Every finding on record at Spring Creek Post-Acute Rehabilitation Center

Based on interview, record review, review of facility job description and employment records, and review of State Agency (SA) records, the facility failed to employ a qualified full-time social worker (SW) in a facility with greater than 120 beds. During the time that the facility failed to have a qualified SW, one resident (Resident (R) 1) was issued a defective discharge notice for which there was also inadequate rationale. The failure to ensure the employment of a qualified SW had the potential to affect all residents in this facility which, per SA records, was currently certified for 226 beds.The findings include:Review of a facility document titled, Social Worker Job Description, copyrighted 2023, revealed a qualified social services worker had a minimum of a bachelor's degree in social work or another human services field and one year of supervised social work experience in a health care setting working directly with individuals.Review of SA records revealed that the facility was certified for a total of 226 beds.During an interview with the former Social Services Director (SSD) on 07/15/2026 at 10:14 AM, she stated she left the facility in March of 2026. During an interview with the current SSD on 07/15/2026 at 2:19 PM, she stated she was just hired in 06/2026. The current SSD stated she was still in training for her position and was not yet fully functioning in her role. Review of employment records revealed that during the time period of 03/13/2026-06/18/2026, the facility did not have a qualified social services worker. Interview with the Customer Service Liaison (CSL) on 07/15/2026 at 3:25 PM revealed that during the time there was no qualified SW, he helped perform social services because he had a background in social services (going to school for it). However, he stated he was not yet a licensed SW. During an interview with the Director of Rehabilitation Services on 07/15/2026 at 4:36 PM, she stated that the facility currently had a SW; however, when they did not, it was part of her job to assist with providing their services, including assessments, and arranging care conferences if she had the resident on therapy. She further stated she did not recall who or how she got involved with helping on the social services aspect, and confirmed that she did not meet the minimum qualifications for a SW. Interview with the Regional Director of Operations (RDO) on 07/14/2026 at 6:15 PM confirmed that the facility, which was certified for over 120 beds, had operated without a qualified SW for a multi-month period. She stated that she had reached out to another facility to see if they had any candidates that they knew of that might be qualified as a social worker, and that the owner was actively recruiting for a social worker during the time period that the facility was without one. The RDO noted that their sister facility had a social worker; however, that was not a viable source to help fill the role because the nearest sister facility was three hours away. She stated they had been trying to fill the role but it just didn't happen, and they struggled for that period of time. During an interview with the Administrator on 07/14/2026 at 12:00 PM, she confirmed that the facility experienced a time period of about three months when they were without a qualified social services worker. The Administrator stated that they worked really hard to try and fill the role but simply did not receive any qualified applicants or applicants with experience in the Long-Term-Care (LTC) sector. The Administrator stated that they had the facility's CSL fill in the role as much as possible until she got the position filled, as the current social services worker had only been there approximately three weeks.During an interview with the facility's Owner on 07/14/2026 at 11:45 AM, he stated he had put out lots of advertisements, hired recruiters, and offered substantial sign-on bonuses to try to fill the social services role but did not have any luck until the new social services director was hired last month.Review of facility records revealed that, during the time that the facility failed to employ a qualified SW on a full-time basis, the facility provided R1 a discharge notice, dated 05/15/2026, for which there was insufficient evidence that the discharge was for the reason stated on the notice. The 05/15/2026 Discharge Notice was also defective, as it failed to provide R1 accurate information needed to assist in appealing the planned discharge. (Refer to F627 and F628.)

Based on interview, record review, and review of the facility's policy, the facility attempted to discharge on e (Resident (R)1)) of 10 sampled residents reviewed for transfer/discharge without adequate evidence, the stated reason for the discharge was accurate. The facility issued a discharge notice using the rationale that R1's condition had improved and the resident no longer needed its service after the state agency responsible for Medicaid , known as the Kentucky Level of Care System (KLOCS ), denied R1's Level of Care evaluation. The findings include:Review of a facility policy titled, Transfer and Discharge (including Against Medical Advice), copyrighted 2025, revealed that, Once admitted , the resident has the right to remain in the facility unless their transfer or discharge meets one of the following specified examples. These six examples mirrored the federal regulation that discharge could only occur when it was necessary for the resident's welfare and their needs could not be met at the facility, the discharge was appropriate because their health had improved sufficiently so that they no longer needed the services provided by the facility, health and/or safety of individuals in the facility was endangered by their presence, non-payment after reasonable notice, and/or closure of the facility. The policy noted that the facility would not discharge a resident based solely on a resident's payment source or change in the resident's payment source.Record review revealed the facility admitted R1 on 05/15/2025. Further review revealed R1's diagnoses included muscle wasting and atrophy, chronic hepatitis C, and unspecified signs and symptoms involving the nervous system.A Medicaid document titled LOC [Level of Care] -001 Application #22000063871 dated 02/03/2026, from the Kentucky Level of Care System (KLOCS - an automated system used for entering information for Medicaid to make Level of Care determinations) was reviewed. This LOC Application noted that a previous request for a Medicaid LOC determination was not reviewed because necessary information was not submitted. Per this document, a letter was sent to the facility on [DATE] requesting more information to make a determination: however, due to the facility's failure to submit the requested information, the request was denied due to lack of information per Kentucky Administrative Regulations ([NAME]) 1:022, Section 10. As a result of the denial (due to the facility's failure to submit requested information), the resident was determined to not meet the level of care needed.Review of a facility document titled, Notice of Resident Transfer or Discharge, dated 05/15/2026, revealed the facility issued a notice of intent to discharge R1. Per this notice (which was given to/signed by R1 on 05/18/2026), the discharge action, effective 06/18/2026, was needed because the resident's health had improved sufficiently so the resident no longer needed the services provided by the facility. Further review of this Discharge Notice revealed that it was issued/signed by the Customer Service Liaison (CSL) on 05/18/2026.Although the written notice stated that R1 was being discharged due to his health improving sufficiently that he no longer needed the facility's service, interview with R1 on 07/13/2026 at 3:31 PM revealed administration told him he needed to discharge because he had no way to pay for his stay and he did not qualify for this level of care. However, R1 stated he felt he had a continued need of a higher level of care. Review of R1's Annual Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 05/20/2026, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating intact cognition.During an interview with the Clinical Liaison (CL) on 07/16/2026 at 10:56 AM, she stated that she was responsible for admissions and marketing and the KLOCS used for entering information for Medicaid to make Level of Care determinations. She stated she has been doing this since 05/22/2023 and noted that she did not have any formal training on how to use KLOCS. The CL stated she would use KLOCS when a resident came in and she realized they would be long term, unless the resident was on Medicaid- that needed to be done before they admitted to the facility. She stated that she would get messages if she needed any more information and she would try to find it herself. However, if she could not find it, she would ask the MDS Nurse to help her locate the information that was needed to complete the form. She stated that she was not a nurse and all the information that was on the level of care form was clinical, so she had to get it from a clinical source. She then stated if the MDS Nurse did not find the information she needed, she just submitted what she had. The CL stated that once KLOCS made a determination she could access it from the message portal and the system would generate a letter to send to the resident to whatever address was on file. She stated that she did not go back and change the resident's addresses in the system so it would just go to whatever home address was on file and she did not send anything out to the residents in the facility. She stated that all she did was the application, and once she got the approval or denial, she shared that information in the morning meeting. Further interview with the CL revealed she did not recall getting a message about R1 and did not know the reason that the facility never responded to the request for additional information to determine R1's LOC eligibility.An interview was conducted on 07/15/2026 at 3:25 PM, with the CSL who signed the Discharge notice. Although the notice he signed/gave to R1 stated the discharge was due to R1's health improving sufficiently so that facility care was not needed, the CSL indicated that he was not aware that the facility was discharging R1 because his condition had allegedly improved. He stated he became aware by either the facility owner or administrator that R1 did not have a payor source and that he thought it had been that way since 02/2026 and was asked if he would talk to the resident to see if he could help find somewhere to transition to as he was not sure if anyone was working with him on his discharge at all. During an interview with the former Social Services Director (SSD) on 07/15/2026 at 10:14 AM, she stated R1 was still a resident when she resigned from the facility in March. She stated she was not sure of his current discharge status and was not aware of what was done regarding the proposed discharge.During an interview with the current SSD on 07/15/2026 at 2:19 PM, she stated she was just hired in 06/2026 and was still in training for her position and was not fully functioning in her role yet. Further interview with the current SSD revealed that she did not know anything about R1's discharge and had not looked into the situation.During an interview with the Business Office Manager (BOM) on 07/15/2026 at 2:00 PM, she stated when she came to work at the facility back in 04/2026, R1 had Medicaid, but he did not meet the KLOCS criteria because he was too high functioning to be in the facility. The BOM added that the Medicaid insurance that R1 had now was for the community, so it would not pay for his room and board in a skilled nursing facility. The BOM stated that she walked into the situation as it was all in process when she got here. She stated they had the Administrator, CSL, and she, in a meeting with the resident in May 2026, and the CSL tried to get him assistance at different places to go, where she did not know, but because the resident did not receive any income, they would not accept him. The BOM stated she had not helped with anything like that, as the last place she worked, the social services department assisted the residents with those types of things. During an interview with the KLOCS Technical Representative on 07/16/2026 at 10:13 AM, she stated R1 had a Medicaid (payor source) reassessment due. On 01/15/2026, a Lack of Information notification was sent to the facility, requesting additional information to determine the resident's level of care. The KLOCS Representative further stated that no additional information was ever received from the facility on behalf of R1. Therefore, a denial letter was sent on 02/03/2026. Per the KLOCS Representative, as of the date of this interview, the facility had still not completed the task requesting additional information for R1.During an interview with the Director of Nursing (DON) on 07/15/2026 at 4:25 PM, she stated R1 went through therapy and met all those goals and when KLOCS did his level of care, they determined that they were no longer going to cover his stay. She stated that she felt the facility gave him an extensive amount of time to try and figure out what happened and expressed the belief that the facility did not violate his rights in any way. Interview with the Administrator on 07/16/2026 at 12:43 PM revealed the Administrator discharged R1 at the orders of the owner, who was notified by his accounting department that R1 did not have a payor source, due to him not qualifying for this level of care. She stated that the decision to discharge the resident was based on the KLOCS denial, and she was unaware, prior to surveyor intervention, that this denial occurred because the facility failed to submit the requested information. The Administrator stated it was the first time she saw the LOC form and she did not have an answer as to why KLOCS did not receive the information they requested to complete R1's evaluation.

Based on interviews, record review, and review of facility job descriptions, the facility failed to provide medically related social services, such as assisting residents with legal and/or financial matters for one (Resident (R)1)) of 10 sampled residents reviewed for transfer/discharge. The facility failed to assist the resident by providing needed information so the state agency responsible for Medicaid could make a determination as to the resident's continuing eligibility for services/payor source. The facility subsequently issued R1 a discharge notice after Medicaid denied eligibility based on the facility's failure to provide the requested information per Kentucky Administrative Regulations ([NAME]) 1:022, Section 10.The findings include:Review of a facility document titled, Social Worker Job Description, copyrighted 2023, revealed that Major Duties and Responsibilities of the position included, Identifying the need for medically related social services and ensuring that these services are provided in accordance with State and Federal regulations. Per the policy, the Social Worker will also assist residents and their representatives in locating and accessing financial, legal, and other community resources.Record review revealed the facility admitted R1 on 05/15/2025, with diagnoses that included muscle wasting and atrophy, chronic hepatitis C, and unspecified signs and symptoms involving the nervous system.Review of a Medicaid document titled LOC [Level of Care] -001 Application #22000063871 dated 02/03/2026, from the Kentucky Level of Care System (KLOCS - an automated system used for entering information for Medicaid to make Level of Care determinations) revealed that a previous request for a Medicaid LOC determination was made for R1. The document noted that the previously submitted application was not reviewed because necessary information was not submitted. Per this document, a letter was sent to the facility on [DATE] requesting more information to make a determination: however, due to the failure to submit the requested information, the request was denied due to lack of information per Kentucky Administrative Regulations ([NAME]) 1:022, Section 10. As a result of the denial (due to the facility's failure to submit requested information), the resident was determined to not meet the level of care needed.Further review of facility documents revealed a Notice of Resident Transfer or Discharge, dated 05/15/2026, was issued to R1 on 05/18/2026, stating the resident's health had improved sufficiently so the resident no longer needed the services provided by the facility. (Refer to F627.) During an interview with the Clinical Liaison (CL) on 07/16/2026 at 10:56AM, she stated that she was responsible for admissions, marketing, and using KLOCS (related to resident eligibility/Level of Care determinations). She stated she has been doing this since 05/22/2023 and noted that she did not have any formal training on how to use KLOCS. The CL stated KLOCS would provide messages if additional information was needed, adding that when this occurred, she would try to find the information herself. If she could not find the needed information, she would ask the Minimum Data Set (MDS) Nurse to help her locate whatever was needed to complete the form. The CL noted that that she was not a nurse and all the information that was on the Level of Care form was clinical, so she had to get it from a clinical source. She added that if the MDS Nurse did not find the information she needed, she just submitted what she had. Further interview with the CL revealed she did not recall getting a message about R1 and did not know the reason that the facility never responded to the request for additional information to determine R1's LOC eligibility/payor source status.Interview with the former Social Services Director (SSD) on 07/15/2026 at 10:14 AM revealed that R1 was still a resident when she resigned from the facility in March 2026, and she was not aware of all that was done regarding the proposed discharge. The former SSD stated that although she was responsible for social services functions, she did not work with KLOCS and had no knowledge as to why the requested information for R1's eligibility determination was not forwarded to Medicaid in 01/2026.During an interview with the KLOCS Technical Representative on 07/16/2026 at 10:13 AM, she stated R1 had a Medicaid (payor source) reassessment due on 01/15/2026. A Lack of Information notification was sent to the facility, requesting additional information in order to determine the resident's level of care. The KLOCS Representative further stated that no additional information was ever received from the facility on behalf of R1. Therefore, a denial letter was sent on 02/03/2026 and as of this date, the facility had still not completed the task requesting additional information for R1.Interview with the Administrator on 07/16/2026 at 12:43 P.M. revealed that the decision to discharge the resident was based on the KLOCS denial, and she was unaware, prior to surveyor intervention, that this denial occurred because the facility failed to submit the requested information. The Administrator stated it was the first time seeing the LOC form and she did not have an answer as to why KLOCS did not receive the information they requested to complete R1's evaluation. Further interview with the Administrator revealed that she had previously identified problems with social services functions not being done.

Based on interview, record review, review of the facility's policy, and review of a Final Order issued by an Administrative Law Judge, the facility failed to provide a discharge notice which met federal requirements for one Resident (R) 1) of 10 sampled residents reviewed for transfer/discharge. The facility failed to ensure that all required information on the discharge notice was accurate, to facilitate a request for an appeal of the discharge decision.The findings include: Review of the facility's policy titled, Transfer and Discharge (including Against Medical Advice), copyrighted in 2025, revealed, The facility's transfer discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided.d. An Explanation of the right to appeal the transfer or discharge to the State. e. The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests. f. Information on how to obtain an appeal form. g. Information on obtaining assistance in completing and submitting the appeal hearing request. h. The name, address (mailing and email) and phone number of the representative of the Office of the State Long-Term Care Ombudsman.Record review revealed the facility admitted R1 to the facility on [DATE], with diagnoses that included muscle wasting and atrophy, chronic hepatitis C, and unspecified signs and symptoms involving the nervous system.Review of the facility's document titled, Notice of Resident Transfer or Discharge, dated 05/15/2026, revealed the facility determined that a discharge was necessary, effective 06/18/2026, with the reason being that the resident's health had improved sufficiently so the resident no longer needed the services provided by the facility. (Refer to F627.) Further review of the Notice of Resident Transfer or Discharge, dated 05/15/2026, revealed that all sections of the form were filled in, with the form listing contact information for agencies related to appeal requests. Review of R1's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/20/2026, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating intact cognition.In an interview with R1 on 07/13/2026 at 3:31 PM, he stated once his insurance ran out, he was told by administration he needed to discharge because he had no way to pay for his stay and he did not qualify for this level of care. R1 stated that he filed an appeal with the assistance of the local ombudsman. R1 further stated that the appeal was upheld on the grounds that the facility failed to include correct appeals and contact information in the discharge notice they gave him. Review of a Final Order for Administrative Hearing No. OIG 26-0528, filed 06/10/2026, confirmed R1's interview that the discharge notice provided by the facility did not contain accurate contact information for all required state agencies. The Final Order, signed by an Administrative Law Judge, noted that Long-term care residents' rights with respect to involuntary transfer or discharge are governed by 900 [NAME] 2:050 and 42 CFR 483.15. Before a resident may be discharged against his wishes, the resident and a family member or legal representative (if known) must be provided with a written notice of the facility's intentions at least thirty (30) days before the date of the discharge or as soon as practicable if the discharge involves the health or safety of the resident or others in the nursing facility. This notice must contain several pieces of information, delineated in 900 [NAME] 2:050 2(5) and 42 CFR 483.15(c)(5). It is noted for the record that the Discharge Notice contains several deficiencies. Continued review of the Final Order for Administrative Hearing No. OIG 26-0528 revealed that the Final Order then noted that the The Notice of Discharge provided by the Appellee Nursing Facility did not satisfy several of these requirements. It did not provide. the name, address (mailing and email) and telephone number of the Cabinet office responsible for receiving requests for appeal; correct information on how to obtain assistance with submitting a request for appeal; and the name, address (mailing and email), telephone number of the state long-term care Ombudsman. A valid notice would contain all the regulatory information listed above. The Final Order then listed the correct contact information for the Cabinet and state-long term care Ombudsman, which was different than the information documented on the Discharge Notice which the facility gave R1. Further review of the Final Order revealed that, For these reasons the undersigned [administrative law judge] finds that the Nursing Facility has failed to provide the Appellant [R1] with a legally sufficient notice of discharge. Interview with the facility's owner on 07/14/2026 at 11:45 AM confirmed that the discharge notice dated 05/15/2026 was defective and did not include the correct information required. He stated that after R1's discharge appeal was upheld, he called the judge to discuss the matter and was told that the notice did not contain the information required by the regulation.In an interview with the Administrator on 07/16/2026 at 12:43 PM, she confirmed that the discharge notice did not ensure that all required information was accurate, stating, He [R1] won because the document was incorrectly filled out.

Based on observation, interview, closed record review, and review of the facility's policy, the facility failed to ensure residents were adequately assisted to prevent accidents for 1 of 4 residents sampled for falls, out of the total sample of 26 residents, (Resident (R)134). The findings include: Review of the facility policy titled, Fall Prevention Program, undated, revealed each resident was to be assessed for fall risk. Further review revealed each resident was also to receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Review of the facility policy titled, Incidents and Accidents, undated, revealed it was the facility's policy for staff to report, investigate, and review any accidents or incidents that occurred or were alleged to occur on facility property which might involve or was alleged to involve a resident. Record review revealed the facility admitted R134 on 12/26/2025, with diagnoses that included Pneumonia, Altered Mental Status, and need for assistance with personal care. Further record review revealed R134 was discharged to the hospital at the daughter's request for further evaluation on 04/30/2026. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 03/03/2026, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) of eight out of 15, indicating the resident had moderately impaired cognition. Review of R134's Comprehensive Care Plan revealed the facility developed a Self-Care Performance Deficit care plan dated 12/29/2025, revealed the goal for the resident's Activities of Daily Living (ADLs) was to improve the current level of function with ADLs through the next review date. Further review revealed an intervention noting R134 must be supervised while on the bedside commode. Review of the facility's Fall Report 04/26/2026, revealed Certified Nursing Assistant (CNA) 14 assisted R134 to the bedside commode. Per review, CNA 14 became distracted by R134's roommate who had been asking for their blanket. Continued review revealed CNA 14 turned her back on R134 as he was sitting on the bedside commode, and the resident fell off the bedside commode. Further review revealed R134 was assessed and returned to bed. Review of the Progress Notes revealed R134 sustained a rib contusion after the fall. During an interview on 05/29/2026 at 10:19 AM, the DON stated the facility's protocol and procedures had been followed when the fall incident involving R134 occurred. The DON said the facility's protocol and procedures had been followed through completing the fall assessment and investigating the incident. She stated the facility identified the root cause of the incident as an accident. The DON further stated the facility had CNA 14 complete additional training on care plans, fall risks, and accidents. During an interview on 05/29/2026 at 11:46 AM, CNA 14 stated R134 had been on the bedside commode, and she turned her back to hand the resident's roommate their blanket. She reported the incident would have been prevented if she had not turned her back on the resident. CNA 14 further stated the incident would have also been prevented if another staff member had been present to assist her. During an interview on 05/29/2026 at 3:54 PM, the Administrator stated her expectation was for CNAs and all other direct care staff to know and follow residents' care plans. She further stated the expectation for direct care staff to follow residents' care plans was in an effort to provide and follow necessary interventions to prevent falls.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 26 sampled residents (Resident (R)529). Immediate Jeopardy (IJ) was identified on 05/09/2025 and was determined to exist on 04/18/2025 in the area of S483.25(d) Accidents Hazards, F689. On 05/09/2025, the Administrator was provided a copy of the CMS Immediate Jeopardy (IJ) Template and notified that the failure to ensure residents were provided supervision and protected from elopement is likely to cause serious injury, impairment, or death and constituted IJ at 42 CFR 483.25 F689. The IJ at F689 also constituted Substandard Quality of Care (SQC) at 42 CFR 483.25, Quality of Care. The IJ was determined to exist on 04/18/2025, when the facility discovered R529 had eloped from the building. The facility provided an acceptable plan for the removal of the IJ on 05/10/2025. The plan alleged the IJ was removed, and the deficient practice was corrected on 05/10/2025. The plan provided by the facility alleged the following: On 04/18/2025 at approximately 2:58 PM, R529 was found outside the facility on the loading dock. She was assisted back into the facility by Certified Nurse Aide (CNA) 3. Immediately following the elopement event, the Unit Manager completed a head-to-toe skin assessment and pain evaluation of R529 with no injuries or pain noted. The wander guard to her left ankle was noted to be in place at that time. R529's Physician and family/responsible party were notified of the event. The Maintenance Director inspected the storage door and found the lock to be broken. He immediately repaired the door by placing a keypad lock on it. An Extended Survey and IJ Removal validation was conducted on 05/10/2025, and the State Survey Agency (SSA) validated the facility's IJ Removal Plan on 05/10/2025. The SSA validated the immediacy of the IJ had been removed on 05/10/2025, as alleged. The findings include: Review of the facility's policy, Accidents and Supervision (Copyright 2024 The Compliance Store, LLC) revealed the resident environment was to remain as free of accident hazards as was possible. Per review, each resident was to receive adequate supervision and assistive devices to prevent accidents which included: identifying hazard(s) and risk(s); evaluating and analyzing hazard(s) and risk(s); implementing interventions to reduce hazard(s) and risk(s); monitoring for effectiveness and modifying interventions when necessary; and supervision. Review of the facility's policy, Elopements and Wandering Residents, undated, revealed the facility was to ensure that residents who exhibited wandering behavior and/or were at risk for elopement received adequate supervision to prevent accidents. Per review, residents exhibiting wandering behavior or who were at risk of elopement were to also receive care in accordance with their person-centered plan of care which was to address the unique factors contributing to wandering or elopement risk. Further policy review revealed, Elopement occurred when a resident left the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Review of the facility's Emergency Preparedness Education page for Facility Elopement (Code Brown) revealed the Resident Elopement Information and Protocol, undated, noted wandering residents were at greater risk of injury if they walked away from the facility. Further review revealed Our Code [NAME] policy addressed that issue and outlined the protocol that allowed the facility to quickly find any missing resident. Review of the facility's Elopement Binder titled, Code [NAME] revealed the facility had assessed 16 residents to be at risk for elopement. The residents were listed in the binder. Review of the closed record Face Sheet for R529 revealed the facility admitted the resident on 04/03/2025, with diagnoses which included mild cognition and alcohol abuse. Review of R529's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. Review of the facility's Elopement Risk assessment dated [DATE] for R529 revealed the resident scored a 3 which indicated on the Score Key a score of 0-5 was low risk for elopement. Review of the facility's Elopement Risk assessment dated [DATE] for R529 revealed the resident scored 13 which indicated on the Score Key a score of 12 or greater was high risk for elopement. Per review, elopement precautions put in place by the facility included: monitoring placement of wander guard every shift; and reporting to the nurse if unable to locate the resident. Continued review revealed an Elopement Risk Care Plan was initiated on 04/16/2025, with interventions to check exit door alarms daily; check wander alert bracelet daily; and to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Further review revealed the interventions also included to observe for exit seeking behaviors and patterns; and to redirect the resident from doors and exit as indicated. Review of R529's Elopement Risk assessment dated [DATE] revealed a score of 14 which the Score Key indicated if 12 or greater indicated the resident was a high risk for elopement. However, further review revealed no additional interventions were added to the Elopement Risk Care Plan. Review of the Comprehensive Care Plan revealed the Elopement Risk Care Plan dated 04/16/2025, noted R529 was to be monitored daily for wander guard placement and the function of the wander guard. Per review, the Elopement Risk Care Plan Goal initiated on 04/16/2025, was the resident would not elope. Continued review of the care plan revealed the interventions included: every 15 minute security checks initiated 04/18/2025 (date of elopement) get the resident with a room in an area with high traffic for increased monitoring initiated 04/18/2025; and a wander guard was placed to the resident's left ankle initiated on 04/16/2025. Further review of the Comprehensive Care Plan dated 04/09/2025 for R529 revealed the facility assessed the resident to have behavioral problems related to walking around not clothed, picking at wounds, and taking dressings off her wounds. Per review, the interventions included: anticipating the resident's needs based on wandering triggers and patterns; assisting R529 in developing more appropriate methods of coping and interfacing, and to express her feelings appropriately. Continued review revealed additional interventions included: letting staff know when R529 was getting upset; diverting the resident's attention, and removing her from situations and taking her to another location if needed. Based on video footage of the elopment provided by the facility on 04/18/2025 at approximately 2:58 PM, R529 walked 71 yards from her room through two sets of double doors, into a staff meeting/break room, out a single storage room door and then through a door outside onto the loading dock. R529 was found on the dock, where she found a lift and was raised 81 inches from the pavement below Review of the facility's Word Document titled, Incident, dated 04/18/2025, revealed on that date at approximately 2:59 PM, the Maintenance Director observed R529 standing near an exit out of the station area as reported by a housekeeper. Per review, the resident was on the facility's premises, and was assisted back to Station 2, assessed for injuries with none noted, and the resident's wander guard was in place and functioning. Further review revealed every 15 minute checks were initiated for R529, and the resident was moved to a room in a higher traffic area, with a pathway by the nurse's station, dining, and therapy before going towards Station 3. Continued review revealed maintenance immediately determined the supply area exit door lock was broken (which led outside), and immediately repaired the door lock. Further review revealed upon completion of the investigation, it was determined there had been no failure with facility policies and processes. Additional review revealed the Incident Report had not been signed. Review of the video of the break room at 2:58 PM, revealed HK5 is sitting at a table with her head down looking at her phone and turned away from the door. R529 entered the room and walked straight to the storage room door. R529 opened the door and went through the door. HK5 never looked up from her phone. During interview with HK 5 on 05/08/2025 at 1:59 PM, she stated she worked the AM shift from 8:00 AM to 4:30 PM the day of R529's elopement. She stated she had been taking a break when the incident occurred, and had not looked up to see the resident come into the break room. HK 5 said she had to pick up briefs for a resident after her break, and never saw R529 up on the dock at all. During a telephone (phone) interview on 05/08/2025 at 9:33 AM, HK4 stated it was his second or third day as a new employee working at the facility, and he was moving beds out of Station 3 to be checked by maintenance. He stated, near 3:00 PM, he went outside looking for the Maintenance Director, and when he opened the door he saw R529 out there on the dock. HK4 stated he said Hello to R529, and she started taking a couple of steps backwards. He stated R529 started talking and pointing at the maintenance man's truck, and he did not want to startle the resident or walk towards her, so he told her to hold on one second. HK 4 stated he ran straight to maintenance and told them he thought there was a resident out on the dock, and they all ran out to the dock. He stated the Maintenance Director called a Code Brown. HK 4 further stated the Maintenance Director went up behind R529 and grabbed hold of her sweat shirt and backed her away from the edge of the dock. In interview with the Maintenance Director on 05/07/2025 at 11:11 AM, he stated on 04/18/2025, my assistant and I were in my office, and a housekeeper came to my office and said there was a resident on the dock. He stated We immediately went and saw her (R529) about 12 foot in the air. The Maintenance Director stated he put out on the What's App (a social media, instant messaging application) that there was a resident outside on the dock. He stated he then went around to the back and up to R529 and grabbed hold of the sweat shirt she had on and held her until staff came out to the dock. The Maintenance Director stated there had been a misunderstanding regarding R529's elopement. He stated the Administrator had been told by someone that R529 had not exited the building; however, he took the Administrator out on the dock (during the state survey) on 05/09/2025 and showed her exactly where R529 had been. The Maintenance Director stated after the incident, he changed the door lock over to a combination lock so it could not be left open. He stated R529's wander guard had been working; however, it had not sounded because the service door she exited out of had no alarm on it for the wanderguard. The Maintenance Director stated, We had no work orders for that specific door, so he had no idea the lock was broken. He stated R529's exit out the service door was not discussed the next morning. In interview on 05/07/2025 at 11:50 AM, the Maintenance Assistant stated he had been in the shop with the Maintenance Director discussing work, when a housekeeper came into the office and said there was someone on the dock. He said We jumped up and went out, and saw R529, who had a wanderguard on her ankle. The Maintenance Assistant stated R529 appeared confused and said she needed to get to her truck and pointed to my truck He explained he told the resident that was his truck and she then said her truck was over here. He stated the Maintenance Director went around behind R529 up the steps and he (Maintenance Assistant) stayed below in case the resident fell . The Maintenance Assistant stated R529 had been right on the edge of the dock, up high, probably about 10 to 12 feet. He further stated the Maintenance Director grabbed her sweatshirt from behind and then lowered the hydraulic dock. He stated by that time a Certified Nurse Aide (CNA) came and took the resident back to her room. During interview on 05/08/2025 at 10:26 AM, the MDS Nurse stated (on the day of R529's elopement) she saw a strange message on the Whats App, that said, General Store. Resident needs help. She stated she got up and walked back to the (break room) area where there were several other staff members. The MDS Nurse stated she was told a resident had gotten out the exit door, and at that time they were bringing R529 back in. She stated the door knob on the exit door was similar to a bedroom door where it was turned and pushed. The MDS Nurse stated she was told the exit door lock had not been working. She stated all she heard was that R529 had gotten out and was found on the dock, but she had not personally seen the resident outside. Per the MDS Nurse, she called the DON and told her R529 had gotten out through the break room exit door, and said she was told to do an immediate skin check of the resident. She stated she told a CNA to do one on one (1:1) with R529, and Registered Nurse (RN) 1 did a head count of all residents and all residents were accounted for. The MDS Nurse explained she walked back to the exit door, and observed the door had been repaired with a combination keypad. She further stated when she interviewed R529 for her MDS Assessment the resident had been confused at times. In interview on 05/07/2025 at 11:57 AM, the DON stated she had worked that day, but had gone home early, around 1:30 PM. She stated she received a call sometime after 3:00 PM from the MDS Nurse, who told her a resident had eloped; however, was okay. The DON stated the Unit Coordinator (UC) had been with R529, and she investigated and determined the resident had gone out the storage room door to the outside. Per the DON Housekeeper (HK) 4 had told her that R529 had been out on the loading dock. The DON stated We assessed R529, placed her on every 15 minute checks, and moved her further away from the doors leading into the unit. She stated with the resident being found out on the loading dock, she (DON) would consider that an elopement. During the interview, the DON stated in hindsight yes, that the incident should have reported. She stated she expected staff to keep residents safe, to make sure doors/locks were not broken, and complete the wander assessments. The DON further stated the facility currently had 16 residents who were wanderers. During interview on 05/07/2025 at 2:02 PM, CNA 3 stated she was the restorative aide (RA). She stated she had been at the business office and heard on the Whats app that a resident had been found out on the dock. The CNA stated that she ran back there, and saw the Maintenance Director and Maintenance Assistant standing on each side of R529 and assisting her towards the door. She further she took over from them, assisted R529 into a wheelchair and transported the resident back to her unit. In interview on 05/08/2025 at 1:52 PM, CNA 4 stated she had worked at the facility for three years and worked on Section 2 most of the time. She stated she saw R529 before 3:00 PM, when the resident's call light went off and she went to her room. The CNA stated five to 10 minutes later, CNA 3 rolled R529 onto the unit in a wheelchair, and told her the resident had gotten out onto the dock. She stated she remembered R529 had been more confused that day than usual. During interview on 05/07/2025 at 2:15 PM, the Station 2 UC stated she had been packing up stuff to leave for the day, when she was alerted a resident from Station 2 had gotten outside. She stated she called the DON and Assistant Director of Nursing (ADON), and assessed R529 to make sure she was not hurt. The Station 2 UC stated she sat with R529 and talked to her for 10 to 15 minutes, trying to find out how the elopement happened. She stated R529 was placed on every 15 minute checks. The UC stated she went with maintenance personnel to see exactly what happened. The Station 2 UC stated she took witness statements, and moved R529 from Station 2 to Station 1 where the resident could be more closely monitored. She stated R529 had tried to exit seek before and we did an Elopement Screen and found she was a high elopement risk. The Station 2 UC stated R529 was on a wander guard and had been found at the doors before. She explained R529's cognition had changed drastically and she had gotten more and more confused, and that was why We did several (risk) assessments. The Station 2 UC stated R529 had been on every 15 checks all weekend. During an additional interview on 05/08/2025 at 2:19 PM, the Maintenance Director stated no one had ever mentioned to him that the (break room) exit door lock was broken. He stated the facility used the TELS system (a building management platform) for staff to communicate any maintenance concerns; however, he had not received any communications about the door lock being broken. During interview with the Administrator on 05/07/2025 at 10:15 AM, regarding the elopement of R529, she stated she had not been at the facility when the incident occurred. The Administrator stated she had been told R529 had not gotten out of the facility, and after discussion with the Director of Nursing (DON) it was decided it had not been an elopement. She further stated however, she had not been aware the resident got out of the door and onto the dock. During additional interview with the Administrator on 05/07/2025 at 4:43 PM, she stated she knew the door the resident exited the building was used as housekeeping storage. However, she had not been in that room. She stated she held an ad hoc meeting over the phone with the Maintenance Director and the DON, but had not talked with the Medical Director. In interview on 05/08/2025 at 4:24 PM, the Director of Social Services (DSS) stated, regarding BIMS scores for R529, the resident did have a cognitive impairment when she was first admitted to the facility. The DSS said R529 had shown exit seeking behavior also; however, she had not seen the resident do that. The DSS reported updating the Code [NAME] book and emailing it to the DON, ADON, Therapy, Maintenance, Housekeeping, UC's, Administration, Dietary and Activities staff. The DSS further stated all the Code [NAME] binders were on the units and were labeled Code Brown. In a phone interview on 05/08/2025 at 4:46 PM, R529's daughter stated she was aware her mother had gotten out of the building. She stated she got her information from her Mom's sister who called her after she heard about anything going on with her Mom. R529's daughter said since she lived in Georgia, her Aunt took care of her Mom, and her Aunt lived with her Mom in her Mom's house. She stated her Mom would not speak with the SSA Surveyor on the phone.

