by any staff members. At 7:50 PM (approximately 20 minutes after arrival to the facility) Registered Nurse (RN #1) made contact with Officer #1, and asked if she could help the officer, and the officer explained why she was there, and that Resident #1 had fallen and an ambulance had been called for the resident. Review of body cam footage from Police Officer #2, showed at 7:30 PM, Resident #1 informed the police officers he called his friend to request an ambulance after he had fallen and felt shaky and was itching. The footage showed at 7:32 PM, Resident #1 again informed the police officers he had fallen. Officer #2 remained with Resident #1 continuously throughout the incident [without staff knowledge]. Further review showed Resident #1 stated he had been in the floor and had not spoken to anyone [facility staff] since he fell . Resident #1 described to Officer #2 how he pulled himself from the floor onto his knees grabbing onto the AC unit adjacent to his bed. Officer #2's body cam footage showed the police officer inspected the entire room and observed dried blood on the HVAC (AC) unit, dried blood spatter noted on the fall mat beside the bed adjacent to the HVAC unit, dried blood smear on the door trim beside the door at the entrance to Resident #1's room, dried blood spatter on the back of Resident #1's room door, and dried blood spatter on the flooring between the doorway and Resident #1's bed. Officer #2's body cam footage showed Resident #1 had a large skin tear on the left elbow with bright red blood. Close up footage of Resident #1's skin injuries showed the skin tear on the left elbow had rolled up skin on the upper aspect of the wound. No dressing was visible on the left arm. Bright red blood was visible on the back of Resident #1's right elbow with another large skin tear. No dressing was visible on the wounds. Bright red blood was also noted on Resident #1's clothing near Resident #1's waist on the right side and was also visible on the resident's bedding. The officer questioned Resident #1 about the observation of blood on his pants and Resident #1 stated he had pain in his back and felt he had injured his back. Continued review of Officer #2's body cam footage showed as staff entered the room with Officer #1 (approximately 20 minutes after the police officers arrived at the facility), both officer's informed them Resident #1 had stated a fall, showed staff evidence of his injuries and the blood spatter throughout the room. Officer #1 was observed pointing out to staff members they were standing in dried blood on the floor. Staff stated to police they were unaware Resident #1 had fallen. Review of Officer #1's body cam footage showed at 7:54 PM staff members approached the officer in the hallway outside Resident #1's door and requested permission to clean [Resident #1] up before transport to the hospital. The officers advised staff an ambulance was in route and not to clean Resident #1's wounds, as EMT's needed to see the resident's injuries and the condition of the room as it was found by the police. Further review of Officer #2's body cam footage showed EMS personnel arrived at the resident's room at 7:55 PM and immediately greeted Resident #1 by his first name. EMS asked the resident if he wanted to go the hospital. Resident #1 stated he did and explained he had fallen and had been injured. Review of Nursing Notes dated 2/17/2024 at 10:04 PM, showed .[Resident #1] in bed in low position with blood noted to left elbow area, alert no complaints of pain, will send to emergency room for evaluation, family members aware . Review of the Police Department Preliminary Investigative Report for Resident #1 dated 2/17/2024, the detective notes revealed .On 2/18/2024, I [Detective] reviewed the officers body camera from this incident .[Officer #1] arrived and for the time the camera was on there was no nurses observed in the hallways .[Resident #1] was in the bed at normal height [and not in a low bed as indicated by the nurse's notes] in his room .[Resident #1] asked if she was the police and began telling her what happened .there was fresh blood on his shirt in the left elbow area, bed sheet, blanket and spatter on the AC .[Officer #1] asked how he [Resident #1] got back in bed and [Resident #1] stated he managed .later told officer that he [Resident #1] used the AC unit to get himself back up which is why it had blood on it .[Officer #1] asked if he [Resident #1] wanted an ambulance and he explicitly said yes .officer asked for his name and birthdate which he gave and spelled without issue .Officer .then went to the front door to await an ambulance .[Officer #1] waited at the front door approximately 15 minutes for the ambulance .went back toward the room and encountered two nurses in the hallway near [Resident #1's] room .One of the nurses asked if she could help her .She explained why she was there, which the nurses appeared to not be aware of .The nurses then entered the room and ask [Resident #1] what happened .one of the nurses said [Resident #1] fell yesterday also and had blood everywhere . Continued review showed .Another nurse returned and asked about going in the room and changing [Resident #1] .[Officer #1] told her not to, because an ambulance was enroute and they needed to see the state he was in . Review of the EMS documents dated 2/17/2024, showed .dispatched to pt [patient] [Resident #1] evaluation request by PD [police department] at [facility] .Upon arrival were led by law enforcement .pt was alert and oriented .stated he had fallen while trying to get to the bathroom .stated he had fallen approximately 1.5 hours ago and was eventually able to get himself back in bed .stated he wanted to go to the hospital .findings of an approximately 6 cm [centimeter] skin tear on left elbow and a 4 cm skin tear on right elbow. Review of the hospital emergency room records dated 2/17/2024, showed Resident #1 underwent laboratory studies, neuroimaging studies and treatment for additional skin tears at the hospital. Review of the triage notes showed, .This RN [Registered Nurse] spoke to the patient family friend [the 911 caller] .[911 caller] stated he called the nursing home approximately 10 to 15 times and ' .never got a response' .states when he could not get ahold of anyone he called the sheriffs office to do a welfare check .Wound care completed on patient's bilateral elbow skin tears and an upper back skin tear . Review of the hospital ER physician notes dated 2/17/2024, showed the physician had documented, .reportedly called family members and stated he had fallen .family .called police .police went to the facility .police then called EMS .patient [Resident #1] was seen here earlier this morning [late night of 2/16/2024 into early morning of 2/17/2024] and had a fall, was discharged to the facility on antibiotics .patient without acute traumatic findings on imaging .noted to have pulmonary infiltrate [Pneumonia] .spoke with patient's facility .they were strongly advised to closely monitor patient over the next few days given his increased fall risk .will discharge Fall prevention literature was included in discharge orders sent back to the facility. Review of the witness statement for RN #1 dated 2/17/2024, showed .Saw police officer outside door [Resident #1's room doorway] .stated he [Resident #1] had fallen and crawled to the door and been there for hours .Stated Resident called family and told them, family called police .[Resident #1] .lying in bed, noted blood to the left arm area .noted blood on air conditioner, minimal amount there and also on mat to the left side of the bed .noted small dried drops at the doorway and about a foot into hall .officer stated you are standing in the blood .From prior night fall [2/16/2024] reported to me by nurses that had him [provided care on the night of 2/16/2024] he had a dressing on left upper (arm) .and steri-strips to right thumb .rt [right] chin had steri strips applied .reported he had crawled to door that night .Nurse stated when he was in emergency room he stated he fell down some stairs . Review of Resident #1's medical record and care plan showed no new intervention had been implemented for the fall or after the resident returned from the hospital on 2/17/2024. Review of the facility document titled, Final Investigation, dated 2/21/2024, signed by the former Administrator showed .Background of the event .911 call placed by friend of [Resident #1] 2/17 [2/17/2024] approximately 7:30 PM .Resident told friend he had fallen and needed help and could not reach anyone [staff at the facility] .Injuries .No known injuries from this alleged event .this resident .with a history of falls and did have previous fall on 2/16/2024 .resulting in trip to the ER [emergency room ] due to fall being unwitnessed .he did have skin injuries to the RLL [right lower limb] and right hand with skin tears to right elbow .Initial Report Summary .Facility nurse notified the Director of Nurses on 2/17 at approximately 8:00 PM that a 911 call had been made by the resident's friend alleging that he [Resident #1] had fallen and could not get help [from the facility staff] .They [Resident #1's family/friend] were concerned . Investigative Activity .Staff on that unit were interviewed regarding the alleged incident .It was determined the resident was in bed at the time of arrival of the EMS/police .There was no indication that he had fallen in that immediate time frame .they [the facility staff] had been in and out of the room throughout this shift to include delivery of meals .Investigative Activity: .Staff interviews made and statements gathered indicate no indication of a fall on this date [2/17/2024] . Based on record review and witness statements there was no fall on this date [2/17/2024] .The residents conversation with friend was most likely describing events of his previous fall [2/16/2024] .It is highly likely due to his unclear speech and dementia with a BIMs of 07 [severe cognitive impairment on scale of 7 out of 15] that the time frames and occurrences were not accurate .Conclusion .The facility camera system recorded events of that .time frame were conducted with [former DON] .[local detective] .and [TBI] [Tennessee Bureau of Investigations] [special agent] .that revealed there was no indication that the resident had fallen .The tape confirmed events surrounding care to include delivery of the evening meal .Based on the above mentioned information I [former Administrator] cannot substantiate that there was a fall, no wrong doing on behalf of the staff .on date of this alleged occurrence [2/17/2024] . Review of the facility ATTESTATION document dated 2/21/2024, signed by the former DON showed .Please accept this document as my attestation and is being submitted as evidentiary material related to the investigation being conducted for [Resident #1] related to 911 call on 2/17/2024 .This event was reported to me on 2/17/2024 via [by way of] telephone call at 7:55 PM by [Registered Nurse, RN #1] .[RN #1] notified me that there were officers here that said they had been called to check on [Resident #1] because he had told his friend that he was in the floor and didn't have help .Resident was in the bed resting when officers responded .I [former DON] asked [RN #1] when the last time he [Resident #1] was seen by staff and she [RN #1] stated he was seen when staff were picking up trays after the dinner time meal and he was resting in bed .and there was no concerns at that time .[RN #1] stated . to me [former DON] that she was told by police that they were waiting on EMS to take the resident to the ER to get checked out .Police told [RN #1] not to touch [Resident #1] that they wanted to send him [to the hospital] how he was .[RN #1] let me know that EMS had come and were picking him up within minutes of notifying me that the police had arrived .Continued review of the attestation document revealed .On 2/20/2023 TBI agent and local detective came to the facility in regard to the 2/17 [2/17/2024] 911 call .They asked me [former DON] what I knew about the event .I stated the above account and stated I had the statements in a folder in my desk .They asked for copies of the statements .Detective asked about cameras in the hallway outside [Resident #1's room] .I let her [Local Detective] know they [the camera footage] go back 3 days roughly 72 hours .we go review the footage from that time period police responded .SSD [Social Services Director] able to pull up camera footage from the area and time frame requested .when reviewing footage .it is seen that [Certified Nursing Assistant] [CNA #2] went to [Resident #1] room and picked up the dinner tray .[Resident #1] was never seen in the hallway or the doorway of his room from the time trays were given out at dinner to the time police responded .TBI agent and detective seemed to have no concerns . Review of the facility incident logs dated 1/1/2024 to 3/27/2024 showed the incident of 2/17/2024 had not been documented. Review of the nursing notes showed on 2/27/2024, Resident #1 had a witnessed fall from his wheelchair while seated in the hallway near the nursing station. Resident #1 complained of right hip pain and staff summoned EMS to the facility. Resident #1 was transferred back to the hospital by EMS for the third time in 10 days related to falls . Review of the EMS records dated 2/27/2024, showed EMS was dispatched to the facility due to a reported fall. On arrival they found Resident #1 in the hallway floor surrounded by staff. Resident #1 complained of right hip pain rated as 10/10. Resident #1 was examined by EMTs and transported to the hospital by ambulance. Review of the hospital records dated 2/27/2024, showed in the emergency room Resident #1 underwent Computer Assisted Tomography (CAT SCAN) which showed .on the right is an acute appearing intertrochanteric fracture with varus angulation and surrounding soft tissue swelling [a displaced fracture of the upper femur, hip fracture ] . Resident #1 was admitted to the hospital and underwent surgical repair of his fractured hip on 2/29/2024. Observation and interview on 3/27/2024 at 6:05 PM, showed Resident #1 lying in his bed at a regular height (between thigh and waist high). A single fall mat was on the left side of the bed between the bed and air conditioning unit. Resident #1 was confused but recalled falling several times at the facility. Resident #1 recalled one incident where he crawled to the doorway and was bleeding, and stated he had fallen into the wall and an ambulance came and transported him to the hospital. The resident stated one time he called his friend (the 911 caller) and showed the surveyor the cellular phone he used .I used this to call .because nobody [facility staff] comes . when you call for assistance. Resident #1 stated, .now I have fallen again, I broke my hip, I can't walk anymore, it's hopeless for me now . During an interview on 3/28/2024, the Interim Director of Nursing (DON) stated he became aware on 3/28/2024, the state and local law enforcement agents and Adult Protective Service Investigators had visited the facility and investigated the incident of 2/17/2024 for Resident #1. The DON reported he had reviewed facility files related to the matter with emails dated 2/21/2024 on the morning of 3/28/2024, and that was when he became aware the police had concerns about the incident. The DON reported the former DON and former Administrator had investigated the incident and determined there was no evidence Resident #1 fell on [DATE]. The Interim DON stated the incident occurred before his, the newly hired Assistant DON's, and the Interim Administrator's start of employment at the facility and they had not been informed of the allegations or specific facility findings related to the incident until the State Survey Agency had begun it's investigation on 3/27/2024. During a telephone interview on 4/1/2024 at 1:00 PM, the 911 caller of 2/17/2024, stated he was a friend of Resident #1 who along with his father had assumed surrogacy roles for Resident #1 because Resident #1 had no children of his own, or relatives in the United States. The 911 caller stated Resident #1 called him on the evening of 2/17/2024 (didn't recall exact time) but knew it was in the late afternoon or early evening hours and reported he had fallen from his bed, was on his back, had called out for help repeatedly and the facility staff had not responded to his calls for help. The 911 caller stated Resident #1 informed him he had been in the floor .over an hour . The 911 caller stated he then immediately attempted to call the facility on the main line, then called both wings in attempts to reach staff, between 10 and 12 times, and each time he called, the phone rang but went unanswered. At that point, he dialed 911 and requested police go to the facility for a welfare check on Resident #1 and the facility. During an interview on 4/1/2024 at 1:15 PM, Certified Nurse Aide (CNA) #3 stated on the night of the incident (2/17/2024), a majority of the patients on the wing were situated on the far end of the unit away from Resident #1's room and staff were on that end of the unit most of the shift. CNA #3 stated around the time of the incident, all 3 staff stationed on the unit were engaged with a family member of another resident. CNA #3 stated CNA #2 had collected Resident #1's meal tray around 6:15 to 6:30 PM that night and at that time the resident was in bed. CNA #2 confirmed she was not aware of the police officer on the unit until around 8:05 PM. (Police Officers entered Resident #1's room at 7:30 PM and left the unit with EMS at 8:03 PM per the body cam footage). CNA #3 stated she had not entered the resident's room during the incident or encountered Officer #2. CNA #3 stated after the incident she cleaned the resident's room and noted blood on the AC unit and floor mat beside the bed. CNA #3 described blood spatter on the AC [air conditioner] vent as appearing like a feather had painted it on the vents. CNA #3 confirmed staff were not aware police officer had entered the building or of Resident #1's fall until they were notified by the police officers. During an interview on 4/1/2024 at 2:10 PM, CNA #2 stated she had seen Resident #1 in his bed around 6:15 to 6:30 PM when she picked up his dinner tray. CNA #2 stated she lowered Resident #1's bed to the lowest setting (indicating lowered to the floor) after removing his tray as she was aware of his fall on 2/16/2024 (this is conflicting as to what was reflected on the police camera footage and police investigative report which stated the bed was at a regular height at approximately thigh to waist high). CNA #2 stated at that time Resident #1 was awake, in bed, and had an intact dressing on his left elbow (the police officer body camera footage showed no dressing or bandage on the resident's left elbow). CNA #2 confirmed she was unaware police had entered the unit until she went to answer a call light in a resident room next door to Resident #1 sometime between 7:00 and 7:30 PM (couldn't recall exact time). CNA #2 confirmed the nurse on duty was also not aware the police officers had entered the facility. CNA #2 stated she had not been in the resident's room or observed the resident after approximately 6:30 PM that evening and was not aware Resident #1 had fallen until the staff had been notified by the police officers. During an interview on 4/1/2024 at 2:45 PM, RN #1 stated she was the nurse on duty at the time of the incident on 2/17/2024. RN #1 corroborated CNA #2 and #3's account of issues with a family member on the far end of the unit at the time the incident with Resident #1 had arisen. RN #1 stated only 2 residents were situated on the rear hallway (Resident #1 and his neighbor in the next room) the rest of the unit's residents were on the front hall. RN #1 was unable to recall the census on the unit on 2/17/2024 but knew it was at least 20 residents. RN #1 stated she had not heard the unit telephone ring that evening but added the only phone was located at the nursing station and could not be heard from the hallways or clinical spaces. RN #1 stated she observed police officers sometime between 6:30 and 7:00 PM but could not recall the exact time (Police entered the unit at 7:30 PM). RN #1 stated after she became aware the police officers had found Resident #1, she immediately telephoned the former Director of Nursing (DON) and informed her of the nature of the situation while police were still on the premises. RN #1 stated she informed the DON that Resident #1 had fallen again and appeared to be injured. RN #1 stated she was aware CNA #2 had last seen the resident around 6:15 PM to 6:30 PM (approximately 1 - 1 hour and 15 minutes before the fall) that evening and the resident had been in bed. RN #1 stated she believed Resident #1 had fallen, and confirmed the fall went undetected by the facility staff until the police arrived. During an interview on 4/1/2024 at 3:50 PM, the Interim DON confirmed the facility Resident #1 had suffered a fall with related injuries on 2/16/2024 and 2/17/2024. The DON confirmed the facility failed to review, revise, and update the care plan to implement interventions in response to Resident #1's fall on 2/17/2024 and the resident had received a serious injury (fractured hip) from the fall on 2/27/2024. The DON confirmed the facility failed to protect Resident #1 from a serious injury related to falls. The DON further confirmed the facility investigation performed on 2/21/2024 by the former Don and former Administrator appeared incomplete and the facility incident log did not include the unwitnessed fall. During an observation and interview on 4/1/2024 at 5:45 PM, showed Resident #1 was on 1 to 1 staff supervision. The DON stated new interventions and enhanced supervision of Resident #1 had been implemented on 3/28/2024, after the corporate office had reviewed the incident which had occurred on 2/17/2024 and due to signs of agitation and increased confusion, Resident #1's room had been moved closer to the nursing station, the bed was lowered to its maximum low setting, a scoop mattress (specialty mattress with raised borders) was added and bilateral fall mats were noted beside the bed. The interventions were implemented 1 month after the fall on 2/27/2024. Refer to F-657 and F-725. Allegation of Compliance (AOC) Removal Plan for F-689 The facility's corrective actions for the removal plan were issued to

Based on facility policy review, medical record review, incident logs, review of census and staffing data review, time punch reports review, police reports and police officer body camera (cam) video footage review, and interviews, the facility failed to maintain sufficient nurse staffing levels on 1 of 2 units on the night of 2/17/2024. The facility's failure to maintain sufficient nurse staffing levels to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial wellbeing of residents on 1 of units (The Mountain Unit) on 2/17/2024 of 60 days reviewed which resulted in facility staff not detecting a fall for Resident #1 for an unspecified amount of time. The facility's failure to maintain safe staffing levels placed Resident #1 in an Immediate Jeopardy (IJ) situation, (A situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to result in serious injury, harm, impairment, or death to a resident, and must be immediately corrected). The facility's failure to maintain safe staffing levels had the potential to impact all 78 residents of the facility. The Facility Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and Regional [NAME] President were notified of the IJ on 4/2/2024 at 8:00 PM, in the conference room. The facility was cited Immediate Jeopardy at F-725 at a scope and severity of J. The IJ began on 2/17/2024 and continued through 4/3/2024. The IJ ended on 4/4/2024 and was removed on site. An acceptable Removal Plan which removed the immediacy was provided by the facility on 4/4/2024 for F-725. The corrective actions were validated on site by the surveyor on 4/5/2024 for F-725. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility's undated policy titled, Nursing Services and Sufficient Staff, showed .It is the policy of this facility to provide sufficient staff to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident .The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis .Licensed Nurses .Other nursing personnel including .nurse aides .Providing care includes .responding to resident needs . Review of the medical record showed Resident #1 was admitted to the facility on [DATE], with diagnoses including Pain in Thoracic Spine, Difficulty Walking, Severe Malnutrition, Chronic Obstructive Pulmonary Disease, Dementia, with Other Behavioral Disturbances, Atrial Fibrillation, Long Term Use of Anticoagulants, and Acute and Chronic Respiratory Failure with Hypoxia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 had a Brief Interview for Mental Status Score (BIMS) of 7 out of 15 which indicated Resident #1 had severe cognitive impairment. Resident #1 required substantial to maximum assistance of 1 or 2 staff members for all activities of daily living. Review of the facility nursing notes dated 2/16/2024, showed Resident #1 had been transported to a local hospital due to a fall with related injuries. Review of the care plan showed Resident #1 had a fall on 2/16/2024 and a new intervention of a fall mat to the bedside was implemented. Review of facility documentation dated 2/17/2024, showed the facility census on the unit in which Resident #1 resided was 27 with staffing of 1 Registered Nurse and 2 Certified Nurse Aides. Continued review showed the entire facility census was 75 with a total staffing pattern of 2 nurses and 5 Certified Nurse Aides. Review of the staffing data and resident census for Resident #1's unit (The Mountain Unit) dated 2/17/2024, showed on the night of the incident (2/17/2024), the unit was originally scheduled to have been staffed with 2 Licensed Practical Nurses (LPNs) and 2 Certified Nurse Aides (CNAs) for 27 residents. Review of the time punch reports for the Mountain Unit, dated 2/17/2024, showed an agency LPN had not reported for duty as scheduled. The unit was staffed with 1 Registered Nurse (RN #1) and 2 CNAs (CNAs #2 and #3) for 27 residents. The open position from the agency nurse went unfilled. Review of the Police Department Preliminary Investigative Report (police report) dated 2/17/2024 at 7:23 PM, showed a friend of Resident #1 called 911 and asked for a welfare check on Resident #1. The 911 caller stated Resident #1 had called him from the facility and stated he had fallen to the floor, was on his back, and his calls for help had not been answered by the staff. The 911 caller informed 911 he had repeatedly attempted to call the facility (10-15 times), but the phone went unanswered. Police arrived to the facility at 7:25 PM. Continued review of the police report showed, .Upon arrival officers made contact with [Resident #1] in room [Resident #1's room] in his bed .[Resident #1] stated he had not seen a nurse in over an hour and a half and that he did fall a while before officers got there .pushed his emergency button but no one came to help him .while officers were on the scene we did not see any nurses throughout the rehab . Resident #1 was bleeding all over both of his arms, his legs, and possibly his back. There was blood in the resident's bed, on the floor from his bed to the heating and air unit (AC unit), all over the heating and air unit itself, across the floor to the doorway and on the wall and the resident's room door. Resident #1 was transported by an ambulance to the hospital. Review of police body cam footage of the incident, time stamped and dated 2/17/2024, showed both police officers who responded to the 911 call activated their body cameras immediately upon entering the facility lobby at 7:30 PM (Police Officer had knowledge of the pass code for the digital keyless entry for the front door of the facility) Body Cam footage from both officers showed no staff members were visible anywhere in the facility as they walked to Resident #1's room from the front lobby and made initial contact with the resident at 7:30 PM in his room. Resident #1 was observed in his bed which was at normal height (approximately between thigh and hip high) (not lowered as documented in the nursing notes) when officers arrived. EMS was summoned by police radio at 7:34 PM. Officer #1 left Resident #1's room at 7:35 PM, walked back to the lobby to await the ambulance and at no time were facility staff visible anywhere in the facility. 15 minutes later, at 7:50 PM (approximately 20 minutes after arrival to the facility), Registered Nurse (RN) #1 approached Officer #1, asked if she could help the officer, and the officer explained why she was there, and that Resident #1 had fallen. Continued review of body cam footage from Officer #2, showed at 7:30 PM, Resident #1 informed the police he had called his friend for help after he had fallen and felt shaky and was itching. The body cam footage showed Resident #1 stated he had fallen and . need to get out of here . Further review showed Resident #1 expressed he had fallen to Officer #2 again at 7:35 PM and stated he had been in the floor and had not spoken to anyone [facility staff] since he fell . Resident #1 then described to Officer #2 how he pulled himself from the floor onto his knees grabbing onto the AC unit adjacent to his bed. Officer #2's body cam footage showed Resident #1 had a large skin tear on the left elbow with bright red blood and a skin tear on the left elbow. Bright red blood was visible on the back of Resident #1's right elbow with another substantial skin tear. Continued review of Officer #2's body cam footage showed as staff entered the room with Officer #1, both officer's informed them Resident #1 reported a fall, showed staff evidence of his injuries and the blood spatter throughout the room. In the background of the police body cam footage, staff stated to police they were unaware Resident #1 had fallen. Staff were also heard to tell officers .there are only 3 of us [facility staff] here . Review of Officer #1's body cam footage showed at 7:54 PM staff members approached the officer in the hallway outside Resident #1's door and requested permission to clean up [Resident #1's] wounds and the room before transport to the hospital. The officer advised staff an ambulance was enroute and not to clean Resident #1, as EMT's needed to see the resident's injuries and the room as found by the police officers. Further review of Officer #2's body cam footage showed EMS personnel arrived at the room at 7:55 PM and transported the resident to the hospital. Review of the Police Department Preliminary Investigative Report showed the detective notes dated 2/18/2024, revealed . On 2/18/2024, I [local detective] reviewed the officers body camera from this incident .[Officer #1] arrived and for the time the camera was on there was no nurses observed in the hallways .[Resident #1] was in the bed at normal height in his room .officer asked for his [Resident #1's] name and birthdate which he gave and spelled without issue .[Officer #1] .then went to the front door to await an ambulance .[Officer #1] waited at the front door approximately 15 minutes for the ambulance which still had not arrived .went back toward the room and encountered two nurses in the hallway near [Resident #1's] room .One of the nurses asked if she could help her .She explained why she was there, which the nurses appeared to not be aware of .The nurses then entered the room and ask [Resident #1] what happened .In the background one of the nurses said [Resident #1] fell yesterday also and had blood everywhere . Continued review showed, .Another nurse returned and asked about going in the room and changing [Resident #1] .[Officer #1] told her not to, because an ambulance was enroute and they needed to see the state he was in . Review of the detective notes on the Preliminary Investigation Report showed an entry dated 2/22/2024, which read, .Agent .and I went to [the facility] on 2/20/2024, and met with Administrator [the former Administrator] .She stated she was aware of an incident, but did not know all the details .then went to get the Director of Nursing [the former DON] .[former DON] .stated written statements were collected from the three nurses who were working [on the evening of 2/17/2024] .The statements indicated the nurses were on that floor and no officer ever came and sought them out .Also that they offered to treat [Resident #1] but the officer would not allow them to .I [local detective] asked about video since there is a camera just outside his [Resident #1] door .Originally I was told it only holds 3 days and the time was up .Later, I learned that it was still on the system .We watched the video which showed a nurse picking up his [Resident #1] tray at approximately 6:15 PM and there was not another nurse went into the room or was even in that hallway prior to the officers arrival at approximately 7:25 PM [approximately 1 hour and 10 minutes later] .This investigation remains ongoing . During an interview on 3/28/204 at 3:15 PM, the facility scheduler, Certified Nurse Aide (CNA) #1 stated the facility used agency staff frequently to fill open shifts. CNA #1 stated in her estimation, around 30 to 40 percent of the facility shifts were filled by contracted agency employees from 2 online staffing services. CNA #1 stated it was not uncommon for employees of the online agencies to accept shift assignments made a week in advance, then cancel their shift with little or no advance notice on the day they were to report for duty. CNA #1 stated she frequently utilized the facility's own employees to cover shifts when agency personnel gave no notice (no call no show) and failed to report to work as scheduled. CNA #1 stated the facility had filed complaints with both online nursing agencies related to this problem repeatedly, but it had little or no recourse other than placing agency employees who failed to come to work as scheduled on do not return list. CNA #1 stated the facility's normal staffing pattern was for 2 nurses and at least 2 CNAs on every unit on night shifts, and 2 nurses and at least 4 CNAs on day shifts. CNA #1 confirmed on the night of 2/17/2024, an agency nurse, had not reported for duty as scheduled with no advance notice. CNA #1 stated she attempted to fill the vacancy with both agency and facility personnel but was unsuccessful. CNA #1 stated on the evening of 2/17/2024, she informed the former DON, The Mountain Unit was staffed with only 1 nurse and 2 CNAs (didn't recall the exact time) and was short staffed, but the DON could not fill the vacancy either. CNA #1 stated no member of the former nursing leadership team came in to work to fill the vacancy when the DON failed to procure a replacement nurse. CNA #1 confirmed the facility had multiple nursing leadership personnel who could have come into work to fill the open slot in the schedule which included the DON, Assistant DON, an MDS Nurse, or the Infection Control Nurse. The scheduler confirmed on the night of 2/17/2024, The Mountain Unit was understaffed. During an interview on 3/28/2024 at 5:56 PM, CNA #4 stated it was not uncommon for agency staff to fail to report for duty as scheduled or to report for duty late. CNA #4 stated she had worked overtime to cover unplanned absences around twice per pay period due to being understaffed. CNA #4 stated the staff absences and understaffing had been reported to administration. During an interview on 3/28/2024 at 6:00 PM, LPN #2 stated she occasionally worked overtime to cover unplanned contract staff absences. LPN #2 stated when agency personnel failed to report for duty the units were understaffed. LPN #2 stated the staff absences and the understaffing had been reported to administration, repeatedly. During an interview on 3/28/2024 at 6:02 PM, CNA #7 stated she had complained several times to the former facility leadership including the former DON and the former Administrator about the issue with reliability of contracted employees and impacts on scheduling and the low staffing levels with the difficulty in providing timely care to all the residents when the facility went understaffed. During an interview on 4/1/2024 at 1:00 PM, the 911 caller reported he was a friend of Resident #1. The 911 caller stated Resident #1 had telephoned him that evening (2/17/2024) (didn't recall exact time) and told him he had fallen, was in the floor and his cries for help went unanswered by staff. The 911 caller stated he attempted to call the facility's main line, and both unit phone numbers at the facility 10 to 15 times over several minutes, in efforts to reach staff and the calls went unanswered. The 911 caller stated after that, he became more concerned for Resident #1 and the facility after Resident #1 failed to answer his phone on return call. The 911 caller immediately dialed 911 and asked for a welfare check on the resident. The 911 caller stated he visited Resident #1 occasionally but never attempted visits after 5:30 PM as the lobby was usually unattended, the front door was locked and staff frequently did not answer the door or the phone, and no staff were ever near the lobby to open the front door, which was kept locked by a digital keypad-controlled lock and the caller did not have knowledge of the pass code to enter the facility. The 911 caller stated he had stopped visiting in the evenings for that reason. The 911 caller stated he felt the facility was always understaffed and was concerned about the situation. During an interview on 4/1/2024 at 1:15 PM, CNA #3 (who was on duty on the night of the incident on The Mountain Unit) stated the unit was understaffed on the night of 2/17/2024. CNA #3 stated she recalled the incident and described the entire shift as apocalyptic due to issues on the unit further compounded by the short staffing. CNA #3 stated most of the Residents on the unit were situated near the front of the unit, while Resident #1 was located near the rear of the unit with only one other resident. CNA #3 stated she had left the unit for around 10 to 15 minutes sometime between 6:45 and 7:00 PM that evening to get fast food for another Resident after a family member had made the demand. During that time, only the nurse (RN #1) and 1 CNA (CNA #2) staffed the unit. CNA #3 stated she was aware her co-worker CNA #2, had collected Resident #1's dinner tray around 6:15 to 6:30 PM and the resident had been in bed at that time. CNA #3 estimated there were around 30 residents on the unit on 2/17/2024. CNA #3 stated she was unaware police had entered the facility due to she and CNA #2 being engaged with other residents, most of whom required 2 persons assistance and who resided on the other end of the unit. CNA #3 stated due to an agency nurse absence, both CNAs were responsible for between 15 to 17 residents each and there was only 1 nurse on the unit that night. CNA #3 stated the unscheduled absences and agency personnel not reporting to work as scheduled was a common occurrence. CNA #3 confirmed she was not aware of the exact time police arrived to the unit on 2/17/2024, and estimated it to be around 8:05 PM. CNA #3 stated she believed the understaffing contributed to staff's failure to notice police officers when they arrived or to detect Resident #1's fall. During an interview on 4/1/2024 at 2:15 PM, CNA #2 stated on 2/17/2024 she last saw Resident #1 between 6:15 and 6:30 PM when she picked up his dinner tray. CNA #2 stated she lowered Resident #1's bed to low setting at that time (this is inconsistent to police body cam footage and police investigative notes which indicated Resident #1's bed was at a normal height ) (approximately between thigh and hip high). CNA#2 stated Resident #2 had a bandage on his left elbow when she last saw him. (This was inconsistent with body camera footage observed by the State Agency (SA) which showed no evidence of dressings on Resident #1's left elbow when police entered the room on the night of 2/17/2024). CNA #2 stated on the night of the incident there were around 30 residents on the unit, then stated many were sick and required 2 staff assistance. CNA #2 stated the staffing pattern on 2/17/2024 of only 1 nurse and 2 CNAs made it difficult for CNAs to complete all assigned duties or monitor the entire unit. CNA #2 stated it was common for scheduled agency personnel to not report for duty and give no notice of their pending absence. CNA #2 stated she and other facility CNAs had repeatedly complained to the scheduler, the former DON, and the former Administrator of their concerns with agency personnel and understaffing when agency personnel failed to report for duty. CNA #2 stated facility employees volunteered for overtime to fill uncovered staff absences but could not meet every need. CNA #2 stated on 2/17/2024 she had not checked on Resident #1 again after picking up his dinner tray around 6:15-6:30 PM on the night of the occurrence. CNA #2 then explained she and the other CNA were providing care to others on the front section of the unit and were unaware Resident #1 had fallen. CNA #2 stated she had not seen the police officers arrive to the unit but noted their presence sometime between 7:00 and 7:30 PM (the police officers arrived to the facility at 7:30 PM and went unnoticed by staff for 20 minutes). CNA #2 confirmed CNA #3 had left the unit around 6:00 PM, to obtain food in efforts to calm another resident's family member, and stated CNA #3 was gone around 20 minutes, which left only her and the nurse on the unit. During an interview on 4/1/2024 at 2:45 PM, RN #1 stated on 2/17/2024 at the time of the incident with Resident #1, she was on the front wing of the unit administering tube feedings and medications to a resident and did not see police enter the facility. RN #1 stated the majority of residents on the Mountain Unit were situated on the front wing of the unit. RN #1 stated Resident #1 and one other resident remained on the rear wing of the unit, confirmed she was the only nurse on duty, and estimated she was assigned .at least 20 . residents. RN #1 corroborated CNA #2 and CNA #3's accounts of an angry family member monopolizing staff attention and CNA #3 had left the unit for around .10 to 15 minutes . to acquire chicken nuggets from a nearby fast-food restaurant in attempts to appease a resident's family member, which left only RN #1 and CNA #2 on the unit. RN #1 stated she estimated she first saw the police officers enter the unit around 7:30 PM as she rounded the nursing station that night on the way to Resident #1's room. (Body cam footage showed this occurred at 7:50 PM, approximately 20 minutes after police arrival to the facility) and asked the Officer if she could help her. Continued interview revealed RN #1 confirmed she did not hear the unit telephone ring that night and reported the phones could not be heard from the hallway and no mobile handsets were in use at the facility. RN #1 stated she had expressed concerns about that to the former DON and Administrator several times before 2/17/2024, to no avail. RN #1 stated problems with agency staffing at the facility were problematic due to frequent no call no shows. RN #1 stated when agency staff failed to report as scheduled the unit was understaffed. RN #1 confirmed on 2/17/2024 an agency nurse failed to report for duty as scheduled. RN #1 stated she had expressed concerns related to understaffing and the reliability of contracted employees to the former Administrator and DON several times before the 2/17/2024 incident and felt the understaffing may have attributed to the staff being unaware of Resident #1's fall. During an interview on 4/1/2024 at 3:50 PM, the DON stated the facility's leadership team in place on 2/17/2024 were no longer employed at the facility. The DON stated this included the former Administrator, DON, Assistant Director of Nursing (ADON), MDS Nurse, and Infection Control Nurse. The DON stated after additional quality assurance reviews of Resident #1's incident on 2/17/2024 were completed by the current leadership team on 3/28/2024 (1 day after the State Agency entered the facility and 40 days after the incident), the facility had reviewed the staffing models and data and had put measures in place to aid the staffing issues. The DON confirmed on 2/17/2024 the Mountain Unit was understaffed but was unable to verify if she felt it attributed to Resident #1's fall. Refer to F-657 and F-689. Allegation of Compliance (AOC) Removal Plan for F725 The facility's corrective actions for the removal plan were issued to the surveyor on 4/3/2024. The corrective action plan included the following: 1. The Chief Regulatory and Compliance Officer provided training to the Administrator, DON, and ADON about their responsibility to ensure sufficient staffing at all times to assure resident safety. 2. The facility leadership and members of the Governing Body reviewed the facility's recruitment and retention program. 3. On 4/2/2024, the Administrator, DON, ADON, members of the Governing Body and Corporate Staff reviewed the allegations (2/17/2024 incident with Resident #1), discussed immediate actions and removal plan. 4. Policies and procedures were reviewed by the DON, ADON, Administrator, VP of Clinical Service and VP of Regulator Compliance. No changes were made to the current policies and procedures. 5. To ensure compliance with staffing requirements the DON, ADON, Administrator, and staff Scheduler will review daily staffing to ensure sufficient staffing at all times. a. When there are nurse or Certified Nursing Assistant (CNA) call ins, facility employees are asked to work with incentives offered and/or request for agency staff. 6. Members of the Governing Body and Corporate team will conduct daily calls, Monday-Friday to review staffing and determine if recruitment efforts are effective. The Removal Plan was validated onsite by the surveyor on 4/4/2024-4/5/2024 and included the following: 1. Surveyor validated through interviews with the facility's administrative and corporate staff they were knowledgeable about their responsibility to ensure sufficient staffing was maintained at the facility. a. The Administrative staff including the Administrator, DON, ADON, and staff scheduler were interviewed and stated daily meetings were being conducted and the staff scheduled were reviewed to ensure sufficient staffing. The interviewed staff stated when there were call ins by nursing staff including CNA's, other facility staff were asked to work and were offered incentives, in addition staffing agencies were called and were requested to assist. As a last resort if and if needed the DON, ADON, Wound Nurse, MDS nurse would assist with covering shifts to ensure safe staffing coverage. Through interviews with 7 CNA's, 5 LPN's, 2 RN's, the Wound Care Nurse, the MDS Coordinator, DON, and ADON revealed they had been educated and in-serviced on call ins and filling in shift as needed to maintain adequate staffing. 2. Review of the Recruitment Plan showed the facility had implemented the following to attain and retain staff: a. Job posting on line, verified through review of Indeed Job Recruitment. b. Social Media platforms c. A free cell phone to full time employees. d. Flyers were posted at the entrance of the facility regarding job openings. e. A Walk In Wednesday for job interviews at the facility. 3. Staffing was observed on both shifts 4/3/2024 to 4/5/2024. No short staffing was observed. Daily monitoring documentation of personnel on floor versus (vs) posted staffing matched. Punch report and staffing snap shots were reviewed and cross referenced against other falls investigated for Residents #3-#7 with no evidence of short staffing on the units and dates those falls occurred. Daily RN staffing was confirmed with observations and punch report checks during the survey period. Final walk through and staff/census counts conducted immediately before exit on 4/5/2024 showed no concerns. 4. Observations and interviews with the DON, ADON and Admin showed they had also underwent additional in service training conducted by the Corporate Compliance Consultant as reported in the AOC. Review of the QAPI sign in sheets and daily staffing calls showed those were completed as reported in the AOC. Medical director participation in the AOC/POC process was verified by her Nurse Practitioner onsite on 4/4/2024 and 4/5/2024. Prior to the exit conference (both participated and signed the QA sheets). 5. Daily observations of the scheduling calendar showed 4 agency personnel called off duty during the survey. All 4 open shifts were covered with other agency personnel or facility staff. The ADON covered a single 4-hour stint on 4/4/2024 until agency alternates could arrive due to staff tardiness due to a family emergency which was called to the ADON 8 hours in advance of the shift. This slot was eventually filled by an agency employee. Review and observation of the facility's AOC/Removal Plan, staffing schedules, staff postings, observation of staff and residents, daily staff meeting, and interviews showed the facility had implemented all corrective actions and the immediacy was removed onsite.

