Every finding on record at Stone River Post Acute

Based on policy review, emergency menu, emergency supply inventory sheet, observation, and interview, the facility failed to ensure the dishwashing machine maintained the correct chemical sanitization concentration and failed to maintain an emergency supply of pureed (food that has been blended into a smooth, creamy, paste consistency) food. The facility had a census of 55 with 52 residents receiving trays, 6 of these residents receiving pureed food. The findings include: 1. Review of the facility policy titled, Dishmachine [dish machine] Use, dated 4/2006, revealed .Food Service staff required to operate the dishmachine will be trained in all steps of dishmachine use by the supervisor or a designee proficient in all aspects of proper use and sanitation.Dishmachine chemical sanitizer concentrations should be between 50-100 ppm [parts per million].If water temperatures or chemical sanitation concentrations do not meet requirements, cease use of dishmachine immediately until temperatures or PPM are adjusted. Review of the facility policy titled, Emergency Food Supply, dated 4/2021, revealed .It is the policy of the facility to establish procedures to ensure that food is available for residents, staff, and volunteers in the case of emergency.The Dietary Manager shall maintain a 3-day supply of nonperishable foods.The type of food will consider resident population and dietary needs, as reflected in the emergency menu. 2. Observation in the dish room on 12/3/2025 at 1:35 PM, revealed the dish machine chemical sanitization concentration was 10 ppm. During an interview on 12/3/2025 at 3:10 PM, the Dietary Manager (DM) was asked what the dish machine chemical sanitization concentration should be according to the facility policy. The DM replied, .50-100 [ppm]. The DM was asked if the dish machine provided the correct chemical sanitization concentration. The DM responded, No. 3. Observation in the dry stock room on 12/3/2025 at 1:40 PM, revealed the emergency food supply did not contain any pureed meat. Review of the undated Emergency Menu, revealed .Puree Ham or sausage.Puree Beef, Chicken, Pork. Review of the undated Emergency Supply inventory sheet, revealed the total servings needed for Puree Ham/Sausage was 40 servings or 0.44 cases needed, and the total servings needed for Puree Beef, Chicken, Pork was 80 servings or 1.33 cases needed. During an interview on 12/3/2025 at 3:15 PM, the DM was asked if there should be pureed meat in the emergency supply stock. The DM stated, Yes.

Based on policy review, medical record review, Closed Account Summary Report, Resident Statement Landscape, and canceled check review, revealed the facility failed to refund the personal funds deposited with the facility to the resident's estate within 30 days upon the death for 4 of 4 (Resident #72, Resident #73, Resident #74 and Resident #75) sampled residents. The findings included: 1. Review of the facility policy titled, Resident Trust Fund, dated [DATE], revealed .The facility Administrator will be responsible for establishing and maintaining a system that assures a full, complete, and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf .Upon death or discharge of a resident with a personal fund account, the facility will convey within 30 days the resident's funds and a final accounting of those funds . 2. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including Acute and Chronic Respiratory Failure, Pleural Effusion, and Diabetes. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #72 was cognitively intact. Review of the Closed Account Summary Report dated [DATE] through [DATE], revealed Resident #72 was discharged from the facility due to death on [DATE], and had a closing balance of $1814.05. Review of the Resident Statement Landscape revealed Resident #72 expired on [DATE], the facility closed the account on [DATE], and disbursed check #1035 for $1814.05 on [DATE]. The check cleared on [DATE]. The facility failed to refund money to Resident #72's estate by [DATE]. 3. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including Systemic Lupus, Dementia, and Neuralgia. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 4, which indicated Resident #73 was severely cognitively impaired. Resident #73 was discharged due to death on [DATE] and had a closing balance of $1493.80. Review of the Resident Statement Landscape revealed Resident #73 expired on [DATE], the facility closed the account on [DATE], and disbursed check #1036 for $1493.80 on [DATE]. The check cleared on [DATE]. The facility failed to refund money to Resident #73's estate by [DATE]. 4. Review of the medical record revealed #74 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Diabetes, and Chronic Obstructive Pulmonary Disease. Review of the annual MDS assessment dated [DATE], revealed a BIMS score of 11, which indicated Resident #74 was moderately cognitively impaired. Resident #74 was discharged due to death on [DATE], with a closing balance of $70.05. Review of the Resident Statement Landscape revealed Resident #74 expired on [DATE], the facility closed the account on [DATE], and disbursed check #1012 for $70.05 on [DATE]. The check cleared on [DATE]. The facility failed to refund money to the estate of Resident #74 by [DATE]. 5. Review of the medical record revealed Resident #75 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis, Acute Respiratory Failure with Hypoxia, and Chronic Respiratory Failure with Hypoxia. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 10, which indicated Resident #75 was moderately cognitively impaired. Resident #75 was discharged due to death on [DATE], with a closing balance of $6,696.84. Review of the Resident Statement Landscape revealed Resident #75 expired on [DATE], the facility closed the account on [DATE], and disbursed check #1015 for $6696.84 on [DATE]. The check cleared on [DATE]. The facility failed to refund money to Resident #75's estate by [DATE]. During an interview on [DATE] at 8:50 AM, the Admissions Coordinator/Interim Business Office Manager (BOM) was asked how long the facility has to refund the trust account balance following discharge from the facility. The Interim BOM stated they have 60-days to settle the account, and that the account has to be evaluated and transferred to the Resident Fund Management Service (RFMS) and has to be approved by the Administrator. The BOM can print the check after the amount has been approved by the Administrator and the BOM. During an interview on [DATE] at 9:38 AM, the Administrator was asked how many days the facility had to refund the resident funds after a resident's death. The Administrator replied .30 days .

Based on policy review, medical record review, observation, and interview, the facility failed to honor food preferences for 2 of 16 (Resident #6 and Resident #26) sampled residents. The findings include: 1. Review of the facility policy titled, Resident Food Preferences, dated 2001, revealed . Nursing/dietary staff will document the resident's food and eating preferences on the diet order and/or meal ticket . 2. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Diabetes. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 had a Brief Interview for Mental Status (BIMS) assessment score of 15, which indicated he was cognitively intact. Resident #15 was coded for receiving a therapeutic diet. Review of the Care Plan dated 11/16/2025, revealed .Resident has a diagnosis of diabetes and is at risk for complications manifested by hyperglycemia.Dietary referral as indicated . Review of the Progress Note dated 11/20/2025 at 3:06 PM, revealed . IDT [Interdisciplinary Team]- Weekly Weight Nutrition Note .DX [diagnosis] .TYPE 2 DM [Diabetes] .CURRENT DIET CCHO [Controlled Carbohydrate] [a diet to keep blood sugar stable] . During an interview on 12/1/2025 at 11:03 AM, Resident #6 stated, .I am diabetic, but they bring me sweet tea every day for lunch and dinner .I always ask for milk instead of tea but I never get it . Observation of Resident #6's lunch tray on 12/2/2025 at 1:16 PM, revealed a cup of sweet tea, 2 packets of regular sugar, and no milk. The meal card on the tray revealed .CCHO . During an observation and interview on 12/03/2025 at 8:39 AM, Resident #6 stated .I told them I don't like oatmeal but there it is .and I asked for a banana but I didn't get one . Resident #6's meal ticket on his tray stated .NO OATMEAL .ADD BANANA . Resident #6 stated .I have to water down my tea [at other meals] to weaken it so I will have something to drink . 3. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Malignant Neoplasm of the Brain, Seizures, and Anxiety. Review of the admission MDS assessment dated [DATE], revealed Resident #26 had a BIMS score of 15, which indicated she was cognitively intact. During an observation and interview on 12/3/2025 at 8:32 AM, Resident #26 was sitting in bed eating breakfast and stated .They know I can't eat sausage . There was a sausage patty on her breakfast plate. Resident #26 stated she had also gotten it the day before and that she just moved it to the side and didn't eat it. Observation of the meal ticket that was on her tray revealed .ALLERGY .SAUSAGE . The word SAUSAGE was highlighted in red. During an interview on 12/04/2025 at 9:16 AM, the Dietary Manager (DM) was shown the Dietary Preferences sheet for Resident #6 and Resident #26, along with the meal tickets that was placed on both Resident's dining trays when they were served. The DM was asked if Diabetics should receive sweet tea if they were on a Controlled Carbohydrate diet and she replied .No . The DM also confirmed that the Resident should receive what he had written on his meal ticket. The DM was asked if a food that was identified as an allergy for a resident should be placed on their meal tray. The DM stated .No .

Based on facility policy review, medical record review, signed written statements, and interview, the facility failed to report a staff to resident allegation of abuse to the State Survey Agency for 1 (Resident #6) of 8 sampled residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse Prohibition Plan, revised 10/24/2022, revealed, The facility has a zero-tolerance policy for abuse .physical abuse .is prohibited .The facility shall attempt to identify and shall investigate any reported violation or allegation of abuse .'Abuse' means the willful infliction of injury .or punishment with resulting physical harm, pain, or mental anguish .'Physical Abuse' includes .slapping .'Alleged violation' is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another healthcare provider, or others but has not yet been investigated .The policy of this facility is that reports of abuse .are promptly and thoroughly investigated .The investigation shall begin immediately .The investigation and conclusion regarding all reported allegations/incidents of abuse shall be reported to the State Agency by way of the web-based Incident Reporting system (IRS) within 5 calendar days of the initial report of the abuse, incident, or allegations .are reported per Federal and State Regulations and Law .The facility shall ensure that alleged violations involving abuse .are reported to the Tennessee Department of Health, Health Care Facilities Division and Adult Protective Services, in accordance with requirements .All alleged violations are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .The Administrator shall report the results of all investigations to the State Agency, within 5 working days of the allegation .All allegations, investigations, conclusions, corrective actions and electronic reports to the State Agency through the 'Incident Reporting System' (IRS) regarding abuse . Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included Acute kidney Failure with Tubular Necrosis, Heart Failure Unspecified, Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Psychotic Disorder with Hallucinations. Resident #6 was discharged from the facility on 9/20/2023. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of twelve (12) which indicated moderate cognitive impairment. Review of the General Nursing Note for Resident #6 dated 8/21/2024 at 10:50 AM revealed, Patient reported to CNA [Certified Nursing Assistant S] that the night shift [CNA Z] smacked her leg last night when changing her. [Resident #6] stated that she told [CNA Z] to stop that hurt and tech [CNA Z] smacked her leg again. Administrator notified by [Registered Nurse (RN) Y] immediately . Review of a signed written statement dated 8/21/2023, by Former Administrator revealed, On 8/21/23, [RN Y] and [CNA S], came to my office to report an occurrence .[Resident #6] advised them that a tech [CNA] overnight had slapped her leg twice .The patient was complaining of pain in her legs .The DON [Director of Nursing] assessed [Resident #6] and stated that the leg .was red, swollen, and warm to touch .[Resident #6] advised that it was painful, and that the tech [CNA] last night hurt it while doing patient care .it was very painful to touch and that it hurt when the tech turned her . Review of the signed written statement dated 8/21/2023, by the Former DON revealed, After [CNA S] reported to [RN Y] and [Former Administrator] .[Resident #6], was saying that the [CNA] overnight had slapped her leg twice, [Former DON] and Administrator went to speak with [Resident #6]. [Resident #6] was complaining of pain in her legs .On assessment .upper thigh is red, swollen, and warm to touch. [Resident #6] stated it was painful and that the [CNA] last night had hurt it . The facility was unable to provide documentation that this abuse allegation was reported to the State Agency. During an interview on 4/17/2024 at 10:30 AM, the Social Services Director (SSD) stated, I was not made aware of any allegation of abuse made by [Named Resident #6] .I usually assist in the reporting of abuse allegations. During a telephone interview on 4/17/2024 at 11:00 AM, RN Y stated, I went and talked with [Named Resident #6] .I went to the [Former Administrator]'s office and reported it immediately. My understanding was that the [Former Administrator] was going to start an investigation. During a telephone interview on 4/17/2023 at 11:30 AM, CNA S stated [Named Resident #6] had told me that the overnight [CNA Z] had slapped her leg twice when giving care. I reported it to [RN Y] and we both went to the [Former Administrator]'s office and reported what [Named Resident #6] had told me. I remember telling the [Former Administrator] who the night [CNA] was, and [Former Administrator] stated he would speak to [Named CNA Z] and [Named Resident #6] and find out what was going on . During an interview on 4/17/2024 at 12:20 PM, the Administrator stated, The documentation on the General Nursing Note for [Named Resident #6] was an allegation of staff to resident abuse and should have been reported to the State Agency on 8/21/2023 .

Based on policy review, medical record review, facility investigation review, and interview, the facility failed to report an allegation of abuse to the abuse coordinator for 1 of 3 (Resident #2) sampled residents. The findings include: Review of the facility's policy titled Abuse Prohibition Plan dated 10/24/2022 revealed .Employees must always report any allegation of abuse or suspicion of abuse immediately to their supervisor. The supervisor shall notify the Director of Nursing and/or the Administrator . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included Dementia without Behavioral Disturbances, Speech Disorder, and a Personal History of Nutritional and Metabolic Disease. Review of the undated care plan revealed Resident #2 was care planned for .At risk for malnutrition, mechanically altered diet . Continued review revealed one of the interventions was .Allow adequate time to eat; provide cues; encouragement, and assistance . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had a Brief Inventory for Mental Status (BIMS) score of 0 which indicated Resident #2 had severe cognitive impairment. Resident #2 required total assistance with eating, and she had a swallowing disorder such as holding food in mouth after a meal. Resident #2 had no speech and could not express her ideas or wants verbally. Resident #2 rarely and/or never understood others when spoken to. Resident #2 rejected care 1 to 3 days in the 7-day look-back period. Review of the facility investigation on 8/2/2023 revealed the the alleged allegation of abuse occurred on 8/1/2023 during the lunch meal. Restorative Certified Nursing Assistant (CNA) reported to the Administrator who was the abuse coordinator on 8/2/2023, she witnessed Family Member #1 speaking ugly to Resident #2 by calling her lazy and telling her she would not go home if she did not get up and forcing her to eat when she was trying to refuse. During an interview on 8/8/2023 at 2:03 PM, the Restorative CNA stated she wittnesed Family Member #1 being demanding and said to Resident #1 keep the food in your mouth you don't want to be lazy. You want to go home don't you? The Restorative CNA stated she thought Family Member #1 had an attitude with Resident #1. During an interview on 8/8/2023 at 2:42 PM, the Director of Therapy stated the alleged verbal abuse happened in the therapy room around 12:00 PM on 7/28/2023. Family Member #1 was present during the session. Family Member #1 would ask daily how Resident #2 was doing and progressing in therapy. During the session, Resident #2 could not complete an exercise, and Family Member #1 made a remark to the Director of Therapy that Resident #2 was acting lazy. The Director of Therapy stated she was uncertain if she should report the incident as potential verbal abuse. The Director of Therapy stated she finally told the Administrator on 8/2/2023 of the incident with Family Member #1 when the Restorative CNA reported her concerns to the Administrator. During an interview on 8/9/2023 at 9:07 AM, the Restorative CNA stated she witnessed Family Member #1 on 8/1/2023 talking really loudly and urged Resident #2 she needed to swallow some fruit, but she kept taking the fruit out of her mouth. The Restorative CNA told Family Member #1 the resident was probably full. Family Member #1 told the Restorative CNA the resident needed to eat all of the food. The Restorative CNA stated she was unsure about reporting what she saw but reported it the next day to the Administrator. The Restorative CNA stated she did not write an incident report. The Restorative CNA confirmed she should have told the abuse coordinator immediately when she suspected abuse, but she was unsure and did not know what to do. During an interview on 8/9/2023 at 9:49 AM, the Administrator stated he expected staff to report suspected or allegations of abuse immediately.

