Every finding on record at West Meade Place

Based on facility policy review, observation, and interview, the facility failed to label opened food items in the stand-alone refrigerator, which were available for use in preparing meals for 74 of 98 residents reviewed who ate meals from the facility kitchen. The deficient practice had the potential for residents to receive meals prepared with outdated/expired food items and had the potential to spread foodborne illnesses. The findings included: A facility policy titled, Safety & Sanitation Best Practice Guidelines, reviewed 06/2025, specified, Labeling 1) All TCS [Temperature Controlled for Safety], ready-to-eat food prepped in-house and leftover, cooked food items must be labeled with the following information: name of food item and the date by which it should be eaten or discarded. An observation of the stand-alone refrigerator in the kitchen on 03/09/2026 at 9:46 AM revealed one clear, opened plastic bag containing rectangular hashbrown patties with no label or discard date; one clear, opened plastic bag of potatoes wedges with no label or discard date; and one clear, opened plastic bag of French toast sticks with no label or discard date. During an interview on 03/09/2026 at 10:02 AM, the Food and Nutrition Services Director (FNSD) stated that all food bags in the refrigerator should be labeled and dated. The FNSD stated the French toast sticks, potato wedges, and hashbrowns should have been labeled with an open date and a discard date. The FNSD stated it was their responsibility to check and make sure all food items were labeled and dated appropriately. During an interview on 03/09/2026 at 11:35 AM, the Regional Registered Dietician (RRD) stated that all food in the refrigerator was to be labeled and dated with an opened date and use-by date. The RDD stated the hashbrowns, potato wedges, and French toast sticks should have been labeled with the date they were opened and should have had a discard date. The RDD stated that all opened food in the refrigerator without a label should be thrown away. During an interview on 03/11/2026 at 2:06 PM, the Director of Nursing (DON) stated the expectation was for all stored food to be labeled and dated. The DON stated the hashbrowns, potato wedges, and French toast sticks should have been stored appropriately, including being sealed and with a label that had the date they were opened and a discard date. The DON stated that the items in opened bags without labels or dates should be thrown away. During an interview on 03/09/2026 12:36 PM, the Administrator stated their expectation was that all food be labeled and dated once they were opened. The Administrator stated that the items in the refrigerator, including the hashbrowns, French toast sticks, and potato wedges, should have been labeled and dated when opened.

Based on facility document review, record review, and interview, the facility failed to implement procedures for missing items and grievances for 1 of 1 (Resident #13) resident reviewed for personal property. The findings included: An undated facility document titled, Personal Funds and Valuables: Continued., indicated, If, at any time during your stay you are missing your personal items, please report your loss immediately. We will assist you in attempting to locate the item. Should investigation of the circumstances lead to suspicion of deliberate misappropriation, the center administrator will initiate appropriate law enforcement involvement as well as notification of state survey agencies. If at any time, you have cause to believe or have knowledge of misappropriation of items. Please follow the process described under GRIEVANCE PROCEDURE in this booklet. An undated facility document titled, L. Grievance Procedure, indicated, If at any time you are not being treated fairly, or if you feel that an employee has mistreated you in any way, please take the following steps: 1. Notify the social worker for assistance in resolving the problem. The social worker serves as the center's in-house 'ombudsman.' An 'ombudsman' investigates complaints on behalf of the administrator and reports findings/resolution to the administrator. The policy further indicated, You are welcome to present the problem verbally or in writing. You may expect a response at each level as quickly as possible, certainly within 5 working days. A resident demographic record revealed the facility admitted Resident #13 on 09/08/2025. According to the resident demographic record, the resident had a medical history that included diagnosis of muscle weakness, depression, and cognitive communication deficit. A significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/18/2025, revealed Resident#13 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The Service Recovery Monthly Quality Improvement Grid for the time frame from 09/2025 through 02/2026 revealed no documented grievances or concerns involving Resident #13. During an interview on 03/09/2026 at 10:06 AM, Resident #13 stated a red plaid shirt went missing when they first came to their room in December 2025. The resident stated the shirt had their name on it. The resident further stated that the facility looked for the shirt but never found it, and they did not offer to replace the item. During an interview on 03/11/2026 at 2:22 PM, Social Worker #3 stated that if the facility was aware of missing items, they completed a grievance form. She stated that missing items were a resident's property, and there was a service recovery process to address a resident's missing items. According to Social Worker #3, the social workers did not always receive missing item concerns from the facility staff as they should. Social Worker #3 stated that there was a message on the software system that the facility used for communication about a missing plaid shirt and pink robe on 12/17/2025 that no one had reacted to or replied. She stated she was not tagged in the message and was not sure whether anybody had seen the message. During an interview on 03/12/2026 at 1:59 PM, the Director of Nursing (DON) stated that when a resident was missing a personal item, staff should let social services staff know about the missing item. The DON stated that there was a service recovery log that included information about the items that were missing, what steps were taken, and the outcome. She stated that social services staff completed the service recovery logs, but it was dependent upon daily communication with the social services department. During an interview on 03/12/2026 at 2:16 PM, the Administrator stated that when a resident reported an item was missing, they searched for the missing item. He stated that if they could not find an item, such as clothing, they often gave the resident or the family the option of buying a replacement item and bringing the receipt to the facility for reimbursement. He stated that the facility used service recovery logs, which social services staff handled. The Administrator further indicated that social services staff needed to be contacted directly so that they could do a quick report and start an investigation to find missing items.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a Continuous Positive Airway Pressure (CPAP) mask was stored in a sanitary manner for 1 (Resident #77) of 2 residents reviewed for respiratory care. Based on observation, interview, record review, and facility policy review, the facility failed to ensure a Continuous Positive Airway Pressure (CPAP) mask was stored in a sanitary manner for 1 (Resident #77) of 2 residents reviewed for respiratory care. The findings included: The facility's undated policy titled, CPAP/BiPAP Cleaning and Storage, indicated, Store equipment in a clean, dry area. Store in a labeled bag or container for the resident. A Resident Face Sheet revealed the facility admitted Resident #77 on 10/16/2025. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD) and chronic obstructive sleep apnea. Resident #77's significant change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/05/2026 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15. The MDS also revealed the resident utilized a non-invasive mechanical ventilator (which includes CPAP) during the assessment look-back period. Resident #77's Care Plan included a problem statement, started 10/17/2025, that indicated the resident was at risk for impaired gas exchange due to COPD and used a CPAP machine at night while sleeping. Resident #77's physician Orders revealed an order started 11/18/2025 for the resident to utilize CPAP at night while sleeping. During an observation on 03/09/2026 at 2:03 PM, Resident #77's CPAP mask was in the top drawer of the resident's nightstand. The mask was not in a bag. During an observation on 03/10/2026 at 9:31 AM, Resident #77's CPAP mask was in the top drawer of the resident's nightstand. The mask was not in a bag. An interview with Resident #77 during the observation revealed that the resident did not use the mask as much anymore. An observation on 03/11/2026 at 11:05 AM, revealed Resident #77's CPAP mask in the top drawer of the resident's nightstand, unbagged. During an interview on 03/11/2026 at 11:06 AM, Certified Nursing Assistant (CNA) #1 stated that any time a CPAP mask was not in use, it needed to be in a plastic bag. During the interview, CNA #1 located Resident #77's CPAP mask in the top drawer of the nightstand and stated that it was important to properly store the mask in a plastic bag to keep it sanitary. During an interview on 03/11/2026 at 11:17 AM, Licensed Practical Nurse (LPN) #2 stated nightshift staff assisted residents with putting on and taking off CPAP masks. She stated that a CPAP mask should be placed in a plastic bag when it was not in use. During the interview, LPN #2 located Resident #77's mask in the resident's top drawer of the nightstand and stated that it was not the proper way to store a CPAP mask. LPN #2 stated it was important for the CPAP mask to be stored in a plastic bag to help prevent germs from getting on the mask. During an interview on 03/11/2026 at 11:27 AM, the Director of Nursing stated that CPAP masks should be placed in a plastic bag when they were not in use and labeled. She stated that she expected CPAP masks to be stored properly in a plastic bag to help prevent any kind of infection. During an interview on 03/11/2026 at 11:52 AM, the Administrator stated that he expected regulations to be followed regarding the proper storage of CPAP masks.