Based on facility policy review, facility investigation review, police report review, medical record review, observation, and interview the facility failed to protect the residents' right to be free from physical abuse by a resident for 2 of 14 (Residents #7 and #3) sampled residents reviewed for abuse. The facility failed to protect the residents' right to be free from abuse on 6/13/2023 when Resident #12 open handed slapped Resident #3 on the hands, wrists, and lower forearms and when Resident #14 hit Resident #7 in the upper left arm causing multiple bruises on 6/1/2024 which resulted in actual HARM for Resident #7. The finding include: Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, revealed .It is the policy of this facility to provide protections for .each resident by developing and implementing written policies .that prohibit and prevent abuse .'Abuse' means the willful infliction of injury .with resulting physical harm .which can include .resident to resident altercations .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm .'Physical Abuse' includes .hitting, slapping, punching, biting, and kicking . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Hypertension, Muscle Weakness, Cognitive Communication Deficit, and Abnormalities of Gait and Mobility. Review of an Order Summary Report physician's order for Resident #7 dated 12/6/2022, revealed the resident was taking Apixaban 5 milligram (mg) twice a day for anticoagulation (slowing of the clotting of the blood). Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 scored a 6 on a Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had severe cognitive impairment. Review of a Comprehensive Care Plan for Resident #7 dated 6/1/2024, revealed Resident #7's resident to resident altercation was addressed. The care plan was person centered and interventions were appropriate to address the issue. Review of the Nurse's Progress Notes for Resident #7 dated 6/1/2024 at 1:15 PM, revealed Resident #7 was heard yelling for help from the resident's room. The nurse observed Resident #14 assaulting Resident #7. The nursing note revealed Resident #7 was hit in the left upper arm and the left side of the face with a closed fist. Licensed Practical Nurse (LPN) A and Certified Nursing Assistant (CNA) C separated the residents, LPN A notified the police, Emergency Medical Services (EMS), Assistant Director of Nursing (ADON), and Manager on Duty of the altercation. Resident #7 was sent to the emergency room for assessment. Review of the Nurse's Progress Notes for Resident #7 dated 6/1/2024 at 3:29 PM, revealed Resident #7 was moved to a different room as an intervention to prevent future altercations with Resident #14. Review of the emergency room (ER) Documentation for Resident #7 dated 6/1/2024, revealed Resident #7 had .soft tissue swelling and bruising over the left upper extremity . No other injuries were found during the emergency room (ER) examination. Resident #7 was discharged back to the facility from the ER. Review of the Encounter Note for Resident #7 dated 6/3/2024 at 1:00 PM, revealed Resident #7 was assessed by the Family Nurse Practitioner (FNP). The FNP documented Resident #7 had .Multiple black bruises to bilateral upper extremities . During an observation in the outside courtyard on 6/17/2024 at 11:30 AM, Resident #7 was observed in a wheelchair with other residents. Resident #7 was wheeling her chair towards the door to go into the building. Resident #7 was alert and calm. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Dementia with Psychotic Disturbance, Adult Failure to Thrive, Anxiety Disorder, and Tremors. Review of a quarterly MDS assessment dated [DATE], revealed Resident #14 scored a 9 on the BIMS assessment, which indicated the resident had moderate cognitive impairment. In addition, the MDS revealed Resident #14 had exhibited no behaviors during the assessment period. Review of a Comprehensive Care Plan for Resident #14 revised 6/1/2024, revealed the resident to resident altercation was added to the Behavior Care Plan on 6/1/2024. The goal and interventions were person centered and appropriate for Resident #14's behavior issues. Review of the Nurse's Progress Notes for Resident #14 on 6/1/2024 at 1:15 PM, revealed the resident was in an altercation with Resident #7 and was transferred to the ER.The nursing note also revealed the ADON and Manager on Duty had been notified. Review of the Nurse's Progress Note on 6/1/2024 at 10:47 PM, revealed Resident #14 returned to the facility that night. Review of the emergency room Documentation for Resident #14 dated 6/1/2024, revealed Resident #14 had no abnormal lab results for blood and urine, and Resident #14 was free from injury. Resident #14 was observed for 6 hours at the emergency room and discharged back to the facility. Review of the Nurse's Progress Notes for Resident #14 on 6/2/2024 at 5:11 AM, revealed the resident was being placed on 1 to 1 supervision for behaviors. Review of the facility investigation of the incident between Residents #7 and #14 dated 6/1/2024 at 4:30 PM, revealed at 1:15 PM staff heard a resident screaming. The staff entered the room where Residents #7 and #14 resided and saw Resident #14 hitting Resident #7 in the left upper arm. The staff separated the residents. CNA C stayed with Resident #14 in the room. LPN A moved Resident #7 out of the room to the nursing station. Resident #7 was assessed for injuries. Residents #7 and #14 were sent to the local hospital ER for evaluation. Review of the Witness Statement from CNA C dated 6/1/2024, revealed Resident #14 was agitated the morning of 6/1/2024 about missing clothes. Resident #7 (Resident #14's roommate) was assisted to get up and dressed. CNA C assisted Resident #7 to the nursing station. The witness statement revealed Resident #7 wheeled herself back to her room. The CNA heard a resident yelling and went to Resident #7's room and witnessed Resident #14 hitting Resident #7. Review of an undated Witness Statement from LPN A revealed .[CNA C] .alerted this nurse that .[Resident #14] saying someone took her clothes .[Resident #7] spent the rest of the morning .around the nurses station until .[Resident #7] wheeled herself back into her room .[LPN A] heard [Resident #7] yell for help. [LPN A] turned back to look .and observed [Resident #14] hitting [Resident #7] in the left upper arm and left side of face with a closed fist . During an observation in the resident's room on 6/17/2024 at 11:25 AM, Resident #14 was observed lying in bed. Resident #14 was on 1:1 supervision 24 hours a day. Resident #14 was calm and smiling. During a phone interview on 6/17/2024 at 2:26 PM, LPN A stated she was right outside Residents #7's and #14's room when she heard a scream. LPN A went into the room and observed Resident #14 closed fist hitting Resident #7 on the left arm and left side of the face. LPN A stated CNA C assisted LPN A to separate the residents. LPN A stated CNA C stayed with Resident #14. CNA C reported to LPN A that Resident #14 was aggressively trying to get away from her to get to Resident #7. During a phone interview on 6/17/2024 at 3:18 PM, the Family Nurse Practitioner (FNP) stated on 6/3/2024, Resident #7 was evaluated due to the incident that happened on 6/1/2024 between Residents # 7 and #14. The FNP stated Resident #7 had bruised on both arms. The FNP stated Resident #7 did remember being hit but did not know why. The FNP stated a resident hitting another resident was considered abuse, and the bruises Resident #7 received from being hit by Resident #14 were considered harm. During a phone interview on 6/18/2024 at 9:36 AM, CNA C stated in the morning on 6/1/2024, Resident #14 was agitated about her clothes missing. CNA C stated Resident #14 often gets upset about clothes are in the laundry and thinks someone took them. CNA C stated Resident #7 (Resident #14's roommate) was trying to get out of bed at the time. CNA C stated she assisted Resident #7 to get cleaned up, dressed, and removed from the room. CNA C stated she reported to LPN A about Resident #14's agitation. CNA C stated after lunch Resident #7 went back to her room on her own. CNA C stated she heard a scream and went to the Resident #7's and #14's room and observed Resident #14 was hitting Resident #7. CNA C stated a nurse was attempting to separate the residents. CNA C assisted the nurse, and then stayed with Resident #14. During that time with Resident #14, CNA C stated that Resident #14 wanted to be let out of the room to get to Resident #7. During an interview on 6/18/2024 at 10:55 AM, the Director of Nursing (DON) stated the plan was for Resident #14 to remain on 1 to 1 supervision the mental health nurse practitioner could complete another assessment to make sure it was safe. The DON stated Resident #14 had no violent episodes since 6/1/2024. The DON stated Resident #14 hitting Resident #7 was abuse, and the injuries Resident #7 received from Resident #14 hitting her met the definition of harm. During an interview on 6/18/2024 at 12:50 PM, the Power of Attorney (POA) for Resident #14 stated the facility called right away to notify him of the incident on 6/1/2024. POA stated he had been updated on the care plan interventions and completely agreed with them. During an interview on 6/18/2024 at 12:56 PM, the Emergency Contact (EC) for Resident #7 stated she was notified of the incident that occurred between Resident #7 and Resident #14 on 6/1/2024. The EC was updated right away after the incident. The EC stated she was updated on the room change and agreed with that change. During an interview on 6/18/2024 at 1:10 PM, the Administrator stated she was out of the facility on 6/1/2024. The Administrator stated she went to the facility as soon as she could. The Administrator stated she was told there was a resident to resident altercation caused by Resident #14 thinking Resident #7 stole her clothes. The Administrator stated she was told Resident #14 hit Resident #7 multiple times in left arm. Staff told the Administrator they separated the residents immediately, the residents were sent to the ER for evaluation, and the DON, Manager on Duty, 911, police and families were notified of the incident. The Administrator stated Resident #14 hitting Resident #7 was considered abuse, and the bruises Resident #7 received from Resident #14 were considered harm. Review of the medical record revealed Resident #3 was admitted to facility on 1/8/2024 with diagnoses including Cerebral Infarction, Hemiplegia and Hemiparesis and Bipolar Disorder. Review of a quarterly MDS assessment dated [DATE], revealed Resident #3 scored a 00 on the BIMS assessment which indicated severe cognitive impairment. The resident had verbal behavioral symptoms directed towards others on 1-3 days of the 7 day look back period and had no pain. Review of the physician's orders for Resident #3 dated 4/24/2024, revealed .Divalproex Sodium [a mental health medication for mood] Oral Tablet Delayed Release 125 MG .by mouth three times a day for mood stabilizer .Quetiapine Fumarate [an antipsychotic medication] .Oral Tablet 50 MG .by mouth two times a day for behaviors . During an observation and interview on 6/17/2024 at 1:05 PM, in Resident #3's room, the resident was dressed in a wheelchair, and stated he didn't remember anyone hitting him or trying to hit him. When asked other questions about his care, he stated .I don't know I don't know anything . Review of a Psychotherapy Progress Note for Resident #3 dated 5/24/2024, revealed .Pt [patient or resident] denied feeling overly sad or anxious. Pt was alert, coherent but minimally engaged. No perceptual disturbances observed .Pt seems stable .he is satisfied with the care here .No recommendations at this time . Review of the facility's investigation documentation for Resident #3 dated 6/13/2024, revealed a resident to resident altercation happened when Resident #3 was .trying to come into courtyard door to dining room .[Resident #12] .attempting to get out to courtyard .[Resident #3] didn't move to let the other resident out .[Resident #12] began yelling incoherently and open hand slapping .residents were separated and taken for assessment . The FNP, family and law enforcement were notified. Review of a Nurse's Progress Note for Resident #3 dated 6/13/2024, revealed .this resident involved in incident with another resident. family and physician notified .initial report submitted. Investigation initiated. Witness statements taken. Final investigative report will be submitted .within five days. Skin and emotional assessments initiated . Review of a Nurse's Progress Note for Resident #3 dated 6/13/2024, revealed .nurse performed skin assessment after resident involved in altercation with another resident. No bruising or impaired areas identified at this time . Review of facility documentation of Resident #3's witness statement dated 6/13/2024, revealed DON and Risk Manager interviewed resident about an altercation. Resident #3 nodded he was OK, when asked if it was a fight, Resident stated no, [expletive] The resident stated he wasn't hurt, he felt safe and he didn't hit first. He showed an open hand when asked how he was hit. Review of a Comprehensive Care Plan dated 6/14/2024, revealed .[Resident #3] have little or no awareness or boundaries related to other's personal space/preferences . with intervention of .Staff will redirect [Resident #3] when he is attempting to redirect other residents . Review of an FNP Progress Note for Resident #3 dated 6/14/2024, revealed .[Resident #3] was involved in an altercation with another resident [Resident #12] and nursing staff is requesting evaluation .He is wheelchair-bound. Yesterday [6/13/2024] another resident [Resident #12] was trying to exit a door into the Courtyard when he [Resident #3] tried to stop the resident .[Resident #12] slapped at him .Nursing staff report no injuries. Nursing staff intervened. He reports nothing happened yesterday and that he does not remember any incident . Review of a Pyschiatric (Psych) NP Progress Note for Resident #3 dated 6/14/2024, revealed .I am seeing the resident today as an initial visit for unspecified mood disorder. Staff request visit with resident after recent resident to resident altercation .He is able to answer some simple questions appropriately but does show some confusion with conversation. Staff reports that this resident [Resident #3] and another resident [Resident #12] were both attempting to go out of the door at the same time during scheduled smoke time . Resident reports that he feels safe and that staff treats him well. No known triggers to behaviors or modifying factors . Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Hypokalemia and Spinal Stenosis. Review of a quarterly MDS assessment dated [DATE], revealed Resident #12 scored a 4 on the BIMS assessment which indicated the resident had severe cognitive impairment, and the resident had no behaviors. The resident had no impairment to upper or lower extremities and ambulated with a wheelchair. Review of a comprehensive care plan for Resident #12 revised 6/13/2024, revealed the resident had .Behavior Care Plan: Potential for impaired or inappropriate behaviors . refuses to discard chewing tobacco when asked .places used chewing tobacco in brief to be chewed later .[Resident #12] smacking at another resident [Resident #3] that was trying to prevent [Resident #12] from exiting the building to go into the courtyard . with intervention of .Intervene as necessary to protect the rights and safety of others .Divert attention. Remove from situation and take to alternative location as needed . Review of the facility's documentation for Resident #12 dated 6/13/2024, revealed a resident to resident altercation when Resident #3 was attempting to get out of dining room door into the courtyard and did not redirect to let another [Resident #3] in the door.[Resident #12] became agitated started yelling incoherently and open hand slapping the other resident [Resident #3] .residents were separated and taken to different areas. At the time of interview, he had no recollection of the event . Resident #12 was assessed and no injuries were noted . The FNP, family and law enforcement were notified. Review of a Nurse's Progress Note for Resident #12 dated 6/13/2024, revealed .skin and emotional assessments initiated . Review of Head to Toe Weekly skin check for Resident #12 dated 6/13/2024, revealed the resident had clear skin with no skin impairment. Review of a Psych NP Progress Note for Resident #12 dated 6/18/2024, revealed .Resident does not recall altercation .reports that he feels safe .at the facility . Review of facility's investigation and reporting documentation dated 6/13/2024, revealed .the allegation was reported to the resident representative .both resident's [residents'] family members were notified .[Resident #3] indicated that he recalled the incident .he was trying to come in from the courtyard when [Resident #12] hurried towards him .attempt to get outside .[Resident #12] started yelling .opened hand slapping [Resident #3], who started yelling .Summary of interviews .perpetrator, [Resident #12] fluctuates with cognition. Upon interview, he was unaware that anything had occurred .allegation is verified by evidence collected during the investigation .employees receive routine training on abuse prohibition policy .Submitted by .[Administrator] . Review of a police document showed report #24061317494 was investigated by an officer on 6/13/2024. Review of Tennessee Adult Protective Services submission report dated 6/13/2024 showed incident was reported at 3:13 PM. Review of facility documentation of the Dietary Director's witness statement dated 6/13/2024, revealed the Dietary Director walked out of the kitchen and saw Resident #12 trying to get into the courtyard through the door. She redirected the resident and left the room, but she heard yelling as soon as she turned the corner into the hall. She went back in and saw the 2 residents throwing punches. The residents were separated. Review of facility documentation of CNA D's witness statement dated 6/13/2024, revealed the CNA was in the dining room returning trays and witnessed Resident #12 fighting with Resident #3 in the courtyard doorway. The CNA rushed to separate the residents, and the Dietary Manager went to get the DON. During an interview on 6/17/2024 at 1:43 PM, the Dietary Director stated on the day of the resident to resident altercation, she had walked into the dining room and Resident #12 was trying to go out the door, and the Director told him to come back in so another resident could get in. She left the room and heard screaming. The Dietary Director came back into the dining room and saw the back of Resident #12 and arm motions only. She stated she saw CNA D was separating Residents #12 and #3. She stated she gave an eye witness account to the facility's management. During an interview on 6/17/2024 at 2:40 PM, CNA D stated she was bringing trays back to the dining room on 6/13/2024 after lunch when she noticed Residents #12 and #3 were having an altercation at the courtyard door of the dining room. The CNA stated she saw Resident #12 swing first and then closed fist punches were being thrown with hands, wrists and lower forearms getting hit. She did not know what was said to start the event. The CNA stated she pulled Resident #12 away from Resident #3, and the Dietary Manager went to get the DON. The CNA stated the event was resident to resident abuse. The CNA stated she took Resident #12 to his room. The CNA stated she noticed no new aggression or fear. During an interview on 6/17/2024 at 3:02 PM, Resident #27, who was cognitively intact, stated he witnessed the resident to resident altercation on 6/13/2024, and stated Resident #12 started the resident to resident altercation and was trying to go out the door to the courtyard in the dining room. He stated .[Resident #3] tried to stop [Resident #12] from going out the door, because he knew he shouldn't be out there .[Resident #12] started swinging and [Resident #3] had his hands up trying to protect himself . During a telephone interview on 6/17/2024 at 7:50 PM, Resident #3's representative stated she was informed of a resident to resident altercation involving her son (Resident #3) on 6/13/2024. The representative stated she was on her way to the facility when the staff called her to notify her of the incident, and she arrived not long after it happened. She stated when she arrived, Resident #3 didn't even remember the event and he did not show any signs of fear or distress. During an interview on 6/17/2024 at 10:09 AM, the DON stated she was made aware of the resident to resident altercation after it occurred at about 1:12 PM, and the residents had already been separated. The staff began interviewing residents that had witnessed the event. She stated staff and residents involved were interviewed, and nurses caring for the involved residents did skin checks on those residents. That was the beginning of the investigation. The staff did psychosocial assessments on residents who were interviewed to make sure they felt safe. The DON stated Psych and medical NPs, risk manager and families were made aware of the incident, and reports were made to State, APS, police and Ombudsman, which was standard for every resident to resident altercation. The DON was told there was physical contact. The DON confirmed that the incident on 6/13/2024 between Residents #3 and #12 was resident to resident abuse. During an interview on 6/18/2024 at 11:00 AM, the FNP stated when there was an abuse allegation, she would assess the resident the next time she was in the building. The FNP stated the altercation between Residents #3 and #12 happened on 6/13/2024, and she assessed both residents the next day, and she did not note any physical or psychosocial harm or injury to either resident. During an interview on 6/18/2024 at 1:33 PM, the Administrator stated she was on a call at about 1:00 PM on 6/13/2024 and was made aware that a resident to resident altercation had taken place. The residents were separated immediately, and staff began skin and emotional assessments. The families of Residents #3 and #12 and the physician were notified, and no injuries or psychosocial harm were noted in either resident. She stated Resident #12 was the resident who struck out first based on witnesses. The Administrator confirmed it was resident to resident abuse.

Based on facility policy review, facility investigation review, police report review, medical record review, observation, and interview the facility failed to protect the residents' right to be free from physical abuse by a resident for 2 of 14 (Residents #7 and #3) sampled residents reviewed for abuse. The facility failed to protect the residents' right to be free from abuse on 6/13/2023 when Resident #12 open handed slapped Resident #3 on the hands, wrists, and lower forearms and when Resident #14 hit Resident #7 in the upper left arm causing multiple bruises on 6/1/2024 which resulted in actual HARM for Resident #7. The finding include: Review of the facility's undated policy titled, Abuse, Neglect and Exploitation, revealed .It is the policy of this facility to provide protections for .each resident by developing and implementing written policies .that prohibit and prevent abuse .'Abuse' means the willful infliction of injury .with resulting physical harm .which can include .resident to resident altercations .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm .'Physical Abuse' includes .hitting, slapping, punching, biting, and kicking . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Hypertension, Muscle Weakness, Cognitive Communication Deficit, and Abnormalities of Gait and Mobility. Review of an Order Summary Report physician's order for Resident #7 dated 12/6/2022, revealed the resident was taking Apixaban 5 milligram (mg) twice a day for anticoagulation (slowing of the clotting of the blood). Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 scored a 6 on a Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had severe cognitive impairment. Review of a Comprehensive Care Plan for Resident #7 dated 6/1/2024, revealed Resident #7's resident to resident altercation was addressed. The care plan was person centered and interventions were appropriate to address the issue. Review of the Nurse's Progress Notes for Resident #7 dated 6/1/2024 at 1:15 PM, revealed Resident #7 was heard yelling for help from the resident's room. The nurse observed Resident #14 assaulting Resident #7. The nursing note revealed Resident #7 was hit in the left upper arm and the left side of the face with a closed fist. Licensed Practical Nurse (LPN) A and Certified Nursing Assistant (CNA) C separated the residents, LPN A notified the police, Emergency Medical Services (EMS), Assistant Director of Nursing (ADON), and Manager on Duty of the altercation. Resident #7 was sent to the emergency room for assessment. Review of the Nurse's Progress Notes for Resident #7 dated 6/1/2024 at 3:29 PM, revealed Resident #7 was moved to a different room as an intervention to prevent future altercations with Resident #14. Review of the emergency room (ER) Documentation for Resident #7 dated 6/1/2024, revealed Resident #7 had .soft tissue swelling and bruising over the left upper extremity . No other injuries were found during the emergency room (ER) examination. Resident #7 was discharged back to the facility from the ER. Review of the Encounter Note for Resident #7 dated 6/3/2024 at 1:00 PM, revealed Resident #7 was assessed by the Family Nurse Practitioner (FNP). The FNP documented Resident #7 had .Multiple black bruises to bilateral upper extremities . During an observation in the outside courtyard on 6/17/2024 at 11:30 AM, Resident #7 was observed in a wheelchair with other residents. Resident #7 was wheeling her chair towards the door to go into the building. Resident #7 was alert and calm. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including Dementia with Psychotic Disturbance, Adult Failure to Thrive, Anxiety Disorder, and Tremors. Review of a quarterly MDS assessment dated [DATE], revealed Resident #14 scored a 9 on the BIMS assessment, which indicated the resident had moderate cognitive impairment. In addition, the MDS revealed Resident #14 had exhibited no behaviors during the assessment period. Review of a Comprehensive Care Plan for Resident #14 revised 6/1/2024, revealed the resident to resident altercation was added to the Behavior Care Plan on 6/1/2024. The goal and interventions were person centered and appropriate for Resident #14's behavior issues. Review of the Nurse's Progress Notes for Resident #14 on 6/1/2024 at 1:15 PM, revealed the resident was in an altercation with Resident #7 and was transferred to the ER.The nursing note also revealed the ADON and Manager on Duty had been notified. Review of the Nurse's Progress Note on 6/1/2024 at 10:47 PM, revealed Resident #14 returned to the facility that night. Review of the emergency room Documentation for Resident #14 dated 6/1/2024, revealed Resident #14 had no abnormal lab results for blood and urine, and Resident #14 was free from injury. Resident #14 was observed for 6 hours at the emergency room and discharged back to the facility. Review of the Nurse's Progress Notes for Resident #14 on 6/2/2024 at 5:11 AM, revealed the resident was being placed on 1 to 1 supervision for behaviors. Review of the facility investigation of the incident between Residents #7 and #14 dated 6/1/2024 at 4:30 PM, revealed at 1:15 PM staff heard a resident screaming. The staff entered the room where Residents #7 and #14 resided and saw Resident #14 hitting Resident #7 in the left upper arm. The staff separated the residents. CNA C stayed with Resident #14 in the room. LPN A moved Resident #7 out of the room to the nursing station. Resident #7 was assessed for injuries. Residents #7 and #14 were sent to the local hospital ER for evaluation. Review of the Witness Statement from CNA C dated 6/1/2024, revealed Resident #14 was agitated the morning of 6/1/2024 about missing clothes. Resident #7 (Resident #14's roommate) was assisted to get up and dressed. CNA C assisted Resident #7 to the nursing station. The witness statement revealed Resident #7 wheeled herself back to her room. The CNA heard a resident yelling and went to Resident #7's room and witnessed Resident #14 hitting Resident #7. Review of an undated Witness Statement from LPN A revealed .[CNA C] .alerted this nurse that .[Resident #14] saying someone took her clothes .[Resident #7] spent the rest of the morning .around the nurses station until .[Resident #7] wheeled herself back into her room .[LPN A] heard [Resident #7] yell for help. [LPN A] turned back to look .and observed [Resident #14] hitting [Resident #7] in the left upper arm and left side of face with a closed fist . During an observation in the resident's room on 6/17/2024 at 11:25 AM, Resident #14 was observed lying in bed. Resident #14 was on 1:1 supervision 24 hours a day. Resident #14 was calm and smiling. During a phone interview on 6/17/2024 at 2:26 PM, LPN A stated she was right outside Residents #7's and #14's room when she heard a scream. LPN A went into the room and observed Resident #14 closed fist hitting Resident #7 on the left arm and left side of the face. LPN A stated CNA C assisted LPN A to separate the residents. LPN A stated CNA C stayed with Resident #14. CNA C reported to LPN A that Resident #14 was aggressively trying to get away from her to get to Resident #7. During a phone interview on 6/17/2024 at 3:18 PM, the Family Nurse Practitioner (FNP) stated on 6/3/2024, Resident #7 was evaluated due to the incident that happened on 6/1/2024 between Residents # 7 and #14. The FNP stated Resident #7 had bruised on both arms. The FNP stated Resident #7 did remember being hit but did not know why. The FNP stated a resident hitting another resident was considered abuse, and the bruises Resident #7 received from being hit by Resident #14 were considered harm. During a phone interview on 6/18/2024 at 9:36 AM, CNA C stated in the morning on 6/1/2024, Resident #14 was agitated about her clothes missing. CNA C stated Resident #14 often gets upset about clothes are in the laundry and thinks someone took them. CNA C stated Resident #7 (Resident #14's roommate) was trying to get out of bed at the time. CNA C stated she assisted Resident #7 to get cleaned up, dressed, and removed from the room. CNA C stated she reported to LPN A about Resident #14's agitation. CNA C stated after lunch Resident #7 went back to her room on her own. CNA C stated she heard a scream and went to the Resident #7's and #14's room and observed Resident #14 was hitting Resident #7. CNA C stated a nurse was attempting to separate the residents. CNA C assisted the nurse, and then stayed with Resident #14. During that time with Resident #14, CNA C stated that Resident #14 wanted to be let out of the room to get to Resident #7. During an interview on 6/18/2024 at 10:55 AM, the Director of Nursing (DON) stated the plan was for Resident #14 to remain on 1 to 1 supervision the mental health nurse practitioner could complete another assessment to make sure it was safe. The DON stated Resident #14 had no violent episodes since 6/1/2024. The DON stated Resident #14 hitting Resident #7 was abuse, and the injuries Resident #7 received from Resident #14 hitting her met the definition of harm. During an interview on 6/18/2024 at 12:50 PM, the Power of Attorney (POA) for Resident #14 stated the facility called right away to notify him of the incident on 6/1/2024. POA stated he had been updated on the care plan interventions and completely agreed with them. During an interview on 6/18/2024 at 12:56 PM, the Emergency Contact (EC) for Resident #7 stated she was notified of the incident that occurred between Resident #7 and Resident #14 on 6/1/2024. The EC was updated right away after the incident. The EC stated she was updated on the room change and agreed with that change. During an interview on 6/18/2024 at 1:10 PM, the Administrator stated she was out of the facility on 6/1/2024. The Administrator stated she went to the facility as soon as she could. The Administrator stated she was told there was a resident to resident altercation caused by Resident #14 thinking Resident #7 stole her clothes. The Administrator stated she was told Resident #14 hit Resident #7 multiple times in left arm. Staff told the Administrator they separated the residents immediately, the residents were sent to the ER for evaluation, and the DON, Manager on Duty, 911, police and families were notified of the incident. The Administrator stated Resident #14 hitting Resident #7 was considered abuse, and the bruises Resident #7 received from Resident #14 were considered harm. Review of the medical record revealed Resident #3 was admitted to facility on 1/8/2024 with diagnoses including Cerebral Infarction, Hemiplegia and Hemiparesis and Bipolar Disorder. Review of a quarterly MDS assessment dated [DATE], revealed Resident #3 scored a 00 on the BIMS assessment which indicated severe cognitive impairment. The resident had verbal behavioral symptoms directed towards others on 1-3 days of the 7 day look back period and had no pain. Review of the physician's orders for Resident #3 dated 4/24/2024, revealed .Divalproex Sodium [a mental health medication for mood] Oral Tablet Delayed Release 125 MG .by mouth three times a day for mood stabilizer .Quetiapine Fumarate [an antipsychotic medication] .Oral Tablet 50 MG .by mouth two times a day for behaviors . During an observation and interview on 6/17/2024 at 1:05 PM, in Resident #3's room, the resident was dressed in a wheelchair, and stated he didn't remember anyone hitting him or trying to hit him. When asked other questions about his care, he stated .I don't know I don't know anything . Review of a Psychotherapy Progress Note for Resident #3 dated 5/24/2024, revealed .Pt [patient or resident] denied feeling overly sad or anxious. Pt was alert, coherent but minimally engaged. No perceptual disturbances observed .Pt seems stable .he is satisfied with the care here .No recommendations at this time . Review of the facility's investigation documentation for Resident #3 dated 6/13/2024, revealed a resident to resident altercation happened when Resident #3 was .trying to come into courtyard door to dining room .[Resident #12] .attempting to get out to courtyard .[Resident #3] didn't move to let the other resident out .[Resident #12] began yelling incoherently and open hand slapping .residents were separated and taken for assessment . The FNP, family and law enforcement were notified. Review of a Nurse's Progress Note for Resident #3 dated 6/13/2024, revealed .this resident involved in incident with another resident. family and physician notified .initial report submitted. Investigation initiated. Witness statements taken. Final investigative report will be submitted .within five days. Skin and emotional assessments initiated . Review of a Nurse's Progress Note for Resident #3 dated 6/13/2024, revealed .nurse performed skin assessment after resident involved in altercation with another resident. No bruising or impaired areas identified at this time . Review of facility documentation of Resident #3's witness statement dated 6/13/2024, revealed DON and Risk Manager interviewed resident about an altercation. Resident #3 nodded he was OK, when asked if it was a fight, Resident stated no, [expletive] The resident stated he wasn't hurt, he felt safe and he didn't hit first. He showed an open hand when asked how he was hit. Review of a Comprehensive Care Plan dated 6/14/2024, revealed .[Resident #3] have little or no awareness or boundaries related to other's personal space/preferences . with intervention of .Staff will redirect [Resident #3] when he is attempting to redirect other residents . Review of an FNP Progress Note for Resident #3 dated 6/14/2024, revealed .[Resident #3] was involved in an altercation with another resident [Resident #12] and nursing staff is requesting evaluation .He is wheelchair-bound. Yesterday [6/13/2024] another resident [Resident #12] was trying to exit a door into the Courtyard when he [Resident #3] tried to stop the resident .[Resident #12] slapped at him .Nursing staff report no injuries. Nursing staff intervened. He reports nothing happened yesterday and that he does not remember any incident . Review of a Pyschiatric (Psych) NP Progress Note for Resident #3 dated 6/14/2024, revealed .I am seeing the resident today as an initial visit for unspecified mood disorder. Staff request visit with resident after recent resident to resident altercation .He is able to answer some simple questions appropriately but does show some confusion with conversation. Staff reports that this resident [Resident #3] and another resident [Resident #12] were both attempting to go out of the door at the same time during scheduled smoke time . Resident reports that he feels safe and that staff treats him well. No known triggers to behaviors or modifying factors . Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Hypokalemia and Spinal Stenosis. Review of a quarterly MDS assessment dated [DATE], revealed Resident #12 scored a 4 on the BIMS assessment which indicated the resident had severe cognitive impairment, and the resident had no behaviors. The resident had no impairment to upper or lower extremities and ambulated with a wheelchair. Review of a comprehensive care plan for Resident #12 revised 6/13/2024, revealed the resident had .Behavior Care Plan: Potential for impaired or inappropriate behaviors . refuses to discard chewing tobacco when asked .places used chewing tobacco in brief to be chewed later .[Resident #12] smacking at another resident [Resident #3] that was trying to prevent [Resident #12] from exiting the building to go into the courtyard . with intervention of .Intervene as necessary to protect the rights and safety of others .Divert attention. Remove from situation and take to alternative location as needed . Review of the facility's documentation for Resident #12 dated 6/13/2024, revealed a resident to resident altercation when Resident #3 was attempting to get out of dining room door into the courtyard and did not redirect to let another [Resident #3] in the door. .[Resident #12] became agitated started yelling incoherently and open hand slapping the other resident [Resident #3] .residents were separated and taken to different areas. At the time of interview, he had no recollection of the event . Resident #12 was assessed and no injuries were noted . The FNP, family and law enforcement were notified. Review of a Nurse's Progress Note for Resident #12 dated 6/13/2024, revealed .skin and emotional assessments initiated . Review of Head to Toe Weekly skin check for Resident #12 dated 6/13/2024, revealed the resident had clear skin with no skin impairment. Review of a Psych NP Progress Note for Resident #12 dated 6/18/2024, revealed .Resident does not recall altercation .reports that he feels safe .at the facility . Review of facility's investigation and reporting documentation dated 6/13/2024, revealed .the allegation was reported to the resident representative .both resident's [residents'] family members were notified .[Resident #3] indicated that he recalled the incident .he was trying to come in from the courtyard when [Resident #12] hurried towards him .attempt to get outside .[Resident #12] started yelling .opened hand slapping [Resident #3], who started yelling .Summary of interviews .perpetrator, [Resident #12] fluctuates with cognition. Upon interview, he was unaware that anything had occurred .allegation is verified by evidence collected during the investigation .employees receive routine training on abuse prohibition policy .Submitted by .[Administrator] . Review of a police document showed report #24061317494 was investigated by an officer on 6/13/2024. Review of Tennessee Adult Protective Services submission report dated 6/13/2024 showed incident was reported at 3:13 PM. Review of facility documentation of the Dietary Director's witness statement dated 6/13/2024, revealed the Dietary Director walked out of the kitchen and saw Resident #12 trying to get into the courtyard through the door. She redirected the resident and left the room, but she heard yelling as soon as she turned the corner into the hall. She went back in and saw the 2 residents throwing punches. The residents were separated. Review of facility documentation of CNA D's witness statement dated 6/13/2024, revealed the CNA was in the dining room returning trays and witnessed Resident #12 fighting with Resident #3 in the courtyard doorway. The CNA rushed to separate the residents, and the Dietary Manager went to get the DON. During an interview on 6/17/2024 at 1:43 PM, the Dietary Director stated on the day of the resident to resident altercation, she had walked into the dining room and Resident #12 was trying to go out the door, and the Director told him to come back in so another resident could get in. She left the room and heard screaming. The Dietary Director came back into the dining room and saw the back of Resident #12 and arm motions only. She stated she saw CNA D was separating Residents #12 and #3. She stated she gave an eye witness account to the facility's management. During an interview on 6/17/2024 at 2:40 PM, CNA D stated she was bringing trays back to the dining room on 6/13/2024 after lunch when she noticed Residents #12 and #3 were having an altercation at the courtyard door of the dining room. The CNA stated she saw Resident #12 swing first and then closed fist punches were being thrown with hands, wrists and lower forearms getting hit. She did not know what was said to start the event. The CNA stated she pulled Resident #12 away from Resident #3, and the Dietary Manager went to get the DON. The CNA stated the event was resident to resident abuse. The CNA stated she took Resident #12 to his room. The CNA stated she noticed no new aggression or fear. During an interview on 6/17/2024 at 3:02 PM, Resident #27, who was cognitively intact, stated he witnessed the resident to resident altercation on 6/13/2024, and stated Resident #12 started the resident to resident altercation and was trying to go out the door to the courtyard in the dining room. He stated .[Resident #3] tried to stop [Resident #12] from going out the door, because he knew he shouldn't be out there .[Resident #12] started swinging and [Resident #3] had his hands up trying to protect himself . During a telephone interview on 6/17/2024 at 7:50 PM, Resident #3's representative stated she was informed of a resident to resident altercation involving her son (Resident #3) on 6/13/2024. The representative stated she was on her way to the facility when the staff called her to notify her of the incident, and she arrived not long after it happened. She stated when she arrived, Resident #3 didn't even remember the event and he did not show any signs of fear or distress. During an interview on 6/17/2024 at 10:09 AM, the DON stated she was made aware of the resident to resident altercation after it occurred at about 1:12 PM, and the residents had already been separated. The staff began interviewing residents that had witnessed the event. She stated staff and residents involved were interviewed, and nurses caring for the involved residents did skin checks on those residents. That was the beginning of the investigation. The staff did psychosocial assessments on residents who were interviewed to make sure they felt safe. The DON stated Psych and medical NPs, risk manager and families were made aware of the incident, and reports were made to State, APS, police and Ombudsman, which was standard for every resident to resident altercation. The DON was told there was physical contact. The DON confirmed that the incident on 6/13/2024 between Residents #3 and #12 was resident to resident abuse. During an interview on 6/18/2024 at 11:00 AM, the FNP stated when there was an abuse allegation, she would assess the resident the next time she was in the building. The FNP stated the altercation between Residents #3 and #12 happened on 6/13/2024, and she assessed both residents the next day, and she did not note any physical or psychosocial harm or injury to either resident. During an interview on 6/18/2024 at 1:33 PM, the Administrator stated she was on a call at about 1:00 PM on 6/13/2024 and was made aware that a resident to resident altercation had taken place. The residents were separated immediately, and staff began skin and emotional assessments. The families of Residents #3 and #12 and the physician were notified, and no injuries or psychosocial harm were noted in either resident. She stated Resident #12 was the resident who struck out first based on witnesses. The Administrator confirmed it was resident to resident abuse.