Based on facility document review, facility policy review, medical record review, observation, and interview, the facility failed to have sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with the facility assessment for 9 of 20 (Resident # 1, #4, #10, #11, #12, #13, #14, #19, and #20) sampled residents reviewed. Failure to assure the facility had sufficient nursing staff had the potential to affect all residents within the facility. The findings include: Review of the Facility Assessment Committee Review dated 4/25/2023 revealed .Based on our resident population and their needs of care and support, the objective of staffing is to ensure that we have enough staff to meet the needs of the residents at any given time .Ensure the type and amount of staff needed to meet resident's daily needs, preferences, and routines in order to help each resident attain or maintain the highest practicable physical, mental, and psychosocial well-being . Review of the Quarterly Payroll Based Journal (PBJ) dated 7/1/2022-9/30/2022 revealed one star staffing ratio. Continued review of the Quarterly PBJ system dated 10/1/2022 - 12/31/2022 revealed one star staffing ratio and excessively low weekend staffing. Review of the Resident Council Meeting Minutes dated 12/16/2022-4/14/2023, revealed statements made by residents about their concerns, .12/16/2022 .tech answered light then said you will have to wait til (until) we find your tech . 1/23/2023 .Call lights taking over 30 minutes to be answered .2/15/2023 .Call lights not being answered in a timely manner .4/14/2023 .Late getting medicine, answer lights timely . Review of the Grievance Record from 12/6/2022-5/16/2023 documented, .12/6/2022 .Staff taking a long time to answer call lights, staff not washing resident's face, brushing teeth, and clothes were not changed . 2/17/2023 Resident #6's call light . not answered timely .resident was told to go on herself .4/4/2023 . medication given late 5/4/2023 .call lights not being answered . Review of the posted Daily Nurse Staffing sheets from 1/19/2023 to 1/31/2023 revealed multiple days with no documentation of resident census, absent staff members, or adjusted shift hours. Review of the facility policy titled, Nursing Services and Sufficient Staff, dated 12/24/2022 revealed, .It is the policy of this facility to provide sufficient nursing staff .as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required .Providing care includes, but is not limited to, assessing, evaluating, planning, and implementing resident care plans and responding to residents needs and call bells promptly .The facility is responsible for submitting timely and accurate staffing data through the CMS [Centers for Medicare and Medicaid Services] Payroll-Based Journal [PBJ] system .the facility must use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Acute Respiratory Failure with Hypercapnia, Type 2 Diabetes Mellitus, and Morbid (Severe) Obesity. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], for Resident #1, revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Further review of the MDS assessment revealed the resident required extensive assistance with toileting, bathing, and bed mobility. Continued review of the MDS assessment revealed Resident #1 was frequently incontinent of bowel and bladder. Review of the Comprehensive Care Plan for Resident #1 revealed a risk for skin integrity complications with intervention to provide frequent position changes, check for incontinence, and change if wet/soiled. Clean skin with mild soap and water. Apply moisture barrier, and hygiene as needed after every incontinent episode. Continued review of the care plan revealed Resident #1 had a self-care deficit R/T [related to]ambulation, bathing, bed mobility, dressing, eating, hygiene, locomotion, and transfers, and bath/shower 3 times a week and as needed. Review of the Bath Sheets revealed there was no documentation Resident #1 had a shower or bath for eight days, from 10/30/2022 to 11/6/2022. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses which included Malignant Neoplasm of Unspecified Kidney, Chronic Obstructive Pulmonary Disease (COPD), and Hypertensive Heart Disease. Review of the Quarterly MDS dated [DATE] revealed Resident #4 had a BIMS score of 10 which indicated moderately impaired cognition. Continued review of the MDS revealed Resident #4 required extensive assistance with dressing and personal hygiene and totally dependent for toileting and bathing. Review of the current care plan revealed Resident #4 had a history of falls, with 6 falls documented from 11/20/2021 to 6/9/2022 with intervention to remind resident to call for assistance before moving from bed to chair and from chair to bed. Continued review of the care plan revealed self-care deficit related to ambulation, bathing, bed mobility, dressing, hygiene, locomotion, and transfers with intervention for bathing, bath/shower 3 times a week and as needed, and toileting with the call light in reach for assistance. During a telephone interview on 5/23/2023 at 7:15 PM, Family Member #2 (for Resident #4) reported, .The facility has staffing issues especially on the weekends. The call light would go off for long periods of time without it being answered. I was told showers or baths can't be given on Saturdays due to the facility being short staff . Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarct affecting Right Dominant side, COPD, and Chronic Respiratory Failure. Review of the Quarterly MDS dated [DATE] revealed Resident #10 had a BIMS score of 14 which indicated no cognitive impairment. Review of the current care plan revealed Resident #10 had a history of falls with a fall documented on 3/14/2023. A Physical Therapy evaluation revealed resident required lift transfer with two persons assist. Further review of the fall care plan revealed an intervention to respond promptly to call for assist to the toilet. Continued review of the care plan documented incontinent of bowel and bladder with intervention to take resident to bathroom before and after meals, at bedtime, upon rising in the morning, and during the night. During an interview on 5/23/2023 at 11:12 AM, Resident #10 stated, .I must wait on my call light to be answered, sometimes 30 minutes . Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Diabetes Mellitus, Peripheral Vascular Disease, Abnormal Weight loss, and Acquired Absence of Left and Right leg above knee. Review of the Annual MDS assessment dated [DATE] revealed Resident #11 had a BIMS score of 9 which indicated moderate impairment in cognition. Continued review of the MDS revealed Resident #11 required extensive assistance with dressing, personal hygiene and total assistance with toileting and bathing. Review of the current care plan revealed Resident #11 had a problem for at risk for impaired skin integrity, abrasions, bruises, skin tears, and fragile skin with interventions for assist and encourage to turn and reposition every 2 hours and incontinence care PRN. Continued review of the care plan revealed a problem of fall risk with 6 falls noted from 4/14/2022 to 8/1/2022 and recent fall from wheelchair on 4/20/2023. Fall intervention included place call bell/light within easy reach, remind to call for assistance before moving from bed to change and from chair to bed and respond promptly to calls for assist to the toilet. Further review of the care plan revealed Resident #11 with self-care deficit related to ambulation, bathing, bed mobility, dressing, eating, hygiene, locomotion, and transfers with intervention to bath/shower 3 x weekly/prn as tolerated alternating days with bed baths. Review of the BM and Bath sheets revealed Resident #11 had no bath or shower for five days, from 5/18/2023 - 5/22/2023. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses which included Acute Kidney Failure, Fusion of Spine, Cervical Region, and Unspecified Fall. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Continued review of the MDS revealed Resident #12 required limited assistance of 1 staff member for dressing, one-person physical assistance with toileting, personal hygiene, and dependent for bathing. Review of the current Care Plan revealed a history of falls with an intervention to respond promptly to calls for assist to the toilet. Continue review of the care plan revealed assistance needed with toileting. Resident #12 required supervision with an intervention to keep nurse call light within easy reach, and Instruct Resident #12 to use call bell or call out for assistance. During an observation and interview in Resident #12's room on 5/23/2023 at 10:53 AM, Resident #12 stated I often need to toilet, I turn on my call light, but I have to wait for 30 minutes or longer which makes it hard for me to hold my urine . Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses which include Chronic Obstructive Pulmonary Disease, Hypertension Heart Disease, Type 2 Diabetes Mellitus, Chronic Respiratory Failure with Hypoxia, Idiopathic Gout Unspecified Site, and Chronic Systolic Congestive Heart Failure. Review the Quarterly MDS dated [DATE] for Resident #13 revealed a BIMS score of 15, which indicated no cognitive Impairment. During an interview on 5/23/2023 at 12:37 PM, Resident #13 stated, . the meals are often late because there is not enough staff to get food out timely .I wait 30 to 45 minutes for the call light to be answered, especially when I want to get out of bed . Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses which include Compression of the Vein, Pleural Effusion not Elsewhere Classified, Type 1 Diabetes Mellitus, and Anemia Unspecified. Review of the Annual MDS dated [DATE] revealed a BIMS score of 15, which indicated no cognitive Impairment. During an interview on 5/23/2023 at 12:40 PM, Resident #14 stated, .meals are often late due to short staffing, sometimes there is only 1 CNA [Certified Nursing Assistant] on the hall, and from 4:00 PM - 9:00 PM there were only 2 CNAs for the entire building (dates unknown) . Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses which included COPD, Emphysema, and Fracture of Unspecified Part of Neck of Left Femur. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated no cognitive impairment. Continued review of the MDS revealed Resident #19 required extensive assistance with dressing, personal hygiene, and total assistance with toileting and bathing. Review of the current care plan revealed Resident #19 had a problem with falls with an intervention to respond promptly to calls for assist to the toilet. Continued review of the care plan revealed Resident #19 was at risk for malnutrition related to recent weight loss with interventions to provide cues, encouragement, and assistance. Continued review of the care plan revealed Resident #19 had a problem of self-care deficit extensive assistance required with bathing, hygiene, dressing and grooming with interventions for total assist with dressing and undressing, bathing 3 times a week and as needed, toileting, and call light in reach for assistance. Review of Resident #19's Bath Sheets revealed from 3/3/2023 to 3/13/2023 (11 days) there were no documented baths or showers given, 4/7/2023 to 4/10/2023 (4 days) no documented baths or showers given, 4/20/2023 to 4/24/2023 (5 days) no documented baths or showers given, and 5/12/2023 to 5/15/2023 (4 days) no documented baths or showers given. During an observation and interview on 5/24/2023 at 12:10 PM, Resident #19 was in bed with dried food observed on her shirt. Resident #19 stated, Staffing is a problem here, not enough staff, I can't always get a bath when I want one . when I am wet with no one to come help me. They know my call light is ringing and it takes a long time to answer it . Several times on the weekends there are only 2 CNAs in the building . Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses which included Acute Pyelonephritis, Hypertension, Arthritis, and Acute Cystitis. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 12 which indicated intact cognitive abilities. Continued review of the MDS revealed extensive assistance required with dressing, toileting, personal hygiene, and total assistance with bathing. Review of the current care plan revealed fall risk with interventions to respond promptly to calls for assistance to toilet and remind to call for assistance before moving from bed to chair and from chair to bed. Continued review of the care plan revealed Resident #20 was at risk for pressure ulcer related to decreased mobility, fragile skin, and incontinence with intervention for turn and reposition routinely. Further review of the care plan revealed Resident #20 had a problem of self-care deficit related to ambulation, bathing, bed mobility, dressing, eating, hygiene, locomotion, and transfers with intervention for bath/shower 3 times a week and as needed. Review of the Bath Sheets revealed there was no documentation Resident #20 had a shower or bath from 2/13/2023 to 2/21/2023 (9 days) and from 2/28/2023 to 3/8/2023 (9 days). There was no documentation Resident #20 had a shower From 2/9/2023 to 5/24/2023 (105 days). During an observation and interview with Resident #20 on 5/24/2023 at 12:20 PM, there was a strong urine odor in Resident #20's room. Resident #20 stated her last bed bath had been over a week ago. Resident #20 further stated, .I turn on my call light and wait .I usually lay wet 30 minutes to an hour just waiting to be cleaned up. The facility doesn't have enough staff and the staff is inconsistent. Many days there are only 2 CNAs in the building . During an interview on 5/24/2023 at 9:10 AM, CNA #4 confirmed the staffing is insufficient and the schedule will reflect names of staff members that do not show up for the shift. During an interview on 5/24/2023 at 9:27 AM, CNA #6 stated, . there is not enough staff . this prevents us from being able to give showers .The residents complain of excessive wait times for care . During an interview on 5/24/2023 at 10:45 AM, the Staffing Coordinator stated, I look at the census to see how many patients we have and just divide the staff between the residents . The turnover is bad right now .There have been times when only 2 CNAs were on the halls for 60 residents . There are times the staff just don't show up .I have reported the staffing concerns to the Administrator . During an interview on 5/24/2023 at 12:30 PM, CNA #6 stated, The workload is hard here because we are short staffed. The staffing Coordinator will post the staffing hours, but half of the staff don't show up, so we just work with what we have in the building. I try my best to give the baths, but I can't always get them done. Staff turn over is bad. During an interview on 5/24/2023 at 1:00 PM, Registered Nurse #3 stated, . There have been times only 2 CNAs (Certified Nursing Assistants in the building. I couldn't tell you how many times, but it has been often . During an interview on 5/24/2023 at 1:10 PM, Assistant Director of Nursing (ADON) stated, .We have staffing issues . During an interview on 5/24/2023 at 1:30 PM, Licensed Practical Nurse (LPN) #3 stated, .Residents have complained that it takes forever for staff to answer call lights. I want the residents to get what they need. Its especially hard at night with only 2 CNAs. It makes it hard to get the residents cleaned up if we only have 2 CNAs. During a telephone interview on 5/24/2023 at 2:15 PM, the Ombudsman stated, I have had several residents complain about their care at the facility. My concerns are the quality of care, staffing concerns .The residents say it is taking the staff 1/2 hour to 1 hour to answer their call lights. I have tried to speak with the Administrator, but he has not been responsive . During a telephone interview on 5/24/2023 at 2:21 PM, The Assistant [NAME] President of Quality confirmed the PBJ (Payroll Based Journal) Staffing Data Report for July 1-September 30, 2022 revealed One Star Staffing Rating and PBJ Staffing Data Report for October 1 - December 31, 2022 revealed One Star Staffing Rating and Excessively Low Weekend Staffing was correct. During an interview with the Director of Nursing (DON) on 5/24/2023 at 3:05 PM, the DON stated, . We have had reports from family that have called due to call lights not answered. We do discuss the staffing issues with the Administration .

Based on facility policy review, facility document review, medical record review, observation, and interview, the facility failed to answer call lights in a timely manner for 8 of 20 (Resident #1, #4, #10, #11, #12, #13, #19, and #20) sampled residents reviewed. The facility failed to provide baths and/or showers for 5 of 20 (Resident #1, #11, #16, #19, and #20) sampled residents reviewed for bathing. The findings include: Review of the facility policy titled, Activities of Daily Living [ADL], dated 3/9/2023 revealed, .Care and services shall be provided for the following activities of daily living .bathing, dressing, grooming, and oral care .Toileting .A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .The facility shall maintain individual objectives of the care plan . Review of the facility policy titled, Call Lights: Accessibility and Response, dated 6/27/2022 revealed, .The purpose of this policy is to ensure call light accessibility and response .The purpose of this policy is to assure the facility is adequately equipped with a call light at each Resident's bedside, toilet, and bathing facility to allow Residents to call for assistance. Call lights will directly relay to a centralized location to ensure appropriate response .All staff members who see or hear an activated call light are responsible for responding . Review of the facility policy titled, Nursing Services and Sufficient Staff, dated 12/24/2022 revealed, .It is the policy of this facility to provide sufficient nursing staff .as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required .Providing care includes, but is not limited to, assessing, evaluating, planning, and implementing resident care plans and responding to residents needs and call bells promptly .The facility is responsible for submitting timely and accurate staffing data through the CMS [Centers for Medicare and Medicaid Services] Payroll-Based Journal [PBJ] system .the facility must use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week . Review of the facility policy titled, Incontinence Skin Care Policy, dated 9/13/2022 revealed, .Residents who are incontinent will receive appropriate treatment and services for the prevention and management of incontinence .Incontinence care is considered routine care that is typically performed by the certified nursing assistant after identified incontinent episodes . Review of the Resident Council Meeting Minutes dated 12/16/2022-4/14/2023, revealed statements made by residents about their concerns, .12/16/2022 .tech answered light then said you will have to wait til (until) we find your tech . 1/23/2023 .Call lights taking over 30 minutes to be answered .2/15/2023 .Call lights not being answered in a timely manner .4/14/2023 .Late getting medicine, answer lights timely . Review of the Grievance Record from 12/6/2022-5/16/2023 documented, .12/6/2022 .Staff taking a long time to answer call lights, staff not washing resident's face, brushing teeth, and clothes were not changed . 2/17/2023 Resident #6's call light . not answered timely .resident was told to go on herself .4/4/2023 . medication given late 5/4/2023 .call lights not being answered . Review of the posted Daily Nurse Staffing sheets from 1/19/2023 to 1/31/2023 revealed multiple days with no documentation of resident census, absent staff members, or adjusted shift hours. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Acute Respiratory Failure with Hypercapnia, Type 2 Diabetes Mellitus, and Morbid (Severe) Obesity. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], for Resident #1, revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Further review of the MDS assessment revealed the resident required extensive assistance with toileting, bathing, and bed mobility. Continued review of the MDS assessment revealed Resident #1 was frequently incontinent of bowel and bladder. Review of the Comprehensive Care Plan for Resident #1 revealed a risk for skin integrity complications with intervention to provide frequent position changes, check for incontinence, and change if wet/soiled. Clean skin with mild soap and water. Apply moisture barrier, and hygiene as needed after every incontinent episode. Continued review of the care plan revealed Resident #1 had a self-care deficit R/T [related to]ambulation, bathing, bed mobility, dressing, eating, hygiene, locomotion, and transfers, and bath/shower 3 times a week and as needed. Review of the Bath Sheets revealed there was no documentation Resident #1 had a shower or bath for eight days, from 10/30/2022 to 11/6/2022. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses which included Malignant Neoplasm of Unspecified Kidney, Chronic Obstructive Pulmonary Disease (COPD), and Hypertensive Heart Disease. Review of the Quarterly MDS dated [DATE] revealed Resident #4 had a BIMS score of 10 which indicated moderately impaired cognition. Continued review of the MDS revealed Resident #4 required extensive assistance with dressing and personal hygiene and totally dependent for toileting and bathing. Review of the current care plan revealed Resident #4 had a history of falls, with 6 falls documented from 11/20/2021 to 6/9/2022 with intervention to remind resident to call for assistance before moving from bed to chair and from chair to bed. Continued review of the care plan revealed self-care deficit related to ambulation, bathing, bed mobility, dressing, hygiene, locomotion, and transfers with intervention for bathing, bath/shower 3 times a week and as needed, and toileting with the call light in reach for assistance. During a telephone interview on 5/23/2023 at 7:15 PM, Family Member #2 (for Resident #4) reported, . The call light would go off for long periods of time without it being answered. I was told showers or baths can't be given on Saturdays due to the facility being short staff . Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarct affecting Right Dominant side, COPD, and Chronic Respiratory Failure. Review of the Quarterly MDS dated [DATE] revealed Resident #10 had a BIMS score of 14 which indicated no cognitive impairment. Review of the current care plan revealed Resident #10 had a history of falls with a fall documented on 3/14/2023. A Physical Therapy evaluation revealed resident required lift transfer with two persons assist. Further review of the fall care plan revealed an intervention to respond promptly to call for assist to the toilet. Continued review of the care plan documented incontinent of bowel and bladder with intervention to take resident to bathroom before and after meals, at bedtime, upon rising in the morning, and during the night. During an interview on 5/23/2023 at 11:12 AM, Resident #10 stated, .I must wait on my call light to be answered, sometimes 30 minutes . Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses which included Diabetes Mellitus, Peripheral Vascular Disease, Abnormal Weight loss, and Acquired Absence of Left and Right Leg above Knee. Review of the Annual MDS assessment dated [DATE] revealed Resident #11 had a BIMS score of 9 which indicated moderate cognitive impairment. Continued review of the MDS revealed Resident #11 required extensive assistance with dressing, personal hygiene and total assistance with toileting and bathing. Review of the current care plan documented Resident #11 was at risk for impaired skin integrity, abrasions, bruises, skin tears, and fragile skin with interventions for assist and encourage to turn and reposition every 2 hours and incontinence care as needed. Review of the care plan revealed Resident #11 with self-care deficit related to ambulation, bathing, bed mobility, dressing, eating, hygiene, locomotion, and transfers with intervention to bath/shower 3 times a week as needed. Review of the Bath Sheets revealed there was no documentation Resident #11 had a bath or shower for five days, from 5/18/2023-5/22/2023 . Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses which included Acute Kidney Failure, Fusion of Spine, Cervical Region, and Unspecified Fall. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Continued review of the MDS revealed Resident #12 required limited assistance of 1 staff member for dressing, one-person physical assistance with toileting, personal hygiene, and dependent for bathing. Review of the current Care Plan revealed a history of falls with an intervention to respond promptly to calls for assist to the toilet. Continue review of the care plan revealed assistance needed with toileting. Resident #12 required supervision with an intervention to keep nurse call light within easy reach, and Instruct Resident #12 to use call bell or call out for assistance. During an interview on 5/23/2023 at 10:53 AM, Resident #12 stated I often need to toilet, I turn on my call light, but I have to wait for 30 minutes or longer which makes it hard for me to hold my urine . Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses which included COPD, Hypertension Heart Disease, Type 2 Diabetes Mellitus, Chronic Respiratory Failure with Hypoxia, Idiopathic Gout Unspecified Site, and Chronic Systolic Congestive Heart Failure. Review the Quarterly MDS dated [DATE] for Resident #13 revealed a BIMS score of 15 which indicated no cognitive Impairment. During an interview on 5/23/2023 at 12:37 PM, Resident #13 stated, .the meals are often late because there is not enough staff to get food out timely .I wait 30 to 45 minutes for the call light to be answered, especially when I want to get out of bed . Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses which included COPD, Emphysema, and Fracture of Unspecified Part of Neck of Left Femur. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated no cognitive impairment. Continued review of the MDS revealed Resident #19 required extensive assistance with dressing, personal hygiene, and total assistance with toileting and bathing. Review of the current care plan revealed Resident #19 had interventions to respond promptly to calls for assist to the toilet. Continued review of the care plan revealed Resident #19 was at risk for malnutrition related to recent weight loss with interventions to provide cues, encouragement, and assistance. Continued review of the care plan revealed Resident #19 had a problem of self-care deficit extensive assistance required with bathing, hygiene, dressing and grooming with interventions for total assist with dressing and undressing, bathing 3 times a week and as needed, toileting, and call light in reach for assistance. Review of Resident #19's Bath Sheets revealed from 3/3/2023 to 3/13/2023 (11 days) there were no documented baths or showers given, 4/7/2023 to 4/10/2023 (4 days) no documented baths or showers given, 4/20/2023 to 4/24/2023 (5 days) no documented baths or showers given, and 5/12/2023 to 5/15/2023 (4 days) no documented baths or showers given. During an observation and interview on 5/24/2023 at 12:10 PM, Resident #19 was in bed with dried food observed on her shirt. Resident #19 stated, . I can't always get a bath when I want one . when I am wet with no one to come help me. They know my call light is ringing and it takes a long time to answer it . Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses which included Acute Pyelonephritis, Hypertension, Arthritis, and Acute Cystitis. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 12 which indicated intact cognitive abilities. Continued review of the MDS revealed extensive assistance required with dressing, toileting, personal hygiene, and total assistance with bathing. Review of the current care plan revealed fall risk with interventions to respond promptly to calls for assistance to toilet and remind to call for assistance before moving from bed to chair and from chair to bed. Continued review of the care plan revealed Resident #20 was at risk for pressure ulcer related to decreased mobility, fragile skin, and incontinence with intervention for turn and reposition routinely. Further review of the care plan revealed Resident #20 had a problem of self-care deficit related to ambulation, bathing, bed mobility, dressing, eating, hygiene, locomotion, and transfers with intervention for bath/shower 3 times a week and as needed. Review of the Bath Sheets revealed there was no documentation Resident #20 had a shower or bath from 2/13/2023 to 2/21/2023 (9 days) and from 2/28/2023 to 3/8/2023 (9 days). There was no documentation Resident #20 had a shower From 2/9/2023 to 5/24/2023 (105 days). During an observation and interview with Resident #20 on 5/24/2023 at 12:20 PM, there was a strong urine odor in Resident #20's room. Resident #20 stated her last bed bath had been over a week ago. Resident #20 further stated, .I turn on my call light and wait .I usually lay wet 30 minutes to an hour just waiting to be cleaned up. The facility doesn't have enough staff and the staff is inconsistent. Many days there are only 2 CNAs in the building . During an observation on 100 hall on 5/24/2023 at 3:45 PM, call lights for room [ROOM NUMBER] and 111 were on, and the call light system was alarming at the nurses' station. At 3:50 PM, 2 employees were standing on the 100 hall, and the call lights for room [ROOM NUMBER] and 111 continued to be on. At 3:55 PM, 2 employees were sitting at the nurses' station while the call light system continued to alarm for room [ROOM NUMBER] and 111. At 4:07 PM, a staff member continued to sit at nurses' station while the call light system alarmed for room [ROOM NUMBER] and 111. At 4:08 PM, there were two employees sitting in the admission office which was two doors down from the nurses' station and close enough to the nurses' station to hear the call light system alarming. At 4:09 PM, this Surveyor went to room [ROOM NUMBER] and 111 to verify the residents were safe (residents were safe). At 4:10 PM, 2 staff members were sitting at the nurses' station while the call light system alarmed for room [ROOM NUMBER] and 111. The Staffing Coordinator answered each call light at 4:14 PM. The call light for rooms [ROOM NUMBERS] alarmed for 29 minutes before being answered. The Staffing Coordinator confirmed the call light was not answered timely. During an interview on 5/24/2023 at 9:27 AM, CNA #6 stated, . there is not enough staff . this prevents us from being able to give showers .The residents complain of excessive wait times for care . During an interview on 5/24/2023 at 12:30 PM, CNA #6 stated, The workload is hard here . I try my best to give the baths, but I can't always get them done . During an interview on 5/24/2023 at 1:30 PM, Licensed Practical Nurse (LPN) #3 stated, . Residents have complained that it takes forever for staff to answer call lights . During a telephone interview on 5/24/2023 at 2:15 PM, the Ombudsman stated, I have had several residents complain about their care at the facility. My concerns are the quality of care .The residents say it is taking the staff 1/2 hour to 1 hour to answer their call lights. I have tried to speak with the Administrator, but he has not been responsive . During an interview with the Director of Nursing (DON) on 5/24/2023 at 3:05 PM, the DON stated, . We have had reports from family that have called due to call lights not answered .

