Every finding on record at Warner Robins Rehabilitation Center

Based on observations, staff interviews, and review of facility's policies titled, Storing Dry Foods, Receiving Foods & Supplies, and Ware washing by Hand; dietary staff failed to ensure pots and pans were stored properly and free from wet nesting to prevent bacteria growth; failed to ensure dented cans were removed from the storage rack, and failed to ensure dietary staff could demonstrate proper usage of the three compartment sink to prevent foodborne illness. This deficient practice had the potential to affect 92 residents receiving an oral diet.Findings include:1. Review of the facility policy titled, Storing Dry Foods, with a revision date of November 14, 2025, documented under Procedure, 10. Store damaged canned goods in a separate and distinct area of the storeroom away from other food items.Review of the facility policy titled, Receiving Food & Supplies, with a revision date of November 14, 2025, documented under Procedure, 4. Inspect quantity, quality, weight, labels, etc. of all food received. Do not accept and return to the supplier any item that is dented, rusty or damaged cans.Observation on 07/10/2026 at 8:35 AM of the dry storage area revealed it contained a metal rack to store canned foods. Continued observation revealed a large can of Mandarin Oranges was in the rack and had a large dent in the middle.During an interview on 07/10/2026 at 8:35 AM, the Dietary Manager (DM) confirmed that the can of Mandarin Oranges was stored in the rack and had a large dent. The DM stated that when dietary staff put away the grocery delivery, they should not have placed the dented can in the rack. The DM stated that the dented can of Mandarin Oranges should have been placed in the dented can area.2. Review of the facility policy titled Ware washing by Hand, with a revision date of November 14, 2025, documented under the section, Three Compartment Sink Method, 10. Remove pots and pans, place open side down and allow to air dry.Observation on 07/10/2026 at 8:58 AM of the stacked steam table pans and pots on a storage shelf under the table with the coffee machine revealed they were all stored in the upright position. The stacks of steam table pans and pots were not stored inverted to prevent physical contamination. Continued observation of a stack of large rectangle steam table pans revealed the inside of the top upright pan had water pooled towards the front.During an interview on 07/10/2026 at 8:58 AM, the DM confirmed that all the pots and pans were being stored in the upright position and had never been told or knew that they needed to be stored inverted to prevent contamination. The DM stated that the facility's contracted dietitian conducts a sanitation round in the kitchen when they come to the facility once a month and the dietitian had never said anything to her regarding the storage of the pots and pans.During an interview on 07/11/2026 at 11:20 AM, the facility's registered dietitian revealed that she conducts sanitation rounds monthly when she is physically in the building. The dietitian stated that she had never noticed during her rounds that pots, pans, and food storage containers were being stored in the upright position and not inverted. The dietitian confirmed that she checked stacked pans for wet nesting but never noticed the upright position of the pans.Observation on 07/12/2026 at 8:45 AM of the steam table pans revealed they were now being stored inverted, however; a stack of six medium sized rectangle steam table pans were pulled apart which revealed they were all saturated with water.During an interview on 07/12/2026 at 8:45 AM, the DM confirmed that each steam table pan in the stack that was pulled apart had a significant amount of water inside while being stored on the shelf. The DM stated that she expected dietary staff to air dry pans before stacking and storing.3. Review of the facility policy titled Ware washing by Hand, with a revision date of November 14, 2025, documented under the section, Three Compartment Sink Method, 9. Transfer rinsed pots, pans, and utensils into the sanitizing sink and let stand in solution for one minute.Observation on 07/11/2026 at 9:50 AM of Dietary [NAME] AA, revealed [NAME] AA used the three compartment sink to wash and sanitize the food processor bowl, lid, and blade between pureeing food items. She washed the bowl, lid, and blade with soapy water, rinsed, and then placed the food processor dishware items in the sanitizing solution for three seconds. The dietary cook then proceeded to walk back to the area to finish the puree task.During an interview on 07/11/2026 at 9:50 AM, Dietary [NAME] AA confirmed that she only had the food processor dishware items in the sanitizing solution for a few seconds and was headed back to complete her puree. The dietary cook stated that she had never received any instructions or in-services on how to properly sanitize dishware using the three-compartment sink. The cook was not aware that dishware needed to be submerged in the sanitizing solution for 60 seconds.During an interview on 07/11/2026 at 10:10 AM, the DM revealed that she expected dietary staff to follow the proper procedures when sanitizing dishware using the three-compartment sink. The DM confirmed that the facility was using a quaternary sanitizing solution which required dishware to be submerged in the sanitizing solution for 60 seconds. The DM stated that she had in-serviced dietary staff on how to properly use the three-compartment sink but was not able to recall when the last in-service was completed.

Based on observations, resident and staff interviews, record review, and review of the facility policies titled, Smoking, and Comprehensive Person-Centered Care Plan, the facility failed to develop and implement a comprehensive care plan to address the resident's smoking for one of seven residents (R) (R77) who smoke. This failure had the potential to place R77 at risk for smoking related safety hazards.Findings include:Review of the facility's policy titled, Smoking, dated October 22, 2024, with a revision date of August 8, 2023, documented the safety and security of the center and its residents, visitors, and employees is of paramount concern. Residents that are active smokers will be identified on admission and reviewed when there is a significant change in status, quarterly, and annually thereafter. Smokers will have a smoking care plan implemented.Review of the facility Policy titled Comprehensive Person-Centered Care Plan, with a revision date of August 2023, documented, The center will develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timetables to meet a resident 's medical , nursing , mental and psychosocial needs that are identified in the comprehensive assessment.Review of the electronic medical record (EMR), documented R77 was admitted to the facility on [DATE] with diagnoses that included but were not limited to, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, anxiety disorder, unspecified, chronic systolic (congestive) heart failure,Review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE], documented R77 had a Brief Interview for Mental Status (BIMS) of 15, which indicated, little to no cognitive impairment.Review of the quarterly MDS dated [DATE], revealed section J1300 documented R77 was a current tobacco user. Review of the facility's smoker list revealed R77 was identified as a resident who smoked.Review of R77's comprehensive care plan revealed the facility had not developed a care plan to address the resident's smoking.Observation on 7/11/2026 at 1:30 PM revealed R77 was participating in the facility's scheduled smoke break.Observation on 07/12/26 9:30 AM revealed R77 was participating in the facility's scheduled smoke break.During an interview on 07/12/2026 at 9:42 AM, MDS Coordinator BB was asked who was responsible for developing care plans related to smoking. BB stated the facility had two MDS Coordinators and that either coordinator may developed and completed a resident's care plan. MDS Coordinator BB acknowledged that R77 did not have a current care plan that addressed smoking. MDS Coordinator BB stated she interviewed R77 in February, and R77 reported he had quit smoking. Based on that information, she deactivated the smoking care plan.During an interview on 07/12/2026 at 11:09 AM, the Director of Nursing (DON) was asked about her expectations for resident care planning. The DON stated she expected staff to develop and update care plans based on each resident's needs and changes in the resident's condition or care. She further stated that changes to a resident's care plan are discussed during the quarterly care plan meetings.

Based on observations, staff interviews, and review of the facility's policy titled Oxygen Administration via Concentrator, the facility failed to ensure that oxygen therapy was administered in accordance with the physician's orders for two of 23 residents (R) (R77 and R29) with physician's orders for oxygen (O2) therapy. The deficient practice had the potential to place R77 and R29 at risk of respiratory complications and unmet needs. Findings include: Review of the facility's policy titled Oxygen Administration via Concentrator, revised 8/2023, revealed the Procedure section included, .2. Turn the proper flow rate as ordered by the physician. 1. Review of R77's clinical record revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, and dyspnea. Review of R77's Quarterly Minimum Data Set (MDS), dated [DATE], revealed Section C documented a Brief Interview for Mental Status (BIMS) score of 3 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented R77 required substantial to maximal assistance with mobility. Section O (Special Treatments, Procedures, and Programs) documented R77 received O2 therapy while a resident at the facility. Review of R77's care plan revealed a Focus area of the resident was on O2 therapy related to shortness of breath. Interventions included administering O2 therapy during meals as ordered. Review of R77's Physicians' Orders revealed an order dated 12/14/2023 for O2 via nasal cannula (NC) at 3 liters per minute (LPM). Observations on 4/14/2025 at 11:52 am, 4/14/2025 at 5:17 pm, 4/15/2025 at 9:20 am, and 4/15/2025 at 2:31 pm revealed R77 receiving O2 via a NC at 4 to 4.5 LPM. In an interview on 4/15/25 at 2:33 pm, Licensed Practical Nurse (LPN) FF stated that residents received O2 according to the physicians' order. In an interview on 4/15/25 at 2:14 pm, the Director of Nursing (DON) stated that O2 should be administered according to the physician's order. She confirmed that R R77 would not be able to adjust the flow meter on the O2 concentrator. The DON confirmed pictures of R77's O2 flow meter set at 4 to 4.5 LPM. 51557 2. Review of R29's electronic medical record (EMR) revealed R29 had diagnoses including, but not limited to, malignant neoplasm of the lung. Review of R29's Admission Minimum Data Set (MDS) assessment, dated 2/18/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 3 (indicating severe cognitive impairment). Section O (Special Treatments, Procedures, and Programs) documented R29 received O2 therapy while a resident at the facility. Review of R29's Physician's Orders' revealed an order dated 3/20/2025 for O2 via NC at 2 LPM as needed for shortness of breath. Observations on 4/14/2025 at 11:59 am and 4/15/2025 at 9:34 am revealed R29 was receiving O2 at 3 LPM via a NC. In an interview on 4/15/2025 at 10:02 am, LPN DD revealed that the licensed nurses were responsible for setting and monitoring the flow rate of the O2. LPN DD stated he did not always look at the setting when providing care to a resident. In a concurrent observation and interview on 4/15/2025 at 12:15 pm, LPN EE confirmed R29's O2 was being administered at 3 LPM. LPN EE stated nurses were responsible for checking that the flow rate was according to the physician's orders. In an interview on 4/15/2025 at 12:50 pm, the DON revealed her expectation was for the licensed nursing staff to monitor the O2 flow rate and follow the physician's orders.