Based on the facility's Infection Control Manual Volume 1 review, facility policy (Centers for Disease Control and Prevention (CDC) guidelines), observation, and interview, the facility failed to follow acceptable and appropriate infection control practices when cleaning a Transmission Based Precautions (TBP) isolation room. the facility failed to post TBP signage on 1 isolation room and filed to don the required Personal Protective Equipment (PPE) when entering a TBP room. The findings include: Review of the facility's Infection Control Manual Volume 1 updated 2/2022, revealed .Routine and Terminal Cleaning .room, cubicle, and bedside equipment of patients in Transmission Based Precautions are cleaned using the same procedure used for patients on Standard Precautions, unless the infecting microorganism(s) and the amount of environmental contamination indicate special cleaning. Standards for handling infectious waste .all containers, bags, and boxes used for containment and disposal of infectious waste must be red in color or labeled as biohazard .infectious waste includes waste from isolation rooms. Infectious waste materials are to be bagged inside the patient's room. Review of the CDC guidelines which the facility presented as COVID 19 policy revealed .HCP (Healthcare Provider)s who enter the room of a patient with suspected or confirmed [CONDITION(S)]-Cov-2 infection should adhere to Standard Precautions and use a NIOSH (National Institute for Occupational Safety and Health) approved N95 or equivalent or higher level respirator, gown, gloves, and eye protection. Observation and interview on the 3rd floor East Hall on 8/31/2022 at 1:26 PM revealed Certified Nursing Assistant (CNA) #5 entered a TBP isolation room without donning the appropriate PPE. signage posted on the door indicated droplet precautions. CNA #5 brought a wheelchair with personal items stored on the seat of the wheelchair out into the hallway and placed two bags of clothing on the hallway floor beside the wheelchair. During interview CNA #5 stated the resident was a new admission. She stated she did not have to wear anything but a mask due to resident being a new admission., Observation and interview in TBP isolation room [ROOM NUMBER] on 8/31/2022 at 1:40 PM revealed no TBP signage posted outside the room. Housekeeping staff mopped the floor without changing the mop head pad. The housekeeper came out of the room wearing her PPE; brought the trash out of the room without it being in a biohazard bag; and placed it on the floor beside the cleaning cart. When she was finished cleaning the TBP room she placed the mop, broom, and dust pan on the cart without disinfecting the equipment. During an interview the housekeeper stated she did not disinfect the cleaning equipment until she had completed at least two Isolation room cleanings. She confirmed she did not disinfect the cleaning equipment after bringing it out of the TBP room [ROOM NUMBER]. During an interview on 8/31/2022 at 1:29 PM Licensed Practical Nurse (LPN) #3 stated she saw CNA #5 enter the TBP isolation room donning a surgical mask. She confirmed the CNA did not follow the required PPE protocol for droplet precautions posted on the door of the room. During an interview on 8/31/2022 at 1:50 PM LPN #3 confirmed room [ROOM NUMBER] did not have a TBP sign posted outside the room. During an interview on 8/31/2022 at 2:00 PM the Housekeeping Supervisor stated she expected the housekeeper to follow infection control guidelines when cleaning all rooms. She stated all cleaning equipment used in TBP rooms should be disinfected before placing it back on the cleaning cart. She stated housekeeping staff was required to remove PPE before coming out of the isolation room. She stated trash removed from the TBP isolation room should be placed in a biohazard bag and disposed of immediately. During an interview on 8/31/2022 at 2:10 PM the Director of Nursing (DON) stated she expected staff to follow infection control protocol for TBP isolation including donning the proper PPE and posting the appropriate TBP signage.

Based on facility policy review, medical record review, observations, and interview, the facility failed to implement interventions on the Care Plan for 1 of 30 sampled residents (Resident # 28) reviewed. The findings include: Review of the facility's policy titled, SECTION VII: PATIENT CARE PLANS, dated 10/2021, revealed, .Problems are patient conditions, needs, or weaknesses which currently do, or potentially could, prevent the patient from achieving or maintaining the highest practicable level of well-being .Care Plan Approaches are specific, individualized steps partners and patients will take together to assist the patient to achieve the goal .Approaches serve as instructions for patient care .Responsibility for each approach is taken by the individuals and/or departments who added them to the care plan . Review of the medical record revealed Resident #28 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #28 required extensive assist with activities of daily living (ADLs). Review of the Care Plan dated 6/21/2022 to present revealed a plan of care developed to address falls with the approach for bedside mat in place to prevent injury due to poor safety awareness. Observation in Resident #28's room on 8/29/2022 at 11:30 AM, 12:16 PM, 8/30/2022 at 8:10 AM, 8/31/2022 at 9:20 AM and 8/31/2022 at 9:20 AM revealed no bedside mat in place. Observation and Interview in Resident #28's room on 8/31/2022 at 10:00 AM Licensed Practical Nurse (LPN) #6 revealed she was the fall champion for the facility. LPN #6 confirmed Resident #28 had a care plan approach for a bedside mat and mat was not in place in her room.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure 1 of 30 sampled residents (Resident #39) had clean and groomed fingernails. The findings include: Review of facility's policy titled, Fingernails/Toenails, Care of, dated 2/2018, revealed .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .nail care included daily cleaning and regular trimming .proper nail care can aid in the prevention of skin problems around the nail bed . Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a staff assessment for mental status that revealed poor short term and long term memory. Continued review revealed Resident #39 required extensive assistance with personal hygiene and extensive assistance with bathing. Observation in Resident #39's room on 8/29/2022 at 12:20 PM, 8/29/2022 at 3:35 PM, and 8/30/2022 at 8:10 AM, revealed brown dried debris under his fingernails on both hands. Observation and interview in Resident #39's room on 8/30/2022 at 8:15 AM, Licensed Practical Nurse (LPN) #2 stated his fingernails need immediate attention and confirmed his fingernails were dirty and need to be trimmed. During an interview on 8/30/2022 at 8:25 AM, the Director of Nursing (DON) confirmed a resident's fingernails should be cleaned and trimmed when dirty.

Based on facility policy review, medical record review, observation, and interview, the facility failed to follow physician's orders for 1 of 3 sampled residents (Resident #29) who required a midline intravenous catheter (used for vascular access for treatments) dressing change. The findings include: Facility policy review titled, Midline Dressing Changes, revised April 2016 revealed, .Change midline catheter dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way . Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Physician's Order dated 8/3/2022, revealed Resident #29 had an order to change midline dressing weekly on Mondays. Observation in Resident #29's room on 8/29/2022 at 12:35 PM, 2:53 PM, and 3:13 PM, revealed midline dressing was dated 8/17/2022. Observation and interview in Resident #29's room on 8/29/2022 at 3:43 PM, Licensed Practical Nurse (LPN) #1 confirmed the midline dressing was dated 8/17/2022 and was ordered to be changed on 8/22/2022 and 8/29/2022. During an interview on 8/29/2022 at 4:27 PM, the Director Of Nursing (DON) confirmed Resident #29's midline dressing was not changed on 8/22/2022 or 8/29/2022. She stated the midline dressing was to be changed weekly on Mondays to prevent infection.

Based on the facility procedure guide review, medical record review, observation, and interview, the facility failed to store nebulizer equipment in a safe and sanitary manner for 3 of 34 residents (Resident #26, Resident #29, and Resident #386) who required respiratory treatments. The findings include: Review of the undated facility procedure guide, titled, Nebulized Aerosol Therapy, revealed, .Place nebulizer circuit in equipment bag and store. Nebulizer assembly can become contaminated if not stored properly . Review of medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #386 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in Resident #26's room on 8/29/2022 at 12:45 PM and 3:15 PM, revealed the nebulizer tubing and mouthpiece were placed on the nebulizer machine not stored in a bag. Observation and interview in Resident #26's room on 8/29/2022 at 3:52 PM, Licensed Practical Nurse (LPN) #1 confirmed the nebulizer tubing and mouthpiece were placed on the nebulizer machine not stored in a bag. Observation in Resident #29's room on 8/29/2022 at 12:35 PM and 3:13 PM, revealed the nebulizer tubing and mouthpiece were placed on the nebulizer machine not stored in a bag. Observation and interview in Resident #29's room on 8/29/2022 at 3:43 PM, LPN #1 confirmed the nebulizer tubing and mouthpiece were placed on the nebulizer machine not stored in a bag. Observation in Resident #386 room on 8/29/2022 at 12:40 PM and 3:14 PM, revealed the nebulizer tubing and mouthpiece were placed on the nebulizer machine not stored in a bag. Observation and interview in Resident #386's room on 8/29/2022 at 3:52 PM, LPN #1 confirmed the nebulizer tubing and mouthpiece were placed on the nebulizer machine not stored in a bag. During an interview on 8/30/2022 at 4:30 PM, the Director of Nursing (DON) stated she expected nebulizer tubing and mouthpiece to be stored in a bag when not in use to prevent infection.

Based on facility policy review, observation, and interview, the facility failed to store an ice scoop used to serve ice and failed to maintain clean dietary equipment in accordance with professional standards of practice for food service safety. The findings include: Review of the facility's policy titled, Safety and Sanitation Best Practice Guidelines, revised 11/2017, revealed, .Use a clean, sanitized container .and ice scoop to transfer ice .Scoops must be stored .in a protected fashion .Cleaning Procedures .Daily and weekly .range .daily, wipe up spills as they occur .loosen all burned-on particles .rinse and wipe dry .clean back apron and drip tray .drip tray may be washed in pot and pan sink .wipe dry .return grids and drip tray to range .Cleaning Equipment .equipment must be cleaned and/or sanitized after use . Observation and interview in the kitchen on 8/29/2022 at 10:50 AM, revealed the small and large drip pan with large amount of black, brown debris. The Dietary Manager confirmed the drip tray had a large amount of dried debris and should be cleaned after every use. He stated, It has been a while since it has been cleaned. Observation and interview on the 3rd Floor East Hall on 8/31/2022 at 1:31 PM, revealed an unprotected ice scoop laying on the cart beside the ice chest. Interview revealed Licensed Practical Nurse (LPN) #3 confirmed the ice scoop was not covered. She stated the ice scoop should be stored in a container to prevent contamination when not in use. During an interview on 8/31/2022 at 2:04 PM, the Director of Nursing (DON) stated she expected staff to store an ice scoop in a protective covering when not in use.