Based on facility policy review, medical record review, and interview, the facility failed to ensure the resident rights for 2 of 4 (Resident #6 and #8) sampled resident reviewed were exercised as evidenced by failure to provide assistance with toileting upon request and required the residents (Resident #6 and #8) to wear briefs. The findings include: Review of facility's policy dated 10/24/2022, titled, Resident Rights and Resident Responsibilities, revealed, .The resident has a right to a dignified existence, self-determination, and communication with access to persons and services .The resident has the right to be free of interference, coercion, discrimination, and reprisal, from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights . Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which include Urinary Tract Infection, Acute Kidney Failure, Chronic Diastolic Congestive Heart Failure, Chronic Respiratory Failure, Morbid Obesity, Muscle Weakness Generalized, Difficulty in Walking, Unsteadiness on Feet, and Gout Unspecified. Review of the Comprehensive Minimum Data Set (MDS) dated [DATE], for Resident #6, revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive Impairment. Further review of the MDS revealed bed mobility and transfer as extensive assistance with 2 plus persons physical assist, toilet use as total dependence with 2 plus persons physical assist, and occasional incontinence. Review of the care plan for Resident #6 revealed, .Hoyer lift transfer with 2 staff .Respond promptly to calls for assist to the toilet .Complete set-up and provide assistance with bathing, grooming, mobility, toileting, and eating .Check for incontinence; change if wet/soiled .Evaluate incontinence pattern to determine voiding schedule .Provide assistance with all Activities of Daily Living (ADL) and mobility .Provide option of no briefs while in bed . Review of the Clinical Note dated 2/17/2023, for Resident #6, revealed, .Resident uses bedpan at this time until OT [Occupational Therapy] and PT [Physical Therapy] evaluation .Patient is not incontinent, using briefs at this time until evaluation from OT . During an interview on 5/23/2023 at 1:14 PM, Resident #6 stated, .Staff would not change me. I would be put on a bed pan for hours. I was told by one Certified Nursing Assistant (CNA) to just urinate on myself .I had issues with getting up so I was dependent on CNAs to help me get to the bathroom when needed. During an interview on 5/24/2023 at 4:30 PM, Social Services stated that an investigation was done regarding Resident #6's allegations of being told to urinate in her diaper. Social Services stated Resident #6 couldn't remember the name of the CNA. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included Unspecified fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing, Chronic diastolic (congestive) heart failure, and Hyperparathyroidism. Review of the Comprehensive MDS Assessment, dated 5/24/2023, for Resident #8, revealed a BIMS score of 14 which indicated no cognitive impairment. Continued review revealed wheelchair had been used, required extensive assistance with transfers and toilet use and limited assistance with dressing, and has occasional pain and a surgical wound with pressure reducing device in chair and bed. Further review revealed resident #8 was deemed always continent. Review of care plan effective 5/23/2023 revealed, a person-centered individualized care plan with appropriate goals and interventions that included resident at risk for pain related to Resident #8 has diagnosis of Tibia fracture s/p (status post) repair, self-care deficit r/t ambulation, bathing, bed mobility, dressing, eating, hygiene, locomotion and transfers. Further review of the plan revealed .Incontinence care PRN [as needed] .Toileting .Provide assistance as needed. Call light within reach for assistance . During an interview on 5/23/2023 at 10:55 AM, Resident #8 stated he arrived 5 days ago (5/18/2023) on a Friday evening and was not allowed to get up over the weekend. Resident #8 stated he needed to have a bowel movement and was told by staff that he could not get up out of bed until he was evaluated, which he was told would happen on Saturday. Resident #8 stated he was offered a bedpan which he was unable to use, therefore, he held his bowels until Monday which caused stomach pain. Review of the Statement of Inservice Training for Employees sheets, dated 3/8/2023, revealed staff was in-serviced on, .A resident should never be told to go ahead and urinate on their brief and they will clean them up later. This promotes incontinence and is against the residents' right to use the restroom . During an interview on 5/23/2023 at 3:20 PM, Certified Occupational Therapist Assistant (COTA) stated, . It is not our policy that the residents are not to get out of bed until evaluated by therapy .The expectation is for the staff to review the admission packet to find out how the resident transfers. The resident is expected to transfer at the same level as reported in that documentation prior to therapy's evaluation . During an interview on 5/23/2023 at 3:30 PM, Registered Nurse (RN) #2 stated, . A resident admitted near the weekend should be allowed to transfer according to hospital discharge information or by interviewing the resident if alert and oriented . During an interview on 5/25/2023 at 12:48 PM, CNA #8 stated she has witnessed CNAs tell residents to use the bathroom on themselves .

Based on facility policy review, record review and interviews, the facility failed to complete a thorough investigation and report an injury of unknown origin for 1 resident (Resident #1) reviewed. Review of the facility policy titled, Abuse, Neglect, and Exploitation Policy, reviewed 8/2021, revealed, .policy of this company for employees to report signs of abuse, neglect, or exploitation .suspected cases of abuse, neglect or exploitation of patients/caregivers including elderly or disabled adults and children are thoroughly investigated and reported .Abuse that results in serious injury or harm must be reported within 2 hours of identification of the abuse . Review of the facility policy titled, Patient Incident/Accident Reporting Policy, reviewed 9/2021, revealed, .policy of this company to establish a procedure for reporting, documenting, investigating, and tracking patient incidents .ensure patient safety and to define the criteria of patient incident/accident to be reported .ensure compliance with all applicable standards and regulations .ensure compliance and report reportable events to the Department of Health .Facilities are also required to report injuries of unknown source . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a BIMS score of 1, which indicated severe cognitive impairment. Resident #1 required limited to total dependence with all Activities of Daily Living (ADL)s. Review of the Comprehensive Care Plan for Resident #1 revealed care plans which included risk for falls, [CONDITION(S)]/[CONDITION(S)] to left side, [CONDITION(S)], and Self Care deficit. Interventions and revisions included gait belt with transfers. Review of the Nurse Practitioner's soap note dated 6/6/2022, revealed, .Nurse requesting I see patient d/t [due to] new onset left arm/shoulder pain .X-ray ordered shows acute fracture of the humerus .sent to ER [emergency room ] for further evaluation . Review of the Clinical Notes Report revealed, .effective 6/5/2022 .entered date 6/8/2022 .Resident c/o [complaint of] ingestion and mild left arm pain .effective 6/6/2022 .entered 6/6/2022 .Resident had xray to left arm r/t [related to] pain and bruise .Xray completed arm broken patient sent to ER . Review of the hospital consultation notes dated 6/6/2022, revealed, resolving ecchymosis around the proximal arm .unclear what the exact etiology is of the fracture .significant osteopenia .trivial injury could cause the fracture .possibly elder abuse .been investigating at the nursing home . Review of the investigation packet provided by the Administrator revealed a list of patients interviewed for concerns of abuse, one statement from CNA #2, documents related to Resident #1's shower/bath schedule, a copy of CNA #1's employee file, a copy of Resident #1's care plan and an in-service on using a gait belt for Resident #1's transfers. Continued review revealed there were no other employee statements, no skin assessments for Resident #1 on the day of discovery, and no skin assessments for other residents on the same assignments on 300 Hall. There was no documentation of reporting to the State Office, the local police or any other authority. Review of a Statement of Inservice Training for Employees dated 6/7/2022, revealed, .Topic: 311 B Transfers .This resident is to be transferred using the gait belt when being transferred with two staff . Review of a Radiology Report for Resident #1 dated 6/6/2022, revealed, .fracture of the Humerus Minimum 2V [view] left .surgical neck/shaft with angulation and displacement . Review of a facility document titled, BM [bowel movement] and Bath, revealed, .6/1/2022 .3:45 .Bath type .Show [shower] .6/2/2022 .10:12 .Bath type .Bed . Review of a facility document titled, Day Shift [Certified Nursing Assistant] CNA Assignment Sheet, revealed CNA #2 was assigned to Resident #1 on 6/4/2022 and she provided the resident with a shower during the 7 AM to 7 PM shift. Continued review revealed CNA #2 was assigned to Resident #1 on 6/5/2022. CNA #3 was assigned to Resident #1 on 6/6/2022. Review of an undated statement provided by CNA #2 revealed, .I .gave [named, Resident] #1 a shower .I didn't see any bruises or swelling on her .Transferred her .She didn't complain about hurting any that day! . Review of the Treatment Administration Record (TAR) for Resident #1 dated 5/2022, revealed, .Skin Audit Weekly . Resident #1's skin audit was documented as completed on 6/3/2022 by Licensed Practical Nurse (LPN) #3. No documentation of findings noted for the skin audit on 6/3/2022. Review of a Word document dated 6/10/2022, revealed nine residents with BIMS scores of 9-15 had no concerns. The Administrator provided this document as part of the investigation of Resident #1's injury. During a telephone interview on 8/2/2022 at 1:13 PM, LPN #1 stated on 6/5/2022 Resident #1 complained of pain in her chest and upper left arm and she gave her medication to help relieve the pain. She stated she did not assess the resident's left arm because the resident said she had indigestion. She stated she returned to assess the resident for results of the pain medication, and she was asleep. During a telephone interview on 8/2/2022 at 2:02 PM, CNA #1 stated she had not provided care to Resident #1 and the facility did not question her about any incident with Resident #1. She stated she found out about Resident #1's injury because someone from Adult Protective Services (APS) called to talk to her about the injury. During an interview on 8/2/2022 at 3:45 PM, LPN #2 stated CNA #4 notified her on 6/6/2022 that Resident #1 had severe pain when she attempted to take off her clothing for a shower. She stated she immediately went to assess the resident. She stated the resident had a bruise on her upper left arm and swelling with the skin dented in over the area of pain. She stated she immediately notified the Nurse Practitioner who came to evaluate the resident. She stated she ordered an Xray and when the results were received, the resident was sent to the ER (emergency room ) for further evaluation. She stated she had completed an event/incident note related to the injury. She stated when an injury or bruise was identified with an unknown cause, an event note was completed which initiated an investigation. During an interview on 8/2/2022 at 5:46 PM, the DON stated when a fall, altercation, unknown bruising, and/or an unknown fracture injury was identified the protocol was to notify the appropriate people and begin an investigation. She stated the investigation would begin with completing an event note on the computer. She stated in the process of completing the event note witness statements would be requested. She stated she interviewed several residents on the same hall as Resident #1 and no one reported any issues or concerns of abuse. She stated she traced the activities of Resident #1 over a couple of days, and they determined it must have happened in the shower during a transfer from her chair. When asked how she determined for sure that was how the fracture and bruise occurred, she stated that was the most likely cause of the fracture due to the resident's contracture of left arm. Continued interview she confirmed the statement from the CNA that provided the shower indicated no abnormal occurrences during the shower or her care on the shift which Administration alleged the injury occurred. She confirmed the investigation she had completed contained nothing found to indicate the injury actually occurred during the transfer. Continued interview she appropriately answered the employee abuse questions. During an interview on 8/2/2022 at 5:46 PM, the Administrator stated she did not believe Resident #1 was abused by anyone in contact with her in the facility. She stated she believed due to the contracture of the left limb; Resident #1's arm fractured during the transfer in the shower. She stated she believed the bruising was caused by the fracture and not from trauma. She reviewed the investigation she provided to this surveyor and confirmed she made her decision about the cause of the fracture based on that investigation and collaboration with staff. She confirmed there was no evidence to prove the fractured arm and bruise occurred in the shower transfer. She confirmed there could have been an unknown event that caused the fracture that was not found during her investigation. She confirmed the incident was not reported to the State because she believed she knew what had caused the injury. During an interview on 8/2/2022 at 7:08 PM, CNA #3 stated Resident #1 was dressed by the shift before hers on 6/6/2022, the day the fracture was discovered. She stated she did not notice any unusual complaints of pain during the resident's care earlier that day. She stated she was familiar with Resident #1 and knew her left arm was sensitive to movement. She stated she was always careful during care not to move that arm unnecessarily. She stated while removing the resident's sweatshirt she gasped and yelled when she began to take off the left sleeve. She stated she observed a large dark purple bruise that covered most of the resident's upper left arm. She stated she immediately called the nurse to come and look at the arm. She stated she did not recall being asked any further questions or to write a statement about the injury. Continued interview she appropriately answered the employee abuse questions.

Based on facility policy review, record review and interviews, the facility failed to complete a thorough investigation and report an injury of unknown origin for 1 resident (Resident #1) reviewed. Review of the facility policy titled, Abuse, Neglect, and Exploitation Policy, reviewed 8/2021, revealed, .policy of this company for employees to report signs of abuse, neglect, or exploitation .suspected cases of abuse, neglect or exploitation of patients/caregivers including elderly or disabled adults and children are thoroughly investigated and reported .Abuse that results in serious injury or harm must be reported within 2 hours of identification of the abuse . Review of the facility policy titled, Patient Incident/Accident Reporting Policy, reviewed 9/2021, revealed, .policy of this company to establish a procedure for reporting, documenting, investigating, and tracking patient incidents .ensure patient safety and to define the criteria of patient incident/accident to be reported .ensure compliance with all applicable standards and regulations .ensure compliance and report reportable events to the Department of Health .Facilities are also required to report injuries of unknown source . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a BIMS score of 1, which indicated severe cognitive impairment. Resident #1 required limited to total dependence with all Activities of Daily Living (ADL)s. Review of the Comprehensive Care Plan for Resident #1 revealed care plans which included risk for falls, [CONDITION(S)]/[CONDITION(S)] to left side, [CONDITION(S)], and Self Care deficit. Interventions and revisions included gait belt with transfers. Review of the Nurse Practitioner's soap note dated 6/6/2022, revealed, .Nurse requesting I see patient d/t [due to] new onset left arm/shoulder pain .X-ray ordered shows acute fracture of the humerus .sent to ER [emergency room ] for further evaluation . Review of the Clinical Notes Report revealed, .effective 6/5/2022 .entered date 6/8/2022 .Resident c/o [complaint of] ingestion and mild left arm pain .effective 6/6/2022 .entered 6/6/2022 .Resident had xray to left arm r/t [related to] pain and bruise .Xray completed arm broken patient sent to ER . Review of the hospital consultation notes dated 6/6/2022, revealed, resolving ecchymosis around the proximal arm .unclear what the exact etiology is of the fracture .significant osteopenia .trivial injury could cause the fracture .possibly elder abuse .been investigating at the nursing home . Review of the investigation packet provided by the Administrator revealed a list of patients interviewed for concerns of abuse, one statement from CNA #2, documents related to Resident #1's shower/bath schedule, a copy of CNA #1's employee file, a copy of Resident #1's care plan and an in-service on using a gait belt for Resident #1's transfers. Continued review revealed there were no other employee statements, no skin assessments for Resident #1 on the day of discovery, and no skin assessments for other residents on the same assignments on 300 Hall. There was no documentation of reporting to the State Office, the local police or any other authority. Review of a Statement of Inservice Training for Employees dated 6/7/2022, revealed, .Topic: 311 B Transfers .This resident is to be transferred using the gait belt when being transferred with two staff . Review of a Radiology Report for Resident #1 dated 6/6/2022, revealed, .fracture of the Humerus Minimum 2V [view] left .surgical neck/shaft with angulation and displacement . Review of a facility document titled, BM [bowel movement] and Bath, revealed, .6/1/2022 .3:45 .Bath type .Show [shower] .6/2/2022 .10:12 .Bath type .Bed . Review of a facility document titled, Day Shift [Certified Nursing Assistant] CNA Assignment Sheet, revealed CNA #2 was assigned to Resident #1 on 6/4/2022 and she provided the resident with a shower during the 7 AM to 7 PM shift. Continued review revealed CNA #2 was assigned to Resident #1 on 6/5/2022. CNA #3 was assigned to Resident #1 on 6/6/2022. Review of an undated statement provided by CNA #2 revealed, .I .gave [named, Resident] #1 a shower .I didn't see any bruises or swelling on her .Transferred her .She didn't complain about hurting any that day! . Review of the Treatment Administration Record (TAR) for Resident #1 dated 5/2022, revealed, .Skin Audit Weekly . Resident #1's skin audit was documented as completed on 6/3/2022 by Licensed Practical Nurse (LPN) #3. No documentation of findings noted for the skin audit on 6/3/2022. Review of a Word document dated 6/10/2022, revealed nine residents with BIMS scores of 9-15 had no concerns. The Administrator provided this document as part of the investigation of Resident #1's injury. During a telephone interview on 8/2/2022 at 1:13 PM, LPN #1 stated on 6/5/2022 Resident #1 complained of pain in her chest and upper left arm and she gave her medication to help relieve the pain. She stated she did not assess the resident's left arm because the resident said she had indigestion. She stated she returned to assess the resident for results of the pain medication, and she was asleep. During a telephone interview on 8/2/2022 at 2:02 PM, CNA #1 stated she had not provided care to Resident #1 and the facility did not question her about any incident with Resident #1. She stated she found out about Resident #1's injury because someone from Adult Protective Services (APS) called to talk to her about the injury. During an interview on 8/2/2022 at 3:45 PM, LPN #2 stated CNA #4 notified her on 6/6/2022 that Resident #1 had severe pain when she attempted to take off her clothing for a shower. She stated she immediately went to assess the resident. She stated the resident had a bruise on her upper left arm and swelling with the skin dented in over the area of pain. She stated she immediately notified the Nurse Practitioner who came to evaluate the resident. She stated she ordered an Xray and when the results were received, the resident was sent to the ER (emergency room ) for further evaluation. She stated she had completed an event/incident note related to the injury. She stated when an injury or bruise was identified with an unknown cause, an event note was completed which initiated an investigation. During an interview on 8/2/2022 at 5:46 PM, the DON stated when a fall, altercation, unknown bruising, and/or an unknown fracture injury was identified the protocol was to notify the appropriate people and begin an investigation. She stated the investigation would begin with completing an event note on the computer. She stated in the process of completing the event note witness statements would be requested. She stated she interviewed several residents on the same hall as Resident #1 and no one reported any issues or concerns of abuse. She stated she traced the activities of Resident #1 over a couple of days, and they determined it must have happened in the shower during a transfer from her chair. When asked how she determined for sure that was how the fracture and bruise occurred, she stated that was the most likely cause of the fracture due to the resident's contracture of left arm. Continued interview she confirmed the statement from the CNA that provided the shower indicated no abnormal occurrences during the shower or her care on the shift which Administration alleged the injury occurred. She confirmed the investigation she had completed contained nothing found to indicate the injury actually occurred during the transfer. Continued interview she appropriately answered the employee abuse questions. During an interview on 8/2/2022 at 5:46 PM, the Administrator stated she did not believe Resident #1 was abused by anyone in contact with her in the facility. She stated she believed due to the contracture of the left limb; Resident #1's arm fractured during the transfer in the shower. She stated she believed the bruising was caused by the fracture and not from trauma. She reviewed the investigation she provided to this surveyor and confirmed she made her decision about the cause of the fracture based on that investigation and collaboration with staff. She confirmed there was no evidence to prove the fractured arm and bruise occurred in the shower transfer. She confirmed there could have been an unknown event that caused the fracture that was not found during her investigation. She confirmed the incident was not reported to the State because she believed she knew what had caused the injury. During an interview on 8/2/2022 at 7:08 PM, CNA #3 stated Resident #1 was dressed by the shift before hers on 6/6/2022, the day the fracture was discovered. She stated she did not notice any unusual complaints of pain during the resident's care earlier that day. She stated she was familiar with Resident #1 and knew her left arm was sensitive to movement. She stated she was always careful during care not to move that arm unnecessarily. She stated while removing the resident's sweatshirt she gasped and yelled when she began to take off the left sleeve. She stated she observed a large dark purple bruise that covered most of the resident's upper left arm. She stated she immediately called the nurse to come and look at the arm. She stated she did not recall being asked any further questions or to write a statement about the injury. Continued interview she appropriately answered the employee abuse questions.