Based on interview, record review, and facility policy review, it was determined the facility failed to review and update the facilitys assessment which had the potential to affect 131 residents. The findings include: Review of the facility's policy titled, Facility Assessment, not dated, revealed the facility would conduct and document a facility-wide assessment to determine what resources were necessary to care for their residents competently during both day-to-day operations and emergencies. Further review revealed the Administrator was responsible for ensuring the completion of the facility's assessment and that it would be reviewed and updated as necessary and at least annually. Review of the Facility Assessment, dated 06//26/2023, revealed a review date of 07/11/2023 and it would be reviewed every third Tuesday of every month. The assessment identified it had the capacity to meet the needs of 226 residents. Further review revealed the census at that time averaged 115 residents. During an interview with the Director of Nursing (DON) on 05/10/2025 at 3:38 PM, she stated she had no responsibility related to the facility's assessment and that was the responsibility of the Administrator. Review of a statement from the Administrator, dated 05/06/2025, revealed she began working at the facility on 03/31/2025 and noticed the facility's assessment had not been updated. During an interview with the Administrator on 05/10/2025 at 4:15 PM, she stated one of the first things she looked at when she assumed her position was the facility's assessment. She stated she noticed it had not been completed since 2023. She stated she was currently working on updating the facility's assessment but was waiting on feedback from the residents and/or their representatives. The Administrator stated she was responsible for ensuring the assessment was reviewed and updated. She stated it takes time to complete and she had not had time to get it into place yet.

Based on observation, interview, and review of facility policy, it was determined the facility failed to ensure food was distributed and served in accordance with professional standards for food service safety for 4 of 26 sampled residents (Resident (R)111, R106, R32, and R122). The findings include: Review of the facility's policy, Serving a Meal, undated, revealed it was the facility's policy to serve meals that met the nutritional needs of residents. Continued review revealed the Policy Explanation and Compliance Guidelines included: Avoid handling actual unwrapped food items with bare hands. Observation of the dinner meal service on 05/06/2025 at 5:15 PM, revealed Licensed Practical Nurse (LPN)14 touched four residents' (R111, R106, R32, and R122's) buns with her bare hands while cutting the residents' sandwiches in half. Further observation revealed LPN14 also touched the residents' straws with her bare hands when placing the straws in the residents' drinks. During interview with LPN14 on 05/09/2025 at 12:15 PM, she stated she honestly should have had gloves on. She stated she thought of the residents as family and had not thought of wearing gloves. In interview on 05/09/2025 at 4:38 PM, the Director of Nursing (DON), stated she expected staff not to touch food and straws with their bare hands. She stated she expected staff to follow the facility's policy. During interview with the Administrator on 05/10/2025 at 4:35 PM, regarding staff using their bare hands with food handling and when opening straws, she stated she expected staff to wear clean gloves when handling food. She stated staff should remove the paper from straws properly, without touching the straw with their bare hands.

Based on observations, interviews, and review of facility policy, it was determined the facility failed to maintain a safe, clean, comfortable and homelike environment for twenty-six (26) sampled residents. The findings include: Review of the facility's policy titled, Routine Cleaning and Disinfection, not dated, revealed it is the facility's policy to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. The policy stated routine surface cleaning and disinfection will be conducted with detailed focus on visibly soiled surfaces and high touch areas to include but not limited to toilet flush handles, bed rails, tray tables, call buttons, IV poles, television remotes, and telephones. Review of the facility's policy titled, Resident Environmental Quality,not dated, revealed it was the facility's policy to ensure the facility was designed, constructed, equipped, and maintained to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. The policy stated preventative maintenance schedules for the maintenance of the building and equipment, should be followed to maintain a safe environment. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Equipment, not dated, revealed reusable resident care equipment will be cleaned and disinfected in accordance with current Centers for Disease Control and Prevention (CDC) recommendations in order to break the chain of infection. Review of the facility's document titled, Grievance/Concern Form, dated [DATE], revealed concerns regarding overall cleanliness of the facility and floors being stained with what appeared to be fecal matter. Further review of the document revealed the facility concluded the floors and walls were stained, but not by fecal matter and deep cleaning of the rooms was to be done by the housekeeping staff. Observations of the facilty on [DATE] at 9:00 AM, [DATE] at 1:50 PM, and [DATE] at 10:00 AM, revealed the bottom of Resident (R) 65's infusion pole was coated in a dried brown substance. Observations on [DATE] at 9:00 AM, [DATE] at 3:00 PM, [DATE] at 1:50 PM, [DATE] at 10:00 AM, and [DATE] at 8:00 AM, revealed the floors throughout the main corridors were heavily stained with large amounts of wax build up and grime. An additional observation of R65's room on [DATE] at 2:44 PM, revealed the floors appeared to have a yellowish film. Review of Resident 65's Facesheet revealed the facility admitted the resident on [DATE], with diagnoses that included cerebral palsy, dysphagia, and adult failure to thrive. Review of R65's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview of Mental Status (BIMS) had not been conducted as R65 was rarely or never understood. In an interview with a State Guardian on [DATE] at 9:59 AM, he stated he came to the facility to see his residents and the facility's overall appearance was dirty and unsanitary. He stated some of the walls had areas of chipped paint, feces or something brown was smeared on some of the walls and privacy curtain. The State Guardian stated the floors were dirty and appeared as if they had not been touched. He stated while he was there they did make some room changes for some of those residents (to deep clean), and he returned at a later date to see for himself if there were any changes. He stated some repairs had been completed, and the floor was cleaner. However, it still needed more than what they had done to improve the safety concerns that he was talking about. He stated that the staff members he encountered seemed apathetic and were not very concerned about taking care of the residents right away and that was a concern to him. He stated his goal was to get all of his guardianship residents moved to another facility where they would be better served and he was actively pursuing that at this time. In an interview with Licensed Practical Nurse (LPN) 4 on [DATE] at 2:43 PM, she stated night shift CNAs were assigned to clean medical equipment. LPN4 stated she did not have Resident 65, but she had taken care of him in the past. She stated when she did she would try to make sure the IV (intravenous) infusion pole was clean. In an interview with Licensed Practical Nurse (LPN)12 on [DATE] at 2:44 PM, she stated nightshift CNA staff was responsible for cleaning medical equipment such as wheelchairs and infusion stands. LPN12 stated if the CNA staff addressed it in report they could pass that task on to day shift to complete if needed. In an interview with Housekeeper (HK) 2 on [DATE] at 2:56 PM, he stated in the past, management was very lax and did not enforce rules and standards for the staff and some staff members would not perform their job duties. He stated resident rooms would not get cleaned and the management did not check the rooms. He stated they still have some things to improve on. He stated that the housekeepers deep clean at least once or twice a month. HK 2 stated that he was the facility's second floor tech and would rescrub floors as needed, as they were not getting cleaned like they should. In an interview with the facility's Floor Technician on [DATE] at 4:18 PM, he stated mostly he cleans the floors, but sometimes he does housekeeping. He stated when he worked as the floor technician he tried to do all of the floors daily. He stated that it had been awhile since the floors had been stripped and waxed. During the interview he stated they had been working on the 100 hall doing those floors first and had not done anything to this side of the building in a long time. The Floor Technician stated the floor wax in R65's room had expired, and that was the reason it had turned yellow in color. He stated if people came into the facility and saw the floors they would think that it was an ill ran facility. He stated he would get orders from the director on when to strip the floors and wax them, but the problem was when to do it as it was an all day job to move residents out of the room and into another room prior to refinishing the floors. In an interview with the Former Environmental Services Director (FESD) on [DATE] at 3:36 PM , He stated it was always a problem trying to keep up with maintaining the facility because administration did not want to spend more money to provide the proper services needed by hiring additional staff and order extra cleaning supplies. He stated he was told he was not doing his job although he barely had any resources to do the job. The FESD stated he had a meeting with the owner of the facility and talked to him a long time about what all he needed, but the owner disagreed with him. He stated he was a housekeeper before he became the director, and he always knew what the facility needed, but he simply could not keep up because he did not have enough housekeeping staff. In an interview with the Current Director of Environmental Services on [DATE] at 12:00 PM, she stated she had only been in this position for approximately two weeks and was still attempting to get things sorted out. She stated she tried to ensure that resident rooms were being cleaned by checking the housekeeping staff's work. She stated she was in the process of revising policies and making new documentation for staff to record when they were performing cleaning duties and what was being done. In an interview with the Director of Nursing (DON) on [DATE] at 3:38 PM, she stated nursing staff was responsible for cleaning the extended use medical equipment. She stated if a resident was discharged then Environmental Services would be responsible for cleaning it once the discharge has occurred. She stated it was her expectations that the facility was kept clean to create a homelike environment for the residents. She stated she would delegate monitoring the environment to her supervisors and make sure that they were monitoring to ensure that the rooms were being clean. In an interview with the Administrator on [DATE] at 4:16 PM, she stated she never knew about the IV pole,and she would discuss it with DON. She stated the CNAs should not mess with any medical equipment at all. The Administrator stated she would get with the DON and discuss it and determine who would be responsible for cleaning the medical equpment. She stated she did not think the CNAs should be doing it . If a nurse saw it was dirty they should take care of it regardless. The Administrator stated she had ordered the staff to stop polishing and putting wax down because she noticed they had placed wax on dirty floors. She stated her responsibility was to ensure compliance overall, including the safety of the residents.

2. Continued review of the facility's policy titled, Infection Prevention and Control Program, undated, revealed environmental cleaning and disinfection was to be performed according to the facility's policy. Per review, all staff had responsibilities related to the cleanliness of the facility. Review of the facility's policy titled, Routine Cleaning and Disinfection, undated, revealed it was the facility's policy to ensure provision of routine cleaning and disinfection of intravenous (IV) infusion poles in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Equipment, undated, revealed reusable resident care equipment was to be cleaned and disinfected in accordance with current Centers for Disease Control and Prevention (CDC) recommendations in order to break the chain of infection. Observations on 05/06/2025 at 9:00 AM; 05/08/2025 at 1:50 PM; and 05/09/2025 at 10:00 AM, revealed the bottom of R65's infusion pole was coated in a dried brown substance. In interview on 05/09/2025 at 2:44 PM, LPN 12 stated the night shift Certified Nurse Aide (CNA) staff were responsible for cleaning medical equipment, such as wheelchairs and infusion poles. In interview on 05/09/2025 at 3:38 PM, the DON stated nursing staff was responsible for cleaning the extended use medical equipment, such as infusion poles. She stated if a resident was discharged from the facility then Environmental Services was responsible for cleaning it once the discharge occurred. In interview on 05/10/2025 at 4:16 PM, the Administrator stated she was not aware that the IV pole needed cleaning, and would discuss that further with the DON. 3. Review of the facility's policy titled, Transmission-Based (Isolation) Precautions, undated, revealed the facility would take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. Per review of the policy, healthcare personnel caring for residents on contact precautions were to wear a gown and gloves for all interactions that might involve contact with the resident. Further review revealed healthcare personnel were to don (put on) personal protective equipment (PPE) upon entering the resident's room. Review of the admission Record for R229, revealed the facility admitted the resident on 04/28/2025, with diagnoses to include: unspecified open wound of abdominal wall, colostomy, and non-pressure chronic ulcer of left calf limited to breakdown of skin. Review of the admission Minimum Data Set (MDS) Assessment with a ARD of 05/01/2025, revealed the facility assessed R229 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Review of the physician's order dated 04/30/2025 at 9:51 PM, revealed an order for the resident to have isolation contact precautions related to a parasite. Staff were to wear all PPE when entering R229's room. Observation on 05/07/2025 at 4:58 PM, revealed CNA 1 entered R229's room with a lunch tray; however, failed to don the required PPE prior to entering the room. During interview with CNA 1 on 05/06/2025 at 5:05 PM, she stated she worked through an agency. CNA 1 stated she should have donned a gown, gloves and mask when she took R229's lunch tray into his room. She stated she had been in a hurry due to only having 15 minutes to pass lunch trays to the other residents. The CNA stated she should have followed the guidelines to prevent herself from getting an infection. She further stated she had received education related to Transmission Based Precautions prior to starting work at the facility. During interview with the DON on 05/09/2025 at 3:38 PM, she stated she was the facility's acting Infection Prevention (IP) Nurse. She stated staff should wear PPE when providing direct care if a resident was on contact precautions. When the State Survey Agency (SSA) Surveyor asked the DON what the requirements were for residents on contact precautions, she said, staff should wear PPE prior to entering a resident's room who was on contact precautions. The DON stated staff could end up with whatever organism the resident had on their clothing and possibly spread it to other residents and staff. She stated she expected her staff to wear PPE as required. The DON stated education was provided to staff during monthly meetings and online trainings were also assigned for staff to review. She explained agency staff were educated by the agency they were hired through and were not permitted to pick up shifts until the education had been completed. The DON further stated however, she did not verify the staff education had been completed. During interview with the Administrator on 05/10/2025 at 4:15 PM, she stated she expected staff to follow the rules on whatever precautions the resident was placed on. She stated a sign was placed on the outside of the resident's door for the precautions staff were to follow. The Administrator stated she expected staff to follow the facility's policy. She stated she did not know if there would be a negative outcome if staff did not follow the precautions; however, they could spread an illness to others in the facility. Based on observation, interview, record review and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 26 sampled residents, (Resident (R)32, R65, R106, R111, R122, and R229) The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, undated, revealed the facility was to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Per review, all staff should assume all residents were potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Continued review revealed hand hygiene should be performed in accordance with the facility's established hand hygiene procedures. Further review of the policy revealed all staff were to use personal protective equipment (PPE) according to established facility policy governing the use of PPE. Review of the facility's policy, Serving a Meal, undated, revealed the Policy Explanation and Compliance Guidelines included: Avoid handling actual unwrapped food items with bare hands. Observation on 05/06/2025 at 5:15 PM, of the dinner meal service, revealed Licensed Practical Nurse (LPN) 14 touched R122, R111, R32, and R106's sandwich buns with her bare hands while cutting their sandwiches in half. Continued observation revealed LPN 14 also touched the residents' straws with her bare hands when placing the straws in the residents' drinks. During interview on 05/09/2025 at 12:15 PM, LPN 14 stated she should have worn gloves when cutting the sandwiches and removing the resident's straw papers as she could pass infections to the residents. In interview on 05/10/2025 at 2:40 PM, the Director of Nursing (DON) stated she expected staff to avoid touching residents' food with their bare hands. She stated straw papers needed to be removed without touching the straw. In interview on 05/10/2025 at 4:35 PM, the Administrator stated she expected staff to wear clean gloves when handling residents' food, and remove the paper from straws without contamination.

Based on observation, interview, medical record review and facility policy review, the facility failed to ensure residents had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility related to residents with eating difficulties for four (4) of 26 sampled residents (Resident (R) 32, 106, R122, , R111) and one (1) unsampled resident (R2). The findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity, undated, revealed the facility would protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintained or enhanced the resident's quality of life by recognizing each resident's individuality. Further review of the policy revealed all staff members were involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 1. Review of Resident R32's Facesheet revealed the facility admitted the resident on 05/20/2019 with diagnoses which included, polyarthritis, muscle wasting and atrophy, and dementia. Review of the Quarterly Minimum Data Set (MDS) assessment for R32 dated 03/20/2025, revealed a Brief Interview for Mental Status (BIMS) score of one (1) out of fifteen (15) which indicated severe cognitive impairment. 2. Review of R106's facesheet revealed the facility admitted the resident on 06/28/2024 with diagnoses which included muscle wasting and atrophy, need for assistance with personal care, and cognitive communication deficit. Review of the Quarterly MDS dated [DATE] revealed a BIMS' score of 9 which indicated the resident had a moderate cognition impairment. 3. Review of R111's facesheet revealed the facility admitted the resident on 01/12/2024 with diagnoses which included: altered mental status, cognitive communication deficit, and need for assistance with personal care. Review of R111's Quarterly MDS dated [DATE] revealed a BIMS' score of 13 which indicated the resident's cognition was intact. 4. Review of R122's facesheet revealed the facility admitted the resident on 03/06/2025 with diagnoses which included chronic pulmonary edema, inappropriate diet and eating habits, adult failure to thrive, and alzheimer's disease with late onset. Review of R122's admission MDS dated [DATE] revealed a BIMS' score of 3 which indicated severe cognitive impairment. During an observation on 05/06/2025 at 12:22 PM in the Station 4 dining room, revealed R32, R106, R111, and R122 were draped with bath towels instead of clothing protectors or napkins. There was a large black plastic container against the wall with a Towels sign above the container. Observation during the dinner meal on 05/06/2025 at 5:15 PM revealed the residents were draped with bath towels again. During an interview with R41 on 05/10/2025 at 2:48 PM, she stated she would like extra napkins but she gets two towels that she lays across her to protect her clothing. R41 stated that she would use a towel because the clothing protectors that the facility looked so raggedy they would not protect anybody's clothing. During an interview on 05/10/2025 at 2:55 PM, R54 stated she always wanted to use something to cover her clothing when eating. During an interview with Certified Nurse Aide (CNA) 9 on 05/09/2025 at 4:32 PM she stated, residents have the right to refuse to use a towel. She stated, We use towels in place of bibs and (they) are used based on BIMS and capabilities. During an interview with Licensed Practical Nurse (LPN) 13 on 05/10/2025 at 2:52 PM, she stated, use of towels for clothing protectors was based on the resident'' ability. She stated, We do not make anybody wear it. During an interview with CNA11, on 05/10/2025 at 4:10 PM she stated, she sometimes offers the residents clothing protectors. When asked to describe it, she stated it looked just like a towel. Don't offer anything else. She stated, there were some residents who prefer to have a napkin in their lap and they do have access to that, stating that it was the paper one that comes on their tray. During an interview with CNA12 on 05/10/2025 at 4:15 PM, she stated she assists with trays. The CNA stated that she offered towels to the residents because she doesn't know where the clothing protectors are, adding she believed they may be on the 400 Hall. CNA12 stated, They have napkins that their utensils are wrapped in. She stated that if she was helping in the dining room she would just go ahead and put a napkin in there lap without asking out of habit. During an interview with the Director of Nursing on 05/09/2025 at 4:38 PM she stated she thought it was fine to use a bath towel as a clothing protector for residents. She stated she was not sure if the facility had clothing protectors and if there were some, there was not enough for all the residents. During an interview with the Administrator on 05/10/2025 at 4:35 PM, she stated, We should ask the residents if they want clothing protectors. Towels are not appropriate at all.