Based on facility policy review, observations, and interviews, the facility failed to provide a homelike environment as evidenced by failing to repair areas of chipped paint in 3 of 54 resident rooms (Rooms #221, #225, and #226) and in 3 of 4 hallways, failing to repair holes to trim boards for 3 of 54 resident rooms (Rooms #123, #220, #225) and in 2 of 4 hallways, failing to repair cracks in the caulking around the heating and air units in 2 of 54 resident rooms (Rooms #219 and #224), and failing to replace the plastic door protector to the entry door of 3 of 54 resident rooms (Rooms #126, #219, and #222) observed. The findings include: Review of the facility's undated policy titled, Resident Environmental Quality, showed .It is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe .sanitary .comfortable environment for the residents . Resident #58 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Hemiplegia and Hemiparesis, Lack of Coordination and Anxiety Disorder. Review of a care plan dated 8/15/2022 showed Resident #58 had an activities of daily living self-care deficit and needed assistance of 1 staff member for personal hygiene. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #58 was cognitively intact and had upper and lower extremity impairment on one side. During an observation on 1/2/2024 at 12:21 PM, in Resident #58's room, the resident was resting on a regular mattress with no sheets on her bed. During an observation and interview on 1/4/2024 at 7:25 AM, Licensed Practical Nurse (LPN) #1 stated Resident #58 didn't have a set of sheets, including a fitted sheet, on her bed. The LPN confirmed the mattress was a regular mattress and didn't have sheets on it. During an observation on 1/5/2024 at 10:06 AM, a clean linen cart was observed in the hall adjacent to Resident #58's room which contained multiple sets of clean linen. During an observation and interview on 1/5/2024 at 10:07 AM, in Resident #58's room, Certified Nursing Assistant (CNA) #1 confirmed there were no sheets on the resident's bed. During an interview on 1/5/2024 at 10:10 AM, in Resident #58's room, the resident stated she wanted sheets on her bed. During an interview on 1/5/2024 at 10:11 AM, the Director of Nursing (DON) stated it was her expectation that to maintain a homelike environment, a resident would have sheets on their bed if they preferred. The DON confirmed it was not a homelike environment for Resident #58 to not have sheets on her bed. During multiple observations on 1/2/2024 from 10:00 AM to 1:38 PM, rooms [ROOM NUMBER] were observed with chips in the paint of various sizes in multiple areas on the walls. During multiple observations on 1/2/2024 from 10:00 AM to 1:38 PM, rooms [ROOM NUMBER] had impairments in the trim boards ranging in size from dime sized to golf ball sized. During multiple observations on 1/2/2024 from 10:00 AM to 1:38 PM, rooms [ROOM NUMBERS] had cracks of various sizes and other impairments to the caulking around the heating and air unit. During multiple observations on 1/2/2024 from 10:00 AM to 1:38 PM, rooms [ROOM NUMBER] had holes of various sizes in multiple areas to the plastic door protector of the entry door. During multiple observations on 1/2/2024 from 10:00 AM to 1:38 PM, on 3 of 4 hallways (Little [NAME] River, Greenbrier, and Wears Valley) needed repairs to the chipped paint present in multiple areas on the walls. During multiple observations on 1/2/2024 from 10:00 AM to 1:38 PM, on 2 of 4 hallways (Little [NAME] River and Greenbrier), the red, adhesive tape placed on the floor was missing in multiple places, and a black dirt-like substance had adhered to the residual adhesive on the floor. During multiple observations on 1/2/2024 from 10:00 AM to 1:38 PM, on 2 of 4 hallways (Little [NAME] River and Wears Valley), the shower room doorway had black scuff marks to the perimeter of the door, holes of various sizes in multiple areas of the trim boards, and areas of chipped paint. During an interview on 1/5/2024 at 9:40 AM, the Maintenance Director (MD) confirmed 3 of 4 hallways needed to have the chipped paint with damaged trim boards repaired, and 2 of 4 hallways needed to have the red, adhesive tape removed from the floor. During an interview on 1/5/2024 at 9:45 AM, the MD confirmed rooms [ROOM NUMBERS] needed the caulking to the heating and air unit repaired, rooms 221, 225,and 226 needed multiple areas of chipped paint repaired, rooms [ROOM NUMBER] needed the plastic door protector replaced to the entry door, and rooms [ROOM NUMBERS] needed the impairments to the trim boards repaired. The MD further confirmed the facility failed to ensure the facility provided a homelike environment.

Based on facility policy review, medical record review, and interviews, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (Resident #2) of 18 residents reviewed for MDS assessments. The findings include: Review of the facility's undated policy titled, Comprehensive MDS Assessments Policy, showed .To provide guidance to conduct initially .comprehensive .accurate .standardized assessment .resident's functional capacity . Resident #2 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Diabetes Mellitus, and Encounter for Palliative Care. Review of the Physician's Orders dated 10/27/2023, showed Resident #2's indwelling urinary catheter was discontinued on 10/27/2023. Review of Resident #2's comprehensive care plan dated 12/4/2023, showed .MIXED bladder incontinence related to disease process .The resident will remain free from skin breakdown due to incontinence and brief use through the review date .Clean peri-area with each incontinence episode . Review of a quarterly MDS assessment dated [DATE] showed Resident #2 had an indwelling urinary catheter. During an observation on 1/3/2024 at 10:30AM, Resident #2 did not have an indwelling urinary catheter present. During an interview on 1/4/2024 at 8:30 AM, Registered Nurse #1 confirmed Resident #2 did not have a urinary indwelling catheter. During an interview on 1/5/2024 at 8:05 AM, the Director of Nursing (DON) confirmed Resident #2 did not have an indwelling urinary catheter, and the MDS assessment dated [DATE] was not accurate.

Based on facility policy, review of a facility document, medical record review, and interviews, the facility failed to ensure that residents acknowledged having, were educated on or offered information regarding advance directives for 7 residents (Residents #47, #7, #13, #18, #27 and #33) of 24 residents reviewed for advance directives. The findings include: Review of the facility policy titled, Advance Directives, dated 9/2022, showed .the resident has a right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy .If the Resident does not have an Advance Directive .facility staff will offer assistance in establishing advance directives .resident or representative is given the option to accept or decline assistance .Nursing staff will document in the medical record the offer to assist and the residents' decision to accept or decline assistance .Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff . Review of a facility document titled Advance Directive Education/Acknowledgment showed .Advance Directive Acknowledgement: Please read the following five statements and place your initials after each statement to indicate confirmation of understanding of each statement. 1. I have been given written materials about my right to accept or refuse medical treatments. 2. I have been informed of my rights to formulate Advance Directives. 3. I understand that I am not required to have an Advance Directive in order to receive medical treatment at this Facility. 4. I understand that the terms of any Advance Directive that I have executed will be followed by the Facility and my caregivers to the extent permitted by law. 5. I acknowledge that it is the Resident's responsibility to provide the Facility with copies of the Advance Directives for incorporation into the Resident's medical record if I have executive an Advance Directive. Please check one of the following statements: I have executed an Advance Directive .I have not executed an Advance Directive . Resident #47 was admitted to the facility on [DATE] with diagnoses including Functional Quadriplegia, Adult Failure to Thrive, Difficulty Walking, and Unspecified Dementia. Review of Resident #47's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. Review of Resident #47's Advance Directive Education/Acknowledgment form dated 7/6/2023 showed the resident did not have an advance directive, and the form had no documentation that education had been offered or provided to assist in completing an advance directive for the resident. Resident #7 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus Type 2 with Diabetic Polyneuropathy, Bipolar Disorder, Schizoaffective Disorder, Personal History of Transient Ischemic Attack, and Unsteadiness on Feet. Review of Resident #7's quarterly MDS assessment dated [DATE] showed the resident was cognitively intact. Review of the medical record revealed Resident #7 did not have a Advance Directive/Education/Acknowledgment form in the record. During an interview on 1/5/2024 at 10:00 AM the Admissions Director confirmed Residents #47 and #7 did not have a completed Advance Directive Education/Acknowledgment form in their medical records. During an interview on 1/5/2024 at 10:10 AM, the Director of Nursing (DON) confirmed she would have expected the Advance Directive Education/Acknowledgment form to be completed upon admission and placed in the residents medical record. 45837 Resident #13 was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy, Dementia and Respiratory Conditions Due to Smoke Inhalation. Review of a significant change MDS assessment dated [DATE] showed Resident #13 had severe cognitive impairment and received hospice care. Review of the Advance Directive Acknowledgement form dated 11/19/2021 showed a blank form, except for the signature of Resident #13's representative, on the signature page. Resident #18 was admitted to the facility on [DATE] and had diagnoses including Anoxic Brain Injury, History of Falling, and Major Depressive Disorder. Review of a quarterly MDS assessment dated [DATE] showed Resident #18 was rarely or never understood and had short- and long-term memory problems. Review of a undated Financial Record Checklist for Resident #18 showed, under the Social Services section, an unchecked box beside Advance Directive. Review of Resident #18's medical record showed no documentation of the Advance Directive Education/Acknowledgment form. Resident #27 was admitted to the facility on [DATE] with diagnoses including Quadriplegia, Dependance on Supplemental Oxygen, and Hyperlipidemia. Review of a quarterly MDS assessment dated [DATE] showed Resident #27 was cognitively intact. Review of an Advance Directive Acknowledgement form showed no documentation that Resident #27 had been educated or informed of her rights to formulate an Advance Directive. Resident #33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Unspecified Fracture of Right Femur, Type 2 Diabetes Mellitus, and Functional Quadriplegia. Review of a quarterly MDS assessment dated [DATE] showed Resident #33 was cognitively intact. Review of the medical record showed no documentation that Resident #33 had been educated on or informed of her rights to formulate an Advance Directive. During an interview on 1/3/2024 at 3:24 PM, the Social Services Coordinator stated the documents for Residents #13, #18, #27 and #33 were not complete and did not document that education or acknowledgement was done and confirmed the facility did not have documentation that education had been offered to or that advance directives were executed by Residents #13, #18, #27 and #33.

Based on Centers for Disease Control and Prevention (CDC) guidance, facility policy review, observation and interview, the facility failed to ensure expired supplies were not available for resident use in 1 of 4 medication carts observed and failed to ensure staff members performed self-testing for COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) according to current guidance for 1 of 1 self-testing observations, which had the potential to result in transmission of COVID-19. The findings include: Review of the CDC guidance titled, COVID-19 Performing Broad-Based Testing for SARS-CoV-2 in Congregate Settings, dated [DATE], showed .For indoor specimen collection activities, designate separate spaces for each specimen collection testing station, either rooms with doors that close fully or protected spaces removed from other stations by distance and physical barriers, such as privacy curtains and plexiglass .To prevent inducing coughing/sneezing in an environment where multiple people are present and could be exposed, avoid collecting specimens in open-style housing spaces with current residents or in multi-use areas where other activities are occurring . Review of the facility's policy, titled Novel Coronavirus (COVID-19), reviewed on [DATE], showed .POLICY .To provide guidance on the novel Coronavirus (COVID-19) so that facilities may protect, to the extent possible, the health safety, and well-being of all residents and Stakeholders .CDC and CMS guidance should be followed for testing and management of COVID-19 during an outbreak . Review of the facility's undated policy titled, COVID-19 GENERAL TESTING POLICY, showed .Covid-testing will be done in a manner to prevent spread of infection .Broad-based approach .will be used if the facility is unable to conduct contact tracing or contacts cannot be identified . During an observation and interview on [DATE] at 10:57 AM, at the Mountain Nurses' Station, Dietary Aide #1 and Cook #1 performed a self-test for COVID-19. Two other staff members and 1 resident were at the nurses' station within 6 feet of where Dietary Aide #1 and Cook #1 performed the self-test for COVID-19. Dietary Aide #1 and Cook #1 stated they had performed the self-test for COVID-19, because the facility was in COVID-19 outbreak status due to a positive employee and testing for COVID-19 was always performed at the nurses' station. During an observation and interview [DATE] 11:08 AM, of the Mountain Front Med Cart with Registered Nurse (RN) #1 there was (1) 22 gauge 1 inch Intravenous (IV) needle with an expiration date of [DATE], (1) 22 gauge 1 inch IV needle with an expiration date of [DATE], (3) 24 gauge .75 inch IV needles with an expiration date of [DATE], and (1) 22 gauge 1 inch IV needle with an expiration date of [DATE]. RN #1 confirmed the IV needles were expired and available for resident use. During an interview on [DATE] at 11:31 AM, the Director of Nursing (DON)/Infection Preventionist (IP) stated the facility was in outbreak status due to a COVID-19 positive employee on [DATE] and outbreak testing was being performed for all staff and residents. The DON/IP stated it was her expectation that COVID-19 testing was performed in an enclosed area away from others, such as the break room. The DON/IP confirmed appropriate infection control practices were not maintained. Continued interview with the DON/IP revealed it was her expectation that supplies were checked for expiration .at least weekly . and expired supplies were to be discarded and not available for resident use. Review of the Results Verification for SARS-COV-2 (COVID-19) results for Cook #1 dated [DATE], showed a negative test. Review of the Results Verification for SARS-COV2 (COVID-19) results for Dietary Aide #1 dated [DATE], showed a negative test. During an interview on [DATE] 9:01 AM, the Administrator stated there was no policy for expired supplies. The Administrator confirmed it was her expectation that expired supplies were discarded and not available for resident use. During an interview on [DATE] at 1:47 PM, the [NAME] President of Regulatory Compliance stated it was the expectation of the facility that COVID-19 testing was performed according to CDC recommendations. The [NAME] President of Regulatory Compliance confirmed appropriate infection control practices were not maintained when 2 staff members performed COVID-19 self-tests at the nurses' station with other staff and residents around. The break room had been designated as the employee COVID-19 testing location as of [DATE]. Dietary Aide #1 and Cook #1 tested negative for COVID-19 on [DATE] and had been assessed for COVID-19 self-test collection competency.

Based on facility policy review, medical record review, and interviews, the facility failed to maintain an accurate medical record for 1 resident (Resident #43) of 18 residents reviewed for medical records. The findings include: Review of the facility's policy titled, Medical Record, dated 2/2023, .licensed staff .shall document all assessments .in the resident's medical record . Resident #43 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including End Stage Renal Disease, Dysphagia, Dependence on Renal Dialysis, Anemia, Functional Quadriplegia, and Congestive Heart Failure. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored a15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact, and received dialysis. Review of Physician's Orders dated 6/13/2023, showed Dialysis .M-W-F [Monday, Wednesday, Friday] . Check Bruit and Thrill of AV [Arteriovenous] Shunt [surgical joining of an artery and a vein under the skin to create a hemodialysis access port] Shunt .report any negative findings .Monitor dialysis shunt site for bleeding .Check Vital Signs pre-dialysis .Check Vital Signs post-dialysis .Check access for bleeding, redness, tenderness, and swelling .notify MD [Medical Doctor] of abnormal findings as indicated .Do Not take BP [blood pressure] or Draw labs in extremity with dialysis access site .Fluid restriction 1500 ml (milliliters, a unit of measure)/24 hours. During an interview on 1/4/2024 at 10:30 AM, Resident #43 stated that staff assessed him before and after dialysis sessions including his shunt area and vital signs. Review of the medical record showed the Dialysis Handoff Communication Form was incomplete on 10/20/2023, 10/23/2023, 10/27/2023, 11/13/2023, 11/17/2023, 12/1/2023, 12/6/2023, 12/8/2023, 12/13/2023, 12/18/2023, 1/1/2024, and 1/3/2024. During an interview on 1/4/2024 at 8:25 AM, Licensed Practical Nurse #1 stated that Dialysis Handoff Communication Form is completed with each dialysis visit. During an interview on 1/5/2024 at 8:05 AM, the Director of Nursing (DON) stated the Dialysis Handoff Communication Form should be completed each time the resident received dialysis. The DON confirmed the Dialysis Handoff Communication Form was missing information for the stated dates.

Based on medical record review and interview, the facility failed to resubmit a Pre-Admission Screening and Resident Review (PASRR) for new diagnoses to the state-designated authority for 1 resident (Resident #18) of 4 residents reviewed for PASRR. The findings include: Resident #18 was admitted to the facility on [DATE] and had diagnoses including Major Depressive Disorder dated 8/1/2021, Anxiety Disorder dated 8/1/2021 and Bipolar Disorder dated 8/1/2021. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #18 was rarely or never understood and had short- and long-term memory problems. The resident had diagnoses of Anxiety, Depression and Bipolar Disorder. Review of a PASRR level I for Resident #18, dated 12/22/2022, showed no mental health diagnoses known or suspected. During an interview on 1/3/2024 at 3:34 PM, the MDS Coordinator stated when quarterly assessments were done, or when there are any new medication or diagnoses, the PASRR was checked again for accuracy, and the PASRR would be updated if needed. Resident #18 had diagnoses of Bipolar Disorder, Major Depressive Disorder and Anxiety Disorder present and not reflected on the PASRR. The MDS Coordinator confirmed a new PASRR was not submitted with the existing mental diagnoses.