Based on facility policy review, observation, and interview the facility failed to date refrigerated perishable foods. The findings include: Review of the facility's policy titled, Dietary Foods revised 7/12/2021, revealed, .left over foods are stored in appropriate containers so that the interior temperature of food chills quickly to < 41 F. They are covered, labeled and dated . Observation in the dietary department freezer with the Registered Dietician on 10/4/2021 at 9:28 AM, confirmed 4 hamburger patties, one bag of cauliflower, two bags of mixed vegtables and 2 bags of potatoes not dated. Observation in the dietary department refrigerator with the Registered Dietician on 10/4/2021 at 9:33 AM, confirmed a large opened jar of mayonaise not dated. During an interview on 10/4/2021 at 12:28 PM, the Dietary Manager stated he expected left over unused food items to be dated.

Based on facility policy review, observation, and interview, the facility failed to prevent the potential spread of infection for 4 of 6 sampled residents (Resident #168, #169, #170, and #171) as evidenced by no posted signage and no appropriate Personal Protective Equipment (PPE) was not available on the 14 day observation unit and staff did not wear appropriate PPE while in observation rooms. The findings include: Review of the facility's policy titled, Coronavirus 2019 (COVID-19) Response Plan and Facility Policy & Protocol, dated March 5, 2020, revealed, .Any patient admitted to the facility, regardless of their admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .Required Transmission Based Precautions: The type of isolation used Standard Precautions, Contact Precautions, Airborne or Droplet Precautions and Eye Protection. The required PPE is a gown, gloves, N95 face mask, goggles or a face shield . Review of the medical record revealed Resident #168 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Isolation Precautions. Resident will remain on Droplet Isolation precautions for 14 days . Review of the baseline care plan dated 9/29/2021, for Resident #168 revealed, .Isolation per MD [Medical Doctor] order Standard Precautions . Review of the medical record revealed Resident #169 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Isolation Precautions. Resident will remain on Droplet Isolation precautions for 14 days . Review of the baseline care plan dated 9/20/2021, for Resident #169 revealed, .At risk for s/sx [signs/symptoms] of COVID-19 . Review of the medical record revealed Resident #170 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the baseline care plan dated 9/16/2021, for Resident #170 revealed, .At risk for s/sx of COVID-19 . Review of the medical record revealed Resident #171 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the baseline care plan dated 9/29/2021, for Resident #171 revealed, .At risk for s/sx of COVID-19 . Observation on the 14 day observation unit on 10/4/2021 at 10:17 AM, revealed no signs posted or appropriate PPE available on the observation unit. Observation and interview on the 14 day observation unit on 10/4/2021 at 10:18 AM, and 10:25 AM, revealed Licensed Practical Nurse (LPN) #1 went into an observation room [ROOM NUMBER] without wearing the appropriate PPE and no biohazard barrels in rooms [ROOM NUMBERS]. LPN #1 confirmed she was not wearing appropriate PPE and there was no biohazard barrels in room [ROOM NUMBER] and 205. Observation and interview on 10/5/2021 at 10:30 AM, revealed Registered Nurse (RN) #1 in isolation room [ROOM NUMBER] without an isolation gown or gloves. RN #1 confirmed she did not have on an isolation gown or gloves on while she was in isolation room [ROOM NUMBER]. Observation and interview on the 14 day observation unit on 10/4/2021 at 10:45 AM, with the Regional Nurse Consultant revealed no isolation gowns or isolation signs were on the 14 day observation unit and a Physical Therapist was in room [ROOM NUMBER] without the appropriate PPE. The Regional Nurse Consultant confirmed there were no isolation gowns or isolation signs on the 14 day observation unit and the Physical Therapist was in observation room [ROOM NUMBER] without the appropriate PPE.

Based on medical record review, and interview, the facility failed to have a complete medical record for 1 of 3 sampled residents (Resident #66) reviewed for closed records. The findings include: Review of the medical record revealed Resident #66 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Resuscitate (CPR) [Cardiopulmonary Resuscitate] . Review of the medical record revealed Resident #66 was discharged from the hospital on [DATE]. Continued review revealed Resident #66's care was discussed by the hospital physician and the resident decided to have comfort measures rather than being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the resident's updated POST form was not in the resident's medical record. During an interview on [DATE] at 2:30 PM, the Administrator confirmed Resident #66's updated POST form was not in the medical record. She stated, I did not know he had an updated POST until my Assistant Director of Nursing (ADON) sent it to me. During a telephone interview on [DATE] at 2:44 PM, the ADON confirmed the updated POST form for Resident #66 was not in the resident's medical record. She stated, I remembered he had and updated POST form, and I had to go to the hospital referral system today to get it.

Based on facility policy review, medical record review and interview the facility failed to implement a care plan for 2 of 27 sampled resident (Resident #18) reviewed for advanced directive code status and (Resident #30) reviewed for nutritional status for weight loss. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised 3/25/2021, revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will be revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment . Review of the medical record revealed Resident #18 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of the comprehensive care plan for Resident #18 dated 1/13/2021, revealed no care plan was implemented for advanced directive code status. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Discharge MDS assessment dated [DATE], revealed Resident #30's cognitive skills were assessed as moderately impaired. Continue review revealed Resident #30 had a 5% weight loss in a month. Review of the comprehensive care plan for Resident #30 dated 4/2/2021, revealed no care plan was implemented for nutritional status for weight loss. During an interview on 10/7/2021 at 10:00 AM, the MDS Coordinator confirmed no advanced directive code status was on the care plan for Resident #18 and Resident #30 did not have a care plan implemented for nutritional status for weight loss. During an interview on 10/7/2021 at 10:17 AM, the Administrator confirmed no advanced directive code status was implemented for Resident #18 and Resident #30 did not have a nutritional status for weight loss on the care plan. She stated she would expect the care plan to contain the residents advanced directive code status and nutritional status.

Based on facility policy review, medical record review, and interview, the facility failed to obtain a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility's policy titled, Physician Verbal Order Policy, dated 5/20/2021, revealed, .Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Enter the order into the medical record manually or electronically . Review of the medical record revealed Resident #29 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #29's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #29's lab report dated 9/27/2021, revealed the resident was positive for Covid-19. Review of Resident #29's comprehensive care plan dated 9/27/2021, revealed, .has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #32 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #32's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #32's lab report dated 9/21/2021, revealed the resident was positive for Covid-19. Review of Resident #32's comprehensive care plan dated 9/21/2021, revealed, .has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 10/4/2021 at 11:50 AM, and on 10/5/2021 at 10:00 AM, revealed Resident #29 and Resident #32 were on the Covid-19 unit. During an interview on 10/5/2021 at 11:05 AM, the Assistant Director of Nursing (ADON) confirmed Resident #29 and Resident #32 were on the Covid-19 unit and did not have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on policy review, medical record review, observations, and interviews, the facility failed to protect 1 of 4 sampled residents (Resident #4) from physical abuse. The findings include: Review of facility policy titled Abuse Prohibition Plan dated 4/1/2018 and revised 6/10/2021 revealed, .The facility has zero tolerance policy for abuse. Verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion is prohibited. The resident will not be subjected to mistreatment, neglect, exploitation, or misappropriation of property. The facility will attempt to identify and will investigate any reported violation or allegation of abuse . Review of facility policy titled,Resident Rightsdated 11/2016 and revised 11/2020 stated, .The facility will inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility .The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States . Review of the completed facility investigation dated 9/13/2021 for Resident #4 revealed the facility performed a skin assessment on Resident #4 and conducted interviews with the residents on hall 300. Further review revealed all staff were educated on abuse and abuse reporting. Further review revealed Certified Nursing Assistant (CNA) #4 was terminated from employment and incident was reported to the state agency. Review of the Employee File for CNA #4 revealed a hire date of 8/27/2021 and a termination date of 9/13/2021. Appropriate reference checks and background checks were completed, including the Abuse Registry. Review of the medical record for Resident #4 revealed she was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) for Resident #4 dated 8/10/2021, revealed the Staff Assessment for Mental /Status, Cognitive Skills for Daily Decision-Making score of 3, which indicated severe cognitive impairment. Further review revealed Resident #4 had moderate difficulty with hearing, unclear speech, rarely never makes herself understood and rarely/never understands others. Resident #4 had impaired vision and does not wear glasses. Further review revealed Resident #4 required total care of 1 staff for bed mobility, transfer, dressing, toilet use, personal hygiene and total dependence with bathing. Further review revealed Resident #4 was always incontinent of bladder and bowel. Review of the Comprehensive Care Plan for Resident #4 dated 11/16/2020, revealed assessments for impaired expressive/receptive communication, unable to make self understood or to understand what is being communicated to her, severe cognitive impairment, self-care deficit, and incontinence. Interventions were implemented appropriately. During observation on 9/20/2021 at 4:25 PM, on 100 hall, interactions between staff and residents were friendly and appropriate, without concerns noted. During an observation on 9/21/2021 at 9:26 AM, staff were in Resident #7's room providing morning care. No concerns were identified with staff assisting the resident. During interviews on 9/20/2021 between 11:08 AM and 2:13 PM with CNA #1, Housekeeping Supervisor, CNA #2, LPN #1, RN #1 and Administrator, they all answered correctly the different types of abuse, what actions to take if abuse was witnessed or suspected, who the Abuse Coordinator was, were they in-serviced on abuse upon hire, who in-services the staff on abuse and how often are in-services held. Attempted to call CNA #4 for interview on 9/20/2021 at 1:00 PM. Received message indicating phone number was no longer in service. No other contact phone numbers available for terminated employee. During an interview on 9/20/2021 at 1:19 PM, RN #1 stated that she conducted the resident interviews for the abuse allegation on 9/11/2021. During further interview she stated that Resident #5 notified staff of the abuse and CNA #4 was immediately suspended pending the investigation. During further interview, RN #1 stated that no other complaints of abuse were reported. During an interview on 9/21/2021 at 2:08 PM, the Administrator confirmed physical abuse did occur to Resident #4 by CNA #4.

Based on facility policy review, medical record review, facility investigation, observation and interview, the facility failed to implement care plan interventions for 1 (#13) of 4 residents reviewed for falls. The facility's noncompliance placed Resident #13 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairement or death to a resident). The Administrator was informed of the Immediate Jeopardy (IJ) on 1/8/2020 at 1:05 PM in her office. F-656 was cited at a scope and severity of J. An extended survey was conducted on 1/8/2020. The Immediate Jeopardy was effective on 1/8/2020. An Immediate Action Removal Plan which removed the immediacy of the jeopardy was received on 1/8/2020 at 8:10 PM and corrective actions were validated on site by the surveyors on 1/8/2020. The facility's noncompliance at F-656 continues at a scope and severity of D for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: Facility policy review, Comprehensive Care Plans, dated 11/2016 and revised 2/2019, revealed .Develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing and psychosocial needs .staff are responsible for carrying out interventions specified in the care plan . Facility policy review, Accidents and Supervision, dated 11/2017, revealed .The resident environment remains as free of accident hazards as is possible .This includes .Implementing interventions to reduce hazard(s) and risk(s) .modifying interventions when necessary .Implementation of Interventions include: Communicating the interventions to all relevant staff .Ensuring that the interventions are put into action . Medical record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of Resident #13's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive impairment. Continued review revealed Resident #13 required extensive assistance with 1 person assist for bed mobility, dressing, and personal hygiene; limited assistance with 1 person for transfer and toilet use; total dependence with support for bathing. Continued review revealed the resident was not steady and only able to stabilize with staff assistance; moving from seated to standing position, moving on and off toilet and surface to surface transfer. Further review revealed Resident #13 had a fall within 30 days prior to admission to the facility. Medical record review of Resident #13's Interdisciplinary Team Occurrence Investigation Worksheet, dated 1/14/2019 revealed Resident #13 had an unwitnessed fall with [CONDITION(S)] on 1/14/2019 and he was sent to emergency room for sutures. Continued review revealed the resident was attempting to use his urinal when he slid from his chair and hit his head on the base of the bedside (overbed) table. Further review revealed the interventions to be put into place were to pad the base of the bedside [overbed] table. Medical record review of Resident #13's Emergency Department record, dated 1/14/2019, revealed .Laceration 4 centimeters [cm] in length. Scalp .5 staples .Bleeding controlled .closed head injury .scalp lac [laceration] . Medical record review of Resident #13's Care Plan dated 1/14/19 revealed .Pad base of bedside[overbed] table r/t Fall 1/14/2019 . Medical record review of Resident #13's Resident Care Summary assessment dated [DATE] and 1/7/2020 revealed .Pad base of bedside [overbed] table . Observation on 1/8/2020 at 10:08 AM in Resident #13's room revealed 2 metal legs and supporting metal bar were not padded on the bedside [overbed] table base. Observation and interview with the Director of Nursing in Resident #13's room on 1/8/2020 at 10:12 AM confirmed fall interventions were not implemented as care planned for Resident #13. Interview with Licensed Practical Nurse (LPN) #3 in the dining room on 1/8/2020 at 1:30 PM confirmed Resident #13 was a high falls risk and she was unaware the bedside [overbed] table base was supposed to be padded. The surveyors verified the Immediate Action Removal Plan by: 1. The surveyors verified Resident #13's bedside [overbed] table base had been padded to prevent any further accidents and hazards as care planned. The Surveyors then verified a new process included placing the order for safety interventions on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The surveyors reviewed and verified the safety interventions were in place for Resident #13. Continued review verified the facility's 100% audit of all 47 resident care plans to ensure interventions to prevent accidents and hazards had been implemented. 3. The surveyors reviewed and verified the education and training for the Nurse Managers to include Director of Nursing, Assistant Director of Nursing, Staffing Coordinator, Unit Manager, Admissions Coordinator and Risk Management by the Administrator regarding the implementation/maintenance of interventions for identified hazards. The surveyors verified the education and training of licensed nurses and certified nursing assistants by the Assistant Director of Nursing regarding the implementation/maintenance of interventions for identified hazards and were instructed to notify their supervisor immediately if interventions were not in place. The surveyors verified the facility's Quality Assurance Process Improvement (QAPI) meeting held on 1/8/2020 to include discussion related to updating and following care plan interventions.

Based on facility policy review, medical record review, facility investigation, observation and interview, the facility failed to eliminate a foreseeable and known accident hazard in the resident's environment for 1 (#13) of 4 residents who were assessed at risk for falls. The facility's noncompliance placed Resident #13 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairement or death to a resident). The Administrator was informed of the Immediate Jeopardy (IJ) on 1/8/2020 at 1:05 PM in her office. F-689 was cited at a scope and severity of J which was Substandard Quality of Care. An extended survey was conducted on 1/8/2020. The Immediate Jeopardy was effective on 1/8/2020. An acceptable Immediate Action Removal Plan which removed the immediacy of the jeopardy was received on 1/8/2020 at 8:10 PM and corrective actions were validated on site by the surveyors on 1/8/2020. The facility's noncompliance at F-689 continues at a scope and severity of D for the monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: Facility policy review, Accidents and Supervision, dated 11/2017, revealed .The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: Identification of Hazards and Risk .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 .All staff are to be involved in observing and identifying potential hazards in environment .Implementation of Interventions include: Communicating the interventions to all relevant staff .Assigning responsibility .Providing training as needed .Ensuring that the interventions are put into action . Medical record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses which included [CONDITION(S)] Affecting Right Dominant Side, Dementia With Behavioral Disturbance, [CONDITION(S)], Low Vision To Right Eye and [CONDITION(S)]. Medical record review of Residents #13's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Continued review revealed Resident #13 required extensive assistance with 1 person for bed mobility, transfer and toilet use. Continued review revealed the Resident was only able to stabilize with staff assistance for all transfers. Medical record review of Resident #13's Interdisciplinary Team Occurrence Investigation Worksheet, dated 1/14/2019 revealed an unwitnessed fall with [CONDITION(S)] on 1/14/2019 and the resident was sent to the emergency room for sutures. Continued review revealed the resident was attempting to use a urinal when he slid from the chair and hit his head on the base of the bedside [overbed] table. Further review revealed facility interventions put into place was to pad the base of the resident's bedside (overbed) table. Medical record review of Resident #13's Emergency Department record, dated 1/14/2019, revealed .Laceration 4 centimeters [cm] in length. Scalp .5 staples .Bleeding controlled .closed head injury .scalp lac [laceration] . Medical record review of Resident #13's Care Plan dated 4/9/2019- Present, revealed .at risk for bleeding r/t [related to] use of anticoagulant [blood thinning medication] .Implement safety precautions such as fall management protocols .At risk for falls r/t decreased mobility .Pad base of bedside [overbed] table r/t Fall 1/14/2019 . Medical record review of Resident #13's Physician Order Sheet dated January 2019 revealed [MEDICATION(S)] [blood thinner] 20 mg [milligram] tablet give one tablet by mouth at bedtime. Medical record review of Resident #13's Physician Order Sheet dated October 2019 and December 2019 revealed [MEDICATION(S)] was changed to [MEDICATION(S)]. Continued review of the Physician Order revealed .[MEDICATION(S)] [blood thinner] 5 mg tablet po [by mouth] BID [twice a day] . Continued review of the Physician Order revealed .Fall precautions . Medical record review of Resident #13's Resident Care Summary assessment dated [DATE] and 1/7/2020 revealed .Pad base of bedside table [overbed table] . Observation on 1/8/2020 at 10:08 AM in Resident #13's room revealed 2 metal legs and supporting bar were not padded on the base of the bedside (overbed) table base. Observation and Interview on 1/8/2020 at 10:12 AM with Director of Nursing present in Resident #13's room confirmed the facility was aware of Resident #13's fall risk and after looking at the base of the bedside [overbed] table, she said there is still the potential for injury for the resident due to the base of the bedside [overbed] table not being padded. Interview with Certified Nurse Assistant (CNA) #1 in the dining room on 1/8/2020 at 1:15 PM confirmed he had been in Resident #13's room the morning of 1/8/2020 and he stated I was not aware [named resident] bedside table [overbed] base was supposed to be padded until I noticed [named staff] Maintenance Supervisor was putting padding on the bedside [overbed] table base. The surveyors verified the Immediate Action Removal Plan by: 1. The surveyors verified on 1/8/2020 Resident #13's room was free of environmental hazards related to padding of the metal base of the bedside [overbed] table removing the foreseeable and known accident hazard. 2. The surveyors reviewed and verified the safety interventions were in place for Resident #13. Continued review verified the facility's 100% audit of all 47 resident care plans to ensure interventions to prevent accidents and hazards had been implemented. 3. The surveyors reviewed and verified the education and training for the Nurse Managers, licensed nurses and certified nursing assistants regarding the implementation/maintenance of interventions for identified hazards had been initiated. The surveyors verified the education and training of licensed nurses and certified nursing assistants regarding instructions to notify their supervisor immediately if interventions were not in place had been initiated. The surveyors verified the facility's Quality Assurance Process Improvement (QAPI) meeting was held on 1/8/2020 to include discussion related to incidents/accidents.