Based on staff interviews and record reviews, the facility failed to ensure laboratory tests were conducted in accordance with professional standards for one of 53 sampled residents (R) (R70). This deficient practice had the potential to place R70 at risk of medical complications, unmet needs, and a diminished quality of life. Findings include: Review of R70's Admission Record revealed diagnoses including, but not limited to, type 2 diabetes. Review of R70's Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Section N (Medications) documented that R70 received insulin injections on seven of the seven days during the look-back period. Review of R70's Physician's Orders revealed an order dated 1/25/2025 for Tresiba subcutaneous (SQ) solution (a medication used to control high blood sugar) 100 unit/ml (milliliter), inject 35 units SQ each am. Further review of the orders revealed no order for daily blood sugar checks. In an interview on 4/15/2025 at 12:30 pm, LPN AA verified R70 received insulin injections and did not have physician orders for daily blood sugar checks. In an interview on 4/15/2025 at 1:51 pm, the Director of Nursing (DON) verified R70's physician's orders of insulin injections and further verified there was no order for daily blood sugar monitoring. The DON stated R70's physician's orders should include blood sugar checks before meals and at bedtime. She stated the nurses were responsible for ensuring an order for blood sugar checks for residents who received insulin. In an interview on 4/16/2025 at 9:21 am, the Administrator stated the Unit Manager and the DON were responsible for checking physician orders. In an interview on 4/16/2025 at 9:36 am, Licensed Practical Nurse (LPN) II stated that if a resident received insulin injections, she would expect a physician's order for blood sugar checks. She further stated there were standing orders for blood sugar checks, and residents who received insulin should have the order initiated.

Based on observations, staff interviews, record reviews, and a review of the facility policy titled Person-Centered Medication Administration Schedule, the facility failed to ensure the medication error rate was less than 5%. A total of 34 opportunities were observed with four errors for two residents (R13 and R15), resulting in an error rate of 11.7%. This failure had the potential to result in medication not being given in accordance with the physician's orders and had the potential to adversely affect R13 and R15's clinical conditions. Findings include: A review of the facility policy titled Person-Centered Medication Administration Schedule, with a revision date of 10/25/2021, revealed the Policy section stated that medications were administered according to the person-centered schedule. The person-centered schedule term of Upon Rising was from 6:00 am to 10:00 am. The term Prior to Bed was from 6:00 pm to 10:00 pm. 1. Review of the clinical record revealed that R13 had a physician's order dated 1/15/2024, for licensed nursing staff to administer one 5 milligram (mg) finasteride tablet daily for urinary retention, one 40mg esomeprazole magnesium delayed release capsule daily for gastroesophageal reflux disease, and one 250-50 microgram (mcg) oral inhalation of wixela inhalation aerosol powder twice daily for chronic obstructive pulmonary disease. The finasteride and esomeprazole medications were scheduled to be administered upon rising. The wixela medication was scheduled to be administered upon rising and prior to bed. However, during an observation on 1/30/2024 at 8:14 am, Licensed Practical Nurse (LPN) BB failed to administer the finasteride tablet, esomeprazole magnesium delayed-release capsule, and the wixela inhalation aerosol powder as scheduled. During an interview on 1/30/2024 at 9:58 am, LPN BB stated that the medications were not available to administer. 2. Review of the clinical record revealed that R15 had a physician's order, dated 1/11/2024, for licensed nursing staff to inject 45 units of insulin detemir solution subcutaneously two times a day for diabetes. The medication was scheduled to be administered upon rising and prior to bed. However, during an observation on 1/30/2024 at 9:05 am, Registered Nurse (RN) DD failed to administer the insulin detemir as scheduled. At the time of the observation, RN DD stated that the insulin pen on the medication cart was empty.

Based on observations, staff interviews, record review, and review of the facility policies titled Person-Centered Medication Administration Schedule, and Ordering & Receiving Medications, the facility failed to ensure that two of 16 sampled residents (R) (R13 and R15) were free from significant medication errors by not ensuring medications were reordered on time. This failure placed R13 and R15 at risk for decreased therapeutic effects of medications and posed health risks. Findings include: A review of the facility policy titled Person-Centered Medication Administration Schedule, with a revision date of 10/25/2021, revealed the Policy section stated that medications were administered according to the person-centered schedule. The person-centered schedule term of Upon Rising was from 6:00 am to 10:00 am. The term Prior to Bed was from 6:00 pm to 10:00 pm. A review of the facility policy titled Ordering & Receiving Medications, with a revision date of 5/22/2018, revealed the Purpose section stated to ensure that medications were available for administration at the correct time, in the correct form and quantity. The Procedure section stated to check medications weekly to determine the need for re-order. 1. A review of the clinical record revealed that R13 had a diagnosis of chronic obstructive pulmonary disease (COPD). Further review of the clinical record revealed that R13 had a physician's order, dated 1/15/2024, for licensed nursing staff to administer one 250- 50 microgram (mcg) oral inhalation of wixela inhalation aerosol powder twice daily for COPD. The wixela medication was scheduled to be administered upon rising and prior to bed. During an observation on 1/30/2024 at 8:14 am, Licensed Practical Nurse (LPN) BB failed to administer the medication as scheduled. During an interview on 1/30/2024 at 9:58 am, LPN BB stated that the medications were not available to administer. LPN BB stated that she had called the pharmacy, and they would deliver the medication that day. A review of the clinical record revealed a 1/30/2024 nurse's note entry that documented the wixela inhaler was not available, and the physician had been notified. There was no evidence in the clinical record that the medication had been reordered prior to 1/30/2024. During an interview on 1/30/2024 at 1:32 pm, Regional Nurse AA stated that it was the Nurses' responsibility to reorder medications when they were down to a week or 7-day supply. 2. A review of the clinical record revealed that R15 had a diagnosis of diabetes. Further review of the clinical record revealed that R15 had a physician's order, dated 1/11/2024, for licensed nursing staff to inject 45 units of insulin detemir solution subcutaneously two times a day for diabetes. The medication was scheduled to be administered upon rising and prior to bed. However, during an observation on 1/30/2024 at 9:05 am, Registered Nurse (RN) DD failed to administer the insulin detemir as scheduled. At the time of the observation, RN DD stated that the insulin pen on the medication cart was empty. A review of the clinical record revealed a Nurse's Medication Administration Note dated 1/30/2024, that documented the physician was notified and ordered to hold the insulin until that night. R15's blood sugar level was documented as 133 and the medication was ordered immediately from the pharmacy.

Based on staff interviews, record reviews, and review of the facility policy titled, Bed-Hold and Permitting Residents to Return to Center, the facility failed to ensure three of three residents (R) (R#1, R#2, and R#3) reviewed for facility emergent transfer to the hospital and/or their Resident Representative (RR) received written be hold notice that included all required information. The deficient practice had the potential to contribute to possible denial of re-admission and loss of the resident's home following a hospitalization for residents transferred to the hospital. Findings include: Review of facility policy titled, Bed-Hold and Permitting Residents to Return to Center, effective date 10/24/2022 revealed under Policy: The center provided written notification to all residents, family members and/or legal representatives of bed-hold policy upon admission, and at the time of transfer, in accordance with federal and state guidelines. Procedure 1. Upon admission, and at the time a resident is transferred to a hospital or goes on a therapeutic leave, a center designee will provide the resident and an immediate family member, surrogate, or representative written information concerning the option to exercise the bed-hold policy. 3. The written information must specify the duration of the bed-hold policy and be issued at the time of transfer. 4. A copy of the bed-hold notice must be sent with the resident at time of transfer. Documentation: Complete the state-specific bed-hold form. Maintain bed-hold forms in the resident's financial file.' 1. Review of R#1's Discharge Minimum Data Set (MDS) revealed the resident was discharged from the facility to the hospital on 3/29/2023. Review of nurse's note dated 3/29/2023 revealed R#1 was discharged to behavior health facility for worsening behaviors. Further review of the medical record revealed no documentation that the resident and/or representative were provided the bed hold policy. 2. Review of R#2's Discharge MDS dated [DATE] revealed resident was discharged from the facility to hospital on 3/27/2023. Review of nurse's noted dated 3/27/2023 revealed R#2 was sent to the hospital for altered mental status. Further review of the medical record revealed no documentation that the resident and/or representative were provided the bed hold policy. 3. Review of R#3's Discharge MDS dated [DATE] revealed the resident was discharged from the facility to the hospital. Further review of the medical record revealed no documentation that the resident and/or representative were provided the bed hold policy. Interview on 5/30/2023 at 11:05 a.m. with the Social Services Director revealed the Charge Nurses are responsible to send the bed-hold form with the resident at time of transfer to the hospital. Stated there is not one kept for facility file. Interview on 5/30/2023 at 11:10 a.m. with the Director of Nursing (DON) revealed a copy of the bed-hold should be scanned into the resident's electronic medical record (EMR). Confirmed R#1, R#2, and R#3 did not have a bed-hold in the EMR. Stated she has been educating the nursing on ensuring that the document is provided at time of transfer.