Based on interview, record review, review of the facility's Director of Nursing (DON) and Administrator's Job Descriptions, and policy review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident related to the facility's Administrator and/or DON failed to notify the state regulatory office on the elopement on 04/18/2025 of R529. The findings include: On 04/18/2025 at approximately 2:58 PM, R529 walked 71 yards from her room through two sets of double doors, into a staff meeting/break room, out a single storage room door and then through a door outside onto the loading dock. R529 was found on the dock, where she found a lift and was raised 81 inches from the pavement below. Review of the facility's policy titled, Governing Body, undated, revealed the facility was to have a governing body or designated persons functioning as a governing body that were legally responsible for establishing and implementing policies regarding the management and operations of the facility. Per review, the governing body was to appoint an Administrator who was licensed by the state where required and responsible for management of the facility. Continued review revealed the governing body was to have a process in place by which the Administrator knew what specific types of problems and information (i.e., survey results, allegations of abuse or neglect, complaints, etc.) were to be reported or not reported to the state agency/agencies. Review of the facility's policy, Elopements and Wandering Residents, undated, under Procedure for Locating Missing Resident, revealed appropriate reporting requirements to the State Survey Agency (SSA) should be conducted. Review of the facility's Administrator Job Description dated 09/10/2020, revealed the Administrator was to plan, coordinate and manage all services and employees of the facility. Per review, the Administrator was responsible for the overall direction, coordination, and evaluation of all care and services provided to the Elders (residents) of the facility. Continued review revealed the facility's Administrator oversaw and maintained quality care, service and culture that was consistent with and exceeded organizational, state and federal regulatory standards as directed by the facility's team. Further review revealed the facility's Administrator was to have the ability to communicate effectively and advocate for Elder centered/directed care to team members, families, and physicians. Additional review of the Administrator Job Description revealed the Administrator was to understand all regulations including, federal, state, and Life Safety Code (LSC) regulations. Review further revealed the Administrator was to ensure all regulations were covered by a facility policy and/or procedure and conversely, to ensure all existing policies and procedures were compliant with said regulations. Review of the facility's DON Job Description, undated, revealed the DON was to manage and direct the day to day functions of the Nursing Department in accordance with established policies, procedures, and practices that complied with federal, state, and local regulations. Per review, the DON was to demonstrate knowledge of the residents' physical, social, emotional, and psychological needs based on the health care required. Continued review revealed the DON was to ensure adequate staffing patterns, and that staff were qualified and trained. Further review revealed the DON's essential functions included: ensuring required documentation was complete and was in compliance with regulations and standards. Additionally, the DON's professional requirements included maintaining regulatory requirements, including all state, federal and local regulations. In interview on 05/07/2025 at 11:57 AM, the DON stated she was not in the facility when R529's elopement took place. She stated she had worked that day, but went home early around 1:30 PM. The DON stayed she received a call sometime after 3:00 PM, from the Minimum Data Set (MDS) Nurse, who told her a resident had eloped. She stated she investigated the incident and determined the resident had gone out the storage room door to the outside. The DON stated she would by definition consider that an elopement. The DON stated she expected staff to keep the residents safe and ensure doors/locks were not broken, and perform wander assessments. When asked by the State Survey Agency (SSA) Surveyor if she should have notified the state of R529's elopement, she stated in hindsight, yes. The DON further stated We will now report that but have not yet. In interview on 05/07/2025 at 10:15 AM, the Administrator stated, regarding the elopement of R529, she had not been there when the elopement happened. She stated she did not report it to the state because she did not think it was an elopement since she was told the resident did not get out of the facility. The Administrator stated she had discussed it with her DON and they decided it was not an elopement. She stated she was unaware the resident got out of the door and onto the dock. The Administrator stated R529 did not get off of the facility's property; however, after the regulation was reviewed with her, she stated it was an elopement and should have been reported to the state agency.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to implement the comprehensive person-centered care plan for one (1) of twenty-eight (28) sampled residents (Resident #61). Resident #61's Comprehensive Care Plan, revised 01/05/2024, revealed an intervention to utilize the mechanical lift with two (2) staff members for transfers. However, on 02/01/2024, Certified Nursing Assistant (CNA) #7 and CNA #14, transferred Resident #61 from the bed to the wheelchair without using a mechanical lift (device used to transfer residents who require support for mobility beyond the manual support provided by caregivers alone). Resident #61 sustained a laceration to the left lateral calf which required a transfer to the hospital emergency room (ER) for placement of three (3) skin clips (medical metallic device used to close open wounds). Additionally, on 02/21/2024, CNA #13 failed to implement Resident #61's Comprehensive Care Plan related to the intervention to utilize the mechanical lift with two (2) staff members for transfers. CNA #13 transferred Resident #61 without the assistance of another staff member and without using the mechanical lift and caused a skin tear to the resident's left lower leg. Refer to F689 The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, undated, revealed a comprehensive, person-centered care plan includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs and is developed and implemented for each resident. The policy further stated the care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The Interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative develops and implements a comprehensive, patient-centered care plan for each resident. Review of the facility policy titled Using the Care Plan, undated, revealed the care plan shall be used in developing the resident's daily care routine and would be available to staff personnel who had the responsibility for providing care or services to the resident. The comprehensive, person-centered care plan would, among other things, describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Identified problem areas would be incorporated into the care plan and assessments of residents were ongoing. Care plans were revised as information about the residents and resident's conditions changed. Review of Resident #61's medical record revealed the facility admitted the resident on 12/18/2019 with diagnoses including dementia in other diseases classified elsewhere, severe with other behavioral disturbance, contractures to left and right Knee, and hypertensive heart disease without heart failure. Review of Resident #61's Annual Minimum Data Set (MDS) Assessment, dated 11/11/2023, revealed the facility assessed the resident as being unable to interview and as rarely or never understood. Further review revealed the facility assessed Resident #61 as totally dependent on staff for transfers. Review of Resident #61's Comprehensive Care Plan, dated 12/18/2019, revised 01/05/2024, revealed a focus problem for Activities of Daily Living (ADLs) self-care performance deficit related to dementia, late-stage Alzheimer's, and contractures. The care plan goal stated the resident would be neat, clean, and well groomed and would maintain current level of functioning through next review. Interventions included the assistance of two (2) staff with use of a mechanical lift for transfers using a Yellow (Liko) or Green (Proactive) sling. This intervention was initiated on 01/05/2024. Resident #61's Mechanical Lift Evaluation, dated 01/05/2024, revealed the resident was assessed for the correct size of sling to use, the sling size information had been care planned, the care plan was updated to reflect change in transfer ability, and staff was educated on change in transfer and correct sling to use. Review of Resident #61's Point Click Care (PCC, a software program used for charting) record, under the Kardex (nurse aide care plan) section, revealed transfers required total care with two (2) staff assist with a mechanical lift with use of a yellow Liko or a Green Proactive sling for transfer to the wheelchair. This intervention was tagged to the Kardex from Resident #61's care plan intervention by the MDS Coordinator on 01/05/2024. Review of Resident #61's Progress Note, dated 02/01/2024 at 11:00 PM, entered by Licensed Practical Nurse (LPN)/ Unit Coordinator (UC) #2, revealed she was notified by the medication nurse, LPN #4, the resident sustained a skin tear to the Left lower extremity. Per the Note, the nurse assessed and documented the wound as a laceration about four to five (4-5) inches wide and deep with bleeding noted. The area was cleansed and the wound edges were approximated (the edges of the wound fit together) and steri-strips (small adhesive strips of wound material) were applied, and covered with a dry dressing. Additional review of the Note, revealed the Nurse Practitioner (NP) was notified and advised LPN/UC #2 she would be in to see Resident #61 before providing new orders. Review of Resident #61's Progress Note, dated 02/01/2024 at 11:56 PM, entered by LPN/UC #2, revealed at 5:05 PM, the CNA notified the nurse the resident received a skin tear during transfer. The nurse immediately cleansed the area and applied a bandage. The Nurse Practitioner and family were notified. Review of Resident #61's Progress Note, dated 02/02/2024 at 3:35 AM, revealed the NP assessed the laceration with LPN/UC #2. Further review revealed the NP gave the order to send Resident #61 to the emergency room . Resident #61's Discharge Summary from the local hospital, dated 02/02/2024, at 3:50 AM, revealed the resident sustained a five (5) centimeter (cm) laceration with controlled bleeding and superficial avulsion (the action of pulling or tearing away) located in the lateral aspect of mid leg, described as U-shaped with convex toward shin. Three (3) skin clips were used to close the laceration. Additional review revealed Resident #61 received a Tetanus immunization, and was deemed stable and discharged back to the facility. In an interview with CNA #7, on 03/08/2024 at 3:22 PM, she stated she recalled she (CNA #7) and CNA #14 assisted Resident #61 from the bed to the wheelchair to get the resident ready for supper without the use of a Hoyer lift (mechanical lift). CNA #7 stated after the transfer it was noted the resident's left leg was bleeding. CNA #7 recalled Resident #61's feet did touch the floor with the transfer, but stated she did not know if the resident's leg hit the chair because the resident's leg was bleeding after the transfer. CNA #7 stated Resident #61 did not make any indication that he/she she had sustained an injury and seeing the blood was what indicated an injury. CNA #7 was questioned if she reviewed the Care plan or Kardex to ensure proper transfer technique prior to this transfer and CNA #7 stated she did not remember checking it, but did recall asking someone how Resident #61 was to be transferred. She could not remember who she had asked. CNA #7 further stated she was unaware Resident #61 required a Hoyer lift for transfer at the time of the transfer on 02/01/2024. During a telephone interview with CNA #14, on 03/08/2024 at 3:31 PM, she stated she no longer worked at the facility. She further stated she (CNA #14) and CNA #7 transferred Resident #61 from the bed to the wheelchair on 02/01/2024 without the use of a Hoyer lift and then they noted the resident's leg was bleeding. CNA #14 stated she recalled Resident #61 required two (2) staff to assist with transfer, but she did not know if the resident required a mechanical lift for transfers. CNA #14 stated she was in orientation on 02/01/2024, at the time of Resident #61's transfer, it was her second or third day on the job, and she did not recall checking the Care plan or Kardex prior to this transfer. During an interview with LPN #4, she stated she recalled the incident on 02/01/2024 related to Resident #61 sustaining a skin tear. She further stated when the CNAs were transferring the resident from the bed to the wheelchair, Resident #61 sustained a skin tear which was located on the resident's left lower extremity, below the knee on the lateral area of the leg and she wrote it up as an incident. LPN#4 could not recall if it was a large skin tear, but stated she dressed the wound. In further interview, LPN #4 stated she could not recall Resident #61's transfer status at the time of the incident because she floated throughout the facility and was not very familiar with the resident. However, she stated the CNAs were expected to check the Care plan or Kardex for information related to providing care for residents. She further stated she left at 11:00 PM that night and LPN/UC#2 relieved her and she gave LPN/UC#2 report. In an interview with LPN/UC #2, on 03/07/2024 at 4:41 PM, she stated on 02/01/2024, she worked from 7:00 PM-11:00 PM as House Supervisor and after 11:00 PM she worked as medication nurse. Further, she stated during her shift LPN #4 asked her to check on a resident who had a skin tear. She stated she assessed Resident #61 and notified the Nurse Practitioner who gave orders to send the resident to the Hospital emergency room (ER). In further interview, LPN/UC #2 stated the CNAs were to review the Care plan and Kardex prior to transferring a resident to ensure they were using the correct transfer technique. LPN/UC #2 stated she was unaware of how Resident #61 was transferred on 02/01/2024 when the resident sustained the skin tear. In an interview with Director of Nursing (DON), on 03/07/2024 at 5:09 PM, she stated she was notified upon arrival to the facility on [DATE], Resident #61 had sustained a laceration. The DON stated she called and obtained a statement from CNA #7 who told her she did not use the mechanical lift because she asked someone else how the resident was transferred and was told Resident #61 was transferred with the assist of two (2) staff. In continued interview with the DON, she stated CNA #7 received Teachable Moment education regarding using the Care Plan and Kardex prior to providing resident care. Additionally, she stated she was not able to reach CNA #14 for a statement as the CNA did not return to work after 02/01/2024. 2. Further review of Resident #61's medical record revealed a Nurse Progress Note, dated 02/21/2024 at 5:00 AM, entered by LPN #5, which revealed this morning upon getting the resident up, as CNA was transferring the resident from the bed to the wheelchair, the resident's left lower leg was bumped up against the wheelchair causing a skin tear. In an interview with LPN #5, on 03/07/2024 at 8:37 PM, she stated on 02/21/2024, CNA #13 informed her Resident #61 received a skin tear to the left lower leg. She stated the CNA informed her he saw blood on the resident's pants after assisting the resident with a transfer independently and without a mechanical lift. LPN #5 stated the new skin tear was next to the previous skin tear on the Left lower extremity. LPN #5 stated she then instructed CNA #13 to never attempt to lift a resident who required a mechanical lift for transfer and to always check the Care Plan or Kardex prior to transferring a resident to ensure proper transfer technique. A phone interview with CNA #13 was attempted on 03/07/2024 at 9:01 AM and 03/08/2024 at 10:02 AM and messages were left; however there was no return phone call. CNA #13 no longer worked at the facility. During an interview with the DON, on 03/08/2024 at 6:47 PM, she stated it was her expectation that all nursing staff utilized the Care plan and Kardex as a reference related to transfer technique. The DON stated the facility would continue to fully educate regarding following the care plan for all residents. In an interview with the Administrator, on 03/08/2024 at 7:09 PM, she stated it was her expectation for staff to discuss the residents in the care plan meetings as a team, follow policy, and procedure related to developing and revising care plans, and provide care according to the care plan for the safety of the residents.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two (2) of twenty-eight (28) sampled residents (Resident #61 and Resident #74). 1. On 02/01/2024, Certified Nursing Assistant (CNA) #7 and CNA #14, transferred Resident #61 from the bed to the wheelchair without using a Hoyer mechanical lift (device used to transfer residents who require support for mobility beyond the manual support provided by caregivers alone). Resident #61 sustained a laceration to the left lateral calf and required transfer to the hospital emergency room (ER) for placement of three (3) skin clips (medical metallic device used to close open wounds). Subsequently, on 02/21/2024, CNA #13 transferred Resident #61 from the bed to the wheelchair, without the assistance of another staff member and without using the mechanical lift and caused a skin tear to the resident's left lower leg. 2. On 01/10/2024, CNA #2 transferred Resident #74 from the bed to the wheelchair using a Hoyer mechanical lift. After the transfer, it was observed by staff, the Hoyer lift pad was improper fitting in size, resulting in skin-shear injury to the resident's left gluteal fold. (The Hoyer lift requires the use of a lift pad that acts a harness under and surrounding the resident for transfer support, stability, and safety). Refer to F656 The findings include: Review of the facility provided policy titled, Using a Mechanical Lifting Machine, dated 2001, revised December 2023, revealed the purpose of the procedure is to establish the general principles of safe lifting using the mechanical lifting device. It is not a substitute for manufacturer's training or instructions. The document includes provisions for general guidelines and procedural steps, including placing the sling under the resident, and visually checking the size to ensure it is not too large or too small. Continued review revealed at least two (2) staff were needed to safely move a resident with a mechanical lift. Review of the facility's policy titled, Safe Lifting and Movement of Residents, dated 12/2023, revealed in order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. The policy stated staff must follow manufacturer's guidelines to operate a (Hoyer) mechanical lift. The document stated staff responsible for direct resident care will be trained in the use of manual and mechanical lifting devices. 1. a) Review of Resident #61's Face Sheet revealed the facility admitted the resident on 12/18/2019, with diagnoses to include dementia with other behavioral disturbance, contractures to left and right knee, and hypertensive heart disease without heart failure. Review of Resident #61's Annual Minimum Data Set (MDS) Assessment, dated 11/11/2023, revealed the facility assessed the resident as unable to interview. Continued review of the MDS Assessment, revealed the facility assessed the resident as totally dependent on staff for transfers. Review of Resident #61's Comprehensive Care Plan, dated 12/18/2019, revised 01/05/2024, revealed a focus of Activities of Daily Living (ADLs) self-care performance deficit related to dementia, late-stage Alzheimer's, and contractures. The goal stated the resident will be neat, clean, and well groomed and will maintain current level of functioning through the next review. Interventions for transfers revealed the resident required total care of two (2) staff assist with a mechanical lift using a Yellow Liko or Green Proactive lift pad. The intervention was added by the Minimum Data Set (MDS) Coordinator on 01/05/2024. Review of the Mechanical Lift Evaluation, dated 01/05/2024, revealed Resident #61 was assessed for the correct size of sling to use. Further review of the Evaluation, revealed the care plan was updated to reflect change in transfer ability, and staff were educated on change in transfer and correct sling to use. Review of Resident #61's Point Click Care (PCC, a software program used for charting) record, under the Kardex (nurse aide care plan) section, revealed transfers required total care with two (2) staff assist with a mechanical lift and the use of a yellow Liko or a Green Proactive sling for transfer to the wheelchair. This intervention was tagged to the Kardex from Resident #61's care plan intervention added by the MDS Coordinator on 01/05/2024. Review of Resident #61's Progress Note, dated 02/01/2024 at 11:00 PM, entered by Licensed Practical Nurse (LPN)/ Unit Coordinator (UC) #2, revealed she was notified by the medication nurse, LPN #4, about a skin tear to Resident #61's Left lower extremity. LPN/UC #2 assessed Resident #61's left lower extremity and documented the wound as a laceration about four to five (4-5) inches wide and deep with bleeding noted. LPN/UC #2 documented the area was cleansed and the wound edges were approximated (the edges of the wound fit together) and steri-strips (small adhesive strips of wound material) were applied, and covered with a dry dressing. Further review of the Note, revealed the Nurse Practitioner (NP) was notified and advised LPN/UC #2 she would be in the see Resident #61 before providing new orders. Review of Resident #61's Progress Note, dated 02/01/2024 at 11:56 PM, entered by LPN/UC #2, revealed at 5:05 PM, the CNA notified the nurse that the resident received a skin tear during transfer. The nurse immediately cleansed the area and applied a bandage. The Nurse Practitioner and family were notified. Review of Resident #61's Progress Note, dated 02/02/2024 at 3:35 AM, revealed the NP went to Resident #61's room to assess the laceration with LPN/UC #2. The NP gave the order to send Resident #61 to the emergency room . Interview with the Nurse Practitioner (NP), on 03/07/2024 at 10:35 AM, regarding Resident #61's injury, confirmed she was notified of the skin injury and advised the caller that she would be in to see Resident #61 the morning of 02/02/2024. The NP confirmed she came to the facility on [DATE] at 3:35 AM to assess Resident #61's wound. However, she stated she did not actually view the wound when she came to the facility. Further, she stated since she trusted the nursing judgement of LPN/UC#2, she went ahead and gave orders to send the resident to the ER. Review of Resident #61's Discharge Summary from the local hospital, dated 02/02/2024, at 3:50 AM, revealed the resident sustained a five (5) centimeter (cm) laceration with controlled bleeding and superficial avulsion (the action of pulling or tearing away) located in the lateral aspect of the mid leg, described as U-shaped with convex toward shin. Three skin clips were used to close the laceration. Further review revealed Resident #61 received a Tetanus immunization, and was deemed stable and discharged back to the facility. During an interview with CNA #7, on 03/08/2024 at 3:22 PM, she stated she recalled that she (CNA #7) and CNA #14 were assisting Resident #61 from the bed to the wheelchair to get the resident ready for supper without the use of a mechanical lift. CNA #7 stated Resident #61's feet touched the floor with the transfer, and after the transfer it was noted the resident's left leg was bleeding. She stated she did not know if the resident's left leg hit the chair with the transfer possibly causing the injury. CNA #7 was asked if she reviewed the Kardex to ensure proper transfer technique prior to this transfer and CNA #7 stated she did not remember checking it, but did recall asking someone how Resident #61 was to be transferred. She could not recall who she had asked. CNA #7 further stated she was unaware CNA #7 required a mechanical lift for transfer at the time. Further, CNA #7 stated Resident #61 did not indicate he/she had sustained an injury during the transfer, but she (CNA #7) noted the resident's leg was bleeding after the transfer. Review of training revealed CNA #7 completed a Relias training with a certificate for Transfers: Mechanical Lift. However, the facility did not provide training information to indicate CNA #7 was checked off on using the lift with return demonstration. In a telephone interview with CNA #14, on 03/08/2024 at 3:31 PM, she stated she could not recall the last day she worked at the facility. During continued interview with CNA #14, she stated, she (CNA #14) and CNA #7 transferred Resident #61 from the bed to the wheelchair on 02/01/2024 without the use of a mechanical lift and then they saw the resident's leg was bleeding. CNA #14 recalled Resident #61 required two (2) persons to assist with transfer, but she did not know if the resident required a mechanical lift for transfers. CNA #14 stated she was in orientation on 02/01/2024, at the time of Resident #61's transfer and it was her second or third day on the job. Review of the Employee Timecard Report for CNA #14, revealed during the recording period of January 28, 2024 through February 03, 2024, CNA #14 worked on 01/29/2024, 01/31/2024, and 02/01/2024. There were no additional hours worked after 6:57 PM on 02/01/2024. In an interview with LPN #4, she stated she recalled the incident on 02/01/2024. She stated when the CNAs were transferring Resident #61 from the bed to the wheelchair, Resident #61 sustained a skin tear. She stated she dressed the wound which was located on the resident's left lower extremity, below the knee on the lateral area of the leg and wrote it up as an incident. In continued interview LPN #4, she stated she could not recall if the resident had a large skin tear nor the resident's transfer status at the time of the incident because she floated throughout the facility and was not familiar with the resident. She stated she left at 11:00 PM that night and LPN/UC#2 relieved her. During interview with LPN/UC #2 on 03/07/2024 at 4:41 PM, she stated on 02/01/2024, she recalled working from 7:00 PM-11:00 PM as House Supervisor and after 11:00 PM, she worked as the medication nurse. She stated during her shift on that date, another LPN asked her to assess Resident #61 related to a skin tear. Further, she stated she then notified the Nurse Practitioner who gave orders to send the resident to the Hospital emergency room (ER). In continued interview, LPN/UC #2 stated she was unaware of how Resident #61 was transferred on 02/01/2024 when the resident sustained the skin tear. During an interview with the Director of Nursing (DON), on 03/07/2024 at 5:09 PM, she stated she was notified upon arrival to the facility on [DATE], Resident #61 had sustained a laceration overnight. The DON further stated she called and obtained a statement from CNA #7 who told her she did not use the mechanical lift because she asked someone else how the resident was transferred and was told Resident #61 was transferred with the assist of two (2) staff. In further interview with the DON, she stated CNA #7 received a Teachable Moment education regarding using the Kardex/Care plan prior to providing resident care. Additionally, the DON stated she was not able to reach CNA #14 for a statement as the CNA did not return to work after 02/01/2024. 1 b) Review of the Nurse Progress Note, dated 02/21/2024 at 5:00 AM, entered by LPN #5, revealed this morning upon getting the resident up, as CNA was transferring resident from the bed to the wheelchair, the resident's left lower leg was bumped up against the wheelchair causing a skin tear. In an interview with LPN #5, on 03/07/2024 at 8:37 PM, she stated on 02/21/2024, CNA #13 informed her there was blood on Resident #61's pants after assisting him/her with a transfer. LPN #5 stated she assessed the resident to have a skin tear to the left lower leg. Further, LPN #5 stated the new skin tear was next to the previous skin tear which was sustained on 02/01/2024 to the Left lower extremity. LPN #5 stated she cleansed the wound, and applied a bandage. LPN #5 further stated she completed change of condition documentation in the medical record and made the required notification. In continued interview, LPN #5 stated CNA #13 informed her he had transferred the resident himself independently and without a Hoyer lift. LPN #5 stated she then instructed CNA #13 to never attempt to lift a resident who required a Hoyer lift for transfer. A phone interview with CNA #13 was attempted on 03/07/2024 at 9:01 AM and 03/08/2024 at 10:02 AM and messages were left for the CNA to return the calls; however there was no return phone call. CNA #13 no longer worked at the facility. Review of the training, revealed CNA #13 had been checked off on 01/04/2024 on using the Hoyer lift as evidenced by documented Total Lift Competency Test and a post-test written quiz. Observation on 03/08/2024 at 2:33 PM, revealed Licensed Practical Nurse (LPN) #1 removed the dressing from Resident #61's Left lower extremity which revealed a horseshoe shaped skin area on the lateral calf. The margins of the laceration were well-approximated with no signs or symptoms of infection. Adjacent to the horseshoe shaped skin area was a skin tear of the left shin which appeared to be healing without signs or symptoms of infection with an approximate area of 0.3 centimeters (cm) x 0.3 cm remaining to fully heal. LPN #1 cleansed the wounds of the horseshoe shaped skin area of the lateral calf and the skin tear, and applied a treatment of Medi honey covered with an adhesive bordered gauze as per current orders initiated 02/21/2024. During interview with the Director of Nursing (DON), on 03/07/2024 at 5:09 PM, she stated on 02/21/2024 she was made aware via text message that Resident #61 received a new skin tear to the left lower leg caused by CNA #13 transferring Resident #61 without assistance and without the lift because it was quicker. In further interview, she stated CNA #13 was given a Performance Improvement notice related to the improper transfer. Review of the written Performance Improvement / final notice regarding the improper transfer on 02/21/2024, revealed it was signed by CNA #13, Assistant Director of Nursing (ADON) and DON. 2. Review of Resident #74's Face Sheet revealed the facility admitted the resident on 08/21/2021 with diagnoses including Parkinson's Disease, Type-2 Diabetes, and chronic kidney disease. Review of Resident #74's Quarterly Minimum Data Set (MDS) Assessment, dated 12/29/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of eight (8) out of fifteen (15) indicating moderate cognitive impairment. Further review revealed the facility assessed the resident as being totally dependent on staff for transfers. Review of Resident #74's Comprehensive Care Plan, dated 11/08/2021, revised 01/05/2024, revealed a focus of Activities of Daily Living self-care performance deficit related to Parkinson's Disease and impaired mobility. The goal revealed the resident would maintain current level of function through the review date. Interventions initiated 01/05/2024, included the assistance of two (2) staff with the use of a mechanical lift for transfers and a blue Liko lift pad for transfers with the Hoyer lift. Review of Resident #74's Point Click Care (PCC, a software program used for charting) record, under the Kardex (nurse aide care plan) section, revealed transfers required the Hoyer lift using the blue Liko lift pad. This intervention was tagged to the Kardex from Resident #74's care plan intervention added by the MDS Coordinator on 01/05/2024. Review of Resident #74's Nurse's Progress Note, dated 01/10/2024 at 2:44 PM, entered by the Director of Nursing (DON) revealed the resident had a new skin impairment, left gluteal fold shearing from lift pad. Review of Resident #74's Nurse's Progress Note, dated 01/10/2024 at 3:14 PM, entered by LPN #2, revealed the resident had shearing to the left gluteal fold related to the lift pad. The resident was changed to a green lift pad. Treatment nurse applied a collagen sheet to the area and covered with a dressing. Nurse Practitioner notified of a new skin injury. Review of Resident #74's Nurse's Progress Note, dated 01/10/2024, at 4:00 PM, entered by the DON, revealed the nurse reviewed the area to the resident's left leg. No drainage noted. No redness or swelling. Resident reports the area did not cause discomfort at this time. Area cleansed and treatment applied from the treatment nurse. In an interview with LPN #2, on 03/07/2024 at 10:30 AM, she stated she was assigned to Resident #74 on 01/10/2024. She reviewed the Progress Note she entered on 01/10/2024 at 3:14 PM, but stated she was not aware of any specific circumstances that happened on 01/10/2024 to cause a problem. She did state CNA #2 told her they needed to get a different lift pad for the resident. In an interview with CNA #2, on 03/07/2024 at 10:40 AM, she stated Resident #74 required the assistance of two (2) staff members for any movement from the bed because of his/her size and mobility issues. She stated a blue lift pad was used to transfer the resident with the Hoyer lift on 01/10/2024. She further stated this was the correct size of lift pad to use at the time, but stated the resident was complaining and seemed to fit tight in the lift pad when being moved so she assisted the resident to bed and removed the lift pad, noting redness at the gluteal fold. She stated she then notified LPN #2 of the skin issue and the need for a larger lift pad for the resident. CNA #2 stated she did not recall who was assisting her with Resident #74 when transferring the resident with the Hoyer lift on the date of the incident. In continued interview with CNA #2 on 03/07/2024 at 10:40 AM, she stated she recalled when the facility contacted Resident #74's family about the new skin injury related to the Hoyer lift pad, they seemed quite upset, and the DON had to intervene. CNA #2 stated the resident was complaining of pain in that same area (left gluteal fold) while sitting in the shower chair and felt like it was pinching his/her leg so they offered to place the resident on a shower bed to reduce pressure and discomfort and the resident declined. CNA #2 then took the State Agency Surveyor to Resident #74's room and the resident was observed to be resting in bed. It was noted there was a green Hoyer lift pad in the wheelchair for use. However, review of the resident's Care plan and Kardex revealed the resident was to use the blue Liko lift pad for transfers with the Hoyer lift. Interview with Resident #74's son, on 03/07/2024 at 10:14 AM, revealed he was contacted by a nurse on staff at the facility on 01/10/2024, who stated the wrong size lift or pad for the Hoyer lift had been used on the resident. He was unable to recall the nurse who made the call. In further interview, he stated the facility knew they were using a lift pad which was too small and they needed to order a larger one. He further stated it wasn't a major issue initially, but concerned him later because this resident has mobility issues. Further, he did not recall what the staff was doing when they were moving Resident #74 on the day of the incident, but might have been transferring the resident for therapy, bed changes, showers, dressing, etc. He stated no other lift accidents since that time had occurred to his knowledge. During interview with the DON, on 03/07/2024 at 1:45 PM, she stated, on 01/10/2024, the blue pad was being utilized for Resident #74 which was a Proactive (manufacturer) blue pad. However, she stated after the resident had complications with shear on that day, he/she was switched to the green pad with the blue stripe manufactured by Liko. When the DON was questioned why Resident #74's care plan and Kardex stated a blue Liko pad should be used for the Hoyer lift transfers instead of the green lift pad, she stated the care plan and Kardex stated the Liko blue lift should be used; however, the facility did not have a blue Liko pad. She further stated the green lift pad which was made by Liko had a blue stripe on it so they called it the blue one. In further interview, she stated Resident #74's Care plan and Kardex should be revised to say the Liko green pad with the blue stripe. In ongoing interview with the DON, on 03/07/2024 at 1:45 PM, she was questioned related to the reason the incorrect size lift pad was used to transfer Resident #74 on 01/10/2024. The DON explained the blue or green lift pads could be used on any resident provided they meet the weight requirement. Further, she stated the blue lift pad had a weight limit of 600 pounds which was appropriate for the resident; however, the resident seemed to fit tightly in the lift pad and he/she was complaining of discomfort so the decision was made to have staff use the green Liko pad only. During a subsequent interview with the DON, on 03/08/2024 at 6:47 PM, she stated since starting employment as the Director of Nursing in December 2023, she had ensured all staff members were trained on the use of the Hoyer lift. She further stated it was her expectation that all nursing staff followed the Care plan and Kardex as a reference related to transfer technique, including whether a Hoyer lift was to be used and what type of lift pad to be used. Further, two (2) staff was to assist with all Hoyer lift transfers. When asked how residents were assessed for sling type per manufacturer's guidelines, she stated height, and weight were used to select the color of the mechanical lift pad. She stated she expected staff to utilize the lift pad according to the color indicated on the care plan/Kardex. Further, she stated staff could work with a nurse to find the right sling pad for the resident if needed In an interview with the Administrator, on 03/08/2024 at 7:09 PM, she stated it was her expectation for staff to follow policies and procedures for use of the Hoyer lift and to ensure correct transfer technique for the safety of the residents. 49350

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by the interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for two (2) of twenty-eight (28) sampled residents (Resident #48 for and Resident #74). On 01/10/2024, staff transferred Resident #74 from the bed to the chair using a Hoyer lift (mechanical body lift). After the transfer, it was observed by staff the Hoyer lift pad was poor-fitting in size, resulting in skin-shear injury to the resident's left gluteal fold. After the incident, the resident's lift pad was changed to the green Hoyer lift pad with the blue stripe manufactured by Liko. However, the resident's CCP was not revised to reflect the change in lift pads. Additionally, Resident #48 sustained a 16.2 pound weight loss from 01/19/2024 until 03/04/2024, indicating a 16.2 pound weight loss in less than two (2) months which would be a significant weight loss of 9.3 % (percent). This was a desired weight loss; however, the CCP was not revised to indicate the desired weight loss. Refer to F689 The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person Centered, revised 12/2016, revealed the interdisciplinary team would review and update the care plan when there had been a significant change in the resident's condition, when the desired outcome was not met, when the resident had been readmitted to the facility from a hospital stay and at least quarterly in conjunction with the required Quarterly Minimum Data Set (MDS) Assessment. 1. Review of Resident #74's medical record revealed the facility admitted the resident on 08/21/2021 with diagnoses to include Parkinson's Disease, Type-2 Diabetes, and chronic kidney disease. Review of Resident #74's Quarterly Minimum Data Set (MDS) Assessment, dated 12/29/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eight (8) out of fifteen (15) indicating moderate cognitive impairment. Additional review revealed the facility assessed the resident as being totally dependent on staff for transfers. Review of Resident #74's Comprehensive Care Plan (CCP), dated 11/08/2021, revised 01/05/2024, revealed a focus related to Activities of Daily Living self-care performance deficit related to a diagnosis of Parkinson's Disease and impaired mobility. The goal dated 05/16/2022, revealed the resident would maintain at current level of function through the next review date. Interventions initiated on 01/05/2024, included the assistance of two (2) staff with the use of a blue Liko lift pad for transfers with the Hoyer lift. Review of Resident #74's Point Click Care (PCC, a software program used for charting) record, under the Kardex (nurse aide care plan) section, revealed the resident's transfers required the Hoyer lift using the blue Liko lift pad. This intervention was tagged to the Kardex from Resident #74's care plan intervention by the MDS Coordinator on 01/05/2024. Resident #74's Nurse's Progress Note, dated 01/10/2024 at 2:44 PM, entered by the Director of Nursing (DON), revealed the resident sustained a new skin impairment, left gluteal fold shearing from lift pad. Resident #74's Nurse's Progress Note, dated 01/10/2024 at 3:14 PM, entered by Licensed Practical Nurse (LPN) #2, revealed the resident had shearing to the left gluteal fold related to the lift pad, and the resident was changed to a green lift pad. Treatment nurse applied a collagen sheet to the area and covered with a dressing; and the Nurse Practitioner was notified of the new skin injury. Resident #74's Nurse's Progress Note, dated 01/10/2024, at 4:00 PM, entered by the DON, revealed the nurse reviewed the area to the resident's left leg. No drainage, redness or swelling noted. Resident reports the area did not cause discomfort at this time. Area cleansed and treatment applied from the treatment nurse. During an interview with LPN #2, on 03/07/2024 at 10:30 AM, she stated she was assigned to Resident #74 on 01/10/2024. She reviewed the Progress Note she entered on 01/10/2024 at 3:14 PM; however, stated she was not aware of any specific circumstances that happened on 01/10/2024 to cause a problem. She did state Certified Nursing Assistant (CNA) #2 informed her they needed to get a different lift pad for the resident. During interview with CNA #2, on 03/07/2024 at 10:40 AM, she stated a blue lift pad was used to transfer Resident #74 with the Hoyer lift on 01/10/2024. Further, she stated this was the correct size lift pad to use at the time, but the resident complained and seemed to fit tight in the lift pad when being moved in the Hoyer lift. She further stated when she assisted the resident to bed and removed the lift pad, she noted redness at the gluteal fold. CNA #2 stated she then notified LPN #2 of the skin issue and the need for a larger lift pad for the resident. CNA #2 did not recall who was assisting her with Resident #74 when transferring the resident with the the Hoyer lift on the date of the incident. During continued interview with CNA #2, on 03/07/2024 at 10:40 AM, she directed the State Agency Surveyor to Resident #74's room and the resident was observed to be resting in bed. Additional observation revealed there was a green Hoyer lift pad in the wheelchair for use. However, review of the resident's CCP and Kardex, revealed the resident required the blue Liko lift pad for transfers with the Hoyer lift. During interview with the DON, on 03/07/2024 at 1:45 PM, she stated, on 01/10/2024, the blue pad was being utilized for Resident #74 which was a Proactive (manufacturer) blue pad. However, she stated after the resident had complications with shear of the skin on that day, it was decided for staff to use the green pad with the blue stripe manufactured by Liko for Hoyer lift transfers for this resident. She stated this was because the resident seemed to fit tightly in the blue lift pad and he/she was complaining of discomfort. The DON was questioned why Resident #74's care plan and Kardex stated a blue Liko pad should be used for the Hoyer lift transfers instead of the green lift pad. She explained the care plan and Kardex stated the Liko blue lift should be used; however, the facility did not have a blue Liko pad. She further stated the green lift pad which was made by Liko had a blue stripe on it, so staff called it the blue one. Further, she stated Resident #74's Care plan and Kardex should have been revised to say the Liko green pad with the blue stripe. 2. Review of Resident #48's medical record revealed the facility admitted the resident on 04/19/2022 with diagnoses to include Type 2 diabetes mellitus with diabetic neuropathy unspecified, Chronic Obstructive Pulmonary Disease (COPD) , and hypertensive heart disease without heart failure. Review of Resident #48's Comprehensive Care Plan (CCP), dated 06/06/2016, revealed a focus related to risk for weight loss related to chronic illness, and overweight as evidenced by a body mass index (BMI) greater than 24.9. The goal initiated on 11/28/2016 stated Resident #48 was to maintain a weight of 170 lbs., by next review. Interventions included feeds self independently, but will provide assist as needed, obtain food preferences and update as needed, history of refusing meals, Dietician to update preferences routinely, initiated 06/06/2016; blood sugar checks as ordered, initiated 04/19/2018; send an evening snack daily, initiated 06/07/2018; monthly weights unless otherwise indicated, initiated 04/09/2021; and medications as ordered, initiated 03/03/2023. Review of Resident #48's Nutrition CCP, dated 11/14/2023, revealed the resident was at risk for impaired nutrition related to chronic illness. The goal stated the resident would maintain a stable weight through next review. Interventions included supplements as ordered, alert the nurse or the dietitian, if not consuming on a routine basis, initiated 11/15/2023; low fat, no added salt diet, regular texture with thin liquids, initiated 12/16/2023; and honor food requests and preferences as applicable and supplements as ordered, initiated 03/05/2024. Review of Resident #48's Physician's orders dated 02/17/2024, revealed orders for a Low Fat, No Added Salt (NAS) diet, regular texture, with large protein portions and house supplement three (3) times daily. Review of Resident #48's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/19/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating intact cognition. Review of Resident #48's weights revealed on 11/20/2023, the resident weighed 182.2 pounds (lbs.); on 12/07/2023 176.8 lbs.; on 01/19/2024 174 lbs.; on 02/12/2024 157 lbs.; on 02/26/2024 161.6 lbs.; and on 03/04/2024 157.8 lbs. This revealed a 16.2 pound weight loss from 01/19/2024 until 03/04/2024 indicating a 16.2 pound weight loss in less than two (2) months which would be a significant weight loss of 9.3 % (percent). Observation of the Restorative Aide and Licensed Practical Nurse (LPN) #3, obtaining a weight for Resident #48 on 03/07/2024 at 12:07 PM, using a mechanical lift revealed a weight of 157 lbs. In an interview with Resident #48, on 03/07/2024 at 12:15 PM, the resident stated he/she had a desire to lose weight when he/she was first admitted to the facility. He/she was surprised at his/her current weight. Resident #48 then stated he/she would like to lose a few more pounds from his/her belly. The resident stated the Dietician had spoken with him/her about losing weight. Further review of Resident #48's CCP, revealed there was no documented evidence the resident was on a desired weight loss plan. In an interview with the Registered Dietician (RD), on 03/08/2024 at 12:10 PM, she stated Resident #48 had voiced a desire to lose weight. She stated she had requested desserts be removed from his/her tray and more vegetables to be served. She further stated she was new to the facility and was receiving training on reviewing and revising care plans. In further interview, she stated Resident #48 should have had a care plan in place for desired weight loss. During an interview with the Director of Nursing (DON), on 03/08/2023 at 6:47 PM, she stated each department was responsible for updating their own care plans, therefore the RD would be responsible for revising Resident #48's Care plan to indicate the resident was on a weight loss regimen. She further stated during the daily clinical meeting, the Unit Coordinators reviewed and revised the care plans if needed. In continued interview, she stated it was her expectation for Care plans to be updated, reviewed and revised when there had been a change in the resident's status. In an interview with the Administrator, on 03/08/2024 at 7:09 PM, she stated it was her expectation for staff to discuss the residents in the care planning meeting as a team, and follow policy and procedure for updating and revising the care plan. She further stated it was her expectation for staff to review, revise and update the care plans to accurately reflect the resident's status and the appropriate care to be provided.

Based on interview, record review and review of facility policy, it was determined the facility failed to ensure the Minimum Data Set (MDS) Assessments accurately reflected the resident's status for three (3) of twenty-eight (28) sampled residents (Residents #21, #112 and #141). Resident #21's Admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 12/08/2023, was coded under Section N as the resident receiving an anticoagulant; however, the resident did not receive an anticoagulant during the seven (7) day look back period. Additionally, review of Resident #112's MDS Assessment with an ARD date of 03/12/2023, was coded under Section N as the resident receiving an anticoagulant; however, the resident did not receive an anticoagulant during the seven (7) day look back period. Moreover, Resident #141's Discharge MDS Assessment, with an Assessment Reference Date (ARD) date of 12/30/2023 was coded under Section A2105 as the resident being discharged to a Short-term General Hospital (acute hospitals, IPPS). However, according to the resident's Discharge Summary and interview with the Social Services Director, the resident was discharged to an Assisted Living facility. The findings include: Review of the facility policy titled, Resident Assessment, revised 11/2019, revealed a comprehensive assessment of every residents' needs was made at intervals designated by the Resident Assessment Instrument Manual. Continued review revealed the interdisciplinary team used the Minimum Data Set (MDS) form currently mandated by federal and state regulations to conduct the resident assessment. Review of the Centers for Medicare & Medicaid Services Long Term Care Facility Resident Assessment Instrument User's Manual, MDS 3.0, dated October 1, 2023, Section N, revealed check if anticoagulant medication was received by the resident at any time during the seven (7) day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel here. 1. Review of Resident #21's medical record revealed the facility admitted the resident on 12/07/2023 with diagnoses including Hypertensive Heart Disease with Heart Failure, Chronic Kidney Disease, and Long Term Use of Aspirin. Review of Resident #21's Admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 12/08/2023, revealed the facility coded Section N as the resident receiving an anticoagulant. Review of Physician's orders, dated 12/2023, revealed Resident #21 was receiving Aspirin Enteric Coated Low dose, delayed release eighty-one (81) milligrams (mg), one (1) tablet by mouth once a day for circulation. However, there was no documented evidence of the resident receiving an anticoagulant drug during the seven (7) day look back period prior to 12/08/2023. 2. Review of Resident #112's medical record revealed the facility admitted the resident on 03/02/2023 with diagnoses to include Rheumatoid Arthritis, Peripheral Vascular Disease and Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. Review of Resident #112's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 03/12/2023, revealed the facility coded Section N as the resident receiving an anticoagulant. Review of Resident #112's Physician's order, dated 03/2023, revealed an order for Aspirin Enteric coated, Low dose Tablet Delayed release 81 mg, give one tablet by mouth once a day for clot prevention. However, there was no documented evidence of the resident receiving an anticoagulant drug during the seven day look back period prior to 03/12/2023. During an interview with the Minimum Data Set (MDS) Nurse #2, on 03/08/2024 at 5:16 PM, she stated medications were to be coded by classification of the drug. She named examples of anticoagulants included Eliquis, Xarelto and Warfarin. She further stated Aspirin was not an anticoagulant, but an antiplatelet and she was aware of the difference. She further stated she could not specifically recall coding aspirin as an anticoagulant. MDS Nurse #2 stated an MDS modification would be initiated. 3. Review of Resident #141's medical record revealed the facility admitted Resident #141 on 12/06/2023 with diagnoses to include Alzheimer's Disease, and Hypertensive Heart Disease without Heart Disease, and Muscle Wasting and Atrophy. Review of Resident #141's Discharge Summary, dated 12/29/2023, revealed the resident was to be discharged to an Assisted Living facility on 12/30/2023. Review of Resident #141's Discharge MDS Assessment with an ARD date of 12/30/2023, revealed it was coded under Section A2105 as the resident being discharged to a Short-term General Hospital {acute hospitals, Inpatient Prospective Payment System (IPPS)}. This triggered the hospitalization task in error, on the Recertification Survey. Review of Resident #141's Discharge MDS Assessment, dated 01/08/2024, Section A, revealed the previous discharge location had been modified and updated to reflect the resident was to be discharged to Home/Community which included Assisted Living. In an interview with the Social Services Director (SSD), on 03/08/2024 at 10:10 AM, she stated she had recalled Resident #141 being discharged as she had been responsible for the discharge summary. She stated Resident #141 was listed as discharging to an Assisted Living facility. After the SSD was made aware the MDS dated [DATE], Section A was coded as Resident #141 being discharged to a Short-term General Hospital, she reviewed it in the system, and stated the MDS Section A, had been modified to Home/Community or assisted living location. In an interview with the MDS Nurse #2, on 03/08/2024 at 10:25 AM, she stated she had been new in her position when Resident #141 was discharged . She stated MDS Nurse #1 had reviewed the MDS after information was requested from the Surveyor regarding Resident #141's discharge and had advised her to modify and correct the deficiency after the survey started. She stated she was in-serviced on the MDS deficiency and moving forward would ensure the MDS Assessments had correct information. In an interview with the Director of Nursing (DON), on 03/08/2024 at 6:08 PM, she stated it was her expectation the MDS Nurses would accurately code the MDS Assessment to reflect the residents' status at the time of the assessment. During an interview with the Administrator, on 03/08/2024 at 7:10 PM, she stated it was her expectation the MDS staff would accurately code the MDS Assessment to reflect the residents' current status, and discharge status. 45914