Based on medical record review and interview the facility failed to accurately assess 1 (#33) of 4 residents reviewed for falls on the Minimum Data Set (MDS). The Findings include: Medical record review revealed Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #33's Interdisciplinary Team Occurrence Investigation Worksheet dated 9/1/2019 revealed .Patient was observed on the floor related to brakes on wheelchair not locked and wheelchair rolled backwards . Medical record review of Resident #33's Quarterly MDS dated [DATE] revealed no falls. Interview with the MDS Coordinator on 1/8/2020 at 6:33 PM in her office confirmed the 9/1/2019 fall for Resident #33 was not captured on the Quarterly MDS dated [DATE].

Based on facility policy review, medical record review, observation and interview, the facility failed to ensure dignity for 1 (#104) of 4 residents reviewed with catheters when the facility failed to ensure the resident's indwelling urinary catheter drainage bag was covered. The findings include: Facility policy review, Promoting/Maintaining Resident Dignity, revised 11/2017 revealed .It is the practice of this facility to 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 maintains or enhances the resident's quality of life by recognizing each resident's individuality . Medical record review revealed Resident #104 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #104's Physician order [REDACTED].maintain indwelling catheter two times a day . Observation on 1/6/2020 at 10:14 AM, 12:30 PM, 1:40 PM, 2:40 PM and 2:50 PM in Resident #104's room revealed the catheter drainage bag visible on the right side of the bed and not covered. Interview with the Licensed Practical Nurse #1 on 1/6/2020 at 2:50 PM in Resident #104's room confirmed the catheter drainage bag was not covered. Interview with the Director of Nursing on 1/7/2020 at 2:40 PM in her office confirmed catheter drainage bags should always be in a privacy bag.

Based on observation, review of facility Quality Assurance/Quality Improvement (QA/QI) committee agenda and minutes, and interview, the facility failed to develop a plan of action related to resident accidents/falls. The facility was cited Immediate Jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death). The facility failed to provide supervision to prevent accidents and failed to ensure residents were provided a safe environment. The facility's failure placed six residents (#104, #135, #35, #64, #86, #101) in Immediate Jeopardy of twenty residents reviewed for falls. The systemic failure to ensure any resident at risk for falls was provided effective interventions; failure to ensure alarm devices were in place and/or functional, and failure to identify and implement new interventions when current interventions were not effective was likely to place any resident at risk for falls in Immediate Jeopardy. The Administrator, the Director of Nursing, Corporate Compliance Consultant #1, and Corporate Compliance Consultant #2 were informed of the Immediate Jeopardy on June 20, 2013, at 3:30 p.m., in the Administrator's office. The Immediate Jeopardy was effective December 12, 2012, and is ongoing. The Findings included: Interview and review of the Leadership Team QA/PI (Quality Assurrance and Performance Improvement) agenda and minutes with the Administrator on June 21, 2013, at 12:20 p.m., in the conference room, revealed the QA/QI committee reviews the "standard" topics each meeting. Review of the Leadership QA/QI agenda dated January 23, 2013, revealed resident falls was a topic of discussion. Review of the resident tracking for falls revealed there were 23 falls in October; 14 falls in November; and 34 falls in December, 2012. Continued interview with the Administrator and review of the agenda confirmed the number of falls was discussed yet there was not an action plan developed. Interview and review of the QA/PI agenda and minutes revealed the increased number of falls was identified as a problem in May 6, 2013. Review of the listed falls for each month revealed there were 30 falls in January 2013; 21 falls in February 2013, and 22 falls in March 2013. Review of the Leadership Team QA/PI agenda dated May 22, 2013, revealed the facility had 28 falls in the month of April, 2013; and there was no documentation of falls being identified as a quality deficiency that required action.There was no evidence of an action plan identified. Review and continued interview with the Administrator revealed the falls were reviewed in the same manner/method as the committee had done on January 23, 2013. Continued interview verified the facility did not develop a plan of action for the reduction of falls for the facility in the meeting on May 22, 2013. Interview and review of the elevated number of falls with the Administrator included an explaination the facility did consider "the change in position from the bed in low position onto a mat as a fall." Additional explaination was offered that some of the residents had frequent falls; "the number of falls is not the number of residents with falls." Interview in the conference room with the corporate team on June 20, 2013, at 2:10 p.m., revealed the facility was instructed in January 2013 to complete a root cause analysis (RCA) for each fall after they reviewed the 4th quarter 2012 (October-December 2012) number of falls. Resident #104 had multiple falls from January-June 2013, and one RCA was conducted. Review of the RCA revealed it had not been entirely completed. Continued interview revealed the facility QA committee failed to capture the facility-wide concern with falls; failed to determine the root causes of the falls and failed to develop a plan of action; and failed to initiate an effective falls program or improve the current process. Interview with the Director of Nursing (DON) in the conference room on June 19, 2013, at 4:35 p.m., verified the facility has made no facility-wide changes concerning the rate of falls; and verified the QA/QI process failed to take any additional action to promote an improved falls reduction committee. Please refer to tag F-323.

Based on observation, review of facility Quality Assurance/Quality Improvement (QA/QI) committee agenda and minutes, and interview, the facility failed to develop a plan of action related to resident accidents/falls. The facility was cited Immediate Jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death). The facility failed to provide supervision to prevent accidents and failed to ensure residents were provided a safe environment. The facility's failure placed six residents (#104, #135, #35, #64, #86, #101) in Immediate Jeopardy of twenty residents reviewed for falls. The systemic failure to ensure any resident at risk for falls was provided effective interventions; failure to ensure alarm devices were in place and/or functional, and failure to identify and implement new interventions when current interventions were not effective was likely to place any resident at risk for falls in Immediate Jeopardy. The Administrator, the Director of Nursing, Corporate Compliance Consultant #1, and Corporate Compliance Consultant #2 were informed of the Immediate Jeopardy on June 20, 2013, at 3:30 p.m., in the Administrator's office. The facility provided an acceptable Credible Allegation of Compliance on July 2, 2013. A revisit on July 8, 2013 and receipt on July 8, 2013, of verification the Administrator and the Medical Director had reviewed and approved all policies implemented on July 2, 2013, revealed the corrective actions implemented removed the Immediate Jeopardy on July 2, 2013. Noncompliance for F-520 continues at an "E" level citation. Validation of the Credible Allegation of Compliance was accomplished by medical record review, review of facility documents, observation and interview with nursing and administrative staff. The facility provided evidence of new policy and procedures related to Fall Prevention, and Quality Assessment and Assurance activities and evidence the new policies were reviewed and approved by the facility administration and medical director. Interview with the Interim Director of Nursing on July 8, 2013, revealed the facility governing body was in-serviced by the Regional Director of Clinical Services and the Vice President of Skilled Nursing Facility Operations, on June 25, 2013, of the survey findings, and corrective actions to identify and mitigate fall risks, in addition to department head specific roles in Quality Assessment and Assurance duties relevant to monitoring the implementation of the new policies and procedures in place. In-service training records including sign in sheets for all staff members related to the new policies and procedures were provided. A review of the facility Quality Assurance Daily Meeting notes revealed the measures contained in the Allegation of Compliance were in place, and ongoing monitoring was in progress. A review of the facility Quality Measure Audit Tools revealed the governing body was involved in ongoing monitoring of the implementation of corrective actions as specified in the Allegation of Compliance. Review of the facility Nurse Event Notes from June 22, 2013, to July 9, 2013, revealed root cause analyses, were being performed as a component of the fall investigations on all new falls which had occurred in the facility. Review of the Daily Quality Assurance Meeting Notes from June 22, 2013 to July 9, 2013, revealed resident specific interventions correlated with the root cause analyses were implemented to address the falls, and ongoing monitoring and evaluation of the responses to the interventions were present in the Daily Quality Assurance Meeting Notes and the medical records of the resident's involved. Interviews with nursing staff members revealed the nursing staff were aware of the new interventions in place to address the falls, and observation of the residents revealed the specific interventions noted in the medical record were in place as ordered by the Medical Director. Review of the facility Quality Audit Measure Tools revealed the leadership team was providing ongoing monitoring of the implementation of and outcomes of the interventions. The facility will remain out of compliance at a Scope and Severity level "E" a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, until it provides an acceptable plan of correction and the facility's corrective measures could be reviewed and evaluated by the Quality Assessment/Performance Improvement Committee.

Based on medical record review and interview, the facility failed to ensure the Medical Director participated in the development and implementation of resident care policies to ensure an effective program for fall prevention. The facility's failure placed six residents (#104, #135, #35, #64, #86, #101) in Immediate Jeopardy of twenty residents reviewed for falls. The systematic failure to ensure any resident at risk for falls was provided effective interventions; failure to ensure alarm devices were in place and/or functional, and failure to identify and implement new interventions when current interventions were not effective was likely to place any resident at risk for falls in Immediate Jeopardy. The Administrator, the Director of Nursing, Corporate Compliance Consultant #1, and Corporate Compliance Consultant #2 were informed of the Immediate Jeopardy on June 20, 2013, at 3:30 p.m., in the Administrator's office. The facility provided an acceptable Credible Allegation of Compliance on July 2, 2013. A revisit on July 8, 2013 and receipt on July 8, 2013, of verification the Administrator and the Medical Director had reviewed and approved all policies implemented on July 2, 2013, revealed the corrective actions implemented removed the Immediate Jeopardy on July 2, 2013. Noncompliance for F-501 continues at an "E" level citation. Validation of the Credible Allegation of Compliance was accomplished by medical record review, review of facility documents, observation and interview with nursing and administrative staff. The facility provided evidence of new policy and procedures related to Fall Prevention, and Quality Assessment and Assurance activities and evidence the new policies were reviewed and approved by the facility Administration and Medical Director. Interview with the Interim Director of Nursing on July 8, 2013, revealed the facility governing body was in-serviced by the Regional Director of Clinical Services and the Vice President of Skilled Nursing Facility Operations, on June 25, 2013, of the survey findings, and corrective actions to identify and mitigate fall risks, in addition to department head specific roles in Quality Assessment and Assurance duties relevant to monitoring the implementation of the new policies and procedures in place. In-service training records including sign in sheets for all staff members related to the new policies and procedures were provided. Interview with the Interim Director of Nursing on July 9, 2013, confirmed the facility leadership team had met with the Interim Medical Director (in person) and the Medical Director (by conference call) on June 25, 2013, and discussed new policies and procedures to reduce falls in the facility, and the next Quality Assessment and Assurance Meeting was scheduled for July 24, 2013, at 10:00 a.m. at the facility. Continued interview revealed the facility Governing Body, including the Medical Director was to meet with the Quality Assessment and Assurance Committee monthly for twelve months to provide ongoing monitoring and evaluation of the facility's implementation of corrective actions to reduce falls. Continued interview revealed the facility governing body would be reporting outcomes of the new policies and procedures to reduce falls to the Corporate Compliance Department monthly for the next twelve months. The facility will remain out of compliance at a Scope and Severity level "E" a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, until it provides an acceptable plan of correction and the facility's corrective measures could be reviewed and evaluated by the Quality Assessment/Performance Improvement Committee.

Based on medical record review and interview, the facility failed to ensure the Medical Director participated in the development and implementation of resident care policies to ensure an effective program for fall prevention. The facility's failure placed six residents (#104, #135, #35, #64, #86, #101) in Immediate Jeopardy of twenty residents reviewed for falls. The systematic failure to ensure any resident at risk for falls was provided effective interventions; failure to ensure alarm devices were in place and/or functional, and failure to identify and implement new interventions when current interventions were not effective was likely to place any resident at risk for falls in Immediate Jeopardy. The Administrator, the Director of Nursing, Corporate Compliance Consultant #1, and Corporate Compliance Consultant #2 were informed of the Immediate Jeopardy on June 20, 2013, at 3:30 p.m., in the Administrator's office. The Immediate Jeopardy was effective December 12, 2012, and is ongoing. An extended survey was conducted on June 20-21, 2013. The findings included: Interview via telephone on June 19, 2013, at 8:15 a.m., with the Medical Director, revealed the physician maintained a personal practice in the community, was the personal physician to the majority of the residents in the facility, and also served as the Medical Director for the facility. continued interview revealed the Medical Director reported no involvement in the development or revision of resident care policies. Please refer to F-323.

Based on medical record review, review of policy, and interview, the facility failed to have a Governing Body to effectively establish and implement policies regarding resident falls. Based on survey findings, the facility was cited Immediate Jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death). The facility failed to provide supervision to prevent accidents and failed to ensure residents were provided a safe environment. The facility's failure placed six residents (#104, #135, #35, #64, #86, #101) in Immediate Jeopardy of twenty residents reviewed for falls. The systematic failure to ensure any resident at risk for falls was provided effective interventions; failure to ensure alarm devices were in place and/or functional, and failure to identify and implement new interventions when current interventions were not effective was likely to place any resident at risk for falls in Immediate Jeopardy. The Administrator, the Director of Nursing, Corporate Compliance Consultant #1, and Corporate Compliance Consultant #2 were informed of the Immediate Jeopardy on June 20, 2013, at 3:30 p.m., in the Administrator's office. The facility provided an acceptable Credible Allegation of Compliance on July 2, 2013. A revisit on July 8, 2013 and receipt on July 8, 2013, of verification the Administrator and the Medical Director had reviewed and approved all policies implemented on July 2, 2013, revealed the corrective actions implemented removed the Immediate Jeopardy on July 2, 2013. Noncompliance for F-493 continues at an "E" level citation. Validation of the Credible Allegation of Compliance was accomplished by medical record review, review of facility documents, observation and interview with nursing and administrative staff. The facility provided evidence of new policy and procedures related to Fall Prevention, and Quality Assessment and Assurance activities and evidence the new policies were reviewed and approved by the facility administration and medical director. Interview with the Interim Director of Nursing on July 8, 2013, revealed the facility governing body was in-serviced by the Regional Director of Clinical Services and the Vice President of Skilled Nursing Facility Operations, on June 25, 2013, of the survey findings, and corrective actions to identify and mitigate fall risks, in addition to department head specific roles in Quality Assessment and Assurance duties relevant to monitoring the implementation of the new policies and procedures in place. In-service training records including sign in sheets for all staff members related to the new policies and procedures were provided. A review of the facility Quality Assurance Daily Meeting notes revealed the measures contained in the Allegation of Compliance were in place, and ongoing monitoring was in progress. A review of the facility Quality Measure Audit Tools revealed the governing body was involved in ongoing monitoring of the implementation of corrective actions as specified in the Allegation of Compliance. Interview with the Interim Director of Nursing on July 9, 2013, confirmed Corporate Compliance staff were to remain in the facility in leadership roles for ongoing monitoring and evaluation of the facility's implementation of the corrective actions, and to provide support and training to the new Director of Nursing, Administrator, MDS Coordinator, and clinical staff on an ongoing basis. Continued interview revealed, the facility Quality Assurance Committee had met with the Interim Medical Director (in person) and the Medical Director (by conference call) on June 25, 2013, and discussed new policies and procedures to reduce falls in the facility, and the next Quality Assessment and Assurance Meeting was scheduled for July 24, 2013, at 10:00 a.m. at the facility. Continued interview revealed the facility Governing Body, including the medical director was to meet with the Quality Assessment and Assurance Committee monthly for twelve months to provide ongoing monitoring and evaluation of the facility's implementation of corrective actions to reduce falls. Continued interview revealed the facility governing body would be reporting outcomes of the new policies and procedures to reduce falls to the Corporate Compliance Department monthly for the next twelve months. The facility will remain out of compliance at a Scope and Severity level "E" a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, until it provides an acceptable plan of correction and the facility's corrective measures could be reviewed and evaluated by the Quality Assessment/Performance Improvement Committee.

Based on medical record review, review of policy, and interview, the facility failed to have a Governing Body to effectively establish and implement policies regarding resident falls. Based on survey findings, the facility was cited Immediate Jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death). The facility failed to provide supervision to prevent accidents and failed to ensure residents were provided a safe environment. The facility's failure placed six residents (#104, #135, #35, #64, #86, #101) in Immediate Jeopardy of twenty residents reviewed for falls. The systematic failure to ensure any resident at risk for falls was provided effective interventions; failure to ensure alarm devices were in place and/or functional, and failure to identify and implement new interventions when current interventions were not effective was likely to place any resident at risk for falls in Immediate Jeopardy. The Administrator, the Director of Nursing, Corporate Compliance Consultant #1, and Corporate Compliance Consultant #2 were informed of the Immediate Jeopardy on June 20, 2013, at 3:30 p.m., in the Administrator's office. The Immediate Jeopardy was effective December 12, 2012, and is ongoing. An extended survey was conducted on June 20-21, 2013. The findings included: Interview on June 21, 2013, at 11:05 in the conference room with the Director of Compliance, Compliance Consultant, and Regional Director of Operations, revealed the corporate team was aware of the facility fall rate and had put a new tool in place in September-October 2012. Interview revealed the tool was an electronic reporting system in which the facility submitted reports of the quality issues including falls, infection rates, etc. Interview revealed the falls are reviewed quarterly at the corporate level. Interview revealed each of the quality concerns on the report has a benchmark (threshold) and the established benchmark for falls is 20%. The corporate team explained the team was not aware of the falls until the first week in January 2013 when they reviewed the 4th quarter 2012 report. The Compliance team revealed the results of the 4th quarter report was the facility fall rate was 56% in the month of December. The Compliance team revealed the facility fall rate for 2013: January-36%, February-33%, March-36%, April-44%, and May 36%. Interview revealed the corporate team does require the facility to submit the reports each month; can review the results on a monthly basis; and does review the report on a quarterly basis. Interview revealed the Compliance team requires a corrective action plan from the facility when benchmarks are not met. Interview revealed the corporate team did receive and accept the action plan submitted by the facility for the 2012-4th quarter one has been requested for the 2013-1st quarter. The Compliance team response to the 4th quarter 2012 report was to require a Root Cause Analysis to be conducted after each fall. Interview revealed the corporate team has a "compliance team member in the facility more often since January...sometimes performing overall work and also to focus on falls." Interview with the Director of Nursing (DON) in the conference room on June 21, 2013, at 3:48 p.m., revealed one RCA has been completed from January-June, 2013, and resident #104 has had multiple falls in that time period. Continued interview verified a RCA is not performed after every fall; and verified the corporate team has been in the facility since January. Continued interview verified the facility has not made effective policy changes to reduce the rate of falls. Please refer to tag F-323.