Based on facility's documentation guidelines review, medical record review, observation, and interview, the facility failed to ensure accurate documentation of code status preference for 1 of 30 sampled residents (Resident #11) reviewed. The findings include: Review of the facility's Documentation Guidelines reviewed and updated ,d+[DATE], revealed, .DO NOT RESUSCITATE [DNR] Orders: An order entered by the patient's treating physician in the patient's record which states that in the event the patient suffers [CONDITION(S)], cardiopulmonary resuscitation should not be attempted . Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Comprehensive Care Plan for Resident #11 revealed, .Code Status: Full Code .Edited: [DATE] .Full Code (See Post Form) . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .[DATE]-Open Ended FULL CODE: CPR [Cardiopulmonary Resuscitation] . Review of the Tennessee Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #11's code status was DNR. Observation and interview on [DATE] at 11:51 AM, the Director of Nursing (DON) reviewed the medical record for Resident #11 and confirmed the code status on the Electronic Health Record (EHR) banner indicated DNR. She confirmed the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #11's code status was Full Code. She stated a new POST form had been signed on [DATE] indicating DNR code status. She stated there was no order for the DNR code status in the medical record. She stated the DNR POST form was not scanned into the medical record. She stated she expected the EHR to reflect accurate and up to date orders for a resident's code status.

Based on facility policy (Centers for Disease Control and Prevention (CDC) guidelines) review, facility document review, manufacturer's guideline review, observation, and interview, the facility failed to conduct testing in a manner that is consistent with current standards of practice for conducting COVID-19 tests. The findings include: Review of the facility's policy titled, Testing Plan, revised 11/29/2021, revealed, .will utilize the CDC website for the policy/procedure .Conduct testing in a manner that is consistent with current standards of practice for conducting COVID-19 test .Collecting and handling specimens correctly and safely is imperative to ensure the accuracy of test results and prevent any unnecessary exposures .During specimen collection, facilities must maintain proper infection control and use recommended personal protective equipment . Review of the facility's document titled, Anterior nares COVID self-collection of specimen competency, dated 6/16/2020, revealed the first and last step of the testing process was, Performs Hand Hygiene. Review of the manufacturer's guideline for BinaxNow Covid-19 Ag Card dated 12/2020, revealed, .In order to ensure proper test performance, it is important to read the results promptly at 15 minutes, and not before .Results should not be read after 30 minutes . Observation of employee Covid-19 testing site on 8/29/2022-8/31/2022 at various times revealed no hand sanitizer or gloves available for use during test procedure. Continued observation revealed a red biohazard bag open and taped to the desk used during testing procedure. Observation of employee self test for Covid-19 on 8/31/2022 at 7:30 AM, revealed a Respiratory Therapist completed her self test without performing hand hygiene before and after testing procedure. Observation of employee self test for Covid-19 and interview on 8/31/2022 at 2:25 PM, revealed a Restorative Tech completed her self test without performing hand hygiene before and after testing. She placed her Covid-19 test in the form for testing and put the test in a box on top of the desk. During interview she stated she had entered the facility at 11:00 AM, and had waited until 2:25 PM to complete her self testing. She stated she had put the test in the box on top of the desk to be read by a nurse. She was not sure what nurse would be reading the test or what time the test would be read. Observation of the employee self testing site and interview on 8/31/2022 at 2:43 PM, revealed no hand hygiene available for performing specimen collection. Continued observation revealed a red biohazard bag open and taped to the desk of the testing site. The biohazard bag contained used Covid-19 testing supplies. A box containing used Covid-19 test pending results was sitting on top of the desk. During interview the Director of Nursing (DON) stated the manufacturer's guidelines were not followed for reviewing the Covid-19 test results for the daily tests contained in the box. She confirmed there was no hand hygiene available at the self testing site as required by infection control guidelines and the biohazard bag should be in a closed container. During an interview on 8/30/2022 at 1:30 PM, the receptionist seated at the front desk stated employees self-tested twice a week before going into the patient care areas of the facility. She provided a step by step verbal statement of the testing procedure. She stated employees that self tested did not have to use hand hygiene during testing because they were collecting their own specimen.

Based on facility policy review, medical record review, observation, and interview the facility failed to clean and ensure the rooms were homelike and the hand rails in the halls were in good order for 16 of 24 (3001, 3002, 3007, 3009, 3031, 3033, 3034, 3036, 3059, and 3061) rooms observed. The findings include: Review of the facility's policy titled, Cleaning and Disinfecting Residents' Rooms revised 8/2011 revealed .1. Housekeeping surfaces (e.g., floor, tabletops) will be cleaned on a regular basis, when spills occur and when these surfaces are visibly soiled .Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled .Clean curtains, window blinds, and walls when they are visibly soiled or dusty . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included Displaced [NAME] Fracture of Left Tibia, Type 2 Diabetes, and [CONDITION(S)]. Review of Resident #2's 5-day Minimum Data Set assessment dated [DATE], revealed Resident #2 required extensive assistance for toileting and total assistance for bathing with one staff member. Resident #2 was continent of bowel and bladder. Resident #2 required meal set-up only during meals. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses which included Hypertensive [CONDITION(S)], Disc Degeneration, and Peripheral Autonomic [CONDITION(S)]. Review of the Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) assessment score of 14 which indicated no cognitive impairments. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease ([CONDITION(S)]), [CONDITION(S)] Disease, and Hypertensive [CONDITION(S)]. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #7 had a a BIMS assessment score of 15 which indicated no cognitive impairment. Observation in room 3036 on 4/27/2022 at 10:15 AM revealed dust on the overbed tables, nightstands, and under the beds. The floor is dirty with what appears to be food crumbs and dirt. Room 3036 bathroom revealed brown water residue around the back of the faucet, mirror noted with smeared film, and water stains around the bottom area of the toilet. Observation and interview in Resident #7's room also known as 3036 A bed on 4/27/2022 at 10:20 AM, Resident #7 revealed the housekeeping staff might clean her room once per week. Resident #7 stated, I try to clean the bathroom myself with soap and a wash rag, I do the best I can with what I have. Before I came into this room, I had cleaning supplies, but they took them out. The facility doesn't have enough housekeepers to keep these rooms cleaned. Observation and interview in Resident #6's room also known as 3036 B bed on 4/27/2022 at 10:30 AM, Resident #6 stated the housekeepers clean her room once per week. Resident #6 stated, The floor needs to be swept now, the housekeepers tell us they are shorthanded. Observation in room 3001, also known as the Complainant's room, on 4/25/2022 at 12:08 PM, revealed the vent in the bathroom was filled with dirt and debris. Observation on the 3rd floor on 4/25/2022 at 12:40 PM revealed wallpaper torn in the halls between rooms 3059-3061, 3001-3003, 3007-3009. There were stains on the wall above the handrail and below the handrail at room 3034 and a bubble in the wallpaper above room 3067. Further observation revealed the door frames to rooms 3061, 3062, 3059 had missing paint and a hole in the wall noted between room 3031-3033. Continued observation in the hall beside the elevator revealed wood handrails which had chips of wood hanging and some chips which were taped with clear tape. The area to the handrails was rough and uneven. Observation in room 3002 on 4/25/2022 at 12:12 PM, revealed dust and debris on the outside of the air conditioner vent. The plastic bin which was placed on the air vent to control where the air flowed had a large crack in the middle. Observation in room 3009 on 4/25/2022 at 12:23 PM, revealed the bathroom vent was full of dust and debris. Observation and interview on the 3rd floor on 4/25/2022 at 1:00 PM with the Administrator, He stated, I know what you are doing you're trying to get all this confirmed. He further stated, This wallpaper and painting has been an ongoing problem, we are looking at other options. Administrator did confirm the wood handrail needed to be removed. During an interview on 4/25/2022 at 8:16 AM, the Complainant stated Resident #2 resided on the 3rd floor during the duration of her time at the facility. The wallpaper surrounding the window was peeling and there was mold on the wall. The facility solution was to stick a pin to hold the wallpaper up. The air vent in Resident #2's room was filthy and the facility left the vent that way during the time Resident #2 was in the facility. The housekeeping staff did not clean Resident #2's room and the room was visibly dirty. During an interview on 4/25/2022 at 12:44 PM, the Housekeeping Supervisor stated she had three housekeepers on staff, two housekeepers had just quit. All the housekeepers were assigned certain halls to treat and clean. The Housekeeper Supervisor confirmed the rooms were to be cleaned every day but it was not getting done. The Housekeeping Supervisor confirmed the vents were supposed to be cleaned by the housekeeping staff, and the Maintenance Director was responsible for putting on the plastic shields on the vents. The Housekeeper Supervisor confirmed the staff had not been cleaning the vents.