35200 Based on review of the facility policy, medical record review, and interview the facility failed to implement an effective discharge planning process to ensure a safe and effective discharge for 3 residents (Residents #11, #25, and #32) of 13 residents reviewed for transfer/discharge requirements which resulted in Resident #11 being hospitalized 12 days after discharge from the facility for altered mental status including hallucinations, worsening confusion, and inability to ambulate; Resident #25 being hospitalized 4 days after discharge from the facility for Purulent Cellulitis, Infection of Pressure Ulcer, and Osteomyelitis, and Resident #32 being discharged home without home health services arranged. The facility's failure resulted in Resident #11, a cognitively impaired resident with multiple medical and psychological conditions and limited family/social support being discharged to an unsupervised home without notice or immediate discharge instructions and Resident #25, who had a Left Below Knee Amputation, Cellulitis of Left Lower Limb (Amputated Stump), Pressure Ulcer of Stump, and Type 2 Diabetes being discharged home without adequate dressing supplies, wound care instructions, a home health wound care provider or therapy arranged. The facility's failure placed Resident #11 and Resident #25 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). Administrator #2 was notified of the Immediate Jeopardy on 1/12/2023 at 7:38 PM in the Administrator's office. The IJ was effective on 12/8/2022 and is ongoing. The findings include: Review of the facility's policy titled, Transfer or Discharge Notice, revised on 12/2016 showed .The resident and/or representative (sponsor) will be notified in writing of the following information .The reason for the .discharge .The effective date of the .discharge .The location to which the resident is being .discharged .The reasons for the transfer or discharge will be documented in the resident's medical record . Review of the facility policy, titled Discharge Summary revised 11/8/2022 showed .The discharge summary provides necessary information to continuing care providers pertaining to the course of treatment while the resident was in the facility and the resident's plans for care after discharge .A discharge summary must include an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions, to ensure that care is coordinated and the resident transitions safely from one setting to another .A discharge summary may help reduce or eliminate confusion among the various facilities, agencies, practitioners, and caregivers involved with the resident's care .In case of discharge to a non-institutional setting such as the resident's home, provision of a discharge summary, with the resident's consent, to the resident's community-based physicians/practitioners allows the resident to receive continuous and coordinated, person centered care .Content of the Discharge Summary Recapitulation of Resident's Stay [concise summary of the resident's stay] .Recapitulation of the resident's stay describes the resident's course of treatment while residing in the facility .The recapitulation includes, but is not limited to, diagnoses, course of illness, treatment, and/or therapy, and pertinent lab, radiology, and consultant results, including any pending lab results . Review of facility policy, Transfer or Discharge, Preparing a Resident for revised date 12/2016, showed Resident will be prepared for discharge. 1. When a resident is scheduled for transfer or discharge, Social Services Director will work with the nursing services on the transfer or discharge so that appropriate procedures can be implemented. 2. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. The plan will be reviewed with the resident, and/or his or her family before the resident's discharge or transfer from the facility. 3. Nursing services is responsible for: a. obtaining orders for discharge or transfer; b. preparing the discharge summary; c. preparing the medications to be discharged with the resident (as permitted by law); d. packing and collecting personal possessions (if the resident is not expected to return); e. assisting with transportation as applicable; f. completing discharge note in the medical record; 4. Social Services (may have assistance from Business Office) is responsible for: a. Discharge planning b. assisting with post discharge needs such as arranging for equipment needed after discharge, assisting with Home Health is ordered . Resident #11 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, Dementia with Behavioral Disturbance, and Major Depressive Disorder with Psychotic Symptoms. Review of Resident #11's History and Physical dated 5/24/2022 showed 77 yo [year old] diabetic .with dementia .ADVANCED CARE PLANNING .The patient has been deemed incompetent to make decisions on their behalf due to advanced dementia . Review of Resident #11's admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #11 was rarely/never understood, had short- and long-term memory problems, and had moderately impaired cognitive skills for daily decision making. The resident exhibited daily physical and verbal behavioral symptoms, rejection of care, and wandering behaviors. Resident #11 required limited assistance of 1 staff member for transfers, walking in room and corridor, dressing, and personal hygiene. Resident #11 required extensive assistance of 1 staff member for toilet use and locomotion off the unit and supervision with set up assistance for eating. The resident had unsteady balance during transitions and walking and required mobility devices including walker and wheelchair. Resident #11 was always incontinent of urine and bowel. Resident #11 and Resident #11's family representative expected Resident #11 to remain in the facility. Review of Resident #11's Care Plan dated 6/7/2022 showed Resident #11 .has impaired cognitive function/dementia or impaired thought processes r/t [related to] Dementia . The care plan did not reflect a discharge plan was in place for Resident #11. Review of Resident # 11's care plan conference summary dated 8/25/2022 showed DON [Director of Nursing] spoke [Responsible Family Representative] today regarding resident's discharge vs [versus] LTC [long term care] .he agreeable to keep in house and keep comfortable for now .agreed to set some goals for her to achieve before he could take her home . Review of a Social Service Quarterly Note dated 11/25/2022, showed .resident [#11] is long term care with no current discharge plans .she is severely impaired for decision skills, scoring 7/15 [score of 7 out of 15 indicates severe cognitive impairment] on BIMS [Brief Interview for Mental Status] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #11 had a BIMS score of 7 indicating severe cognitive impairment. Resident #11 required extensive assistance of 2 staff members for personal hygiene and extensive assistance of 1 staff member for dressing and toilet use. The resident required limited assistance of 1 staff member for bed mobility and supervision of 1 staff member for transfers, eating, and ambulation. Resident #11 was always incontinent of bladder and bowel. Continued review of the MDS for the Discharge Plan showed there was no active discharge planning. Review of the Care Plan Conference Summary dated 12/1/2022, showed Resident #11's responsible family representative attended a care plan meeting to discuss .home vs [versus] long term care . It was noted .Care plan meeting completed this day .[Responsible Family Representative] .said he is responsible for 15 y/o [year old] son of [Resident #11's daughter] and that he has to work outside of the home. He would need a caregiver for some time [if Resident #11 discharged home]. Can revisit [discharge planning] when [Resident #11's daughter] gets out of jail . Review of the Care Plan conference summary dated 12/1/2022 showed the Responsible Family Representative wasn't able to provide the care needed at home for Resident #11. The facility documentation of the care plan meeting on 12/1/2022 did not reflect there any discharge plans for a specific target date. Review of a Psychiatric Progress note for Resident #11 dated 12/5/2022 showed .Hospice Patient .Dementia .FTT [failure to thrive] seeing this resident today for treatment of dementia depression and insomnia .is awake she is alert she is oriented to herself and somewhat situation .she continues to have the delusion that she will soon be going home . Review of a Skilled Nursing note for Resident #11 dated 12/7/2022 at 9:39 AM, showed .Residents' attention span is short .is Disoriented/confused .has impaired decision-making ability .Unsteady Gait . Review of a Nurse Practitioner's (NP) note dated 12/8/2022 showed .discharging home under hospice with family today .Discussed all discharge instructions and medications with [Resident #11] and family member at bedside. Voice no questions and have no concerns at this time. Copy of discharge packet will be given at time of departure .Hospice aware of discharge today . (Interview with NP on 1/10/2023 below in the narrative shows the NP stated that this documentation was made in error, and she had not educated the responsible family representative on discharge instructions or medications). Medical record review showed this was the first documentation of a planned discharge from the facility for Resident #11. Review of the Resident Discharge instruction form dated 12/8/2022, showed there was no discharge time or transportation arrangements documented. A handwritten note on the discharge document showed .to [name of Responsible Family Representative] and/or Hospice Nurse . Review of the document showed it did not contain relevant resident specific information for discharge such as behaviors, ambulation, bladder, bowel, feeding, usual level of functioning, date, and time of transfer/discharge, transfer/discharged to, and any personal effects sent home with the resident. On the top of the document there was a handwritten note from the Nurse Practitioner that stated .Give to [Resident #11's Responsible Family Representative] and/or Hospice Nurse . Continued review showed a list of the resident's medications while at the facility, but it did not include any instructions to continue or discontinue the medications or the date and time the medications were last administered. Review of a Master of Social Work (MSW) Hospice note dated 12/7/2022 at 7:29 PM, showed .[Hospice] MSW VISITED WITH PT [patient - Resident #11] .FACILITY NURSE .REPORTED THAT PT [Resident #11] IS ACTUALLY GOING HOME NEXT WEEK. [Hospice] MSW WAS UNAWARE OF PLAN .DURING PARTNERSHIP MEETING WITH [facility Social Worker], SHE CONFIRMED THAT PT IS BEING DRIVEN TO HER HOME .BY [facility] STAFF .POLICE WILL BE NOTIFIED IF [Responsible Family Representative] WILL NOT LET HER IN (AS HOME BELONGS TO PT) .PT NO LONGER MEETS CRITERIA TO STAY IN FACILITY DESPITE FACT SHE IS ON HOSPICE .WILL NOTIFY MORRISTOWN OFFICE OF PT'S RETURN TO THEIR SERVICE AREA . Review of a Hospice Master of Social Worker (MSW) note dated 12/9/2022, showed .CALLED [Resident #11's Responsible Family Representative] .PATIENT [Resident #11] HAS BEEN IN A NURSING HOME IN [name of town] .HE REPORTS THAT THE NURSING HOME SENT HER [Resident #11] HOME AND THERE WAS NOBODY THERE .THE POLICE WAS CALLED .HE DISCUSSED HOW HE CANNOT TAKE CARE OF HER AND HER DAUGHTER IS IN JAIL. HE REPORTS IT'LL BE ANOTHER MONTH OR TWO MAYBE LONGER BEFORE SHE [Resident #11's daughter] GETS OUT THAT SHE [Resident #11] NEEDS TO GO TO THE FACILITY FOR LONG-TERM CARE .STATES THAT SHE CANNOT STAY THERE BY HERSELF HE WORKS AND THERE'S NO WAY HE CAN HAVE SOMEBODY THERE 24/7 . Review of a Hospice Nurse note dated 12/9/2022 showed .REQUESTED BY CG [Care Giver] REGARDING TRANSFER FROM SNF [skilled nursing facility] .PT [Resident #11] WAS RELEASED FROM SNF [Skilled Nursing Facility] WITH NO NEW SCRIPTS [prescriptions] OR ORDERS TO CONTINUE MEDICATIONS .SN [Skilled Nurse] NOTIFIED [pharmacy] .OF REQUIRED SCRIPTS. NEW ORDER OBTAINED FOR LORTAB [narcotic pain medication] .Q6H [every 6 hours] .PATIENT A/O X2 [alert and oriented times 2 - to person and place] WITH SOME CONFUSION/FORGETFULNESS .UNABLE TO PROVIDE DAY OF WEEK AND CURRENT MONTH WITH OUT PROMPTING .PT IS FRAIL, 02 [oxygen] DEPENDENT .CAN AMBULATE WITH USE OF WALKER AND REQUIRES STANDBY ASSIST .OCCASIONAL EPISODES OF INCONTINENCE .NO SUPPLIES IN THE HOME . Review of a Hospice Nursing note dated 12/20/2022 showed .CG NOTIFIED ON CALL [Hospice Agency Staff] REGARDING CHANGE IN PATIENT'S [Resident #11] STATUS. HE REPORTED INCREASED ANXIETY AND CONFUSION .UPON ARRIVAL TO HOME .PATIENT LOOKED CONFUSED AND UNABLE TO ANSWER .PATIENT WAS CONFUSED INABLE TO FOLLOW COMMAND .SUSPECTED UTI [urinary tract infection] .ORDERED MACROBID [medication used to treat infection] . Review of the hospital Emergency documentation dated 12/20/2022, showed .[Resident #11] admitted for Altered Mental Status, Acute on Chronic alteration in mental status .Encounter for home safety review for injury prevention .Pt [patient] was discharged from nursing home 8 days ago [12 days] .POA [Power of Attorney] unable to care for her at home he is employed full-time, so patient is often home alone . Resident #11 had been hallucinating, had confusion, and had been unable to ambulate to the bathroom. Her speech was garbled, and she thought it was the 1800's. Review of hospital Admission History and Physical Report dated 12/20/2022, showed [Resident #11] Released from nursing home 1 week ago [12 days]. Hallucinating confused unable to ambulate to bathroom since 1 am today. Speech garbled thinks it is late 1800's . she had been increasing wandering trying to get out front door .door to the basement where there is stairs .Assessment/Plan .Acute on chronic alteration in mental status .Encounter for home safety review for injury prevention .Case Management for assistance with placement .Confusion .Chronic and stable, patient does have dementia .Adult Failure to Thrive . Resident #11 was admitted to the hospital for changes in mental status and concerns for home safety. Case management was consulted for assistance with nursing home placement. Review of the hospital Discharge Summary dated 1/5/2023, showed .Discharge Diagnosis .Adult failure to thrive .Anorexia .At risk for falls, COPD .Dementia .Encounter for home safety review for injury prevention .Hypothyroidism .Type 2 diabetes mellitus .Hospital Course .admitted after being discharged from the nursing home 1 week prior to admission with hallucinations, confusion, unable to ambulate .admitted on [DATE] [12/20/2022] for acute on chronic alteration of mental status .Case management for assistance with patient SNF [skilled nursing facility] placement. Patient was accepted at [another long-term care facility] for long-term care . During an interview on 1/11/2023 at 5:28 PM, the MDS Coordinator confirmed the discharge planning started on admission. She stated MDS was responsible for care planning based on the resident's goals, preferences, and plans for discharge. The MDS Coordinator stated she and Social Services were responsible for the discharge planning for residents. The MDS Coordinator confirmed Resident #11 had no discharge care plan. During an interview on 1/9/2023 at 2:15 PM, the Social Worker (SW) stated she was responsible for assisting residents with home health referrals, medical equipment, notifying hospice and family, and setting up transfer arrangements for residents at discharge. Resident #11's Responsible Family Representative attended a care plan meeting on 12/1/2022 with the Business Office Manager and the MDS Coordinator. During the care plan meeting, Resident #11's Responsible Family Representative stated that he would be unable to take Resident #11 home at that time because he was working outside the home and would need a caregiver for Resident #11. The SW stated Resident #11 verbalized that she wanted to go home (on an unknown date), and the SW completed a BIMS score for the resident on 12/5/2022. Resident #11 scored 10 on the BIMS assessment, which indicated the resident had moderate cognitive impairment. The SW stated at this facility, if a resident's BIMS score was greater than 8, that indicated the resident was able to make their own decisions, and because Resident #11's BIMS score was 10, she was able to make the decision on her own if she wanted to go home. The SW left a voicemail message with Resident #11's Responsible Family Representative on 12/6/2022 that Resident #11 would be discharged home on 12/8/2022. The SW stated she was unaware if Resident #11's Responsible Family Representative received the message and stated she never heard back from him. The SW confirmed there was no documentation of the Responsible Family Representative notification. Resident #11 was discharged home in the SW's private vehicle on 12/8/2022 by the SW and the Hospitality Aide. Upon arrival to Resident #11's home, there were no family members present and the SW called the police and fire department to gain entry to the home because Resident #11 did not have a key. The police arrived and stated they could not give access to the home. The SW stated Resident #11 entered the home through the back door and the SW went across the street to retrieve a neighbor (unable to provide any identifying information about the neighbor) who came to the resident's home to stay with the resident until family returned. The SW left the patient discharge instructions and medications in a .drawer . Resident #11's Responsible Family Representative left a message for the SW on 12/8/2022 and stated he was unable to locate the discharge instructions and medications. The SW stated she returned the call to the Responsible Family Representative the next day on 12/9/2022 and the family member was able to find the discharge documents and medications (unable to provide a timeframe as there was no facility documentation regarding Resident #11's discharge). The SW was unable to provide further documentation of Resident #11's discharge on 12/8/2022. The SW stated it was decided between the DON, Administrator and Resident #11 that she had the right to go home since she had scored a 10 on the BIMS score. During an interview on 1/9/2023 at 3:30 PM, the Director of Nursing (DON) stated Resident #11 came into her office upset (unable to provide date of occurrence) and stated she wanted a lawyer and wanted to go home. The DON was aware that Resident #11 had diagnoses of Dementia and End Stage Chronic Obstructive Pulmonary Disease. The DON stated she was unaware of the care plan meeting that occurred on 12/1/2022 with Resident #11's Responsible Family Representative, the Business Office Manager, and the MDS Coordinator where discharge planning was discussed. The DON confirmed the Responsible Family Representative was to be notified prior to discharge and stated she .assumed . the SW notified him. She stated she was unaware Resident #11 was sent home without family present. The DON confirmed there was incomplete documentation of Resident #11's discharge in the medical record. The DON stated there was a corporate policy that stated if the resident had a BIMS score greater than 8, the resident was able to make their own decisions. The DON was unable to provide the policy as requested related to BIMS scores and resident decision making. The DON stated Resident #11's BIMS score was 10 and she wanted to go home and .it was her right to go home . The DON stated .I've never been very big in the discharge process as a DON . The DON stated to her knowledge no other care plan discharge meeting had been completed other that the care plan meeting on 12/1/2022. The DON stated a safe resident discharge included notification and communication with family, and coordination of home health and/or hospice services. During an interview on 1/10/2023 at 9:55 AM, the MDS Coordinator stated she attended the care plan meeting on 12/1/2022 with Resident #11's Responsible Family Representative and the Business Office Manager (who was no longer employed). She stated the Social Worker was unable to attend this meeting. The MDS coordinator stated Resident #11's Responsible Family Representative stated he was aware Resident #11 wanted to go home, but he was unable to care for Resident #11 at that time because the resident's daughter was in jail, and he was working outside the home. He stated he wanted to wait until the daughter returned to the home before proceeding with Resident #11 discharging home. The MDS Coordinator confirmed she relayed the care plan meeting information to the Social Worker (unaware of what date that occurred), but there was no documentation to state the conversation between the MDS Coordinator and Social Worker had taken place. During an interview on 1/10/2023 at 3:30 PM, the Nurse Practitioner (NP) stated she was notified by the Social Worker when residents were being discharged . The NP stated she was not involved in the discharge process. The NP stated the Social Worker arranged home health needs, medical equipment needs, and verified with family the details of the discharge, documented the information on a form and gave the form to the NP. The NP reviewed the resident's medication list and printed the transfer discharge record. The NP printed a hospital summary, if pertinent, and last labs and put the documents in a discharge packet. She stated there should be 1 discharge packet for the resident or family and 1 packet for the facility. The NP stated if the family was present at the time of discharge, she would review the discharge papers. Otherwise, it was the nurse's responsibility at the time of discharge. The NP confirmed if the family was not home at the time of discharge, she would not have left Resident #11 at her home unattended. She stated the Social Worker told her Resident #11 was going to be discharged and the family had agreed to the discharge. The NP confirmed she was unaware Resident #11 was discharged without family supervision. The NP confirmed she did not discuss the discharge instructions or medication instructions with Resident#11's Responsible Family Representative as previously documented in her progress noted dated 12/8/2022. The NP stated .it was documented in error . During an interview on 1/10/2023 at 4:00 PM, Administrator #1 stated in this facility, if a resident had a BIMS score greater than 8, the resident could make their own decisions. He stated the Social Worker coordinated the discharge and .gets with the NP . The Administrator stated he had not been involved in the discharges. He stated Resident #11 wanted to go home and she could make her own decisions based on Resident #11's last BIMS score. The Administrator stated he was unsure what Resident #11 could do for herself. He stated the Social Worker called him after the resident had been dropped off at her residence. He stated he was unaware the resident had not received adequate discharge instructions and Resident #11's family was not present at the home at the time of the resident's discharge. Administrator #1 stated it was the Administrator's responsibility to ensure all residents at the facility had a safe transfer or discharge. The Administrator stated the Social Worker, and the NP usually made the decisions of a resident being discharged . During an interview on 1/10/2023 at 4:50 PM, the Medical Director confirmed Resident #11 had substantial Dementia, had poor problem-solving skills and poor insight. The resident was not capable or competent to be discharged without a caregiver. The Medical Director stated she was unaware Resident #11 was discharged without discharge instructions or without notification to the Responsible Family Representative. The Medical Director stated a BIMS score greater than 8 alone was a .single slice of time . and not enough information and evidence to base a decision of resident competence on. The Medical Director confirmed Patient #11's discharge from the facility to the resident's home was not a safe discharge. During an interview on 1/11/2023 at 9:50 AM, the Regional Clinical Regulatory Compliance Risk Manager confirmed Resident #11 was sent home without notification to the family or family representative. She stated discharge planning should start on admission. She stated it was not a common practice to discharge residents in staff private vehicles. She stated it was her expectation for residents and/or family representatives to receive discharge instructions prior to being discharged . She stated this was not a safe discharge for Resident #11 and the facility's policy and procedure for discharge was not followed. The interview revealed there was not sufficient preparation for Resident #11's discharge from the facility on 12/8/2022. During an interview on 1/11/2023 at 3:52 PM, the DON confirmed Resident #11 had no discharge care plan and there was no documentation of a discharge care plan discussion. She stated .I've never been very big in the discharge process as a DON . During a telephone interview on 1/12/2023 at 8:42 AM, Resident #11's Responsible Family Representative stated he received a call from his [AGE] year-old stepson on 12/8/2022 that someone was trying to get in the house. He stated he instructed him to keep doors locked and keep out of sight and call the police. When he returned to the residence on 12/8/2022, he found Resident #11 at the home. He stated he notified hospice to visit, and they could not find the resident's medications or discharge instructions. He stated he was upset there were no discharge instructions or medications to be found, so he called the facility on 12/8/2022 to inquire about the discharge instructions and medications and did not hear back until the following day (12/9/2022). When he got the phone call from the facility (unsure who he spoke with) on 12/9/2022, he was informed the discharge instructions and medications were left in a drawer. He stated the resident did not receive any medications until the afternoon of 12/9/2022. He stated the resident had a decline about 3 days after discharge. Resident #11 had stopped eating and drinking and was more confused and was wandering around the house looking out the front door. He contacted and requested a hospice visit. The hospice nurse visited, and they started her on an antibiotic to treat a possible urinary tract infection. The resident was taken to the hospital and was admitted for a change in mental status, and the hospital stated that her dementia had worsened. The resident stayed in the hospital until she was transferred to a different nursing home on 1/5/2023 and was currently residing at a different nursing home. Review of the facility's documentation showed there were 2 care plan meetings regarding Resident #11's discharge from the facility: a meeting on 8/25/2022 and a meeting on 12/1/2022. 18784 Resident #25 was admitted to the facility on [DATE] with diagnoses including Left Below Knee Amputation, Cellulitis of Left Lower Limb (Amputated Stump), Pressure Ulcer of Stump, and Type 2 Diabetes. Review of the 5-day MDS assessment, dated 12/15/2022, showed Resident #25 was cognitively intact with a BIMS score of 14, was wheelchair bound, and required limited assistance of 1 person for transfer. Review of the Comprehensive Care Plan, dated 12/16/2022, showed .ADL, self-care performance deficit r/t [related to] weakness, left BKA [below knee amputation] with cellulitis and pressure ulcer, lack of coordination, use of prothesis to left leg, difficulty walking, extensive assist with adls .Focus .Pressure Ulcer location .Left Lateral Stump Unstageable . and the interventions included Current treatment per order . Further review showed .Return to Community Care Plan .wants to return home. Discharge planning r/t [related to] desire to return home when appropriate . Review of Resident #25's initial Pressure Wound Note from day of admission, 12/9/2022, revealed Resident #25 had 1 pressure ulcer identified on the left lateral stump that was Unstageable and measured 5.5 cm (centimeters) in length, 4.5 cm in width, and 0.3 cm in depth with 90% slough (dead) tissue present in the wound. Review of the resident's weekly Pressure Wound Note, dated 1/2/2023, revealed the left lateral stump pressure ulcer remained Unstageable and measured 4.5 cm in length, 3.5 cm in width, and 1 cm in depth with 20% slough. Review of the treatment orders for the left lateral stump pressure ulcer revealed the orders were changed on 1/2/2023, to Treatment to the left lateral stump (unstageable) [pressure ulcer] cleanse with NS [normal saline] - apply hydrogel soaked gauze and cover with 6x6 [6-inch by 6-inch] border dressing daily and PRN [as needed] if soiled. Every day shift for Wound Healing. Review of the facility's nursing Discharge Summary, dated 1/6/2023, showed under Special Treatment, Wound Care was checked. Further review of the Summary included .Discharge Instructions provided .Education (Select all that apply) . Continued review showed no indication there was a need for supplies to be sent with the resident on discharge and no dressing change education was provided. Continued review showed there was no indication education was provided for skin care and treatments. Resident #25 was discharged from the facility on Friday, 1/6/2023. Review of Social Service's resident discharge instructions, dated 1/6/2023, showed Home Health Company: [name of agency] with a phone number provided and indications Home Health was needed for Skilled Nursing, and evaluation for therapy (Physical and Occupational Therapies). During a telephone interview with Resident #25 on 1/10/2023 at 10:45 AM, he stated, .Friday morning [1/6/2023] was the last time it [pressure wound] was bandaged .[dressing] stayed on till yesterday [1/9/2023]. I had one bandage [supplies] to change yesterday .I called [facility Social Worker] 2 to 3 times since yesterday .[the facility] was supposed to have set up home health for me .she [the Social Worker] told me to call the [home health agency phone number] on my discharge papers Monday [1/9/2023] to set up a time for home health .it was the wrong office. It's for [name of city] and I live in [name of city] .[home health agency] said they couldn't take me .I called [the facility Social Worker] and she said she would fax [name of a second home health agency] .later in the day [name of second agency] said they didn't get a fax .called [Social Worker] back again to make sure she had the right fax number .I still haven't heard anything else from her or them .I'm afraid my leg is going to get infected again .I can't drive .because of swelling. I can't get my prosthesis on . During an interview with the Director of Nursing (DON) on 1/10/2023 at 1:20 PM, accompanied by the Social Worker, the DON stated Resident #25 had been referred to a third home health agency on 1/10/2023. During an interview on 1/10/2023 at 3:30 PM, the NP explained the discharge process she had developed with the Social Worker. The NP stated she was notified by the Social Worker when a date for the resident's discharge was projected. The NP stated she was at the facility 5 days each week and usually participated in deciding the date of discharge. The NP stated the Social Worker arranged all home health and medical equipment needs for discharge. The NP stated on Resident #25's discharge day (1/6/2023) she discussed the discharge instructions for medications to be continued and wound care instructions with the resident. The NP showed a copy of the residen [TRUNCATED]

Based on facility policy review, medical record review, and interview, the facility failed to provide written notification of a discharge to a resident's representative for 1 resident (#11) of 13 residents reviewed for transfer/discharge requirements. The facility's failure resulted in Resident #11, a cognitively impaired resident with multiple medical and psychological conditions and limited family/social support, being discharged to an unsupervised home without notice to a care giver and placed Resident #11 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). Resident #11 was hospitalized 12 days after discharge from the facility for altered mental status including hallucinations, worsening confusion, and inability to ambulate. Administrator #2 was notified of the Immediate Jeopardy on 1/12/2023 at 7:38 PM, in the Administrator's office. The IJ began on 12/8/2022 and is ongoing. The findings include: Review of a facility policy, titled Transfer or Discharge Notice revised 12/2016 showed .Our facility shall provide a resident and/or the resident's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge .The resident and/or representative (sponsor) will be notified in writing of the following information .The reason for the transfer or discharge .The effective date of the transfer or discharge .The location to which the resident is being transferred or discharged .A statement of the resident's rights to appeal the transfer or discharge .The facility bed-hold policy .The name, address, and telephone number of the Office of the State Long-term Care Ombudsman .The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with a mental disorder or related disabilities .The name, address and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices .The reasons for the transfer or discharge will be documented in the resident's medical record . Resident #11 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Diabetes, Dementia with Behavioral Disturbance, and Major Depressive Disorder with Psychotic Symptoms. Review of Resident #11's History and Physical dated 5/24/2022 showed .77 yo [year old] diabetic .with dementia .endstage COPD .transfers for continued care and multi-disciplinary rehabilitation .ADVANCED CARE PLANNING .The patient has been deemed incompetent to make decisions on their behalf due to advanced dementia . Review of Resident #11's admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #11 was rarely/never understood, had short- and long-term memory problems, and had moderately impaired cognitive skills for daily decision making. The resident exhibited daily physical and verbal behavioral symptoms, rejection of care, and wandering behaviors. Resident #11 required limited assistance of 1 staff member for transfers, walking in room and corridor, dressing, and personal hygiene. Resident #11 required extensive assistance of 1 staff member for toilet use and locomotion off the unit and supervision with set up assistance for eating. The resident had unsteady balance during transitions and walking and required mobility devices including walker and wheelchair. Resident #11 was always incontinent of urine and bowel. Resident #11 and Resident #11's family representative expected Resident #11 to remain in the facility. Review of Resident #11's Care Plan dated 6/7/2022 showed Resident #11 .has impaired cognitive function/dementia or impaired thought processes r/t [related to] Dementia .At risk for falls related to weakness and need for assistance with ADL's [Activities of Daily Living], unsteady gait, confusion, medication .at risk for impaired nutrition r/t poor appetite . Review of Resident #11's Care Plan dated 6/17/2022, showed .resident has an ADL self-care performance deficit r/t dementia, decreased mobility .resident has a communication problem r/t dementia .resident has bowel incontinence .resident has bladder incontinence .resident is on pain medication therapy .resident has a mood problem .resident has a terminal prognosis - end stage COPD .oxygen therapy . Review of Resident #11's quarterly MDS assessment dated [DATE], showed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident had severe cognitive impairment. The resident required limited assistance of 1 staff member for bed mobility and supervision of 1 staff member for transfers and walking in room and corridor. Resident #11 required extensive assistance of 1 staff member for dressing, toilet use and personal hygiene. Review of a Social Service Quarterly Note dated 11/25/2022 showed .resident [#11] is long term care with no current discharge plans .she is severely impaired for decision skills, scoring 7/15 [7 out of 15 which indicated severe cognitive impairment] on BIMS . Review of a quarterly MDS assessment dated [DATE], showed Resident #11 had a BIMS of 7, indicating severe cognitive impairment. Resident #11 required extensive assistance of 1 staff member for personal hygiene, toilet use, and dressing, limited assistance of 1 staff member for bed mobility, and supervision for transfers, eating, and ambulation. Resident #11 was always incontinent of bladder and bowel. The MDS for discharge planning showed there was no active discharge plan. Review of the Care Plan Conference Summary dated 12/1/2022, showed Resident #11's responsible family representative attended a care plan meeting with the Business Office Manager and the MDS Coordinator to discuss .home vs [versus] long term care . It was noted .Care plan meeting completed this day .[Responsible Family Representative] .said he is responsible for 15 y/o [year old] son of [Resident #11's daughter] and that he has to work outside of the home. He would need a caregiver for some time [if the resident was discharged home]. Can revisit [possible discharge planning] when [Resident #11's daughter] gets out of jail . Review of a Psychiatric Progress note dated 12/5/2022 for Resident #11 showed .Hospice Patient .Dementia .FTT [failure to thrive] .seeing this resident today for treatment of dementia depression and insomnia .is awake she is alert she is oriented to herself and somewhat situation . Review of a standalone BIMS exam dated 12/5/2022, completed by the Social Worker and not in conjunction with any other assessments such as the MDS, showed a score of 10, indicating Resident #11 had moderate cognitive impairment. Review of a skilled nursing note dated 12/7/2022 at 9:39 AM, showed .Residents' [#11] attention span is short .is Disoriented/confused .has impaired decision-making ability .Unsteady Gait .BED MOBILITY .Limited assistance One person physical assist .TRANSFER: Limited assistance One person .EATING: Limited assistance One person .TOILET: Limited assistance One person . Review of a Master of Social Work (MSW) Hospice note dated 12/7/2022 at 7:29 PM, showed the Hospice MSW was informed by the facility SW that Resident #11 was going home the next week. The Hospice MSW was unaware of any discharge planning. Review of a Nurse Practitioner (NP) order dated 12/8/2022, showed an order to discharge Resident #11 home with hospice. Review of a NP note dated 12/8/2022, showed .[Resident #11] discharging home under hospice with family today .Hospice aware of discharge today . Review of Resident #11's medical record revealed no documentation a discharge notice was provided to the Responsible Family Representative/care giver prior to discharge. Review of a Hospice Master of Social Worker (MSW) note dated 12/9/2022, showed .CALLED [Responsible Family Representative] .PATIENT [Resident #11] HAS BEEN IN A NURSING HOME IN [name of town] .HE REPORTS THAT THE NURSING HOME SENT HER HOME AND THERE WAS NOBODY THERE AND THEY BROKE IN THE DOOR HE REPORTS THAT THE POLICE WAS CALLED .HE DISCUSSED HOW HE CANNOT TAKE CARE OF HER [Resident #11] AND HER DAUGHTER IS IN JAIL. HE REPORTS IT'LL BE ANOTHER MONTH OR TWO MAYBE LONGER BEFORE SHE [daughter] GETS OUT THAT SHE [Resident #11] NEEDS TO GO TO THE FACILITY FOR LONG-TERM CARE .STATES THAT SHE CANNOT STAY THERE BY HERSELF HE WORKS AND THERE'S NO WAY HE CAN HAVE SOMEBODY THERE 24/7 . Review of the hospital Emergency Documentation dated 12/20/2022, showed Resident #11 presented to the Emergency Department with her Responsible Family Representative for worsening Altered Mental Status and concerns with home safety. Resident #11 had been hallucinating, had confusion, and had been unable to ambulate to the bathroom. Her speech was garbled, and she thought it was the 1800's. The Responsible Family Representative stated he had been attempting to care for Resident #11 at home but was employed full-time, so she was often home alone. He hoped to have Resident #11 placed in a nursing home as he was unable to provide safe care for her at home. Review of the hospital Admission History and Physical Report dated 12/20/2022, showed Resident #11 had a past medical history of dementia and presented to the emergency department with increased confusion, mumbled speech, and playing with her hands. Resident #11 had recently been discharged from a nursing facility and since then she had increased wandering, with exit seeking behaviors. The Responsible Family Representative was seeking long term placement. Resident #11 was admitted to the hospital for changes in mental status and concerns for home safety. Case management was consulted for assistance with nursing home placement. Resident #11 was diagnosed with confusion, dementia, and adult failure to thrive. Review of the hospital Discharge Summary for Resident #11 dated 1/5/2023, showed .Discharge Diagnosis .Adult failure to thrive .Anorexia .At risk for falls, COPD .Dementia .Encounter for home safety review for injury prevention . During an interview on 1/9/2023 at 2:15 PM, the Social Worker (SW) stated she left a voicemail message with Resident #11's Responsible Family Representative on 12/6/2022 that Resident #11 would be discharged home on 12/8/2022. The SW stated she was unaware if Resident #11's Responsible Family Representative received the message and stated she never heard back from him. The SW confirmed Resident #11's Responsible Family Representative was not sent a written notice of the resident's discharge and there was no documentation of the Responsible Family Representative notification on 12/6/2022. Resident #11 was discharged home in the SW's private vehicle on 12/8/2022 by the SW and the Hospitality Aide. Upon arrival to Resident #11's home, there were no family members present and the SW called the police and fire department to gain entry to the home because Resident #11 did not have a key. The police arrived and stated they could not give access to the home. The SW stated entrance was gained to the home through the back door and the SW went across the street to retrieve a neighbor who came to the resident's home to stay with the resident until family returned. The SW was unable to provide documentation of Resident #11's discharge on 12/8/2022 and unable to provide any identifying information for the neighbor. During an interview on 1/9/2023 at 3:30 PM, the Director of Nursing (DON) stated Resident #11 came into her office upset (unable to provide date of occurrence) and stated she wanted a lawyer and wanted to go home. The DON was aware that Resident #11 had diagnoses of Dementia and End Stage Chronic Obstructive Pulmonary Disease. The DON stated she was unaware of the care plan meeting that occurred on 12/1/2022 with Resident #11's Responsible Family Representative, the Business Office Manager, and the MDS Coordinator where discharge planning was discussed. The DON confirmed the Responsible Family Representative was to be notified prior to discharge and stated she .assumed . the SW notified him. During a telephone interview on 1/9/2023 at 7:18 PM, the Hospice Registered Nursed (RN) stated she was notified on 12/8/2022 at 4:30 PM, that Resident #11 was discharged home from the nursing home, and the Hospice RN was to make a visit to complete the admission. The Hospice RN arrived at Resident #11's home on 12/8/2022 between 6:00 PM and 6:30 PM. Resident #11's Responsible Family Representative stated he had not been made aware Resident #11 was being discharged from the facility on 12/8/2022. During a telephone interview on 1/9/2023 at 7:50 PM, Resident #11's Responsible Family Representative stated he was Resident #11's son-in law and the legal representative for Resident #11. He stated he attended a meeting at the facility approximately a week prior to 12/7/2022. He stated the plan was for Resident #11 to be discharged home when her daughter was out of jail, and they were able to get some care assistance from Medicaid Choices. The Responsible Family Representative stated he received a call from a nurse at Resident #11's hospice agency on 12/8/2022 asking if he had been notified that Resident #11 was being discharged from the nursing home that day. The Responsible Family Representative stated he had not received notice from the nursing home that the resident was being discharged home. During an interview on 1/10/2023 at 3:30 PM, the NP stated she was notified when residents were being discharged . The NP stated she was unaware that Resident #11's family was not notified that the resident was discharging from the facility on 12/8/2022. The SW told the NP Resident #11's family had agreed to take the resident home. The NP stated if she had been aware that Resident #11's Responsible Family Representative had not agreed to the discharge, she would not have approved Resident #11's discharge. During an interview on 1/10/2023 at 4:50 PM, the Medical Director stated Resident #11 had substantial Dementia, poor problem-solving skills, and poor insight. The resident was not capable or competent to be discharged without a caregiver. During an interview on 1/11/2023 at 9:50 AM, the Regional Clinical Regulatory Compliance Risk Manager confirmed Resident #11 was discharged home without notification to the family or family representative. The Regional Clinical Regulatory Compliance Risk Manager stated residents, or the resident representative was to be notified of discharge prior to the discharge.