Based on staff interviews and record review, the facility failed to ensure that psychotropic medications, specifically a hypnotic, were not ordered as needed (PRN) for more than 14 days unless clinically indicated for one of five residents (R) (#82) reviewed for unnecessary medications. Findings include: Record review of quarterly Minimum Data Set (MDS) for R#82 dated 1/21/2023 revealed a in section N-Medications revealed resident received hypnotic medication during the look back period. Record review of R#82 physician orders revealed an order dated 10/19/2022 for zolpidem tartrate 5 milligrams (mg) one tablet by mouth every 24 hours as needed at bedtime. There was no stop date for the medication. Review of Pharmacy consult dated 10/26/2022 with recommendations to discontinue use of zolpidem. There is no evidence the facility notified the Physician of the recommendation. Review of Pharmacy consult dated 12/30/2022 revealed a repeated recommendation to discontinue use of zolpidem. There is no evidence the facility notified the Physician of the recommendation. Review of Pharmacy consult dated 2/28/2023 revealed a repeated recommendation to discontinue use of zolpidem. Physician agreed with recommendation to discontinue use of medication on 3/14/2023. Record review of the Medication Administration Record (MAR) for R#82 on 3/16/2023 revealed the zolpidem had not been discontinued and the order was still active. Interview on 3/15/2023 at 11:13 a.m. with the Regional Nurse Consultant confirmed the Pharmacy consults had not been addressed by the Physician because the previous Director of Nursing had not submitted them to him. Further revealed that medication should have had a 14 day stop date unless the Physician had clinical rationale for the medication to be used beyond the 14 days.

Based on observations, staff interviews record review, and review of facility's policy titled, Central Vascular Access Device (CVAD) Dressing Change, the facility failed to change the Peripherally Inserted Central Catheter (PICC) Line dressing in timely manner for one of 24 sampled resident (R#64). Findings include: Review of facility policy titled 'Central Vascular Access Device (CVAD) Dressing Change' last revised 6/1/2021 revealed 'Guidance: 1. Perform sterile dressing changes using Standard-ANTT (Aseptic Non Touch Technique) .1.2 At least weekly. Review of the admission Minimum Data Set for R#64 dated 2/11/2023 revealed in section O-Special Treatments and Programs revealed resident receiving intravenous medications. Review of the physician orders for R#64 dated 2/7/2023 revealed an order to change PICC line dressing every week Tuesday (7 a.m.-3 p.m.) shift. Observation on 3/14/2023 at 10:10 a.m. revealed R#64's PICC line dressing was dated 2/28/2023. Observation on 3/15/2023 at 9:42 a.m. revealed R#64's PICC line dressing was still dated 2/28/2023. Interview on 3/15/2023 at 1:25 p.m. with Licensed Practical Nurse (LPN) AA revealed that the Wound Care Nurse was responsible for changing R#64's PICC line dressings. Interview on 3/15/2023 at 1:30 p.m. with LPN BB (Wound Care Nurse) revealed R#64 should have his PICC line dressing changed every week on Tuesdays according to the Physician's orders. LPN BB also revealed that the dressing should have been changed on 3/7/2023 and 3/14/2023. LPN BB confirmed the PICC line dressing was dated 2/28/2023. LPN BB revealed the charge nurse on duty those days should have changed the resident's PICC line dressing. Interview on 3/16/2023 at 1:42 p.m. with Director of Nursing (DON) she stated it is her expectation that physician orders be followed and the PICC line dressing should have been changed on 3/7/2023 and again on 3/14/2023.

Based on staff interviews, record review, review of the facility policy titled, Abuse & Neglect Prohibition, the facility failed to report an allegation of resident-to-resident abuse to the State Survey Agency (SSA) for one of four residents (R) (#96) reviewed related to abuse. Findings include: Record review of facility policy Abuse & Neglect Prohibition revised 5/23/2017 revealed the facility will conduct an investigation of any alleged abuse/neglect or misappropriation of resident property in accordance with state or federal law. The facility will report such allegations to the state, as per state/federal regulation. The facility will report immediately but no later than 2 hours after forming the suspicion if the events that cause the allegation involve abuse or result in serious bodily injury. Record review revealed R#96 had diagnoses including Neurocognitive Disorder with Lewy Bodies, Alzheimer's Disease, Dysthymic Disorder, Unspecified Dementia, and Psychotic Disorder with Delusions. Review of the Progress Notes revealed on 2/13/2023, the resident was found on the floor. Another resident pushed him down in front of the vending machines. Resident who hit him was sent to the mental health facility. There was no documented evidence that resident-to-resident abuse was reported to the SSA. Interview on 3/16/2023 at 9:30 a.m., Licensed Practical Nurse (LPN) EE stated the resident was pushed down in one incident. He was standing in front of the coke machine and another resident came up and pushed him down. LPN EE stated if there is an altercation between two residents she would separate the residents, communicate with Social Services, and the aggressor will be sent to Behavioral Health. Interview with the Social Services Manager on 3/16/2023 at 10:00 a.m. revealed if there is an altercation between two residents they will be separated, interview both residents, and try to determine the instigator. If there was resident to resident contact, notify Psych Services and call the family and doctor. Interview with the Administrator on 3/16/2023 at 11:10 a.m. revealed the resident was pushed down by another resident on 2/13/2023, but there were no injuries, and this was not reported to the state. The Administrator states since there were no injuries the information did not have to be reported to the state.

Based on record review and staff interviews the facility failed to ensure that the staff designated as the Dietary Manager (DM) was certified or had a similar food service management certification or degree. The deficient practice had the potential to affect 87 of 98 residents who received an oral diet. Findings include: Review of facility policy was requested from the DM and the Nursing Home Administrator (NHA) on 10/5/2021 and 10/6/2021 but was not received. Review of the DM's Certificate dated 2016 revealed she had completed the course work but did not reflect that she had successfully completed the requirements to obtain a certification that included an issue and expiration date. An interview with the Dietary Manager on 10/6/21 10:03 a.m. revealed she was not certified. Although she has a certificate, that revealed she had completed the coursework in 2016, the DM had never sat for her exam. The DM stated she is scheduled to take her Dietary Manager's Certification Test in November of 2021. An interview with the NHA on 10/6/21 10:12 a.m. revealed she was aware the Dietary Manager had not taken her Dietary Manager's Certification test but was scheduled to take the exam in November of 2021. The NHA acknowledged that the Dietary Manager must be certified even though she has only been employed at that facility for approximately six months.

Based on observation, interviews, and review on the service manual from the manufacturer the facility failed to ensure the filter for the oxygen concentrator for one of 24 residents, that received respiratory treatment, (R#36) was cleaned and/or changed. Findings include: Review on the service manual from the manufacture revealed preventive maintenance of the concentrators is every three years. Filters are changed if they look dirty or there is a drop in oxygen purity. The intake cabinet per manufacture guidelines has a schedule for cleaning and dusting filter. Record review revealed R#36 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plans for R#36, last updated 6/9/2021, revealed the resident was care planned for oxygen therapy related to impaired gas exchange. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 10/4/2021 at 1:30 p.m. with Registered Nurse (RN) DD concerning R#36's oxygen concentrator filter revealed that RN DD observed the oxygen concentration filters and stated they were dirty and nasty. Interview on 10/4/2021 at 2:00 p.m. the Maintenance Director (MD) stated he has only been at the facility for three months. He stated the facility owns the oxygen concentrators and they are supposed to be maintenance free for three years. The MD revealed he has not maintained the machines since he started at this facility. The filters were observed to be dirty and needed changing but he doesn't have any filters here at the facility to exchange. Interview on 10/5/2021 at 11:45 a.m. with the Administrator (ADM) revealed the facility does not have a respiratory care equipment policy and states they use the manufacture guidelines for maintenance.

Based on record review, review of the facility document titled Change in Condition Guideline and interviews, the facility failed to notify the responsible party of weight loss for one of four sampled residents (R) (R#1). Findings include: R#1 was admitted to the facility on [DATE] and discharged from the facility on 3/2/2021. R#1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nutritional assessment dated [DATE] revealed R#1 had a 22 percent (%) weight loss related to suboptimal by mouth intake in the last 90 days. Recommendations for the protein supplement Ready Care 2.0, 90 milliliters (ml), two times a day. On 2/11/2021 the Dietitian recommended increasing Ready Care 2.0 to 120 ml two times a day. Review of the Medication Administration Records (MAR) for R#1 revealed the recommendations of the Dietitian were ordered, transcribed on to the MAR and given as ordered for the months of January 2021 through March 2021. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed R#1 had a Brief Interview of Mental Status (BIMS) score of 5, indicating severe cognitive impairment. A review of the Nursing Notes and the care plan meeting minutes, Social Service Notes and Dietary Notes for January 2021 through March 2021 revealed no evidence that the resident representative was notified of the resident's significant weight loss and the changes in the interventions implemented including protein supplement additions and changes. During an interview on 5/3/2021 at 7:52 a.m., family of R#1 revealed no knowledge and was not contacted regarding the resident's weight loss. During an interview with the Administrator on 5/5/2021 at 8:34 a.m. she stated that she believed that some of the weight losses occurred during COVID restrictions when residents were required to stay in their rooms. She stated that her expectations were that her staff communicate with family members about important issues. A review of the undated Change in Condition Guideline document provided by the facility revealed: The facility must inform the resident, consult with the resident's physician, and notify the resident's family member or legal representative when there is a change requiring such notification. Example situations requiring notification include: 2. A significant change in the resident's physical, mental, or psychosocial status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. 3. A need to alter treatment significant; that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment.