Based on facility policy review, facility investigation review, medical record review, observation, and interview the facility failed to prevent abuse by one resident (Resident #4) to another resident (Resident #3). The findings include: Review of the facility's policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 12/11/2017, revealed .Abuse, Neglect, Misappropriation of Patient Property and Exploitation, as hereafter defined, will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitors, or any other individual in this center. The patient has the right to be free from abuse, neglect, misappropriation of patient property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. The center administrator is responsible for assuring that patient safety, including freedom from risk of abuse or neglect, holds the highest priority .Verbal Abuse: the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability, to comprehend, or disability .Physical Abuse: includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment . Review of the undated facility's policy titled, Patient Rights revealed .The patient is responsible for being considerate of the rights of other patients and center personnel, and assisting in the control of noise, smoking, and the number of visitors. The patient is responsible for being respectful of the property of other persons and of the center . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) assessment score of 6, which indicated severe cognitive impairment. Review of the current care plan dated 4/5/2021 revealed .[named Resident #3] has cognitive deficits related to Dementia evidenced by dx Alzheimer's Disease, Dementia in other diseases classified elsewhere with Behavioral Disturbances .[named Resident #3] has had a physical altercation with another resident in which she was the recipient of aggressive behavior. Approach: Allow [named Resident #3] time to calm herself and discuss the incident. Event Chart x [times] 3 days . Review of Resident #3's progress notes dated 2/16/2022 at 2:00 PM revealed .Resident involved in altercation with peer please-see SW [Social Worker] notes. Staff will continue to monitor and intervene as needed . Review of the progress notes dated 2/16/2022 revealed .SS [Social Service] NOTE: SW was made aware this date by staff that resident was involved in a peer-to-peer altercation as victim earlier today. SW visited with resident in her room; resident did not recall incident and states she is doing fine and smiled at writer. She was noted to be thumbing through a magazine while seated in her wheelchair at time of writer's visit and seemed her usual self and in good spirits. Resident with no injury noted per nursing staff, and staff will continue to monitor for any changes in resident's mood and/or behavior s/p [status post [MEDICAL RECORD OR PHYSICIAN ORDER] . SW will also continue to follow-up with resident to provide supportive visits over the next few days to ensure no mood decline post altercation. Resident also referred to psych services for follow-up. SW spoke with resident's daughter, [named family member], this date and advised her of all the above. Dtr. [daughter] Expressed appreciation for call and follow-up. SW remains available to resident and family as needed . Review of Resident #3's Behavioral Health Notes dated 2/25/2022 revealed .Patient alert lying in bed at the time of exam. Patient reports she has been well since last visit. Patient has no overt SI/HI [Suicide Ideation/Homicidal Ideation], no known [CONDITION(S)] .notes indicate no behaviors of interest, patient calm and compliant with care, tolerant of med pass. No significant anxiety in recent months. Patient has good eye contact today, speech baseline, tangential. [named Resident #3] reports she continues to stay in touch with her family. Patient able to answer very simple questions but is extremely forgetful, [named Resident #3] was recently the victim in a resident-to-resident altercation, she was not injured and has no recollection of being struck by another resident. Patient and staff deny need for psych intervention. Patient appears largely unchanged from last exam . Review of the medical record revealed Resident #4 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE] revealed Resident #4 had a BIMS assessment score of 14, which indicated no cognitive impairment. Review of the current care plan for Resident #4 revised on 8/25/2021 revealed .[named Resident #4] is at risk for behaviors/Mood r/t [related to] Adjustment Disorder. Approach: Escort pt [patient] to Atrium and return to floor by change of shift .[named Resident #4] has had a physical altercation with another resident in which she was the aggressor. Approach: Allow resident to calm herself and discuss incident .[named Resident #4] has physically threatening behavior toward one particular resident. She makes a fist gesture at other resident as if to hit her. Approach: Resident will call for staff assistance when feeling threatened or unsafe with other resident(s). Monitor resident if she is in the hallway to ensure there is no altercation with the other resident . Review of Resident #4 Group Therapy Notes dated 2/3/2022 revealed .Patient has periods of dysthymia in which she acts out interpersonally, socially withdraws, won't leave the bed, increased by relational stress or death in facility .Patient was not very interested in group topics but did talk about her frustrations that she was behind her schedule with leaving the facility, patient understood how COVID restrictions and staff issues had helped her get behind but also said she slacked off too much during December, patient told the group she would get back on the ball with her PT [physical therapy] to get back on schedule . A review of Resident #4's Group Therapy Notes dated 3/10/2022 revealed .Patient has periods of vegetative symptoms, social withdrawal, hiding under covers, irritability, acting out, hopelessness .patient endorsed being angry to the group, frustrated that she is not meeting her goals to live on her own, group supported same, patient said she was working on turning the anger into motivation to work harder in her pt, patient's supported her and said they were backing her . Review of the progress notes dated 2/16/2022 at 5:08 PM revealed .SS Note: SW was made aware by staff this date that resident was involved in a peer-to-peer altercation as the aggressor earlier this date. SW visited with resident to discuss, and also spoke with unit staff and staff witness to obtain further information. Resident to writer that she was wanting to enter the 3rd floor dining room and that another female resident in her wheelchair was blocking [MEDICATION(S)]. Resident states that she said to female peer move yourself out of [MEDICATION(S)], or I'll move you!. Resident then states that female peer cursed at her and stated, Don't touch me or I'll whop you! Resident stated that she then raised her arm at female peer and hit her on the back of her neck, not hard at all! Resident then states that staff witnessed this and intervened to separate her from her peer .Resident does have a hx [history] of peer-to-peer verbal and physical altercations with female peer and staff continue to ensure that resident and peer are not seated next to one another in social events, dining room etc . Review of the facility investigation dated 2/16/2022 revealed the Director of Nursing (DON) and the Social Worker (SW) were made aware of a resident-to-resident altercation. Resident #4 was coming off the elevator and Resident #3 was seated in the hallway next to the elevator. Resident #4 was trying to pass Resident #3 and Resident #4 asked her to let her pass but she refused. Resident #4 stated if Resident #3 did not move then she would move her. Resident #3 stated she would whop Resident #4. Resident #4 then hit Resident #3 on the back of her neck. The staff who witnessed the interaction attempted to break up the fight. Both residents were separated and an assessment was conducted which revealed no injuries to either resident. Review of the facility investigation dated 3/28/2022 revealed the DON and SW were notified of the altercation which occurred between Resident #3 and Resident #4 on 3/24/2022. Staff heard a resident yelling in the dining room of the 3rd floor and observed Resident #4 hitting Resident #3. The staff intervened to separate the two female residents to ensure their immediate safety. Residents were found to have no injuries. SW interviewed Resident #3 but she did not recall the incident occurring and was noted to be seated in wheelchair, calm and in good spirits. The SW interviewed Resident #4 and she stated She was bothering me, Resident #3 was making noise/singing and whistling while resident was watching television in the dining room. Resident #4 stated she told her to stop and Resident #3 made a response back to her that she did not like and then they began to engage in a verbal and then physical altercation. SW attempted to educate Resident #4 related to above response/altercation and notifying staff to assist whenever needed, though Resident #4 did not seem to benefit from education and did not demonstrate understanding at that time. Interdisciplinary Team decision for new intervention at this time for residents to be on separate floors in the facility to potentially aide in deterring future altercations, in addition to interventions already in place. Resident #4 was offered a private room on 2nd floor to which the resident and representative were agreeable for the resident to move. Resident #3 will remain in her current room to benefit from a very familiar and structured environment with similar staff and routines due to moderate cognitive impairment. The facility failed to follow interventions that were in place post the 2/16/2022 incident which stated staff to offer to assist Resident #4 back to the unit to ensure residents do no encounter each other. The Care Plan revealed Resident #4 should be escorted to Atrium and return to the floor by change of shift, Resident #4 did not call for staff assistance, and the two residents were not monitored to ensure there were no further altercations. Observation and interview in the dining room on 4/26/2022 at 8:38 AM, revealed Resident #3 was leaving the dining room and asked the surveyor what she was doing? During the conversation, Resident #4 stated she liked everyone at the facility, and she was treated nicely. Resident #3 stated, the building is beautiful. Resident #3 stated she did not remember being hit by Resident #4 or anyone in the facility. During an interview on 4/26/2022 at 10:35 AM, Licensed Practical Nurse (LPN) #1 stated Resident #4 was always pleasant to her. Resident #4 went to the atrium to sit and loved to go to activities such as bingo. Resident #4 took her medications with no issues. Resident #4 liked to be by herself most of the time. Resident #4 had no problems with other residents or staff. On 3/24/2022, LPN #1 went to the nourishment room to refill her water pitcher. An agency CNA was working at the time and walked beside her on her way to the nourishment room. At the same time, walking LPN #1 heard voices and went to the dining room. Resident #3 and Resident #4 were seated in their wheelchairs. Resident #4 was behind Resident #3, grabbed her collar on her shirt, and hit her with her other hand behind the neck. LPN #1 separated them. The Activities staff had just had a group activity in the dining room. The Assistant Activities Director had put on a movie for the residents to watch, but it was not a group activity; any resident could watch as they pleased. LPN #1 suspected Resident #4 had told Resident #3 to be quiet and caused the incident to escalate. LPN #1 confirmed no staff was in the dining room when she found Resident #4 hitting Resident #3. LPN #1 stated that the only way to monitor Resident #3 and Resident #4 while in the dining room with no group activity was to conduct frequent checks. Further interview revealed Resident #3 had not had any altercations with other residents. During an interview on 4/26/2022 at 5:12 PM, Licensed Practical Nurse (LPN) #1 stated she heard a commotion 2/16/2022. It started as a verbal altercation. Resident #4 was trying to get to the door of the doorway as Resident #3 was coming out of the dining room. I witnessed Resident #4 hit Resident #3 on her back. LPN #1 did not remember what happened as clearly as the latest incident on 3/24/2022. Further interview revealed the facility separated Resident #3 and Resident #4. During an interview and observation on 4/27/2022 at 10:50 AM, Resident #4 was sitting outside in the atrium enjoying the sun. Resident #4 revealed she can go outside any time she wants and is able to wheel throughout the facility from floor to floor whenever she desires to. Resident #4 stated, I used to have a room on the 3rd floor but me and that woman kept fighting. Resident #4 named Resident #3. She further stated, That woman always arguing, cursing but she always lost when she tried that with me. Resident #4 revealed she has had no other issues with any other resident in the facility. Resident #4 further stated, She called me a [OBSCENITY] , she is ignorant, tells me to kiss her ass, so I just haled off and hit her in the mouth. Resident #4 was asked how many times she has hit Resident #3? Resident #4 stated, I have hit her quite a few times. The resident thought they had an altercation about a month ago. Resident #4 giggled while telling surveyor. Resident #4 stated, I haven't seen her since they moved me to the 2nd floor. Resident #4 was asked when did staff become involved when the altercations started and she stated, They always show up after the fact. Resident #4 further stated, She deserves a poke in the mouth, I don't know why she wants to fight with me unless she knows she can get a rise out of me. Resident #4 then demonstrates how she hits the resident by balling up her fist, puts her two hands together and says [NAME], and laughs out loud. Resident #4 then stated, She does fight back a little. During an interview on 4/27/2022 at 6:41 PM, the DON stated she did not witness the incidents on 2/16/2022 and 3/24/2022. The DON confirmed resident-to-resident altercations happened as well as abuse in both physical altercations on 2/16/2022 and 3/24/2022, with Resident #4 hitting Resident #3.