Based on facility policy review, medical record review, and interview, the facility failed to follow their discharge policies and procedures and failed to meet the requirements for an appropriate discharge for 1 resident (#11) of 13 residents reviewed for discharge requirements. The facility's failure resulted in Resident #11, a cognitively impaired resident with multiple medical and psychological conditions and limited family/social support being discharged to her unsupervised home and placed Resident #11 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). Resident #11 was hospitalized 12 days after discharge from the facility for altered mental status including hallucinations, worsening confusion, and inability to ambulate. Administrator #2 was notified of the Immediate Jeopardy on 1/12/2023 at 7:38 PM in the Administrator's office. The IJ began on 12/8/2022 and is ongoing. The findings include: Review of a facility policy, titled Transfer or Discharge Notice revised 12/2016 showed .Our facility shall provide a resident and/or the resident's representative (sponsor) with a thirty (30)-day written notice of an impending transfer or discharge .The resident and/or representative (sponsor) will be notified in writing of the following information .The reason for the transfer or discharge .The effective date of the transfer or discharge .The reasons for the transfer or discharge will be documented in the resident's medical record . Review of facility's policy titled, Transfer or Discharge, Preparing a Resident for, revised on 12/2016, showed .Resident will be prepared for discharge. 1. When a resident is scheduled for transfer or discharge, Social Services Director will work with nursing services on the transfer or discharge so that appropriate procedures can be implemented. 2. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family before the resident's discharge or transfer from the facility .Nursing services is responsible for .d. packing and collecting personal possessions (if the resident is not expected to return); e. assisting with transportation as applicable; f. Completing discharge note in the medical record; 4. Social Services (may have assistance from Business Office) is responsible for: a. Discharge planning b. Assisting with post discharge needs . Resident #11 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Diabetes, Dementia with Behavioral Disturbance, and Major Depressive Disorder with Psychotic Symptoms. Review of Resident #11's History and Physical dated 5/24/2022 showed .77 yo [year old] diabetic .with dementia .endstage COPD .transfers for continued care and multi-disciplinary rehabilitation .ADVANCED CARE PLANNING .The patient has been deemed incompetent to make decisions on their behalf due to advanced dementia . Review of Resident #11's admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #11 was rarely/never understood, had short- and long-term memory problems, and had moderately impaired cognitive skills for daily decision making. The resident exhibited daily physical and verbal behavioral symptoms, rejection of care, and wandering behaviors. Resident #11 required limited assistance of 1 staff member for transfers, walking in room and corridor, dressing, and personal hygiene. Resident #11 required extensive assistance of 1 staff member for toilet use and locomotion off the unit and supervision with set up assistance for eating. The resident had unsteady balance during transitions and walking and required mobility devices including walker and wheelchair. Resident #11 was always incontinent of urine and bowel. Resident #11 and Resident #11's family representative expected Resident #11 to remain in the facility. Review of Resident #11's Care Plan dated 6/7/2022 showed Resident #11 .has impaired cognitive function/dementia or impaired thought processes r/t [related to] Dementia .At risk for falls related to weakness and need for assistance with ADL's [Activities of Daily Living], unsteady gait, confusion, medication .at risk for impaired nutrition r/t poor appetite . Review of Resident #11's Care Plan dated 6/17/2022, showed .resident has an ADL self-care performance deficit r/t dementia, decreased mobility .resident has a communication problem r/t dementia .resident has bowel incontinence .resident has bladder incontinence .resident is on pain medication therapy .resident has a mood problem .resident has a terminal prognosis - end stage COPD [Chronic Obstructive Pulmonary Disease] .oxygen therapy . Review of Resident #11's quarterly MDS assessment dated [DATE], showed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident had severe cognitive impairment. The resident required limited assistance of 1 staff member for bed mobility and supervision of 1 staff member for transfers and walking in room and corridor. Resident #11 required extensive assistance of 1 staff member for dressing, toilet use and personal hygiene. Review of a Social Service Quarterly Note dated 11/25/2022 showed .resident [#11] is long term care with no current discharge plans .she is severely impaired for decision skills, scoring 7/15 [7 out of 15 - severe cognitive impairment] on BIMS . Review of a quarterly MDS assessment dated [DATE], showed Resident #11 had a BIMS score of 7 indicating severe cognitive impairment. Resident #11 required extensive assistance of 1 staff member for personal hygiene, toilet use, and dressing, limited assistance of 1 staff member for bed mobility, and supervision for transfers, eating, and ambulation. Resident #11 was always incontinent of bladder and bowel. The MDS for discharge planning showed there was no active discharge plan. Review of Resident #11's financial statement dated 12/1/2022 showed Resident #11 had a balance due of $3,435.00. Review of a Transaction Report dated 1/1/2020-1/31/2023 for Resident #11 showed 2 payments to the facility of $87.00 on 12/5/2022 and $600.00 on 12/8/2022. Continued review showed the facility had received monthly reimbursement of $235.53 per day from Hospice. Review of the Care Plan Conference Summary dated 12/1/2022, showed Resident #11's responsible family representative attended a care plan meeting with the Business Office Manager and the MDS Coordinator to discuss .home vs [versus] long term care . It was noted .Care plan meeting completed this day .[name of Responsible Family Representative] talked with [name of previous Business Office Manager] to clear up issues with payment He said he did not know payments were declined giving different payment info .before he left said he is responsible for 15 y/o [year old] son of [Resident #11's daughter] and that he has to work outside of the home. He would need a caregiver for some time [if Resident #11 was discharged back to the home]. Can revisit [possible discharge planning] when [Resident #11's daughter] gets out of jail . Review of a Psychiatric Progress note dated 12/5/2022 for Resident #11 showed .Hospice Patient .Dementia .FTT [failure to thrive] .seeing this resident today for treatment of dementia depression and insomnia .is awake she is alert she is oriented to herself and somewhat situation .she continues to have the delusion that she will soon be going home . Review of a standalone BIMS exam dated 12/5/2022, completed by the Social Worker and not in conjunction with any other assessments such as the MDS, showed a score of 10, indicating Resident #11 had moderate cognitive impairment. Review of a Nurse's note dated 12/7/2022 at 9:02 AM, showed .Resident's [#11] attention span is short. The resident is Disoriented/confused .Resident has impaired decision-making ability .makes repetitive statements . Review of a Skilled Nursing note dated 12/7/2022 at 9:39 AM, showed .Resident's [#11] attention span is short .is Disoriented/confused .has impaired decision-making ability .Unsteady Gait .BED MOBILITY .Limited assistance One person physical assist .TRANSFER: Limited assistance One person .EATING: Limited assistance One person .TOILET: Limited assistance One person . Review of a Master of Social Work (MSW) Hospice note dated 12/7/2022 at 7:29 PM, showed .MSW [Hospice MSW] VISITED WITH PT [patient - Resident #11] .FACILITY NURSE .REPORTED THAT PT IS ACTUALLY GOING HOME NEXT WEEK. [Hospice] MSW WAS UNAWARE OF PLAN .DURING PARTNERSHIP MEETING WITH [facility SW], SHE CONFIRMED THAT PT IS BEING DRIVEN TO HER HOME .BY [facility] STAFF .POLICE WILL BE NOTIFIED IF [Responsible Family Representative] WILL NOT LET HER IN (AS HOME BELONGS TO PT) .PT NO LONGER MEETS CRITERIA TO STAY IN FACILITY DESPITE FACT SHE IS ON HOSPICE .WILL NOTIFY MORRISTOWN OFFICE OF PT'S RETURN TO THEIR SERVICE AREA . Review of a Nurse Practitioner's (NP) note dated 12/8/2022 showed .discharging home under hospice with family today .Copy of discharge packet will be given at time of departure .Hospice aware of discharge today . Review of the Resident Discharge instruction form dated 12/8/2022, showed there was no discharge time or transportation arrangements documented. A handwritten note on the discharge documents showed .to [name of Responsible Family Representative] and/or Hospice Nurse . Review of the document showed it did not contain relevant resident specific information for discharge such as behaviors, ambulation, bladder, bowel, feeding, usual level of functioning, date, and time of transfer/discharge, transfer/discharged to, and any personal effects sent home with the resident. On the top of the document there was a handwritten note from the Nurse Practitioner that stated .Give to [Resident #11's Responsible Family Representative's first name] and/or Hospice Nurse . Review of a Hospice Master of Social Worker (MSW) note dated 12/9/2022 showed .CALLED [Resident #11's Responsible Family Representative] .PATIENT HAS BEEN IN A NURSING HOME IN [name of town] .HE REPORTS THAT THE NURSING HOME SENT HER [Resident #11] HOME AND THERE WAS NOBODY THERE . HE REPORTS THAT THE POLICE WAS CALLED .HE DISCUSSED HOW HE CANNOT TAKE CARE OF HER AND HER DAUGHTER IS IN JAIL. HE REPORTS IT'LL BE ANOTHER MONTH OR TWO MAYBE LONGER BEFORE SHE [daughter] GETS OUT THAT SHE [Resident #11] NEEDS TO GO TO THE FACILITY FOR LONG-TERM CARE .STATES THAT SHE [Resident #11] CANNOT STAY THERE BY HERSELF HE WORKS AND THERE'S NO WAY HE CAN HAVE SOMEBODY THERE 24/7 . Review of a Hospice Nurse note dated 12/9/2022 showed .[Hospice visit] REQUESTED BY CG [care giver] REGARDING TRANSFER FROM SNF [skilled nursing facility] .PT [Resident #11] WAS RELEASED FROM SNF WITH NO NEW SCRIPTS [prescriptions] OR ORDERS TO CONTINUE MEDICATIONS .SN [Skilled Nurse] NOTIFIED [pharmacy] .OF REQUIRED SCRIPTS .PATIENT .WITH SOME CONFUSION/FORGETFULNESS .UNABLE TO PROVIDE DAY OF WEEK AND CURRENT MONTH WITH OUT PROMPTING .PT IS FRAIL .CAN AMBULATE WITH USE OF WALKER AND REQUIRES STANDBY ASSIST .OCCASIONAL EPISODES OF INCONTINENCE .NO SUPPLIES IN THE HOME . Review of a Hospice Nursing note dated 12/20/2022 showed .CG NOTIFIED [Hospice Agency] ON CALL REGARDING CHANGE IN PATIENT'S [Resident #11] STATUS. HE REPORTED INCREASED ANXIETY AND CONFUSION .UPON ARRIVAL TO HOME .PATIENT LOOKED CONFUSED AND UNABLE TO ANSWER .PATIENT WAS CONFUSED . Review of the hospital Emergency Documentation dated 12/20/2022, showed Resident #11 was seen in the Emergency Department on 12/20/2022 for Altered Mental Status. It was noted .Associated Diagnoses: Acute on chronic alteration in mental status; Encounter for home safety review for injury prevention .Chief Complaint .Released from nursing home 1 week ago [12 days]. Hallucinating, and confused unable to ambulate to bathroom since [1:00 AM] today. Speech garbled thinks it is the 1800's .History of Present Illness .presents with altered mental status .disoriented and confused XXX[AGE] year old female presents to ER [emergency room ] with her [Power of Attorney/Responsible Family Representative] who reports the patient has had worsening confusion .Patient was discharged from nursing home 8 days ago [12 days] after scoring higher on her mini mental exam .He has been attempting to care for her at home but is employed full-time, so the patient is often home alone. He is hoping to have the patient placed in a nursing home in this area .Disposition .Admit: to Observation .Discussed with POA [Power of Attorney] that there is no obvious cause for patient's worsening confusion noted on medical imaging or laboratory study results .POA unable to care for patient at home. Will speak with hospitalist regarding admission due to unsafe discharge with hopes of possible SNF placement considering patient was discharged from SNF less than 30 days ago . Review of the hospital Admission History and Physical Report dated 12/20/2022, showed .[Resident #11] Released from nursing home 1 week ago. Hallucinating, confused unable to ambulate to bathroom since 1 am today. Speech garbled thinks it is the 1800's .Surrogate Decision Maker: [Responsible Family Representative] .unfortunate [AGE] year old .female .past medical history of dementia, chronic UTIs who presents to the emergency room with increased confusion .discharged from the nursing home 8 days ago .she had been increasing wandering trying to go out the front door and to the door to the basement where there is stairs. He states that she has been more argumentative with him, and he states that she has stopped talking she just mumbles and plays with her hands .he felt that it possibly could be a urinary tract infection so he brought her to the emergency room today for further evaluation .I did have a lengthy discussion with him via phone, as the patient does have choices [CHOICES - State Medicaid Plan] .however they [CHOICES Medicaid] are understaffed and no one is available for assistance. He is looking at long term placement .In the emergency room , she did have laboratory and radiological studies. White count [white blood cells - high count indicative of an infection] is normal, H&H [hemoglobin and hematocrit] is stable, platelets are normal .Urinalysis is essentially negative .CT [computerized tomography] of brain which shows no acute intracranial findings .Assessment/Plan .Acute on chronic alteration in mental status .Encounter for home safety review for injury prevention .Consult case management for assistance with placement .Confusion .patient does have dementia .Adult failure to thrive . Review of the hospital Discharge Summary dated 1/5/2023, showed .Discharge Diagnosis .Adult failure to thrive .Anorexia .At risk for falls, COPD .Dementia .Encounter for home safety review for injury prevention .Hospital Course .admitted after being discharged from the nursing home 1 week prior to admission with hallucinations, confusion, unable to ambulate .admitted on [DATE] for acute on chronic alteration of mental status .Case management for assistance with patient SNF placement. Patient was accepted at .[another long-term care facility] for long-term care . During an interview on 1/9/2023 at 2:15 PM, the facility Social Worker (SW) stated Resident #11's Responsible Family Representative attended a care plan meeting on 12/1/2022 with the Business Office Manager and the MDS Coordinator. During the care plan meeting Resident #11's Responsible Family Representative stated that he would be unable to take Resident #11 home at that time because he was working outside the home and would need a caregiver for Resident #11. The SW stated Resident #11 verbalized that she wanted to go home (unknown what date the resident expressed this), and the SW completed a BIMS score for the resident on 12/5/2022 to determine if Resident #11 had the cognitive ability to make that decision. Resident #11 scored 10 on the BIMS assessment which indicated the resident had moderate cognitive impairment. The SW stated the facility determined that residents scoring greater than 8 on the BIMS, indicated the resident was able to make their own decisions and because Resident #11's BIMS score was 10, she was able to make the decision on her own if she wanted to go home. The SW stated she left a voicemail message with Resident #11's Responsible Family Representative on 12/6/2022 that Resident #11 would be discharged home on 12/8/2022. The SW stated she was unaware if Resident #11's Responsible Family Representative received the message and stated she never heard back from him. Resident #11 was discharged and taken home in the SW's private vehicle on 12/8/2022 by the SW and the Hospitality Aide. The SW stated upon arrival to Resident #11's home, there was no family members present and the SW called the police and fire department to gain entry to the home because Resident #11 did not have a key. The police arrived and stated they could not give access to the home. The SW stated Resident #11 entered the home through the back door and the SW went across the street to retrieve a neighbor (unable to provide any identifying information of the neighbor) who came to the resident's home to stay with the resident until family returned. The SW stated she left the patient discharge instructions and medications in .a drawer . The location of the drawer was unknown. She stated Resident #11's Responsible Family Representative left a message on 12/8/2022 for the SW and stated he was unable to locate the discharge instructions and medications. The SW was unable to provide documentation of Resident #11's discharge on 12/8/2022. The Social Worker stated .he was not paying her [Resident #11] bill .He [Responsible Family Representative] was living in her house .She had a right to go home . During an interview on 1/9/2023 at 2:40 PM, Certified Nurse Aide (CNA) #4 stated Resident #11 was a feisty little thing. The resident required supervision to ambulate, and assistance of 1 for toileting. The CNA stated her behavior would change from day to day. Some days she was confused and thought everyone was stealing her things. During an interview on 1/9/2023 at 3:30 PM, the Director of Nursing (DON) stated Resident #11 came into her office upset (unable to provide date this occurred) and stated she wanted a lawyer and wanted to go home. The DON confirmed she was aware Resident #11 had diagnoses of Dementia and End Stage Chronic Obstructive Pulmonary Disease. The DON stated she was unaware of the care plan meeting that occurred on 12/1/2022 with Resident #11's Responsible Family Representative, the Business Office Manager, and the MDS Coordinator where discharge planning was discussed. She stated she was unaware Resident #11 was sent home without family present. The DON confirmed there was no documentation of Resident #11's discharge in the medical record. The DON stated there was a corporate policy that stated if the resident had a BIMS score greater than 8, the resident was able to make their own decisions. The DON was unable to provide the policy as requested. The DON stated Resident #11's BIMS score was 10 and she wanted to go home and .it was her right to go home . During a telephone interview on 1/9/2023 at 7:18 PM, the Hospice Registered Nurse (RN) stated she was notified on 12/8/2022 at 4:30 PM, that Resident #11 was discharged home from the nursing home, and the Hospice RN was to make a visit to complete the admission. The Hospice RN arrived at Resident #11's home on 12/8/2022 between 6:00 PM and 6:30 PM. Resident #11 was unaware of the month, date, and year and was unable to repeat the 3 words the Hospice RN asked her to remember. During a telephone interview on 1/9/2023 at 7:50 PM, Resident #11's Responsible Family Representative stated he was Resident #11's son-in law and the legal representative for Resident #11. He stated he attended a meeting at the facility approximately a week prior to 12/7/2022 with an Office Manager and a Case Manager. The Responsible Family Representative told the facility he lived in Resident #11's home with a minor child. Resident #11's daughter was incarcerated, and the Responsible Family Representative was the only possible care giver in the home, and he was working outside the home. He stated the plan was for Resident #11 to be discharged home when her daughter was out of jail, and they were able to get some care assistance from Medicaid Choices. The Responsible Family Representative stated he received a call from a nurse at Resident #11's hospice agency on 12/8/2022 asking if he had been notified that Resident #11 was being discharged from the nursing home that day. The Responsible Family Representative stated he was at work, no one was home, the doors were locked, and he was unable to get home until later in the afternoon. The Responsible Family Representative stated he had not received notice from the nursing home that the resident was being discharged home. The Responsible Family Representative stated he had made a payment for Resident #11's care on the day of the care plan meeting. During an interview on 1/10/2023 at 7:30 AM, the Wound Care Nurse stated Resident #11 was a sassy little lady. She was on hospice and had dementia with periods of confusion. She stated the resident was incontinent of bowel and bladder at times, required oxygen continuously, and required assistance with ADLs and supervision to ambulate. During an interview on 1/10/2023 at 7:50 AM, CNA #9 stated Resident #11 was a small lady who required oxygen. He stated the resident had dementia with periods of confusion. The CNA stated there were times the resident would be talking to the wall, thought she was in her home, and looking for her parked car. He stated the resident required supervision with ambulation and assistance of 1 staff for ADLs and toileting. During an interview on 1/10/2023 at 8:15 AM, Hospitality Aide #1 stated she accompanied the Social Worker to take Resident #11 home on 12/8/2022 in the Social Worker's private vehicle. He stated they arrived at Resident #11's home and the resident did not have a key. He stated the front door was locked, no one answered the door and the police showed up. He stated the police stated they could not gain entry into the house and the police left. He stated he entered an unlocked basement door and Resident #11 told him to go in and unlock the front door, which he did. He stated the resident entered the house and sat on the couch. The Hospitality Aide stated a neighbor was present with the resident when they left. He was not able to provide any information about the neighbor the resident was left with on 12/8/2022. During an interview on 1/10/2023 at 9:55 AM, the MDS Coordinator stated she attended the care plan meeting on 12/1/2022 with Resident #11's Responsible Family Representative and the Business Office Manager (no longer employed at the nursing facility). She stated the Social Worker was unable to attend this meeting. The MDS coordinator stated Resident #11's Responsible Family Representative stated he was aware Resident #11 wanted to go home but he was unable to care for Resident #11 at that time because the resident's daughter was in jail, and he was working outside the home. The Responsible Family Representative stated he wanted to wait until Resident #11's daughter returned home before proceeding with Resident #11 returning home. The MDS Coordinator confirmed she relayed the care plan meeting information to the Social Worker. During an interview on 1/10/2023 at 3:30 PM, the NP stated she was notified when residents were being discharged . The NP stated she was unaware that Resident #11's family was not notified that the resident was discharging from the facility on 12/8/2022. The SW told the NP Resident #11's family had agreed to take the resident home. The NP stated if she had been aware that Resident #11's Responsible Family Representative had not agreed to the discharge, she would not have approved Resident #11's discharge. During an interview on 1/10/2023 at 4:00 PM, Administrator #1 stated in this facility, if a resident had a BIMS score greater than 8, the resident was able to make their own decisions. He stated the Social Worker coordinated the discharge and .gets with the NP . The Administrator stated he had not been involved in the discharges. He stated Resident #11 wanted to go home and she could make her own decisions based on Resident #11's last BIMS score (dated 12/5/2022). The Administrator stated he was unsure what Resident #11 was capable of doing for herself. He stated the Social Worker called him after the resident had been dropped off at her residence. He stated he was unaware Resident #11's family was not present at the home at the time of the resident's discharge. Administrator #1 confirmed it was the Administrator's responsibility to ensure all residents at the facility had a safe transfer or discharge. Administrator #1 stated Resident #11's discharge .wasn't a direct billing problem .that's [discharge] what she [Resident #11] wanted and she can make her own decisions . Administrator #1 stated Resident #11 was not discharged due to non-payment. During an interview on 1/10/2023 at 4:50 PM, the Medical Director confirmed Resident #11 had substantial Dementia, had poor problem-solving skills and poor insight. The resident was not capable or competent to be discharged without a caregiver. The Medical Director stated a BIMS score greater than 8 alone is a .single slice of time . and not enough information and evidence to base a decision of resident competence. The Medical Director confirmed Resident #11's discharge from the SNF to the resident's home was not a safe and orderly discharge. During a telephone interview on 1/11/2023 at 8:30 AM, Police Officer #1 stated he was called to Resident #11's home on 12/8/2022. He stated on arrival, there was a female and male employee from a nursing home with Resident #11 in the back seat. He stated the employees told him the facility .hadn't received a payment since May . and they requested the officer assist them in gaining entry to the home. The Officer stated he instructed the nursing home employees that he could not gain entry into the resident's home without just cause. The female nursing home staff (Social Worker) asked the police officer if the officer could take the resident with him. The Officer stated to the SW he could not take the resident. The Officer stated when he left, the 2 nursing home employees were outside of Resident #11's residence. The Officer stated the same day, an hour or 2 later, he received a call from Resident #11's Responsible Family Representative who stated there was damage done to the basement door by facility staff and the resident was left at the home unattended, and he had not been notified. The Responsible Family Representative declined to press charges against the facility for the damaged basement door. During an interview on 1/11/2023 at 9:50 AM, the Regional Clinical Regulatory Compliance Risk Manager confirmed Resident #11 was sent home without notification to the resident's Responsible Family Representative. She stated it was not normal procedure to discharge residents in staff private vehicles. She stated this was not a safe discharge for Resident #11 and the facility's policy and procedure for discharge was not followed. During an interview on 1/11/2023 at 3:52 PM, the Director of Nursing (DON) stated Resident #11 came to her office .probably a little before Thanksgiving . and stated she knew her rights and wanted to go home. The Social Worker did a BIMS assessment on 12/5/2022 to determine if Resident #11 was safe to go home. Resident #11 scored a 10 on the BIMS assessment on 12/5/2022 and that indicated she was able to make her own decision to go home. The DON stated she felt Resident #11 was safe to go home because she was told by the Social Worker that Resident #11's Responsible Family Representative was going to be the resident's caregiver. The DON confirmed Resident #11 needed a caregiver in the home. During a telephone interview on 1/12/2023 at 8:42 AM, Resident #11's Responsible Family Representative stated he received a call from his minor stepson on 12/8/2022 that someone was trying to get in the house. He stated he instructed him to keep the doors locked and keep out of sight and call the police. He stated when he returned to the residence on 12/8/2022 he found Resident #11 at the home unsupervised. He stated he notified hospice of Resident #11's discharge and called the hospice agency to request a nursing visit. The Responsible Family Representative and the hospice nurse were unable to locate the resident's discharge instructions and medications. He stated he called the facility to inquire about the discharge instructions and medications and did not hear back until the following day, 12/9/2022. He stated the resident had a decline in her condition, stopped eating and drinking, was more confused, and was wandering around the house looking out the front door. Resident #11 was later taken to the emergency department at the hospital and was admitted to the hospital until she was transferred to a different nursing home.

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to ensure that a Certified Nursing Assistant (CNA) provided care within the scope of practice for 1 resident (Resident #1) of 6 residents reviewed and failed to provide a Peripherally Inserted Central Catheter (PICC- thin soft tube inserted into a blood vein the arm to provide medications) line dressing change for 1 resident (Resident #2) of 3 residents reviewed for PICC lines. The findings include: Review of the facility policy titled, Administering Medications, revised 4/2019, showed .Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so . Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating he was cognitively intact. Review of Resident #1's current physician's orders showed a physician's order dated 4/19/2022 for Dulcolax suppository [medication for constipation given via the rectum] 10 milligrams one per rectum daily for constipation. Review of the facility's investigation showed Resident #1 reported on 4/20/2022 that on the evening on 4/19/2022, he had requested a suppository. The resident stated a CNA (CNA #1) brought him a suppository and stated he could not administer the suppository. The resident told the aide he would administer himself. Further review showed CNA #1 stated he did take a suppository to the patient and left the room. He did not witness the resident administer the suppository. During an interview on 5/24/2022 at 12:55 PM, (CNA) #1 stated on 4/19/2022, .I went in there and was picking up dinner trays about 5:55 PM he told me he had been waiting on a suppository all day . The CNA stated he told the nurse (Licensed Practical Nurse -LPN #1). He stated .the nurse [LPN #1] told me to just give it him to take .he told me he could give it to himself .I laid it on the table and walked out . CNA #1 stated he told the resident he could not administer the suppository. During an interview on 5/24/2022 at 1:54 PM, LPN #1 stated on 4/19/2022, CNA #1 had told her Resident #1 had asked for a suppository and she had obtained an order from the Nurse Practitioner. LPN #1 stated, when CNA #1 came and told her the resident was needing a suppository, .there was a lot going on .I had a new admission who was dying, and the mother was standing there asking questions .and I was about to fall apart . LPN #1 stated the CNA had told her the resident said he would administer it himself and she had given the suppository to the CNA. LPN #1 confirmed CNAs were not permitted to take medications to residents. The LPN stated .the only reason [CNA #1] did what he did [take medication to a resident] was he saw the frustration in my face, he just tried to help me . The LPN stated .but this man had been so demanding that I didn't want to make him wait .it was just really bad judgement . During an interview on 5/24/2022 at 2:11 PM, the Director of Nursing (DON), confirmed that nurses are not permitted to give medications to a CNA to deliver to a resident. She confirmed CNAs are not permitted to deliver medications to residents. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was discharged [DATE]. Review of facility policy Midline Dressing Changes, revised April 2016, revealed Change midline catheter dressing .every 5 - 7 days, or if it is wet, dirty, not intact, or compromised in any way . Review of an admission MDS dated [DATE] revealed Resident #2 had severe cognitive impairment and was unable to complete a Brief Interview for Mental Status. The MDS showed Resident #2 was total dependence with 2 persons physical assistance. Review of a care plan dated 5/2/2022 for Resident #2 revealed the resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of a Physician Order Report for Resident #2 dated 5/1/2022 - 5/15/2022 revealed .05/02/2022 .PICC Line dressing change every week . Medical record review of a General Order dated 5/2/2022 revealed .PICC Line dressing change every week .FYI (for your information) Only . Medical record review of a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of nursing progress notes for Resident #2 dated 5/2/2022 - 5/15/2022 revealed no documentation the PICC line site dressing had been changed. During an interview on 5/24/2022 at 1:30 PM the DON stated the physician ordered the PICC line dressing to be changed every 5-7 days. The DON stated the physician order was transcribed as FYI and did not show up on the MAR. The DON stated there was no documentation showing the PICC line dressing had been changed since admission for Resident #2.

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to ensure an allegation of abuse was reported to the Abuse Coordinator timely for 1 resident (Resident #1) of 6 residents reviewed. The findings include: Review of the facility policy titled, Abuse Investigation and Reporting, revised 7/2017, showed .All reports of resident abuse, neglect .All alleged violations involving abuse, neglect .will be reported by the facility administrator .An alleged violation of abuse, neglect .will be reported immediately, but not later than .Two (2) hours if the alleged violation involves abuse . Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's admission Minimum Data Set assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating he was cognitively intact. Review of Resident #1's current physician's orders showed a physician's order dated 4/19/2022 for Dulcolax suppository [medication for constipation given via the rectum] 10 milligrams one per rectum daily for constipation. Review of the facility's investigation showed Resident #1 reported on the afternoon of 4/20/2022 that on the evening on 4/19/2022, he had requested a suppository. The resident stated (Certified Nursing Assistant- CNA #1) brought him a suppository and stated he could not administer the suppository. The resident told the aide he would administer it himself. The resident stated when he started to insert the suppository, he had a bowel movement and soiled his hands and wrists. The resident stated the CNA left the room abruptly and did not return. The resident stated later 2 female CNAs (CNA #3 & #4) entered the room. The resident requested a wash basin to clean his hands. He stated one of the female CNA's filled the wash basin and tossed it toward him. He stated the aides did not clean him up. The Resident stated that no one assisted him all night. He stated the next morning (4/20/2022) a different female CNA (CNA #2) came in and cleaned him up. Stated he was soiled for over 18 hours, and no one assisted him. Further review showed: (CNA #1)- the CNA stated he did take a suppository to the patient and left the room. He did not witness the resident administer the suppository or have a bowel movement. He stated the resident did not ask for any assist after that. (CNA #4) - stated nurse (Registered Nurse-RN #2) asked her to assist in providing a suppository and when they went in the room, he (the resident) told them he didn't need a suppository anymore because he already received it. The resident requested a wash basin and soap to wash his hands. The CNA stated she offered to assist with cleaning his hands and he declined. She stated she emptied his urinal around 4-4:30 AM and the resident was sleeping. She stated the other times during the shift when he used his call light, the other CNA (CNA #3) had answered it. (CNA #3)- stated early in the shift the light was on and the resident had asked for the nurse. She noticed the wash basin and asked if she could empty it and she also emptied the urinal. She stated she emptied the urinal at least 2 more times during the shift and the resident did not ask for any other assistance. Charge Nurse-(RN #2)- stated when she went to the resident's room with a suppository with the CNA (CNA #4), the resident stated he already had one from earlier from the dayshift aide (CNA #1). The resident requested a wash basin and wash cloths and the aide (CNA #4) provided. She stated the resident later received an x-ray and no concerns were reported from x-ray techs, (Registered Nurse -RN #2) stated she gave the resident his medications at 8:30 PM and the resident did not express any needs. (CNA #2)- stated she arrived on duty at 7:30 AM on 4/20/2022 she was passing trays and took resident his tray, she noted he was soiled and needed to be changed. She finished passing trays and cleaned him up. He told her he had been sitting soiled since the shift change the previous night (4/19/2022). Review of the facility investigation conclusion showed the resident was alert and oriented and able to express his needs. He was not on a check and change program due able to express his needs. Staff was not asked to change him the night on 4/19/2022 and staff reported they did not smell any bowel movement in the resident's room. Resident was added to a check and change of brief to ensure needs were met even if not verbalized. During an interview on 5/24/2022 at 12:55 PM, CNA #1 stated on 4/19/2022, .I went in there and was picking up dinner trays about 5:55 PM he told me he had been waiting on a suppository all day . The CNA stated he told the nurse (Licensed Practical Nurse-LPN #1). He stated he took the suppository to the resident close to shift change with the nightshift and the resident had not turned on his call light after he laid the suppository on the table and left the room. During an interview on 5/24/2022 at 1:54 PM, LPN #1, stated on 4/19/2022, CNA #1 had told her Resident #1 had asked for a suppository and she had obtained an order from the Nurse Practitioner. The LPN stated the resident had not mentioned needing a suppository to her when she gave him his medications. LPN #1 stated the CNA had told her the resident said he would administer it himself and she had given the suppository to the CNA. The LPN confirmed the resident had been provided with the suppository close to shift change with the night shift. During a telephone interview on 5/24/2022 at 2:53 PM, CNA #2, stated on the morning of 4/20/2022, .I went in there and we had trays [breakfast trays] on the racks and he said he was dirty and had been dirty for 15 hours since evening shift change the night before .you could smell it on him .I got him cleaned up and he said it reminds him of elder abuse .the charge nurse did not report it within 2 hours .I reported it to [RN #1] . She stated she had come on shift around 7:30 AM and the resident had reported the allegation to her. During an interview on 5/24/2022 at 3:27 PM, the Director of Nursing (DON) confirmed the report was sent to the State Survey Agency on 4/20/2022 at 4:59 PM. During an interview on 5/24/2022 at 3:32 PM, RN #1 stated a conversation was overheard about the resident stating he had not been checked all night, but it wasn't reported .directly to me . RN #1 stated CNA #1 had not reported an allegation of abuse. During a telephone interview on 5/24/2022 at 7:00 PM, RN #2 stated on 4/19/2022 it had shown on her Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #2 stated she had asked CNA #4 to go to Resident #1's room with her to assist her to position the resident so she could administer the suppository. RN #2 stated when she and CNA #4 entered the resident's room, he stated he did not need the suppository, but he did ask for a pan of water and some washcloths. RN #2 stated CNA #4 got the water and wash cloths and gave them to the resident. RN #2 stated the resident did not say he had a bowel movement or needed to be cleaned up. The RN stated the resident was able to tell staff when he had a bowel movement and request to be cleaned. The RN stated the resident had not made any complaints to her that night and she had been in the room later to give his medications and again the morning of 4/20/2022 prior to shift change. She stated she had not smelled bowel movement in the room any of the times she had been in the resident's room that night and he had not reported the need to be cleaned up to her. During a telephone interview on 5/24/2022 at 7:19 PM, CNA #4 stated she went into Resident #1's room on the night of 4/19/2022 with RN #2 because the nurse thought he needed a suppository. She stated when she and RN #2 entered the room, the resident said he didn't need a suppository .he said it was taken care of .he said he wanted a basin of water and a washcloth .he did have BM [bowel movement] on his fingers . CNA #4 stated she offered to help him clean his fingers and he refused assistance. The CNA stated the resident was alert and oriented and he never allowed the staff to help him with care other than to empty his urinal. She stated she had been in the room to empty the urinal later that night and did not smell any odor of a bowel movement during the night. CNA #4 stated most of the care he was offered was refused and he would say I can do it myself. During a telephone interview on 5/24/2022 at 8:01 PM, CNA #3 stated she had answered the resident's call light on the night of 4/19/2022 and he had asked her to empty his urinal. While in the resident's room, she noticed the wash basin and asked if he was through with the basin and he said yes, so she emptied the wash basin. CNA #3 stated the resident did not say why he had the wash basin, and he did not report he had a bowel movement. She stated she .did not smell anything [bowel movement] when I was in there [in the resident's room] . The CNA stated .I remember going in and emptying another little bit of urine [from the urinal] but I didn't smell any bowel .I went in on last round between 4:00 AM and 6:00 AM and I did not smell anything . The CNA stated the resident had not reported having a bowel movement or requested to be cleaned during the shift. During an interview on 5/25/2022 at 7:48 AM, the Social Services Director (SSD) stated on 4/20/2022 the resident came to her office in a wheelchair. The SSD stated .he [Resident #1] was asking for a suppository and the CNA brought him a suppository, when he [the resident] went to insert it, he had already went to the bathroom .he said he had asked for assistance .the CNA did not come back but 2 female CNAs came in and he asked for washcloth and basin .he said the aides didn't help clean him. He said no one had came to see him all night .he said the next morning that someone came in and cleaned him up . The SSD stated she then reported the incident to the Administrator and DON. During an interview on 5/25/2022 at 7:58 AM, the DON confirmed CNA #2 had been aware of the resident's allegation of abuse on 4/20/2022 at approximately 7:30 AM but the allegation had not been reported to the Administrator at that time. The allegation was reported to the DON on 4/20/2022 at 4:00 PM by the SSD at which time it had been reported to the State Survey Agency. The DON confirmed the allegation of abuse had not been reported timely.

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to ensure a resident was assessed for the ability to safely self-administer medications prior to being allowed to do so for 1 resident (Resident #1) of 6 residents reviewed. The findings include: Review of the facility policy titled, Administering Medications, revised 4/2019 showed, .Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely . Review of the facility policy titled, Self-Administration of Medications, revised 2/2021, showed .Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so . Record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating he was cognitively intact. Review of Resident #1's current physician's orders showed a physician's order dated 4/19/2022 for Dulcolax suppository [medication for constipation given via the rectum] 10 milligrams one per rectum daily for constipation. Medical record review showed no documentation a self-administration of medication assessment had been completed. Review of Resident #1's care plan showed no documentation the resident could self-administer medications. Review of the facility's investigation showed Resident #1 reported on 4/20/2022 that on the evening on 4/19/2022, he had requested a suppository. The resident stated a CNA (Certified Nursing Assistant -CNA #1) brought him a suppository and stated he could not administer the suppository. Further review showed the CNA stated he did take a suppository to the patient and left the room. The CNA reported he did not witness the resident administer the suppository or have a bowel movement. During an interview on 5/24/2022 at 12:55 PM, CNA #1 stated on 4/19/2022, .I went in there and was picking up dinner trays about 5:55 PM .he told me he had been waiting on a suppository all day . The CNA stated he told the nurse (Licensed Practical Nurse- LPN #1). He stated .the nurse [LPN #1] told me to just give it him to take .he [Resident #1] told me he could give it to himself .I laid it on the table and walked out . CNA #1 stated he told the resident he could not administer the suppository. During an interview on 5/24/2022 at 1:54 PM, LPN #1, stated on 4/19/2022, CNA #1 had told her Resident #1 had asked for a suppository and she had obtained an order from the Nurse Practitioner. LPN #1 stated, when CNA #1 came and told her the resident was needing a suppository, .there was a lot going on .I had a new admission who was dying, and the mother was standing there asking questions .and I was about to fall apart . LPN #1 stated the CNA had told her the resident said he would administer it himself and she had given the suppository to the CNA. The LPN confirmed resident's must be assessed for the ability to self-administer medication and Resident #1 had not been assessed for his ability to safely self-administer a suppository .there should have been [an assessment to self-administer] but this man had been so demanding that I didn't want to make him wait .it was just really bad judgement . During an interview on 5/24/2022 at 2:11 P, the Director of Nursing (DON), confirmed the resident should not have been allowed to self-administer a medication (the suppository) without first being assessed for the ability to do so. During an interview on 5/25/2022 at 7:58 AM, the DON confirmed the facility had not completed a self-administration of medication assessment for Resident #1.