Based on interviews, record review, and policy review, the facility failed to provide a thorough initial assessment of a pressure ulcer for one resident (R) (#7) from a total sample of three residents. Findings include: The facility had a pressure ulcer policy. The Pressure Ulcer and Skin Care Management policy dated 4/25/17 revealed that the licensed nurse documents the evaluation or presence of skin concerns. R#7 was admitted to the facility on [DATE] with the following but not limited to Diagnoses: [REDACTED]. The Weekly Pressure Ulcer QA & A Log dated 6/18/2020 documented that R#7 had a facility acquired area to the right buttock measuring 1.5 cm x 3.5 cm x 0.2 cm. The notes revealed that the treatment was a [MEDICATION NAME] dressing. However, the nurse's notes failed to describe the stage of the wound. On 6/25/2020 it was documented that R#7 had a facility acquired area to the right buttock measuring 1.5 cm x 3.0 cm x 0.2 cm. The notes revealed that the treatment was a [MEDICATION NAME] dressing. However, the nurse's notes failed to describe the stage of the wound. On 7/2/2020 it was documented that R#7 had a facility acquired stage 3 area to the sacrum measuring 6.0 cm x 6.0 cm x 0.1 cm. The notes revealed that the treatment was Santyl. Nursing Progress Notes dated 6/18/2020 and 6/25/2020 stated the resident has a facility acquired pressure ulcer to the right buttocks and the wound care physician would visit the resident on a weekly basis. However, a thorough description of the pressure ulcer was not documented until the wound care physician's consultation on 7/1/2020. Wound Care Physician Notes dated 7/1/2020 documented that the patient presents with an area on his sacrum. At the request of the referring physician, a thorough wound care assessment and evaluation was performed today. The wound measured 6 cm x 6 cm x 0.1 cm, with light serous drainage, surface area 36 cm, and 100% granulation tissue. The note further stated that the wound was in an [MEDICAL CONDITION] stage and is unable to progress to a healing phase because of the presence of biofilm. During an interview with the Interim Director of Nursing on 8/11/2020 at 4:38 p.m. she stated the treatment nurse does not stage wounds, the facility waits on the wound care physician to come every week and he does that. During an interview with the Administrator on 8/12/2020 at 8:45 a.m. she confirmed that the treatment nurse doesn't stage wounds, that the facility does not do that, they wait on the wound care physician to do it and he comes every Wednesday. During an interview with the Wound Care Physician on 8/12/2020 at 9:20 a.m. he confirmed that he makes rounds every week with the treatment nurse to see new patients. He also confirmed the first visit for R#7 was on 7/1/2020, then the resident went to the hospital. He further stated that R#7 developed the area on the sacrum, and the measurements are deceptive, because the wound was a cluster of two small open areas. The whole wound was open when I saw him the first time with denuded skin that looked like a moisture problem, sloughing off when it was wiped away. The policy here is that the facility wants me to stage wounds, however, there needs to be a description of the wound bed. He further stated that he reserved [MEDICATION NAME] dressings for stage two wounds.

Based on observation, record review and staff interview, the facility failed to serve one resident (R) (#5) a strawberry milkshake as ordered by the physician from a total sample of 12 residents. Findings include: R#5 was admitted to the facility on [DATE] and had the following but not limited to Diagnoses: [REDACTED]. Review of the resident's weight record revealed the had an 8.3% weight loss in two months from 96 pounds on 6/6/20 to 88 pounds on 8/7/20. The resident had a physician's orders [REDACTED]. During observations of the resident's lunch trays on 8/5/20 at 12:45 p.m., 8/6/20 at 12:10 p.m. and 8/10/20 at 12:40 p.m., the resident was not served a homemade strawberry milkshake as ordered. During an observation of the resident's lunch tray with the Administrator on 8/10/20 at 1:15 p.m., she confirmed the resident was not served the milkshake. She stated they did make homemade milkshakes there because they had nutritional supplements that were ready to serve available. During a subsequent interview with the Administrator on 8/10/20 at 1:30 p.m., she stated she called the Registered Dietician who stated that she and the previous Dietary Manager decided they would try some homemade milkshakes for the resident. She also stated the Registered Dietician told her she meant to discontinue the milkshake when the resident returned from the hospital on [DATE] because the resident did not need the milkshake. Review of a list of residents who were reviewed by the Registered Dietician on 7/23/20 noted that R#5 was receiving a strawberry milkshake with lunch trays. However, during an interview with the Dietary Manager on 8/10/20 at 3:29 p.m., she stated she has been the Dietary Manager since 12/2019 and they have never made homemade milkshakes. She also stated after receiving the list of supplements from the Registered Dietician on 7/23/20, she did not ensure R#5 was receiving the homemade strawberry milkshakes. Although the resident had not received the homemade milkshake as ordered, he was receiving an appetite stimulant since 7/13/20, fortified foods with all meals since 5/21/20, and Readycare 2.0 90 milliliters twice a day since July 2020.

Based on observation, record review and staff interview, the facility failed to implement a care plan intervention to provide supplements as ordered for weight loss for one resident (R) (#5) from a total sample of 12 residents. Findings include: R#5 had a care plan for at risk for nutrition/dehydration related to history of poor intake and a history of weight loss. It was revised on 6/29/20 to reflect a 5% weight loss due to a recent hospital stay. On 7/23/20 a revision noted the resident continued to have weight loss. The care plan had an intervention to provide supplements as ordered. The resident had a physician's orders [REDACTED]. During observations of the resident's lunch trays on 8/5/20 at 12:45 p.m., 8/6/20 at 12:10 p.m. and 8/10/20 at 12:40 p.m., the resident was not served a homemade strawberry milkshake as ordered. Cross refer to F692.

Based on observation, interview, review of facility menus, it was determined the facility failed to follow the approved menu for 79 residents receiving an oral diet. The facility census was 88 residents. Findings include: A review of the 8/5/2020 posted daily menu revealed cubed steak, white rice, lima beans cornbread w/butter and fruit. Beef steak was substituted. No butter or other condiments were noted on the meal trays or serving carts available for residents. The Week at a Glance menu stated Wednesday 8/5/2020 lunch meal would be cube steak, french fries, french green bean medley. A review of the 8/6/2020 posted daily menu revealed lunch as fried chicken, potato salad, mixed vegetables, cornbread w/butter, and chocolate pudding. The dessert served was lemon pie. No butter was available on the trays. A review of the 8/10/2020 posted daily menu revealed cubed steak, white rice, buttered zucchini, dinner roll w/ butter, and carrot cake w/frosting. No butter was served with the trays, the cake did not have frosting. Record review revealed the Week at a Glance menu stated Monday 8/10/2020 lunch meal would be lemon herb fish with paprika rice, zucchini medley, bread or roll & butter or margarine, carrot cake, milk, beverage of choice. The observed meal that was served was cube steak, white rice w/gravy, zucchini medley (cauliflower mix), carrot cake, dinner roll. An interview on 8/10/2020 at 2:03 p.m. with the Dietary Manager revealed that she doesn't always get the food that she orders, she stated for example I might get a substitute if I order fish and we are supposed to serve fish but if they are out, they might send me something else. She confirmed the menu's had been changed and that sometimes the posted daily menu doesn't match what is being served because she writes that menu to look good, meaning that the cake with frosting on the posted daily menu wasn't actually served with frosting. An interview on 8/11/2020 with the Administrator confirmed that sometimes the facility doesn't get what they order, further stating that if 50 buildings are all ordering the same thing, they may not get it or they may not get a substitute that's why she has always ordered hamburger steaks to make sure the residents have something to eat if an order doesn't come in or a substitute isn't sent. An observation on 8/12/2020 at 1:50 p.m. of the posted daily menu revealed the same menu as the day before, the Administrator revealed the Dietary Manager is out today and confirmed the daily posted menu had not been updated.

Based on observations, interviews and record reviews, the facility failed to ensure one resident (A) was not served food items they were allergic to, as care planned, from a total sample of 16 residents. Findings include: Resident (R) A was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A care plan was developed and included the resident's medication and food allergies [REDACTED]. An intervention included that the resident would not receive pork products. However, dietary and nursing staff failed to ensure that the RA did not receive pork as care planned. The resident was served and ate pork on 10/22/19 for the supper meal. During an observation on 10/22/19 at 5:53 p.m., RA was observed being assisted to eat in her room by Certified Nursing Assistant CC. The plate of food included an open-faced pork roast sandwich with gravy. CNA CC confirmed that she had given the resident a small amount to eat. A review of the diet card included with the supper plate revealed that No Pork was printed in a general area on the card and pork was also listed in the dislike section of the card, but not in the allergy section of the card. Licensed Practical Nurse (LPN) BB removed the supper tray from the room and notified Resident A's responsible party and physician and carried out the physician's orders [REDACTED]. Cross refer to F806.