Based on facility policy review, facility investigation, medical record review, and interviews the facility failed to implement the behavioral care plan for 1 of 7 sampled residents (Resident #4) which resulted in two resident to resident altercations. The findings include: Review of the facility's undated policy titled, Section VII: Patient Care Plans revealed, .the center will ensure an interdisciplinary and comprehensive approach to the development of the patient's care plan of care .patients goals for care and preferences will be determined and used to develop their plan of care .all clinical assessments will be completed before the meeting is convened and will be used to inform the care plan development .to comply with the Resident Assessment Instrument (RAI) manual times frames for care plan completion . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive impairment. Review of the current care plan dated 4/5/2021 revealed .[named Resident #3] has cognitive deficits related to Dementia evidenced by dx Alzheimer's Disease, Dementia in other diseases classified elsewhere with Behavioral Disturbances .[named Resident #3] has had a physical altercation with another resident in which she was the recipient of aggressive behavior. Approach: Allow [named Resident #3] time to calm herself and discuss the incident. Event Chart x [times] 3 days . Review of the medical record revealed Resident #4 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE] revealed Resident #4 had a BIMS score of 14, which indicated no cognitive impairment. Review of the current care plan for Resident #4 revised on 8/25/2021 revealed .[named Resident #4] is at risk for behaviors/Mood r/t [related to] Adjustment Disorder. Approach: Escort pt [patient] to Atrium and return to floor by change of shift .[named Resident #4] has had a physical altercation with another resident in which she was the aggressor. Approach: Allow resident to calm herself and discuss incident .[named Resident #4] has physically threatening behavior toward one particular resident. She makes a fist gesture at other resident as if to hit her. Approach: Resident will call for staff assistance when feeling threatened or unsafe with other resident(s). Monitor resident if she is in the hallway to ensure there is no altercation with the other resident . Review of the facility investigation dated 2/16/2022 revealed the Director of Nursing (DON) and the Social Worker (SW) were made aware of a resident-to-resident altercation. Resident #4 was coming off the elevator and Resident #3 was seated in the hallway next to the elevator. Resident #4 was trying to pass Resident #3 and Resident #4 asked her to let her pass but she refused. Resident #4 stated if Resident #3 did not move then she would move her. Resident #3 stated she would whoop Resident #4. Resident #4 then hit Resident #3 on the back of her neck. The staff who witnessed the interaction attempted to break up the fight. Both residents were separated and an assessment was conducted which revealed no injuries to either residents. The SW followed up with Resident #3 and she did not remember the incident and was noted to be in good spirits. The SW continued to follow up with emotional support. Review of the facility investigation dated 3/28/2022 revealed the DON and SW were notified of the altercation which occurred between Resident #3 and Resident #4 on 3/24/2022. Staff heard a resident yelling in the dining room of the 3rd floor and observed Resident #4 hitting Resident #3. The staff intervened to separate the two female residents to ensure their immediate safety. Residents were found to have no injuries. SW interviewed Resident #3 she did not recall the incident occurring and was noted to be seated in wheelchair, calm and in good spirits. The SW interviewed Resident #4 and she stated She was bothering me, Resident #3 was making noise/singing and whistling while resident was watching television in the dining room. Resident #4 stated she told her to stop and Resident #3 made a response back to her that she did not like and then they began to engage in a verbal and then physical altercation. SW attempted to educate Resident #4 related to above response/altercation and notifying staff to assist whenever needed, though Resident #4 did not seem to benefit from education and did not demonstrate understanding at that time. Interdisciplinary Team decision for new intervention at this time for residents to be on separate floors in the facility to potentially aide in deterring future altercations, in addition to interventions already in place. Resident #4 was offered a private room on 2nd floor to which the resident and representative were agreeable for the resident to move. Resident #3 will remain in her current room to benefit from a very familiar and structured environment with similar staff and routines due to moderate cognitive impairment. The facility failed to follow interventions that were in place post the 2/16/2022 incident which stated staff to offer to assist Resident #4 back to the unit to ensure residents do no encounter each other. The Care Plan revealed Resident #4 should be escorted to Atrium and return to the floor by change of shift, Resident #4 did not call for staff assistance, and the two residents were not monitored to ensure there was no further altercations. During and interview on 4/27/2022 at 6:41 PM, DON confirmed that Resident #4 came up the elevator by herself unaccompanied and the facility failed to move Resident #4 when the two residents were in the same room together. She confirmed the facility did not follow the interventions on the Care Plan.