Based on facility policy review, review of the facility Plan of Correction (POC) dated 10/18/2019 and 11/5/2021, medical record review, and interview, the facility's Quality Assurance Performance Improvement (QAPI) program failed to identify a quality deficiency and implement interventions to address the facility's failure to implement and effective falls prevention program which resulted in 3 residents (Resident #7, #1, and #13) sustaining falls with injuries and actual harm, and resulted in 8 residents (Residents #4, #5, #6, #8, #9, #11, #12, and #14) sustaining falls with potential for major injuries. The facility's failure resulted in Resident #7 sustaining a fall on 12/29/2021 which resulted in a laceration to the right side of the head which required 4 sutures, Resident #1 sustained a fall on 1/13/2022 which resulted in a right [CONDITION(S)], and Resident #13 sustained a fall on 2/5/2022 which resulted in a subdural hematoma (pooled blood between the brain and it's outermost covering) and a fall on 2/13/2022 which resulted in a superior and inferior pubic rami (pelvis) fracture and a L1 (first lower back vertebrae) compression fracture. The facility's failure to have an effective QAPI program placed Residents #7, #1, #13, #4, #5, #6, #8, #9, #11, #12, and #14 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements for participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator, Director of Nursing (DON), Regional Director of Clinical Services, Regional Minimum Data Set (MDS) Nurse, and Divisional Vice President of Operations were notified of the Immediate Jeopardy on 3/16/2022 at 6:18 PM. The facility was cited an Immediate Jeopardy at F-655 (K), F-657 (K) and F-689 (K). The facility was cited Substandard Quality of Care at F-689 (K). The Immediate Jeopardy was removed onsite and was effective 12/29/2021-3/16/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 3/17/2022 at 7:19 PM and the corrective actions were validated onsite by the surveyors on 3/17/2022. The findings include: Review of facility policy titled, Quality Assurance and Performance Improvement (QAPI) Plan, dated 5/2021, showed .This facility shall develop, implement, and maintain an ongoing, facility wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems .Provide a means to identify and resolve present and potential negative outcomes related to resident care and services .This committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments . Review of the facility policy titled, Assessing Falls and Their Causes, revised 3/2018 showed .The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall .Residents must be assessed upon admission and regularly afterward for potential risk for falls. Relevant risk factors must be addressed promptly .When a resident falls, the following information should be recorded in the resident's medical record .The condition in which the resident was found .Assessment data, including vital signs and any obvious injuries .Completion of a falls risk assessment .Appropriate interventions taken to prevent future falls . Review of the facility POC dated 10/18/2019, showed the facility was cited at F-689 for failure to provide an environment free of accident hazards. The facility POC showed the affected resident's care plan was reviewed and updated. Current residents' care plan interventions for falls were reviewed. Education was provided to the staff on following fall interventions and appropriate seating for residents. In the daily clinical meeting, the Interdisciplinary Team (IDT) was to review falls and fall interventions for appropriateness. Once the intervention was reviewed by the IDT, the therapy department or the Restorative department would assess that the intervention was in place. Current fall interventions would be reviewed after each fall for continued need, revision, update, or discontinuation in the daily clinical meeting. Fall interventions were to be reviewed quarterly with each MDS assessment by the IDT for continued need, revision, update, or discontinuation. The audits were to be completed daily times 2 weeks, then 3 times a week for 2 months on 10% of residents to ensure fall interventions were in place and being followed. Results of the audits would be reviewed in the monthly QAPI committee meeting. The QAPI committee was to review and discuss the findings and make suggestions for further review and or changes as needed. Review of the facility POC dated 11/5/2021, showed the facility was cited at F-689 for failure to report a fall to the nurse so the resident could be assessed for injury. The facility POC showed the affected resident was assessed and the physician was notified with new orders implemented. The Certified Nursing Assistant (CNA) was re-educated on reporting falls. The facility was to interview current staff to determine if any falls had not been reported. The facility staff were in-serviced on the process of reporting falls to a licensed nurse. Daily clinical meeting review of the 24-hour report and falls to ensure compliance and follow-up by the interdisciplinary team was implemented. The department managers would interview 5 staff 3 times per week for 4 weeks, then 2 times per week for 4 weeks, and then 1 time per week for a month. Failure to adhere to the facility process would result in disciplinary action. The facility would report of overall findings to the QAPI Committee to review progress, and/or need for amendment to any of the current plan of correction. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review for Resident #7 showed the resident was at high risk for falls and the fall risk assessment was not completed until 12/30/2021 (20 days after admission). On 12/29/2021 at 7:15 PM, Resident #7 was left in the bathroom unattended by the nurse and fell . The resident was sent to the emergency room and received 4 sutures for a laceration to the forehead. Resident #7 had another fall on 1/13/2022 at 3:00 PM and received a skin tear to the right elbow. The facility failed to implement an effective fall prevention program to ensure Resident #7 had fall risk assessments completed, fall investigations completed, appropriate interventions in place to prevent injuries from falls, and care plans in place. Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review for Resident #1 showed a Fall Risk Assessment Tool was not completed on admission for Resident #1. The resident had 5 falls between 12/21/2021 and 1/13/2022. On 1/13/2022 the resident had a fall that resulted in a [CONDITION(S)]. The facility failed to implement an effective fall prevention program to ensure Resident #1 had fall risk assessments completed, fall investigations completed, appropriate interventions in place to prevent injuries from falls, and care plans in place. Medical record review showed Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review showed Resident #13 was at high risk for falls. The resident had 6 falls between 12/11/2021 and 2/13/2022. The resident had a fall on 2/5/2022 at 1:30 AM and sustained a laceration to the right side of the forehead, swelling, and a subdural hemorrhage (pooling of blood between the brain and outermost covering). The resident had a fall on 2/13/2022 at 11:30 PM and sustained a subdural hematoma, a fractured pelvis and a L1 (spine) compression fracture. The facility failed to implement an effective fall prevention program to ensure Resident #13 had fall risk assessments completed, fall investigations completed, appropriate interventions in place to prevent injuries from falls, and care plans in place. Medical record review showed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review showed Resident #4 was a high risk for falls and had 2 falls between 12/2/2021 and 12/6/2021. The facility failed to implement an effective fall prevention program to ensure Resident #4 had fall risk assessments completed, fall investigations completed, interventions in place to prevent injuries from falls, and care plans in place. Medical record review showed Resident #5 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review showed Resident #5 was a high risk for falls, had 3 falls between 12/3/2021 and 12/9/2021. The resident was frequently observed with unsafe behaviors of climbing in and out of the bed and sustained a hematoma to the knee on 12/13/2021. The facility failed to implement an effective fall prevention program to ensure Resident #5 had fall risk assessments completed, fall investigations completed, interventions in place to prevent injuries from falls, and care plans in place. Medical record review showed Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review showed Resident #6 was a high risk for falls, had 5 falls between 10/25/2021 and 2/27/2022. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was to have a contour mattress in place to prevent falls and observations showed the resident did not have a contour mattress in place. The facility failed to implement an effective fall prevention program to ensure Resident #6 had fall risk assessments completed, fall investigations completed, interventions in place to prevent injuries from falls, and care plans in place. Medical record review showed Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review showed Resident #8 did not have a fall risk assessment completed and had a fall 3 days after admission to the facility. The facility failed to implement an effective fall prevention program to ensure Resident #8 had fall risk assessments completed, fall investigations completed, interventions in place to prevent injuries from falls, and care plans in place. Medical record review showed Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review revealed Resident #9 had 2 falls in 2 days. The resident was a high falls risk with no interventions implemented to address the resident's risk for falls. The facility failed to implement an effective fall prevention program to ensure Resident #9 had fall risk assessments completed, fall investigations completed, interventions in place to prevent injuries from falls, and care plans in place. Medical record review showed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review revealed Resident #11 had 2 falls and had to be sent to the emergency room (ER) for a head injury. The resident was a high falls risk. The facility failed to implement an effective fall prevention program to ensure Resident #11 had fall risk assessments completed, fall investigations completed, interventions in place to prevent injuries from falls, and care plans in place. Medical record review showed Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review showed Resident #12 was a moderate risk for falls. The resident had a fall on 3/4/2022, witnessed by a Certified Nursing Assistant, and was not reported timely to the nurse. An investigation was not completed timely, fall risk assessment was not completed, and the care plan was not updated timely. Medical record review showed Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review revealed Resident #14 had 2 falls between 1/22/2022 and 2/26/2022. The resident was a high falls risk and was supposed to have room close to the nurse's station. The resident's room was not close to the nurse's station during the 2 falls. The facility failed to implement an effective fall prevention program to ensure Resident #14 had fall risk assessments completed, fall investigations completed, interventions in place to prevent injuries from falls, and care plans in place. During an interview on 3/15/2022 at 1:18 PM, the DON stated she started as the DON in this facility in December 2021. She stated she did not get a computer for 2-3 weeks and did not get a sign in for the computer for 1 month. The DON was not able to look up medical records for the residents that had falls. The DON stated there was no one overseeing falls at this facility when she started, and she was told she was to oversee the fall prevention program but was not told what her responsibilities were for the fall prevention program. She stated .because I've been a DON for a long time, they assumed I knew it, but different companies have different policies and procedures . The DON stated the nurse who completed the admission for a resident was responsible to complete the Fall Risk Assessment Tool and if the resident was identified as being at high risk for falls then interventions should be put into place for fall prevention by initiating a fall risk care plan. The DON stated she was unsure if all nurses had been trained on how to initiate a baseline care plan. The DON confirmed the baseline care plan should be started on admission. The admission nurse .is responsible to at least get it [baseline care plan] started .other people can add their part . and a falls risk baseline care plan should be completed as soon as the resident has been identified as high risk for falls. The DON confirmed the baseline care plan was to be completed within 48 hours of the resident's admission to the facility. The DON confirmed the floor nurses were not initiating care plans and stated .I think that the nurses on the floor have not been trained to do it or they just don't do it . The DON stated she and the ADON had been doing the baseline care plans for the past 2 weeks after they identified a concern with falls .just trying to get everything caught up .we need to get them caught up . The DON stated she had been training nurses on how to initiate and revise care plans and stated .we are going in and showing them how .I don't know how many nurses I've went in and showed them how to do a care plan this week .they didn't know how . The DON stated falls were to be discussed in the morning clinical meetings, but they were held sporadically and only about once per week. She stated during the clinical meetings, falls were discussed to see if a new intervention had been added but .didn't drill down any farther if the intervention sounded appropriate then that was it .the incident was finished, and the care plan was put in . The DON confirmed fall risk assessments were to be completed upon admission and quarterly. She stated she had recently been educated that fall risk assessments were also to be completed after each fall. The DON attended QAPI meetings. The DON confirmed the facility had not followed their policy to complete fall risk assessments and did not add new fall interventions to prevent and protect residents from injury during falls .It's a system failure . During an interview on 3/15/2022 at 3:27 PM, the Medical Director (MD) stated the previous Administrator had her attend a .work group . with various department heads where they did discuss falls. The MD stated the work group meeting occurred in .late December [2021] or January [2022] . The MD stated the facility wanted to create a code pink which is a response to falls. The MD stated the previous Administrator (the Administrator resigned 2/2022) wanted to make sure the facility systemized a response to falls. The MD stated her input for the meeting was to be available to review the medications the residents were taking after a fall. She stated the previous Administrator had provided her with some data related to falls last month (2/2022) but it was not trending data, just the number of falls from the previous month. The MD stated falls were reviewed in QAPI, but it was only the number of falls that had occurred and there had been no discussion of any details of the fall process or any issues related to falls. The MD confirmed the fall Resident #7 had on 12/29/2021 while left unattended in the bathroom in which she sustained a laceration to the right side of her forehead which required 4 sutures had caused the resident actual harm. The MD stated Resident #1 had a fall prior to admission and sustained a fractured left hip and then fell at the facility on 1/13/2022 and sustained a fracture to the other hip (right). The MD confirmed a resident with a [CONDITION(S)] would experience increased pain with movement. The MD confirmed the fracture had caused Resident #1 actual harm. The MD further confirmed Resident #13 had sustained actual harm when he fell on [DATE] which resulted in a subdural hematoma and on 2/13/2022 which resulted in a pelvic fracture and a L1 compression fracture. During an interview on 3/15/2022 at 7:24 PM, the Regional Director of Clinical Services (RDCS) stated the corporation had taken ownership of the facility on 8/1/2021. At that time, the policies had been reviewed and the previous Administrator and previous DON were provided access to the policies, but the RDCS was unsure if the previous Administrator or previous DON had trained any other staff. The RDCS stated she was not aware if staff had access to the policies. The RDCS stated when the current DON started at the facility in December 2021, the RDCS was unable to communicate with the DON for the first few weeks. The RDCS stated she had discussed falls with the previous DON and the previous DON had been having clinical meetings each morning at 9:00 AM, but the meeting was often .pushed back . by the previous Administrator or sometimes no one would show up for the meetings. The RDCS stated the previous DON left the facility in 10/2021 and the facility had an interim DON for a few weeks before the current DON started. The RDCS stated the interim DON had not received orientation from the previous DON and the current DON did not receive orientation from the interim DON. The RDCS stated the facility started the clinical meetings again since the surveyors had been at the facility. She stated 2 falls had been discussed in the clinical meeting this morning (3/15/2022) but confirmed no root cause analysis had been completed for those falls to determine appropriate interventions. The RDCS stated the facility had started a Performance Improvement Plan (PIP) for falls on 2/28/2022 to address interventions not being added after falls, but the PIP did not include the entire fall process. The RDCS confirmed the breakdown in the falls process occurred when oversite was not provided during the transition of DONs to ensure the facility fall prevention program was followed. During an interview on 3/16/2022 at 10:16 AM, the RDCS stated the Plan of Corrections (POC) from the previous accident deficiencies were not effective. She stated the last accident deficiency in 10/2021 showed staff were to be educated to report falls, educated on what a fall was, and the facility had focused on one part of the fall system and not the whole process. She stated the facility focused on knowing when a fall occurred and .not the intent of the regulation only what we were cited for . The RDCS confirmed the facility's last POC from 10/2021 had not been effective to identify the failure of implementation of the falls process. She confirmed the previous POC should have been taken to QAPI and the falls process should have been reviewed every month until they reached substantial compliance or reviewed more often if needed. The RDCS also confirmed the fall process should have been taken to QAPI after the incident on 12/29/2021 when Resident #7 had a fall and sustained a laceration that required 4 sutures. Continued interviewed confirmed Resident #7 did not have a baseline care plan in place, was not assessed or identified as a falls risk on admission. The RDCS confirmed the facility should have identified the quality deficiency related to the failure of the falls process. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was provided on 3/17/2022 at 7:30 PM, and the corrective actions were validated on-site by the surveyors on 3/17/2022 through review of care plans, fall risk assessments, audits, education, and staff interviews. Based on facility policy review, medical record review, fall investigation review, interview, and facility census review, the facility failed to revise comprehensive care plans after falls for 6 residents (Resident #1, #13, #6, #7, #12, and #14) of 8 residents reviewed for comprehensive care plans. The facility's failure resulted in Resident #1 falling on 1/13/2022 and sustaining a right [CONDITION(S)], and Resident #13 falling and sustaining a subdural hematoma on 2/5/2022 and falling on 2/13/2022 and sustaining a superior and inferior pubic rami (pelvic) fracture and a L1 (first lower back vertebrae) compression fracture, which caused actual harm to Resident #1 and #13. The facility's failure placed Resident #1, #13, #6, #7, #12, and #14 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements for participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator, Director of Nursing (DON), Regional Director of Clinical Services, Regional Minimum Data Set (MDS) Nurse, and Divisional Vice President of Operations were notified of the Immediate Jeopardy on 3/16/2022 at 6:18 PM. The Immediate Jeopardy was removed onsite and was effective 1/6/2022 -3/16/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 3/17/2022 at 7:19 PM and the corrective actions were validated onsite by the surveyors on 3/17/2022. The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, showed .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . Review of the facility policy titled, Falls and Fall Risk, Managing, revised 3/2018, showed .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .The staff, with input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8, indicating the resident had moderate cognitive impairment. The resident required extensive assistance of 1 person for bed mobility, limited assistance of 1 person for transfers, supervision of 1 person to walk in the room, supervision with 1 person assistance for locomotion on the unit, and extensive assistance of 1 person for toileting. The resident had a fall within the last month prior to admission and had a fall within the last 6 months prior to admission. Review of Resident #1's fall investigation dated 1/6/2022 at 2:44 PM, showed the resident had a fall with no injury. Further review revealed .Evaluation Notes .Contour mattress for repositioning . Review of Resident #1's comprehensive care plan showed it was updated 1/21/2022, and there was an intervention of a contour mattress with a start date of 1/6/2022. The intervention was added to the care plan 15 days after the fall on 1/6/2022 and had not been revised timely. Review of Resident #1's fall investigation dated 1/9/2022, showed .No Injury Noted .WALKING OUT OF THE ROOM WITH WATER PITCHER IN HER HAND .Evaluation Notes .Ensure patient's water pitcher is full and in reach . Review of Resident #1's comprehensive care plan showed an intervention of .Ensure patient's pitcher has water and is in reach . Further review showed the intervention had a created date of 1/21/2022 (12 days after the fall). Review of Resident #1's fall investigation dated 1/13/2022, showed .I was in the room with [roommates name] tending to her .and heard [Resident #1] yelling in the hallway. I came out of the room and found her on the floor, she said her right arm and right leg hurt .Evaluation Notes .Sent to ER [emergency room ] Fx [fractured] hip . Review of Resident #1's comprehensive care plan showed an intervention .OT [Occupational Therapy] to screen for positioning with wheelchair/cushion . Further review showed the intervention had an edited date of 1/21/2021 (8 days after the fall) and had not been revised timely. Review of Resident #1's progress notes dated 1/15/2022, showed at 2:15 PM .Upon arriving on shift this nurse was given report of this patient possibly having a broken hip [right hip] from a fall that happened previously [1/13/2022] .patient having continuous complaints of pain .patient to be send [sent] to hospital for further evaluation .patient was being admitted with a fractured hip . Review of Resident #1's progress notes dated 1/22/2022, .Pt [patient] returned from [name of hospital] at 1100 [11:00 AM] .She has a displaced [fracture where the bone was moved out of its original position] .fx of the right femur [thigh bone] (incision [surgical cut] present), hx [history] of the left femur [left [CONDITION(S)]] . During an interview on 3/9/2022 at 10:48 AM, Registered Nurse (RN) #4 stated she was assigned to Resident #1 when she fell on [DATE]. The RN stated Resident #1 was walking with a water pitcher in her hand and .just slipped . The RN confirmed the resident was not safe to be walking unassisted. RN #4 confirmed she had not revised Resident #1's care plan with the new fall intervention after the fall on 1/9/2022. During an interview on 3/15/2022 at 1:18 PM, the DON confirmed Resident #1 did not have an immediate intervention added to the care plan after the 1/6/2022 fall. She confirmed Resident #1's fall intervention for the contour mattress, which was a new intervention to be put into place after the 1/6/2022 fall, had not been added to the comprehensive care plan until 1/21/2022 (15 days after the 1/6/2022 fall). The DON confirmed the contour mattress was added to the care plan after the 1/13/2022 fall. The DON stated the facility knew Resident #1 was at risk for falls when she was admitted and stated .that's why she came here .she fell and broke her hip [left hip] . The DON confirmed Resident #1's comprehensive care plan had not been revised timely after her falls. The DON confirmed the resident had a fall on 1/13/2022. The resident began complaining of pain in her right hip on 1/14/2022. The resident was sent to the hospital on 1/15/2022 and was found to have sustained a right [CONDITION(S)] from the fall. The DON confirmed the comprehensive care plan had not been revised with a new fall intervention after the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review showed Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's admission MDS assessment dated [DATE], showed a BIMS score of 8, indicating the resident had moderate cognitive impairment. The resident required limited assistance of 1 person for bed mobility, transfers, and dressing, and required supervision to walk in room and for toilet use. The resident required extensive assistance of 2 people for personal hygiene and had a fall prior to admission to the facility and a fall care plan was to be developed. Review of Resident #13's facility fall investigation dated 12/11/2021, showed the resident had an unwitnessed fall in the resident's room with no injury. The new fall intervention was a chair alarm. Further review showed .Evaluation notes .FALL MATS AT BEDSIDE . Medical record review of Resident #13's comprehensive care plan dated 12/11/2021 showed the care plan included only 2 areas of concern - activities of daily living (ADL) function/rehabilitation potential and activity participation. Review showed .ADL Functional/Rehabilitation Potential .Resident able to get on ground noted does get off bed and gets in floor for no apparent reason and does use fall mates [mats] can go to fall mate [mat] if desires . There was no care plan to address the resident's fall risk and no interventions to prevent falls. Review of Resident #13's fall investigation dated 12/16/2021, showed the resident had an unwitnessed fall in the resident's room at 5:05 AM with no injury. An intervention was added for fall mats at the bedside and to move the resident closer to the nurse's station. Review of Resident #13's comprehensive care plan showed the care plan had not been revised to include the interventions of fall mats at the bedside and to move the resident closer to the nurse's station after the fall on 12/16/2021 at 5:05 AM. Review of Resident #13's fall investigation dated

Based on facility policy review, medical record review, facility investigation review, hospital documentation review, interview, facility census review, and observation, the facility failed to provide adequate supervision to prevent falls for 3 residents (#7, #1 and #13); failed to implement interventions to prevent falls for 10 residents (#7, #1, #13, #4, #5, #6, #8, #9, #11, and #14); failed to complete fall risk assessments for 11 residents (#7, #1, #13, #4, #5, #6, #8, #9, #11, #12, and #14); failed to complete post fall documentation for 6 residents (#7, #1, #13, #8, #12, and #14); and failed to complete a thorough investigation to determine the cause of the fall for 11 residents (#7, #1, #13, #4, #5, #6, #8, #9, #11, #12, and #14) of 11 residents reviewed for accidents. The facility's failure to implement an effective fall prevention program to prevent falls for residents at high fall risk resulted in Resident #7 sustaining a laceration to the right side of the head which required 4 sutures after a fall on 12/29/2021; Resident #1 sustaining a right [CONDITION(S)] after a fall on 1/13/2022; and Resident #13 sustaining a subdural hematoma after a fall on 2/5/2022, and on 2/13/2022 the resident sustained a superior and inferior pubic rami (pelvis bone) fracture and L1 (first vertebra of the lower back) compression fracture (when the bone collapses). The facility's failure placed Residents #7, #1, #13, #4, #5, #6, #8, #9, #11, #12, and #14 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements for participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator, Director of Nursing (DON), Regional Director of Clinical Services, Regional Minimum Data Set (MDS) Nurse, and Divisional Vice President of Operations was notified of the Immediate Jeopardy on 3/16/2022 at 6:18 PM. The facility was cited an Immediate Jeopardy at F-689 (K), which constitutes Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective 12/29/2021-3/16/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 3/17/2022 at 7:19 PM and the corrective actions were validated onsite by the surveyors on 3/17/2022. The finding include: Review of the facility policy, titled Falls and Fall Risk, Managing, revised 3/2018, showed .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling .If falling reoccurs despite initial interventions, staff will implement additional or different intervention, or indicate why the current approach remains relevant . Review of the facility policy, titled Assessing Falls and Their Causes, revised 3/2018, showed .Review the resident's care plan to assess for any special needs of the resident .Residents must be assessed upon admission and regularly after for potential risk of falls. Relevant risk factors must be addressed promptly .assess resident's level of consciousness and neurological status .and After a Fall .If resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities .Obtain and record vital signs .Notify the resident's .physician and family .Observe for delayed complications of a fall for approximately .48 .hours .will document findings in the medical record .Document .any changes in level of responsiveness/consciousness [neurological checks] and overall function .Complete an incident report for resident falls no later than 24 hours after the fall occurs. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing .Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident .Documentation .When a resident falls, the following information should be recorded in the resident's medical record .The condition in which the resident is found .Assessment data, including vital signs .Interventions, first aid, and or treatment .Notification of physician and family .Completion of a falls risk assessment .Appropriate interventions taken to prevent future falls .The signature and title of the person recording the data . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] with Behavior Disturbance, Hypertension, [CONDITION(S)], and Abnormalities of Gait. Review of a Fall Risk Assessment Tool for Resident #7 showed the observation date was 12/10/2021, but the tool had an electronic stamp indicating it was completed on 12/30/2021 (20 days after admission). Review of the tool showed the resident was assessed as high risk for falls. Medical record review revealed there was no documentation of interventions that were implemented to prevent falls for Resident #7. Review of Resident #7's MDS assessment dated [DATE], showed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #7 had severe cognitive impairment. The resident required extensive assistance of 1 staff for bed mobility and dressing and was totally dependent of 1 staff for personal hygiene and toilet use. The resident had a fall in the past month prior to admission, and in the past 6 months prior to admission. Review of Resident #7's progress note dated 12/29/2021, showed .Resident was observed wandering the hall. Resident had very poor gait and very poor safety awareness. Resident stated that she needed to Pee and was going to pee on herself. Resident was assisted to the toilet. Resident was under observation during this process related to the residents poor safety awareness. While resident was sitting on the toilet her roommate called out for assistance. Nurse exited the residents restroom and asked the resident [roommate] if she could wait just a movement [moment]. During that statement a loud thud was heard. Nurse looked back into the restroom and observed the resident [#7] lying in front of the toilet .blood was observed coming from the resident head . Review of a fall investigation for Resident #7 dated 12/29/2021 at 7:15 PM, showed .Resident had very poor gait and very poor safety awareness .Resident was assisted to the toilet .Nurse exited the resident's restroom and asked the resident [roommate] if she could wait just a movement [moment] .Nurse looked back into the restroom and observed the resident [#7] lying in front of the toilet .blood was observed coming from the resident head .EMS [emergency medical system] called .transported to Hospital ER [emergency room ] . Review of the documentation showed there was no indication the facility conducted an investigation to determine the cause of the fall in order to determine interventions needed to prevent recurrence. The documentation did not indicate what fall interventions, if any, were in place at the time of the fall. Review of Resident #7's Hospital Emergency documentation dated 12/30/2021, showed .pt [patient] presents from [name of facility] for a fall .pt has a large hematoma [collection of blood outside a blood vessel resulting in bruising] to her right forehead .Patient fell from standing position .noted to have hematoma and laceration to the forehead .skin .2.5 cm [centimeters] deep laceration .to the right forehead .Laceration closed using sutures . The resident was discharged from the emergency roiagnom on [DATE] at 4:50 AM. Review of Resident #7's progress note dated 12/30/2021 at 5:22 AM, showed .Resident arrived at the facility .Resident has 4 stitches [sutures] that were observed on right side of forehead . Medical record review showed there were no documented assessments including neurological (neuro) checks for Resident #7 after she sustained a head injury requiring sutures on 12/29/2021. Review of Resident #7's care plan dated 12/30/2021, showed .At risk for fall related injury related to: 12/29/2021 fall. Risk factors present as determined by the Fall Risk Screening. Fall Risk score 23 [high risk for falls] . with interventions including .Toileting program assist resident to toilet before meals and at bedtime .Adequate glare free lighting .Area free of clutter .Low/Platform Bed .Non-slip socks/shoes .Observe for and/or report to nurse side effects of any drugs .Provide/observe use of adaptive devices .Wheelchair .Referral for screen & treatment as needed .PT [Physical Therapy] .Report falls to physician and responsible party .Use call light and request assistance prior to transfers/ambulation [Resident #7 had severe cognitive impairment] . Further review showed no interventions were implemented to address the resident's poor safety awareness and to not be left unattended in the bathroom. Review of the resident census showed Resident #7 was moved to a room closer to the nurse's station on 1/12/2022 at 10:04 PM. Review of a fall investigation for Resident #7 dated 1/13/2022 at 3:00 PM, showed the resident had a 2nd fall that was witnessed by the roommate. Continued review showed .FALL SKIN TEAR TO RIGHT ELBOW .AT BATHROOM DOOR-TRYING TO SHUT DOOR PER ROOM MATE . The facility investigation did not include details of the fall or witness statements; did not indicate if interventions implemented on the 12/30/2021 care plan including low bed, non-slip socks/shoes, and toileting program were in place at the time of the fall; and there was no documentation the facility completed an investigation to determine the cause of the fall. Medical record review showed a nurse's note was not completed after Resident #7's fall on 1/13/2022. Medical record review showed a Fall Risk Assessment was not completed after Resident #7's fall on 1/13/2022. Review of Resident #7's care plan dated 1/13/2022, showed a new intervention was added to move Resident #7 closer to the nurse's station, which had already been implemented 1/12/2022. There were no interventions implemented to address the cause of the fall on 1/13/2022. During an interview on 3/10/2022 at 10:44 AM, Physical Therapist (PT) #1 stated Resident #7 was evaluated by PT on 12/11/2021 and discharged from PT on 1/19/2022. PT #1 stated Resident #7 required maximum assistance of 1 staff for bed mobility and transfers, had instability in standing, had impaired safety awareness, and was a fall risk. Further interview confirmed Resident #7 had poor trunk control and was not safe to leave unattended in the bathroom. During an interview on 3/10/2022 at 4:40 PM, Registered Nurse (RN) #4 stated Resident #7 had a fall on 1/13/2022 that was witnessed by the resident's roommate. Resident #7 had an agency nurse assigned to her on 1/13/2022. RN #4 stated the agency nurse and a Certified Nursing Assistant (CNA) assisted Resident #7 from the floor. RN #4 stated the agency nurse should have documented a nurse's note after the fall. RN #4 did not have the thorough information including details of the fall to complete the falls investigation. RN #4 was not aware a fall risk assessment was to be completed after a fall. RN #4 added the room change to be closer to the nurse's station to the care plan as a new intervention after the 1/13/2022 fall because .I was trying to cover the fall . After reviewing the resident census, RN #4 confirmed Resident #7 had been moved to a new room on 1/12/2022, the day before her fall on 1/13/2022, and there were no new interventions implemented to address the cause of the fall on 1/13/2022. During a telephone interview on 3/14/2022 at 11:58 AM, Licensed Practical Nurse (LPN) #5 stated he was the nurse on duty on 12/29/2021. He stated on 12/29/2021, he observed Resident #7 ambulating in the hall without clothing or footwear, and he assisted her to the bathroom. LPN #5 stated Resident #7 was confused, not able to use the call light, and leaned while seated on the toilet on 12/29/2021. LPN #5 had never seen Resident #7 out of bed before 12/29/2021. The LPN stated he heard a family member call for him and he told Resident #7 to stay on the toilet and he left the resident unattended in the bathroom. LPN #5 was unsure if Resident #7 understood to wait for assistance. LPN #5 heard .her head hit the wall . The LPN stated Resident #7 was on the floor bleeding from her head. He sent the resident to the emergency room . LPN #5 confirmed he did not complete a fall risk assessment and did not implement any interventions to prevent further falls after Resident #7's fall on 12/29/2021. During an interview on 3/15/2022 at 1:18 PM, the DON confirmed Resident #7's fall risk assessment dated [DATE] was completed on 12/30/2021, after the resident had a fall on 12/29/2021. The DON discovered the resident did not have an admission fall risk assessment and the DON attempted to complete one on 12/30/2021. She stated no fall risk assessment was completed after the 1/13/2022 fall. Further interview confirmed Resident #7 had cognitive impairment and the intervention to remind the resident to use the call light was not appropriate. She confirmed there were no interventions for supervision of the resident implemented after the resident fell and received 4 sutures on 12/29/2021, and no immediate intervention was implemented after the resident returned from the ER. She confirmed the fall investigation was incomplete for Resident #7's fall on 1/13/2022. The DON stated the facility had no evidence neuro checks had been completed after the resident sustained a head injury on 12/29/2021. The DON stated Resident #7 was moved to a different room on 1/12/2022, the day before the fall on 1/13/2022, and there were no new interventions implemented to address the cause of the fall on 1/13/2022. During an interview on 3/15/2022 at 3:27 PM, the Medical Director (MD) confirmed the fall Resident #7 had on 12/29/2021 while unattended in the bathroom resulted in a laceration to the right side of her forehead which required 4 sutures and caused the resident actual harm. Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses including Fracture of Left Femur, Dementia with Behavioral Disturbance, Difficulty Walking, Abnormalities of Gait and Mobility, and Lack of Coordination. Medical record review showed a Fall Risk Assessment Tool was not completed on admission for Resident #1. Medical record review revealed there was no documentation of interventions that were implemented to prevent falls for Resident #1. Further review showed the resident was admitted to the facility after she had a fall at another facility and sustained a left [CONDITION(S)]. Review of Resident #1's progress note dated 12/21/2021, showed the resident had a witnessed fall with no injury. Review of a facility fall investigation for Resident #1 dated 12/21/2021 a 6:00 AM, showed the resident was witnessed ambulating in the resident's room and fell backwards to a sitting position with no injury. The resident had nonskid socks in place but the .skid part of socks worn sideways . The immediate intervention on the fall investigation was to provide rest for the resident. Further review showed an evaluation note .Increased staff supervision with intensity based on resident need . There was no indication an investigation was completed to determine the cause of the fall and no intervention was added to address incorrect use of nonskid socks. Medical record review showed a Fall Risk Assessment Tool was not completed after Resident #1's fall on 12/21/2021. Review of Resident #1's 5-day MDS assessment dated [DATE], showed Resident #1 had a BIMS score of 8, which indicated the resident had moderate cognitive impairment. Resident #1 required extensive assistance of 1 staff for bed mobility and toileting, limited assistance of 1 staff for transfers, and walked in the room with supervision of 1 staff member. The resident had a fall within the last month prior to admission and had a fall within the last 6 months prior to admission. Review of a Fall Risk Assessment Tool dated 1/1/2022, showed the resident was assessed as high risk for falls. Medical record review of Resident #1's care plan dated 1/1/2022, showed .Assist with toileting and transfers PRN [as needed] .Complete designated Fall Risk screening tool on admission [the resident was admitted on [DATE] with fall risk assessment tool completed on 1/1/2022, 12 days after admission] .Cue for safety awareness [Resident #1 had moderate cognitive impairment] . Review of Resident #1's progress notes dated 1/3/2022, showed the resident had a 2nd fall.Resident noted to have fall with no injury in room beside bed. Resident attempting to transfer from bed to wheelchair, tripping on legs of side table in the process. Resident assessed per writer with mild left leg pain, although no injury, noted. Resident returned to bed without issue. Event note completed. Will continue to monitor . Review of Resident #1's fall investigation dated 1/3/2022 at 1:00 PM, showed .Resident noted to have returned from therapy with mild anxiety present. As visualized per writer, resident noted to attempt ambulation from bed to wheelchair, tripping on the legs of the side table. Resident in a right side laying position on the floor with mild complaints of left leg pain. Resident assessed per writer and returned to bed once deemed safe .Evaluation notes .Toileting program . Further review showed an intervention to keep area clear and safe. There was no indication an investigation was completed to determine the cause of the fall and no documentation of what fall interventions, if any, were in place at the time of the fall. Medical record review showed a Fall Risk Assessment Tool was not completed for Resident #1 after the fall on 1/3/2022. Review of Resident #1's care plan updated 1/3/2022, showed an intervention to keep environment safe and uncluttered and prompted toileting after lunch. Review of Resident #1's progress note dated 1/4/2022, showed Resident #1 complained of pain to the left hip and leg after the fall on 1/3/2022 and an x-ray was ordered. Review of Resident #1's progress note dated 1/5/2022 at 7:08 PM, showed patient returned from ER .xray were clear . Review of Resident #1's progress note dated 1/6/2021, showed the resident had a 3rd fall .experienced fall this shift while attempting to self transfer into a wheelchair, resident baseline confused and unable to give detailed explanation. No injury noted, resident has no c/o [complaints of] pain. Resident helped back into bed and reeducated on call light use [Resident #1 had moderate cognitive impairment] for any needs . Review of Resident #1's fall investigation dated 1/6/2022 at 2:44 PM, showed the resident had a fall with no injury. There was no other documentation noted on the fall investigation including vital signs, assessment, details of the fall, and no immediate intervention to prevent further falls was implemented. There was no indication an investigation was completed to determine the cause of the fall and no documentation of whether the fall interventions of safe uncluttered environment and prompted toileting was implemented at the time of the fall. Further review revealed .Evaluation Notes .Contour mattress for repositioning . Medical record review showed a Fall Risk Assessment Tool was not completed after Resident #1's fall on 1/6/2022. Review of Resident #1's care plan showed it was updated with an intervention of a contour mattress with a start date of 1/6/2022. Review of Resident #1's fall investigation dated 1/9/2022 at 4:00 PM, showed the resident had a 4th fall.No Injury Noted .WALKING OUT OF THE ROOM WITH WATER PITCHER IN HER HAND .Evaluation Notes .Ensure patient's water pitcher is full and in reach . Further review showed there was no documentation to indicate if any fall interventions, including the contour mattress was in place at the time of the fall. There was no documentation to indicate the water pitcher was empty at the time of the fall and investigation to determine the cause of the fall. Review of Resident #1's care plan showed .Ensure patient's pitcher has water and is in reach. BIMS 8 . with a start date of 1/9/2022. Review of the facility census showed Resident #1 was moved from a room located across the hall from the nurse's station to a room on the facility's COVID unit on 1/10/2022. The resident's room on the COVID unit was not near the nurse's station and was approximately halfway down the hallway from the nurse's station. Review of Resident #1's fall investigation dated 1/13/2022 at 5:54 PM, showed the resident had a 5th fall.I was in the room with [roommates name] tending to her .and heard [Resident #1] yelling in the hallway. I came out of the room and found her on the floor, she said her right arm and right leg hurt .Evaluation Notes .Sent to ER .Fx [fracture] hip . There was no other documentation on the fall investigation and no investigation into the cause or circumstances of the fall. The investigation did not show if the resident had been sitting in a wheelchair prior to the fall or if she had been walking independently. Medical record review showed there was no post fall documentation on 1/13/3022 to include details of the fall, observation of the resident for delayed complications, signs and symptoms of pain, swelling, bruising, deformity, decreased mobility, and changes in level of consciousness or overall function after Resident #1's fall on 1/13/2022. Review of Resident #1's care plan showed an intervention with an implementation date of 1/13/2022 .OT [Occupational Therapy] to screen for positioning and wheelchair/cushion . Review of Resident #1's progress notes dated 1/15/2022 at 2:15 PM, showed .Upon arriving on shift this nurse [LPN #2] was given report of this patient possibly having a broken hip from a fall that happened previously .patient to be send [sent] to hospital for further evaluation .patient was being admitted with a fractured hip . Review of Resident #1's progress note dated 1/22/2022, showed .Pt [patient] returned from [name of hospital] at 1100 [11:00 AM] .She has a displaced [when the bone is moved from its original position] .fx of the right femur [thigh bone] . Review of Resident #1's Fall Risk Assessment Tool dated 1/22/2022, showed the resident was assessed as high risk for falls. Review of Resident #1's Physical Therapy Evaluation dated 1/24/2022, showed .Reason for Referral/Current Illness .s/p [status post- after] L [left] [CONDITION(S)] and percutaneous pinning [surgery for the fracture] 12/14 [12/14/2021]. She had a second fall resulting in a R hip fx .fall risk . Review of Resident #1's Physician's History and Physical dated 1/25/2022, showed .advanced dementia and wandering behaviors transfers to recuperate from Right hip hemi-arthroplasty [hip surgery] after a fracture .She was found to have Covid + [positive] status .transferred to the Covid unit. There she fell [fall on 1/13/2022], unwitnessed, was evaluated by staff, and upon monitoring began showing signs of pain behavior referent to the right leg. Xrays were obtained .showed a R [CONDITION(S)] .had an inpatient stay at [name of hospital] .found to have a displaced .fracture of the R femur .treated .with a Right hip hemi-arthroplasty .now transferred for multi-disciplinary rehabilitation . During a telephone interview on 3/3/2022 at 10:05 AM, LPN #2 stated she had not received training at the facility regarding fall prevention. The LPN stated she was the nurse responsible for Resident #1 on 1/15/2022. LPN #2 received report from the previous nurse that Resident #1 had a fall. The LPN stated the resident was sent out to the hospital on 1/15/2022. During an interview on 3/9/2022 at 10:48 AM, RN #4 stated Resident #1 had a fall on 1/9/2022. Resident #1 was walking with her water pitcher through the door and slipped. RN #4 saw Resident #1 walking and .she ended up on the floor right as we were getting to her. She was walking alone . RN #4 stated Resident #1 was unsafe to ambulate independently. RN #4 stated the intervention for increased staff monitoring of Resident #1 (after the fall on 12/21/2021) was not done. She stated when the facility had residents up walking around and needed one to one supervision, it was difficult to supervise the residents. Further interview confirmed RN #4 did not implement any immediate interventions to prevent further falls after the fall on 1/9/2022. During an interview on 3/9/2022 at 4:00 PM, RN #5 stated Resident #1 was at high risk for falls due to a fall prior to admission and the resident had been placed in a room close to the nurse's station on admission because of her fall risk. RN #5 stated Resident #1 was very impulsive, would not wait for assistance, and would attempt to take herself to the bathroom. RN #5 stated the immediate intervention implemented after the fall 12/21/2021 was for the resident to rest. RN #5 stated the resident's next fall was on 1/3/2022. The resident tripped over her side table, and she was .maybe a little disoriented and maybe a little bit tired . The RN stated the new intervention he added had been to keep the room decluttered. He stated he did not add the intervention for prompted toileting to the care plan or the fall investigation on 1/3/2022. He stated that intervention was added later by the DON when she reviewed the 1/3/2022 fall investigation. The RN confirmed the resident had not expressed a need to be assisted to the bathroom at the time of the fall on 1/3/2022 and she wasn't able to express her needs to the staff. Continued interview revealed the intervention of prompted toileting was not appropriate for the fall on 1/3/2022. During an interview on 3/9/2022 at 4:51 PM, LPN #6 stated she was not provided training on the facility falls prevention program. LPN #6 stated Resident #1 was confused and could not comprehend to call the staff for assistance. Resident #1 required assistance for ambulation but frequently ambulated without assistance. LPN #6 stated the resident was not on a toileting program (intervention after the fall on 1/3/2022) and the resident would walk around her bed, transferring herself to the bed or the chair. The LPN stated Resident #1's room was in front of the nurse's station .we couldn't watch her 24/7 [24 hours a day, 7 days a week] . She stated the CNA's found Resident #1 in front of the chair on the floor on 1/6/2022. LPN #6 stated the intervention of the contour mattress after the fall on 1/6/2022 was not placed on Resident #1's bed on 1/6/2022. LPN #6 confirmed Resident #1 could not comprehend to use the call light to ask for assistance from staff (intervention in progress notes after the fall on 1/6/2022). During an interview on 3/10/2022 at 10:44 AM, PT #1 stated Resident #1 had a left [CONDITION(S)] on admission to the facility. Resident #1 required minimum assistance of 1 for bed mobility, required moderate assistance of 1 staff for transfers, was a falls risk, and had impaired safety awareness. PT #1 stated Resident #1 required assistance to ambulate. Further interview confirmed the PT evaluated Resident #1 on 1/24/2022 and Resident #1 had poor safety awareness, required maximum assistance with bed mobility and transfers, and was totally dependent for ambulation. During a telephone interview on 3/14/2022 at 9:17 AM, LPN #1 stated she did not receive training or education on the facility falls prevention program. LPN #1 stated she cared for Resident #1 on 1/14/2022 (1 day after Resident #1's fall on 1/13/2022). LPN #1 stated she did not recall a contour mattress being placed on the resident's bed. During a telephone interview on 3/14/2022 at 11:18 AM, CNA #1 stated Resident #1 was unsteady at times, could not use the call light, required total care, and was always incontinent of bowel and bladder. CNA #1 stated she worked on 1/13/2022 and 1/14/2022. The CNA stated Resident #1 had a fall on 1/13/2022 and CNA #1 and LPN #1 picked the resident up off the floor in the hallway and placed her in bed. CNA #1 stated Resident #1 was on the COVID unit. During an interview on 3/15/2022 at 1:18 PM, the DON confirmed the fall risk assessments were not completed. The DON confirmed she placed the prompted toileting program on the care plan. The DON stated .not 100% sure if the [contour] mattress was on the bed .call light intervention was not appropriate .don't think she would remember to use . The DON stated all water pitchers should be kept full and she was unsure if the water pitcher was empty at the time of the fall on 1/9/2022. Further interview confirmed Resident #1 .should not have been ambulating on her own .we knew she was a falls risk when we took her, that's why she came here .she was in an assisted living and fell and broke her hip [left] .the interventions did not include different measures of supervision . The DON stated Resident #1 had falls on 12/21/2021, 1/6/2022, and 1/9/2022 and no interventions were put in place until after the 1/13/2022 fall. Resident #1 sustained a [CONDITION(S)] (right), and no intervention was implemented until she returned from the hospital on 1/21/2022. During an interview on 3/15/2022 at 3:27 PM, the MD stated Resident #1 wandered frequently, and she wasn't safe to be wandering by herself. The MD stated Resident #1 had a fall prior to admission and sustained a fractured left hip and then fell at the facility on 1/13/2022 and sustained a fracture in the other hip (right). The MD confirmed the fracture had caused Resident #1 actual harm. Medical record review showed Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Metabolic [CONDITION(S)], Repeated Falls, Dementia with Behavior Disturbance, Delusions, and Anxiety Disorder. Review of Resident #13's Fall Risk Assessment Tool dated 11/22/2021, showed the resident was assessed as high risk for falls. Medical record review revealed there was no documentation of interventions that were implemented to prevent falls for Resident #13. Review of Resident #13's admission MDS assessment dated [DATE], showed the resident had a BIMs score of 8, which indicated the resident had moderate cognitive impairment. The resident had no behaviors, required limited assistance of 1 staff for bed mobility, transfers, and dressing, required extensive assistance of 2 staff for personal hygiene, and needed supervision to walk in the room and toilet use. Review of a facility fall investigation dated 12/11/2021 at 4:26 AM, showed Resident #13 had an unwitnessed fall in the resident's room with no injury. The resident had been lying on the bed prior to the fall. A new intervention of a chair/wheelchair alarm was implemented. Further review showed .NO INJURY NOTED .FALL MATS AT BEDSIDE . There was no indication an investigation was completed to determine the cause of the fall and no documentation of what fall interventions, if any, were in place at the time of the fall. Review of Resident #13's progress note dated 12/11/2021, showed .witnessed by tech [CNA] on floor by bottom of bed of roommate .stated [Resident #13] .he was walking in room no injury apparent .follow up neuro [neurological] checks . Review of Resident #13's Activities of Daily Living (ADL) Functional/Rehabilitation care plan dated 12/11/2021, showed .Resident able to get on ground noted does get off bed and gets in floor for no apparent reason .can go to fall mate [mat] if desires [Resident #13 required assistance with transfers per the 11/23/2021 MDS assessment] . The intervention for the use of a chair alarm was not added to the care plan. Review of a facility fall investigation for Resident #13 dated 12/16/2021 at 5:05 AM, showed the resident had a 2nd fall that was an unwitnessed fall in the resident's room without injur [TRUNCATED]