Based on medical record review, facility policy review, observations, and interview, the facility administration failed to provide an effective system to ensure supervision and an environment free of accident hazards. The facility's failure resulted in multiple falls and placed six residents (#104, #135, #35, #64, #86, #101) in Immediate Jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death) of twenty residents reviewed for falls. The systematic failure to ensure any resident at risk for falls was provided effective interventions; and failure to identify and implement new interventions when current interventions were not effective was likely to place any resident at risk for falls in Immediate Jeopardy. The Administrator, the Director of Nursing, Corporate Compliance Consultant #1, and Corporate Compliance Consultant #2 were informed of the Immediate Jeopardy on June 20, 2013, at 3:30 p.m., in the Administrator's office. The facility provided an acceptable Credible Allegation of Compliance on July 2, 2013. A revisit on July 8, 2013 and receipt on July 8, 2013, of verification the Administrator and the Medical Director had reviewed and approved all policies implemented on July 2, 2013, revealed the corrective actions implemented removed the Immediate Jeopardy on July 2, 2013. Noncompliance for F-490 continues at an "E" level citation. Validation of the Credible Allegation of Compliance was accomplished by medical record review, review of facility documents, observation and interview with nursing and administrative staff. The facility provided evidence of new policy and procedures related to Fall Prevention, and Quality Assessment and Assurance activities and evidence the new policies were reviewed and approved by the facility administration and medical director. The facility provided evidence the survey findings were reviewed and shared with the facility leadership group and staff members. In-service training records including sign in sheets for all staff members related to the new policies and procedures were provided. Review of facility documents revealed, the leadership group was involved in daily Quality Assessment and Assurance Activities related to facility operations, and implementation of corrective measures to prevent falls. Observation revealed, all fall related interventions ordered and documented were in place for residents #104, #35, #64, #86, #101. (Resident #135 was discharged from the facility on December 10, 2011) Interview with the new facility Administrator on July 8, 2013, at 11:00 a.m., revealed the facility leadership group, medical director, and interim medical director reviewed the findings of the survey on June 25, 2013, and implemented follow up audit measures to assure compliance with corrective actions during a specially called Quality Assessment and Assurance meeting. Interview with the Regional Director of Clinical Services and Interim Director of Nursing on July 8, 2013, at 3:00 p.m., revealed, the facility had replaced the Administrator and Director of Nursing on June 22, 2013, and the Interim Director of Nursing was aware of the facility survey findings, and corrective action plans related to falls. The facility will remain out of compliance at a Scope and Severity level "E" a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, until it provides an acceptable plan of correction and the facility's corrective measures could be reviewed and evaluated by the Quality Assessment/Performance Improvement Committee.

Based on medical record review, facility policy review, observations, and interview, the facility administration failed to provide an effective system to ensure supervision and an environment free of accident hazards. The facility's failure resulted in multiple falls and placed six residents (#104, #135, #35, #64, #86, #101) in Immediate Jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death) of twenty residents reviewed for falls. The systematic failure to ensure any resident at risk for falls was provided effective interventions; and failure to identify and implement new interventions when current interventions were not effective was likely to place any resident at risk for falls in Immediate Jeopardy. The Administrator, the Director of Nursing, Corporate Compliance Consultant #1, and Corporate Compliance Consultant #2 were informed of the Immediate Jeopardy on June 20, 2013, at 3:30 p.m., in the Administrator's office. The Immediate Jeopardy was effective December 12, 2012, and is ongoing. An extended survey was conducted on June 20-21, 2013. The findings included: Interview with the Administrator on June 20, 2013, at 3:45 p.m., in the Administrator's Office, confirmed the facility Administrator was aware the facility had a high number of falls, especially with resident #104, who had suffered harm with falls. Refer to F 323

Based on medical record review, review of facility documentation, interview, observation, and review of facility policy, the facility failed to implement an effective falls prevention program for six residents (#104, #135, #35, #64, #86, #101). The facility's failure to implement new interventions and have an effective falls prevention program placed resident #104 in Immediate Jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death) and resulted in Harm to one resident (#135). The systematic failure to ensure any resident at risk for falls was provided effective interventions, failure to ensure alarm devices were in place and/or functional, and failure to identify and implement new interventions when current interventions were not effective was likely to place any resident at risk for falls in Immediate Jeopardy. The facility provided an acceptable Credible Allegation of Compliance on July 2, 2013. A revisit on July 8, 2013 and receipt on July 8, 2013, of verification the Administrator and the Medical Director had reviewed and approved all policies implemented on July 2, 2013, revealed the corrective actions implemented removed the Immediate Jeopardy on July 2, 2013. Noncompliance for F-323 continues at an "E" level citation. Validation of the Credible Allegation of Compliance was accomplished through medical record review, review of facility documents, observation, and interview with nursing and administrative staff. The facility provided evidence of new policies and procedures related to the assessment and identification of fall risk factors, and the management of fall risk factors, as well as root cause analysis of fall events, documentation of fall interventions, and daily Quality Assurance follow up assessment of fall reduction interventions provided to residents. The facility implemented new fall investigation competency training and testing protocols. In-service and training records including sign-in sheets for all facility staff related to the new policies and procedures were provided. Observation revealed, all fall related interventions ordered and documented were in place for residents #104, #35, #64, #86, #101. (Resident #135 was discharged from the facility on December 10, 2011) Interviews with nursing staff revealed, nurses were following the new policies and procedures related to the assessment and management of fall risk factors, and were documenting interventions to reduce fall risks and prevent falls as well as monitoring and evaluating new fall interventions for effectiveness daily. The facility will remain out of compliance at a Scope and Severity level "E" a pattern of deficient practice that constitutes no actual harm with potential for more than minimal harm, that is not Immediate Jeopardy, until it provides an acceptable plan of correction and the facility's corrective measures could be reviewed and evaluated by the Quality Assessment/Performance Improvement Committee. .

Based on medical record review, review of facility documentation, interview, observation, and review of facility policy, the facility failed to implement an effective falls prevention program for six residents (#104, #135, #35, #64, #86, #101). The facility's failure to implement new interventions and have an effective falls prevention program placed resident #104 in Immediate Jeopardy (a situation in which the provider's noncompliance has caused, or is likely to cause serious injury, harm, impairment, or death) and resulted in Harm to one resident (#135). The systematic failure to ensure any resident at risk for falls was provided effective interventions, failure to ensure alarm devices were in place and/or functional, and failure to identify and implement new interventions when current interventions were not effective was likely to place any resident at risk for falls in Immediate Jeopardy. The Immediate Jeopardy became effective on December 12, 2012, and is ongoing. The Administrator, Director of Nursing (DON), and two Nurse Consultants were informed of the Immediate Jeopardy on June 20, 2013, at 3:28 p.m., in the Administrator's office. The Immediate Jeopardy for F-323 "K" constitutes Substandard Quality of Care. The findings included: Resident #104 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Admission Minimum Data Set (MDS) dated [DATE], revealed the resident was severely cognitively impaired, and required extensive assistance with all Activities of Daily Living (ADLs). Medical record review revealed the resident had twenty-four falls between October 30, 2012, and June 1, 2013. Medical record review of a Fall Risk Assessment on admission to the facility revealed the resident scored a 17 on the risk scale, indicating the resident was a moderate risk for falls, with a score of 20 or more being high risk. Medical record review of the resident's current care plan, dated November 3, 2012 revealed, "...is at risk for decline in ADL's (activities of daily living) and for injury/falls r/t (related to) assistance needed with ADLS and recurrent falls..." Medical record review of a Nurse Event Note dated October 30, 2012, revealed the resident had a fall in a merrywalker without injury, "...found resident lying on floor in merrywalker (an assistive device combining a wheeled walker and available seating)...lying on left side..." Continued review of the Nurse Event Note dated October 30, 2012 revealed, "...Interventions Implemented to Prevent Reoccurrence: put to bed, checked q (every) 2 hour and prn (as needed)..." Review of a fall investigation dated October 30, 2012, revealed, "Preventative measures in place prior to fall...Assistive Devices: merrywalker..." Interview with the Director of Nursing (DON) on June 19, 2013, at 8:35 a.m., in the DON's office revealed the intervention of putting the resident to bed and checking on the resident every 2 hours was a new intervention, continued interview confirmed the intervention was not updated on the resident's plan of care. Medical record review of a Nurse Event Note dated October 31, 2012, revealed the resident had a fall without injury after attempting to get out of bed "...noted resident half sitting and lying with head/shoulders on wardrobe..." Continued review of the Nurse Event Note revealed, "...Interventions Implemented to Prevent Reoccurrence: resident wanting up OOB (out of bed). Placed in merrywalker at nurse desk for close observation..." Review of a fall investigation dated October 31, 2012, revealed, "...Preventative measures in place prior to fall...low bed..." Medical record review of a Fall Risk assessment dated [DATE], revealed the resident scored a 20 on the risk scale indicating the resident was at a high risk for falls. Interview with the DON on June 19, 2013, at 8:35 a.m., in the DON's office, confirmed placing the resident in a merrywalker for close observation was the intervention to address the resident's fall on October 31, 2012. Medical record review of a Therapy Fall Screen dated November 1, 2012, revealed, "...10-30-12 Noted resident lying on floor in merrywalker in 300 Hallway...10-31-12 noted resident half sitting and lying with head/sh (shoulder) on wardrobe lying in floor..." Continued review of the Therapy Fall Screen note revealed, "...Pt (patient) currently on case load. Continue using merrywalker but with close observation..." Medical record review of a Nurse Event Note dated November 7, 2012, revealed the resident had a fall in the merrywalker without injury "...res (resident)...noted sitting on floor inside merrywalker (walker sitting up right) with leg stretched out underneat (sic) merrywalker seat...(in another resident's room) (resident) was stuck...on furniture and...fell '..." Continued review of the Nurse Event Note revealed, "...Interventions Implemented to Prevent Reoccurrence: staff inservice..." Review of facility documentation of a staff inservice dated November 7, 2012, revealed the facility provided inservice training to 8 Certified Nurse Assistants (CNA): "...(resident #104) while up in merrywalker if resident seen walking with merrywalker in res (resident) room or tight places assit (sic) resident back on to open public space..." Review of a fall investigation dated November 7, 2012, revealed, "...Preventative Measures in place prior to fall: Assistive Devices: merrywalker..." Medical record review of a Therapy Fall Screen dated November 7, 2012, revealed the resident was evaluated by the Physical Therapist with no new recommendations "...PT (physical therapy) not indicated. No functional decline..." Medical record review of a Nurse Event Note dated November 12, 2012, revealed the resident had a fall in the merrywalker at 9:15 p.m. without injury "...resident was found on the floor in the lobby in...merrywalker..." Continued review of the Nurse Event Note revealed, "...Interventions Implemented to Prevent Reoccurrence: Assess resident throughout the day for excessive tiredness and assist to bed for rest period..." Review of a fall investigation dated November 12, 2012, revealed, "...Preventative measures in place prior to the fall: Assistive Devices: merrywalker..." Medical record review of the resident's care plan, updated November 12, 2012, revealed, "Interventions...check q (every) 30 minutes while in bed..." Medical record review of a Nurse Event Note dated November 13, 2012, revealed the resident had a fall in the merrywalker at 10:45 a.m. without injury "...resident seen backing up in merrywalker out of medical records room. Merrywalker got caught on door facing, resident flipped merrywalker over resident landed on rt (right) side..." Medical record review of a Therapy Fall Screen dated November 13, 2012, revealed, "...11-12-12 resident found on the floor in the lobby in (resident's) merrywalker...11-13-12 Merrywalker got caught on door forcing (sic) merrywalker flipped over, pt (patient) landed on left side..." Continued review of the Therapy Fall Screen revealed physical therapy recommended adding weights to the merrywalker in an attempt to reduce the resident's falls from the merrywalker "...recommend 16# (pounds) added at merrywalker to lessen this pt to...pick up (resident's) merrywalker for balance. PT (physical therapy) not indicated due to pt (patient) continue walking alone with merrywalker and (resident) is in max (maximum) potential..." Medical record review of a Nurse Event Note dated November 14, 2012, revealed the resident had a fall from the bed at 8:30 p.m. without injury "...resident sitting on foot of bed...assisted in merrywalker and taken to NS (nurse station) for observation..." Continued review of the Nurse Event Note revealed, "...Interventions Implemented to Prevent Reoccurrence: placed in merrywalker and put at ns (nurse station) for observation. Further review of the Nurse Event Note revealed additional intervention added "...place mat beside bed..." Review of a fall investigation dated November 14, 2012, revealed, "...Preventative measures in place prior to the fall:...low bed...merrywalker..." Medical record review of a Therapy Fall Screen dated November 15, 2012, revealed the resident was evaluated by the Physical Therapist with no new interventions recommended "...PT (physical therapy) not indicated, pt (patient) functioning at same functional skill..." Medical record review of a Nurse Event Note dated December 12, 2012, revealed the resident had a fall without injury from the merrywalker at 5:30 p.m. "...res. (resident) tipped over meriwalker (sic). Another res stated...saw res just lean over and tipped chair over..." Continued review of the Nurse Event Note revealed, "...Interventions Implemented to Prevent Reoccurrence...look at labs and assess..." Medical record review of the resident's care plan revealed an update to the resident's plan of care "...Alarm to bed and chair-keep in good working condition..." Review of a fall investigation dated December 12, 2012, revealed, "...Preventative measures in place prior to fall...Assistive Devices: merriwalker...Other:...padded helmet, padded underwear..." Continued review of the fall investigation revealed no documentation the resident's merrywalker had weights in place at the time of the fall. Medical record review of a Nurse Event Note dated December 12, 2012, revealed the resident had a fall from the merrywalker at 9:15 p.m. without injury "...found resident laying on right side after (resident) turned over...gait unsteady more than normal and leaning to left side ...d/t (due to) increase confusion, (resident) leaning...sent to ER (emergency room )...(resident) sat down hard a number of times on safety belt or seat..." Continued review of the Nurse Event Note revealed, "...Interventions Implemented to Prevent Reoccurrence...toileting schedule and monitor blood sugar levels...send to ER for eval (evaluation) r/t noted change in medical condition..." Medical record review of emergency room records dated December 12, 2012, revealed the resident's blood sugar was "mildly elevated at 178." Continued review of emergency room physician notes revealed, "...CT (computed tomography) (imaging test) of the brain is negative..." Further review of the emergency room records revealed the resident was admitted to the hospital and treated with intravenous fluids for dehydration and returned to the facility on [DATE]. Review of a fall investigation dated December 12, 2012, revealed "...Preventative measures in place prior to the fall...Personal Alarm...Assistive Devices: merrywalker..." Continued review of the fall investigation revealed no documentation the resident's merrywalker had weights in place at the time of the fall. Interview with the DON on June 19, 2013, at 8:35 a.m., in the DON's office, confirmed the fall investigation dated December 12, 2012, documented the use of the resident's personal alarm. Further interview with the DON confirmed the resident's care plan was updated with intervention of alarm to "...bed and chair..." and confirmed alarms included both a pressure pad alarm and personal clip alarm. Continued interview with the DON, confirmed preventative and protective devices of personal alarm, helmet and hip-pads could not be confirmed as in place or functioning at the time of the resident's fall. Medical record review of a Nurse Event Note dated December 14, 2012, revealed the resident had a fall without injury in the resident's room and was found "...sitting on floor...walked to the br (bathroom)..." Continued review of the Nurse Event Note revealed, "...Interventions Implemented to Prevent Reoccurrence: freq (frequent) visual checks..." Review of a fall investigation, not dated, revealed, "...Preventative measures in place prior to the fall...low bed...Other: merrywalker..." Interview with the DON on June 19, 2013, at 8:35 a.m., in the DON's office, confirmed the undated fall investigation (located on the back of the Nurse Event Note) did not indicate the use of a personal alarm at the time of the resident's fall on December 14, 2012, and was unable to confirm the resident's personal alarm was in place or functioning at the time of the fall as documented on the resident's care plan. Medical record review of a Nurse Event Note dated December 15, 2012, revealed the resident had a fall from the bed at 11:30 p.m. without injury in the resident's room "...pt sitting (lying) on mat next to bed..." Continued review of the Nurse Event Note revealed intervention put in place to prevent future falls "...freq (frequent) safety cues and freq checks..." Review of a fall investigation dated December 15, 2012, revealed interventions in place at the time of the fall were "...low bed ...personal alarm...bed alarm...Assistive Devices: walker..." Interview with the DON on June 19, 2013, at 8:35 a.m., in the DON's office, confirmed the Nurse Event Note and the fall investigation did not indicate if the resident's personal alarm or bed alarm were in place and functioning at the time of the resident's fall on December 15, 2012. Continued interview with the DON, confirmed the intervention documented to prevent future falls "...frequent safety cues and freq checks..." were not a new intervention to protect the resident from injury, and was a standard of care which was to be provided to all residents at all times. Continued interview confirmed no new interventions to prevent further falls were implemented. Medical record review of a Nurse Event Note dated December 18, 2012, revealed the resident had a fall from the bed at 3:25 a.m. without injury in the resident's room "...resident found laying in floor, supine position...got resident up in merrywalker..." Continued review of the Nurse Event Note revealed no new interventions were implemented. Review of a fall investigation dated December 18, 2012, revealed interventions in place at the time of the resident's fall were "...low bed...bed alarm...mat to floor..." Interview with the DON on June 19, 2013, at 8:35 a.m., in the DON's office, confirmed the fall investigation did not indicate if the resident's personal alarm or bed alarm were on and functioning at the time of the resident's fall. Continued interview with the DON, confirmed no new interventions were implemented to protect the resident from future injury after the fall on December 18, 2012, at 3:25 a.m. Medical record review of a Nurse Event Note dated December 18, 2012, revealed the resident had a fall at 6:00 a.m. without injury in the merrywalker "...resident turned meriwalker over. Found in floor laying on (resident's) back. Meriwalker bar under legs. Strap intact. Walker on its side..." Continued review of the Nurse Event Note revealed no new interventions were implemented. Review of a fall investigation dated December 18, 2012, revealed interventions in place at the time of the resident's fall were "...meriwalker...Other...protective helmet..." Continued review of the fall investigation revealed no documentation the resident's merrywalker had weights in place at the time of the fall. Interview with the DON on June 19, 2013, at 8:35 a.m., in the DON's office, confirmed the fall investigation and nursing documentation did not indicate if the resident's personal alarm was on and functioning at the time of the resident's fall. Continued interview with the DON, confirmed no new interventions were implemented to protect the resident from future injury after the second fall on December 18, 2012. Medical record review of a Therapy Fall Screen dated December 18, 2012, revealed the Physical Therapist evaluated the resident on December 18, 2012, after the resident's falls on December 12, 2012, December 14, 2012, and the two falls on December 18, 2012. Continued review of the Therapy Fall Screen note revealed no new recommendations "...PT (physical therapy) not indicated due to inability to follow command at this time, screen attempted 3x (times). Recommend to continue merriwalker..." Medical record review of a Nurse Event Note dated December 21, 2012, revealed the resident had a fall at 9:00 p.m. without injury in the merrywalker "...pt walking in hallway in merrywalker. Was observed lying on (resident's) left side, apparently having tripped and knocked over merrywalker..." Continued review of the Nurse Event Note revealed no new interventions were implemented to protect the resident from future injury "...pt given evening meds and assisted to bed..." Review of a fall investigation dated December 21, 2012, revealed interventions in place at the time of the resident's fall "...low bed...bed alarm...Assistive Devices...walker..." Continued review of the fall investigation revealed no documentation the resident's merrywalker had weights in place at the time of the fall. Medical record review of a Therapy Fall Screen dated December 24, 2012, revealed the resident was evaluated by the Physical Therapist after the resident's fall on December 21, 2012, with no new recommendations "...PT (physical therapy) not indicated due to inability to follow command..." Interview with the DON on June 19, 2013, at 8:35 a.m., in the DON's office, confirmed the intervention of a bed alarm at the time of the resident's fall was not appropriate to prevent injury from falls in the merrywalker. Continued interview with the DON, revealed the DON could not confirm the resident's personal alarm was in place and functioning at the time of the resident's fall. Further interview with the DON, confirmed the intervention of putting the resident to bed was not a new intervention to protect the resident from future injury. Medical record review of a Nurse Event Note dated December 25, 2012, revealed the resident had a fall at 8:45 p.m. without injury in the merrywalker "...resident found at end of hall merrywalker and resident in floor resident laying on L (left) side. Merrywalker around (resident) tipped over on L side...resident had protective helmet and padded hipster pants for protection..." Continued review of the Nurse Event Note revealed intervention listed to prevent future falls "...therapy to reevaluate mobility of merrywalker and weights..." Review of a fall investigation dated December 25, 2012, revealed interventions in place at the time of the resident's fall as "...personal alarm...Assistive Devices (checked but did not indicate which assistive devices were utilized)..." Continued review of the fall investigation revealed no documentation the resident's merrywalker had weights in place at the time of the resident's fall. Interview with the DON on June 19, 2013, at 8:35 a.m., in the DON's office, revealed the DON could not confirm the resident's personal alarm was on and functioning at the time of the resident's fall. Medical record review of a Nurse Event Note dated December 26, 2012, revealed the resident had a fall from the bed at 11:50 p.m. in the resident's room without injury "...found in the floor just past doorway. Resident laying in floor on (resident's) back...no injury found..." Continued review of the Nurse Event Note revealed new intervention implemented to prevent future falls "...move resident closer to nurse station (room change)..." Review of a fall investigation, not dated, revealed interventions in place at the time of the fall were "...low bed...merriwalker...bed alarm..." Interview with the DON on June 19, 2013, at 8:35 a.m., in the DON's office, revealed the DON could not confirm the resident's personal alarm or bed alarm were in place and functioning at the time of the resident's fall. Continued interview with the DON, confirmed the resident's room had not been moved closer to the nurse station, and the resident was currently in the same room as at the time of the fall on December 27, 2012. Medical record review of a Nurse Event Note dated December 28, 2012, revealed the resident had a fall at 12:25 a.m., without injury, in the resident's room after the resident got up out of bed "...CNA (Certified Nurse Assistant) came and told nurse resident was on floor. Found resident laying on floor inside doorway of (another resident's room)..." Continued review of the Nurse Event Note revealed no new interventions were implemented at the time of the resident's fall. Review of a fall investigation dated December 28, 2012, did not document the use of protective or preventative devices: low bed, personal alarm, mat to bedside, or pad alarm at the time of the resident's fall. Medical record review of a Nurse Event Note dated December 28, 2012, revealed the resident had a fall at 6:15 p.m. without injury in the merrywalker "...Saw a tech (CNA) run from the DR (dining room) to hallway -noted resident in the floor in merri-walker laying on...left side...protective helmet on..." Continued review of the Nurse Event Note documented new intervention to prevent future falls "...Sent to ER for evaluation..." Review of a fall investigation, not dated, revealed no documentation the resident's personal alarm was in place and functioning at the time of the fall. Continued review of the fall investigation revealed no documentation the resident's merrywalker had weights in place at the time of the fall. Interview with the DON on June 19, 2013, at 8:35 a.m., in the DON's office, confirmed the fall investigations (not dated but located on the back of the Nurse Event Notes) for the resident's falls on December 28, 2012, were incomplete and could not confirm the resident's personal alarm was in place or functioning at the time of the resident's fall. Continued interview with the DON, confirmed no new interventions were put in place to protect the resident from future injury after the falls on December 28, 2012. Medical record review of a Therapy Fall Screen dated December 31, 2012, revealed the resident was evaluated by the Physical Therapist with new recommendation to "...d/c (discontinue) merrywalker and use a Rocking Go w/c (wheelchair) (wheelchair with seat and back which allows for the seat to rock like a rocking chair)..." Medical record review of a Social Services Note dated January 25, 2013, revealed, "...Pt now up daily in his rock and go w/c. No longer, as of 1/2/13 to use merrywalker, due to having several falls..." Interview with the Physical Therapist on June 20, 2013, at 8:35 a.m., in the Conference Room, confirmed the therapist put weights on the resident's merrywalker on November 13, 2012. Further interview with the Physical Therapist, revealed the Physical Therapist did not believe adding more weights to the resident's merrywalker was appropriate after continued falls "...because (the resident) was too strong and kept tipping (the merrywalker over)..." Continued interview with the Physical Therapist, confirmed the therapist was aware the resident continued to have multiple falls (a total of six) in the merrywalker after placement of weights, and confirmed the Physical Therapist did not recommend discontinuation of the merrywalker until the evaluation on December 31, 2012. Medical record review of a Nurse Event Note dated February 1, 2013, revealed the resident had a fall at 7:45 p.m. without injury from the Rock 'n Go chair. Continued review of the Nurse Event Note revealed new interventions to prevent falls from Rock 'N Go chair "...shorten length on body alarm...foot rest on Rock & Go..." Review of a fall investigation dated February 1, 2013, revealed no documentation the resident's personal alarm was in place or functioning at the time of the resident's fall. Medical record review of a Therapy Fall Screen dated February 4, 2013, revealed the resident was evaluated by the Physical Therapist with no recommendations "...PT (physical therapy) not indicated due to pt. (patient) inability to follow command..." Interview with the DON on June 19, 2013, at 835 a.m., in the DON's office, confirmed the fall investigation for February 1, 2012, was incomplete, and confirmed the protective device of personal alarm could not be confirmed as in place or functioning at the time of the resident's fall. Medical record review of a Nurse Event Note dated February 21, 2013, revealed the resident had a fall at 2:45 p.m. from the Rock 'N Go chair with no injury "...Res (resident stood up out of (resident's) rock and go chair and took two steps before (resident) fell ...maintenence (sic) man slid under (resident) to break (resident's) fall..." Continued review of the Nurse Event Note revealed new interventions were put in place at the time of the resident's fall on February 21, 2013, "...keep chair in pulled back position. Put to bed after dinner with floor mat on floor and bed in lowest position-continue chair/bed alarm...have restorative work with (resident) to stand and encourage resident to take steps as desire..." Interview with the DON on June 21, 2013, at 8:35 a.m., in the DON's office, confirmed the preventative device of the resident's personal alarm or chair alarm could not be confirmed as being in place or functioning at the time of the resident's fall on February 21, 2013. Medical record review of a Nurse Event Note dated February 21, 2013, revealed the resident had a fall at 10:00 p.m. from the bed without injury "...heard body alarm sound and went to room...found resident sitting in floor legs extended in front of (resident's) body. Was wet and floor was wet...mat was pushed towards foot of bed..." Continued review of the Nurse Event Note revealed new intervention instituted at that time to prevent future falls "...concave bed mat when available..." Medical record review of a Therapy Fall Screen dated February 22, 2013, revealed the resident was evaluated by the Physical Therapist with no new recommendations "...PT (physical therapy) not indicated due to inability to follow command..." Medical record review of a Therapy Fall Screen dated February 25, 2013, revealed the resident was evaluated a second time by the Physical Therapist with no new recommendations "...PT (physical therapy) not indicated secondary inability to follow command..." Medical record review of the resident's Care Plan revealed the Care Plan was updated with a new intervention on February 21, 2013, "...concave overlay..." Continued review of the resident's Care Plan updated February 21, 2013, revealed a line drawn through "...concave overlay..." and "...D/C (discontinue)..." documented next to the entry. Further review of the resident's Care Plan revealed an additional entry dated February 21, 2013, "...assist to bed post (after) dinner as (resident) tolerates..." Interview with the DON on June 19, 2013, at 8:35 a.m., in the DON's office, confirmed the facility had identified a concave mattress as a new intervention to prevent falls from the resident's bed. Continued interview with the DON, revealed the DON stated, "...I applied the mattress the next day..." Observation and interview with the DON on June 19, 2013, at 9:37 a.m., in the resident's room, confirmed the absence of the concave mattress, or alarm to the resident's bed. Interview with the Assistant Director of Nursing (ADON) on June 19, 2013, at 9:37 a.m., in the Lobby area, revealed the ADON was responsible for ordering specialty mattresses or medical equipment. Continued interview with the ADON, confirmed concave mattresses were not kept in stock and must be ordered by the ADON. Further interview with the ADON revealed, "...we use bolsters on the side of the bed but nurses refer to them as concave mattresses..." Observation and interview with Licensed Practical Nurse (LPN) #2 on June 18, 2013, at 3:26 p.m., in the resident's room, revealed the resident sleeping in the bed with a personal clip alarm in place. Continued observation of the resident revealed no pad alarm in place on the resident's bed, and no concave mattress or bolsters on the resident's bed. Interview with LPN #2 confirmed the resident did not have a pad alarm, concave mattress, or bolsters at the time of the observation. Further interview with LPN #2 confirmed, "...to my knowledge..." the resident has never had a pad alarm, concave mattress, or bolsters in place on the resident's bed "...only clip alarm..." Continued interview with LPN #2 revealed, "...unsure..." of how to obtain a concave mattress or bolsters if recommended or ordered by the physician. Medical record review of a Nurse Event Note dated March 17, 2013, revealed the resident had a fall at 1:05 a.m. from the bed with injury "...found resident laying on the floor on (resident's) right side. Had (resident's) brief and grip socks, and gown on. Was clean and dry, found (the resident) laying in front of closet on other side of the room and found cream in chair by door from where (the resident) may have sat there. Sent resident to ER (emergency room ) for eval (evaluation) d/t (due to) knot on R (right) temple, and saying (the resident's) R shoulder and back was hurting, would not answer on what (the resident) was trying to do, yelled out if head, back or neck was touched. Alarm was going off, and staff answer right away..." Continued review of the Nurse Event Note revealed intervention initiated to prevent future fall and injury "...refer back to therapy..." Medical record review of a physician's orders [REDACTED]. Medical record review of the emergency room report dated March 17, 2013, revealed, "...The patient presents following fall...The fall was described as fell 2 feet...The character of symptoms is pain..." Continued review of the emergency room report revealed, "...Impression and Plan...Diagnosis...Cervical sprain...lumbar strain...Concussion with no loss of consciousness...Condition...stable..." Further review of the emergency room report revealed the resident was discharged back to the facility. Review of a fall investigation dated March 17, 2013, revealed documentation the resident was in a low bed at the time of the fall. Continued review revealed no documentation a fall mat, concave mattress or bolsters were in place at the time of the resident's fall on March 17, 2013. Interview with the DON on June 19, 2013, at 8:35 a.m., in the DON's office, confirmed preventative and protective devices of fall mat, concave mattress, or bolsters could not be confirmed as in place at the time of the resident's fall on March 17, 2013. Continued interview with the DON, confirmed the DON would expect for the concave mattress or bolsters to be documented on the fall investigation if those interventions were in place at the time of the resident's fall. Continued interview with the DON, confirmed an intervention of "...refer back to therapy..." was not a new intervention and the resident had continued to be evaluated after each fall with no new recommendations from the Physical Therapist since the fall on February 4, 2013. Further interview with the DON, confirmed the resident sustainined a concussion as a result of the fall, and a concussion was considered a major injury. Further interview with the DON, confirmed the resident was harmed as a result of the resident's fall March 17, 2013. Medical record review of a Nurse Event Note dated March 19, 2013, revealed the resident had a fall at 6:20 a.m. from his bed without injury "...CNA called (nurse) to room...resident laying in floor on (resident's) R side gown and floor wet..." Continued review of the Nurse Event Note revealed the intervention initiated after the resident's fall was "...toilet q 2 hour during the night..." Review of a fall investigation