Based on facility policy review, facility investigation, medical record review, observation, and interview the facility failed to revise a care plan for 3 of 7 (Resident #1, Resident #3, and Resident #4) residents reviewed. The findings include: Review of the facility's undated policy titled, Section VII: Patient Care Plans revealed, .the center will ensure an interdisciplinary and comprehensive approach to the development of the patient's care plan of care .patients goals for care and preferences will be determined and used to develop their plan of care .all clinical assessments will be completed before the meeting is convened and will be used to inform the care plan development .to comply with the Resident Assessment Instrument (RAI) manual times frames for care plan completion . Review of the RAI manual chapter 2 dated 10/2019, revealed .Care Planning - establishing a course of action .that moves a resident toward resident-specific goals utilizing individual resident strengths and interdisciplinary expertise .crafting the [how] of resident care .determining the expected outcome forms the basis for evaluating resident-specific goals and interventions to help residents achieve those goals .Implementation .putting that course of action [specific interventions derived through interdisciplinary individualized care planning] into motion by staff knowledgeable about the resident's care goals and approaches; carrying out the [how] and [when] of resident care .Evaluation .critically reviewing individualized care plan goals, interventions, and implementation in terms of achieved resident outcomes and assessing the need to modify the care plan .to adjust to changes in the resident's status, goals or improvement or decline . Further review of the manual revealed .Care plan completion based on the Care Area Assessments [CAA] process is required for Omnibus Budget Reconciliation Act [OBRA] - required comprehensive assessments .however, the resident's care plan must be reviewed after each assessment .and revised based on changing goals, preferences, and needs of the resident and in response to current interventions . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE]. Resident #1 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #1 required extensive 2 staff assistance for bed mobility, transfer, dressing, toileting, and total assistance with bathing. Review of the Care Plan dated 3/3/2022, revealed Resident #1 was at risk for falls related to weakness from recent hospitalization , recurrent falls, Left rib fracture and recent [CONDITION(S)]. The Care Plan approaches were noted to ensure a safe environment free from clutter, ensure fall interventions are in place as ordered, ensure that (Resident #1) is wearing appropriate non skid footwear when ambulating or in wheelchair, fall risk assessment quarterly and as needed (prn), keep call light in reach, answer promptly, observe for unsafe actions and intervene immediately, Physical Therapy/Occupation Therapy to evaluate and treat as indicated, report to Medical Director and family any fall occurrence. All approaches were dated for 3/3/2022. Review of the Fall/Incident Report Check List for falls 3/2/2022, 3/19/2022, 3/29/2022 and 4/1/2022 interventions were not on the Care Plan. During an interview on 4/27/2022 at 7:35 PM, DON confirmed Resident #1's fall Care Plan does not reflect all the interventions nor does it reflect a person-centered Care Plan for Resident #1. Review of the facility investigation dated 2/16/2022 revealed the Director of Nursing (DON) and the Social Worker (SW) were made aware of a resident-to-resident altercation. Resident #4 was coming off the elevator and Resident #3 was seated in the hallway next to the elevator. Resident #4 was trying to pass Resident #3 and Resident #4 asked her to let her pass but she refused. Resident #4 stated if Resident #3 did not move then she would move her. Resident #3 stated she would whop Resident #4. Resident #4 then hit Resident #3 on the back of her neck. The staff who witnessed the interaction attempted to break up the fight. Both residents were separated and an assessment was conducted which revealed no injuries to either resident. Review of the facility investigation dated 3/28/2022 revealed the DON and SW were notified of the altercation which occurred between Resident #3 and Resident #4 on 3/24/2022. Staff heard a resident yelling in the dining room of the 3rd floor and observed Resident #4 hitting Resident #3. The staff intervened to separate the two female residents to ensure their immediate safety. Residents were found to have no injuries. SW interviewed Resident #3 she did not recall the incident occurring and was noted to be seated in wheelchair, calm and in good spirits. The SW interviewed Resident #4 and she stated She was bothering me, Resident #3 was making noise/singing and whistling while resident was watching television in the dining room. Resident #4 stated she told her to stop and Resident #3 made a response back to her that she did not like and then they began to engage in a verbal and then physical altercation. SW attempted to educate Resident #4 related to above response/altercation and notifying staff to assist whenever needed, though Resident #4 did not seem to benefit from education and did not demonstrate understanding at that time. Interdisciplinary Team decision for new intervention at this time for residents to be on separate floors in the facility to potentially aide in deterring future altercations, in addition to interventions already in place. Resident #4 was offered a private room on 2nd floor to which the resident and representative were agreeable for the resident to move. Resident #3 will remain in her current room to benefit from a very familiar and structured environment with similar staff and routines due to moderate cognitive impairment. The facility failed to follow interventions that were in place post the 2/16/2022 incident which stated staff to offer to assist Resident #4 back to the unit to ensure residents do no encounter each other. The Care Plan revealed Resident #4 should be escorted to Atrium and return to the floor by change of shift, Resident #4 did not call for staff assistance, and the two residents were not monitored to ensure there was no further altercations. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had a BIMS score of 6 which indicated severe cognitive impairment. Review of the current care plan dated 4/5/2021 revealed .[named Resident #3] has cognitive deficits related to Dementia evidenced by dx Alzheimer's Disease, Dementia in other diseases classified elsewhere with Behavioral Disturbances .[named Resident #3] has had a physical altercation with another resident in which she was the recipient of aggressive behavior. Approach: Allow [named Resident #3] time to calm herself and discuss the incident. Event Chart x [times] 3 days . Review of the medical record revealed Resident #4 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE] revealed Resident #4 had a BIMS score of 14, which indicated no cognitive impairment. Review of the current care plan for Resident #4 revised on 8/25/2021 revealed .[named Resident #4] is at risk for behaviors/Mood r/t [related to] Adjustment Disorder. Approach: Escort pt [patient] to Atrium and return to floor by change of shift .[named Resident #4] has had a physical altercation with another resident in which she was the aggressor. Approach: Allow resident to calm herself and discuss incident .[named Resident #4] has physically threatening behavior toward one particular resident. She makes a fist gesture at other resident as if to hit her. Approach: Resident will call for staff assistance when feeling threatened or unsafe with other resident(s). Monitor resident if she is in the hallway to ensure there is no altercation with the other resident . During an interview on 4/27/2022 at 6:41 PM, the DON confirmed the Care Plans were not updated after 2/16/2022 which resulted in another incident which happened on 3/24/2022 and post altercation on 3/24/2022. During an interview on 4/27/2022 at 8:07 PM and 8:26 PM, the MDS Coordinator confirmed the Care Plans had not been updated after each physical confrontation for Resident #3 and Resident #4.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the undated facility policy titled, admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] .admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE]. Resident #1 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #1 required extensive assistance for bed mobility, transfer, dressing, toileting, and total assistance with bathing. The MDS also revealed the resident and direct care staff believes he is capable of increased independence in at least some of his Activities of Daily Living (ADLs). Further review of the MDS revealed Resident #1 did not receive Speech Therapy (ST), Occupational Therapy (OT), or Physical Therapy (PT). Review of the facility Medical Director (MD) note dated 3/3/2022 revealed .[Resident #1] .admits for inpatient rehab PT, OT, ST being consulted .discussed with wife and nursing team involved in care plan .fall and safety precautions reviewed - PT/OT/ST .being consulted . Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 4/27/2022 at 9:25 AM and 6:00 PM, the PT Director confirmed Resident #1 did not have therapy orders, he should have had orders, I only go by orders. PT was shown the Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . PT Director confirmed, I guess I went against practice, I was not notified, I am over the department and I dropped the ball. PT Director confirmed Resident #1 should have had therapy evaluations and treatment as indicated.

Based on facility policy, medical record review, observation, and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 7 sampled residents (Resident #1). Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE]. Resident #1 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 5 indicating poor cognitive abilities. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and discharged on [DATE]. Resident #5 admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment . Review of the Resident Progress Notes for Resident #1 revealed, .3/2/2022 found on the floor face down and screaming for help .3/3/2022 MD visited [Resident #1] with wife at side .[Resident #1] complained of pain and chest x-ray was ordered .3/7/2022 Resident #1 was readmitted back to facility post hospital stay from 3/4-3/7/2022 where he was transported from [CONDITION(S)] to the hospital on 3/4/2022 .3/9/2022 he is back from [CONDITION(S)] is lethargic and complains of back pain .3/17/2022 at 11:55 AM [Resident #1] was constantly calling out, [help me], staff go into room and ask if he needs anything and he states [help me, help me] .3/17/2022 at 12:36 PM resident yells out throughout shift, [help], when asked what he needs help with, he says, he's talking to himself, or he doesn't realize he's doing it .3/19/2022 at 4:28 AM resident noted restless, unable to sleep most of the night, calling for help after assisted, yelling the whole night .3/22/2022 at 1:51 AM patient has scooted his bottom off of low bed and onto fall mat, patient will not allow us to assist him back to bed, he says he has back pain from jumping out of helicopters in Vietnam, patient refusing to let us put him to bed .3/24/2022 at 5:50 PM, patient lowering himself off his bed onto his fall mat, when he is put back to bed he lowers himself back onto the mat again .3/24/2022 at 10:20 PM resident continues to yell out, and continues to get out of bed onto the mat, then he yells out to get back into bed .3/28/2022 at 6:45 PM [Resident #1] returned from [CONDITION(S)] .severe anxiety need .resident continuously calls 911, 911 reported calls from resident, resident unable to state needs and reason for calling 911 .3/29/2022 at 10:20 AM patient found lying on mat in floor with head towards foot of bed .3/29/2022 at 10:30 AM wound care nurse asks the resident if he was intentionally placing himself on the floor .he could potentially harm himself, resident stated, I am doing it to get attention 3/29/2022 at 7:24 PM .6:55 PM resident again put himself on the floor .resident placed in geri chair [reclining chair] and in less than 3 minutes of seeing resident he was .on the floor, resident reported that he is going to do it over and over again because he wants to .3/29/2022 at 11:00 PM [Resident #1] continues to scoot out of bed onto the mat, and states that he doesn't know why .3/30/2022 at 4:00 PM [Resident #1] returned from [CONDITION(S)] per emergency management staff (EMS), resident with increased confusion and agitation, EMS reports encounter with resident was abnormal, [CONDITION(S)] clinic had to stop treatment early due to confusion and agitation, 911 was contacted for transport .back from emergency room visit at 9:54 PM emergency room nurse reported CT was negative and MD [NAME] communicated to consider an outside source for psych consultation .continues to yell out, get out of bed onto the mat on 3/30/2022 at 11:30 PM, 4/1/2022 at 12:02 AM .12:20 PM .4/4/2022 LPN #2 spoke with Administrative Officer of the Day (AOD) at VA emergency room for direct admit for Psych Services, resident requiring one on one for safety related to frequently throwing self in floor and yelling out .resident to be transferred by First Call tonight and report given to emergency room nurse . Resident #1 had a Psychiatric Diagnostic Interview completed on 3/29/2022 revealed, .Patient alert, sitting in common area at time of exam .patient admitted [DATE] for Skilled Nursing Facility due to weakness, falls .patient previously lived with spouse and intends to return to that setting .has been difficult to manage since admission with staff citing anxiety, yelling and frequent falls .he has had no major injury from the falls but does admit they happen almost every day .he admits to depression and anxiety, but states both are due to wanting to go home with his wife .he reports his wife has [CONDITION(S)] and is having a Hysterectomy tomorrow which adds to his stress .Patient states depression and [CONDITION(S)] are under control but I suspect he is withholding the truth, patient often swings his legs over the bed and attempts to ambulate without help, leading to falls and he admits to this behavior, patient is able to verbalize his own needs, denies needs for psych, remains adamant he wants to discharge home .BIMS 12 today .affect constricted .mood frustrated .diagnosis .major depressive disorder .adjustment disorder with mixed anxiety and depressed mood .will cross titrate from [MEDICATION(S)] to [MEDICATION(S)] to target [CONDITION(S)] [[CONDITION(S)]] anxiety and agitation .family consulted and agrees with plan, staff encouraged to visit often for emotional support and as part of fall prevention . During an interview on 4/26/2022 at 4:15 PM, Social Worker (SW) revealed she recalls Resident #1 having behaviors, she called his wife because he was throwing himself in the floor and doing this on purpose. SW was unable to find an admission note and stated, I was struggling some by myself, we usually have two SW. She further stated, I honestly don't know when the behaviors were assessed, we felt like he was a danger to himself, we had exhausted all measures. SW stated, I didn't know the goal was for him to go home, the wife had told me she just got diagnosed with [CONDITION(S)] and was going to have a Hysterectomy. During the interview SW did confirm the behaviors were not addressed by specialist until 3/29/2022 and resident was under a lot of stress due to his wife's recent diagnosis. During a telephone interview on 4/27/2022 at 5:00 PM, Resident #5 revealed he was a roommate to Resident #1. Resident #5 revealed Resident #1 was constantly calling out for his wife, trying to get up without help, he fell trying to go to the bathroom, he kept me up. He further stated, Finally [NAME] asked what was wrong with me and I told them I am only averaging about 3 hours of sleep per night, they got him up in a chair and I could hear him yelling in the hall way. Resident #5 stated, I finally told them I was going to leave and they moved me back to the second floor in a private room. Review of the Resident Progress Notes for Resident #5 revealed he changed rooms of 3/10/2022. During an interview on 4/27/2022 at 8:45 PM, the Director of Nursing (DON) confirmed that Resident #1 did not receive behavioral health care and psychiatric services until 3/29/2022.