Based on observation, interviews and record reviews, the facility failed to ensure that food served accommodated the food allergies [REDACTED]. Findings include: Resident (R) A was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A care plan was developed and included the resident's medication and food allergies [REDACTED]. However, dietary and nursing staff failed to ensure that the RA did not receive pork. The resident was served and ate pork on 10/22/19 for the supper meal. A Review of the POS [REDACTED]. During an observation on 10/22/19 at 5:53 p.m., RA was observed being assisted to eat in her room by Certified Nursing Assistant CC. The tray and plate included beets, mashed potatoes, roll, brownie, and a slice of bread topped with shredded meat and gravy. CNA CC stated she did not know what the meat was on the resident's plate and stated that she had given the resident a small amount to eat. A review of the diet card included with the supper plate revealed that No Pork was printed in a general area on the card and pork was also listed in the dislike section of the card, but not in the allergy section of the card. The allergy section of the card documented none. At 5:55 p.m. Licensed Practical Nurse (LPN) BB was notified of the consumption of possible pork product and removed the supper tray from the room and returned it to the kitchen, where dietary staff initially stated it was beef roast, but dietary staff DD confirmed that the meat was pork roast and that the alternate supper option was a hamburger. LPN BB notified Resident A's responsible party and physician. The physician ordered 4 milligrams (mg) of [MEDICATION NAME] and 50 mg of [MEDICATION NAME] be administered. An order was also given to obtain vital signs every four hours and transfer the resident to the emergency room if swelling or difficulty breathing occurred. There was no evidence that RA had an allergic reaction to the pork that was consumed. During an interview on 10/22/19 at 6:55 p.m., family of RA stated that in the [AGE] years they had been together, she had not had a reaction to pork because she avoided it. The family member stated that another family member told him that if the resident ate enough of pork, her throat would swell, and she would break out in hives. During an interview on 10/23/19 at 2:43 p.m., the physician stated that the pork allergy may or may not be an error from the resident's past, but he would expect the allergy to remain in her clinical record.

Based on observations, record review, and interview, the facility failed to provide ten sampled residents (R) (R#13, #30, R#34, R#39, R#52, R#67, R#81, R#82, R#90, and R#143), seven residents (R#6, R#34, R#39, R#53, R#68, R#71, R#81 attending the resident group meeting, and 11 residents prescribed pureed diets out of a total of 95 residents with palatable food. Food was prepared without seasoning such as salt and pepper; condiments were not available during meals and pureed items were not prepared according to recipes. This created the potential for resident dissatisfaction and weight loss. Findings include: 1. Interviews with Residents The Resident Group Interview was held on 9/18/18 at 10:00 a.m. in the main dining room with seven residents (R#6, R#34, R#39, R#53, R#68, R#71, R#81). Residents stated they were not provided with salt and pepper for their meals and they were served dry lunch meat sandwiches without mayonnaise/condiments. Some of the residents ate meals in their rooms and some in the dining room. R#143 was interviewed in her room on 9/17/18 at 3:42 p.m. The resident stated she ate meals in her room and did not like institutional food and reported the food had no seasoning. The resident stated, It has no salt or pepper or anything. They don't give it (salt and pepper) to us on our tray. There is no Sweet and Low. I get unsweetened tea without anything in it. I have my daughter bring it (Sweet and Low). Nothing is offered. The resident stated she was not served butter/margarine for her roll today at lunch. 2. Dining observations a. Lunch on 9/17/18 from 12:05 p.m. - 12:55 p.m. Review of the Week at a Glance Menu - Week Three revealed the following was to be served for lunch: orange glazed chicken, buttered zucchini, wild rice, dinner rolls with margarine/butter, and lemon cake. Observations were made in the restorative dining room from 12:05 p.m. - 12:20 p.m. There were several tables with approximately eight residents seated. No margarine or butter was observed to be served or available for any of the residents served dinner rolls. There were no salt and pepper shakers or salt and pepper packets observed on the tables or having been applied to residents' food. At 12:20 p.m. the 400 Hall food cart arrived for residents who were eating in their rooms on the 400 Hall. The trays were observed inside the food cart. None of the trays had margarine/butter for the dinner rolls or salt and pepper placed on them. At 12:25 p.m. observations began in the Oaks main dining room. There were 10 tables in the dining room with approximately 35 residents seated. Residents were being served beverages. There were five staff in the dining room passing out drinks and bringing residents in and getting them seated and ready to eat. At 12:29 p.m., meal service commenced. The chicken, rice and zucchini were all served on the same plate. A layer of water from the zucchini covered the bottom of plate. The zucchini was mushy, transparent, and did not hold its shape. None of the residents were served margarine/butter with the dinner rolls. There were no salt and pepper shakers on the table and salt and pepper packets were not served or offered to residents except for one resident as noted below. Observations included: At 12:34 p.m. R#82 asked for salt and pepper. A staff member brought him one salt and one pepper packet. He was the only resident offered salt and pepper during the meal in the dining room. At 12:40 p.m. R#39 said she did not like the zucchini, reporting it was mushy and soft. She had not eaten any of it. At 12:45 p.m. R#90 had pushed his plate into the center of the table and was not eating. He had eaten less than 25% of all items on the plate. He stated he did not want it and reported the rice was bland. At 12:47 p.m. R#34 stated she did not like the chicken and did not like the zucchini. She pointed to the soggy zucchini with her fork. She had not eaten the chicken or zucchini. At 12:50 p.m. R#81 stated the food could be better. He stated he did not like mushy zucchini. He had not eaten any of the zucchini. At 12:52 p.m. R#13 was interviewed and verified he had not been offered butter or margarine with the dinner roll. At 12:53 p.m. R#67 stated she did not like the meal and had eaten less than 25% of the menu items. At 12:55 p.m. R#30 had a puréed diet on the table in front of him. He was wheeling his wheelchair away from the table to leave the dining room. He had eaten the pureed chicken only and had not eaten any of the pureed zucchini or mashed potatoes. When asked if he liked the pureed zucchini and mashed potatoes, he shook his head back and forth indicating, No and left the dining room. Staff members came through the dining room after the surveyor and asked residents #39, #90, #34, #81 and #67 if they wanted egg salad sandwiches. Several residents accepted the egg salad sandwiches. The remaining residents did not want the egg salad sandwiches. b. Breakfast on 9/18/18 from 8:18 a.m. - 8:49 a.m. On 9/18/18 at 8:18 a.m. observations were made in the main dining room; there was no salt or pepper located on the tables or evidence it had been served except for one resident. R#82 stated he had to ask for salt, pepper, sugar and creamer this morning as these items had not been served to him with his breakfast. The opened packets were observed on the table at his place setting. On 9/18/18 at 8:21 a.m. the Cart for the 500 Hall was observed. CNAs were serving trays to residents eating in their rooms on the 500 Hall. No salt or pepper packets were observed on any of the residents' trays. On 9/18/18 at 8:49 a.m. R#52 was observed in her room. She was lying in bed and had been served a pureed meal consisting of pureed breakfast meat, pureed eggs, and pureed French toast. The resident required extensive staff assistance with eating per the 8/3/18 Annual Minimum Data Set. The meal tray contained unopened condiment packets of margarine and syrup intended to be added to the French toast. Staff failed to put the condiments on the pureed French toast. Although the resident had eaten some of the eggs and meat, she had not eaten any of the pureed French toast. The resident was not interviewable; she had a [DIAGNOSES REDACTED]. There were no salt and pepper packets observed to have been served with the meal. c. Breakfast observation on 9/19/18 at 8:35 a.m. for the 500 Hall cart revealed there was no salt or pepper on any of the trays. 3. Pureed diet preparation Observation on 9/19/18 at 11:30 a.m. the surveyor tasted several pureed menu items that were on the tray line and ready to be served for lunch. The foods included pureed spinach and pureed pasta. The pureed spinach and pureed pasta were bland and flavorless. Cook TT was asked how she prepared these items. Cook TT stated for the pureed spinach, she pureed the spinach with the water it was cooked in and then added thickener. For the pureed pasta, she stated she pureed the pasta using the water it was cooked in and added thickener. In neither case did Cook TT indicate she added margarine/butter nor salt and pepper/seasoning. The cook stated she followed recipes located in a notebook on the shelf; however, the recipes directed the addition of margarine and pepper as well as liquids that were not water. Observations on 9/19/18 at 4:15 p.m. of the preparation of pureed foods were made in the kitchen. No recipes were referred to during the preparation of pureed foods. Cook SS prepared pureed vegetable soup and mashed potatoes. The vegetable soup consisted of a broth with a small amount of vegetables. Cook SS poured 12 cups of broth into the food processor and added 1/3 of a scoop (reported by the cook as being 1/3 cup) of thickener, processed the mixture, then added another 1/3 scoop of thickener, processed it some more and then added another 1/3 scoop of thickener and processed it some more. No crackers or bread crumbs were added to the soup as directed per the Daily Spreadsheet Wednesday Day 18. The surveyor tasted the pureed soup and it was bland and without flavor. Cook SS was asked if she used salt or seasoning when cooking. The cook stated she did not use salt; however, stated she used Mrs. Dash a salt free seasoning blend. Cook SS indicated there were some residents who could not have salt and that was why she did not add salt when preparing foods. Cook SS then prepared the mashed potatoes. She removed a large pot of hot water from the stove, and mixed six cups of instant mashed potatoes and one and half cups of melted margarine in with the water and stirred the mixture by hand. The mashed potatoes were sampled and were bland. The recipe for preparing pureed potatoes specifically directed staff not to add water, and to add broth or hot milk when preparing pureed starches (see below). The pureed diet recipes were reviewed with the following noted: Review of the Orange Glazed Chicken recipe revealed the recipe called for two teaspoons of salt and two teaspoons of pepper for 100 servings. Review of the Buttered Spinach recipe revealed it called for spinach, margarine, and two teaspoons of ground black pepper (for 100 portions). Review of the recipe for fettuccine noodles revealed it called for fettucine, and margarine. Review of the Puree Recipe Book dated 2013 revealed a food processor should be used to puree the food. Food was to be cut into two-inch pieces and placed in the food processor. Then liquid should be slowly added such as broth, milk, or juice but not water. Thickener was to be added as needed and per recipe. The pureed potatoes, pasta, rice and other grains recipe called for either potatoes pasta or rice cooked and drained, broth, or hot 2% milk, and margarine and thickener. The starch was to be added to the food processor with hot broth or hot milk, and then margarine was to be added. The pureed soup recipe called for soup regular portion and thickener. Review of the cycle menu Daily Spreadsheet Wednesday Day 18 revealed crackers or breadcrumbs were also to be added during the pureeing procedure. This was not done. 4. Test Tray A test tray of a regular diet was delivered to the restorative dining room on 9/20/18 at 11:55 a.m. The meal consisted of a veal patty with gravy, spinach, fettucine noodles, and a roll; all these items were served together on a dinner plate. The dessert consisted of vanilla pudding. The meal was evaluated once all the residents had been served and assisted with their meals at 11:59 p.m. by the surveyor without dietary staff present. The temperatures of the hot items were acceptable; however, the spinach was bland and flavorless. The pasta was also bland and dry with no discernable margarine. The water from the spinach covered the bottom of the plate. The pudding was lukewarm with a temperature of 76 degrees Fahrenheit. Interview on 9/20/18 at 2:05 p.m. the Dietary Manager was interviewed in his office. He stated he was the interim Dietary Manager and had been employed in this capacity for six weeks. The Dietary Manager was asked about the use of seasonings and use of salt during the cooking process. The Dietary Manager stated, Salt has been removed from order guide. There is no salt for cooking. The Dietary Manager pulled up the order guide on the computer and showed the surveyor that bulk salt could not be ordered. The Dietary Manager stated the corporation had blocked salt from being ordered by the facility. The Dietary Manager stated, If you give staff bulk salt, you run the risk of over salting the food. The Dietary Manager stated the only salt available in the kitchen were the salt packets intended for individual use. The Dietary Manager stated staff were to provide condiments, so residents could add their own salt and pepper if they wanted it. The Dietary Manager stated if a resident was on a regular diet, staff should put salt and pepper on residents' trays. If residents were on a restricted sodium diet, staff should put the pepper packets on the trays. When notified staff did not put salt and pepper packets on trays during survey observations, he stated he was not aware of that. The Dietary Manager stated he attended one resident council meeting since his employment began and the residents expressed food concerns to him. He stated he was working on improving the food. Interview with the Registered Dietitian (RD) on 9/19/18 3:20 p.m. in the dietary office, revealed that her role was clinical. She stated she did not have oversight responsibilities within the dietary department, adding that was the Dietary Manager's role. She stated she had been employed as the consultant Dietitian since 8/1/18. In an interview on 9/20/18 at 3:42 p.m. the Director of Nursing (DON) was asked about the role of nursing staff's participation in dining. The DON stated nursing staff were responsible for serving residents their meals off the hall carts and in the dining rooms. The DON stated, Residents should have salt and pepper.