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure a resident with Dysphagia (difficulty swallowing food or liquid) and at risk for choking, received food that was appropriate for the residents assessed diet for one (1) of three (3) sampled residents (Resident #5) who were at risk for aspiration and/or choking. On [DATE], the Speech Language Pathologist evaluated Resident #5 and determined the resident had a change in his/her condition that led to the resident's therapeutic diet being downgraded to a Dysphagia Level 1, which meant the resident's diet consisted of regular thin liquids as the resident had difficulty chewing and swallowing his/her foods. On [DATE]; however, at approximately 12:50 AM, Certified Nursing Assistant (CNA) # 6 gave Resident #5 a piece of her cheeseburger, causing the resident to choke. Staff initiated the Heimlich maneuver on the resident and was able to dislodge some of the food the resident had consumed; however, the resident became unresponsive and the Emergency Medical Services (EMS) were contacted. The resident was transported to the emergency room (ER) where he/she was intubated. Review of the physician's ER Discharge Note revealed the residents condition was unchanged and critical. The resident was placed on the Intensive Care Unit (ICU) where he/she expired on [DATE]. The facility's failure to provide the ordered diet for Resident #5 has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE], and was determined to exist on [DATE], in the areas of 42 CFR S483.21 Comprehensive Person-Centered Care Plans, (F656); and 42 CFR S483.60 Food and Nutrition Services, (F803) all at the highest Scope and Severity (S/S) of a J. The facility was notified of the IJ on [DATE]. IJ is ongoing. (Refer to F656) The findings include: Review of the facility's policy titled, Dysphagia - Clinical Protocol, revised [DATE], revealed facility staff and the physician would identify individuals with a history of swallowing difficulties or related diagnoses such as Dysphagia, as well as, an individual who had difficulty chewing or swallowing food. Review of the facility's policy titled, Therapeutic Diets, revised [DATE], revealed a therapeutic diet was considered a diet ordered by a physician, practitioner, or dietitian as part of (the resident's) treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: an altered consistency diet. Review of the facility's policy titled, Emergency Procedure - Choking, revised [DATE], revealed that trained staff would assist a choking resident by attempting to expel the foreign body from the resident's airway. Continued review revealed staff were to proceed with cardiopulmonary resuscitation (CPR) immediately if the resident had no pulse or respirations and report information in accordance with facility policy and professional standards of practice. Review of the facility's policy, Change in a Resident's Condition or Status, revised [DATE], revealed a significant change of condition was a major decline or improvement in the resident's status that would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Closed record review revealed Resident #5's Admission Record revealed the facility admitted the resident on [DATE] with diagnoses that included: Oropharyngeal Dysphagia, Delusional Disorders and Cognitive Communication Deficit. Review of the resident's Aspiration Comprehensive Care Plan, dated [DATE], revealed Resident #5 had a swallowing problem related to Dysphagia oropharyngeal phase with interventions for all staff to be informed of special dietary and safety needs, diet to be followed as prescribed, referral to speech therapist for Swallowing Evaluation and watching for shortness of breath, choking, labored respirations, and lung congestion. Review of Resident #5's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's cognition was severely impaired. Review of the resident's Nutrition Comprehensive Care Plan, updated on [DATE] by the Minimum Data Set (MDS) Nurse revealed the resident had a diet change to a consistent, constant, or controlled carbohydrate diet (CCHO) with no added salt (NAS), Dysphagia Level 1, regular thin liquids and no straws. Review of the Certified Nursing Assistant (CNA) Kardex/Care Plan, undated revision date, revealed the resident's diet changed to CCHO, NAS, Dysphagia Level 1, regular thin liquids with no straws. Review of the Speech Language Pathologist (SLP) evaluation dated [DATE], revealed Resident #5 was referred to Speech Therapy by the physician due to a decline in the resident's cognitive communication and increased signs and symptoms of Dysphagia. Continued review revealed Resident #5 was on a Dysphagia Level 2 diet, with pureed meat (all meat would be ground, pressed, and/or strained to a soft, smooth, consistency; however, other foods would consist of a soft-texture and easily formed into a bolus. Additionally, this would have required the resident to have the ability to chew). Review of the SLP Note, dated [DATE], revealed Resident #5 participated in Dysphagia treatment. Further review of the Note revealed the SLP directed the resident in his/her therapeutic diet during his/her morning meal which consisted of a Dysphagia Level 2 diet, with pureed meat. The SLP noted Resident #5 had increased impulsive feeding behaviors with rapid stuffing of his/her oral cavity with residue post swallow. Further review revealed Resident #5 had variable alertness level during the therapy session and was falling asleep with food present in his/her mouth. The SLP recommended a diet texture modification to puree. Review of the SLP's form titled, Order Details, dated [DATE] at 10:17 AM, revealed a change in Resident #5's diet. The new diet was a consistent, constant, or controlled carbohydrate diet (CCHO) with no added salt (NAS). Additionally, the resident's Dysphagia diet was downgraded to a Dysphagia Level 1 (most impaired with poor jaw or tongue control, and delayed swallowing). A continued review of the SLP's order revealed the resident was to be provided thin liquids with no straws. A review of the American Dietetic Association, undated, revealed a Dysphagia Level 1 was a diet that consisted of pureed, homogenous, and cohesive foods. Further review revealed the food would be pudding-like with no coarse textures, raw fruits or vegetables, nuts, and so forth allowed. Continued review revealed any food that required bolus formation, controlled manipulation, or mastication were excluded. Review of the facility's five (5) day follow-up investigation, dated [DATE], revealed Resident #5 had reached for a staff's cheeseburger. The staff member, Certified Nursing Assistant (CNA) #6 gave the resident a bite and the resident choked while eating, requiring CPR and was transferred to the emergency room by Emergency Medical Services (EMS). The incident was reported to the State Guardian and next of kin on [DATE]. On [DATE], the incident was reported to the Ombudsman, Adult Protective Services (APS) and the State Agency. The facility staff did not check to see what kind of diet the resident was on prior to feeding him/her part of the{staff's} sandwich. CNA #6 and CNA #7 were both suspended on [DATE]. Licensed Practical Nurse (LPN) #6 (Agency) was not allowed to return to work in the building. LPN #5 was suspended and then terminated from the facility. LPN #5 was also reported to the nurse licensing board. Review of a Nursing Progress Alert Note, dated [DATE] at 2:10 AM, documented by Licensed Practical Nurse (LPN) #5, revealed Resident #5 was sitting at the nurses ' station eating and talking with the nursing staff. A continued review of the note revealed the resident had asked for something to drink and a staff member (CNA #6) went to get it. Continued review revealed LPN #5 and an Aide (CNA #7) was headed down the hall to assist in the collection of labs from another resident and an Aide (CNA #6) was heard stating, Are you choking? To these words, LPN #5 returned to the nurses' station to help assess. Further review of the Note revealed the resident was trying to cough but was not coughing very hard or forceful. LPN #5 started the Heimlich maneuver, which was unsuccessful, and the resident then went limp in the chair and was not breathing. Continued review of the Note revealed staff checked the code status of the resident and it was noted the resident was a Full Code. The resident was laid flat on the floor and compressions were started as LPN #5 informed the supervisor, Licensed Practical Nurse (LPN) #7, and another Aide (CNA #7) called 911. The supervisor, LPN #7, brought the crash cart and set up the suction. Compressions were continued until EMS arrived; at which time they took over directing the code. The resident's airway was cleared, and a heartbeat was restored. The nursing staff helped load the resident onto the stretcher and into the ambulance. EMS left with the resident at 2:00 AM. Review of the Emergency Medical Services (EMS) Run Sheet, dated [DATE], revealed EMS was dispatched at 1:00 AM and arrived to the facility at 1:04 AM. Further review revealed EMS departed the facility at 1:37 AM, arriving at the emergency room (ER) at 1:42 AM. Review of the emergency room (ER) Record, dated [DATE], revealed the resident's chief complaint at triage was that EMS found the resident unresponsive with CPR in progress. The resident was in asystole (when the electrical system that kept the resident's heart beating stopped). Upon arrival to the emergency room Resident #5 was intubated with intravenous access (IV) and had one (1) Epinephrine (the primary drug administered during cardiopulmonary resuscitation (CPR) to reverse cardiac arrest) prior to arrival. The emergency room physician's Discharge Note, dated [DATE], revealed the resident had a cardiac arrest secondary to asystole and respiratory arrest (choked on a hamburger). Further review revealed the resident was admitted to the hospital and was placed on the Intensive Care Unit (ICU). The physician noted the resident's condition was unchanged and critical. Review of the Hospital's Discharge Summary, dated [DATE], revealed the resident had expired on [DATE] at 11:11 PM in ICU. During an interview with Certified Nursing Assistant (CNA) #6, on [DATE] at 10:49 AM, she stated she was working the night Resident #5 choked. Per the interview, she stated Licensed Practical Nurse (LPN ) #5 went to pick up coffee and food from a local fast-food restaurant. The CNA stated that after LPN #5 returned with the coffee and food, she took the cheeseburger out of the wrapper, removed two (2) pickles from the sandwich, and then tore the cheeseburger into smaller pieces. CNA #6 stated she handed a piece of the cheeseburger to the resident and the resident took a bite of the cheeseburger. Further, she stated the resident told her he/she wanted something to drink. She stated that when she turned her back from the resident to get the resident something to drink, she heard someone say, The resident was choking. CNA #6 stated two (2) different staff had tried to get the food up while performing the Heimlich maneuver without success. In further interview with Certified Nursing Assistant (CNA) #6, on [DATE] at 10:49 AM, she stated the resident became unresponsive in his/her wheelchair and staff eased the resident onto the floor. She stated she did a finger sweep in the resident's mouth to see if there was food that could be removed, but she did not feel any food. Per the interview, she stated she initiated CPR on the resident while CNA #7 called 911 and the nursing supervisor. The CNA stated the nursing supervisor arrived with the crash cart and started setting up the portable suction machine. She stated the Emergency Medical Service (EMS) arrived and began working on the resident's airway while the facility staff continued CPR as instructed. CNA #6 stated EMS was able to clear the resident's airway by removing a pickle and a piece of the cheeseburger. The resident was intubated by EMS staff and the resident's pulse returned. CNA #6 stated she did not check the resident's diet before giving the resident the cheeseburger to eat but should have. Further, she stated the resident's care plan should have been reviewed as the potential for harm was choking. In an interview, on [DATE] at 11:17 AM, with CNA #7, she stated she was working the night Resident #5 choked. Per the interview, the CNA stated she did not know if LPN #6 was familiar with the resident's diet before the cheeseburger was provided to the resident. CNA #7 stated she knew she had seen the resident eat crackers and sandwiches in the past. She stated that when the resident started to choke LPN #5 attempted the Heimlich maneuver on the resident without success. She stated the resident became unresponsive and CNA #6 and CNA #7 eased the resident to the floor. She further stated CPR was started until EMS arrived with further instructions. CNA #7 stated she thought EMS was able to retrieve the resident's pulse prior to being transported on the ambulance. CNA #7 stated that the staff that worked that night were unfamiliar with the resident's diet and no one had checked the resident's diet order. During a telephone interview with Licensed Practical Nurse (LPN) #6 (Agency nurse), on [DATE] at 2:20 PM, she stated she had worked the 11:00 PM shift, the night Resident #5 choked. Further, she stated she was assigned to the resident; however, was eating with her back to the resident. She stated she then heard someone say, The resident was choking. LPN #6 stated she got up to check the resident's Code Status but had not checked the resident's diet order. She stated she performed CPR on the resident when the resident became unresponsive. In an additional interview with LPN #6, on [DATE] at 5:02 PM, the LPN stated she was not aware of Resident #5's recent diet change. Per the interview, she stated any new orders would be found in the medical record. The LPN stated she did not know if anyone had checked Resident #5's diet prior to feeding the resident the cheeseburger. In an interview with LPN #5, on [DATE] at 3:18 PM, the LPN stated she was working the night Resident #5 choked. She stated she was heading down the hall to get a urinalysis from a resident when she heard someone say, he's/she's choking. She stated she returned to the nurses' station and initiated the Heimlich maneuver on the resident. Per the interview, she stated she was able to dislodge some of the food the resident had consumed; however, the resident became unresponsive and 911 was contacted. Further, she stated the nursing supervisor had been called and when EMS arrived, facility staff continued to assist with compressions while EMS secured the resident's airway. Per the interview, LPN #5 stated the resident's pulse returned and compressions were discontinued. LPN #5 stated she was not familiar with Resident #5's ordered diet; however, stated she had bought the cheeseburger for CNA #6, not for the resident to consume. During an interview with the Nurse Aide (NA) #20, on [DATE] at 3:46 PM, she stated the night of the choking event with Resident #5, the NA was assigned to watch Resident #5 to keep him/her from falling. According to the NA, LPN #5, LPN #6, CNA #6, and CNA #7 were all at the nurses' station when she went to the bathroom because she was sick. NA #20 stated she heard a commotion; she went back to the nurses' station where she saw CNA #6 sitting to the left of Resident #5 and LPN #5 to the right of the resident. She reported she saw the cheeseburger in LPN #5's hand and heard her say, he/she is choking as the LPN pulled the burger away from the resident's mouth. She was unsure if anyone had checked the resident's diet prior to feeding the burger to the resident. The Nurse Aide stated LPN #5 attempted the Heimlich maneuver but was not successful in bringing up the foreign body. Per the interview, she stated LPN #5 and CNA #7 began CPR when the resident became unresponsive, and the nursing supervisor brought the crash cart with the suction machine. In continued interview with Nurse Aide (NA) #20, on [DATE] at 3:46 PM, she stated EMS had arrived and was managing the resident's airway while the facility staff continued CPR. Further, the NA stated that while EMS suctioned the resident's airway, a pickle from the airway was removed. The NA stated Resident #5's heartbeat started before he/she left the facility with EMS. The NA stated that after the incident occurred, LPN #7, Nursing Supervisor, told the staff to retrieve all the food wrappers and trash together and put it all in a separate bag. NA #20 stated the Nursing Supervisor told the staff, No one was to say anything about this or you will be in a lot of trouble. The NA stated she did not know what the Nursing Supervisor was referring to, whether it was the fast food, trash, or the choking incident. Further, the NA stated she reported the incident to the Administrator and discovered she was the only staff who reported the incident. The NA stated the CNA should have reviewed the resident's Care Plan before feeding the resident and added, it was a wrongful death. In an interview with Licensed Practical Nurse (LPN) #7/Nursing Supervisor, on [DATE] at 2:49 PM, she stated she was called by staff (could not recall the staff member) to assist with Resident #5 when he/she got choked on the cheeseburger. LPN #7 stated she grabbed the crash cart as soon as the incident was reported to her. Per the interview, she stated she recalled the resident was choking and had become unresponsive at which time staff initiated CPR. LPN #7 stated she did not know the resident's diet prior to the resident choking on the cheeseburger. In an additional interview with LPN #7 (the nursing supervisor), on [DATE] at 4:40 PM, she stated she did not inform staff they would get in trouble for reporting the incident. She stated she notified the Assistant Director of Nursing (ADON) about the incident on the morning of [DATE]. In an interview with the Speech Language Pathologist (SLP), on [DATE] at 10:29 AM, she stated on [DATE], the resident's diet was downgraded to Pureed Dysphagia Level 1 texture with thin liquids consistency and no straws. Further, she stated she had recently picked the resident back up on her caseload due to the resident's cognition and problems with his/her Dysphagia. The SLP further stated the resident had contracted COVID and had a change in condition, in which the resident had more swallowing difficulties. She stated a potential outcome of not following the resident's diet would be Aspiration, choking, and pneumonia. The SLP stated it would have been her expectation that staff would have sought out information on the resident if they were unsure of the resident's diet either in the chart or the care plan. In a telephonic interview with the Medical Director, on [DATE] at 1:49 PM, he stated the resident's diet order would be found in the physician's orders, as well as, on the Care Plan. He stated he was made aware of the incident and his expectation was for staff to follow the physician's orders and the resident's Plan of Care. In an interview with the Director of Nursing (DON), on [DATE] at 12:30 PM, she stated the Assistant Director of Nursing (ADON) informed her of Resident #5's choking incident on [DATE] at 6:16 AM, by text message. She stated she expected staff to be aware of and follow the residents' diet orders. Further, she stated the residents had a list of their diets posted in the nutrition room on the refrigerator to remind staff of the resident's diet. During an interview with the Administrator, on [DATE] at 11:38 AM, she stated she had been the Administrator since May of 2023. She stated she was notified of Resident #5's incident when she received a text message from the Assistant Director of Nursing on [DATE] at 6:16 AM that said, Resident #5 had choked on some food around 12:50 AM and staff did the Heimlich maneuver until the resident coded. The text further stated CPR was initiated and 911 was called. Further, EMS was able to revive Resident #5 and he/she was transported to the hospital. In further interview with the Administrator, she stated on Monday [DATE], NA #20 was waiting on her with a written statement. She stated the more she read the sicker she got. The Administrator stated she watched the facility's video, of the night the incident occurred, and stated, It was horrible. Per the interview, the video was not available for the State Survey Agency (SSA) to review as it re-recorded every seventy-two (72) hours. The Administrator stated it was her expectation that staff would follow the resident's diet orders. She stated staff should have been made aware of Resident #5's diet change. She further stated someone should have checked the current order or the care plan and followed it.

Based on interview, record review and a review of the facility's policy, it was determined the facility failed to implement the resident's Person-Centered Comprehensive Care Plan for one (1) of three (3) sampled residents (Resident #5), who required a specific diet. On [DATE], the Speech Language Pathologist evaluated Resident #5 and determined the resident had a change in his/her condition that led to the resident's therapeutic diet being downgraded to a Dysphagia Level 1, which meant the resident's diet consisted of regular thin liquids, as the resident had difficulty chewing and swallowing his/her foods. The resident's care plan was revised on the same day, to reflect the change in the resident's diet. Staff failed to implement the resident's care plan. Subsequently, on [DATE], Certified Nursing Assistant (CNA) # 6 gave Resident #5 a piece of her cheeseburger, causing the resident to choke. The resident was transported to the emergency room (ER) where he/she was intubated. Review of the physician's ER Discharge Note revealed the resident's condition was unchanged and critical. The resident was placed on the Intensive Care Unit (ICU) where he/she expired on [DATE] at 11:11 PM. The facility's failure to implement the resident's Comprehensive Person-Centered Care Plan related to the resident's therapeutic diet has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE], and was determined to exist on [DATE], in the areas of 42 CFR S483.21 Comprehensive Person-Centered Care Plans, (F656); and 42 CFR S483.60 Food and Nutrition Services, (F803) all at the highest Scope and Severity (S/S) of a J. The facility was notified of the IJ on [DATE]. IJ is ongoing. (Refer to F803) The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised [DATE], revealed a comprehensive, person-centered care plan included measurable objectives and timetables that met the resident's physical, psychosocial, and functional needs. Further review of the policy revealed care plans would be developed and implemented for each resident. The care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Continued review revealed the care plan would incorporate identified problem areas, risk factors associated with identified problems, reflect treatment goals, timetables and objectives in measurable outcomes, aid in preventing or reducing decline in the resident's functional status and/or functional levels and reflect currently recognized standards of practice for problem areas and conditions. Review of the facility's policy titled, Therapeutic Diets, revised [DATE], revealed Therapeutic diets were prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. The resident ' s attending physician (or non-physician provider) must prescribe a therapeutic diet. The attending physician may delegate this task to a registered or licensed dietitian as permitted by state law. Continued review of the policy revealed a therapeutic diet was considered a diet ordered by a physician, practitioner, or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example, altered consistency diet. If a mechanically altered diet was ordered, the provider would specify the texture modifications. Closed record review revealed the facility admitted Resident #5 on [DATE] with diagnoses that included Dysphagia, Oropharyngeal Phase, Delusional Disorders, and Cognitive Communication Deficit. Review of Resident #5's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognition was severely impaired. Review of the resident's Aspiration Comprehensive Care Plan, dated [DATE], revealed Resident #5 had a swallowing problem related to dysphagia oropharyngeal phase with interventions for all staff to be informed of his/her special dietary and safety needs, diet to be followed as prescribed, referral to speech therapist for Swallowing Evaluation and watching for shortness of breath, choking, labored respirations, and lung congestion. Review of the Speech Language Pathologist ' s (SLP) form titled, Order Details, dated [DATE] at 10:17 AM, revealed a change in Resident #5's diet. The new diet was a consistent, constant, or controlled carbohydrate diet (CCHO) with no added salt (NAS). Additionally, the resident's Dysphagia diet was downgraded to a Dysphagia Level 1 (most impaired with poor jaw or tongue control, and delayed swallowing). A continued review of the SLP's order revealed the resident was to be provided thin liquids with no straws. Review of Resident #5's Nutrition care plan, updated [DATE], by the Minimum Data Set (MDS) Nurse, indicated a diet change to CCHO, NAS, Dysphagia Level 1, regular thin liquids, and no straws. Review of the CNA Kardex (CNA Care Plan), initiated on [DATE] with no revision date provided, revealed the resident's diet was changed to CCHO, NAS, Dysphagia Level 1, regular thin liquids with no straws. Review of the facility's five (5) day follow-up investigation, dated [DATE], revealed Resident #5 had reached for a staff's cheeseburger. The staff member, Certified Nursing Assistant (CNA) #6 gave the resident a bite and the resident choked while eating, requiring CPR and was transferred to the emergency room by Emergency Medical Services (EMS). Further review of the investigation revealed the facility staff did not check to see what kind of diet the resident was on prior to feeding him/her part of the{staff's} sandwich. Review of the emergency room (ER) Record, dated [DATE], revealed the resident's chief complaint at triage was that EMS found the resident unresponsive with CPR in progress. The resident was in asystole (when the electrical system that kept the resident's heart beating stopped). Upon arrival to the emergency room Resident #5 was intubated with intravenous access (IV) and had one (1) Epinephrine (the primary drug administered during cardiopulmonary resuscitation (CPR) to reverse cardiac arrest) prior to arrival. The emergency room physician's Discharge Note, dated [DATE], revealed the resident had a cardiac arrest secondary to asystole and respiratory arrest (choked on a hamburger). Further review revealed the resident was admitted to the hospital and was placed on the Intensive Care Unit (ICU). The physician noted the resident's condition was unchanged and critical. Review of the Hospital's Discharge Summary, dated [DATE], revealed the resident had expired on [DATE] at 11:11 PM in ICU. In an interview, on [DATE] at 11:17 AM, with Certified Nursing Assistant (CNA) #7, she stated she was working the night Resident #5 choked. She stated she did not know if the nurse checked the resident's diet order before the cheeseburger was given to the resident. CNA #7 stated she knew she had seen the resident eat crackers and sandwiches in the past but was unfamiliar with the resident's care plan related to his/her diet. During an interview with the Nurse Aide (NA) #20, on [DATE] at 3:46 PM, she stated she worked in the facility for about five (5) weeks. She stated she was unsure if anyone had checked the resident's diet prior to feeding the burger to the resident but should have. Further, the NA stated she was not feeling well the night of the incident, [DATE]. She stated she was assigned to sit with Resident #5, to prevent the resident from falling. Per the interview, she stated she left the resident at the nurses ' station and went to the bathroom. She stated she heard a commotion and came back out of the bathroom to see what was going on. NA #20 stated she saw CNA #6 sitting to the left of the resident and LPN #5 sitting to the resident's right and she observed the resident to be choking. Further, she stated she saw LPN #5 with a cheeseburger in her hand but was uncertain of the staff member who fed the cheeseburger to the resident. The NA was not sure if anyone had checked the Kardex or Care Plan for the residents diet. The NA stated the CNAs should have reviewed the residents Care Plan before feeding the resident and added, It was a wrongful death. During a telephonic interview with Licensed Practical Nurse (LPN) #6 (Agency nurse), on [DATE] at 2:20 PM, she stated she had worked at 11:00 PM the night Resident #5 choked. She stated she was assigned to the resident but had been eating at the nurses' station with her back to the resident when someone stated the resident was choking. LPN #6 stated she had checked the resident's Code Status but had not checked the diet order for the resident. In an additional interview with LPN #6, on [DATE] at 5:02 PM, the LPN stated she was unaware Resident #5's diet had recently changed. Further, she stated any new orders would be found in the residents medical record. LPN #6 stated she did not know if anyone had checked Resident #5's diet prior to feeding the resident a burger. In an interview with the Speech Language Pathologist (SLP), on [DATE] at 10:29 AM, she stated the resident's diet changed on [DATE] to Pureed Dysphagia Level 1 texture with thin liquid consistency and no straws. She stated she had recently picked the resident back up on her caseload related to the resident's cognition and problems with Dysphagia. The SLP further stated that after the resident had contracted COVID, the resident had increased swallowing difficulties. She stated that when staff did not follow the residents' care plans, related to their diets, a potential negative outcome would be Aspiration, choking, and pneumonia. In an interview with the Minimum Data Set (MDS) Nurse, on [DATE] at 11:49 AM, she stated when she received notice of Resident #5'a diet from the Speech Therapist (ST), she updated the residents Kardex (CNA care plan) and his/her Comprehensive Person-Centered Care Plan on [DATE]. The MDS nurse stated she educated staff when she made the change to the residents care plans. During a telephonic interview with the resident's Medical Director, on [DATE] at 1:49 PM, he stated it was his expectation that staff would follow the physician's orders, as well as, the resident's Comprehensive Care Plan. Further, the Medical Director stated there could be a bad outcome when resident care plans were not followed. In an interview with the Director of Nursing (DON), on [DATE] at 2:00 PM, she stated when a new order was written the nurse would enter the information on the Care Plan in the morning meeting with the Interdisciplinary Team. She stated her expectation was that the Care Plan / Kardex would be followed to meet the needs of the resident. In an additional interview with the Director of Nursing (DON), on [DATE] at 12:30 PM, she stated the Assistant Director of Nursing (ADON) informed her of Resident #5's choking incident on [DATE] at 6:16 AM, by text message. She stated she expected staff to be aware of and follow the residents ' diet orders. Further, she stated the residents had a list of their diets posted in the nutrition room on the refrigerator to remind staff of a resident ' s diet. During an interview with the Administrator on [DATE] at 11:38 AM, she stated she was notified of Resident #5's incident when she received a text message from the Assistant Director of Nursing (ADON), on [DATE] at 6:16 AM and was again notified of the incident on [DATE], when NA #20 was waiting on her with a written statement. She stated the more she read the written statement the sicker she got. The Administrator stated an investigation was initiated. Further, she stated someone should have checked the resident's care plan and followed it.

Based on interviews, record review, and review of facility policy, it was determined the facility failed to ensure one (1) of eighteen (18) sampled residents' environment remained free from accident hazards (Resident #3). On 06/11/2023, Resident #3 reported to Certified Nursing Assistant (CNA) #14 that CNA #16 had grabbed his/her upper inner left arm while repositioning him/her in bed, resulting in two (2) bruises on the resident's left upper arm. The findings include: Review of the facility's policy, Falls, revision dated 11/08/2022, revealed the intent of this requirement was to ensure the facility provided an environment that was free from accident hazards over which the facility had control and provided supervision and assistive devices to each resident to prevent avoidable accidents. Further review revealed definitions were provided to clarify terms related to providing supervision and other interventions to prevent accidents where Accident had referred to any unexpected or unintentional incident which resulted or may have resulted in injury or illness to a resident. Review of the Long-Term Care Facility-Self Reported Incident Form, dated 06/11/2023, revealed Resident #3 had reported CNA #16 was rough when providing care. CNA #16 was suspended pending investigation. All residents with a Brief Interview of Mental Status (BIMS) score of eight (8) or higher were interviewed. Residents with a BIMS below eight (8) had skin assessments completed. Review of the Investigation Summary for the incident on 06/11/2023, undated, revealed the facility had not found any reasonable cause to believe the alleged abuse occurred toward Resident #3. Review of the facility's document, untitled, dated 06/11/2023 and completed by Registered Nurse (RN) #2, revealed a skin assessment was completed for Resident #3. Further review revealed a BIMS of fourteen (14), and a diagram with a notation of a bruise on Resident #3's upper left arm, with a written statement indicating an observation of two (2) bruises to the left upper arm. Review of the Nurse's Progress Notes, dated 06/11/2023 at 3:20 PM, completed by Licensed Practical Nurse (LPN) #15, revealed RN #2 had reported Resident #3's skin assessment noted two (2) purple bruises measuring 11/2 inch in length times two (2) centimeters wide (round) to his/her left inner arm. Review of Certified Nursing Assistants (CNA) #16's signed witness statement, dated 06/11/2023 at 8:00 AM, revealed her statement revealed she had answered Resident #3's call light around 4:00 AM, when he/she had asked for a drink of water. Further review revealed CNA #16 then stated she had sat Resident #3 up in the bed slightly and gave him/her a drink until he/she had stopped drinking. Continued review revealed CNA #16 had answered Resident #3's call light again at approximately 5:30 AM and gave the resident his/her cell phone. Additional review revealed CNA #16 had stated, I did not touch the resident. Review of Resident #3's pictures, dated 06/11/2023 and timestamped at 12:42 PM, provided by Family Member #2, revealed two (2) purple marks that bore a resemblance of two (2) fingers. Review of Resident #3's closed medical record revealed the facility admitted the resident, on 06/06/2023, with diagnoses that included: Diverticulosis and and age-related physical debility. Review of Resident #3's Admission Minimum Data Set (MDS) Assessment, dated 06/12/2023, revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) of fifteen (15), which indicated no cognitive impairment. Further review of the MDS assessment revealed Resident #3 required extensive assistance of two (2) staff for bed mobility needs. Review of Resident #3's Activities of Daily Living (ADL) Care Plan, dated 06/07/2023, revealed Bed Mobility required one (1) to two (2) staff to turn and reposition in bed. Further review revealed a cancellation date of 06/30/2023 when Resident #3 was discharged from the facility. However; the MDS Assessment revealed the resident required an extensive assistance of two (2) staff for bed mobility needs. Review of Resident #3's Admission Progress Note, dated 06/08/2023, completed by the Advanced Practice Registered Nurse (APRN) #1, revealed Resident #3 had orders to continue Aspirin 81 milligrams (MG)by mouth every other day. Further review of Resident #3's physical exam indicated no abnormal bruising. In an interview with Family Member #2, on 10/25/2023 at 7:12 PM, he stated Resident #3 had told him that Certified Nursing Assistant (CNA) #16 left a bruise when moving him/her up in the bed. Family Member #2 stated this was an isolated incident. He stated Resident #3 had been a two (2) person assist to his knowledge, and CNA #16 had adjusted Resident #3 alone. He stated the Administrator had assured him that CNA #16 would no longer be assisting Resident #3, and an investigation would be completed. Family Member #2 stated Resident #3 had no bruising on his/her upper arm prior to the incident. He further stated he had taken pictures the day of the incident which had clearly shown two (2) purple marks on Resident #3's upper left arm. In an interview with Certified Nursing Assistant (CNA) #14, on 10/25/2023 at 4:40 PM, she stated she was working the morning shift when Resident #3 had shown her bruises on the inner part of his/her upper left arm. Resident #3 stated it was caused by CNA #16 who grabbed his/her arm too hard while moving him/her up in the bed. She stated CNA #16 was the only staff working the night shift on Station 2 where Resident #3 resided on 06/11/2023. Certified Nursing Assistant (CNA) #14 stated she was aware of the importance of following facility policy. She stated the facility and staff were there to protect residents, ensure they were safe, and provided a comfortable homelike environment. The State Survey Agency (SSA) surveyor attempted a telephonic Interview with Certified Nursing Assistant (CNA) #16, on 10/24/2023 at 1:40 PM. The call was unsuccessful and the SSA surveyor was unable to leave a message. In an interview with Registered Nurse (RN) #2, on 10/25/2023 at 4:50 PM, she stated she had been a weekend supervisor on the day Resident #3 told her that CNA #16 answered his/her call light and had been rough with him/her causing a bruise to the inside of Resident #3's upper left inner arm. RN #2 stated she had observed the bruises on Resident #3's arm and documented the findings. She stated she completed Resident #3's skin assessment and reported the incident to the Assistant Director of Nursing (ADON). She stated the ADON, DON, and Administrator had taken over the investigation from that point. She stated the administrative staff had arrived immediately after the incident and she believed that the facility's policy had been implemented properly. She stated having something in place to ensure resident's rights were respected and their safety had been a priority. In an interview with the Assistant Director of Nursing (ADON), on 10/26/2023 at 3:57 PM, she stated review of Resident #3's admission MDS had shown no noted bruising prior to the incident. She stated staff members should not attempt to move any resident by themselves if residents were care planned as a two assist. The ADON stated she believed Resident #3 had an updated care plan that changed to one-assist. She stated there was always a potential for harm to the residents when staff had not followed the care plan. The ADON stated her expectations were for all staff to follow the residents' care plans. She stated staff should prioritize safety for the residents they were caring for, and in all situations if assistance was needed, they should ask for it. In an interview with the Director of Nursing (DON) #1, on 10/27/2023 at 10:15 AM, she stated that CNAs would have access to the Kardex (CNA care plan), and the resident's comprehensive care plan which would have shown if Resident #3 was a one (1) or two (2) assist with bed mobility. She stated the admission MDS had shown two (2) assist but was certain that had changed to one (1) assist before the incident had occurred. Review of the resident's care plan; however, revealed the resident was care planned to have a one (1) to two (2) person assist with bed mobility. Further, the resident's MDS assessment revealed the resident was assessed as requiring an extensive assistance of two (2) staff, which was different from the resident's care plan that stated the resident required 1-2 staff assistance. In a further interview with the Director of Nursing (DON), on 10/27/2023 at 10:15 AM, she stated the facility's policy, care plans, and resident rights were essential and were created to protect the residents. She further stated she expected all staff to utilize the guidance provided to ensure they were providing appropriate care to the residents. In an interview with the Administrator, on 10/27/2023 at 11:30 AM, she stated she expected all staff to follow the facility policy and protocols. She stated it was her responsibility to ensue the residents received the best care possible, were safe in the facility, and free from harm or injury.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to maintain a system that accepted accounting principles and proper bookkeeping techniques, in order to maintain the ongoing balance for each resident's personal funds entrusted to the facility on the resident's behalf for two (2) of eighteen (18) sampled residents (Resident #6 and Resident #8). Additionally, the facility failed to refund the resident's representative upon the death or discharge of a resident (Resident #8). The findings include: Review of the facility's policy titled, Resident Funds Policy and Procedure, not dated, revealed the purpose of the policy was to ensure the facility's residents had access to and were able to manage their personal funds. The facility would keep track of such funds through an established system in order to document the date, time, and the amount of funds received from or dispersed. The policy further stated the facility would ensure through established systems in place that it would safeguard against misappropriation of resident's funds. Continued review of the policy revealed proper bookkeeping techniques included an individual record established for each resident on which only those transactions involving his or her personal funds were recorded and maintained. Further, the record would have information on when the transactions occurred, what they were, and maintain the ongoing balance for every resident. For each transaction, the resident would be given a receipt and the facility would retain a copy. Review of the facility's Admission Packet, section titled, Resident Admission and Financial Agreement, revealed when a resident was discharged and did not return to the facility, a refund would be made to the resident, the resident's responsible party, or to the estate within thirty (30) days from the resident's date of discharge from the facility. Review of the facility's policy titled Resident funds, not dated, revealed the facility's residents had the right to manage his/her own financial affairs. This included the right to know, in advance, what charges the facility may impose against a resident's personal funds. Section IV revealed conveyance upon discharge, eviction, or death of a resident with a personal fund, the facility should covey within thirty (30) days the resident's funds and a final accounting of those funds to the resident or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law. Review of page four (4) of the Facility's Admission Packet, revised 09/01/2023, revealed that if the resident had a trust account, the facility would provide to the resident and or the resident's responsible party a quarterly statement reflecting the activity in the trust account. 1) Record review of Resident #6's admission record revealed the facility admitted the resident on 05/17/2016 with diagnoses to include Polyneuropathy, and Anemias. Review of Resident #6's Quarterly Minimum Data Set (MDS) Assessment, dated 10/07/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Record review of Resident #6's transaction history with the Kentucky Guardianship Fiduciary Information System (KYGFIS) revealed on 02/21/2022, Resident #6 had two hundred and forty ($240) dollars transferred from his/her account to the facility for extra personal needs. Further record review revealed on 02/22/2022 he/she had sixteen ($16) dollars transferred from his/her account to the facility for a phone plus tax. In an interview with Resident #6, on 10/23/2023 at 4:05 PM, he/she stated he/she had resided within the facility for the last several years. Resident #6 stated he/she never received any of the money he/she had requested for the phone he/she was trying to purchase, and no one has been able to tell him/her anything about it. The resident further stated he/she had no idea what his/her access to his/her money entailed. In an interview with Resident #6's State Guardian, on 10/23/2023 at 3:20 PM, he stated that Resident #6 stated that he/she wanted to purchase a cell phone. He stated that he was okay with Resident #6 having a cell phone so he sent money to the facility through the state fiduciary on 02/21/2022 in the amount of two hundred and forty ($240) dollars as extra personal funds to cover the cost of the cell phone service for one (1) year, and on 02/22/2022 in the amount of sixteen ($16) to cover the cost of the cell phone plus any sales tax. State Guardian stated that Social Services Director (SSD) #2 at that time was assisting Resident #6 with acquiring his/her phone. Per the interview, the State Guardian stated he never received any receipts that Resident #6 received his/her phone or where the money went. He further stated that when he inquired about the transactions with the facility, the facility stated to him that they did not know anything about it despite his documentation of the cleared bank transactions. In an interview with the former Social Services Director (SSD) #2, on 10/23/2023 at 3:30 PM, she stated that she was the Social Service Worker who was assisting Resident #6 with getting a cell phone because he/she wanted to try and locate his/her children. She stated Resident #6 stated to her that he/she had his/her state guardian send money to the facility for a cell phone, but when she checked with the Business Office, the former Business Office Manager would never give her a direct answer as to where the money went, and eventually told her that it was never sent. The Social Services Director (SSD) #2 stated that she contacted Resident #6's state guardian and the state guardian told her that he had sent the money. She also stated Resident #6 would always have issues with getting his/her money from the facility from time to time. SSD #2 further stated she resigned from her position at the facility in November of 2022 and at the time of her resignation, the missing money had not been located. During an interview with the facility's Chief Operations Officer (COO), on 10/25/2023 at 4:15 PM, he stated that he would have the business office issue a refund to Resident #6 in the amount of two hundred and fifty-six ($256) dollars. He also stated that he would try to contact the former owners of the facility to find out where the resident's money went. During an interview with the facility's current Business Office Manager (BOM), on 10/23/2023 at 5:10 PM, she stated she had been at the facility for approximately three (3) weeks. She stated that the residents had a Resident Funds Management Services (RFMS) account. and their money goes into and the facility handles missing money by investigating when and where it was brought in and who it was given to. Further, she stated the facility would trace back the steps of the missing money. In a continued interview, she stated that there were no records during the time period that Resident #6's money went missing because the facility had a different owner, and she did not have access to any records from them. In an interview with the Director of Nursing (DON), on 10/26/2023 at 4:09 PM, she stated missing money and items were reported to Social Services, then they filled out a grievance. She also stated that anyone could fill out a grievance, but the Social Service Department would handle the process of investigating and following it through. She stated she was not the DON during this time period but the process now was that the residents would report their concerns and social service would file a grievance on their behalf. Further, she stated an investigation would be started, and a third-party billing office would assist in the investigation. (did we contact the third-party billing office of an additional interview?) In an interview with the Accounts Receivable Director at the third-party billing company, on 10/27/2023 at 9:00 AM, she stated the resident's money may be held until all outstanding balances were paid. She also stated she thinks there was a breakdown in communication due to the change in Business Office Manager staff that caused Resident #6's money to become unaccounted for. In interviews with the Administrator on 10/25/2023 at 3:56 PM and also on 10/27/2023 at 11:30 AM, she stated she was not aware that Resident #6 did not receive his/her money for his/her cell phone. She stated that most of the facility's documentation was destroyed when the ice storm occurred, causing pipes in the office area to burst and the office was flooded. She further stated the facility had no access to any of the previous owner's records. The Administrator stated the previous business office manager was not performing her job duties as required and was temporarily restricted from seeing any of the Business Office Records. She stated she now had a new office manager who was more experienced. Further, the Administrator stated she was confident the new Business Office Manager would ensure that all deposits would be made timely and that residents had access to their money. 2) Closed record review of Resident #8's admission record revealed the facility admitted the resident on 10/26/2022 with diagnoses to include: Unspecified dementia, unspecified severity, with other behavioral disturbance, Cognitive communication deficit and unspecified Osteoarthritis, unspecified site. Further review of Resident #8's record revealed the resident was discharged on [DATE], due to his/her death. Review of Resident #8's Quarterly Minimum Data Set (MDS) Assessment, dated 03/31/2023, revealed a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which indicated the resident was severely cognitively impaired and not interviewable. Review of Resident #8's resident ledger effective 01/01/2022 through 11/30/2023 revealed a credit of four thousand one hundred sixty dollars and zero cents ($4160.00). In an interview with Resident #8's daughter, on 10/24/2023 at 10:38 AM, she stated she had contacted the facility directly requesting a refund on the monies she had paid for her family member's stay and was not given a reason as to why the money had not been refunded. In further interview with the resident's family, she stated she could not recall who she spoke with related to not receiving a refund after the resident's death. In an interview with the Business Office Manager (BOM) on 10/24/2023 at 2:21 PM, she stated she had only been at the facility for three (3) weeks. The BOM stated a resident and/or resident's family should be refunded any due credits within thirty (30) days of discharge or death. In an interview with the Chief Operations Officer (COO), on 10/24/2023 at 2:40 PM, he stated he did not know why the resident's funds had not been refunded unless it was because the facility was waiting on an insurance payment. He stated the family had not contacted the facility requesting a refund to his knowledge. The COO stated he had already spoken to the corporate office and the facility would issue the refund today, on 10/24/2023. In an interview with the Administrator, on 10/25/2023 at 3:56 PM, she stated she thought the issue of the funds not being refunded to Resident #8's family started when the previous BOM was at the facility. Per the interview, the Administrator stated the previous BOM resigned, and her last day was 07/18/2023. However, the facility was in the process of terminating her due to her poor job performance. The Administrator stated another employee who had business office experience had helped until they could get someone hired and trained. Further, she stated the facility utilized a third-party vendor that provided oversight of the residents' accounts. The administrator stated she would expect all resident accounts to be monitored and addressed timely and that the facility's policy would be followed. 47798