Based on facility policy review, facility documentation, observations and interviews, the facility failed to check the thermometers for 9 of 9 refrigerated/freezer appliances, failed to label and dated opened packed food, and failed to maintain a sanitary work area. The findings include: Review of the facility's policy titled, Sanitation revised 11/2017 revealed .A thermometer will be placed in all refrigerators and temperatures will be checked and recorded by assigned person . Review of the facility's policy titled, Food Brought into Center from outside Sources revised 11/2017, revealed, .1. Food and/or beverage items brought into the center should be securely packaged and labeled with patient's name and the date the item(s) were brought into the center. The center should have large zip-type storage bags and markers, or other appropriate supplies, available for packing, labeling, and identifying food brought in from, and outside source. 2. Food or beverage items may be stored in center nourishment pantries, refrigerators, freezers, or patient's personal room refrigerators, if applicable . Observation in the kitchen on 4/25/2022 at 6:54 AM, revealed the walk-in freezer, walk-in cooler, 2 reach in coolers, milk cooler, drink cooler, top tray line cooler, bottom tray line cooler, and cold prep cooler did not have a completed temperature logs. Observation in the kitchen on 4/25/2022 at 6:59 AM, revealed a white rag with brown stains placed below the spout of a coffee dispenser. Observation and interview in the kitchen on 4/25/2022 at 7:03 AM with Dietary Aide #2 revealed two 3 lbs. (pounds) tubs of chicken salad, one 3 lbs. tub of pimento cheese, and a package of deli ham were opened and undated. Dietary Aide #2 confirmed the food was supposed to be dated after opening. During an interview on 4/25/2022 at 7:13 AM, Dietary Aide #1 confirmed the rag was not supposed to be placed under the spout of the coffee dispenser. During an interview on 4/25/2022 at 7:29 AM, the Dietary Manager (DM) expected staff to take temperatures of all refrigerators and freezers on daily basis and to follow the directions on the log sheets. During an interview on 4/26/2022 at 3:50 PM, the DM confirmed all food items needed to be labeled and dated. Further interview revealed the coffee maker needed to be replaced if coffee was leaking from the spout and if staff was going to place a towel it needed to be in a sanitation solution bucket to wipe down the table where the coffee spout leaked on.

Based on facility policy, medical record review, observation and interview, the facility failed to ensure accuracy of Medication Administration Record (MAR) for 1 of 7 sampled residents (Resident #1). The findings include: Review of the facility's policy titled, Medication Ordering and Receiving from Pharmacy, dated 1/1/2019 revealed .medication orders are written on a medication order form .telephone order sheet, reorder form, electronically, written in the chart by the physician, electronic order, or written on a transfer order form .all other new medication orders are received and available for administration after the next routine delivery . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE]. Resident #1 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. Review of the hospital discharge medication list for 3/7/2022 revealed Resident #1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR revealed an order 3/8/2022 for Insulin [MEDICATION(S)] U-100 solution; 100 unit/ml amount to administer : 6 units subcutaneous with meals and the administration times are put in as 8:00 AM, 12:00 AM, 5:00 AM, 12:00 PM, 5:00 PM, instead of just order times with meals. During an interview on 4/27/2022 at 8:45 PM, Licensed Practical Nursing (LPN) #4 and Directory of Nursing (DON) reviewed the MAR and confirmed the insulin order was put in incorrectly.