Based on observations, record review and staff interview, the facility failed to assess the effectiveness of interventions and review and revise the plan of care in an attempt to prevent further falls for three (3) residents ("A", #4 and #15) with multiple falls from a sample of forty (40) residents. This failure resulted in actual harm for two (2) residents ("A" and #4). Findings include: 1. Review of the clinical record for resident "A" revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Interdisciplinary Team (IDT) notes and Accident/Incident log revealed the resident had twelve (12) falls between 10/09/11 and 4/27/12 with three (3) falls resulting in hematomas to the resident's head, 12/02/11, 1/28/12 and 2/03/12. Resident also received an abrasion measuring approximately 81/2 inches by 2 inches to right lower back during a fall on 12/29/11. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as requiring extensive assistance with transfers and bed mobility, Activities of Daily Living (ADLs) with the exception of eating, and occasionally incontinent. The resident was assessed at risk for falls and had a Brief Interview for Mental Status (BIMS) score of twelve (12), with fifteen (15) as the highest possible score. Review of the resident care plan dated 7/09/11 revealed that the resident was at risk for falls related to history of falls, use of [MEDICAL CONDITION] medication, Parkinson disease, visual impairment and poor safety awareness. Interventions included assist with toileting as needed, bed in lowest position, call light in reach, encourage to use it for assist as needed and prompt response to all request for assistance, ensure environment is free of clutter, evaluate effectiveness and side effects of psychoactive drugs for possible decrease in dosage/elimination of medication, have commonly used articles within easy reach, medication as ordered, monitor vital signs and labs as ordered, reinforce need to call for assistance, therapy to screen if indicated and bed and chair alarm. Continued review of the resident care plan revealed an intervention dated 5/12/12 to reinforce the need to use the call light for assistance, this intervention had been on the original care plan of 7/09/11. There was no evidence that the resident had been reassessed for the effectiveness of the interventions or that the care plan had been revised to reflect new interventions. 2 Resident # 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the IDT notes and accident/incident log revealed that the resident had eleven (11)falls between 9/21/11 and 5/06/12. The resident sustained [REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as requiring extensive assist with ADL's, transfers and bed mobility, was non-ambulatory, incontinent of bowel/bladder, and cognitively impaired with short/long term memory loss, and poor decision making ability with a BIMS score of 3. Review of the resident care plan, reviewed by the facility 5/11/12, revealed that the resident was at risk for falls related to a history of falls, use of [MEDICAL CONDITION] medication, impaired balance, unsteady gait and poor endurance. Interventions created on 7/19/10 included, assist with toileting as needed, bed in lowest position, call light in reach, educate resident on safety and to use handrails or assistive devices properly, ensure environment is free of clutter, evaluate effective ness and side effects of [MEDICAL CONDITION] drugs, floor mat at bedside when in bed if indicated, commonly used articles within easy reach, medication as ordered, monitor labs and vital signs as ordered, 1/4 side rails up to assist with repositioning, turning and to define parameters of the bed, reinforce need to call for assistance, non slip footwear, therapy to screen as necessary, transfer and change positions slowly, bed alarm and restorative program if indicated. On 9/28/10 the care plan was revised to include a chair alarm, place resident in a highly visible area as much as possible and a lap buddy to the wheel chair to assist with positioning-resident is able to remove. On 12/01/11 the care plan was revised to include the intervention redirect as needed. Continued review revealed that there was no evidence that the resident had been assessed for the effectiveness of the interventions initiated 7/19/10 or that the care plan had been revised to reflect any new interventions after 12/01/11. Interview on 6/1/2012 at 11:00 a.m. with the Director of Nursing (DON) confirmed that the plan of care, and the interventions had been in place since admission, had been reviewed, but no new approaches had been implemented. 3. Resident #15 was admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the IDT notes and accident/incident log revealed that the resident had three (3) falls from 12/06/11-5/06/12. Review of the MDS assessment dated [DATE] revealed the resident was assessed as requiring extensive assistance with ADLs, transfers, was non-ambulatory, incontinent of bowel and bladder and cognitively impaired with a BIMS score of seven (7). Review of the care plan dated as revised on 10/19/2011 revealed that the resident was at risk for falls related to history of falls, use of [MEDICAL CONDITION] medications and cognitive deficit. Interventions developed on 3/10/10 included bed in lowest position, call light in reach, educate resident on safety upon admission and as needed, ensure environment is free of clutter, evaluate effectiveness and side effects of [MEDICAL CONDITION] drugs, medication as ordered, monitor vital signs and labs as ordered, and reinforce need to call for assistance. On 12/06/11 the care plan was revised to include a wheelchair alarm. Continued review revealed no evidence that the resident had been assessed for the effectiveness of the interventions initiated 10/19/11 or that the care plan had been revised to reflect any new interventions after 12/06/11. Review of the facility policy for Nursing Responsibilities Post Incident/Accident revealed #8-Update Care Plan with new interventions. Cross Refer to F323, examples 1, 2 and 4