Based on observation, interview, record review and facility policy review it was determined the facility failed to follow the written plan of care for one (1) of three (3) sampled residents (Resident #1). The facility care planned Resident #1 for staff to provide every fifteen (15) minute security checks initiated on 08/05/18 after Resident #1 had a fall in the dining room on 08.05/18. However, review of the every 15 minute security check documentation sheet revealed the every 15 minute checks were initiated at 8:30 AM on 08/05/18 and were completed every thirty (30) minutes for twenty-four hours, not every 15 minutes. In addition, Resident # 1 was care planned to have a clip alarm while in the wheelchair after a second fall on 08/05/18. Resident #1 sustained a fall on 09/04/18; the pull away clip alarm was not in place resulting in the resident hitting his/her head during the fall. The resident sustained [REDACTED]. The facility's failure to follow the care plan related to doing every fifteen (15) minute security checks and providing a chair alarm has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 09//13/18 and determined to exist on 08/05/18. The facility was notified of the Immediate Jeopardy on 09/13/18. An acceptable Allegation of Compliance (AoC) was received on 09/19/18. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 09/18/18. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Resident Care Plan, last revised (MONTH) (YEAR), revealed the Interdisciplinary Team will develop and implement a comprehensive person-centered care plan for each resident from information on the Minimum Data Set (MDS), resident's medical record and observations made while interviewing the resident and if applicable the resident's representative. Comprehensive care plans must be reviewed and revised by the interdisciplinary team after each assessment, when a significant change in a resident occurs, it is the policy of this facility to provide appropriate treatment and services to maintain or improve the resident's abilities, Care Conference/Care Plan review will be completed by the interdisciplinary team and the following focuses will be reviewed: Activities of Daily Living, falls, safety concerns, muscullarskeletal (fractures, amputations, arthritis), interventions and measurable objectives and time frames will be written for each problem addressed on the comprehensive resident care plan and staff not following the plan of care will receive appropriate counseling up to and/or including suspension and/or termination. Record review revealed the facility admitted Resident #1 on 07/13/18 with [DIAGNOSES REDACTED]. Review of a Falls Risk assessment dated [DATE], after a fall that occurred forty-five (45) minutes after admission (5:00 PM) revealed a score of seventy-five (75). Further review of the form revealed a score of sixty-one {61} or above indicated the resident was at high risk for falls Review of the Admission Minimum Data Set (MDS) assessment, dated 07/17/18, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of six (6) which indicated the resident was not interviewable. Review of a facility's Fall Investigation for Resident #1 revealed on 08/05/18 at 7:55 AM, Resident #1 was found on the floor in the day room/dining room with no injuries. Contributing factors listed included; resident was alone, unattended, and confused. The root cause was listed as the resident overestimates abilities. Further review of the investigation revealed an initial intervention for security checks every fifteen (15) minutes for twenty-four (24) hours. Review of the Comprehensive Care Plan for falls dated 07/13/18, revealed an intervention for security checks every 15 minutes for twenty four hours was added on 08/05/18. However, review of the Safety Check Sheets dated 08/05/18-08/06/18 revealed staff did an initial check on 08/05/18 at 8:30 AM, then resumed thirty minute security checks at 3:30 PM on 08/05/18 (after returning from the hospital) through 1:00 PM on 08/06/18. Interview with Certified Nursing Assistant (CNA) #1 on 09/11/18 at 3:17 PM revealed Resident #1 was on every fifteen (15) or thirty (30) minute safety checks and the 8:35 AM fall happened between the checks. She stated this time the resident complained of leg/hip pain and was sent to the emergency room . Further interview with CNA #1 on 09/18/18 at 1:45 PM revealed she filled out the Safety Check sheet that was given to her by the nurse and followed it. She stated she was aware the resident was to be on every 15 minute security checks, but she did not remember if it the form indicated every 30 minutes or every 15 minutes. Interview with Licensed Practical Nurse (LPN) #2, Unit Manager #4, on 09/12/18 at 10:50 AM revealed she did not know why staff did not do every 15 minute safety checks per the Care Plan after the first fall on 08/05/18 at 7:55 AM. Interview with Registered Nurse (RN) #1 on 09/19/18 at 11:07 AM, revealed she was given re-education about using the correct security check sheet as she had given the CNA's the every 30 minute check sheet instead of the every 15 minute check sheet. RN #1 stated she knew Resident #1 had been care planned for every 15 minute checks, and it was a failure on her part. During further interview, RN #1 stated the hospital nurse told her it would be fine to do every 30 minute checks after the resident returned from the hospital on [DATE]. RN #1 stated she was educated that the hospital could not change the facility's Plan of Care (P[NAME]). She stated there was no one in the dining room with Resident #1 when the falls occurred as the CNA's were picking up the breakfast trays and she and the other nurse (that no longer works at the facility) was passing medications. Review of the fall investigation dated 08/05/18 at 8:35 AM, revealed Resident #1 was found on the floor in the dining room/day room, alone and unattended. The resident stated, I guess I was trying to lay down. The intervention put in place was to assist the resident to bed between meals and to apply a pull away alarm to the wheelchair. Review of the Comprehensive Care Plan dated 07/13/18, revealed interventions for a bed pad alarm connected to the call system in place to alert staff when the resident was up without assist; and, a pull away alarm to the wheelchair, check for placement of alarms every shift and if they are not functioning properly, notify the charge nurse for replacement; this was put in place on 08/14/18. However, review of a fall's investigation, dated 09/04/18 at 5:15 PM revealed Resident #1 fell to the floor on the left side and alarm being used at the time of fall on the form was checked as No. Review of a Nurse's Note on 09/04/18 at 7:40 PM, revealed Resident #1 was sitting at the nurse's desk in his/her wheelchair. Further review revealed the nurse saw the resident standing and she attempted to reach the resident, but the resident took a step sideways and fell striking his/her head on the left side. The resident loss consciousness for approximately thirty( 30) seconds. Resident #1 was sent to the emergency room (ER) for evaluation. Review of the hospital's History & Physical Report on 09/04/18, from the emergency room revealed the resident had a Computed Tomography (CT) Scan which indicated Resident #1 had a left frontal hemorrhage (bleed) as well as a hemorrhage in the back part of the left side of the ventricle (cavity) of the brain. Interview with CNA #3 on 09/12/18 at 3:21 PM revealed Resident #1 would play with the pull away alarm, and would lean forward and grab at it. CNA #3 stated the resident did undo the alarm on 09/04/18. He (CNA#3) stated he felt the nurses knew the resident tried to disconnect the alarm and messed with the alarm. Interview with LPN #1 on 09/12/18 at 3:32 PM revealed when Resident #1 fell on [DATE], the pull away alarm did not sound because it was connected to the wheelchair and not the resident. Interview with Registered Nurse (RN) #3 on 09/11/18 at 10:33 AM revealed no alarm went off on 09/04/18 when Resident #1 fell because the clip alarm was found attached to the wheelchair after the resident fell . Interview with the Director of Nursing (DON) on 09/12/18 at 1:49 PM revealed RN #1 was educated on using the correct Safety Check sheets as she used the every thirty (30) minute safety check sheet instead of the every 15 minutes safety check sheet. She stated staff should have completed every 15 minute security checks as care planned after the fall on 08/05/18 at 7:55 AM, and the alarm had been checked forty-five minutes prior to the fall on 09/04/18. She stated they do not check the alarms every thirty minutes. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 09/13/18, the Interdisciplinary Team, consisting of the Assistant Director of Nursing, Unit Coordinator 4, and Social Services conducted review of Resident #1's falls since admission and ensured that current fall care plan interventions were appropriate to address identified the root cause of falls and to ensure that his/her environment remained as free of accident hazards as possible and that adequate supervision and assistive devices were in place to prevent future accidents. Based on this review, it was determined that current care plan interventions were appropriate based on the resident's condition. 2. On 09/13/18, the Interdisciplinary Team, consisting of Director of Nursing, Assistant Director of Nursing, Rehab Director, Licensed Social Workers, Unit Coordinators, and Weekend Supervisor, completed a review of all falls in the past 90 days for current residents to ensure that current fall care plan interventions were appropriate to address identified the root cause of falls and to ensure that his/her environment remained as free of accident hazards as possible and that adequate supervision and assistive devices are in place to prevent future accidents. 3. On 09/14/18, the Administrator and Director of Nursing conducted a training with licensed nurses and nursing assistants titled, Innovative Fall Prevention Strategies and Interventions in Long Term Care that was created by Proactive Medical Review and Consulting. The training included: Identification of key risk factors for geriatric falls, how to incorporate evidence based practice into falls prevention, falls response, and falls management across the interdisciplinary team, key individualized care plan interventions and facility wide approaches to managing common fall risk variables: how to utilize effective caregiver and patient training tools and develop effective discharge plans for long term fall risk reduction; and, essential documentation components associated with falls prevention and management. After the training, the employees were divided into groups, given a photograph, ten (10) questions to ask about each fall and were required to complete a fall scene investigation report as a group. This review and completion served as a competency of the material covered. Review of the following policies was a part of the in-service: Fall prevention protocol, fall scene investigation and Security Checks and Resident Care Plans. The employees were informed that all policies were now in the binder at each nurses's station for quick reference purposes. Additional education sessions were completed for licensed nurses and nurse aides on 09/14/18 and 09/15/18 by the Clinical Educator, Staffing Coordinator, Admissions, Assistant Director of Nursing, and/or Director of Nursing. No licensed nurse or nursing assistant will work past 09/16/18 without receiving this training. Any licensed nurse or nursing assistant on vacation or leave of absence received verbal correspondence regarding the mandatory required education prior to working. Additionally, written notification is posted at the time clock regarding this requirement. The Staffing Coordinator is continuously monitoring to assure that no licensed nurse or nurse aide works prior to receiving the education. 4. The Director of Nursing or Assistant Director of Nursing will review new fall occurrences, no later than the next business day, to ensure that immediate appropriate interventions were implemented based on the identified root cause of falls and to ensure that his/her environment remained as free of accident hazards as possible and that adequate supervision and assistive devices were in place to prevent future accidents. On weekends and holidays, the Nursing Supervisor will review the new fall occurrences to ensure that this protocol is followed seven (7) days a week. This process begins 09/17/18 an will continue until the next annual relicensure survey. 5. An Ad-Hoc QA meeting was held on 09/14/18 to review alleged deficient practice. Attendees of the meeting included the Administrator, Director of Nursing, and Assistant Director of Nursing, Unit Coordinator 1, Unit Coordinator 2, Unit Coordinator 4, Social Services, Activities, Admissions Coordinators, Dietician, Dietary Manager, Clinical Educator, Medical Records, Maintenance, Facility Assistant, Business Office, Environmental Supervisor, Rehab Supervisor, and the facility secretary. The team reviewed the alleged deficient practices and the plans of action established to correct practices, which included education content, policy updates, and required accountability. Following the meeting, the Administrator and Medical Director met and reviewed the alleged deficient practices and the plan of action established to correct the practices, which included education content, policy updates, and required accountability. 6. The Director of Nursing, Assistant Director of Nursing, or Nursing Supervisor will review new fall occurrences, no later than the next business day, to ensure that appropriate immediate interventions were implemented based on identified root cause and that current fall care plan interventions are provided in accordance with the written plan of care. Any noted non-compliance with appropriate interventions being provided in accordance with the written plan of care will result in re-education of staff assigned to the resident at the time of the identified non-compliance and may include disciplinary action up to and including termination for non-compliance with providing care in accordance with the written plan of care. The holidays and weekends will be covered by the Nursing Supervisors. This process began 09/17/18 and will continue until next annual relicensure survey. 7. A fall Quality Assurance Performance Improvement (QAPI) sub-committee, consisting of Director of Nursing and/or Assistant Director of Nursing, Unit Coordinator, Therapy Representative, Licensed Nurse, and Nurse Aide will meet weekly and review residents at high risk (fall score >60), residents with multiple falls, and residents with falls in the past 30 days to ensure that appropriate immediate interventions were implemented based on identified root cause and that current fall care plan interventions are provided in accordance with the written plan of care. This will begin 09/21/18 and will continue until our next facility annual relicensure survey. 8. An Ad-Hoc QA meeting was held with the Medical Director, Director of Nursing, and Administrator on 09/17/18 to review allegation of compliance. Fall care plan interventions for residents with any new falls from 09/18/18 and forward will be reviewed to ensure compliance in accordance with the written plan of care in daily clinical meeting and by Weekend Nursing Supervisor until the next annual relicensure survey. 9. With any new resident falls, care plan intervention audits will be conducted starting 09/17/18 and be completed for the next four weeks. The disciplines to provide the audits will be the Director of Nursing, Assistant Director of Nursing, Unit Coordinators, RN Supervisors, Staffing Coordinator, Social Services, Therapy, MDS staff, Lead CNAs and RSA staff. These audits will be conducted weekly after the first four weeks. The process will be ongoing until the annual relicensure survey. Results of fall care plan implementation reviews will be reviewed by QAPI committee weekly for a minimum of four weeks and then at least quarterly until our next annual relicensure survey. Further recommendations on additional corrective actions to maintain compliance. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Based on review of the current care plan for Resident #1 it was determined the care plan contained revisions as of 09/17/18 with more appropriate interventions to include resident to be laid down promptly after meals, provide 1:1 care from 09/05/18 at 2:00 PM through 09/06/18 at 6:30 AM, offer activity table when up in chair, check for placement and function of alarms every shift and if not functioning properly, notify charge nurse for replacement. 2. Review of the facility's falls investigation sheets revealed all residents with falls in the last ninety days had appropriate interventions for each fall and more appropriate root cause determination (not just overestimating abilities). Record reviews for Residents #4, #5, #6, #7, #8, and #9 revealed no concerns with the fall's investigation related to root cause interventions. 3. Review of sheets signed by staff attending the training revealed all staff except those on vacation, or FMLA (Family Medical Leave Act) were inserviced and provided fall scenarios training on 09/14/18 by the Administrator and DON. Observation on 09/24/18 at 3:00 PM revealed policies on fall prevention protocol, investigation, protocol on security checks and care plans were in a binder at the nursing station. Observation on 09/24/18 at 4:00 PM revealed a notification of mandatory training at the time clock. Review of QA Meeting Notes dated 09/14/18, revealed members were informed of the Immediate Jeopardy tags and what they entailed, what measures would be put in place to correct deficiencies, trainings that would be held, and measures implemented to sustain solutions. Review of QA Committee (Medical Director, DON, ADON, Administrator, Unit Coordinators for Units 1, 2 and 4, LSW, Admissions Director, Business Office Manager, Clinical Educator, Rehab Director,MDS Coordinator, Maintenance Director, Food Services Director, Infection Control RN, Registered Dietician, Pharmacy Director, Secretary, and Activities Director) Sign In sheet revealed all signees were inserviced on Falls Prevention Protocol, falls scene investigation, security checks and Care Plan Protocol by the Administrator, DON, Clinical Educator, Staffing Coordinator, Admissions Director and ADON on 09/14/18. Review of a letter sent out to all staff by the Administrator on 09/13/18 revealed there would be education on: Innovative Falls Prevention Strategies and Interventions, fall prevention protocol policy update, fall scene investigation, security checks policy update, resident care plans with explanation by the Administrator about each tag, notation that the education is required and that there would be future education inservices. Review of scenarios with examples of falls and staff documenting what they would do revealed the ten (10) questions to ask if a fall occurs in order to identify the root cause of the fall, description of the fall, all factors involved in the fall, interview all staff to determine what the resident was doing during or just prior to the fall, ask the resident (regardless of their cognitive status) about what they were trying to do, contributing factors, fall huddle with any and all staff which might have seen the fall or observed the resident after the fall, licensed nurse must provide the correct security check sheet, the team must determine the root cause of the fall at the time of the fall, provide an intervention to prevent a future fall, and fall care plan is to be updated. Interview with CNA #3 on 09/24/18 at 3:55 PM and interviews on 09/25/18 with CNA #2 at 11:50 AM, CNA #4 at 4:40 PM, CNA #5 at 5:15 PM, CNA # 6 at 5:25 PM, CNA #7 at 4:50 PM and CNA #3 on 09/25/18 at 11:50 AM revealed they have had inservice training on fall prevention protocol, fall scene investigation scenarios, security checks, resident care plans, following care plans, appropriate interventions for residents to prevent falls, dementia care, policies being in a binder at the nursing station, notification of training at the time clock, that staff would not be allowed to work until they had the training, getting to the root cause of a fall specific to that resident,checking alarms, closer monitoring of residents at high risk for falls, and communicating with other team members. Interviews with Licensed Practical Nurses (LPN's) #1, #2 #3, #4, #5 and # 6 revealed they had training/education on getting to the root cause of falls, having interventions specific for each resident, and being sure the care plan is followed. Interview with the Clinical Educator and ADON on 09/25/18 at 4:00 PM revealed they were involved in updating falls policy, educating staff on getting to the root cause of falls by asking more in depth questions, following the care plans and updating the care plans. Interview with Registered Nurse (RN) #3 on 09/24/18 at 11:30 AM revealed she had training on following care plans, making sure the care plan has specific interventions appropriate for each resident, and getting to root cause of falls by investigating. Interview with Licensed Worker on 09/25/18 at 3:00 PM and Physical Therapist on 09/25/128 at 3:13 PM revealed they had training on getting to root cause of falls, and appropriate care plan interventions. Interviews with the DON and Administrator on 09/25/128 at 5:40 PM revealed all staff have been educated except for a few on vacation and on FMLA leave and they will not be allowed to work until they receive the training. The Administrator stated she and the DON have gone over with the staff about fall prevention protocols, policies, documentation, security checks, checking alarms, getting to the root cause, following the care plan, and Dementia care. 4. Review of the new falls audit revealed there were no new falls since 09/17/18. Interviews with DON on 09/25/18 at 5:40 PM, and the Unit Manager (Coordinator) for Station 4 on 09/24/18 at 4:05 PM revealed the facility has been doing audits on any new falls to ensure what appropriate interventions were in place and that the root cause was thoroughly investigated. 5. An Ad-Hoc QA meeting was held on 09/14/18 to review alleged deficient practice . Attendees of the meeting included the Administrator, Director of Nursing, and Assistant Director of Nursing, Unit Coordinator 1, Unit Coordinator 2, Unit Coordinator 4, Social Services, Activities, Admissions Coordinators, Dietician, Dietary Manager, Clinical Educator, Medical Records, Maintenance, Facility Assistant, Business Office, Environmental Supervisor, Rehab Supervisor, and the facility secretary. The team reviewed the alleged deficient practices and the plans of action established to correct practices, which included education content, policy updates, and required accountability. Following the meeting, the Administrator and Medical Director met and reviewed the alleged deficient practices and the plan of action established to correct the practices, which included education content, policy updates, and required accountability. Interview obtained in a return post-survey call from the Medical Director on 09/26/18 at 4:28 PM revealed he had met twice with the Administrator and was part of the QAPI team, concerning the deficient practice and measures to be put in place. He stated he expected staff to follow the care plans and do a better job of figuring out the root cause of falls and to do closer monitoring of those at high risk of falls and that he felt measures put in place now would be sustainable. 6. Review of audit of new falls revealed there were no new falls since 09/17/18. Interview with the ADON and Clinical Educator on 09/25/18 at 4:00 PM revealed they did a 90 day review of falls with the care plan interventions, security checks, and dementia care. All staff were told they could not work until they had the training. They stated monitoring was being done to sustain what had been put in place, and closer monitoring of residents at risk of falls was being done. They also stated all falls care plans will be monitored for appropriate interventions on a weekly basis. Interview with LPN # 3 on 09/25/18 at 3:42 PM revealed they have been doing audits on any new falls and care plans. She stated there have been no falls on Station One in the past thirty days. Interview with CNA #4 on 09/25/18 at 4:40 PM revealed she was the Lead CNA on Unit Four and was responsible for checking fall care plans on her unit to make sure they have appropriate interventions and that the facility was doing audits on any new falls. 7. Review of the sub-QAPI signature sheet and notes for 09/21/18 revealed there were no falls since 09/21/18. Interview with the ADON and Clinical Educator on 09/24/18 at 5:00 PM revealed they will be having a Falls Sub committee Meeting weekly four (4) weeks starting 09/21/18 and then monthly to monitor any falls for the last thirty days; to monitor any residents with falls risk scores of sixty or greater, and any residents with multiple falls to ensure appropriate immediate interventions are in place based on the root cause and that fall care plans interventions were appropriate. 8. Interview with the Medical Director on 09/26/18 at 4:28 PM revealed he had been present at the QA meeting on 09/17/18 and was aware of the deficient practices and what they entailed, and was aware of measures put in place to correct the deficient practice. 9. Interview with the ADON and Clinical Educator on 09/24/18 at 5:00 PM revealed they would be doing new falls