Based on facility policy review, medical record review, fall investigation review, interview, and facility census review, the facility failed to revise comprehensive care plans after falls for 6 residents (Resident #1, #13, #6, #7, #12, and #14) of 8 residents reviewed for comprehensive care plans. The facility's failure resulted in Resident #1 falling on 1/13/2022 and sustaining a right [CONDITION(S)], and Resident #13 falling and sustaining a subdural hematoma on 2/5/2022 and falling on 2/13/2022 and sustaining a superior and inferior pubic rami (pelvic) fracture and a L1 (first lower back vertebrae) compression fracture, which caused actual harm to Resident #1 and #13. The facility's failure placed Resident #1, #13, #6, #7, #12, and #14 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements for participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator, Director of Nursing (DON), Regional Director of Clinical Services, Regional Minimum Data Set (MDS) Nurse, and Divisional Vice President of Operations were notified of the Immediate Jeopardy on 3/16/2022 at 6:18 PM. The Immediate Jeopardy was removed onsite and was effective 1/6/2022 -3/16/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 3/17/2022 at 7:19 PM and the corrective actions were validated onsite by the surveyors on 3/17/2022. The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, showed .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . Review of the facility policy titled, Falls and Fall Risk, Managing, revised 3/2018, showed .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .The staff, with input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls .If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8, indicating the resident had moderate cognitive impairment. The resident required extensive assistance of 1 person for bed mobility, limited assistance of 1 person for transfers, supervision of 1 person to walk in the room, supervision with 1 person assistance for locomotion on the unit, and extensive assistance of 1 person for toileting. The resident had a fall within the last month prior to admission and had a fall within the last 6 months prior to admission. Review of Resident #1's fall investigation dated 1/6/2022 at 2:44 PM, showed the resident had a fall with no injury. Further review revealed .Evaluation Notes .Contour mattress for repositioning . Review of Resident #1's comprehensive care plan showed it was updated 1/21/2022, and there was an intervention of a contour mattress with a start date of 1/6/2022. The intervention was added to the care plan 15 days after the fall on 1/6/2022 and had not been revised timely. Review of Resident #1's fall investigation dated 1/9/2022, showed .No Injury Noted .WALKING OUT OF THE ROOM WITH WATER PITCHER IN HER HAND .Evaluation Notes .Ensure patient's water pitcher is full and in reach . Review of Resident #1's comprehensive care plan showed an intervention of .Ensure patient's pitcher has water and is in reach . Further review showed the intervention had a created date of 1/21/2022 (12 days after the fall). Review of Resident #1's fall investigation dated 1/13/2022, showed .I was in the room with [roommates name] tending to her .and heard [Resident #1] yelling in the hallway. I came out of the room and found her on the floor, she said her right arm and right leg hurt .Evaluation Notes .Sent to ER [emergency room ] Fx [fractured] hip . Review of Resident #1's comprehensive care plan showed an intervention .OT [Occupational Therapy] to screen for positioning with wheelchair/cushion . Further review showed the intervention had an edited date of 1/21/2021 (8 days after the fall) and had not been revised timely. Review of Resident #1's progress notes dated 1/15/2022, showed at 2:15 PM .Upon arriving on shift this nurse was given report of this patient possibly having a broken hip [right hip] from a fall that happened previously [1/13/2022] .patient having continuous complaints of pain .patient to be send [sent] to hospital for further evaluation .patient was being admitted with a fractured hip . Review of Resident #1's progress notes dated 1/22/2022, .Pt [patient] returned from [name of hospital] at 1100 [11:00 AM] .She has a displaced [fracture where the bone was moved out of its original position] .fx of the right femur [thigh bone] (incision [surgical cut] present), hx [history] of the left femur [left [CONDITION(S)]] . During an interview on 3/9/2022 at 10:48 AM, Registered Nurse (RN) #4 stated she was assigned to Resident #1 when she fell on [DATE]. The RN stated Resident #1 was walking with a water pitcher in her hand and .just slipped . The RN confirmed the resident was not safe to be walking unassisted. RN #4 confirmed she had not revised Resident #1's care plan with the new fall intervention after the fall on 1/9/2022. During an interview on 3/15/2022 at 1:18 PM, the DON confirmed Resident #1 did not have an immediate intervention added to the care plan after the 1/6/2022 fall. She confirmed Resident #1's fall intervention for the contour mattress, which was a new intervention to be put into place after the 1/6/2022 fall, had not been added to the comprehensive care plan until 1/21/2022 (15 days after the 1/6/2022 fall). The DON confirmed the contour mattress was added to the care plan after the 1/13/2022 fall. The DON stated the facility knew Resident #1 was at risk for falls when she was admitted and stated .that's why she came here .she fell and broke her hip [left hip] . The DON confirmed Resident #1's comprehensive care plan had not been revised timely after her falls. The DON confirmed the resident had a fall on 1/13/2022. The resident began complaining of pain in her right hip on 1/14/2022. The resident was sent to the hospital on 1/15/2022 and was found to have sustained a right [CONDITION(S)] from the fall. The DON confirmed the comprehensive care plan had not been revised with a new fall intervention after the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review showed Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #13's admission MDS assessment dated [DATE], showed a BIMS score of 8, indicating the resident had moderate cognitive impairment. The resident required limited assistance of 1 person for bed mobility, transfers, and dressing, and required supervision to walk in room and for toilet use. The resident required extensive assistance of 2 people for personal hygiene and had a fall prior to admission to the facility and a fall care plan was to be developed. Review of Resident #13's facility fall investigation dated 12/11/2021, showed the resident had an unwitnessed fall in the resident's room with no injury. The new fall intervention was a chair alarm. Further review showed .Evaluation notes .FALL MATS AT BEDSIDE . Medical record review of Resident #13's comprehensive care plan dated 12/11/2021 showed the care plan included only 2 areas of concern - activities of daily living (ADL) function/rehabilitation potential and activity participation. Review showed .ADL Functional/Rehabilitation Potential .Resident able to get on ground noted does get off bed and gets in floor for no apparent reason and does use fall mates [mats] can go to fall mate [mat] if desires . There was no care plan to address the resident's fall risk and no interventions to prevent falls. Review of Resident #13's fall investigation dated 12/16/2021, showed the resident had an unwitnessed fall in the resident's room at 5:05 AM with no injury. An intervention was added for fall mats at the bedside and to move the resident closer to the nurse's station. Review of Resident #13's comprehensive care plan showed the care plan had not been revised to include the interventions of fall mats at the bedside and to move the resident closer to the nurse's station after the fall on 12/16/2021 at 5:05 AM. Review of Resident #13's fall investigation dated 12/16/2021 at 4:00 PM, showed the resident had a witnessed fall from his wheelchair with no injury. Further review showed the new intervention added was to move the resident closer to the nurse's station. Review of Resident #13's comprehensive care plan initiated 12/16/2021, showed .Assess for placement closer to the nurses desk . was added to the care plan after the 12/16/2021 fall at 4:00 PM. Review of Resident #13's census showed the resident had been moved to a room closer to the nurse's station on 12/17/2021. Review of Resident #13's comprehensive care plan updated 1/1/2022, showed an intervention for fall mats at the bedside (16 days after the fall on 12/16/2021 at 5:05 AM). The care plan was not revised timely. Review of Resident #13's fall investigation dated 2/5/2022, showed the resident had an unwitnessed fall in the resident's room and sustained a laceration to his right forehead. The intervention was to move the resident closer to the nurse's station. Review of Resident #13's progress notes dated 2/5/2022 at 2:20 PM, showed .Pt [patient] has deep laceration to R [right] forehead that is approximated [closed] with steristrips [wound closure tape] .wound dressing was removed to be changed and revealed laceration was deep. Pt also began complaining of R rib pain .Pt sent via [by] ambulance to .hospital for further eval [evaluation] . Review of Resident #13's comprehensive care plan updated 2/5/2022, showed an intervention .Move closer to nurse's station . Further review showed the intervention had a created date of 2/18/2022 (13 days after the fall on 2/5/2022) and had not been revised timely. Review of Resident #13's progress notes dated 2/6/2022 at 2:18 PM, showed .returned from [name of hospital] at 0800 [8:00 AM] .No stitches were put in the laceration to the right forehead while in ED [emergency department] .a steri strip attached .Ct [cat scan] of brain/head .small actebsubdural [acute subdural] hematoma [a pool of blood between the brain and its outermost covering] .still have discomfort to his head and right outer chest . During a telephone interview on 3/14/2022 at 11:36 AM, Licensed Practical Nurse (LPN) #8 stated she had not received training on how to initiate and revise care plans. During a telephone interview on 3/14/2022 at 2:26 PM, LPN #9 stated she had not received any training on how to revise a care plan and stated she thought the team that reviewed the investigation would add an intervention into the care plan after a resident had a fall. The LPN stated she did not revise the care plan with a new intervention to prevent future falls. During an interview on 3/14/2022 at 3:03 PM, RN #6 stated she had not received any training on how to initiate or revise a care plan in the computer system. During an interview on 3/14/2022 at 5:44 PM, RN #2 confirmed she was assigned to Resident #13 when he had a fall on 12/16/2021 at 5:05 AM. The RN stated she had not revised the care plan to include the interventions of fall mats at the bedside, to keep the bed in low position, and to move the resident closer to the nurse's station. During an interview on 3/15/2022 at 1:18 PM, the DON confirmed Resident #13 had a fall on 12/11/2021 and the care plan had not been revised to include the intervention of a chair alarm. The DON confirmed Resident #13 had a fall on 12/16/2021 at 5:05 AM and the care plan had not been revised timely with the new interventions for fall mats at bed side, bed in low position, use of call light, and the resident to be moved closer to nurse's station. The DON confirmed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review showed Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's admission MDS assessment dated [DATE], showed the resident had a BIMS score of 2, indicating he had severe cognitive impairment. The resident required extensive assistance of 2 staff members for bed mobility and transfers, and extensive assistance of 1 staff for toileting. The resident had one fall since admission with no injury and he was incontinent of bowel and bladder. Review of Resident #6's fall investigation dated 12/12/2021, showed the resident had a fall without injury in the resident's room. The new fall intervention added was to apply non-slip socks. Review of Resident #6's comprehensive care plan showed it was updated on 1/1/2022, and an intervention for .Non-skid socks to be worn as resident allows . The intervention was added to the care plan 20 days after the fall on 12/12/2021 and had not been revised timely. Review of Resident #6's fall investigation dated 1/17/2022, showed .FALL WITNESSED BY ROOM MATE. RESIDENT TRYING TO GET OUT OF BED .RESIDENT IN FLOOR BESIDE OF BED . Review of Resident #6's comprehensive care plan updated on 1/17/2022, showed an intervention of .Contour mattress for positioning . Further review showed the intervention had a created date of 1/21/2022 (4 days after the fall on 1/17/2022) and had not been revised timely. Review of Resident #6's fall investigation dated 2/27/2022, showed the resident had an unwitnessed fall in the resident's bathroom. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's comprehensive care plan showed it was updated on 3/2/2022, 3 days after the fall on 2/27/2022, and an intervention of .Encourage use of wheel chair versus walking due to unsteady on feet . The care plan had not been revised timely. During an interview on 3/10/2022 at 5:02 PM, RN #5 confirmed Resident #6 had a fall on 12/12/2021 when the resident tried to walk from the bed to the doorway of his room. The RN stated he added nonskid socks as the new fall intervention. The RN confirmed he had not revised the resident's care plan for the intervention of nonskid socks after the fall on 12/12/2021. During an interview on 3/15/2022 at 1:18 PM, the DON confirmed Resident #6 had a fall on 12/12/2021 and the care plan had not been revised with the new fall intervention for the resident to wear nonskid socks until 1/1/2022. She confirmed she had revised the care plan on 1/21/2022 for the resident to have a contour mattress after the 1/17/2021 fall. The DON confirmed the care plan was not revised timely after the 2/27/2022 fall until 3/2/2022 to encourage the use of a wheelchair. The DON confirmed Resident #6's comprehensive care plan had not been updated timely after the falls on 12/12/2021, 1/17/2022, and 2/27/2022. Medical record review showed Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's admission MDS assessment dated [DATE], showed Resident #7 had a BIMS score of 3, indicating the resident had severe cognitive impairment. The resident required extensive assistance of 1 staff for bed mobility and dressing and was totally dependent on 1 staff for personal hygiene and toilet use. The resident had a fall in the past month prior to admission and in the past 6 months prior to admission. Review of the facility census showed Resident #7 was moved to a room closer to the nurse's station on 1/12/2022. Review of Resident #7's fall investigation dated 1/13/2022, showed Resident #7 had tried to shut the bathroom door and the resident's roommate had witnessed the fall. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's comprehensive care plan showed an intervention .Transfer to room closer to nurses station . Further review showed the intervention was created on 1/21/2022 and had not been revised timely (8 days after the fall on 1/13/2022 and 9 days after the resident had been moved on 1/12/2022). During an interview on 3/10/2022 at 4:36 PM, RN #4 confirmed she had completed Resident #7's fall investigation on 1/13/2022 but she was not the nurse assigned to the resident. The RN confirmed she had not revised the care plan with a new intervention. The RN stated the nurse assigned to the resident was an agency nurse and had not received training on what needed to be completed after a resident fall. During an interview on 3/15/2022 at 1:18 PM, the DON confirmed Resident #7 had a fall on 1/13/2022 and the care plan had not been revised timely with the interventions to prevent future falls. Medical record review showed Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's comprehensive care plan dated 3/21/2019, showed .risk for falls due to: requiring assist with all transfers an [and] toileting . Review of Resident #12's quarterly MDS dated [DATE], showed she had a BIMS score of 15, indicating she was cognitively intact. She required extensive assistance of 1 staff member for bed mobility, transfers, and toilet use, and had 1 fall since the last assessment with no injury. Review of Resident #12's fall investigation dated 3/4/2022, showed the resident slid to floor when getting out of the shower with a CNA in the bathroom. The resident stated she had nonskid socks on while in the shower. There was no injury noted with a new intervention for use of tennis shoes while in the shower. Review of Resident #12's care plan showed it was updated 3/8/2022 (4 days after the fall), to add the intervention for tennis shoes or water shoes to be used in the shower and nonskid mat in the wheelchair. The care plan was not updated timely. During a telephone interview on 3/14/2022 at 3:42 PM, RN #6 stated she was assigned to Resident #12 when she had a fall on 3/4/2022 but the CNA that assisted the resident from the floor had not reported the fall to the RN. RN #6 stated she did not revise the care plan to include a new intervention. During an interview on 3/15/2022 at 1:18 PM, the DON confirmed Resident #12 had a fall on 3/4/2022 witnessed by a CNA, but the fall had not been reported to the nurse. The DON confirmed the care pan had not been revised to include a new intervention until 3/8/2022 and had not been revised timely. Medical record review showed Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #14's quarterly MDS assessment dated [DATE], showed the resident had severe cognitive impairment. She required limited assistance of 1 staff member for bed mobility and transfers, required supervision of 1 staff member to walk, and extensive assistance of 1 staff member for toilet use. Review of Resident #14's fall investigation dated 2/26/2022, showed the resident had an unwitnessed fall while walking from her bathroom, with injury to her head and back. Further review showed .Pertinent Diagnosis .difficulty in gait and mobility .Indicate measures taken .rest . Review of Resident #14's comprehensive care plan showed it was updated on 3/2/2022 (4 days after the fall on 2/26/2022), with an intervention for .free to ambulate but has unsteady gait at times . The care plan was updated on 3/4/2022, (6 days after the fall on 2/26/2022) for .Non skid strips on floor and bathroom floor . The care plan had not been revised timely after the fall on 3/4/2022. During an interview on 3/15/2022 at 1:18 PM, the DON confirmed Resident #14 had a fall on 2/26/2022 with no immediate fall interventions added. The DON confirmed the care plan had not been revised until 3/2/2022 (4 days after the resident's fall on 2/26/2022). The DON confirmed the care plan had been revised on 3/4/2022 with an intervention for nonskid strips to the floor. She confirmed the care plan had not been revised timely. During an interview on 3/9/2022 at 10:48 AM, RN #4 stated the nurse who completed the fall investigation was responsible for adding a new intervention. RN #4 stated the new intervention would need to be passed to other staff in report or the other staff would need to review the fall investigation to see what new intervention was added. RN #4 stated she was unsure if all staff including Certified Nursing Assistants (CNA)'s would have access to see the fall investigation to see what new intervention had been put in place after a fall to provide care for the residents. During an interview on 3/15/2022 at 1:18 PM, the DON stated if the resident was identified as high risk for falls, then interventions should be put into place for fall prevention by initiating a fall care plan. The DON stated she was unsure if all nurses had access to resident care plans or if they had received training on care plan revision. The DON stated .I don't know how many nurses I've went in and showed them how to do a care plan this week .they didn't know how . An acceptable Removal Plan, which removed the immediacy of the jeopardy, was provided on 3/17/2022 at 7:30 PM, and the corrective actions were validated on-site by the surveyors on 3/17/2022 through review of care plans, fall risk assessments, audits, education, and staff interviews. The Removal Plan presented to the survey team by the facility documented the following immediate corrective actions implemented: Resident #1, #4, #5, #7, #8 and #9 had been discharged prior to 3/1/2022. On 3/8/2022 a licensed nurse completed a fall risk assessment for Resident #13. On 3/16/2022 a licensed nurse completed a fall risk assessment for Resident #6. On 3/16/2022 the ADON completed fall risk assessments for Residents #11, #12, and #14. All residents had a fall risk assessment completed by DON/ADON/Licensed Nurse between 3/4/2022 - 3/16/2022 and their care plans had been reviewed to ensure fall prevention interventions were in place by the Regional MDS/DON/ADON. The Regional MDS Nurse and the Divisional Vice President of Operations completed audits of all fall risk assessments and fall care plans to ensure that all residents had a current fall risk assessment and fall care plan on 3/17/2022. The Interdisciplinary Team (IDT) consisted of DON, ADON, Therapy, Housekeeping Supervisor and Activities. The IDT team did a resident room to care plan intervention comparison on 3/16/2022-3/17/2022, to ensure all interventions were implemented. All falls will have an event report entered into the electronic health record and will have a new fall risk assessment completed. All unwitnessed falls will have neuro checks initiated. A post incident investigation and management checklist will be initiated by the licensed nurse at the time of the fall, and it will be given to the DON or ADON and be reviewed in the morning clinical meeting. The post incident investigation and management check list included steps to complete the incident report and the investigation process. All fall incident reports entered into the electronic medical record will be printed out and reviewed during the clinical meeting to include, but not limited to the DON, ADON, Administrator, Therapy, MDS nurse, Activities, and Social Services. They will review the fall, review the root-cause, and ensure that the immediate care plan intervention is resident specific and appropriate. Full morning clinical meetings will be held Monday through Friday and led by the DON/ADON. The weekend manager on duty gathers information on events (falls), admits, discharges, and contacts the nurse on call to review. Beginning on 3/16/22, licensed nursing staff and certified nurse assistants had been re-educated by the DON/ADON or licensed nurse that an appropriate intervention needs to be initiated after each fall and the intervention is to be added to the fall care plan. The intervention needs to be resident specific and appropriate. The determination of an appropriate intervention will be determined by identifying the cause of the fall. Licensed Nurses were educated on the process to initiate and complete an incident report in the electronic medical record system which included entering all event information, including the date and time the event occurred and a short description/summary of the event, and completing the event details page questions including vital signs, orders, and progress notes. Licensed nursing staff had been educated to initiate the post incident investigation and management checklist. Staff not working including contracted staff will be re-educated prior to working. On 3/16/2022-3/17/2022 the Regional Director of Clinical Services compared the schedule to education sign in sheet to ensure all appropriate staff had been in-serviced prior to working. Residents with falls in the past 30 days had been reviewed to identify any trends by the Regional MDS Nurse and/or licensed nurse. The Administrator has direct oversight and responsibility to direct, discipline, and communicate areas of concern and process improvement including QAPI. On a weekly basis the Administrator will utilize the incident/occurrence worksheet to validate that the clinical team has completed all the aspects related to a fall event initiated on 3/17/2022. This form was developed on 1/4/2022 by the governing body. This includes reviewing the incident report, care plan with an appropriate resident specific intervention, a completed fall risk assessment, and a root cause. The QAPI program includes a systematic approach to address fall prevention and management. The QAPI committee will meet quarterly or more frequently to analyze all resident reportable incidents and make systematic changes to facility policies and practices to prevent and report adverse event occurrences. The Regional Director of Nursing and the Divisional Vice President of Operations in-serviced the Interdisciplinary team which included, the Administrator, DON, ADON, Social Service Director, Therapy Director, and MDS coordinator on using the 5 whys tool to help determine a root cause and on tracking and trending, using numbers/dates/times/locations of falls to look for patterns related to falls on 3/16/2022. Residents with a fall pattern were identified and reviewed to ensure appropriate fall interventions were in place and care planned by the Regional Director of Clinical Services on 3/16/2022. On 3/16/2022, a root cause analysis was completed for citation of F657 with findings of floor staff failed to initiate fall interventions and update care plans. The morning clinical meeting failed to review incidents and update care plans. Clinical staff failed to investigate falls. The Regional MDS Nurse reviewed the last 30 days of admissions and checked for a comprehensive care plan on 3/14/2022. Licensed nursing staff were educated on the process for creating and adding interventions to the care plan. Licensed nursing staff were educated on the regulatory requirements of a care plan which includes: The facility must develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Residents admitted in the last 48 hours were evaluated to ensure they had a care plan put in place on 3/16/2022 by the Regional Director of Clinical Services. The DON is responsible for oversight of baseline care plans. Monitoring of baseline care plans is the responsibility of the clinical team. The clinical team includes but not limited to the DON, ADON, Social Services, and Activities. Beginning on 3/16/2022 licensed nursing staff had been re-educated by the DON/ADON/Licensed nurse that the baseline care plan needs to be completed within 48 hours of admission and on the directions to initiate a baseline care plan. Licensed nursing staff had been educated on the regulatory requirements of a baseline care plan which includes- Based on the resident's previous history, and fall assessment score an at risk fall care plan will be initiated. Resident specific interventions will be added to the care plan and put into place as required. The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- (A) Initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. Staff not working including contracted staff will be re-educated prior to working. On 3/17/2022, the surveyors validated Resident #6 had a fall risk assessment completed on 3/16/2022, Resident #11 had a fall risk assessment completed on 3/16/2022, Resident #12 had a fall risk assessment completed on 3/16/2022, Resident #13 had a fall risk assessment completed on 3/8/2022, and Resident #14 had a fall risk assessment completed on 3/16/2022. On 3/17/2022, the surveyors validated all residents had a fall risk assessment completed between 3/4/2022- 3/16/2022 and their care plans had been reviewed to ensure that fall prevention interventions were in place. On 3/17/2022, surveyors validated an audit of all fall risk assessments and fall care plans had been completed and a room-to-care plan intervention comparison had been completed [TRUNCATED]