Based on observations, record reviews, review of the facility Falls policy, review of the facility Falls Management Program, and resident and staff interviews, the facility failed to provide appropriate supervision to prevent falls for nine (9) residents ("A", #4, #143, #15, #130, #126, #93, #147, and #3) which were identified by the facility to be at risk for falls and/or had a history of [REDACTED].# "A" and # 4). Findings include: 1. Review of the clinical record for resident "A" revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as requiring extensive assistance with transfers and bed mobility, Activities of Daily Living (ADLs) with the exception of eating, and occasionally incontinent. The resident was assessed at risk for falls and had a Brief Interview for Mental Status (BIMS) score of twelve (12), with fifteen (15) as the highest possile score. Revew of the Accident Incident Log and Interdisciplinary Team (IDT) notes revealed the following falls: - 10/9/11-found lying face down on the floor-stated was trying to use the urinal-no injury - 11/15/11-found lying supine on floor at bedside, stated slid out of bed-no injury - 11/17/11-alarm sounded, resident found on buttocks on bathroom floor, holding on to handrail on the right ide of the toilet-no injury -12/01/11-found on floor after attempting to get to wheelchair to go to the bathroom-no injury -12/2/11-found on the floor on knees, egg sized hematoma noted to forehead, ice applied, to hospital for evaluation - 12/26/11- found on floor in front of toilet-no injury - 12/29/12-alarm sounded, resident found on floor in the bathroom, lying on back with feet up against the wall-abrasion to back appropximately 81/2 inches by 2 inches to right lower back-12/30/12-complained of right side rib pain-chest x-ray and urinalysis done-both normal - 1/28/12- found on floor face down-two (2) hematomas to left side of forehead-stated he rolled to fast in an attempt to sit on the side of the bed and flipped forward and off the bed-sent to hospital for evaluation - 2/3/12-alarm sounded, resident found on the floor next to the bed, stated was trying to sit up in bed-hematoma to the forehead and an abrasion to the wrist -sent to hospital for evaluation. - 3/29/12- found on floor by bed attempted to transfer from bed to wheelchair-no injury - 4/2/12-found sitting on bathroom floor, stated took himself to bathroom, reached for assit rail and fell -no injury 4/27/12-found on the floor in room-states was going to the bathroom-no injury Interview on 5/17/12 at 10:15 a.m. with Licensed Practical Nurse (LPN) "CC", revealed that she was new to the unit and not aware of what interventions were in place for the resident but stated that she tried to anticipate the resident's needs due to his visual impairment. Observation on 5/17/12 at 10:15 a.m. with the LPN revealed that the resident was sitting in a wheelchair in his/her room.There was no chair alarm attached to the wheelchair. There was no bed alarm noted on the bed. The resident's call light was on and the resident stated that he/she needed help to go to the bathroom. LPN "CC" confirmed that neither the wheelchair or bed alarm were in place. The resident had twelve (12) documented falls with three (3) emergency visits for inury of hematoma. 2. Resident # 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed as requiring extensive assist with ADL's, assistance of two for transfers, non-ambulatory, incontinent of bowel/bladder and cognitively impaired with short/long term memory loss, poor decision making ability and a BIMS score of 3. Review of the IDT notes and accident/incident log revealed the following falls: -9/21/2011 at 11:30 a.m. the resident was found on the floor on the right side. It appeared the resident removed the "lap buddy" (a pillow cushion that is applied to the wheel chair to prevent the resident from rising), and fell from the wheel chair. assessed with [REDACTED]. The resident was transported to the local emergency room (ER) for evaluation and treatment. The resident returned to the facility with the following diagnosis, Subluxation of Cervical Disc 1 and 2, (C1-C2 subluxation is basically a misalignment of the first 2 cervical vertebrae. It is usually caused by trauma.), Fall with Contusions. The resident is to keep the cervical hard collar on until a follow-up appointment is obtained. -9/24/2011 at 3:26 a.m. the resident was found on the floor on the mat next to the bed with the chair alarm sounding. The resident sustained [REDACTED]. -10/9/2011 at 12:50 p.m. the resident was observed sliding underneath the lap buddy to the floor. No injury. Review of the IDT documentation dated 10/10/2011 revealed continue with the same interventions, chair/bed alarm, mat on the floor, low bed, lap buddy which the resident removes ad lib. Review of the Behavior documentation dated 10/13/2011 at 11:37 a.m. and 12: 40 p.m. revealed the resident continues to remove the lap buddy attempting to get out of the wheel chair. -10/15/2011 at 12:40 p.m. the resident was found on the right side with right arm outstretched under the head with head resting against the wall. Resident complained of right hip pain, and received a skin tear to the right elbow. The physician ordered an X-ray of the skull, cervical and lumbar spine and right hip. All x-rays were completed with no fractures observed. -11/15/2011 at 11:45 p.m. the resident was in the wheel chair with the lap buddy across the lap, the Certified Nursing Assistant (CNA) pushed the resident to the room to prepare for dinner, left the resident unattended and when the CNA returned the resident was on the floor. No injury. -11/23/2011 at 12:54 a.m. the resident was found on the floor in a common area, no injury. -12/20/2011 at 12:50 a.m. the resident was found on the floor at the nurse's station. The resident complained of pain to the right arm. -1/29/2012 at 12:24 p.m. the resident got out of the wheel chair and laid on the floor, no injury. -1/31/12 at 10:00 a.m. the resident removed the lap buddy and fell on the floor with no injury. -2/25/2012 at 9:20 a.m. the resident was found on the floor in the common area in front of the television, no injury. -5/4/2012 at 3:07 p.m. the resident was found on floor in front of the wheel chair, lap cushion hanging from the side of the chair. The resident sustained [REDACTED]. -5/6/2012 at 6:05 p.m. the resident was found on the floor in the dining room, laying on the right side, a hematoma was observed, bruising and discoloration was observed over the bridge of the nose with a small amount of bleeding and an open area on the nose. The resident was sent to the local ER for evaluation and returned to the facility at 11:25 p.m. with a [DIAGNOSES REDACTED]. On 5/7/2012 at 6:55 a.m., the resident was observed vomiting. The nurse assessed the resident to have sluggish reacting pupils and the resident was sent back to the hospital. The resident was admitted to the hospital with [REDACTED]. The resident returned to the facility on [DATE] at 2:32 p.m.. Observation on 5/31/2012 at 9:50 a.m. revealed the resident in the common area sitting in a wheel chair with a lap buddy on the chair and a chair alarm. The resident was holding the right arm, bent at the elbow, to the chest wall. Over the resident's right eye was a circular green bruise. Continued observations until 10:30 a.m. revealed the resident sitting in the common area without any evidence of trying to remove the lap buddy. Observation on 5/31/2012 at 4:40 p.m. revealed the resident laying in the bed in low position, with a mat on the floor. Observation on 6/1/2012 at 9:35 a.m. revealed the resident sitting in the common area in the wheel chair with the chair alarm and lap buddy. Interview on 6/1/2012 at 11:00 a.m. with the Director of Nursing (DON) included detailed review of the resident clinical records including occurrence reports, IDT documentation and care plan review. The DON confirmed that each of the above falls occurred and that the resident had twelve (12) documented falls, with three (3) ER visits and one hospital admission. The DON confirmed that the resident sustained [REDACTED]. 3. Resident #143 was re-admitted to the facility on [DATE] after a hospital stay with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed the resident was assessed as requiring extensive assistance with ADLs, requiring assist of two (2) for transfers, non-ambulatory, incontinent of bowel and bladder and was cognitively impaired, no BIMS score recorded. Review of the IDT notes and Accident/Incident log revealed the following falls: -9/30/2011 at 2:04 p.m. the resident tried to self-transfer out of the wheel chair in the common area and fell to the floor, no injury. -11/22/2011 at 4:45 p.m. the resident fell attempting to ambulate without assistance, no injury. -11/23/2011 at 10:12 a.m. the resident fell in the common area attempting to transfer to sofa. -12/8/2011 at 3:40 p.m. the resident was observed sitting on the landing strip on the side of the bed, no injury. -12/10/2011 at 4:30 p.m. the resident was observed on the mat on the floor at the bedside, no injury. -12/14/2011 at 12:40 p.m. the resident was in the common area, and tried to transfer unassisted from the wheel chair to a arm chair, and fell , x-ray of the hip was ordered and there was no fracture. -1/3/2012 at 3:30 a.m. the resident fell at the beside, no injury. -1/3/2012 at 4:40 p.m. the resident slid to the floor, the chair alarm sounded and the pummel cushion was in place, no injury. -1/5/2012 at 3:10 p.m. the resident was found on the mat at the beside, no injury. -1/13/2012 at 4:30 p.m. the resident was found on the floor, resident was lying on back with head under the foot of the bed with head on bottom railing of the bed and legs bent with feet flat on the floor. The resident's wheel chair was beside the bathroom door, the resident sustained [REDACTED]. -1/18/2012 at 11:25 a.m. the resident was found on the floor in the common area with feet on the sofa, no injury. -1/18/2012 at 3:19 p.m. the resident was found on the floor sitting on the right side of the mat, no injury. -2/3/2012 at 6:42 p.m. the resident was sitting on the floor in the lobby after sliding out of the wheel chair, no injury. -2/18/2012 (no time is documented) the resident fell , no injury. -3/7/2012 at 10:20 a.m. the resident was sitting on the floor in front of the wheelchair, no injury. -3/8/2012 at 9:49 a.m. the resident was attempting to transfer out of the wheel chair to the sofa and fell , no injury. -3/15/2012 at 5:30 p.m. the resident had a fall without injury. -3/21/2012 at 3:17 p.m. a housekeeper found the resident on the floor beside the bed on the mat, no injury. -3/28/2012 at 3:35 p.m. the resident slid out of the wheel chair with the pommel cushion in the chair, no injury. -5/21/2012 at 6:50 a.m. a CNA called for assistance reporting that during a transfer, the resident refused to stand, and had to be lowered to floor, no injury. -5/21/2012 at 7:24 p.m., the resident slipped out of the wheel chair, no injury. Interview on 6/1/2012 at 10:45 a.m. with the DON revealed that the resident had twenty-one (21) falls in six (6) months. 