Based on medical record review, review of facility investigation, review of facility policy, observation, and interview, the facility failed to prevent the unnecessary use of antipsychotic drugs, for one resident, #135 of sixty-three residents reviewed. The facility's failure to prevent the unnecessary use of antipsychotic medications, and the concurrent use of multiple psychoactive medications for resident #135 resulted in Toxic [MEDICAL CONDITION] (generalized [MEDICAL CONDITION] marked by varying degrees of impairment of speech, cognition, orientation and arousal), a [MEDICAL CONDITION], and facial trauma (Harm) for resident #135. The findings included: Review of the facility policy, Antipsychotic Medication Use, dated November 2012, revealed, "...antipsychotic medications may be used for the following conditions/diagnoses, as documented in the record...dementing illnesses with associated behavioral symptoms (only if unresponsive to other behavioral management interventions)...the symptoms such as auditory, visual, or other hallucinations; delusions (such as paranoia or grandiosity are being due [MEDICAL CONDITIONS])...the symptoms are severe enough that the individual is experiencing one or more of the following: inconsolable or persistent distress...a significant decline in function...or substantial difficulty receiving needed care..." Resident #135 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) dated , December 2, 2011, revealed the resident was able to understand speech, verbalized needs, had mild cognitive deficits, mild depressive symptoms, and was free of behavioral symptoms. Continued review revealed the resident required extensive assistance of one person for transfers, hygiene, and activities of daily living. Medical record review of the facility Behavioral Monitoring Flow Sheets from October of 2010, to December 2011, revealed the resident did not have any documented behavioral disturbances. Medical record review of the Psychiatric Progress Notes dated from February 5, 2008, to October 11, 2011, signed by the attending Psychiatrist revealed, the resident did not have any documented behavioral disturbances. Medical record review of the facility Medication Administration Record [REDACTED] [MEDICATION NAME]/APAP 2.5/500milligram (mg) (two and one half milligrams of [MEDICATION NAME] per five hundred milligrams of Tylenol) ([MEDICATION NAME], a narcotic) three times daily. [MEDICATION NAME] 0.25mg (one quarter milligram of [MEDICATION NAME] a benzodiazepine) three times daily. [MEDICATION NAME] 25mg daily every morning and 200mg daily at bedtime. (antipsychotic) [MEDICATION NAME] 2mg daily in the morning and 5mg daily at bedtime. (antipsychotic) [MEDICATION NAME] 10mg daily in the morning. (antidepressant). Medical record review of facility documents dated December 10, 2011, revealed, "...Fall 12-10-2011 345 pm...found in floor of room...alarm sounded...blood on left arm and hand...bruising skin tear to forehead...on left side...complained of nose pain...w/c (wheelchair) in close proximity...stated...was trying to walk to dining room..." Medical record review of a physician's verbal order dated December 10, 2011, revealed, "... ER (emergency room for eval (evaluation) per verbal order..." Continued review of the document revealed it was signed by the facility medical director. Medical record review of the facility Transfer Form dated December 10, 2011, revealed, "...Reason for Transfer...S/P (status [REDACTED].{none} transfers with {one} assist... Last wt. (weight)...12 {pounds}..." Medical record review of the facility Discharge Summary dated December 10, 2011, revealed, "...Medication administered d/t (due to) multiple co-morbidities with changes as needed under medical director and phychiatrist (psychiatrist) recommendations...resident was sent to...(local hospital)...due to fall...was admitted for observation and noted injuries..." Review of ambulance service documents dated December 10, 2011, revealed, "...EKG (electrocardiogram, a measure of the heart's electrical activity, rate, and rhythmn)... interpretation sinus [MEDICAL CONDITION] (slow heart rate)...Chief Complaint... fall with head injury... BP (blood pressure)...178/80 pulse rate 48... No active bleeding...Eyes open to speech... verbal...motor...localizes...GCS (Glascow Coma Scale, an instrument used to measure mental status in victims of head or neurological injuries) 9 (indicating moderate head injury)... Narrative...staff reports fell from wheelchair...causing contusion abrasion...had no significant blood loss...bleeding...controlled...they denied LOC (loss of consciousness) or mental status changes since event...pt (patient) is supine (lying on the back) beside bed with obvious facial injury...is awake...lethargic...non- verbal...staff states this is... baseline neuro (neurological status)..." Record review of the hospital Admission History and Physical and the emergency room record dated December 10, 2011, revealed the resident was evaluated in the emergency department and admitted to the facility for treatment. Continued review of the documents revealed, "...admitting [DIAGNOSES REDACTED]. Continued review of the emergency room record revealed the resident was mostly unresponsive during the initial evaluation by the attending emergency room physician. "...also has some dementia...history additionally of psychiatric problems...diagnosed in the past with Paranoid [MEDICAL CONDITION] have noticed over the past several weeks seemed to be somewhat more confused than usual...more lethargic than usual...has gotten much worse over past 48 hours...son went to see... today...said...was...sitting in...wheelchair...was very sleepy...mumbling incoherently...his sister subsequently went to see...patient was slumped over in...wheelchair...apparently...fell out of the wheelchair and has a pretty significant hematoma (an elevated bruise caused by pocketing of blood beneath intact skin) involving the middle of...forehead...was sent to the ER...responds only to painful stimuli...will kind of move around a little bit...but does not speak...there is really no meaningful interaction...does not follow any commands..." Continued review of the emergency room record revealed, "...Assessment...1. Altered Mental Status question if this is related to over medication...I am going to [MEDICATION NAME] ([MEDICATION NAME], a benzodiazepine sedative for anxiety), [MEDICATION NAME] (an atypical antipsychotic medication), [MEDICATION NAME] (a narcotic used to treat pain), [MEDICATION NAME] (an atypical antipsychotic medication), [MEDICATION NAME](a sedative hypnotic drug for [MEDICAL CONDITION])...2. Dehydration...we will give IV (intravenous) fluid overnight...5. [MEDICAL CONDITION] change to one half the dose while...8.Humerus Fracture...the patient has been placed in a sling in the ER...This will be nonsurgical management..." Review of the hospital Discharge Summary dated December 14, 2011, revealed, "...Primary Discharge Diagnoses...1. Toxic [MEDICAL CONDITION]ly secondary to sedative medications...2. Possible B12 (vitamin B12) deficiency...3... right humerus fracture, felt best non operatively managed..." Continued review revealed, "...Radiographs and Procedures of Interest...1. X-Ray of the right shoulder on admission showing an impacted [MEDICAL CONDITION] neck of the humerus...was admitted to our facility with the provisional [DIAGNOSES REDACTED]. Continued review of the hospital Discharge Summary revealed, "...By hospital day 2, the patient's mentation improved by the afternoon...was awake, conversant, and oriented...On hospital day 3, the patient continued to be with improved cognition...no signs of either benzodiazepine or narcotic withdrawal...antipsychotics we continued to hold...evaluated the patient on hospital day 3 and deemed...appropriate candidate for transfer...was transferred to...Geriatric Psychiatric Hospital on December 12 in stable condition..." Interview with Family Member #2 ( FM#2) on June 17, 2013, at 8:44 p.m. by telephone, revealed on December 10, 2011, (the day of the fall) FM#2 had visited the resident in the facility, and found the resident seated in a wheelchair, slumped forward, with the right arm dangling near the base of the wheelchair wheel, the resident's chin resting on the right arm of the wheelchair, and the resident was asleep. Continued interview revealed the resident was unattended by staff, was difficult to arouse, and was unrestrained in the chair. Continued interview revealed the resident could not take oral fluids or eat due to obvious fatigue. Continued interview revealed FM#2 summoned a staff member to the dining area, and requested to have the resident placed in bed, and proceeded to address concerns related to the medication regimen of the resident with a facility nurse. Continued interview revealed FM#2 had requested the discontinuation of antipsychotic drugs for resident #135 in December 2010, (one year prior to the resident's fall on December 10, 2011). Continued interview revealed FM#2 was unaware antipsychotic medications were still in use at the time of the fall, until informed by the emergency room physician who reviewed the medication list received from the facility and informed the family during the hospital admission. Continued interview revealed FM#2 used a cellular telephone to photograph the resident seated in the wheelchair, unattended, and unrestrained, in a sedated state, approximately three hours prior to the fall, and before summoning staff to the dining hall and requesting the resident be placed in bed. Interview with FM#2 and observation of the photographs downloaded from FM#2's cellular phone on June 18, 2013, at 11:50 a.m., off site from the facility revealed, resident #135 seated in a wheelchair, with a body alarm wire visible clipped to the left shoulder of the resident's sweater. Continued observation revealed the resident's right arm dangling off the wheelchair with the right hand exhibiting discoloration consistent with an extended period of dependent positioning near the base of the wheelchair wheel. Continued observation revealed the resident's chin, and right portion of the cheek were positioned on the right wheelchair arm. Interview with the Medical Records Director (MRD) on June 18, 2013, at 9:15 a.m., in the Social Services Office revealed, MRD was familiar with the incident on December 10, 2011, and was the house charge nurse at the time of the fall. Continued interview revealed, MRD administered first aid to the resident after the fall, summoned an ambulance to the facility, and completed the facility documents related to the incident. MRD revealed prior to the fall, the resident "would periodically request a nap in the afternoon, dozed off in the wheelchair before, but can't recall it being a frequent thing, but when it did happen...would ask to be helped to bed usually." Continued interview revealed the resident was prone to periods of lethargy "it usually happened in the morning time and...would stay in bed." Continued interview revealed the MRD did not recall any significant behavioral problems with the resident which impaired daily function or socialization in the facility, did not recall any episodes of aggression, hallucinations, severe agitation, elopement attempts, wandering, or self-endangerment. MRD stated "I vaguely remember some paranoia", and went on to state the resident was "sociable with the people on... end of the hall." Interview with LPN #2 on June 18, 2013, at 8:00 a.m., in the facility beauty shop revealed, LPN #2 was familiar with the resident, but had no recollection of the specific events related to the fall. LPN #2 revealed, he/she was the floor charge nurse for the unit on which the resident resided. During continued interview the LPN stated she had no knowledge of the resident exhibiting hallucinations, aggression, combative behaviors, refusal of hygiene or activities of daily living, wandering, or any problem behaviors. Interview with the facility Clinical Psychologist on June 18, 2013, at 1:30 p.m., in the Social Services Office ,revealed, the resident had received psychotherapy services for the managment of depression and anxiety, and was under the care of the Psychologist in December of 2011. Continued interview revealed the resident was experiencing symptoms of cognitive decline during later years of therapy. Continued interview revealed the Psychologist recalled no presence of aggression, combativeness, suicidal or homicidal ideation, hallucinations, or elopement attempts in the resident. During continued interview the Psychologist reported "signs and symptoms of persistent delusions and persistent paranoia in the later years of therapy." Interview with the facility Consultant Pharmacist (CP), on June 18, 2013, at 2:30 p.m., in the Social Services Office revealed, the consultant pharmacist confirmed antipsychotic, antidepressant, narcotic, benzodiazepine, and sedative hypnotic drugs all carry a risk of "central nervous system depression" During continued interview the CP confirmed the concurrent use of those medications "significantly increased the risk of central nervous system depression in elderly users" and clarified it as "sedation". Interview with the DON, on June 18, 2013, at 3:25 p.m., in the DON office, confirmed there was no documentation present in the facility behavioral management logs from October 2010, to December 2011, which indicated the presence of problem behaviors, and the resident was administered multiple psychoactive medications which placed the resident at risk for sedation and falls. Interview with the facility Medical Director (MD), on June 19, 2013, at 8:45 a.m., by telephone, in the Assistant Director of Nursing's Office, revealed the the resident's [DIAGNOSES REDACTED]. The MD stated the resident "manifested symptoms of all three diagnosis." During continued interview the MD reported all [MEDICAL CONDITION] medications were prescribed in "close consultation" with the attending Psychiatrist stated "all antipsychotic medications were controlled, monitored, and prescribed by the facility Psychiatrist." When questioned regarding the residents prior [DIAGNOSES REDACTED]." Continued interview with the MD revealed the MD stated "absolutely" when asked if the medication regime in place when resident #135 fell (December 10, 2011) would place the resident at high risk for sedation Interview with the facility Psychiatrist, on June 20, 2013, at 10:15 a.m., by telephone, revealed Psychiatry's role in the facility, was to evaluate residents and confer with the attending medical doctors, facility staff, and family members, regarding proposed plans of care, including medication management concerns. After review of the medical records for resident #135, the Psychiatrist explained the resident was initially prescribed antipsychotic medications due to manifestations of behavioral and psychological symptoms of dementia (BPSD). During continued interview, and review of the prescribed antipsychotic medications including the duplicative antipsychotic therapy of [MEDICATION NAME] and [MEDICATION NAME], the Psychiatrist stated " had not prescribed [MEDICATION NAME]." The Psychiatrist stated on September 6, 2011, the Psychiatrist ordered a reduction in the resident's [MEDICATION NAME] dosage after a review of the resident's medical record. The Psychiatrist stated the resident's dosage of [MEDICATION NAME] had been increased by the facility Medical Director. The Psychiatrist did not recall symptoms of medication side effects present during an examination of resident #135 on September 6, 2011. During continued interview, the Psychiatrist stated no consultations with the Medical Director regarding the prescription of [MEDICATION NAME] had occured. During continued interview, the Psychiatrist did not recollect being contacted by the facility nursing staff, Administration, Medical Director, or the family, at any time, regarding medication side effects, or requests to reduce psychoactive medication doses. C/O