Based on facility policy review, medical record review, hospital documentation review, interview, and facility investigation review, the facility failed to initiate baseline care plans to ensure interventions were implemented for residents who were high risk for falls for 8 residents (Residents #7, #1, #4, #5, #8, #9, #11, and #13) of 11 residents reviewed for baseline care plan. The facility's failure resulted in Resident #7 sustaining a fall on 12/29/2021, resulting in a laceration to the right side of her head which required 4 sutures and caused actual harm to the resident. The facility's failure placed Residents #7, #1, #4, #5, #8, #9, #11, and #13 in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements for participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator, Director of Nursing (DON), Regional Director of Clinical Services, Regional Minimum Data Set (MDS) Nurse, and Divisional Vice President of Operations were notified of the Immediate Jeopardy on 3/16/2022 at 6:18 PM. The Immediate Jeopardy was removed onsite and was effective 12/29/2021-3/16/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 3/17/2022 at 7:19 PM and the corrective actions were validated onsite by the surveyors on 3/17/2022. The findings include: Review of the facility policy titled, Care Plans- Baseline, revised 12/2016, showed .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission .To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission . Review of the facility policy titled, Fall Risk Assessment, revised 3/2018, showed .The nursing staff, in conjunction with the attending physician, consulting pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information .Upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time .The nursing staff will ask the resident and/or his/her family about any history of the resident falling .The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living (ADL) capabilities, activity tolerance, and cognition .The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's Fall Risk Assessment Tool dated 12/10/2021, showed the resident was at high risk for falls. (The fall risk assessment was not completed until 12/30/2021, 20 days after admission.) Medical record review showed no documentation Resident #7 had a baseline care plan initiated within 48 hours of admission. Review of Resident #7's Minimum Data Set (MDS) assessment dated [DATE], showed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated Resident #7 had severe cognitive impairment. The resident required extensive assistance of 1 staff for bed mobility and dressing and was totally dependent on 1 staff for personal hygiene and toilet use. The resident had a fall in the past month prior to admission and in the past 6 months prior to admission. Review of Resident #7's progress note dated 12/29/2021, showed .Resident was observed wandering the hall. Resident had very poor gait and very poor safety awareness. Resident stated that she needed to Pee and was going to pee on herself. Resident was assisted to the toilet. Resident was under observation during this process related to the residents poor safety awareness. While resident was sitting on the toilet her roommate called out for assistance. Nurse exited the residents restroom and asked the resident [roommate] if she could wait just a movement [moment]. During that statement a loud thud was heard. Nurse looked back into the restroom and observed the resident [#7] lying in front of the toilet .blood was observed coming from the resident head . Review of Resident #7's Hospital Emergency documentation dated 12/30/2021, showed .pt [patient] presents from [name of facility] for a fall .pt has a large hematoma [collection of blood outside a blood vessel resulting in bruising] to her right forehead .Patient fell from standing position .noted to have hematoma and laceration to the forehead .skin .2.5 cm [centimeters] deep laceration .to the right forehead .Laceration closed using sutures . The resident was discharged from the emergency roiagnom on [DATE] at 4:50 AM. Review of Resident #7's baseline care plan showed the baseline care plan was initiated on 12/30/2021 (20 days after admission and a day after the resident's fall). Review of the care plan showed .At risk for fall related injury related to: 12/29/2021 fall. Risk factors present as determined by the Fall Risk Screening. Fall Risk score 23 [high risk for falls] . with interventions including .Toileting program assist resident to toilet before meals and at bedtime .Adequate glare free lighting .Area free of clutter .Low/Platform Bed .Non-slip socks/shoes .Observe for and/or report to nurse side effects of any drugs .Provide/observe use of adaptive devices .Wheelchair .Referral for screen & treatment as needed .PT [Physical Therapy] .Report falls to physician and responsible party .Use call light and request assistance prior to transfers/ambulation . During a telephone interview on 3/14/2022 at 11:58 AM, Licensed Practical Nurse (LPN) #5 stated he had not received training on how to initiate a baseline care plan and had been told that Registered Nurse (RN) #4 and RN #5 would complete care plans. The LPN confirmed he had been the nurse working on 12/29/2021 when Resident #7 fell . The LPN stated the resident was observed walking in the hall with no clothing and no footwear on. The LPN stated he assisted her to the bathroom and someone in the room asked for assistance. He told Resident #7 to wait for him and he exited the resident's bathroom. The LPN confirmed the resident leaned while sitting on the toilet and he was unsure if she could understand when he told her to wait for him. He then heard the resident fall. The LPN stated the resident hit her head on the wall and then fell into the floor and was bleeding from her head. The LPN stated that night was the first time he had witnessed the resident walking, and she had always been in the bed on his shift (night shift). The LPN confirmed the resident had no baseline care plan for falls prevention at the time of the fall and he did not know how to initiate a baseline care plan. During an interview on 3/15/2022 at 4:27 PM, the DON confirmed Resident #7 was admitted to the facility on [DATE] and did not have a baseline fall care plan initiated until 12/30/2021 (20 days from her admitted ). The DON confirmed she had initiated the care plan on 12/30/2021, after Resident #7 had a fall on 12/29/2021 when she had been left unattended in the bathroom and fell , sustaining a laceration to the right side of her head requiring 4 sutures. Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review showed no documentation a baseline care plan to address Resident #1's fall risk was developed within 48 hours from admission. Review of Resident #1's progress notes dated 12/21/2021, showed .Resident noted to have a witnessed fall with no injury . Review of Resident #1's fall investigation dated 12/21/2021, showed the resident had a fall at 6:00 AM (1 day after admission). The resident was ambulating in her room and fell backwards to a sitting position. The resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the immediate intervention implemented was to provide rest to the resident. Continued review showed .Evaluation notes .No injury noted. No pain noted. Increased staff supervision with intensity based on resident need . Medical record review showed the facility did not develop a baseline care plan to address Resident #1's risk for falls after the resident had a fall on 12/21/2021, 1 day after admission. Review of Resident #1's 5-day MDS assessment dated [DATE], showed Resident #1 had a BIMS score of 8, which indicated the resident had moderate cognitive impairment. Further review showed the resident required extensive assistance of 1 staff for bed mobility, limited assistance of 1 staff for transfers, walked in the room with supervision of 1 staff member, and required extensive assistance of 1 person for toileting. The resident had a fall within the last month prior to admission and had a fall within the last 6 months prior to admission. Review of Resident #1's baseline care plan dated 1/1/2022, showed .Resident is at risk for falls related to: Dementia, Poor Safety Awareness . with interventions including .Assist for toileting and transfers PRN [as needed] .Complete designated Fall Risk screening tool on admission .Cue for safety awareness . Further review showed no documentation of the intervention for increased staff supervision with intensity based on resident need, which was to be implemented after the fall on 12/21/2021. Continued review revealed the baseline care plan was initiated 13 days after admission. Review of Resident #1's fall investigation dated 1/3/2022, showed .Resident noted to have returned from therapy with mild anxiety present. As visualized per writer, resident noted to attempt ambulation from bed to wheelchair, tripping on the legs of the side table. Resident in a right side laying position on the floor with mild complaints of left leg pain. Resident assessed per writer and returned to bed once deemed safe . Further review showed a new intervention was added to keep area clear/safe. Review of Resident #1's baseline fall care plan showed an intervention for .Keep environment safe & uncluttered . with a start date of 1/3/2022. Further review showed an intervention with a start date of 1/3/2022 for .Prompted toileting after lunch . which had a created date of 1/21/2022 (18 days after the fall). Review of Resident #1's fall investigation dated 1/6/2022, showed the resident had a fall with no injury. Further review showed .Evaluation Notes .Contour mattress for positioning . Review of Resident #1's baseline fall care plan showed a start date of 1/6/2022, for .Contour mattress for positioning . Further review showed an edited date of 1/21/2022 for the intervention (15 days after the fall on 1/6/2022). During an interview on 3/9/2022 at 10:48 AM, RN #4 confirmed she had completed the fall investigation for Resident #1 after the 12/21/2021 fall. She confirmed the resident did not have a baseline care plan initiated prior to the fall and she had not initiated a baseline care plan after the fall on 12/21/2021. During an interview on 3/9/2022 at 4:00 PM, RN #5 stated the nurse who completed Resident #1's admission on 12/20/2021 should have completed the baseline care plan for fall prevention. RN #5 stated Resident #1 was at high risk for falls due to a fall prior to admission. RN #5 stated Resident #1 was very impulsive, would not wait for assistance, and would attempt to take herself to the bathroom. RN #5 stated the immediate intervention added to the fall investigation dated 12/21/2021 was for the resident to rest. RN #5 confirmed the intervention had not been added to the baseline care plan because no baseline care plan had been completed for Resident #1. RN #5 confirmed no baseline fall care plan had been initiated after the 12/21/2021 fall. RN #5 stated the resident's next fall was on 1/3/2022. The resident tripped over her side table, and she was .maybe a little disoriented and maybe a little bit tired . The RN stated the new intervention he added to the baseline care plan had been to keep the room decluttered. He stated he did not add the intervention for prompted toileting to the baseline care plan. He stated that intervention was added later by the DON when she reviewed the 1/3/2022 fall investigation. The RN confirmed the resident had not expressed a need to be assisted to the bathroom at the time of the fall on 1/3/2022 and she wasn't able to express her needs to the staff. Continued interview revealed the intervention of prompted toileting was not appropriate for the fall on 1/3/2022. During a telephone interview on 3/9/2022 at 4:51 PM, LPN #6 stated she had not been provided training on how to initiate or update a baseline care plan. She confirmed she was assigned to Resident #1 when the resident fell on [DATE]. The LPN stated Resident #1 frequently ambulated without assistance but did need assistance for safe ambulation. The resident was unable to use the call light due to her cognitive status. During an interview on 3/15/2022 at 1:18 PM, the DON confirmed Resident #1 was admitted to the facility on [DATE], she did not have a baseline care plan to address fall risk within 48 hours of admission and did not have one initiated after the fall on 12/21/2021. The DON confirmed Resident #1's baseline fall care plan had not been initiated until 1/1/2022 (13 days after admission). Medical record review showed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of a Fall Risk Assessment Tool dated 12/1/2021, showed Resident #4 was at high risk for falls. Medical record review showed no documentation Resident #4 had a baseline fall care plan initiated after being identified as high risk for falls on the Fall Risk Assessment Tool dated 12/1/2021. Review of Resident #4's progress notes dated 12/2/2021, showed .8:46 [AM] .Confusion .marked [clearly noticeable] confusion due to [CONDITION(S)] [any brain disease that alters brain function] diagnosis .Resident resting in bed . Review of Resident #4's fall investigation dated 12/2/2021, showed the resident was noted to be sitting in the floor on the left side of the bed at 9:25 AM. The resident was assessed and found to have a left facial cheek abrasion and a bandage was applied. Further review revealed the new intervention added after the fall was a fall mat to the left side of the bed. Continued review showed .Evaluation note .Bed in low position. Fall mat in place . Review of Resident #4's progress notes dated 12/2/2021, showed .Resident noted to be in a sitting position on the floor beside residents bed .Fall Mat applied to left side of bed as intervention . Review of Resident #4's baseline care plan dated 12/2/2021, showed .At Risk for Fall related injury related to: Confusion, AMS [Altered Mental Status] [CONDITION(S)] DX [diagnosis] . with an intervention for .Fall Mat on left side of bed . Review of Resident #4's admission MDS assessment dated [DATE], showed Resident #4 was rarely understood, had behaviors noted, required extensive assistance of 2 staff for bed mobility, was totally dependent on 2 staff for toileting, total dependance on 1 staff for dressing, required 2 staff assistance for transfers, and was always incontinent of bladder and bowel. Review of Resident #4's fall investigation dated 12/6/2021, showed the resident was noted to be sitting on the right side of the bed on a fall mat with a new intervention for .fall mats to bilateral [both] sides of the bed . No injury was noted. Review of Resident #4's baseline care plan showed no documentation the baseline care plan had been revised to include the intervention for fall mats to bilateral sides of the bed. During an interview on 3/10/2022 at 5:02 PM, RN #5 stated Resident #4 had a fall on 12/2/2021. The RN stated the resident's bed was in the low position on 12/2/2021 and the resident was very impulsive. The fall had occurred when the resident tried to crawl off the left side of the bed. RN #5 stated the resident did sustain a skin tear on her face. The RN stated the resident was found on the left side of the bed, so a fall mat was placed on the left side of the bed. The RN confirmed Resident #4 had a fall on 12/6/2021 and was found sitting at the bedside on a fall mat on the right side of the bed. The RN stated a new intervention of bilateral fall mats was added. The RN stated the baseline care plan had not been revised to reflect the need for bilateral fall mats. During an interview on 3/15/2022 at 1:18 PM, the DON stated Resident #4 was admitted to the facility on [DATE] and was at high risk for falls. The DON confirmed Resident #4's baseline care plan was not initiated until after the resident fell on [DATE].The DON further confirmed the baseline care plan had not been revised with a new intervention after Resident #4 had a fall on 12/6/2021. Medical record review showed Resident #5 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review showed no documentation Resident #5 had a baseline fall care plan initiated within 48 hours of admission to the facility. Review of Resident #5's fall investigation dated 12/3/2021, showed the resident was calling out for assistance. The resident was observed on the floor with no clothes on and stated she was too hot. No injuries were noted. Further review showed interventions were for the resident to rest. Medical record review showed no documentation Resident #5 had a baseline fall care plan initiated after the fall on 12/3/2021 and no care plan interventions to address the resident's risk for falls. Medical record review of a Fall Risk Assessment Tool dated 12/4/2021, showed Resident #5 was at high risk for falls. Medical record review showed no documentation Resident #5 had a baseline fall care plan initiated after the 12/4/2021 Fall Risk Assessment Tool indicated the resident was at high risk for falls. Review of Resident #5's admission MDS assessment dated [DATE], showed Resident #5 had a BIMS score of 00, which indicated the resident had severe cognitive impairment. The resident had behaviors towards others, required extensive assistance of 2 staff for bed mobility and transfers, and required extensive assistance of 1 staff for dressing, toilet use, and personal hygiene. The resident was always incontinent of bladder and bowel, and the resident had a fall with a fracture within the past 6 months. Review of Resident #5's fall investigation dated 12/7/2021, showed the resident was found on the floor of her bathroom, calling out for assistance, with no injury noted. Interventions implemented were to instruct the resident to call for assistance, to keep the call light within reach, and a fall mat was to be placed at the resident's bedside. Review of Resident #5's baseline care plan dated 12/8/2021 (5 days after admission), showed an ADL care plan .function of impaired balance . with an intervention for .Resident can be on floor if she feels more comfortable than being in the bed instead . Further review showed the baseline care plan did not address the resident's risk for falls. Review of Resident #5's progress notes dated 12/9/2021, showed .patient was sitting on side of bed this morning when nurse entered hall. She was wearing a sports bra and sitting on the floor and yelling at staff. She is care planned for the floor . Medical record review showed Resident #5's baseline care plan was not updated with interventions to address the resident's continued falls on 12/9/2021. Review of Resident #5's fall investigation dated 12/13/2021, showed the resident was .observed climbing in and out of bed .No interventions used . Further review showed .assisted her to bed. Residents left knee has hematoma present with no c.o [complaints of] pain or discomfort observed . Medical record review showed Resident #5's baseline care plan was not updated with interventions to address the resident's continued falls and unsafe transfers of climbing in and out of the bed. During a telephone interview on 3/14/2022 at 11:58 AM, LPN #5 stated when Resident #5 fell on [DATE], the new intervention added to the fall investigation was for the resident to rest. The LPN confirmed the intervention had not been added to the care plan because he was unable to initiate a baseline care plan. The LPN stated there was .no effective communication process [at the facility] . to communicate the intervention to staff members without a baseline care plan. LPN #5 stated on 12/13/2021, a baseline care plan for fall risk was not initiated. The LPN stated the resident was .constantly trying to get out of bed . The LPN stated Resident #5 was unable to understand to use a call light due to her cognitive status and was not safe to transfer herself to the floor because .she had tremors .She had dyskinesia . The LPN further stated Resident #5 was unable to communicate a desire to sit in the floor and the intervention for the resident to sit in the floor if she was more comfortable was not an appropriate intervention for the resident. During an interview on 3/14/2022 at 5:44 PM, RN #2 confirmed she was assigned to Resident #5 when she had the fall on 12/7/2021. RN #2 stated the resident was .probably not . safe to transfer herself and could not remember to use a call light to ask for assistance. RN #2 confirmed a baseline fall care plan was not initiated after the 12/7/2021 fall. RN #2 stated the resident was not safe to transfer herself from the bed to the floor and the resident had never expressed a desire to be on the floor to the RN. During an interview on 3/15/2022 at 1:18 PM, the DON confirmed Resident #5 had been admitted to the facility on [DATE], and did not have a baseline fall care plan initiated within 48 hours of her admission, did not have one initiated after the falls on 12/3/2021, 12/7/2021, 12/9/2021, or on 12/13/2021, and the resident did not have a baseline fall care plan initiated after she was identified as a high risk for falls on the 12/4/2021. Medical record review showed Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review showed no documentation Resident #8 had a baseline fall care plan completed within 48 hours of admission. Review of Resident #8's fall investigation dated 2/14/2022, showed the resident had an unwitnessed fall in the resident's room with no injury noted. Further review showed interventions were .recliner locked .bed to lower position . Medical record review showed no documentation Resident #8 had a baseline fall care plan initiated with interventions to prevent further falls after the fall on 2/14/2022. Review of Resident #8's 5-day MDS assessment dated [DATE], showed the resident had a BIMS score of 15, indicating the resident was cognitively intact. He required limited assistance of 1 staff for bed mobility, walk in corridor, dressing, toilet use, and personal hygiene, required extensive assistance of 2 staff for transfers, was frequently incontinent of bladder and bowel, and the resident had a fall prior to admission to the facility. During an interview on 3/7/2022 at 6:30 PM, RN #2 stated that she added a new intervention for Resident #8's recliner to be locked and the bed to be kept in the low position on the fall investigation. RN #2 stated she thought the intervention would automatically generate to the resident's care plan. RN #2 confirmed a baseline care plan was not initiated after the fall on 2/14/2022. During an interview on 3/15/2022 at 1:18 PM, the DON confirmed Resident #8 was admitted to the facility on [DATE] and he did not have a baseline care plan to address his falls risk within 48 hours of admission or after the fall on 2/14/2022, .I think this guy [Resident #8] never had a care plan at all and he was here from 2/11 [2/11/2022] to .2/18 [2/18/2022] . The DON confirmed Resident #8 had a fall on 2/14/2022 with a new intervention on the fall investigation to keep his recliner locked and his bed in low position, but the nurse did not initiate a baseline fall care plan with the new interventions. Medical record review showed Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's Falls Risk Assessment Tool dated 2/10/2022, showed Resident #9 was at high risk for falls. Medical record review showed no documentation Resident #9 had a baseline fall care plan developed after he was identified as high risk for falls on the Fall Risk Assessment Tool dated 2/10/2022. Review of Resident #9's fall investigation dated 2/11/2022, showed Resident #9 had an unwitnessed fall in the resident's room at 12:00 AM without injury. Further review showed the resident's bed was in low position at the time of the fall and no new intervention had been implemented. Medical record review showed no documentation Resident #9 had a baseline fall care plan developed with interventions to prevent falls after the fall on 2/11/2022. Review of Resident #9's fall investigation dated 2/13/2022, showed Resident #9 had an unwitnessed fall in the resident's room without injury on 2/12/2022 at 11:45 PM. Further review showed interventions were .Rest . Medical record review showed no documentation Resident #9 had a baseline fall care plan developed with interventions to prevent falls after the fall on 2/12/2022. Review of Resident #9's 5-day MDS assessment dated [DATE], showed the resident had severe cognitive impairment. During an interview on 3/14/2022 at 5:44 PM, RN #2 confirmed she had completed the Fall Risk Assessment Tool for Resident #9 on 2/10/2022 and stated she did not initiate a baseline care plan for the resident's falls risk. During an interview on 3/15/2022 at 1:18 PM, the DON confirmed Resident #9 was admitted to the facility on [DATE] .he was admitted for falls . The DON confirmed Resident #9 did not have a baseline care plan to address fall risk initiated within 48 hours of admission. The DON stated the resident did not have a fall care plan initiated after he was identified as high risk for falls on the fall risk assessment dated [DATE], or after the falls on 2/10/2022 and 2/13/2022. Medical record review showed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #11's Fall Risk Assessment Tool dated 2/16/2022, showed the resident was at high risk for falls. Medical record review showed no documentation Resident #11 had a baseline fall care plan developed after she was identified as high risk for falls on the Fall Risk Assessment Tool dated 2/16/2022. Review of Resident #11's fall investigation dated 2/17/2022, showed the resident had an unwitnessed fall from the bed with no injury noted. Further review showed a fall intervention was not added and the care plan was not revised because the resident was a .new admit . Review of Resident #11's admission MDS assessment dated [DATE], showed a BIMS score of 4, indicating the resident had severe cognitive impairment. The resident required extensive assistance of 2 staff for bed mobility and toilet use and had not transferred or walked in the past 7 days. The resident was incontinent of both bowel and bladder. The resident had 1 fall with no injury since admission to the facility. Review of Resident #11's baseline care plan dated 3/2/2022 (14 days after admission), showed .Resident is at risk for falls due to .weakness . Further review showed an intervention for increased staff supervision with intensity based on resident need. During an interview on 3/15/2022 at 1:18 PM, the DON confirmed Resident #11 was admitted to the facility on [DATE] and was identified as a high falls risk on admission. The DON confirmed no baseline fall care plan had been initiated after the fall on 2/17/2022. The DON confirmed a baseline care plan to address fall risk was not initiated until 3/2/2022 (15 days after the admitted ). Medical record review showed Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review showed no documentation Resident #13 had a baseline fall care plan developed within 48 hours of admission Review of Resident #13's Fall Risk Assessment Tool dated 11/22/2021, showed the resident was at high risk for falls. Medical record review showed no documentation Resident #13 had a baseline fall care plan developed after the Fall Risk Assessment tool completed on 11/22/2021 identified the resident as a high falls risk. Review of Resident #13's admission MDS assessment dated [DATE], showed a BIMS score of 8, indicating the resident had moderate cognitive impairment. Further review showed the resident had no behaviors, required limited assistance of 1 person for bed mobility, transfers, and dressing, required supervision to walk in room, toilet use, and he required extensive assistance of 2 people for personal hygiene. The resident had a fall prior to admission to the facility and a fall care plan was to be developed by the facility. During an interview on 3/15/2022 at 1:18 PM, the DON confirmed Resident #13 was admitted to the facility on [DATE] and a baseline care plan was not initiated within 48 hours of admission or after Resident #13 was identified as a high risk for falls on 11/22/2021. During an interview on 3/9/2022 at 10:48 AM, RN #4 stated she was unsure who was responsible to complete baseline care plans. She stated it had been the responsibility of the nurse assigned to the resident, then for a period it was the DON or the Assistant Director of Nursing (ADON) who was responsible for completing the baseline care plan for the residents. She and RN #5 trained new staff, but she was unsure if the new staff were trained on how to complete a baseline care plan. She stated the nurse who completed the fall investigation was responsible for adding a new intervention. RN #4 stated the new intervention would need to be passed to other staff in report or the other staff would need to review the fall investigation to see what new intervention was added. RN #4 stated she was unsure if all staff including Certified Nursing Assistants (CNA)'s would have access to see the fall investigation to see what new intervention had been put in place after a fall to provide care for the residents. During an

Based on facility policy review, medical record review, fall investigation review, hospital documentation review, and interview, the facility failed to ensure pain management was provided to 1 resident (Resident #1) of 3 residents reviewed for pain. The facility's failure to effectively provide effective pain management resulted in actual harm to Resident #1 when the resident complained of pain after the fall on 1/13/2022 and was not sent to the hospital until 1/15/2022 and was found to have a right femur fracture. The findings include: Review of the facility policy titled, Pain-Clinical Protocol, revised 3/2018 showed .The physician and staff will identify individuals who have pain or who are at risk for having pain .includes .with or without .fractures .The nursing staff will assess each individual for pain .when there is onset of new pain or worsening of existing pain .The nursing staff will identify any situations or intervention where an increase in the resident's pain may be anticipated .The physician will help identify causes of pain .by examining the resident directly, reviewing the resident's history, and discussion with the resident and staff . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's 5-day MDS assessment dated [DATE], showed Resident #1 had a BIMS score of 8, which indicated the resident had moderate cognitive impairment. Further review revealed the resident required extensive assistance of 1 staff for bed mobility, limited assist of 1 staff for transfers, and the resident had a fall within the last month prior to admission and had a fall within the last 6 months prior to admission. The resident denied pain in the past 5 days prior to the assessment. Review of a fall investigation dated 1/13/2022 at 5:54 PM, showed .I was in the room with [roommates name] tending to her .and heard [Resident #1] yelling in the hallway. I came out of the room and found her on the floor, she said her right arm and right leg hurt .Evaluation Notes .Sent to ER [emergency room ] Fx [fractured] hip . Review of Resident #1's progress note dated 1/14/2022 at 5:42 PM, showed .C/O [complaints of] pain in Right hip, d/t [due to] fall last night, MD [medical doctor] notified of need for mobile xray .Awaiting N.O [new order] . Review of an Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Physician's Order dated 1/14/2022 showed ASAP [as soon as possible] .Plain xrays Right hip .dx [diagnoses] pain in R [right] hip after a fall .please call NP [Nurse Practitioner] on call with results . Continued review of the Physicians order showed canceled per DON [Director of Nursing] D/T [due to] covid [a corona virus that causes a respiratory illness] Isolation . Review of Resident #1's progress note dated 1/15/2022 at 2:15 PM, showed .Upon arriving on shift this nurse was given report of this patient possibly having a broken hip from a fall that happened previously .patient having continuous complaints of pain .patient to be send [sent] to hospital for further evaluation . Medical record review revealed Resident #1 was sent to theER on [DATE], 2 days after the fall. The resident had not been sent to theER on [DATE] as indicated in the progress note. Review of Hospital Discharge Documentation dated 1/21/2022, showed the resident was admitted to the hospital on 1/15/2022 at 1:57 PM. Continued review showed .New .right femoral neck fracture [thigh bone fracture] .hospitalized about 1 month ago for left hip fracture .Appears now patient has a right .femoral neck fracture .patient underwent operative intervention [hip surgery] .on January 16th [1/16/2021] .completed right hip hemiarthroplasty [hip surgery], has been very slow to participate in physical therapy .due to her .acute [recent onset] immobilization related to her fracture . Review of Resident #1's progress note dated 1/22/2022 showed, .Pt returned from [name of hospital] at 1100 [11:00 AM] .She has a displaced [when the bone is out of its original position] .fx of the right femur . During a telephone interview on 3/3/2022 at 10:05 AM, Licensed Practical Nurse (LPN) #2 stated she was the nurse responsible for Resident #1 on 1/15/2022. The LPN stated she received report from the previous nurse that Resident #1 had a fall 2 days ago (1/13/2022). The LPN stated .it was obvious she had a fracture .couldn't move her leg .she was in extreme pain when we [staff] moved that leg .the resident was hollering out . LPN #2 stated she contacted the DON, and the resident was sent out to the hospital on 1/15/2022. During a telephone interview on 3/14/2022 at 9:17 AM, LPN #1 stated she worked on 1/14/2022 with Resident # 1. The LPN stated during rounds with the Certified Nursing Assistant (CNA) she noticed Resident #1 was in pain, .I gave her the Tylenol she had, and I told the doctor she needed to be assessed. The resident was wet and had to be turned and she moaned when she was turned and had facial grimacing . LPN #1 stated Tylenol was the strongest pain medication that was ordered for Resident #1. LPN #1 stated she reported Resident #1's condition, left her shift, and passed it on to the oncoming nurse, Physician, and DON. The LPN stated the Physician said she would go assess the resident on 1/14/2022. During a telephone interview on 3/14/2022 at 11:18 AM, CNA #1 stated she worked on 1/13/2022 and 1/14/2022. The CNA stated Resident #1 had a fall on 1/13/2022 and she and the nurse picked the resident up off the floor in the hallway and placed the resident in bed. CNA #1 stated Resident #1 was on the COVID unit. The CNA stated Resident #1 remained at facility the rest of the day. The CNA stated on 1/14/2022, Resident #1 was no longer able to ambulate after the fall and stated .she [Resident #1] was uncomfortable .grabbed her hip when she was turned . Continued interview confirmed Resident #1 had pain with movement and was not sent out to the hospital on 1/14/2022. During an interview on 3/15/2022 at 1:18 PM, the DON stated she became aware Resident #1 had a fall on 1/13/2022 on 1/14/2022. She stated Resident #1 was on the COVID Unit and she did not assess the resident. The DON stated .2 nurses had already assessed her . The DON stated the resident was not sent to the emergency roiagnom on [DATE] and was sent on 1/15/2022 (2 days later). During an interview on 3/15/2022 at 3:27 PM, the Medical Director stated she was aware Resident #1 had a fall on 1/13/2022 and the Nurse Practitioner was notified on 1/13/2022. The MD was unsure if she had assessed Resident #1 on 1/14/2022 and had no documentation of an assessment on 1/14/2022 of the resident. The Medical Director confirmed she would expect a resident with a fracture to have pain with movement. The MD confirmed the fall on 1/13/2022 resulted in a right hip fracture and actual harm for Resident #1.

Based on facility policy review, medical record review, review of fall investigations, hospital documentation review, and interview, the facility failed to follow the Medical Doctor's (MD) orders and provide treatment timely for 1 resident (#1) of 11 residents reviewed for falls. The facility's failure to provide timely treatment to obtain an ordered x-ray after a fall resulted in Resident #1 sustaining a delay of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure resulted in actual harm to Resident #1. The findings include: Review of the facility policy titled, Pain-Clinical Protocol, revised 3/2018 showed .The physician and staff will identify individuals who have pain or who are at risk for having pain .The physician will order appropriate tests as needed to help clarify sources of pain. For example, an x-ray may help to identify the cause of joint pain . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's 5-day Minimum Data Set (MDS) assessment dated [DATE], showed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. Resident #1 required extensive assistance of 1 staff for bed mobility and toileting, limited assistance of 1 staff for transfers, and walked in the room with supervision of 1 staff member. The resident had a fall within the last month prior to admission and had a fall within the last 6 months prior to admission. Review of Resident #1's facility fall investigation dated 1/13/2022 at 5:54 PM, showed .I was in the room with [roommates name] tending to her .and heard [Resident #1] yelling in the hallway. I came out of the room and found her on the floor, she said her right arm and right leg hurt .Evaluation Notes .Sent to ER [emergency room ] .Fx [fracture] hip . Review of Resident #1's progress note dated 1/14/2022 at 5:42 PM, showed .C/O [complaints of] pain in Right hip, d/t [due to] fall last night, MD notified of need for mobile xray .Awaiting N.O [new order] . Review of a Physician's order dated 1/14/2022 showed ASAP [as soon as possible] .Plain xrays Right hip .dx [diagnoses] pain in R [right] hip after a fall .please call NP [Nurse Practitioner] on call with results . Continued review of the Physician's order showed canceled per DON [Director of Nursing] D/T [due to] covid [a corona virus that causes a respiratory illness] Isolation . Review of Resident #1's progress notes dated 1/15/2022 at 2:15 PM, showed .Upon arriving on shift [day shift] this nurse [Licensed Practical Nurse (LPN) #2] was given report of this patient possibly having a broken hip from a fall that happened previously .patient having continuous complaints of pain .patient to be send [sent] to hospital for further evaluation . Review of Hospital Discharge Documentation dated 1/21/2022, showed the resident was admitted to the hospital on 1/15/2022 at 1:57 PM. Continued review showed .New .right femoral neck fracture [thigh bone fracture] .hospitalized about 1 month ago for left [CONDITION(S)] .Appears now patient has a right .femoral neck fracture .patient underwent operative intervention [hip surgery] .on January 16th [1/16/2021] .completed right hip hemiarthroplasty [hip surgery], has been very slow to participate in physical therapy .due to her .acute [recent onset] immobilization related to her fracture . Review of Resident #1's progress note dated 1/22/2022, showed .Pt [patient] returned from [name of hospital] at 1100 [11:00 AM] .She has a displaced [when the bone is moved from its original position] .fx of the right femur . Review of Resident #1's Physician's History and Physical dated 1/25/2022, showed .advanced dementia and wandering behaviors transfers to recuperate from Right hip hemi-arthroplasty [hip surgery] after a fracture .She was found to have Covid + [positive] status .transferred to the Covid unit. There she fell [fall on 1/13/2022], unwitnessed, was evaluated by staff, and upon monitoring began showing signs of pain behavior referent to the right leg. Xrays were obtained .showed a R [CONDITION(S)] .had an inpatient stay at [name of hospital] .found to have a displaced .fracture of the R femur .treated .with a Right hip hemi-arthroplasty .now transferred for multi-disciplinary rehabilitation . During a telephone interview on 3/3/2022 at 10:05 AM, LPN #2 stated she was the nurse responsible for Resident #1 on 1/15/2022. The LPN stated she received report from the previous nurse that Resident #1 had a fall 2 days ago (1/13/2022). The LPN stated .it was obvious she had a fracture .couldn't move her leg .she was in extreme pain when we [staff] moved that leg .the resident was hollering out . LPN #2 stated she contacted the DON, and the resident was sent out to the hospital on 1/15/2022. During a telephone interview on 3/14/2022 at 9:17 AM, LPN #1 stated she worked on 1/14/2022 with Resident # 1. The LPN stated during rounds with the CNA she noticed Resident #1 was in pain, .I told the doctor she needed to be assessed . LPN #1 stated she reported Resident #1's condition, left her shift, and passed it on to the oncoming nurse, Physician, and DON. The LPN stated the Physician said she would go assess the resident on 1/14/2022. During a telephone interview on 3/14/2022 at 11:18 AM, CNA #1 stated she worked on 1/13/2022 and 1/14/2022. The CNA stated Resident #1 had a fall on 1/13/2022 and she and the nurse picked the resident off the floor in the hallway and placed the resident in bed. The CNA stated Resident #1 remained at facility the rest of the day. The CNA stated on 1/14/2022, Resident #1 was no longer able to ambulate after the fall. Continued interview confirmed Resident #1 had pain with movement and was not sent out to the hospital on 1/14/2022. During an interview on 3/15/2022 at 1:18 PM, the DON stated she became aware Resident #1 had a fall on 1/13/2022 on 1/14/2022. She stated Resident #1 was on the COVID Unit and she did not assess the resident. The DON stated .2 nurses had already assessed her . The DON confirmed there was an order from the MD for an ASAP x-ray to be obtained on 1/14/2022, and a note for the x-ray to be cancelled by her (the DON) due to the resident's COVID isolation status. The DON confirmed .what I should have done was tell her [LPN #1] to go ahead and send her [Resident #1] out [to the hospital] but I don't know why I didn't . The DON stated the fall investigation on 1/13/2022 showed the resident was sent to the emergency room for a hip x-ray. The DON stated the resident was not sent to the emergency roiagnom on [DATE] and was sent on 1/15/2022 (2 days later). She confirmed the resident had not received an x-ray timely .I know we didn't do the right thing . During an interview on 3/15/2022 at 3:27 PM, the Medical Director stated she was aware Resident #1 had a fall on 1/13/2022 and the Nurse Practitioner was notified on 1/13/2022. The MD was unsure if she had assessed Resident #1 on 1/14/2022 and had no documentation of an assessment on 1/14/2022 of the resident. The Medical Director stated she wrote an order on 1/14/2022 for an x-ray and she had not been notified the x-ray had not been obtained. She stated she would expect the resident to receive the x-ray in the COVID unit and if that was not possible, the resident should have been sent out for an x-ray .I expected she would have x-rays and a timely response to the findings . The MD confirmed the fall on 1/13/2022 resulted in a right [CONDITION(S)] and actual harm for Resident #1.

Based on medical record review, review of a facility investigation, review of a pharmacy fax confirmation, review of a coaching session, review of a drug reference, and interview, the facility failed to notify the physician of the unavaibility of pain medication to adminster after a resident request for ordered pain medication for pain intensity of 10 (on a scale of 1-10) resulting in a 2 hour delay and (Harm) in administration of the pain medication for one resident (#3) of five residents reviewed. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the hospital Clinical Summary dated 12/24/14, at 9:11 AM, revealed Resident #3 received [MEDICATION NAME] 30 mg (milligrams) at 3:25 AM and 8:31 AM on 12/24/14 prior to transfer to the facility. Review of the pharmacy Admission/Re-Admission Cover Sheet revealed the fax listing Resident #3's medication was received by the pharmacy on 12/24/14 at 11:46:57 AM. Medical record review of the Nursing Admission Information dated 12/24/14 at 12 noon, revealed the resident was oriented to person, place, and time. Medical record review of the admission physician's orders [REDACTED]. Review of the pharmacy fax to the Nurse Practitioner to approve the [MEDICATION NAME] prescription revealed the fax was sent on 12/24/14 at 3:57 PM. Medical record review of the Pain Flow Sheet for 12/24/14 at 10 PM, revealed the current intensity of pain to be at a 10 (on a scale of 1-10) with vocal complaints of pain related to back surgery. Review of the facility's interview with Registered Nurse (RN) #4 (no date), the nurse on duty on 12/24/14 from 6 PM to 6 AM, revealed At approximately 8 PM resident c/o (complained of) pain told resident that I was going to check with pharmacy.8:30 PM spoke with pharmacy.Pharmacist stated meds on way. Pharmacist was asked if I could get meds from e-box (emergency) supply. Pharmacist stated no prescription was filled and on its way.8:45 PM returned to room to inform resident.Resident stated I want my medicine. Encouraged to deep breath and relax.9:10 PM returned to room to check on resident. Resident c/o pain and I asked if back brace would help.Resident stated she only had to wear it when she was out of bed.9:30 PM went to check on resident. Spoke with her to help divert her pain and to comfort her. 9:45 PM called pharmacy.stated delivery was in driveway.10 PM pain meds were administered.10:30 PM resident was resting quietly without pain. Review of a coaching session dated 12/30/14 completed by the Director of Nursing (DON) with RN #4 revealed the nurse was coached on the options available when the pharmacy tells you that the prescription cannot be obtained due to the medication has already been filled including calling the physician or nurse practitioner to obtain a one-time order and notification of the DON if the nurse has any difficulties or is in need of guidance. Telephone interview with the Pharmacy Director on 5/18/15 at 12:40 PM, revealed the E-Box located on A Wing does not contain the 15 mg [MEDICATION NAME] but does contain [MEDICATION NAME] 5 mg 2 tabs and other medications used for pain or pain symptoms. Interview with RN #4 on 5/19/15 at 4:05 PM, revealed the nurse did not remember the exact time on 12/24/14 when Resident #3 first asked for pain medication. Further interview revealed the resident was moaning and relief was obtained within 30 minutes of administration of the pain medication. Continued interview confirmed the nurse did not call the physician or the nurse practitioner for a one-time order for some type of pain medication. Interview with the Pharmacy Consultant on 5/20/15 at 11:30 AM, in the Chapel revealed per the Lexicomp Drug Reference the duration of the [MEDICATION NAME] IR to be 3-6 hours, with peak effect 0.5 to 1 hour with onset 10-15 minutes. Further interview revealed the last dose of [MEDICATION NAME] IR was at 8:31 AM on 12/24/14, at the hospital prior to transfer to the facility and the next dose was at 10:00 PM on 12/24/15, which was a 13.5 hour span. Continued interview confirmed, She could have been in pain. Interview with the Corporate Nurse and the Administrator on 5/20/15 at 2:15 PM, in the Chapel confirmed the facility failed to use other options, such as a one-time order or notification of the physician to obtain some type of pain medication to administer for Resident #3 on 12/24/14, resulting in Resident #3's complaint of pain at 8 PM and the resident did not receive medication for the pain until 2 hours later (10 PM) at which time the pain intensity was at the level of 10 (hurts worst).

Based on medical record review, review of a facility investigation, review of a pharmacy fax confirmation, review of a coaching session, review of a drug reference, and interview, the facility failed to ensure pain medication was adminstered after a resident request for ordered pain medication for pain intensity of 10 (on a scale of 1-10) resulting in a 2 hour delay and (Harm) in administration of the pain medication for one resident (#3) of five residents reviewed for pain management. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the hospital Clinical Summary dated 12/24/14, at 9:11 AM, revealed Resident #3 received [MEDICATION NAME] 30 mg (milligrams) at 3:25 AM and 8:31 AM on 12/24/14 prior to transfer to the facility. Review of the pharmacy Admission/Re-Admission Cover Sheet revealed the fax listing Resident #3's medication was received by the pharmacy on 12/24/14 at 11:46:57 AM. Medical record review of the Nursing Admission Information dated 12/24/14 at 12 noon, revealed the resident was oriented to person, place, and time. Medical record review of the admission physician's orders [REDACTED]. Review of the pharmacy fax to the Nurse Practitioner to approve the [MEDICATION NAME] prescription revealed the fax was sent on 12/24/14 at 3:57 PM. Medical record review of the Pain Flow Sheet for 12/24/14 at 10 PM, revealed the current intensity of pain to be at a 10 (hurts worst) with vocal complaints of pain related to back surgery. Review of the facility's interview with Registered Nurse (RN) #4 (no date), the nurse on duty on 12/24/14 from 6 PM to 6 AM, revealed At approximately 8 PM resident c/o (complained of) pain told resident that I was going to check with pharmacy.8:30 PM spoke with pharmacy.Pharmacist stated meds on way. Pharmacist was asked if I could get meds from e-box supply. Pharmacist stated no prescription was filled and on its way.8:45 PM returned to room to inform resident.Resident stated I want my medicine. Encouraged to deep breath and relax.9:10 PM returned to room to check on resident. Resident c/o pain and I asked if back brace would help.Resident stated she only had to wear it when she was out of bed.9:30 PM went to check on resident. Spoke with her to help divert her pain and to comfort her. 9:45 PM called pharmacy.stated delivery was in driveway.10 PM pain meds were administered.10:30 PM resident was resting quietly without pain. Review of a coaching session dated 12/30/14 completed by the Director of Nursing (DON) with RN #4 revealed the nurse was coached on the options available when the pharmacy tells you that the prescription cannot be obtained due to the medication has already been filled including calling the physician or nurse practitioner to obtain a one-time order and notification of the DON if the nurse has any difficulties or is in need of guidance. Telephone interview with the Pharmacy Director on 5/18/15 at 12:40 PM, revealed the E-Box located on A Wing does not contain the 15 mg [MEDICATION NAME] but does contain [MEDICATION NAME] 5 mg 2 tabs and other medications used for pain or pain symptoms. Interview with RN #4 on 5/19/15 at 4:05 PM, revealed the nurse did not remember the exact time on 12/24/14 when Resident #3 first asked for pain medication. Further interview revealed the resident was moaning and relief was obtained within 30 minutes of administration of the pain medication. Continued interview confirmed the nurse did not call the physician or the nurse practitioner for a one-time order for some type of pain medication. Interview with the Pharmacy Consultant on 5/20/15 at 11:30 AM, in the Chapel revealed per the Lexicomp Drug Reference the duration of the [MEDICATION NAME] IR to be 3-6 hours, with peak effect 0.5 to 1 hour with onset 10-15 minutes. Further interview revealed the last dose of [MEDICATION NAME] IR was at 8:31 AM on 12/24/14, at the hospital prior to transfer to the facility and the next dose was at 10:00 PM on 12/24/15, which was a 13.5 hour span. Continued interview confirmed, She could have been in pain. Interview with the Corporate Nurse and the Administrator on 5/20/15 at 2:15 PM, in the Chapel confirmed the facility failed to use other options, such as a one-time order or notification of the physician to obtain some type of pain medication to administer for Resident #3 on 12/24/14, resulting in Resident #3's complaint of pain at 8 PM and the resident did not receive medication for the pain until 2 hours later (10 PM) at which time the pain intensity was at the level of 10 (hurts worst).

Based on medical record review, a facility investigation, pharmacy fax confirmation review, and interview, the facility failed to provide, in a timely manner, routine and emergency drugs and biologicals to prevent or manage pain, resulting in a 2 hour delay of administration (Harm) of pain medication upon the resident' request, for one resident (#3) of five residents reviewed for pain management. The findings included: Medical record review revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission physician's orders [REDACTED]. Review of the pharmacy Admission/Re-Admission cover sheet revealed Resident #3's medication list was received by the pharmacy on 12/24/14 at 11:46:57 AM. Review of the pharmacy fax confirmation to the Nurse Practitioner to approve the Oxycodone prescription revealed the fax was sent on 12/24/14 at 3:57 PM. Review of the facility's investigation revealed an interview (no date) with Registered Nurse (RN) #4, on duty 12/24/14 from 6 PM to 6 AM, revealed At approximately 8 PM resident c/o (complained of) pain told resident that I was going to check with pharmacy.8:30 PM spoke with pharmacy.Pharmacist stated meds on way. Pharmacist was asked if I could get meds from E-box (emergency) supply. Pharmacist stated no prescription was filled and on its way.8:45 PM returned to room to inform resident.Resident stated I want my medicine.9:45 PM called pharmacy.stated delivery was in driveway. Telephone interview with the Pharmacy Director on 5/20/15 at 1:05 PM, revealed the resident's orders moved through the pharmacy and were packaged and ready to go around 5 ish. The medications were picked up from the pharmacy (in Knoxville) at 6:15 PM and should have been at the facility at 8:02 PM but something happened with the driver, enough to be fired. The driver left the only other stop in Knoxville at 7:12 PM and did not arrive at the facility until 9:45 PM to 10:00 PM. When the pharmacy director was asked if the pharmacist should have told the nurse on 12/24/14 to call for a one time order the pharmacist stated, We should all the time, but honestly don't know if we did this time. Continued interview revealed the director stated he had instructed his staff, especially if the resident is in distress, to say, hey, you have this option, call the Dr. Further interview confirmed the medication should have been at the facility by 8:02 PM and would have been available upon the resident' request but due to delievery problems did not arrive until 9:45 PM to 10:00 PM, which was 2 hours after the resident's first request for pain medication and 10 hours after the pharmacy's first receipt of the resident's admission orders [REDACTED].