Based on observation, interview, record review and facility policy review, it was determined the facility failed to provide adequate supervision and assistance devices to prevent accidents for one (1) of three (3) sampled residents (Resident #1). The facility failed to implement appropriate, effective interventions to prevent falls and failed to monitor for the effectiveness of interventions and make modifications after Resident #1 had a fall within forty-five minutes of admission (07/13/18) and sustained a broken right hip. Resident #1 sustained two (2) falls on the same day (08/05/18) within a forty (40) minute interval, one resulting in a [MEDICAL CONDITION]. With the last fall (09/04/18), Resident #1 sustained a brain bleed subsequently leading to the decrease in Activities of Daily Living (ADL's) and according to the physician, a more rapid decline in health. The facility's failure to ensure residents were provided adequate supervision and assistive device to prevent accidents has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 09/13/18 and determined to exist on 08/05/18. The facility was notified of the Immediate Jeopardy on 09/13/18. An acceptable Allegation of Compliance (AoC) was received on 09/19/18. The State Survey Agency validated the AoC and determined the Immediate Jeopardy was removed on 09/18/18. The Scope and Severity was lowered to a D for 42 CFR 483.21, Comprehensive Resident Centered Care Plan, F659 and 42 CFR 483.25 Quality of Care, F689, while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Fall Prevention Protocol, last revised (MONTH) (YEAR), revealed nursing assesses all patients/residents for risk of falling using the Fall Scale and performs assessments upon admission, when there is a significant change, or fall event and quarterly. Physical Therapy (PT) also assesses. Fall interventions are based on risk levels of none, low risk and high risk. Score of sixty-one (61) or greater is high risk. Standard Fall Prevention interventions include apply yellow fall risk clasp, orient to environment, place phone and personal items in reach, safe environment, assess coordination and balance before transfer and mobility activities, collaborate with PT, approach resident toward unaffected side, evaluate potential for increased fall risk due to polypharmacy, individualize equipment to resident, non skid footwear, and follow the care plan and update as needed. If High Risk for falls, supplement Standard Fall Prevention Interventions with place near nursing station when possible, consider use of alarms, use low beds, facilitate activities that encourage resident involvement, reorient frequently to surroundings, assess for physical discomfort, evaluate response to medications, include family in planning, and consider PT evaluation. Further review of the policy also revealed at the time of a resident fall occurrence, to ensure appropriate interventions are documented in the resident's plan of care that are specific to the root cause of the fall. Review of the facility's policy titled, Resident Alarms, last revised (MONTH) (YEAR), revealed an alarm is any physical or electronic device that monitors resident movement and alerts the staff, by either audible or inaudible means, when movement is detected. Types of alarms listed were: bed alarms are devices such as sensor pad alarms on the bed or a device that clips to the resident's clothing, chair alarms are devices such as sensor pad alarms placed on the chair or wheelchair or a device that clips to the resident's clothing. The use of alarms does not eliminate the need for adequate supervision of the resident, when alarms are used, additional monitoring will be utilized such as verifying alarms are used in accordance with the resident's care plan, and verifying alarms are in place and functioning properly, Record review revealed the facility admitted Resident #1 on 07/13/18 with [DIAGNOSES REDACTED]. Interview with the Guardian of Resident #1 on 09/11/18 at 2:23 PM revealed Resident #1 moves quickly and had fallen twice at home. The Guardian stated the resident had Dementia and he/she does not remember he/she cannot walk. Review of a facility Falls Investigation for Resident #1 revealed on 07/13/18 at 5:00 PM the resident was found in his/her room lying on right side (forty-five minutes after admitted ). Continued review revealed the resident's mental status prior to the fall was listed as confusion and the resident stated I don't know why I got up. Further review revealed the resident was alone and unattended at the time of the fall and no alarms were in place. The resident was pleasantly confused, oriented to self and family only, makes needs/wants known, and was last toileted at 4:55 PM. The root cause of fall was listed as Dementia and new admission. Additional action listed as move closer to nursing station upon return to facility. Upon return to facility on 07/17/18 after surgery for [REDACTED]. Interviews on 09/12/18 with Registered Nurse (RN) #3 at 10:33 AM and Licensed Practical Nurse (LPN) #1 at 3:32 PM revealed there was no time to do a complete fall risk assessment on admission prior to the resident's fall on 07/13/18. Review of Falls Assessment for Resident #1 revealed on 07/13/18 the resident was assessed as a high risk for falls with a score of seventy (70), which was after the fall on 07/13/18 at 5:00 PM. Review of the Comprehensive Care Plan for Falls initiated on 07/13/18 revealed the resident was at risk for falls related to recent fall with fracture with interventions to perform fall risk assessment quarterly and after each fall, low bed, place frequently used items within easy reach, and maintain pathways clear and clutter free. However, there was no intervention to address the resident's risk for falls related to being alone and unattended and the resident's history of falls. Review of the Admission Minimum Data Set (MDS) assessment, dated 07/17/18, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of six (6) which indicated the resident was not interviewable. Further review of this MDS revealed the resident required extensive assistance of two (2) staff with bed mobility and transfers, limited assistance of one (1) staff with ambulation in corridor, extensive assist of two staff for toileting, and was frequently incontinent of urine and always continent of bowel. Review of a facility Fall Investigation for Resident #1 revealed on 08/05/18 at 7:55 AM, Resident #1 was found on the floor in the day room/dining room by his/her wheelchair. Fall unwitnessed. Further review revealed the resident was eating breakfast just prior to the fall. The resident reported he/she did not know where he/she was going. Contributing factors listed were: resident was alone, unattended, and confused. Root cause listed as resident overestimates abilities. Further review of the investigation revealed an initial intervention put in place was for security checks every fifteen (15) minutes for twenty-four (24) hours and the team agreed with interventions. There was no injuries sustained from this fall. Review of the Comprehensive Care Plan for falls revealed an intervention for security checks every 15 minutes for twenty four hours was added on 08/05/18. However, there was still no interventions put in place to address the resident being alone and unattended while overestimating his/her abilities to stand and walk. Review of the Resident #1's 30 minute Security Check form revealed the checks were started at 8:30 AM on 08/05/18 with one check completed at 8:30 AM, five minutes prior to the fall. The checks resumed at 3:30 PM on 08/05/18 upon return from the emergency room (ER) through 1:00 PM on 08/06/18. However, the checks were completed every thirty minutes instead of every fifteen minutes as care planned. Interview with Housekeeping Aide #2 on 09/12/18 at 1:07 PM revealed she was taking out the trash on 08/05/18 and went by the dining room and Resident #1 was in his/her wheelchair. She stated when she came back by about five (5) minutes later, the resident was in the floor with the wheelchair by the table and no breakfast tray was in sight. She stated the resident's head was towards the television and feet facing the Physical Therapy door. She revealed there was no staff in Physical Therapy as this was a weekend and there was no staff or other residents in the dining room and she did not know where the staff were. She stated she had Housekeeping Aide #1 go get the nurse and she stayed with the resident. She revealed when the nurse got there to assess the resident she left. Interview with Housekeeping Aide #1 on 09/12/18 at 11:40 AM revealed Housekeeping Aide #2 found Resident #1 on the floor, and asked her to get the nurse. She stated there was no staff or other residents in the dining room at the time, which was on 08/05/18 around breakfast time. Review of the facility's Fall Investigation for Resident #1 revealed on 08/05/18 at 8:35 AM Resident #1 was found on the dining room/day room floor again. The resident was attempting to self-transfer, and resident lost strength, appeared to get weak, and the resident stated I guess I was trying to lay down. Contributing factors identified included confused without behavioral disturbance, and alone and unattended. The root cause was listed as Resident overestimating abilities. Intervention to prevent future falls was to assist to bed between meals and a pull away alarm to wheelchair with a notation that the team agreed with the intervention. Review of a Nursing Note, dated 08/05/18 at 8:35 AM revealed Resident #1 was sent to the emergency room due to complaining of left hip pain after the fall. On 08/05/18 at 3:00 PM, the facility received a report from the hospital that the resident had a hairline left [MEDICAL CONDITION] and was sent back to the facility on [DATE]. Review of a Nurse's Note, dated 08/07/18 at 1:15 PM revealed the facility received a report from the orthopedic surgeon's office that the left hip hairline fracture had progressed and would require surgery. The resident subsequently was admitted to the hospital on [DATE], had surgical repair of the left [MEDICAL CONDITION] and returned to the facility on [DATE]. Interview with Certified Nursing Assistant (CNA) #1 on 09/11/18 at 3:17 PM revealed on 08/05/18 at 7:55 AM, Resident #1 was in his/her wheelchair and was sitting in the day room/dining room when she and another aide went by. CNA #1 stated Resident #1 was on every fifteen (15) or thirty (30) minute safety checks and the fall at 8:35 AM happened between the checks. The CNA stated she and the other CNA sat the resident in the hall so they could keep a closer watch on him/her after the fall at 7:55 AM. She stated she and the other aide were passing breakfast trays and were going up and down the halls a lot, then five (5) minutes later Resident #1 was on the floor. She stated they used a lift to get the resident up into his/her wheelchair and the resident was assessed by the nurse with no complaints of pain and his/her breakfast was set up. CNA #1 stated at 8:35 AM the same day, the resident was intent on going back to bed that day and apparently tried to stand up as he/she forgets he/she cannot walk, and fell . She stated this time the resident complained of leg/hip pain and was sent to the emergency room . Further interview with CNA #1 on 09/12/18 at 3:37 PM revealed pull tab alarms were attached to the resident's clothing and would alarm if the resident moved forward enough and staff was responsible for making sure the alarm was attached and working. She stated she provided care for Resident #1 on 08/05/18 and to her knowledge, no one was with Resident #1 when the resident fell twice on 08/05/18. Interview with CNA #1 on 09/18/18 at 1:45 PM revealed she filled out the security check sheet that was given to her by the nurse and followed it. She stated she was aware the resident was to be on every 15 minute security checks, but she does not remember if it was done for every 30 minutes or every fifteen minutes. CNA #1 revealed there was a big window at Station 2 and staff peek in as they go by to look in the dining room every five (5) minutes or so. She stated at the time of the first fall on 08/05/18 the CNA's were passing breakfast trays and were looking in on Resident #1. She stated Resident #1 did not have anyone assigned to him/her as the resident was not a feeder. CNA #1 stated she was coming back from break when the second fall occurred at 8:35 AM. Interview with CNA #2 on 09/12/18 at 11:30 AM revealed Resident #1's first fall at 7:55 AM, on 08/05/18 was one where a CNA found him/her and the resident was fine, and did not complain (c/o) any pain, and got him/her up with lift. She stated the second fall on 08/05/18 at 8:35 AM, the resident had finished breakfast and when she passed by, while picking up trays, she saw the resident was lying on his/her side. She stated at the time of the first fall there were other residents in dining room with the resident. CNA #2 stated the second time there probably were no other residents or staff with the resident as nurses were passing medications (meds.) and aides were on the floor. She revealed she did not remember why the every fifteen minute checks were not done as per the Care Plan and she did not remember if the nurse gave the CNAs the wrong sheet for every thirty minutes safety checks instead of the every fifteen minutes checks. Interview with Licensed Practical Nurse (LPN) #2, Unit Manager for Station (Hall) 4 on 09/12/18 at 10:10 AM revealed she was not sure about the fall's policy related to high risk. The LPN stated she would have to look at it regarding considering placing an alarm. Interview at 10:50 AM on 09/12/18 revealed Resident #1 was assessed initially at 6:59 PM on 07/13/18 and scored seventy (70), indicating the resident was at high risk for falls on Falls Risk Assessment, with high risk being sixty-one (61) or greater. She stated it was up to the nurses if they put an alarm in place, and she was not aware the resident had falls prior to admission. Further interview revealed Resident #1 was close to therapy, the dining room and 200 Hall nursing station, and the CNA's were passing breakfast trays and nurses were passing out medications. She stated she did not know why no one saw or caught the resident before the falls and she did not know why staff did not do every 15 minute safety checks per the care plan after the first fall at 7:55 AM on 08/05/18. She further stated Resident #1 was in the dining room at the time of both falls on 08/05/18 and did have a [MEDICAL CONDITION] hip on 08/05/18 after the second fall. Review of a falls assessment revealed Resident #1 was assessed at high risk for falls with a score of ninety-five on 08/13/18, after readmission after the two falls on 08/05/18. Further review of the Comprehensive Care Plan for falls revealed on 08/14/18 interventions were added for bed pad alarm connected to call system in place to alert staff of being up without assist, pull away alarm to wheelchair, to check for placement of alarms every shift and if not functioning properly, notify charge nurse for replacement. Review of the facility's Falls Investigation revealed Resident #1 had a witnessed fall on 09/04/18 at 5:15 PM while sitting in his/her wheelchair at the nursing station. The contributing factors were identified as resident lost balance, alone and unattended, confused, and unable to verbalize what he/she was trying to do. Further review revealed for the question Alarm being used at the time of fall?, with response checked as No. The root cause of the fall listed as cognitive status, overestimates abilities and attempted to ambulate. Intervention to prevent future falls included chair pad alarm and activity table. Review of a Nursing Note on 09/04/18 at 7:40 PM, revealed Resident #1 was sitting at nurse's desk in wheelchair, nurse saw resident standing and attempted to reach resident but resident took a step sideways and fell striking his/her head on the left side with loss of consciousness for approximately thirty (30) seconds. Resident # 1 was sent to the emergency room (ER) for evaluation. Review of the hospital History & Physical (H&P) Report for 09/04/18 revealed a Computed Tomography (CT) scan (type of specialized X-ray) showed Resident #1 had an acute (sudden) [MEDICAL CONDITION] (bleeding within the brain) after a fall with closed head injury. Medical History from this H & P revealed no previous history of [MEDICAL CONDITION]. Resident #1 was discharged back to the facility on [DATE]. Review of Nurse's Notes revealed Resident #1 returned to facility on 09/05/18 at 11:00 AM and was talking, alert, but confused. However, further review of the Nurse's Notes revealed the resident had a [MEDICAL CONDITION] (convulsion) on 09/05/18 at 2:15 PM, a second [MEDICAL CONDITION] on 09/07/18 at 8:17 PM, and a possible third [MEDICAL CONDITION] (witnessed by daughter) on 09/08/18 at 3:44 PM. Review of physician's orders [REDACTED].#1 was started on [MEDICATION NAME] ([MEDICAL CONDITION] medication) Intravenously (IV) for two (2) doses, then [MEDICATION NAME] five-hundred (500) milligrams (mg.) orally twice a day on 09/07/18 at 8:00 PM, then increased to seven-hundred fifty (750) mg. on 09/07/18 at 7:25 PM. Further review revealed the resident was started back on IV [MEDICATION NAME] on 09/12/18 as resident was not alert enough to swallow the oral medication. The resident did not have a history of [MEDICAL CONDITION] prior to the fall with head injury. Review of the Summary of PT Notes from 08/14/18 through 09/04/18 prior to fall, provided by the Director of Rehabilitation revealed Resident #1 was able to perform bed mobility with minimal assistance, transfer with minimal assistance, and ambulate with a rolling walker a distance of fifty (50) to one hundred fifty (150) feet. The resident was able to complete total body dressing with minimal to moderate assist, total body bathing with moderate assist, and self feeding with stand by assistance. However, interviews on 09/12/18 with Speech Therapist at 9:00 AM and Physical Therapy Assistant at 9:15 AM revealed the resident had declined since the head injury. The ST stated Resident #1 was now non-verbal, had to be changed to pureed diet with nectar thick liquids when he/she had been on a Regular diet with nectar thick liquid prior to the 09/04/18 fall; and, now it takes an hour for him/her to finish meal with being fed. The Physical Therapy Assistant revealed since 09/04/18 the resident opens his/her eyes and the only thing they were doing for the resident was Range of Motion (ROM) and repositioning for the resident. Interview with LPN #1 on 09/12/18 at 3:32 PM revealed when Resident #1 fell on [DATE], the pull away alarm did not sound because it was connected to the wheelchair and not the resident. She stated Resident #1 was sitting at the nurse's desk in wheelchair, and she saw the resident standing and attempted to reach resident but resident took a step sideways and fell striking his/her head on the left side with loss of consciousness for approximately thirty (30) seconds. Interview with CNA #3 on 09/12/18 at 3:21 PM revealed Resident #1 would play with the pull away alarm, and would lean forward and grab at it. CNA #3 stated the resident removed the alarm on 09/04/18 and he felt the nurses knew the resident tried to disconnect the alarm and messed with the alarm. Interview with Registered Nurse (RN) #3 on 09/11/18 at 10:33 AM revealed no alarm went off on 09/04/18 when Resident #1 fell because the clip alarm was found attached to the wheelchair after the resident fell . Observation on 09/11/18 at 8:35 AM revealed Resident #1 was lying in bed on back and had a bruised area to left temple size of half dollar, no knot, but appeared like an indentation. The resident had Intravenous Fluids (IVF) infusing at sixty-five (65) ml. per hour in left lower arm. Resident #1 did not speak when spoken to at this time. Observation on 09/12/18 at 8:35 AM revealed the resident to be lying in bed with oxygen mask on, IVF'S infusing, and resident not responding to verbal or tactile stimulation. Observation on 09/13/18 at 8:05 AM revealed Resident #1 in bed lying on back, wash cloth on forehead, IVF'S infusing. Resident #1 did not respond at this time and had intermittent congested sounding cough. Interview with the Director of Nursing (DON) on 09/12/18 at 10:05 AM revealed she was not sure if the daughter told them Resident #1 had fallen twice at home and she was not sure about the policy related to high risk falls. Further interview with the DON on 09/12/18 at 1:49 PM revealed RN #1 gave the CNA's the wrong sheet to use as she gave them the every 30 minute safety check sheet instead of the every 15 minute safety check sheet. She stated RN #1 was educated on using the correct sheets. The DON stated staff should have completed every 15 minute security checks as the resident was care planned for every 15 minute safety checks on 08/05/18 after the fall at 7:55 AM. She further revealed the facility would have discussed other options about fall interventions if the resident had been able to be up in wheelchair after he/she was back from the hospital after the fall on 09/04/18. Further interview with the DON on 09/12/18 at 4:46 PM and 09/13/18 at 9:50 AM revealed on Unit One (1) and Four (4), a CNA was assigned when the residents were in dining room, but on Unit two (2), there was no constant cueing of residents to eat needed so not as much help was needed on Unit 2 and no one was assigned. The DON stated overestimating abilities means the resident forgets he/she cannot walk and tries to walk, and the facility uses that information to decide what type of intervention to put in place. Interview with the Administrator on 09/11/18 at 5:00 PM revealed she thinks her staff did the best they could with Resident #1 as the resident was not cognizant enough for the safety lap belt because he/she could not release it on his/her own and they could not restrain the resident as the facility was a restraint free facility. She stated Physical Therapy was working with the resident. The DON stated no one was giving her any extra money to hire enough staff to have someone to sit with these residents 24/7 to keep them from falling. She stated she felt her staff did a good job in taking care of Resident #1. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 09/13/18, the Interdisciplinary Team, consisting of the Assistant Director of Nursing, Unit Coordinator 4, and Social Services conducted review of Resident #1's falls since admission and ensured that current fall care plan interventions were appropriate to address identified the root cause of falls and to ensure that his/her environment remained as free of accident hazards as possible and that adequate supervision and assistive devices were in place to prevent future accidents. Based on this review, it was determined that current care plan interventions were appropriate based on the resident's condition. 2. On 09/13/18, the Interdisciplinary Team, consisting of Director of Nursing, Assistant Director of Nursing, Rehab Director, Licensed Social Workers, Unit Coordinators, and Weekend Supervisor, completed a review of all falls in the past 90 days for current residents to ensure that current fall care plan interventions were appropriate to address identified the root cause of falls and to ensure that his/her environment remained as free of accident hazards as possible and that adequate supervision and assistive devices are in place to prevent future accidents. 3. On 09/14/18, the Administrator and Director of Nursing conducted a training with licensed nurses and nursing assistants titled, Innovative Fall Prevention Strategies and Interventions in Long Term Care that was created by Proactive Medical Review and Consulting. The training included: Identification of key risk factors for geriatric falls, how to incorporate evidence based practice into falls prevention, falls response, and falls management across the interdisciplinary team, key individualized care plan interventions and facility wide approaches to managing common fall risk variables: how to utilize effective caregiver and patient training tools and develop effective discharge plans for long term fall risk reduction; and, essential documentation components associated with falls prevention and management. After the training, the employees were divided into groups, given a photograph, ten (10) questions to ask about each fall and were required to complete a fall scene investigation report as a group. This review and completion served as a competency of the material covered. Review of the following policies was a part of the in-service: Fall prevention protocol, fall scene investigation and Security Checks and Resident Care Plans. The employees were informed that all policies were now in the binder at each nurses's station for quick reference purposes. Additional education sessions were completed for licensed nurses and nurse aides on 09/14/18 and 09/15/18 by the Clinical Educator, Staffing Coordinator, Admissions, Assistant Director of Nursing, and/or Director of Nursing. No licensed nurse or nursing assistant will work past 09/16/18 without receiving this training. Any licensed nurse or nursing assistant on vacation or leave of absence received verbal correspondence regarding the mandatory required education prior to working. Additionally, written notification is posted at the time clock regarding this requirement. The Staffing Coordinator is continuously monitoring to assure that no licensed nurse or nurse aide works prior to receiving the education. 4. The Director of Nursing or Assistant Director of Nursing will review new fall occurrences, no later than the next business day, to ensure that immediate appropriate interventions were implemented based on the identified root cause of falls and to ensure that his/her environment remained as free of accident hazards as possible and that adequate supervision and assistive devices were in place to prevent future accidents. On weekends and holidays, the Nursing Supervisor will review the new fall occurrences to ensure that this protocol is followed seven (7) days a week. This process begins 09/17/18 an will continue until the next annual relicensure survey. 5. An Ad-Hoc QA meeting was held on 09/14/18 to review alleged deficient practice. Attendees of the meeting included the Administrator, Director of Nursing, and Assistant Director of Nursing, Unit Coordinator 1, Unit Coordinator 2, Unit Coordinator 4, Social Services, Activities, Admissions Coordinators, Dietician, Dietary Manager, Clinical Educator, Medical Records, Maintenance, Facility Assistant, Business Office, Environmental Supervisor, Rehab Supervisor, and the facility secretary. The team reviewed the alleged deficient practices and the plans of action established to correct practices, which included education content, policy updates, and required accountability. Following the meeting, the Administrator and Medical Director met and reviewed the alleged deficient practices and the plan of action established to correct the practices, which included education content, policy updates, and required accountability. 6. The Director of Nursing, Assistant Director of Nursing, or Nursing Supervisor will review new fall occurrences, no later than the next business day, to ensure that appropriate immediate interventions were implemented based on identified root cause and that current fall care plan interventions are provided in accordance with the written plan of care. Any noted non-compliance with appropriate interventions being provided in accordance with the written plan of care will result in re-education of staff assigned to the resident at the time of the identified non-compliance and may include disciplinary action up to and including termination for non-compliance with providing care in accordance with the written plan of care. The holidays and weekends will be covered by the Nursing Supervisors. This process began 09/17/18 and will continue until next annual relicensure survey. 7. A fall Quality Assurance Performance Improvement (QAPI) sub-committee, consisting of Director of Nursing and/or Assistant Director of Nursing, Unit Coordinator, Therapy Representative, Licensed Nurse, and Nurse Aide will meet weekly and review residents at high risk (fall score >60), residents with multiple falls, and residents with falls in the past 30 days to ensure that appropriate immediate interventions were implemented based on identified root cause and that current fall care plan interventions are provided in accordance with the written plan of care. This will begin 09/21/18 and will continue until our next facility annual relicensure survey. 8. An Ad-Hoc QA meeting was held with the Medical Director, Director of Nursing, and Administrator on 09/17/18 to review allegation of compliance. Fall care plan interventions for residents with any new falls from 09/18/18 and forward will be reviewed to ensure compliance in accordance with the written plan of care in daily clinical meeting and by Weekend Nursing Supervisor until the next annual relicensure survey. 9. With any new resident falls, care plan intervention audits will be conducted starting 09/17/18 and be completed for the next four weeks. The disciplines to provide the audits will be the Director of Nursing, Assistant Director of Nursing, Unit Coordinators, RN Supervisors, Staffing Coordinator, Social Services, Therapy, MDS staff, Lead CNAs and RSA staff. These audits will be conducted weekly after the first four weeks. The process will be ongoing until the annual relicensure survey. Results of fall care plan implementation reviews will be reviewed by QAPI committee weekly for a minimum of four weeks and then at least quarterly until our next annual relicensure survey. Further recommendations on additional corrective actions to maintain compliance. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Based on review of the current care plan for Resident #1 it was determined the care plan contained revisions as of 09/17/18 with more appropriate interventions to include resident to be laid down promptly after meals, provide 1:1 care from 09/05/18 at 2:00 PM through 09/06/18 at 6:30 AM, offer activity table when up in chair, check for placement and function of alarms every shift and if not functioning properly, notify charge nurse for replacement. 2. Review of the facility's falls investigation sheets revealed all residents with falls in the last ninety days had appropriate interventions for each fall and more appropriate root cause determination (not just overestimating abilities). Record reviews for Residents #4, #5, #6, #7, #8, and #9 revealed no concerns with the fall's investigation related to root cause interventions. 3. Review of sheets signed by staff attending the training revealed all staff except those on vacation, or FMLA (Family Medical Leave Act) were inserviced and provided fall scenarios training on 09/14/18 by the Administrator and DON. Observation on 09/24/18 at 3:00 PM revealed policies on fall prevention protocol, investigation, protocol on security checks and care plans were in a binder at the nursing station. Observation on 09/24/18 at 4:00 PM revealed a notification of mandatory training at the time clock. Review of QA Meeting Notes dated 09/14/18, revealed members were informed of the Immediate Jeopardy tags and what they entailed,

Based on observation, interview, record review, facility policy and procedure review; and, review of the Hospital emergency room Record and Hospital Discharge Record, it was determined the facility failed to provide services in accordance with each resident's written plan of care for one (1) of five (5) sampled residents (Resident #1). On 08/11/15, the facility assessed and care planned Resident #1 to require the assistance of two (2) staff for transfers; however, on 08/17/15, CNA #1 transferred the resident without the assistance of another staff; the resident's left leg caught underneath the bed and twisted. Resident #1 sustained a fractured tibia and was non-weight bearing for two (2) weeks which caused the resident's rehabilitation and discharge back into the community to be delayed. The findings include: Review of the facility's policy titled, Resident Care Plan, dated 08/2014, revealed the Interdisciplinary Team will develop a comprehensive resident care plan from information on the Minimum Data Set (MDS) Assessment, the resident's medical record and observations made while interviewing the resident. Staff should check the plan of care daily for updates. Staff not following the plan of care will receive appropriate counseling up to and/or including suspension and/or termination. Record review revealed the facility admitted Resident #1 on 08/11/15, after a forty-nine (49) day stay in the hospital with [DIAGNOSES REDACTED]. Review of the Initial Minimum Data Set (MDS) Assessment, dated 08/18/15, revealed the facility assessed Resident #1's cognition as cognitively intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Further review of the Initial MDS Assessment, dated 08/18/15 and review of the Comprehensive Care Plan and MDS Kardex Report, dated 08/11/15, revealed Resident #1 was assessed and care planned to require the extensive assistance of two (2) staff for transfers. Interview with CNA #1, on 09/10/15 at 8:18 AM, revealed she responded to Resident #1's call light on the evening of 08/17/15 and the resident requested to be assisted to bed. CNA #1 stated she asked the resident's spouse how the resident was assisted and the spouse stated, By two (2) people and she (spouse) would help with the transfer. CNA #1 revealed she did not want the resident's spouse to feel she was ignoring what he/she had told her, so she proceeded to attempt to transfer the resident. However, when she attempted to transfer the resident the resident's spouse did not assist her and she struggled to place the resident on the bed so the resident would not fall. CNA #1 said the spouse told her the resident's left leg was caught under the bed and twisted; the resident never complained of pain. The CNA stated she did not use a gait belt during the transfer and she did not report the incident to the nurse because she was not aware the resident had sustained any injury. CNA #1 stated there were three (3) sources to determine how a resident was to be cared for, which included the care plan, the kiosk and the nurse on duty. The CNA stated she did not use any of these forms of communication before attempting to transfer the resident alone. Review of a Nursing Progress Note, dated 08/18/15 at 11:00 AM, revealed Resident #1 complained of increased left knee pain. Resident #1 stated, When being put to bed last night, my knee extended backward and has hurt some since. The resident's left knee was noted to be warm, red and swollen. The Physician was notified and orders were received to send the resident to the hospital ER for evaluation and treatment, if indicated. Review of the Hospital emergency room Record and Hospital Discharge Record, dated 08/18/15, revealed on 08/18/15 the resident complained of increased knee pain since sustaining a twisting injury and a hyperextension of the knee when his/her leg was caught under the bed on the evening of 08/17/15. The ER Physician documented that the resident's radiological study (Computerized Tomography {CT} Scan) revealed a displaced [MEDICAL CONDITION] left tibia medial aspect with osteochondral [MEDICAL CONDITION] plateau and loose bodies and a joint effusion. Resident #1 was discharged back to the facility on [DATE] with a knee immobilizer and orders to continue the brace with non-weight bearing to the left lower extremity for two (2) weeks. Interview with LPN/Charge Nurse #4, on 09/10/15 at 1:13 PM; Physical Therapy Assistant (PTA), on 09/10/15 at 11:10 AM; and, the Unit Coordinator on Station Two (2) and Three (3), on 09/09/15 at 7:37 AM, revealed Resident #1 was in bed on 08/18/15 complaining of increased pain to the left knee rating his/her pain at an eight (8) on a ten (10) point pain scale. Resident #1's knee was noted to be swollen, red and hot to touch with decreased range of motion. Further interview with LPN/Charge Nurse #4 revealed the resident stated his/her knee had been hurting more since the evening before when one (1) staff member transferred him/her back to bed and caught his/her leg under the bed and twisted it. LPN/Charge Nurse #4 contacted the physician and the resident was sent to the ER. Resident #1 returned from the ER the same day with orders for a leg brace and to be non-weight bearing for two (2) weeks. The resident required an increased amount of assistance after the injury and continued to take pain medications which he/she would call for as needed. They stated the staff should have followed the care plan, which required the extensive assistance of two (2) staff for transfers. Observation of Resident #1, on 09/10/15 at 10:55 AM, revealed he/she was in a therapy session with the PTA. The resident was noted to have a knee hinged immobilizer to the left knee and he/she required extensive assistance with transfers and the assist of a walker. In addition, staff used a gait belt with transfers to a wheelchair which was approximately five (5) steps. Interview with the Certified Occupational Therapy Assistant (COTA), on 09/10/15 at 11:20 AM, revealed Resident #1 sustained a decline in his/her therapy routine related to the resident having restriction of not being able to bear weight on the left leg for two (2) weeks. He stated he expected the nursing staff to follow the Physical and Occupational Therapy evaluation and to use the care plan and kardex as their guide for transfers. He stated this resident required moderate to maximum assistance for transfers. Interview with Resident #1's Primary Care Physician, on 09/11/15 at 10:32 AM, revealed the resident had just spent forty-nine (49) days in the hospital related to a septic left knee infection from a steroid injection he/she received. He stated that while in the hospital, the resident became very weak and malnourished causing him/her to require rehabilitation at this nursing facility. He stated the [MEDICAL CONDITION] knee has caused a major setback for this resident and has delayed his/her rehabilitation potential which has caused his/her discharge back into the community to be on hold at this time. He further stated the fracture should not have happened if the proper techniques had been used that were safe for this resident. Interviews on 09/10/15 with CNA #2 at 1:45 PM, CNA #3 at 1:58 PM, CNA #4 at 2:10 PM, and CNA #5 at 2:25 PM revealed all staff should follow the care plan. CNA #3 and CNA #4 stated they have cared for Resident #1 many times and have always transferred the resident with two (2) staff assistance. The CNAs further stated when a staff did not provide the assessed amount of persons needed for a transfer, they would be concerned the resident could fall or sustain an injury. Interview with the Director of Nursing (DON), on 09/09/15 at 7:15 AM, revealed on 8/17/15, CNA #1 transferred Resident #1 by herself without the assistance of another staff member per the resident's care plan. The DON stated CNA #1 said she asked the spouse how many (persons) it took to transfer the resident and the spouse told her two (2) persons but that she would help her. Further interview with the DON revealed CNA #1 admitted she did not follow the care plan. The DON stated she expected staff to follow the care plan related to the amount of staff needed for care.

Based on observation, interview, record review, hospital emergency room record review, and the facility's policy and procedure review, it was determined the facility failed to ensure adequate supervision and an assistive device to prevent accidents was provided for one (1) of five (5) sampled residents (Resident #1). The facility admitted Resident #1 for rehabilitation due to weakness after being in the hospital for forty-nine (49) days for an Acute Septic Left Knee. On 08/17/15 at 8:00 PM, Certified Nurse Aide (CNA) #1 failed to transfer Resident #1 from the chair to the bed with a gait belt and the assistance of another staff, as required by the care plan. Resident #1's left leg got caught underneath the bed and twisted during the transfer. CNA #1 failed to report the incident to her supervisor so the resident could be assessed for injury. On the morning of 08/18/15, Resident #1 complained of pain and his/her knee was noted to be red, swollen and hot to touch. Resident #1 had sustained a fracture of the left tibia which required the resident to be non-weight bearing for two (2) weeks and delayed the resident's rehabilitation so the resident could be discharged back to the community. The findings include: Review of the facility's policy titled, Resident Care Plan, dated 08/2014, revealed the interdisciplinary team will develop a comprehensive resident care plan from information on the Minimum Data Set (MDS) Assessment, the resident's medical record and observations made while interviewing the resident. Staff should check the plan of care daily for updates. Staff not following the plan of care will receive appropriate counseling up to and/or including suspension and/or termination. Review of the facility's policy titled, Nursing Assistant Worksheets, dated 08/19/15, revealed all services are furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Review of the facility's policy titled, Gait Belt, dated 07/2013, revealed nursing staff will use gait belts for residents needing one (1) or more staff assistance in transfer and ambulation, unless contraindicated. Review of the facility's Certified Nursing Assistant (CNA) Organizational Expectations, dated 07/14/15, revealed the CNA shall promote a culture of safety for residents and employees through proper identification, reporting, documentation and prevention. Review of the facility's policy titled, Incident /Reportable Events Reporting, dated 03/2015, revealed the person discovering an incident or having the primary responsibility for an incident occurring should initiate a report of the incident. Reporting should be completed for incident/events that any actual or potential physical injury resulting from an accident on the promises. Record review revealed the facility admitted Resident #1 on 08/11/15 after a forty-nine (49) day stay in the hospital with [DIAGNOSES REDACTED]. Review of the Initial Minimum Data Set (MDS) Assessment, dated 08/18/15, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. In addition, the facility assessed Resident #1 required extensive assistance of two (2) staff for transfers. Review of the Comprehensive Care Plan, dated 08/11/15, revealed Resident #1 had an Activities of Daily Living (ADL) self-care performance deficit related to activities intolerance and an intervention for the assistance of two (2) persons with a knee brace and non-weight bearing to the left leg. Review of the MDS Kardex Report, dated 08/11/15, revealed ADLs for transfer required extensive assistance of two (2) persons. Interview with CNA#1, on 09/10/15 at 8:18 AM, revealed she responded to Resident #1's call light on the evening of 08/17/15 and the resident requested to be assisted to bed. She stated she asked the resident's spouse how the resident was assisted and the spouse stated two (2) people and he/she would help with the transfer. During further interview, CNA #1 stated she did not want the spouse to feel she was ignoring what he/she had said, so she proceeded to attempt to transfer the resident. She stated she attempted to transfer the resident, but the resident's spouse offered no assistance and she struggled to place the resident on the bed so the resident would not fall. CNA #1 said the spouse said the resident's left leg was caught under the bed and the resident's leg was twisted. She stated she did not know the resident's leg had become trapped under the bed, as the resident never complained of pain. CNA #1 stated she did not use a gait belt during the transfer and she did not report the incident to the nurse because she was not aware the resident had sustained any injury. She further stated, she should have followed the facility's policy and used the gait belt. She also stated there were three (3) sources to determine how a resident is to be cared for which included the care plan, the Kiosk and the nurse on duty. CNA #1 stated she was told by LPN #4 that Resident #1 required the assistance of two (2) staff for transfers. Review of CNA #1's Lift Belt Agreement, revealed CNA #1 signed and acknowledged that she had received proper training on the use of a gait belt and had received a copy of the facility's policy on the use of gait belts and agreed to follow this policy which was to use the gait belt for residents needing one (1) or more staff assistance in transfers and ambulation. Review of the Nursing Progress Note, dated 08/18/15 at 11:00 AM, revealed Resident #1 complained of increased left knee pain; he/she stated, When being put to bed last night, my knee extended backward and has hurt some since. The resident's left knee was noted to be warm, red and swollen. The Physician was notified and orders were received to send the resident to the Hospital ER for evaluation and treatment, if indicated. Interview with the Physical Therapy Assistant (PTA), on 09/10/15 at 11:10 AM, revealed on the morning of 08/17/15, Resident #1 was in bed complaining of increased pain to the left knee rating his/her pain at an eight (8) on a ten (10) point pain scale. The PTA stated when she examined the resident's knee she observed the knee was swollen, red and hot to touch with decreased range of motion. The PTA revealed the resident stated his/her knee had been hurting more since the evening before when one (1) staff member transferred him/her back to bed and caught his/her knee under the bed and twisted it. The PTA stated she called the Physical Therapist (PT) to come and evaluate the knee and was assisted by the nurse. Further interview revealed the PTA stated the Physician was notified and orders were received to transfer the resident to the emergency room (ER) for further evaluation. Interview with the Licensed Practical Nurse (LPN)/Charge Nurse #4, on 09/09/15 at 12:15 PM, revealed Resident #1 had placed his/her call light on and asked to be assisted to bed on the evening of 08/17/15. LPN #4 stated she informed the resident he/she required the assistance of two (2) staff to assist him/her to bed and she would get two (2) CNAs to assist him/her as soon as they were free. LPN #4 said she informed CNA #1, the resident was requesting to be assisted to bed and he/she needed the assistance of two (2) staff members. Further interview with LPN/Charge Nurse #4, on 09/10/15 at 1:13 PM, revealed she expected staff to follow the care plan when it stated assist of two (2) staff. LPN #4 stated she was called by PT to come in and evaluate the resident's leg on 08/18/15. She contacted the Physician and received orders to send the resident to the ER for evaluation. LPN #4 stated the resident returned from the ER the same day with orders for a leg brace and non-weight bearing for two (2) weeks. LPN #4 stated she expected her staff to know a resident's care plan, follow the care plan or ask a nurse if unclear. LPN #4 stated the resident required an increased amount of assistance after the injury and continued to take pain medications which he/she would call for as needed. LPN #4 stated she considered this event to be an unusual event and it should have been reported to the Charge Nurse as soon as it occurred so the nurse could have completed an assessment of the resident to determine if he/she had been injured. Interview with the Unit Coordinator on Station Two (2) and Three (3), on 09/09/15 at 7:37 AM, revealed Resident #1 was admitted with a septic left knee due to steroid injection prior to admission. She stated CNA #1 was pivoting the resident to bed without the use of a gait belt and the resident's leg went up under the bed and his/her knee twisted backward on 08/17/15. The Unit Coordinator stated that prior to this incident, the resident was able to weight bear on that leg. She stated the Comprehensive Care Plan identified the resident required two (2) person assistance with transfers and she expected CNA #1 to have asked another staff to assist her with the transfer of Resident #1. She stated the resident did not immediately complain of pain; however, the next day the PTA noted the resident's knee was swollen, redden and hot to touch. She stated the Physician was notified and the resident was sent to the ER for evaluation and the resident was identified as having a fracture of the left tibia. She stated the policy of the facility was all residents that required assistance with ambulation or transfers must be assisted by the staff using a gait belt. Additionally, she stated any incident or event affecting a resident must be reported to the Charge Nurse immediately. Review of the Hospital emergency room Record, dated 08/18/15, revealed on 08/18/15 the resident complained of increased knee pain since getting his/her leg caught under the bed on the evening of 08/17/15. The Physician documented the resident reported he/she sustained a twisting injury when his/her leg became caught under the bed and his/her leg twisted and hyper-extended the knee on 08/17/15 at 8:00 PM. Further review revealed the resident complained of pain with weight bearing. The ER Physician further documented a radiological study (CT Scan) was performed which showed a displaced fracture of the proximal left tibia medial aspect with osteochondral fracture of the tibia plateau and loose bodies and a joint effusion. Review of the Hospital ER Discharge Record dated 08/18/15, revealed a knee immobilizer was placed on the resident and the resident returned to the the facility with orders to continue the brace, with non-weight bearing to the left lower extremity for two (2) weeks. Review of the Orthopedic physician progress notes [REDACTED]. The Surgeon continued the treatment plan of non-weight bearing for two (2) weeks. Observation of Resident #1, on 09/10/15 at 10:55 AM, revealed he/she was in a therapy session with the PTA. He/she was noted to have a knee hinged immobilizer to the left knee and required extensive assistance with transfers and the assist of a walker. In addition, staff used a gait belt with the transfer to a wheelchair which was approximately five (5) steps. Interview with the Certified Occupational Therapy Assistant (COTA), on 09/10/15 at 11:20 AM, revealed Resident #1 sustained a decline in his/her therapy routine related to the resident having restriction of not being able to bear weight on the left leg for two (2) weeks. He stated he expected the nursing staff to follow the Physical and Occupational Therapy evaluation and to use the care plan and kardex as their guide for transfers. He stated this resident required moderate to maximum assistance for transfers. Interview with CNA #5, on 09/10/15 at 2:25 PM, revealed she was working on 08/17/15 but was never asked to assist with transferring Resident #1 to bed. She stated staff should check the care plan daily for changes, follow it and if there are questions the Charge Nurse should be notified. She stated gait belts should be used on all residents with transfers and this has always been the facility's policy. Interview with CNA #2, on 09/10/15 at 1:45 PM, revealed all staff should follow the care plan and staff should use a gait belt with anyone that requires assistance with transfers. She stated she would be concerned of an injury or fall if a resident was transferred by one person when they required two (2) persons. Interview with CNA #3, on 09/10/15 at 1:58 PM, revealed a care plan should always be followed and if the family member tried to dictate the care of the resident, the care plan should still be the guide for the resident's care. She stated she had cared for Resident #1 many times and had always transferred him/her with two (2) person assist. CNA #3 stated she had never witnessed anyone transferring him/her alone or without a gait belt. Interview with CNA #4, on 09/10/15 at 2:10 PM, revealed she had cared for Resident #1 and that he/she has always been an assist of two (2) person. She stated the care plan should be followed without exception and a gait belt should be used on every resident with transfers and ambulation. Interview with the Director of Nursing (DON), on 09/09/15 at 7:15 AM, revealed on 08/17/15, CNA #1 transferred Resident #1 by herself without a gait belt per facility policy and without the assistance of another staff member per the resident's care plan. The DON revealed CNA #1 admitted she did not follow the care plan or facility policy and, she expected staff to follow the care plan related to the amount of staff needed for care and to follow the facility's policy and use a gait belt for all transfers. In addition, she stated any incident or unusual event involving a resident should be reported to the Charge Nurse immediately so an investigation could be completed. Interview with Resident #1's Primary Physician, on 09/11/15 at 10:32 AM, revealed Resident #1 had spent forty-nine (49) days in the hospital related to a septic left knee infection from a steroid injection he/she received. The Physician stated while in the hospital, the resident became very weak and malnourished causing him/her to require rehabilitation at this nursing facility. The Physician revealed the fracture of the left knee caused a major setback for this resident and has delayed the resident's rehabilitation potential which has caused his/her discharge back into the community to be on hold at this time. The Physician further stated the fracture would not have happened if the proper techniques had been used that were safe for this resident.