4. Resident # 15 was admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment dated 2/09/12 revealed the resident was assessed as requiring extensive assistance with ADLs, requiring assist of two (2) for transfers, non-ambulatory, incontinent of bowel and bladder and is cognitively impaired with a BIMS score of seven (7). Observation on 5/31/2012 at 4:45 p.m. revealed the resident was awake in the bed with the bed in low position and the bed alarm was on. Review of the IDT notes and Accident/Incident log revealed the following falls: -12/6/2012 at 3:33 p.m. the resident fell from the wheelchair to the floor while trying to self ambulate, No injuries. -3/8/2012 at 3:16 p.m. the resident fell in the bathroom, with assistance from a Certified Nursing Assistant (CNA) no injuries. -5/6/2012 at 9:40 p.m. the resident was found on the floor, next to the bed stating trying to go to bed, no injuries. 5. Resident # 130 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed the resident was assessed as requiring extensive assist with ADL's, requiring assistance of two for transfers, non-ambulatory, frequently incontinent of bowel/bladder and cognitively impaired with a BIMs score of 5. Review of the IDT notes and Accident/Incident log revealed the following falls: -10/3/2011 at 11:39 p.m. the resident was found on the floor with two (2) skin tears to the left forearm,, stated trying to stand up and slipped out of the wheelchair. No injury -10/5/2011 at 11:00 p.m. the resident was sitting in the wheelchair, in the common area and stood up and tried to ambulate and fell on the left side, hitting the back of the head. The resident was transferred to the hospital emergency room for evaluation and returned with report of no injury. -10/21/2011 at 12:00 a.m. the resident was found on the floor laying on the back in the lobby area, with the chair alarm sounding. The resident stated that trying to get up and fell out of the wheelchair, hitting the head. The nurse assessed the resident and found small raised area on the back of the head and neck. The resident complained of head and neck pain. The resident was transferred via Emergency Management System (EMS) on a back-board and neck collar to the hospital emergency room for evaluation including X-ray with negative results. The resident was transferred back to the facility. -10/24/2011 at 11:24 a.m. responded to alarm sounding in the resident's room, resident was found on the floor in sitting position, stating hit the elbow, no injury. -10/28/2011 at 3:58 p.m. resident was observed on the floor in front of the bathroom door, no injury. -11/21/2011 at 6:55 a.m. the resident reported to staff a fall on 11/20/2011. The resident complained of left hip and knee pain. The physician ordered x-rays, with mild degenerative changes to the left hip, no fracture or dislocation, left knee with mild osteoarthritis no fracture or dislocation. -12/27/2011 at 11:18 p.m. a CNA informed the nurse that the resident had a fall. The CNA stated that the resident was standing at the sink in the bathroom, and the CNA left the bathroom, upon returning the resident was on the floor, no injuries. Interview on 6/1/2012 at 10:45 am with the DON, revealed the resident should not have been left alone. -1/7/2012 at 11:56 p.m. the resident was found sitting on the floor beside the bed. The resident said trying to go to the bathroom, the staff re-oriented to use the call bell. -2/8/2012 at 3:00 p.m. the resident was found sitting on the floor. The resident stated slid out of the floor, no injury. -2/13/2012 at 3:44 p.m. the resident was sitting in the bedroom, slid out of the wheelchair, no injuries. -3/7/2012 at 4:52 p.m. the resident was found on the floor in the bedroom, stated was trying to go to bed, no injuries. -3/12/2012 at 11:28 p.m. the resident was found on the floor, no injuries. -4/6/2012 at 11:22 p.m. the resident was found on the floor in the bedroom, no injuries. -4/8/2012 at 5:50 p.m. a CNA found the resident on the floor in the dining room, no injuries. -4/23/2012 at 2:42 p.m. the resident slid out of the wheelchair in the dining room, no injuries. Observation on 5/31/2012 at 9:50 a.m. revealed the resident sitting in a wheelchair, alert with a chair alarm on the wheelchair. Interview on 6/1/2012 at 10:00 am the DON reviewed the record and each fall. The DON confirmed that the resident has a total of fifteen falls since 9/29/2011 with one (1) emergency room visit. 6. Resident # 126 was admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed the resident was assessed as requiring extensive assist with ADL's, requiring assistance of two for transfers, non-ambulatory, incontinent of bowel/bladder and cognitively impaired with a BIMs score of 13. Review of the IDT notes and Accident\Incident log revealed the following falls: -4/12/2012 at 7:30 p.m. the resident fell trying to sit up on the side of bed. A mat was beside the bed. There were no injuries. -4/26/2012 at 9:00 a.m. the resident was found laying on the left side in the floor, no injuries. -5/03/2012 at 12:10 p.m., a nurse was assisting the resident to the bathroom, and assisted the resident to the floor. -5/23/2012 at 12:30 a.m. the resident was found on the floor, no injuries. -5/31/2012 at 11:35 p.m. alarm sounded and resident was found on the floor-no injury Interview on 6/01/2012 at 11:00 am the DON confirmed the above. 7. Review of the clinical record for resident #93 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed that the resident was assessed as requiring extensive assistance with transfer, bed mobility and ADLs except eating, was frequently incontinent with no toileting program and had impairment to one side of the lower extremities. The resident was also assessed with [REDACTED]. Review of the IDT notes and accident incident log revealed the following falls: -9/03/11-attempted to go to bathroom unassisted and fell -no injury -9/12/11-attempted to go to bathroom unassisted and fell -no injury -10/13/11- fell in the bathroom when transferring from toilet to wheel chair, complained of right knee pain-sent to hospital for evaluation-no fracture -11-8-11-found sitting on floor beside wheelchair-no injury -3-01-12- found on floor in bathroom-went to bathroom unassisted, tried to transfer from the wheelchair to the toilet and fell -no injury -3/09/12-fell transferring from toilet unassisted-no injury -3/15/12-found on floor in bathroom-no injury -4/22/12- resident had a fall trying to transfer to a recliner, wheelchair slid from under the resident-no injury 8. Review of the clinical record for resident #147 revealed that the resident was admitted to the facility on [DATE] and readmitted on [DATE] after hospitalization with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed that the resident was assessed as requiring extensive assistance with transfer, bed mobility and ADLs except eating, was frequently incontinent and had BIMS score of 2. Review of the IDT notes and accident incident log revealed the following falls: -10/21/11-fell from low bed-no injury -2/15/12-leaning over in the wheelchair and fell bumped head-skull films done-no fracture -3/23/12-found on the floor in room stated was taking wet linens off bed 9. Review of the clinical record for resident #3 revealed that the resident was admitted to the facility on [DATE] and readmitted on [DATE] after hospitalization with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment dated [DATE] revealed that the resident was assessed as requiring extensive assist with transfer, bed mobility and ADLs except eating, was occasionally incontinent, and had a BIMS score of 10. Review of the IDT notes and accident incident log revealed the following falls: -1/31/12-observed sitting on the floor next to the heater-no injury -2/04/12-observed lying on the floor between the low bed and the unlocked wheelchair-no injury -2/07/12-observed sitting on the floor-no injury -2/12/12-observed sitting on the floor to the left of the bed-stated was dreaming and fell to the floor-no injury -3/04-12-attempting to ambulate without assistance, lost balance and fell -no injury -4/18/12-found sitting on floor in front of wheelchair-attempted to go to the bathroom and slid from wheelchair-skin tear to right flank Interview with the Administrator on 6/01/12 at 8:30 a.m. revealed that falls had been identified as a concern in January, 2012 and taken to the Quality Assurance Committee for tracking and trending of falls This is an ongoing process. Continued interview revealed that the numbers of falls in the facility has fallen from forty eight (48) falls in January to sixteen (16) falls in May. The falls management program has been reevaluated and a revised falls management program will be initiated in June, 2012. Interview on 6/01/12 at 2:20 p.m. with Licensed Practical Nurse (LPN) "DD" revealed that if a resident had a fall, she would assess for injury before moving, check the vital signs and assist to bed if no evidence of injury. The physician would be notified, as well as the responsible party and would do as directed by the physician. If deemed appropriate, an alarm would be place on the bed and or chair. If the resident hits the head, they would be sent to the emergency room for evaluation and neurochecks would be done as per facility protocol. Interview on 6/01/12 at 2:25 p.m. with LPN "EE" revealed that if a resident had a fall, she would call for assistance, assess the resident for injury before moving and contact the physician and responsible party. If she felt it was appropriate, she would place an alarm on the bed and/or chair. If the resident hit their head, they soul be sent to the emergency room for evaluation and initiate neurochecks. Interview on 6/01/12 at 2:30 p.m. with Certified Nursing Assistant (CNA) "FF" revealed that if a resident had a fall, she would immediately get the nurse by using the call light to call for help. She would take the resident vital signs and assist the resident into bed or the chair as instructed by the nurse. She would not leave the resident until nurse had assessed.