Based on medical record review, review of facility investigation, review of facility policy, observation, and interview, the facility failed to prevent the unnecessary use of antipsychotic drugs, for one resident, #135 of sixty-three residents reviewed. The facility's failure to prevent the unnecessary use of antipsychotic medications, and the concurrent use of multiple psychoactive medications for resident #135 resulted in Toxic [MEDICAL CONDITION] (generalized [MEDICAL CONDITION] marked by varying degrees of impairment of speech, cognition, orientation and arousal), a [MEDICAL CONDITION], and facial trauma (Harm) for resident #135. The findings included: Review of the facility policy, Antipsychotic Medication Use, dated November 2012, revealed, "...antipsychotic medications may be used for the following conditions/diagnoses, as documented in the record...dementing illnesses with associated behavioral symptoms (only if unresponsive to other behavioral management interventions)...the symptoms such as auditory, visual, or other hallucinations; [MEDICAL CONDITION] (such as paranoia or grandiosity are being due [MEDICAL CONDITIONS])...the symptoms are severe enough that the individual is experiencing one or more of the following: inconsolable or persistent distress...a significant decline in function...or substantial difficulty receiving needed care..." Resident #135 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) dated , December 2, 2011, revealed the resident was able to understand speech, verbalized needs, had mild cognitive deficits, mild depressive symptoms, and was free of behavioral symptoms. Continued review revealed the resident required extensive assistance of one person for transfers, hygiene, and activities of daily living. Medical record review of the facility Behavioral Monitoring Flow Sheets from October of 2010, to December 2011, revealed the resident did not have any documented behavioral disturbances. Medical record review of the Psychiatric Progress Notes dated from February 5, 2008, to October 11, 2011, signed by the attending Psychiatrist revealed, the resident did not have any documented behavioral disturbances. Medical record review of the facility Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] [MEDICATION NAME]/APAP 2.5/500milligram (mg) (two and one half milligrams of [MEDICATION NAME] per five hundred milligrams of Tylenol) ([MEDICATION NAME], a narcotic) three times daily. [MEDICATION NAME] 0.25mg (one quarter milligram of [MEDICATION NAME] a benzodiazepine) three times daily. [MEDICATION NAME] 25mg daily every morning and 200mg daily at bedtime. (antipsychotic) [MEDICATION NAME] 2mg daily in the morning and 5mg daily at bedtime. (antipsychotic) [MEDICATION NAME] 10mg daily in the morning. (antidepressant). Medical record review of facility documents dated December 10, 2011, revealed, "...Fall 12-10-2011 345 pm...found in floor of room...alarm sounded...blood on left arm and hand...bruising skin tear to forehead...on left side...complained of nose pain...w/c (wheelchair) in close proximity...stated...was trying to walk to dining room..." Medical record review of a physician's verbal order dated December 10, 2011, revealed, "... ER (emergency room for eval (evaluation) per verbal order..." Continued review of the document revealed it was signed by the facility medical director. Medical record review of the facility Transfer Form dated December 10, 2011, revealed, "...Reason for Transfer...S/P (status [REDACTED].{none} transfers with {one} assist... Last wt. (weight)...12 {pounds}..." Medical record review of the facility Discharge Summary dated December 10, 2011, revealed, "...Medication administered d/t (due to) multiple co-morbidities with changes as needed under medical director and phychiatrist (psychiatrist) recommendations...resident was sent to...(local hospital)...due to fall...was admitted for observation and noted injuries..." Review of ambulance service documents dated December 10, 2011, revealed, "...EKG (electrocardiogram, a measure of the heart's electrical activity, rate, and rhythmn)... interpretation sinus [MEDICAL CONDITION] (slow heart rate)...Chief Complaint... fall with head injury... BP (blood pressure)...178/80 pulse rate 48... No active bleeding...Eyes open to speech... verbal...motor...localizes...GCS (Glascow Coma Scale, an instrument used to measure mental status in victims of head or neurological injuries) 9 (indicating moderate head injury)... Narrative...staff reports fell from wheelchair...causing contusion abrasion...had no significant blood loss...bleeding...controlled...they denied LOC (loss of consciousness) or mental status changes since event...pt (patient) is supine (lying on the back) beside bed with obvious facial injury...is awake...lethargic...non- verbal...staff states this is... baseline neuro (neurological status)..." Record review of the hospital Admission History and Physical and the emergency room record dated December 10, 2011, revealed the resident was evaluated in the emergency department and admitted to the facility for treatment. Continued review of the documents revealed, "...admitting [DIAGNOSES REDACTED]. Continued review of the emergency room record revealed the resident was mostly unresponsive during the initial evaluation by the attending emergency room physician. "...also has some dementia...history additionally of psychiatric problems...diagnosed in the past with Paranoid [MEDICAL CONDITION] have noticed over the past several weeks seemed to be somewhat more confused than usual...more lethargic than usual...has gotten much worse over past 48 hours...son went to see... today...said...was...sitting in...wheelchair...was very sleepy...mumbling incoherently...his sister subsequently went to see...patient was slumped over in...wheelchair...apparently...fell out of the wheelchair and has a pretty significant hematoma (an elevated bruise caused by pocketing of blood beneath intact skin) involving the middle of...forehead...was sent to the ER...responds only to painful stimuli...will kind of move around a little bit...but does not speak...there is really no meaningful interaction...does not follow any commands..." Continued review of the emergency room record revealed, "...Assessment...1. Altered Mental Status question if this is related to over medication...I am going to [MEDICATION NAME] ([MEDICATION NAME], a benzodiazepine sedative for anxiety), [MEDICATION NAME] (an atypical antipsychotic medication), [MEDICATION NAME] (a narcotic used to treat pain), [MEDICATION NAME] (an atypical antipsychotic medication), [MEDICATION NAME](a sedative hypnotic drug for [MEDICAL CONDITION])...2. Dehydration...we will give IV (intravenous) fluid overnight...5. [MEDICAL CONDITION] change to one half the dose while...8.Humerus Fracture...the patient has been placed in a sling in the ER...This will be nonsurgical management..." Review of the hospital Discharge Summary dated December 14, 2011, revealed, "...Primary Discharge Diagnoses...1. Toxic [MEDICAL CONDITION]ly secondary to sedative medications...2. Possible B12 (vitamin B12) deficiency...3... right humerus fracture, felt best non operatively managed..." Continued review revealed, "...Radiographs and Procedures of Interest...1. X-Ray of the right shoulder on admission showing an impacted [MEDICAL CONDITION] neck of the humerus...was admitted to our facility with the provisional [DIAGNOSES REDACTED]. Continued review of the hospital Discharge Summary revealed, "...By hospital day 2, the patient's mentation improved by the afternoon...was awake, conversant, and oriented...On hospital day 3, the patient continued to be with improved cognition...no signs of either benzodiazepine or narcotic withdrawal...antipsychotics we continued to hold...evaluated the patient on hospital day 3 and deemed...appropriate candidate for transfer...was transferred to...Geriatric Psychiatric Hospital on December 12 in stable condition..." Interview with Family Member #2 ( FM#2) on June 17, 2013, at 8:44 p.m. by telephone, revealed on December 10, 2011, (the day of the fall) FM#2 had visited the resident in the facility, and found the resident seated in a wheelchair, slumped forward, with the right arm dangling near the base of the wheelchair wheel, the resident's chin resting on the right arm of the wheelchair, and the resident was asleep. Continued interview revealed the resident was unattended by staff, was difficult to arouse, and was unrestrained in the chair. Continued interview revealed the resident could not take oral fluids or eat due to obvious fatigue. Continued interview revealed FM#2 summoned a staff member to the dining area, and requested to have the resident placed in bed, and proceeded to address concerns related to the medication regimen of the resident with a facility nurse. Continued interview revealed FM#2 had requested the discontinuation of antipsychotic drugs for resident #135 in December 2010, (one year prior to the resident's fall on December 10, 2011). Continued interview revealed FM#2 was unaware antipsychotic medications were still in use at the time of the fall, until informed by the emergency room physician who reviewed the medication list received from the facility and informed the family during the hospital admission. Continued interview revealed FM#2 used a cellular telephone to photograph the resident seated in the wheelchair, unattended, and unrestrained, in a sedated state, approximately three hours prior to the fall, and before summoning staff to the dining hall and requesting the resident be placed in bed. Interview with FM#2 and observation of the photographs downloaded from FM#2's cellular phone on June 18, 2013, at 11:50 a.m., off site from the facility revealed, resident #135 seated in a wheelchair, with a body alarm wire visible clipped to the left shoulder of the resident's sweater. Continued observation revealed the resident's right arm dangling off the wheelchair with the right hand exhibiting discoloration consistent with an extended period of dependent positioning near the base of the wheelchair wheel. Continued observation revealed the resident's chin, and right portion of the cheek were positioned on the right wheelchair arm. Interview with the Medical Records Director (MRD) on June 18, 2013, at 9:15 a.m., in the Social Services Office revealed, MRD was familiar with the incident on December 10, 2011, and was the house charge nurse at the time of the fall. Continued interview revealed, MRD administered first aid to the resident after the fall, summoned an ambulance to the facility, and completed the facility documents related to the incident. MRD revealed prior to the fall, the resident "would periodically request a nap in the afternoon, dozed off in the wheelchair before, but can't recall it being a frequent thing, but when it did happen...would ask to be helped to bed usually." Continued interview revealed the resident was prone to periods of lethargy "it usually happened in the morning time and...would stay in bed." Continued interview revealed the MRD did not recall any significant behavioral problems with the resident which impaired daily function or socialization in the facility, did not recall any episodes of aggression, hallucinations, severe agitation, elopement attempts, wandering, or self-endangerment. MRD stated "I vaguely remember some paranoia", and went on to state the resident was "sociable with the people on... end of the hall." Interview with LPN #2 on June 18, 2013, at 8:00 a.m., in the facility beauty shop revealed, LPN #2 was familiar with the resident, but had no recollection of the specific events related to the fall. LPN #2 revealed, he/she was the floor charge nurse for the unit on which the resident resided. During continued interview the LPN stated she had no knowledge of the resident exhibiting hallucinations, aggression, combative behaviors, refusal of hygiene or activities of daily living, wandering, or any problem behaviors. Interview with the facility Clinical Psychologist on June 18, 2013, at 1:30 p.m., in the Social Services Office ,revealed, the resident had received psychotherapy services for the managment of depression and anxiety, and was under the care of the Psychologist in December of 2011. Continued interview revealed the resident was experiencing symptoms of cognitive decline during later years of therapy. Continued interview revealed the Psychologist recalled no presence of aggression, combativeness, suicidal or homicidal ideation, hallucinations, or elopement attempts in the resident. During continued interview the Psychologist reported "signs and symptoms of persistent [MEDICAL CONDITION] and persistent paranoia in the later years of therapy." Interview with the facility Consultant Pharmacist (CP), on June 18, 2013, at 2:30 p.m., in the Social Services Office revealed, the consultant pharmacist confirmed antipsychotic, antidepressant, narcotic, benzodiazepine, and sedative hypnotic drugs all carry a risk of "central nervous system depression" During continued interview the CP confirmed the concurrent use of those medications "significantly increased the risk of central nervous system depression in elderly users" and clarified it as "sedation". Interview with the DON, on June 18, 2013, at 3:25 p.m., in the DON office, confirmed there was no documentation present in the facility behavioral management logs from October 2010, to December 2011, which indicated the presence of problem behaviors, and the resident was administered multiple psychoactive medications which placed the resident at risk for sedation and falls. Interview with the facility Medical Director (MD), on June 19, 2013, at 8:45 a.m., by telephone, in the Assistant Director of Nursing's Office, revealed the the resident's [DIAGNOSES REDACTED]. The MD stated the resident "manifested symptoms of all three diagnosis." During continued interview the MD reported all [MEDICAL CONDITION] medications were prescribed in "close consultation" with the attending Psychiatrist stated "all antipsychotic medications were controlled, monitored, and prescribed by the facility Psychiatrist." When questioned regarding the residents prior [DIAGNOSES REDACTED]." Continued interview with the MD revealed the MD stated "absolutely" when asked if the medication regime in place when resident #135 fell (December 10, 2011) would place the resident at high risk for sedation Interview with the facility Psychiatrist, on June 20, 2013, at 10:15 a.m., by telephone, revealed Psychiatry's role in the facility, was to evaluate residents and confer with the attending medical doctors, facility staff, and family members, regarding proposed plans of care, including medication management concerns. After review of the medical records for resident #135, the Psychiatrist explained the resident was initially prescribed antipsychotic medications due to manifestations of behavioral and psychological symptoms of dementia (BPSD). During continued interview, and review of the prescribed antipsychotic medications including the duplicative antipsychotic therapy of [MEDICATION NAME] and [MEDICATION NAME], the Psychiatrist stated " had not prescribed [MEDICATION NAME]." The Psychiatrist stated on September 6, 2011, the Psychiatrist ordered a reduction in the resident's [MEDICATION NAME] dosage after a review of the resident's medical record. The Psychiatrist stated the resident's dosage of [MEDICATION NAME] had been increased by the facility Medical Director. The Psychiatrist did not recall symptoms of medication side effects present during an examination of resident #135 on September 6, 2011. During continued interview, the Psychiatrist stated no consultations with the Medical Director regarding the prescription of [MEDICATION NAME] had occured. During continued interview, the Psychiatrist did not recollect being contacted by the facility nursing staff, Administration, Medical Director, or the family, at any time, regarding medication side effects, or requests to reduce psychoactive medication doses. C/O