Based on interview and review of the facility's Administrator's Job Duties, it was determined the facility failed to ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to ensure a safe environment by allowing the alleged perpetrators to continue to work with residents after an allegation of abuse was made for one (1) of eight (8) sampled residents (Resident #1). On 04/17/14, Resident #1 accused staff of pulling his/her hand/arm, slapping him/her across the face, and pulling his/her ear and hair during a lunch meal. Additionally, he/she accused staff of yelling at him/her. Review of the facility's investigation, dated 04/17/14, revealed the alleged perpetrators were not suspended pending completion of the investigation, as per policy, nor were they removed from duty on the day of the incident. Certified Nursing Assistants (CNA) #1, CNA #2 and CNA #3 were allowed to work a full shift on 04/17/14, 04/18/14, and 04/21/14. The facility also failed to conduct an investigation which included assessment of other residents to ensure no abuse had occurred. The facility's failure to ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 04/24/14 and was determined to exist on 04/17/14. Refer to F225 and F226. The findings include: Review of the facility's policy and procedure titled, "Resident Abuse/Mistreatment, revised 11/2012, revealed "The supervisor should ask the person in which the allegation was made against to leave the facility immediately pending an investigation." Review of the Administrator's job description, (no date), revealed the Administrator promotes culture of safety for patients and employees through proper identification and prevention. Additionally, she assures that errors made by staff are investigated thoroughly and results are documented. Interview with Resident #1, on 04/22/14 at 10:40 AM, revealed on the day of the alleged incident (04/17/14), he/she was wanting to eat and someone kept putting a spoon in his/her mouth with nothing on it. The resident stated "They" slapped him/her across the right side of the face. Further interview revealed Resident #1 felt he/she had been mistreated a lot but this was the "first time lately". Resident #1 also stated staff would move his/her water pitcher out of reach as a joke. Interview with the Administrator, on 04/24/14 at 9:25 AM, revealed she couldn't suspend everyone in the building as Resident #1 was blind and could not identify any of the CNAs in the room so she talked to all the CNAs on duty that were in the resident's room. She stated before she made her decision not to suspend any staff pending the investigation, she checked the employees' files and none of the CNAs being accused had ever been written up for anything. Additionally, she revealed she had revised the abuse policy on 04/17/14 to state "If a complaint is basic in nature then after physical examination of resident, administration may choose not suspend any party." The Administrator stated she changed the policy because there was no way she could suspend all three (3) CNAs, who had been in the resident's room when there was no physical evidence the resident had been abused. **The State Survey Agency validated the corrective action taken by the facility as follows: Review of the facility's investigation, on 05/05/14, revealed the facility initiated an internal investigation on 04/17/14 (date of alleged abuse) and continued the investigation through 04/21/14. Review of the policy titled "Resident Abuse/Mistreatment", on 05/05/14, revealed the policy was updated to include the following addendums: A. A Physical assessment of resident and/or residents who alleged abuse and /or mistreatment will be completed. A Psychosocial assessment of resident and/or residents show signs/symptoms they were allegedly abused and/or mistreated. B. All residents under the care of the alleged perpetrator will be assessed physically and psycho-socially. Resident #1 was assessed on 04/17/14 with no signs of abuse or injury noted. Review of the skin assessment dated [DATE] revealed no signs of abuse. Review of facility's policies titled "Employment Practices" and " Resident Vulnerability Investigation" on 05/05/14, revealed they were reviewed and revised in April 2014. Review of skin assessments on all residents on Units 1, 2, 3 and 4, on 05/05/14, revealed the residents had skin assessments completed from 04/21/14-04/25/14 with no concerns noted. On 04/25/14 all residents on each unit received a psychosocial assessments from one of the three (3) Social Workers in the building. Review of the sign in log for Abuse and Neglect training dated 04/30/14 provided by the Purchase District Ombudsman, on 05/05/14 revealed it included signatures of the Administrator, DON, and the Ombudsman as having received training related to reporting abuse and/or neglect, when to suspend suspected employees, and instruction on completing an investigation. Review of competency exams and inservice logs related to abuse and neglect, on 05/05/14, revealed two-hundred and three (203) staff including the DON, Administrator, Registered Nurses, Unit Coordinators, Clinical Educator, ADON, Social Workers and CNAs received training on when and to whom to report abuse as well as the different types of abuse between the dates of 04/30/14 and 05/04/14. Additionally, no employee would be allowed to return to work before receiving the inservice related to abuse and /or neglect. The DON and the Administrator initiated a new facility form titled "Problem Resolution/OIG LOG" dated 2014, to monitor daily complaints, timely reporting and investigating of all abuse/mistreatment reporting. Data is to be collected by the Unit Coordinators, Social Services, and Nursing Administration. The DON is to report finding in the QA meetings. A new Measurement and Assessment Report for performance improvement dated 04/14 was implemented for tracking and trending abuse/neglect. Review of the forms revealed the facility had implemented them and was monitoring the results in the morning meeting. Interview with Registered Nurse (RN) #1, (Unit Coordinator), on 05/05/14 at 4:56 PM, revealed she was in-serviced by the DON. She stated once an allegation of abuse has been made the alleged perpetrator was to be removed from duty. A head to toe assessment was to be completed on the victim and every resident that was under the care givers care will be assessed by nursing and social services. (Nursing can do the Social Services assessment as well). Social Services will contact the proper authorities like Adult Protective Services, Office of Inspector General, etc. Additionally, she stated she would contact the family, physician, DON, and Administrator. She stated a competency exam was given related to the different types and signs of abuse, whom to report to, and when reporting was to be done. Following the chain of command was also discussed. Interview with LPN #1, (MDS Coordinator), on 05/05/14 at 5:05 PM, revealed she was inserviced on the four (4) types of abuse and what to do if abuse occurred, who to notify, when to notify as well as how to identify signs and symptoms of abuse. She stated she took a competency exam which included reporting abuse and following the chain of command. Additionally, she stated if abuse was suspected she would remove the caregiver, assure the resident was safe, assess for injury with the number one (1) priority being resident safety. Interview with CNA #1, on 05/05/14 at 5:07 PM, revealed the House Supervisor provided his inservice on abuse. He stated he was taught what he should do when abuse happens, who he should report to, and when to report. Additionally, he stated if he was a witness to abuse he would report it immediately. He stated he was given a competency exam and was taught on the different types of abuse. Interview with LPN #2, on 05/05/14 at 5:12 PM, revealed she was given a test related to abuse and was inserviced on the types of abuse, how to follow the chain of command, remove the resident from danger, and when to remove the caregiver from direct resident care. She stated she was to report to the allegation of abuse to the supervisor and send the suspected abuser home for a three (3) day suspension pending investigation. Additionally, she was to report to the on call nurse and Social Services as well as call the Ombudsman if no one else was available. Interview with CNA #2, on 05/05/14 at 5:21 PM, revealed she was in-serviced to report abuse immediately and how to notice changes in the resident's behaviors. She stated she was told to report to the Charge Nurse and if she identified physical changes like bruising or skin tears then she would report that as well. She revealed her first priority would be to get the resident safe and report abuse immediately. Additionally, she stated she was given a test after the inservice related to abuse and neglect. Interview with the Dietary Supervisor, on 05/05/14 at 5:34 PM, revealed she was inserviced on reporting abuse, signs of abuse, and to whom to report abuse. She stated she would go to the Administrator or DON right away if she witnessed abuse. Additionally, she stated she would say something to the person doing the abusing and try to get the resident to safety. She stated she took a post test as well. Interview with an Environmental Service Aide, on 05/05/14 at 5:43 PM, revealed he was inserviced to report abuse and to whom to report it. He stated he would report suspected abuse immediately. Additionally, he stated he was given a post test after the inservice.

Based on interview, record review, and review of the facility's "Resident Abuse/Mistreatment" policy and procedure, it was determined the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of one (1) of eight (8) sampled residents (Resident #1). On 04/17/14, Resident #1 accused staff of putting an empty spoon in his/her mouth, pulling his/her hand/arm, slapping him/her across the face, and pulling his/her ear and hair during a lunch meal. Additionally, he/she accused staff of yelling at him/her. Review of the facility's investigation, dated 04/17/14, revealed the facility failed to follow their Abuse/Mistreatment Policy related to suspending the alleged perpetrators pending the completion of the investigation and conducting a thorough investigation by assessing other residents to determine if there were residents with sign/symptoms of abuse. The facility's failure to implement its Resident Abuse/Mistreatment policy has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/22/14 and determined to exist on 04/17/14. The findings include: Review of the facility's policy and procedure, titled "Resident Abuse/Mistreatment", last revised 11/2012, revealed, "Residents have the right to be free from forms of abuse, neglect, mistreatment, or misappropriation of property. The supervisor should ask the person in which the allegation was made against to leave the facility immediately pending an investigation." Additionally, during the investigation of abuse, the resident will be closely monitored and notification may be made to the following by the Social Worker, Adult Protective Services, Division of Protection and Permanency Centralized Intake, and Office of Inspector General. The investigation will include the name of the resident involved, date, time, and place of the alleged incident, where the incident occurred, the name(s) of the person(s) or description of the person involved in the incident, name of any known witnesses to the incident, and other pertinent information needed. Physical and psychosocial assessments for the resident(s) who were under the care of the alleged perpetrator would be conducted during the investigation. Record review revealed the facility admitted Resident #1, on 02/06/12, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 02/14/14, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of twelve (12), which indicated the resident was interviewable. Interview with Resident #1, on 04/22/14 at 10:40 AM, revealed he/she was wanting to eat and someone kept putting a spoon in his/her mouth with nothing on it and "They" slapped him/her across the right side of the face but not hard enough to cause redness. Further interview revealed Resident #1 felt he/she had been mistreated a lot but this was the first time lately. Additionally, Resident #1 accused staff of moving the water pitcher out of reach as a joke. Review of the facility's investigation, dated 04/17/14 and completed on 04/21/14, revealed Resident #1 had been assessed immediately by Licensed Practical Nurse (LPN) #1, Unit Coordinator, after the alleged incident occurred and there were no physical signs of abuse noted. However, further review revealed there was no documented evidence the alleged perpetrators were suspended and an investigation conducted to determine if any other residents had been abused per the facility's policy and procedure. Review of the alleged perpetrators punch in and out times revealed Certified Nursing Assistants (CNA) #1, CNA #2 and CNA #3 were allowed to work a full shift on 04/17/14, 04/18/14, and 04/21/14. Interview with LPN #1, on 04/23/14 at 11:00 AM, revealed she assessed Resident #1 on 04/17/14 immediately after CNA #2 told her the resident wanted to speak with her and there were no physical signs of abuse to Resident #1's face, neck, arm, or chest area. She stated the resident never identified any staff by name nor if the staff accused were male and/or female. Additional interview, on 04/24/14 at 11:10 AM, revealed LPN #1 stated she did not assess other residents for sign/symptoms of abuse because Resident #1 had no signs of abuse and the Director of Nursing (DON) did not instruct her to assess other residents. Interview with the Director of Nursing (DON), on 04/24/14 at 9:25 AM, revealed there was nothing to pinpoint one (1) CNA in particular in the abuse allegation. Therefore no one was suspended, per the facility's policy, because they would have had to be three (3) CNAs suspended pending the investigation. Additionally, she stated there was no reason to complete any other resident skin assessments because there was no injury to Resident #1. Interview with the Administrator, on 04/24/14 at 9:25 AM, revealed Resident #1 was blind and couldn't identify the CNAs therefore, they talked to all three (3) CNAs that had been in the room. Additionally, she stated, "I realize when I didn't suspend them, I wasn't following my own policy". She stated before she made her decision not to suspend anyone, she reviewed the employees' files for the CNAs involved in the allegation and none of them had ever been written up for anything. She stated, "I revised the policy to say that it was her decision as to whether or not to suspend any employee pending investigation of a complaint". **The facility implemented the following actions to remove the Immediate Jeopardy: Resident #1 was admitted to the facility on [DATE] and currently resides at the facility. The facility initiated an internal investigation on 04/17/14 (date of alleged abuse) and continued the investigation through 04/21/14. A physical assessment was conducted for Resident #1 on 04/17/14 by the Station Three Unit Coordinator and a Psychosocial interview was conducted on 04/17/14 by the Social Worker. A care conference was scheduled for 04/22/14. 1. Review of the policy titled "Resident Abuse/Mistreatment" revealed the policy was updated in 2014 and addendums were added were as follows: A. Physical assessment of resident and/or residents who alleged abuse and /or mistreatment. Psychosocial assessment of resident and/or residents who show they were allegedly abused and/or mistreated. B. All residents under the care of the alleged perpetrator will be assessed physically and psycho-socially. 2. Resident #1 was assessed on 04/17/14 with no signs of abuse or injury noted. Review of the skin assessment, dated 4/17/14, revealed no signs of abuse. 3. Skin assessments were completed on all residents on Units 1, 2, 3 and 4 from 04/21/14-04/25/14 with no concerns noted. On 04/25/14, all residents on each unit received a psychosocial assessments from one (1) of the three (3) Social Workers in the building. 4. Abuse and Neglect training was provided on 04/30/14 by the Purchase District Ombudsman, which included signatures of the Administrator, DON, and the facility Ombudsman. 5. A Resident Vulnerability Assessment was implemented in April 2014 to assess residents for changes in behaviors and mood placing them in a potential abuse situation. 6. Facility policies titled "Employment Practices" and "Resident Vulnerability Investigation" were reviewed and revised in April 2014. 7. The Nursing Director and Administrator were inserviced on resident rights, bullying and proper abuse reporting by the facility Ombudsman on 04/30/14. The Nursing Director provided inservicing and Competency exams to the Registered Nurses, Unit Coordinators, Clinical Educator, Social Workers and Associate Director of Nursing on 04/30/14, on appropriate abuse reporting, the new revised resident abuse policy, definitions of abuse, neglect, misappropriation of property and the new Vulnerability policy and tool to follow-up on investigations at the facility. The Nursing Director, Registered Nurses, Unit Coordinators, Clinical Educator, and Associate Director of Nursing provided inservicing and competency exams to all two-hundred and three (203) staff related to abuse and neglect related to when and to whom to report abuse as well as the different types of abuse between the dates of 04/30/14 and 05/04/14. Additionally, no employee would be allowed to return to work before receiving the inservice related to abuse and /or neglect. 8. All training is completed on the Health Stream Tracker computer system and when inservices are planned for the future the system places the dates on the calendars. Ex; Quarterly in-services will be documented on a calendar and a reminder given for the date of the in-service. The monitoring of education requirements for new employees is to begin after 05/04/14. 9. The DON and the Administrator initiated a new facility form titled "Problem Resolution/OIG LOG" dated 2014, to monitor daily complaints, timely reporting and investigating of all abuse/mistreatment reporting. Data is to be collected by the Unit Coordinators, Social Services, and Nursing Administration. The DON is to report findings in the QA meetings. A new Measurement and Assessment Report for performance improvement dated 04/14 was implemented for tracking and trending abuse/neglect. **The State Survey Agency validated the corrective action taken by the facility as follows: Review of the facility's investigation, on 05/05/14, revealed the facility initiated an internal investigation on 04/17/14 (date of alleged abuse) and continued the investigation through 04/21/14. Review of the policy titled "Resident Abuse/Mistreatment", on 05/05/14, revealed the policy was updated to include the following addendums: A. A Physical assessment of resident and/or residents who alleged abuse and /or mistreatment will be completed. A Psychosocial assessment of resident and/or residents show signs/symptoms they were allegedly abused and/or mistreated. B. All residents under the care of the alleged perpetrator will be assessed physically and psycho-socially. Resident #1 was assessed on 04/17/14 with no signs of abuse or injury noted. Review of the skin assessment dated [DATE] revealed no signs of abuse. Review of facility's policies titled "Employment Practices" and " Resident Vulnerability Investigation" on 05/05/14, revealed they were reviewed and revised in April 2014. Review of skin assessments on all residents on Units 1, 2, 3 and 4, on 05/05/14, revealed the residents had skin assessments completed from 04/21/14-04/25/14 with no concerns noted. On 04/25/14 all residents on each unit received a psychosocial assessments from one of the three (3) Social Workers in the building. Review of the sign in log for Abuse and Neglect training dated 04/30/14 provided by the Purchase District Ombudsman, on 05/05/14 revealed it included signatures of the Administrator, DON, and the Ombudsman as having received training related to reporting abuse and/or neglect, when to suspend suspected employees, and instruction on completing an investigation. Review of competency exams and inservice logs related to abuse and neglect, on 05/05/14, revealed two-hundred and three (203) staff including the DON, Administrator, Registered Nurses, Unit Coordinators, Clinical Educator, ADON, Social Workers and CNAs received training on when and to whom to report abuse as well as the different types of abuse between the dates of 04/30/14 and 05/04/14. Additionally, no employee would be allowed to return to work before receiving the inservice related to abuse and /or neglect. The DON and the Administrator initiated a new facility form titled "Problem Resolution/OIG LOG" dated 2014, to monitor daily complaints, timely reporting and investigating of all abuse/mistreatment reporting. Data is to be collected by the Unit Coordinators, Social Services, and Nursing Administration. The DON is to report finding in the QA meetings. A new Measurement and Assessment Report for performance improvement dated 04/14 was implemented for tracking and trending abuse/neglect. Review of the forms revealed the facility had implemented them and was monitoring the results in the morning meeting. Interview with Registered Nurse (RN) #1, (Unit Coordinator), on 05/05/14 at 4:56 PM, revealed she was in-serviced by the DON. She stated once an allegation of abuse has been made the alleged perpetrator was to be removed from duty. A head to toe assessment was to be completed on the victim and every resident that was under the care givers care will be assessed by nursing and social services. (Nursing can do the Social Services assessment as well). Social Services will contact the proper authorities like Adult Protective Services, Office of Inspector General, etc. Additionally, she stated she would contact the family, physician, DON, and Administrator. She stated a competency exam was given related to the different types and signs of abuse, whom to report to, and when reporting was to be done. Following the chain of command was also discussed. Interview with LPN #1, (MDS Coordinator), on 05/05/14 at 5:05 PM, revealed she was inserviced on the four (4) types of abuse and what to do if abuse occurred, who to notify, when to notify as well as how to identify signs and symptoms of abuse. She stated she took a competency exam which included reporting abuse and following the chain of command. Additionally, she stated if abuse was suspected she would remove the caregiver, assure the resident was safe, assess for injury with the number one (1) priority being resident safety. Interview with CNA #1, on 05/05/14 at 5:07 PM, revealed the House Supervisor provided his inservice on abuse. He stated he was taught what he should do when abuse happens, who he should report to, and when to report. Additionally, he stated if he was a witness to abuse he would report it immediately. He stated he was given a competency exam and was taught on the different types of abuse. Interview with LPN #2, on 05/05/14 at 5:12 PM, revealed she was given a test related to abuse and was inserviced on the types of abuse, how to follow the chain of command, remove the resident from danger, and when to remove the caregiver from direct resident care. She stated she was to report to the allegation of abuse to the supervisor and send the suspected abuser home for a three (3) day suspension pending investigation. Additionally, she was to report to the on call nurse and Social Services as well as call the Ombudsman if no one else was available. Interview with CNA #2, on 05/05/14 at 5:21 PM, revealed she was in-serviced to report abuse immediately and how to notice changes in the resident's behaviors. She stated she was told to report to the Charge Nurse and if she identified physical changes like bruising or skin tears then she would report that as well. She revealed her first priority would be to get the resident safe and report abuse immediately. Additionally, she stated she was given a test after the inservice related to abuse and neglect. Interview with the Dietary Supervisor, on 05/05/14 at 5:34 PM, revealed she was inserviced on reporting abuse, signs of abuse, and to whom to report abuse. She stated she would go to the Administrator or DON right away if she witnessed abuse. Additionally, she stated she would say something to the person doing the abusing and try to get the resident to safety. She stated she took a post test as well. Interview with an Environmental Service Aide, on 05/05/14 at 5:43 PM, revealed he was inserviced to report abuse and to whom to report it. He stated he would report suspected abuse immediately. Additionally, he stated he was given a post test after the inservice.

Based on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to protect one (1) of eight (8) sampled residents (Resident #1); and, other residents by not removing the alleged perpetrators from resident care pending the outcome of the facility's investigation; and, failed to conduct a thorough investigation by not assessing other residents for signs/symptoms of abuse. On 04/17/14, Resident #1 accused staff of putting an empty spoon in his/her mouth, pulling his/her hand/arm, slapping him/her across the face, and pulling his/her ear and hair during a lunch meal. Additionally, he/she accused staff of yelling at him/her. Review of the facility's investigation, dated 04/17/14, and interviews revealed none of the alleged perpetrators were suspended pending completion of the investigation and no other residents were assessed for signs/symptoms of abuse. Review of the alleged perpetrators' punch in and out times revealed they (Certified Nursing Assistants (CNA) #1, CNA #2, and CNA #3) were allowed to work a full shift on 04/17/14, 04/18/14, and 04/21/14. The facility's failure to take action to prevent further potential abuse and, failure to assess other residents during the investigation of an abuse allegation caused or was likely to cause serious injury, harm, impairment or death of a resident. Immediate Jeopardy was identified on 04/24/14 and was determined to exist on 04/17/14. The findings include: Review of the facility's "Resident Abuse/Mistreatment" policy and procedure, last revised 11/2012, revealed, "Residents have the right to be free from forms of abuse, neglect, mistreatment, or misappropriation of property. The facility provides prevention, protection, and screening strategies to prevent occurrences of abuse. Residents will be monitored for changes that could trigger abusive behavior and will be reassessed on a regular basis to determine the effectiveness of the strategies. The supervisor should ask the person in which the allegation was made against to leave the facility immediately pending an investigation." Record review revealed the facility admitted Resident #1 on 02/06/12, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment, dated 02/14/14, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of twelve (12) which indicated the resident was interviewable. The resident was assessed as requiring extensive assistance of one (1) person for eating and drinking and had a history of [REDACTED]. Interview with Resident #1, on 04/22/14 at 10:40 AM, revealed on the day of the alleged incident (04/17/14), he/she was wanting to eat and someone kept putting a spoon in his/her mouth with nothing on it. The resident stated, "They" slapped him/her across the right side of the face but not hard enough to leave a red mark. Further interview revealed Resident #1 felt he/she had been mistreated a lot but this was the "first time lately". Resident #1 also stated staff would move his/her water pitcher out of reach as a joke. Review of the facility's investigation, dated 04/17/14 and completed on 04/21/14, revealed Resident #1 had been assessed immediately by Licensed Practical Nurse (LPN) #1, Unit Coordinator, after the alleged incident occurred and there were no physical signs of abuse noted. However, further review revealed there was no documented evidence LPN #1 removed the CNAs from providing resident care and no evidence other vulnerable residents were assessed for signs/symptoms of abuse. Review of the alleged perpetrators' punch in and out times revealed CNA #1, CNA #2 and CNA #3 were allowed to work a full shift on 04/17/14 (the date of the alleged incident), 04/18/14, and 04/21/14. Interview with CNA #1, on 04/23/14 at 10:00 AM, revealed she was assisting CNA #3 in passing lunch trays on 04/17/14. She stated she and CNA #3 entered the room at the same time and left at the same time because Resident #1 was care planned to have two (2) staff present at all times. CNA #1 revealed CNA #2 entered the room to inquire if they needed any help. CNA #1 stated the resident was care planned for staff to assist him/her with meals because he/she was blind and they were to take the resident's hand to show him/her where items were placed on the meal tray. Additionally, she revealed Resident #1 was supposed to wear ear buds to help with hearing but refused, and accused staff of yelling when they raised their voice to speak to him/her. Further interview revealed the resident had never accused her of mistreatment prior to this incident. She stated she was not removed from resident care because of the abuse allegation. Interview with CNA #2, on 04/23/14 at 1:28 PM, revealed she answered the resident's call light and the resident had asked to speak with her. CNA #2 stated the resident revealed to her that "the girls" were giving him/her a meal tray and yanked him/her, slapped his/her hand and face, and pulled his/her hair and ear. CNA #2 stated she reported the allegation to the Unit Manager (LPN #1). Interview with LPN #1, on 04/23/14 at 11:00 AM, revealed she assessed Resident #1 on 04/17/14 immediately after CNA #2 told her the resident wanted to speak with her and there were no physical signs of abuse to Resident #1's face, neck, arm, or chest area. She stated later in the day she and another nurse completed a full body audit on the resident with no injuries identified. The LPN revealed she notified the Director of Nursing (DON) and the resident's Aunt, who was also the resident's Power of Attorney (POA). Additionally, she stated the resident never identified any staff by their name nor did he/she state if the staff was male or female. Further interview on 04/24/14 at 11:10 AM, revealed she did not assess/interview other residents for signs/symptoms of abuse because Resident #1 did not have any signs/symptoms of being abused. Interview with the DON, on 04/24/14 at 9:25 AM, revealed there was nothing to pinpoint one (1) CNA in particular in the abuse allegation; therefore, no one was suspended because there would have had to be three (3) CNAs suspended pending an investigation. Additionally, she stated there was no reason to complete any other skin assessments because there was no injury noted to Resident #1. Interview with the Administrator, on 04/24/14 at 9:25 AM, revealed she could not suspend everyone in the building. She stated Resident #1 was blind and couldn't identify the CNA so every CNA in the room was interviewed. She stated she checked the employees' files for the CNAs involved in the allegation, and none of them had ever been written up for anything. Further interview with the Administrator, revealed she changed the facility's policy because she could not suspend three (3) CNAs when the resident had no physical symptom of being abused. **The facility implemented the following actions to remove the Immediate Jeopardy: Resident #1 was admitted to the facility on [DATE] and currently resides at the facility. The facility initiated an internal investigation on 04/17/14 (date of alleged abuse) and continued the investigation through 04/21/14. A physical assessment was conducted for Resident #1 on 04/17/14 by the Station Three Unit Coordinator and a Psychosocial interview was conducted on 04/17/14 by the Social Worker. A care conference was scheduled for 04/22/14. 1. Review of the policy titled "Resident Abuse/Mistreatment" revealed the policy was updated in 2014 and addendums were added were as follows: A. Physical assessment of resident and/or residents who alleged abuse and /or mistreatment. Psychosocial assessment of resident and/or residents who show they were allegedly abused and/or mistreated. B. All residents under the care of the alleged perpetrator will be assessed physically and psycho-socially. 2. Resident #1 was assessed on 04/17/14 with no signs of abuse or injury noted. Review of the skin assessment, dated 4/17/14, revealed no signs of abuse. 3. Skin assessments were completed on all residents on Units 1, 2, 3 and 4 from 04/21/14-04/25/14 with no concerns noted. On 04/25/14, all residents on each unit received a psychosocial assessments from one (1) of the three (3) Social Workers in the building. 4. Abuse and Neglect training was provided on 04/30/14 by the Purchase District Ombudsman, which included signatures of the Administrator, DON, and the facility Ombudsman. 5. A Resident Vulnerability Assessment was implemented in April 2014 to assess residents for changes in behaviors and mood placing them in a potential abuse situation. 6. Facility policies titled "Employment Practices" and "Resident Vulnerability Investigation" were reviewed and revised in April 2014. 7. The Nursing Director and Administrator were inserviced on resident rights, bullying and proper abuse reporting by the facility Ombudsman on 04/30/14. The Nursing Director provided inservicing and Competency exams to the Registered Nurses, Unit Coordinators, Clinical Educator, Social Workers and Associate Director of Nursing on 04/30/14, on appropriate abuse reporting, the new revised resident abuse policy, definitions of abuse, neglect, misappropriation of property and the new Vulnerability policy and tool to follow-up on investigations at the facility. The Nursing Director, Registered Nurses, Unit Coordinators, Clinical Educator, and Associate Director of Nursing provided inservicing and competency exams to all two-hundred and three (203) staff related to abuse and neglect related to when and to whom to report abuse as well as the different types of abuse between the dates of 04/30/14 and 05/04/14. Additionally, no employee would be allowed to return to work before receiving the inservice related to abuse and /or neglect. 8. All training is completed on the Health Stream Tracker computer system and when inservices are planned for the future the system places the dates on the calendars. Ex; Quarterly in-services will be documented on a calendar and a reminder given for the date of the in-service. The monitoring of education requirements for new employees is to begin after 05/04/14. 9. The DON and the Administrator initiated a new facility form titled "Problem Resolution/OIG LOG" dated 2014, to monitor daily complaints, timely reporting and investigating of all abuse/mistreatment reporting. Data is to be collected by the Unit Coordinators, Social Services, and Nursing Administration. The DON is to report findings in the QA meetings. A new Measurement and Assessment Report for performance improvement dated 04/14 was implemented for tracking and trending abuse/neglect. **The State Survey Agency validated the corrective action taken by the facility as follows: Review of the facility's investigation, on 05/05/14, revealed the facility initiated an internal investigation on 04/17/14 (date of alleged abuse) and continued the investigation through 04/21/14. Review of the policy titled "Resident Abuse/Mistreatment", on 05/05/14, revealed the policy was updated to include the following addendums: A. A Physical assessment of resident and/or residents who alleged abuse and /or mistreatment will be completed. A Psychosocial assessment of resident and/or residents show signs/symptoms they were allegedly abused and/or mistreated. B. All residents under the care of the alleged perpetrator will be assessed physically and psycho-socially. Resident #1 was assessed on 04/17/14 with no signs of abuse or injury noted. Review of the skin assessment dated [DATE] revealed no signs of abuse. Review of facility's policies titled "Employment Practices" and " Resident Vulnerability Investigation" on 05/05/14, revealed they were reviewed and revised in April 2014. Review of skin assessments on all residents on Units 1, 2, 3 and 4, on 05/05/14, revealed the residents had skin assessments completed from 04/21/14-04/25/14 with no concerns noted. On 04/25/14 all residents on each unit received a psychosocial assessments from one of the three (3) Social Workers in the building. Review of the sign in log for Abuse and Neglect training dated 04/30/14 provided by the Purchase District Ombudsman, on 05/05/14 revealed it included signatures of the Administrator, DON, and the Ombudsman as having received training related to reporting abuse and/or neglect, when to suspend suspected employees, and instruction on completing an investigation. Review of competency exams and inservice logs related to abuse and neglect, on 05/05/14, revealed two-hundred and three (203) staff including the DON, Administrator, Registered Nurses, Unit Coordinators, Clinical Educator, ADON, Social Workers and CNAs received training on when and to whom to report abuse as well as the different types of abuse between the dates of 04/30/14 and 05/04/14. Additionally, no employee would be allowed to return to work before receiving the inservice related to abuse and /or neglect. The DON and the Administrator initiated a new facility form titled "Problem Resolution/OIG LOG" dated 2014, to monitor daily complaints, timely reporting and investigating of all abuse/mistreatment reporting. Data is to be collected by the Unit Coordinators, Social Services, and Nursing Administration. The DON is to report finding in the QA meetings. A new Measurement and Assessment Report for performance improvement dated 04/14 was implemented for tracking and trending abuse/neglect. Review of the forms revealed the facility had implemented them and was monitoring the results in the morning meeting. Interview with Registered Nurse (RN) #1, (Unit Coordinator), on 05/05/14 at 4:56 PM, revealed she was in-serviced by the DON. She stated once an allegation of abuse has been made the alleged perpetrator was to be removed from duty. A head to toe assessment was to be completed on the victim and every resident that was under the care givers care will be assessed by nursing and social services. (Nursing can do the Social Services assessment as well). Social Services will contact the proper authorities like Adult Protective Services, Office of Inspector General, etc. Additionally, she stated she would contact the family, physician, DON, and Administrator. She stated a competency exam was given related to the different types and signs of abuse, whom to report to, and when reporting was to be done. Following the chain of command was also discussed. Interview with LPN #1, (MDS Coordinator), on 05/05/14 at 5:05 PM, revealed she was inserviced on the four (4) types of abuse and what to do if abuse occurred, who to notify, when to notify as well as how to identify signs and symptoms of abuse. She stated she took a competency exam which included reporting abuse and following the chain of command. Additionally, she stated if abuse was suspected she would remove the caregiver, assure the resident was safe, assess for injury with the number one (1) priority being resident safety. Interview with CNA #1, on 05/05/14 at 5:07 PM, revealed the House Supervisor provided his inservice on abuse. He stated he was taught what he should do when abuse happens, who he should report to, and when to report. Additionally, he stated if he was a witness to abuse he would report it immediately. He stated he was given a competency exam and was taught on the different types of abuse. Interview with LPN #2, on 05/05/14 at 5:12 PM, revealed she was given a test related to abuse and was inserviced on the types of abuse, how to follow the chain of command, remove the resident from danger, and when to remove the caregiver from direct resident care. She stated she was to report to the allegation of abuse to the supervisor and send the suspected abuser home for a three (3) day suspension pending investigation. Additionally, she was to report to the on call nurse and Social Services as well as call the Ombudsman if no one else was available. Interview with CNA #2, on 05/05/14 at 5:21 PM, revealed she was in-serviced to report abuse immediately and how to notice changes in the resident's behaviors. She stated she was told to report to the Charge Nurse and if she identified physical changes like bruising or skin tears then she would report that as well. She revealed her first priority would be to get the resident safe and report abuse immediately. Additionally, she stated she was given a test after the inservice related to abuse and neglect. Interview with the Dietary Supervisor, on 05/05/14 at 5:34 PM, revealed she was inserviced on reporting abuse, signs of abuse, and to whom to report abuse. She stated she would go to the Administrator or DON right away if she witnessed abuse. Additionally, she stated she would say something to the person doing the abusing and try to get the resident to safety. She stated she took a post test as well. Interview with an Environmental Service Aide, on 05/05/14 at 5:43 PM, revealed he was inserviced to report abuse and to whom to report it. He stated he would report suspected abuse immediately. Additionally, he stated he was given a post test after the inservice.

Based on interview, record review and review of the facility's policy and procedure it was determined the facility failed to consult with one (1) of five (5) sampled residents' (Resident #1) physician when there was an accident that resulted in injury and had the potential for requiring physician intervention and a need to alter treatment. On 10/09/13 at 3:15 AM, Certified Nurse Aide (CNA) #1 provided care to Resident #1. When she rolled the resident over to his/her side, the resident fell from the bed onto his/her left knee and shins. The resident complained of pain to the left knee; staff identified a knot on the resident's left knee with increased swelling. The on-call physician was faxed at 3:15 AM, but the nurse did not call the physician's office to consult with the physician until 9:16 AM. The physician's office called the facility back at 10:51 AM with orders to send the resident to the emergency room for x-rays. The physician was not consulted for approximately six (6) hours after the fall with injury. Resident #1 was sent to the emergency room and it was determined the resident had a fractured left femur. The resident returned to the facility and continued to complain of pain to the right leg. Resident #1 was sent back to the hospital and it was determined the resident had a fractured right tibia. The findings include: Record review revealed the facility admitted Resident #1 on 03/26/08 with [DIAGNOSES REDACTED]. Review of a Nursing Note, dated 10/09/13 at 8:29 AM, revealed Licensed Practical Nurse (LPN) #1 documented she was called to Resident #1's room by CNA #1 at 3:15 AM. The CNA stated she was providing care to Resident #1 and when she turned the resident on his/her side the resident slid off of the bed onto his/her left knee and bilateral shins. When LPN #1 entered the room, the resident was sitting on the floor on his/her bottom with his/her knees bent and had complaints of pain in the left knee. The LPN assessed the resident for injury and identified bruising to the bilateral shins and a skin tear to the right wrist. The resident complained of pain to the left knee and exhibited more pain with turning and repositioning. Further review of the clinical record record revealed the resident was given more pain medication. At 4:03 AM, the Nurse placed an ice pack on Resident #1's left knee related to a knot on the resident's knee and increased swelling. There was no documented evidence the on call or primary care physician was consulted about the fall with injuries and the resident's increased complaints of pain. Review of the POS [REDACTED]. Review of a facsimile (fax) sent to the on-call physician's office related to Resident #1's fall revealed a date of 10/09/13, with no time noted. Interview with LPN #1, on 11/01/13 at 8:37 AM, revealed she did not call the on call physician at the time of the incident (3:15 AM) but sent a fax because it was so early in the morning. Further review of the Nursing Notes revealed the primary physician's office was called on 10/09/13 at 9:16 AM, approximately six (6) hours after the fall, and the physician's staff was made aware of Resident #1's fall, injuries and that the LPN had identified the resident had crackles in the lower bases of his/her lungs. Review of a Nurse's Note, dated 10/09/13 at 10:51 AM, revealed the facility received orders to send the resident to the emergency room to obtain an x-ray of the resident's left knee to rule out a fracture and his/her chest to rule out pneumonia. Review of the emergency room Record, dated 10/09/13 at 11:50 AM, revealed Resident #1 was transferred to the hospital and an x-ray, dated 10/09/13 at 1:16, revealed there was no fracture to the right leg; however, review of an x-ray, dated 10/09/13 at 2:48 PM, revealed a [MEDICAL CONDITION] femur. Resident #1 stayed in the hospital for nine (9) days and was discharged back to the nursing facility on 10/18/13 at 1:05 PM. Review of Nursing Notes and pain assessments, dated 10/18/13 -10/23/13 revealed Resident #1 was having pain to the right leg. The resident was given [MEDICATION NAME] for the pain but the pain continued. Review of a Nurse's Note, dated 10/23/13 at 3:36 AM, revealed Resident #1 had a large amount of dark, coffee ground emesis and complaints of pain in the right leg. A physician's orders [REDACTED]. Review of the Radiology report, dated 10/23/13 at 7:19 AM, revealed an acute, impacted [MEDICAL CONDITION] tibia, which was not revealed on the prior radiographic examination of the right knee from 10/09/13. Interview with Resident #1's primary care physician, on 11/06/13 at 9:00 AM, revealed he never received a phone call and even though a fax was sent to the on-call physician regarding the incident, a phone call should have been made as well, as this was the protocol per the hospital and nursing home policy. The Physician stated he felt the right tibia fracture was not seen on the first x-ray done on 10/09/13 and the Radiologist and Orthopedic doctor both read the x-ray film and missed the break.

Based on observation, interview, record review, and review of the facility's policy and procedure it was determined the facility failed to ensure one (1) of five (5) sampled residents (Resident #1) received adequate supervision to prevent accidents. Resident #1 was assessed and care planned for two (2) staff assistance with bed mobility; however, the Minimum Data Set (MDS) Kardex Report (CNA Care Plan) stated the resident required one (1) person assist with bed mobility. On 10/09/13, Certified Nurse Aide (CNA) #1 provided care for Resident #1 without the assistance of another staff. When she turned the resident to his/her side the resident slid from the bed onto the floor landing on his/her left knee and bilateral shins. Resident #1 sustained a fractured left femur and right tibia. The findings include: Review of the facility's policy titled, "Risk Team", last revised 02/2011, revealed "The Risk Team" promotes resident safety and reduces risk to residents through an environment that encourages recognition and acknowledgment of risks to resident safety; initiation of interventions to reduce these risks; internal reporting of what has been found and the actions taken; focus on process and systems; Non-punitive management of errors and occurrences. The maintenance and improvement of resident safety, is a coordinated and collaborative effort, the approach to optimal safety establishing the plans, processes and mechanisms that compromise the resident safety activities at the nursing facility. Record review revealed the facility admitted Resident #1 on 03/26/08 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 08/16/13, revealed the facility assessed Resident #1 as being cognitively intact. The resident required the extensive assistance of two (2) staff for bed mobility. Review of the Comprehensive Care Plan for Activities of Daily Living (ADL) Self-Care Performance, last revised 08/20/13, revealed the resident required two (2) staff assist and one-half (1/2) side rails to aide in turning and repositioning. However, review of the MDS Kardex Report (CNA care plan), no date, revealed the resident required assist of one (1) staff to turn and reposition in bed every two (2) hours, and as necessary. Review of the Nursing Note, dated 10/09/13 at 8:29 AM, revealed Licensed Practical Nurse (LPN) #1 was called to Resident #1's room at 3:15 AM. Further review revealed the CNA revealed to LPN#1 that she was providing care to Resident #1 and when she turned the resident to his/her side, the resident slid off the bed onto his/her left knee and bilateral shins. The LPN documented when she entered the room, the resident was sitting on the floor on his/her bottom with his/her knees bent. The resident complained of pain to the left knee. When assessed, the LPN identified the resident had a skin tear to the right wrist and bruising to the bilateral shins. The resident was transferred back to bed per mechanical lift; the resident exhibited symptoms of increased pain when turned and repositioned. Resident #1 was administered pain medication. Further review of the Nursing Notes revealed at 4:03 AM, the LPN placed an ice pack on Resident #1's left knee because there was a knot on the resident's knee and increased swelling. The resident's physician's office was notified of the fall with injury at 9:16 AM and, at 10:51 AM nursing received a telephone order to send the resident to the emergency room for x-rays of the left knee to rule out a fracture and an x-ray of the chest to rule out pneumonia. Review of the emergency room Record, dated 10/09/13 at 11:50 AM, revealed Resident #1 was transferred to the hospital and x-rays were obtained of the left and right leg. Review of the x-ray reports, dated 10/09/13 revealed there was no fracture to the right leg however, the resident had a fractured left femur. Resident #1 stayed in the hospital for nine (9) days and was discharged back to the nursing facility on 10/18/13 at 1:05 PM. Review of the Nursing Notes and pain assessments, dated 10/18/13 -10/23/14 revealed Resident #1 was having pain to the right leg. Review of a Nurse's Note, dated 10/23/13 at 3:36 AM, revealed Resident #1 had a large amount of dark, coffee ground emesis and complaints of pain in the right leg. A physician's orders [REDACTED]. Review of the Radiology report, dated 10/23/13 at 7:19 AM, revealed an acute, impacted fracture of the right proximal metaphysis of the tibia, which was not revealed on the prior radiographic examination of the right knee from 10/09/13. Interview with Resident #1's primary care physician, on 11/06/13 at 9:00 AM, revealed he felt the right tibia fracture was not seen on the first x-ray done on 10/09/13 and the Radiologist and Orthopedic doctor both read the x-ray film and missed the break. Interview with CNA #1, on 11/01/13 at 8:07 AM, revealed when she entered the resident's room the resident had vomited and was lying on his/her back. The vomit was on the side of the bed closest to the door. She stated she normally provided care from the other side of the bed. CNA #1 stated she began cleaning the resident and changing the bed linens. When she reached for the call light to call for assistance, the resident's legs slipped off of the bed. CNA #1 stated when she raised her hand off of the resident's legs to pull the call light out of the wall for an emergency call, the resident's upper body was still on the bed and his/her knees were on the floor. She stated she and another CNA, LPN #1, and LPN #2 assisted the resident to the floor. Further interview revealed CNA #1 cared for the resident upon return to the facility after the hospital stay. She stated the resident never returned to his/her self and had increased pain after the fall. Additionally, CNA #1 stated the CNA Care Plan revealed the resident required one (1) staff assistance for bed mobility until after the fall when it was changed to two (2) staff assistance. She stated she cared for the resident by herself most of the time because the resident was able to assist with turning and positioning and in hind sight she felt she should have called for assistance prior to assisting the resident. Interview with Licensed Practical Nurse (LPN) #1 , on 11/01/13 at 8:37 AM, revealed that on 10/09/13 she was called to the resident's room by CNA #1, who was providing care to Resident #1 after the resident had vomited on the bed and on himself/herself. CNA #1 reported to LPN #1 that when she turned the resident over on his/her side to change the bed linen, the resident's legs slid off the bed. When she reached for the call light to call for assistance, the resident continued to slide off the bed onto the floor landing on his/her bilateral knees. The LPN stated when she entered the room, the CNA had the resident and the bed stripped and she did not see any vomitus on the bed or the resident. The resident was lying on the floor nude. While the resident was on the floor, LPN #1 revealed she assessed the resident by performing range of motion to all extremities. LPN #2 left the room to get paperwork ready and make phone calls to send the resident to the emergency room for evaluation. Additionally, LPN #1 stated the resident did not complain of pain until he/she was placed back in the bed and was being repositioned so she could perform an assessment. The resident was complaining of pain in the left knee; there was a knot noted on the resident's left knee. The resident sustained [REDACTED]. LPN #1 stated she placed an ice pack on the resident's left knee due to increased pain and swelling. An order was received to send the resident to the emergency room for an x-ray of the left knee. She stated there was no reason for the CNA to attempt to provide care for the resident alone when the care plan revealed the resident required two (2) staff assist. Interview with LPN #2, on 11/01/13 at 9:00 AM, revealed when she entered the resident's room the resident was in an odd position. She stated his/her left hip was on the bed side table and his/her feet were underneath him/her. Upon assessment she stated the resident revealed his/her back was hurting. She further revealed the resident was a large person and the bed he/she was on was not large enough to accommodate him/her. She stated after the resident was safely on the floor, she left the room to aide in getting paperwork ready to send the resident to the emergency room and to make the necessary phone calls. She agreed that the resident should have been assisted with two (2) staff for safety. Interview with LPN #3, on 11/03/13 at 11:31 AM, revealed she was not familiar with Resident #1 but she did recall the resident's condition changed over the past three (3) or so months prior to his/her death as he/she did not get out of bed and requested increased amounts of pain medication. Additionally, she revealed there was no reason for the accident to have occurred if the care plan had been followed. Interview with Registered Nurse (RN) #1, on 11/04/13 at 12:40 PM, revealed Resident #1 did not want to get out of bed and had been steadily deteriorating in his/her health status. He stated the fall had a major impact on his/her mental status as well as resulting in an increase in pain and medication. Additionally, he stated the CNA Care Plan indicated the resident required two (2) staff assist for bed mobility and he did not feel there was any reason for the CNA to care for the resident alone. Interview with the Assistant Director of Nursing (ADON), on 11/05/13 at 4:15 PM, revealed she did not know why the Comprehensive Care Plan stated Resident #1 required two (2) assist with bed mobility and the CNA care plan stated one (1) staff for bed mobility. The ADON stated she would have expected the CNA to question a change to the CNA Care Plan when bed mobility changed from two (2) staff assist to one (1) staff assist. She revealed the CNAs are taught a resident's status may change daily and they are to check the CNA Care Plan prior to beginning care on each shift. Additionally, she revealed if a CNA was aware a resident required two (2) staff assist and provided care alone whether an injury resulted or not, they would be reprimanded for not following the care plan. She stated she was responsible for the supervision of staff. Interview with the Director of Nursing (DON), on 11/04/13 at 10:00 AM, revealed the CNA care plan indicated one (1) staff assist and the coding could have been changed in the computer system as a glitch. She further stated she chose not to council the CNA because she felt the CNA was doing what she thought she was supposed to do by getting the resident out of the vomit.

Based on interview, record review, and review of the facility's policy and procedure it was determined the facility failed to ensure the services provided or arranged by the facility were provided by qualified persons in accordance with each resident's written plan of care for one (1) of five (5) sampled residents (Resident #1). Review of Resident #1's Comprehensive Care Plan revealed a plan of care for two (2) person assistance with bed mobility. However; the Minimum Data Set (MDS) Kardex Report (CNA Care Plan) stated the resident required one (1) person assist with bed mobility. Certified Nurse Aide (CNA) #1 provided care for Resident #1 alone. When she turned the resident over in the bed, the resident slid from the bed to the floor landing on his/her left knee and bilateral shins. The resident sustained [REDACTED]. The findings include: Review of the facility's policy and procedure titled, "Resident Care Plan", last revised 09/2013, revealed staff should check the plan of care daily for updates. Review of the facility's policy and procedure titled, "Nursing Assistant Kardex", last revised 07/2013, revealed the Nurse Aide Care Plan should be initiated on admission then updated as needed with change in condition and for hospital stay information. It should include but not be limited to: Mobility, Transfer, Special Equipment, Reposition, Falls, and Safety Device Documentation. Change in condition (improvement or decline) should be reported to the licensed staff for update of the care plan, as needed. "It's the responsibility of each employee to follow the resident's plan of care, (i.e. if a resident requires two assist for transfers then staff is not to transfer resident with one assist)." Record review revealed the facility admitted Resident #1 on 03/26/08 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/16/13, revealed the facility assessed Resident #1 as being cognitively intact and the resident required the extensive assist of two (2) staff for bed mobility and transfer. In addition, the resident was non-ambulatory. Review of the Comprehensive Care Plan for "ADL Self-Care Performance", last revised 08/20/13, revealed the resident required two (2) staff assist and one-half (1/2) side rails to aide in turning and repositioning. However, review of the MDS Kardex Report (CNA Care Plan), not dated, revealed the resident required the assistance of one (1) staff to turn and reposition in bed every two (2) hours and as necessary. Review of a Nursing Note, dated 10/09/13 at 8:29 AM, revealed Licensed Practical Nurse (LPN) #1 documented she was called to Resident #1's room by CNA #1 on 10/09/13 at 3:15 AM. The CNA stated she was providing care to Resident #1 and when she turned the resident to his/her side the resident slid off of the bed onto his/her left knee and bilateral shins. When LPN #1 entered the room, the resident was sitting on the floor on his/her bottom with his/her knees bent. The resident complained of pain in the left knee. The LPN assessed the resident for injury and identified bruising to the bilateral shins and a skin tear to the right wrist. The resident was transferred back to bed with a mechanical lift. The resident complained of pain to the left knee and exhibited more pain with turning and repositioning; the resident was given pain medication. At 4:03 AM, LPN#1 placed an ice pack on Resident #1's left knee related to a knot on his/her knee and increased swelling. At 10:51 AM, nursing received a telephone order to send the resident to the emergency room for x-rays of the left knee to rule out a fracture and an x-ray of the chest to rule out pneumonia. Interview with CNA #1, on 11/01/13 at 8:07 AM, revealed the MDS CNA Kardex revealed the resident required one (1) staff assistance for bed mobility and was changed after the fall to two (2) staff assistance. She admitted to caring for the resident by herself most of the time because the resident was able to assist with turning and positioning. CNA #1 stated in hind sight she felt she should have called for assistance prior to assisting the resident. Additionally, she stated she did not question the change in the care plan from two (2) staff assist to one (1) person assist. Interview with Licensed Practical Nurse (LPN) #1 , on 11/01/13 at 8:37 AM; and, on 11/05/13 at 2:00 PM, revealed on 10/09/13 she was called to the resident's room by CNA #1 who was providing care to Resident #1 after the resident had vomited on the bed and on himself/herself. CNA #1 reported to LPN #1 that when she turned the resident over on his/her side to change the bed linen, the resident's legs slid off the bed. When she reached for the call light to call for assistance, the resident continued to slide off the bed to the floor landing on his/her bilateral knees. Additionally, she revealed that when she entered the room the CNA had the resident and the bed stripped and she did not see any vomitus on the bed or the resident. The resident was lying on the floor nude. LPN #1 revealed the resident did not complain of pain until he/she was placed back in the bed per lift and was being repositioned for assessment. The resident was complaining of pain in the left knee; there was a knot noted on the resident's left knee. The resident sustained [REDACTED]. LPN #1 stated she placed an ice pack on the resident's left knee due to increased pain and swelling. An order was received to send the resident to the emergency room for an x-ray of the left knee on 10/09/13 at 10:51 AM. Review of the emergency room Record, dated 10/09/13 at 11:50 AM, revealed Resident #1 was brought to the hospital and x-rays were conducted on the left and right leg. Review of the x-ray reports, dated 10/09/13 revealed there was no fracture to the right leg however, the resident had a fractured left femur. Resident #1 stayed in the hospital for nine (9) days and was discharged back to the nursing facility on 10/18/13 at 1:05 PM. Review of the Nursing Notes and pain assessments, dated 10/18/13 -10/23/13 revealed Resident #1 was having pain to the right leg. Review of a Nurse's Note, dated 10/23/13 at 3:36 AM, revealed Resident #1 had a large amount of dark, coffee ground emesis and complaints of pain in the right leg. A physician's orders [REDACTED]. Review of the Radiology report, dated 10/23/13 at 7:19 AM, revealed an acute, impacted [MEDICAL CONDITION] proximal metaphysis of the tibia, which was not revealed on the prior radiographic examination of the right knee from 10/09/13. Interview with Resident #1's primary care physician, on 11/06/13 at 9:00 AM, revealed he felt the right tibia fracture was not seen on the first x-ray done on 10/09/13 and the Radiologist and Orthopedic doctor both read the x-ray film and missed the break During further interview, LPN #1 stated she felt there was no reason for the CNA to attempt to provide care for the resident alone when the care plan stated the resident required two (2) staff assistance. She stated even if staffing was an issue, the CNA should find someone to assist with care especially if the resident required two (2) staff assist. Additionally, the facility failed to conduct an investigation to identify the root cause of the fall. LPN #1 stated she knew what happened and did not feel the need to do an investigation. Interview with CNA #3 on 11/05/13 at 1:45 PM, revealed she had taken care of Resident #1 and the CNA Care Plan indicated the resident required one (1) staff assist for bed mobility. She stated she would usually care for the resident without assistance because the resident could assist with bed mobility. Interview, with CNA #4, on 11/05/13 at 3:00 PM, revealed Resident #1's CNA Care Plan called for two (2) staff assist for bed mobility and transfers. She stated if she needed to, she would provide care to a resident by herself even if the care plan indicated the resident required two (2) staff assistance if there was no staff available because they were on break or busy assisting other residents. Interview with Registered Nurse (RN) #1, on 11/04/13 at 12:40 PM revealed Resident #1 did not want to get out of bed and had been steadily deteriorating in his/her health status. He stated the fall had a major impact on his/her mental status as well as resulting in increased pain and medication. Additionally, he stated the CNA Care Plan indicated the resident required two (2) staff assist for bed mobility and he did not feel there was any reason for the CNA to care for the resident alone. Interview with the Assistant Director of Nursing (ADON), on 11/05/13 at 4:15 PM, revealed she did not know why the Comprehensive Care Plan stated Resident #1 required two (2) assist with bed mobility and the CNA care plan stated one (1) staff for bed mobility. The ADON revealed she would have expected the CNA to question a change to the CNA care plan when bed mobility changed from two (2) staff assist to one (1) staff assist. She stated the CNAs were taught a resident's status may change daily and they were to check the CNA Care Plan prior to beginning care on each shift. Additionally, she stated if a CNA was aware a resident required two (2) staff assist and provided care alone whether an injury resulted or not, they would be reprimanded for not following the care plan. She stated it was her responsibility to supervise all staff, from the Unit Managers down the line. Interview with the Director of Nursing (DON), on 11/04/13 at 10:00 AM, revealed the CNA Care Plan indicated one (1) staff assist and the coding may have been changed in the computer system as a glitch. She further stated she chose not to council the CNA because she felt the CNA was doing what she thought she was supposed to do by getting the resident out of the vomit.

Based on observations, interviews, and record reviews, the facility failed to ensure the residents' environment remained as free from accident hazards as is possible related to the failure to assess for the safe use of specialty mattresses for ten residents (#1, #2, #4, #6, #7, #17, #18, #19, #21, and #22), in the selected sample of twenty-seven residents. Each of these residents were placed back on the specialty mattress with no evidence and assessment had been completed related to the safe use of the air mattress. The facility failed to thoroughly investigate to determine the causal factor for the falls and implement new interventions to prevent future falls. The findings include: 1. A record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment, dated 07/22/11, revealed the facility assessed Resident #6 to require extensive assistance of two staff for bed mobility and toilet use. He/she required total dependence of one staff for dressing, eating, personal hygiene and bathing. Additionally, Resident #6 was frequently incontinent of bowel and bladder. A review of the Comprehensive Care Plan, dated 07/22/11, revealed Resident #6 to be at risk for falls related to weakness, decreased mobility and history of falls. Further record review revealed Resident #6 experienced four (4) falls from a specialty air mattress (EasyAir), dated 09/02/10 through 04/20/11, two falls were with injury. On 09/02/10 at 7:30 PM, Resident #6 attempted to self-transfer from the bed to a chair with no injury noted. The facility added a bed alarm to the care plan at that time. An accident investigation form, dated 09/02/10, revealed resident had a previous history of falls with interventions of a low bed and his/her call light within reach. On 09/03/10 at 7:00 PM, Resident #6 attempted to self-transfer from his/her wheel chair back to the bed with no injury noted. An accident investigation form, dated 09/03/10, revealed an intervention was added for a pull alarm while up in chair. A review of a nurses' note, dated 03/19/11 at 12:15 AM, revealed Resident #6 reported he/she was "reaching for the urinal and rolled out of the bed onto the floor." The resident was sent to the emergency room for an evaluation and treatment due to the skin tears on his/her right arm and a swollen right wrist. An accident investigation form, dated 03/19/11, listed the causative factor to be "resident was reaching for urinal." The facility added a pull away alarm to the bed on 03/19/11. Interventions in place at the time of the fall, on 03/19/11, were for the staff to place frequently used items within easy reach, the bed was to be in an appropriate position for safe transfer, staff assistance with all transfers and a pull away alarm in place to the wheelchair. On 04/20/11 at 7:05 PM, Resident #6 was found on the floor next to his/her dresser and was sent to the emergency room for an evaluation and treatment due to a laceration on his/her forehead. The resident sustained [REDACTED]. A review of the Comprehensive Care Plan, dated 04/20/11, revealed an intervention was added for a bed alarm into the call light system. Resident #6 was observed on a Plexus 2500 air mattress, on 07/26/11 at 3:50 PM , 07/27/11 at 9:15 AM, 07/28/11 at 4:14 PM, and 07/29/11 at 6:05 PM; he/she was on an EasyAir mattress at the time of his/her falls per the staff. Resident #6 was moved from an EasyAir mattress to the Plexus 2500 air mattress in May 2011, when he/she began receiving hospice services, related to a hospice contract. Observations, on 07/26/11 at 3:50 PM, 07/27/11 at 9:15 AM, 07/28/11 at 4:14 PM and 07/29/11 at 6:05 PM, revealed Resident #6 to be lying on a Plexus 2500 air mattress. An observation, on 07/27/11 at 5:45 PM, revealed a bed mat alarm was under the resident, but did not function when the staff tested it and the bed mat alarm was not hooked into the call light system as care planned, after the fall on 04/20/11. Interview with Unit Supervisor #1 and Licensed Practical Nurse (LPN) #8, on 07/27/11 at 5:45 PM, revealed the bed mat alarm was placed under Resident #6 but did not function. The bed alarm was not hooked into the call light system as care planned, after the fall on 04/20/11, when Resident #6 sustained the cervical fracture. A record review revealed there was no documented evidence Resident #6 was assessed for the safe use of a specialty air mattress. 2. A record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the admission Nursing Care Plan, dated 07/20/11, revealed Resident #19 was disoriented and required the assistance of two staff with ambulation and transfer. He/she required staff assistance with positioning, dressing, and grooming and was incontinent of bowel. A review of a nurses' note, dated 07/20/11 at 4:56 PM, revealed Resident #19 "was fearful of falling" at the time of admission. He/she grabbed the therapists' arms and stated " I'm falling, I'm falling." Further review of a nurses' note, dated 07/23/11 at 12:00 PM, revealed Resident #19 was found "laying beside his/her bed on his/her left side on the floor". He/she was noted to have skin tears on his/her left forearm, right forearm, right ring finger and left wrist. A review of accident investigation form, dated 07/23/11 at 12:00 PM, revealed Resident #19's "bed/chair alarms were in place, but not attached to the box." The reason listed as to why the intervention was not successful was "alarms do not keep residents from falling." The accident investigation form revealed the mat was added to the left side of the bed. A review of the falls risk care plan, dated 07/23/11, did not reflect the bed and chair alarm or a mat on the left side of the bed as interventions. Further record review revealed Resident #19 was assessed to be a falls risk upon admission; however, he/she was not care planned for falls until after his/her fall on 07/23/11. A review of the admission care plan, dated 07/20/11, revealed the bed alarm and chair alarm were added on 07/21/11. A review of a Resident Care Plan, dated 07/21/11, revealed the pressure reducing mattress was added due to a stage III pressure ulcer to the coccyx area. Resident #19 was not assessed for the safe use of the specialty air mattress before or after the fall on 07/23/11. Observations, on 07/28/11 at 4:15 PM and 07/29/11 at 4:15 PM, revealed Resident #19 was lying on a specialty air mattress. An interview with Certified Nurse Aide (CNA) #4, on 07/29/11 at 5:50 PM, revealed she completed an entire bed change for Resident #19 on 07/23/11 and did not realize his/her bed alarm was not "hooked up." She stated she checked the bed alarm and chair alarm when she arrived at work; however, she did not notice it was not connected on 07/23/11, the date of the fall. An interview with Licensed Practical Nurse (LPN) #7, on 07/29/11 at 5:45 PM, revealed Resident #19 did not function well alone. She expressed concern about his/her confusion, about being very "busy" while in the bed and he/she did better with people around. She stated that Resident #19's alarm was not plugged in at the time of the incident on 07/23/11. She verbalized her expectation of the CNA was to check residents' bed alarms and chair alarms during rounds to ensure they functioned. 3. A record review revealed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual MDS assessment, dated 06/20/11, revealed the facility assessed the resident to require total assistance with all Activities of Daily Living (ADLs). The resident was cognitively impaired and at increased risk for falls related to poor vision and poor decision-making skills. The resident required extensive assistance of two staff for bed mobility and transfers. He/she required extensive/total dependence with the assistance of two staff and was not able to follow directions at all times. A review of the Resident #21's comprehensive care plan, dated 06/29/11, revealed potential for falls related to a history of falls, Dementia, unsteady balance and poor safety awareness. A record review revealed, on 06/19/11 at 12:37 AM, Resident #21 was found on the mat next to his/her bed. The resident was assisted back to his/her specialty air mattress and then assisted into the wheel chair due to being wide awake and was brought to the nurses' station. Further review revealed there was no documented assessment for the safe use of an air mattress. Observations, on 07/29/11 at 1:30 PM, 3:00 PM and 5:00 PM, revealed Resident #21 was resting on a specialty air mattress. 4. A record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS, dated [DATE], revealed the facility assessed the resident to be moderately cognitively impaired. The resident made poor decisions and required cues and supervision. The resident required extensive assistance of two staff and was totally dependent on the staff for ADLs. A review of nurses' notes revealed, on 12/18/10 at 4:45 AM, Resident #22 was found sitting on the floor on the left side of his/her bed. The resident sustained [REDACTED]. Further record review revealed there was no completed assessment for the safe use of the specialty mattress after the resident was found sitting on the floor. An observation, on 07/28/11 at 9:55 AM, revealed he/she was sitting up in a chair with bilateral heel lift boots in place. Resident #22's bed was observed to have a specialty mattress (Easy Air Mattress), with the setting on rotating and the comfort level was set at "5". 5. A record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the significant change MDS, dated [DATE], revealed the facility assessed Resident #1 to be severely cognitively impaired and his/her range of motion was impaired on one of his/her upper extremities. A review of the Comprehensive Care Plan, dated 06/02/11, revealed the resident was a potential for falls related to a history of falls, unsteady balance, lack of coordination and decreased cognition. A review of the nurses' notes, dated 07/18/11, revealed Resident #1 rolled out of the bed at 1:30 AM. The resident was assisted back to bed by staff. Further review revealed there was no assessment for the safe use of the specialty air mattress. An observation, on 07/27/11 at 3:15 PM, revealed Resident #1 was lying on a specialty air mattress with settings of ROTATION-NORMAL and COMFORT LEVEL #3. Further observation, on 07/28/11 at 4:50 PM, revealed the resident was lying on a specialty air mattress with settings of ALTERNATING-NORMAL and COMFORT LEVEL #3. 6. A record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the significant change MDS, dated [DATE], revealed the facility assessed Resident #17 to be cognitively independent and required extensive assistance with transfer and ambulation. A review of the Comprehensive Care Plan, dated 04/14/11, revealed the resident was at risk for falls related to history of a fall, episodes of syncope and decline in functional mobility. A review of the nurses' notes, dated 02/20/11, revealed Resident #17 slid off the low bed at 6:16 AM. The resident was assisted back to bed. Further review revealed there was no assessment for the safe use of the specialty air mattress. An observation, on 07/28/11 at 2:40 PM, revealed Resident #17 was lying on a specialty air mattress with settings of COMFORT LEVEL #5. 7. A record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS, dated [DATE], revealed the facility assessed Resident #4 to be severely cognitively impaired and required extensive assistance with mobility and transfer. A review of the Comprehensive Care Plan, dated 07/06/11, revealed the resident was at risk for falls related to a history of falls, restlessness, unsteady gait and unsteady balance. A review of the nurses' notes, dated 05/20/11 at 9:00 PM, revealed Resident #4 was sitting on the left side of the bed with his/her legs stretched forward. A review of another nurses' note, dated 05/21/11 at 3:08 PM, revealed Resident #4 rolled out of the bed and was found on the gray mat by the bed. The resident was assisted back to the bed on both occasions. Further review revealed there was no assessment for the safe use of the specialty air mattress. An observation, on 07/26/11 at 2:55 PM, revealed Resident #4 was lying on a specialty air mattress with settings of NORMAL AIR FLOAT and COMFORT LEVEL #4. 8. A record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the significant change MDS, dated [DATE], revealed the facilty assessed Resident #2 to be severely cognitively impaired. The resident required total care with all of his/her ADLs. A review of the nurses' note, dated 07/23/11 at 7:17 AM, revealed Resident #2 fell from the bed. The resident was assisted back to bed by the staff. He/she received a one inch cut to his/her right eyebrow. Further review revealed there was no assessment for the safe use of the specialty air mattress. An observation, on 07/27/11 at 9:00 AM, revealed Resident #2 was lying on a specialty air mattress with settings of ALTERNATING-NORMAL and COMFORT LEVEL #2. 9. A record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the significant change MDS, dated [DATE], revealed the facility assessed Resident #7 to have a BIMS score of four (4). Resident #7 was non-ambulatory and required extensive to total assistance with all ADLs. A review of the Post Fall Assessment, dated 01/25/11 at 12:30 AM, revealed Resident #7 sat up on the side of his/her bed and attempted to transfer himself/herself and fell . A gray mat was placed on the right side of his/her bed. Further review revealed there was no assessment for the safe use of the specialty air mattress. An observation, on 07/27/11 at 9:05 AM, revealed Resident #7 was lying on a specialty air mattress with a setting of 225. 10. A record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].. A review of the significant change MDS, dated [DATE], revealed the facility assessed Resident #18 to have a BIMS score of seven (7). Resident #18 required extensive assistance with all of his/her ADLs. A review of the nurses' note, dated 03/10/11 at 1:30 AM, revealed Resident #18 fell from the bed. The resident was assisted back to his/her bed with a mechanical lift. A review of the nurses' note, dated 04/19/11 at 5:00 AM, revealed Resident #18 rolled out of the bed. The resident was transferred back to his/her bed with a lift. A review of the nurses' note, dated 05/11/11 at 11:06 PM, revealed Resident #18 was found on the floor next to his/her bed. The resident was transferred back to his/her bed with assistance of two staff and a lift. A review of the nurses' note, dated 06/16/11 at 3:30 AM, revealed Resident #18 attempted to self-transfer from the bed. He/she was transferred back to bed. A review of the nurses' note, dated 07/02/11 at 5:45 AM, revealed Resident #18 was found on the gray mat beside his/her bed. He/she attempted to self-transfer self from the bed, but was transferred back to the bed by the staff. Further review revealed there was no assessment for the safe use of the specialty air mattress following any of the five (5) falls. Observations, on 07/26/11 at 2:55 PM and on 07/29/11 at 5:55 PM, revealed Resident #18 was lying on a specialty air mattress with settings of ALTERNATING-NORMAL and COMFORT LEVEL #2. An interview with Treatment Nurse #1, on 07/29/11 at 12:15 PM, revealed "it was a nursing call as to what type of bed was to be used." Treatment Nurse #1 verbalized there was no specific form used to assess for risks versus benefits before using a specialty mattress. She stated settings for the specialty mattress were to be set on what the resident liked; however, there was no facility protocol to determine the settings. Interviews with Treatment Nurse #2 and #3, on 07/29/11 at 1:10 PM, revealed the Treatment Nurses were responsible to determine who required a specialty mattress. Treatment Nurse #2 and #3 stated it was nursing judgement as to what type of bed was used. They were not aware of any type of assessment to be completed prior to placement of a resident on a specialty air mattress. Interviews with members of the Falls Committee which included Unit Supervisor #3, Minimum Data Set (MDS) LPN, Social Worker, Assistant Director of Nursing (ADON), and the Administrator, on 07/29/11 at 2:55 PM, revealed there was no assessment currently in place for the specialty mattress. The Administrator stated the ADON and Unit Supervisor #3 were working on a policy, "Safety issues related to Specialty Beds and Bed Rails," but the policy was not completed and was not currently being implemented. It was reported no training was completed as of yet related to the identification of a safety concern with the specialty mattresses. When questioned if anyone assessed to see if residents felt unsafe in bed, had a fear of falling, felt unstable, or whether or not the specialty bed enabled a fall, it was reported no assessment was completed for the use of the specialty mattress at that point. An interview with the Administrator, on 07/28/11 at 3:00 PM, revealed no assessments were conducted to address the risks verses benefits for the safe use of the air mattresses. She stated, "I have not considered the air mattresses a fall risk until now".