Based on facility policy review, medical record review, observations and interviews, the facility failed to provide a sanitary environment for 6 (Rooms #3036, 3037, 3038, 3040, 3042, and 3rd Floor South Wing Central Bath) of 8 rooms reviewed. The findings include: Review of the undated facility's document titled, Patient Rights, revealed, .we support the patient/resident's right to live in an environment which is individualized for them .We strive to cultivate and sustain an excellent quality of life for each individual with person-centered care and services, by honoring and supporting each patient/resident's preferences, choices, values and beliefs . Review of facility policy titled, Cleaning and Disinfecting Residents' Rooms, revised 8/2011, revealed, .The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms .1. Housekeeping surfaces (e.g. [for example], floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled .2. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times a week) and when surfaces are visibly soiled . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Bi-Polar Disorder, [CONDITION(S)] Disorder and Body Dysmorphic Disorder. Review of the 5-day Minimum Data Set (MDS) Assessment for Resident #1 dated 8/11/2021, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with a readmission on 05/18/2021. Diagnoses included [CONDITION(S)] and [CONDITION(S)] following Cerebral Infarction, Dysphagia and Cerebral Aneurysm. Review of the Annual MDS Assessment for Resident #4 dated 08/19/2021, revealed a BIMS score of 15, which indicated no cognitive impairment. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included Chronic [CONDITION(S)], [CONDITION(S)] and Hypertensive [CONDITION(S)]. Review of the Annual MDS Assessment for Resident #5 dated 08/12/2021, revealed a BIMS score of 15, which indicated no cognitive impairment. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included Hypertensive Chronic Kidney Disease, Cervicalgia and Restless Leg Syndrome. Review of the Quarterly MDS Assessment for Resident #6 dated 10/08/2021, revealed a BIMS score of 14 which indicated no cognitive impairment. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Hypertensive Chronic Kidney Disease and Anxiety Disorder. Review of the MDS Assessment for Resident #7 dated 09/17/2021, revealed a BIMS score of 4, which indicated severe cognitive impairment. Observation of the 3rd Floor South Wing Central Bath on 11/8/2021 at 9:29 AM, revealed a strong smell of urine, debris on the floor, a yellow sling laying on the floor next to the commode and soiled linen on the floor. Observation of room 3042 on 11/8/2021 at 9:31 AM revealed debris (appeared to be crumbs and dust) in the floor. Observation of room 3040 on 11/8/2021 at 11:02 AM revealed debris on the floor of the bathroom, a used washcloth under the sink on the floor, a pink pan with brown debris in it under the sink, the sink vanity top was dirty, a brown smudge under the toilet flush handle on the toilet tank. Observation of the room revealed a clean adult brief in the floor and blue incontinent pads on the floor beside A bed. Further observation revealed a plastic bag that was tied up with linen in it on the floor and a bath pan that contained 4 water pitchers on the floor. Observation of the bathroom in room 3042 on 11/8/2021 at 12:05 PM revealed adult briefs, a grey blanket, and a basket with toiletries on the floor of the bathroom. The commode had black/brown debris in the bowl. The sink vanity was cluttered with personal items and a tube of denture adhesive without a lid. Further observation in room 3042 revealed a trash can without a liner near the B bed with debris in the bottom of the can. There was dust on the head board and foot board of both beds and on all furniture surfaces. Observation of A bed side, revealed a yellow/brown smudge on the wall above the trash can, the overbed table drawer edge had splattered dried debris, a white substance on the floor near the head of the bed and on the bedside table. Observation of room 3037 on 11/8/2021 at 12:17 PM revealed the toilet had yellow liquid in it, and smelled of urine. The bathroom floor had debris and 2 gloves on it. The sink vanity was soiled with a brown debris and no liner in the trashcans. The trashcans had brown debris in the bottom of them. Further observation revealed dust on the headboards and footboards and on all furniture surfaces. Observation of room 3038 on 11/8/2021 at 12:19 PM revealed there was debris and dust covering the bathroom floor. Further observation revealed partially dried orange/yellow/brown substance around the toilet base. There was dried crusty debris under 2 uncovered toothbrushes on the sink vanity and no liner in the trashcan. Observation of room 3036 on 11/8/2021 at 12:20 PM revealed the windowsill with rings of dirt and debris on the surface. Further observation revealed a dried white substance behind the commode in the bathroom, a black, dried piece of debris on the wall next to the vanity, and brown/black debris around the base of the commode. Observation in the South Wing 3rd Floor hallway, outside the Central Bath, revealed a chair with 2 large white dried smears on the cushion. During a phone interview on 11/8/2021 at 9:17 AM with Resident #1, she stated she was here in August for rehabilitation, and her bathroom was nasty. She stated she asked the Administrator to have someone come and clean it, so he sent someone, but the toilet was still dirty after the housekeeper left. She stated the bathtub in her room had a brown film on it, and she refused to take a bath and only took showers while she was there. During an interview on 11/8/2021 at 11:02 AM with Resident #4, she stated, They clean my room. The bathroom needs some attention though. During an interview on 11/8/2021 at 12:05 PM with Resident #5, she stated, Housekeeping hasn't been in here today. Sometimes, when the techs (Certified Nursing Assistants) can't stand it anymore, they will sweep up the floor and pick up a little. When housekeeping does come in, all they do is sweep the floor. My roommate went and bought her own toilet bowl cleaner and tries to clean her toilet herself. During an interview on 11/08/2021 at 12:14 PM, Certified Nursing Assistant (CNA) #1 stated, I work through agency, but I have worked in this facility a lot over the past three years. This facility is the dirtiest place that I have ever worked. They don't have anyone to work in housekeeping, the CNAs sweep a little every now and then when it gets overwhelming. During an interview on 11/8/2021 at 12:17 PM with Resident #7, she stated, Housekeeping doesn't come in very often. During an interview on 11/8/ at 12:20 PM with Resident #6, she stated, Housekeeping usually comes in once a week. They (housekeepers) tell me they don't have enough help. When I ask for my room to be cleaned, it's like pulling teeth. During an interview on 11/8/2021 at 12:29 PM with the Housekeeping Supervisor, he confirmed the facility is experiencing a huge shortage in housekeeping personnel. He stated he only has 2 Full Time Housekeepers and there is not enough to clean the rooms as they should be. He stated recruitment efforts are ongoing and they have contacted an agency, but the price was unreasonable compared to what the facility's base pay for a housekeeper was. During a interview and walking observation with the Housekeeping Supervisor on 11/8/2021 at 12:34 PM, he confirmed rooms 3042, 3041, 3040, 3039, 3037, 3038, and the 3rd floor South Wing Central Bath were dirty and had not had housekeeping services as required. During an interview on 11/8/2021 at 1:25 PM with the Administrator, he stated the facility has been struggling with housekeeping staffing for a while.

Based on medical record review, review of Event Report, interview, and observation, the facility failed to ensure Care Plans were followed for 5 residents (#2, #6, #7, #8, #9) of 11 residents reviewed. Resident #2 sustained HARM (laceration to head which required stitches) during a fall when staff failed to follow his Care Plan for using 2 staff to provide care. In addition, the facility failed to follow other Care Plan interventions designed to prevent accidents, such as low bed, fall mats, and call light in reach for Resident #8; failed to provide respiratory care for Resident #6 and #9; and failed to use geri-sleeves to prevent skin tears for Resident #7. The findings included: Medical record review revealed Resident #2 was admitted to the facility on [DATE]. The resident had a [MEDICAL CONDITION] and was dependent on supplemental oxygen. The resident's [DIAGNOSES REDACTED]. Review of an Event Report dated 1/1/16 revealed the resident was lowered to floor. Review of the investigation notes revealed, while she was giving him a bed bath, resident coughed violently multiple times that had him leaning off bed. For safety, resident was lowered to floor to keep from falling off bed .Care Plan to reflect x2 (2 staff) assist for all care. Continued review revealed the staff were educated to use x2 assist for Activities of Daily Living (ADLs) and turning. Review of the 11/16/16 Minimum Data Set (MDS) revealed Resident #2 continued to require total assistance of 2 staff for ADLs, as noted on his Care Plan, which indicated the resident was at risk for falls r/t (related to) impaired mobility, need for 2 staff members with ADL assistance. Review of an Event Report dated 12/4/16 revealed at 6:00 AM, Resident #2 sustained a fall when staff failed to follow the Care Plan and provided only 1 staff during ADL care. Per the resident, the 1 Certified Nurse Aide (CNA) had resident turned twards (towards) herself as she was providing incontinent (incontinence) care. Resident began to forcefully cough multiple times. Resident's body came off the bed and (staff) was unable to stop him from falling due to weight. The Event Report noted the resident had a 2-inch gash above the right eye. The resident was transferred to the hospital, where stitches were applied to the laceration above the resident's eye. In addition, review of the hospital report revealed a computerized tomography (CT) scan of the resident's head was conducted and found a small amount of new intraventricular hemorrhage within the atria of both lateral ventricles, greatest on the left. Interview with the Quality Assurance (QA) Nurse on 9/19/17 at 11:04 AM on the first floor administration wing revealed she had been responsible for the investigation of the incident. She stated the fall with injury occurred when the resident's Care Plan was not followed. The QA Nurse confirmed the Care Plan called for 2 staff to be present whenever ADL care was given; however, only one staff was present to give care when the fall occurred. The QA Nurse stated the CNA, who no longer worked at the facility, was aware of the resident's Care Plan, stating the CNA knew that there were supposed to be 2 people in the room, but she was in a hurry. She made a big mistake resulting in a fall from the bed requiring stitches to a laceration on the forehead (Harm). Medical record review revealed Resident #6 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 30 day MDS dated [DATE] revealed the resident was cognitively intact with modified independence, and altered level of consciousness that fluctuated; was bed bound and was dependent with assistance of 1 person for bed mobility, dressing, eating, hygiene, bathing and toileting. Continued review revealed the resident had bilateral upper extremity impairments and received services from Respiratory Therapy for oxygen, suctioning, [MEDICAL CONDITION] care and ventilator care. Review of a facility investigation dated 7/26/17 revealed Resident #6 pushed his call light between 8:00 AM and 8:30 AM and told CNA #5 he needed respiratory therapy. The CNA told Respiratory Therapist (RT) #1 the resident requested him and he said OK. The RT was caring for another resident at that time. The resident pushed his call light a 2nd time and CNA #8 answered the call light and was told he needed respiratory because he couldn't breathe. The CNA informed RT #1 who was caring for another resident, stated OK, thanks. Approximately 5 minutes later the call light went off a 3rd time and CNA #8 answered it and the resident again stated he needed respiratory and he couldn't breathe. The CNA asked if RT #1 had made it in yet and the resident said No. The CNA said she would let him know again and found RT #1 sitting at a table in the hallway charting. CNA #8 told him Resident #6 still needed him because he said he couldn't breathe, and the RT smiled and said OK, thanks. The resident pushed his call light a 4th time and CNA #5 and Licensed Practical Nurse (LPN #7) entered the resident's room and he asked to be transferred out of the facility because he didn't feel safe. Medical record review of the Comprehensive Care Plan dated 6/2/17 revealed a problem of Impaired Gas Exchange-Ventilation with approaches to Perform Ventilator Checks every 4 hours and as needed.; a problem of Impaired Gas Exchange-Oxygenation with an approach to initiate SP02 (peripheral capillary oxygen saturation - an amount of oxygen in the blood) monitoring; a problem of Airway Patency and [MEDICAL CONDITION] Hygiene with approaches to Administer [MEDICATION NAME][MEDICATION NAME] via Nebulizer per orders, Tracheal Suctioning as needed. Review of a Tek-Care Report dated 7/31/17 revealed the ventilator alarm for Resident #6 went off on 7/26/17 at 8:49:42 AM and alarmed for 5 minutes, 18 seconds. Continued review revealed the oxygen saturation alarm went off on 7/26/17 at 8:49:53 AM and alarmed for 3 minutes, 44 seconds. Medical record review of the Respiratory Treatment Flo Administration History dated 7/1/17-7/31/17 revealed End Tidal Capnography every 4 hours (checks carbon [MEDICATION NAME] level) was scheduled to be checked at 8:00 AM on 7/26/17. RT #1 documented it was checked at 9:50 AM. Continued review revealed Resident #6 received his breathing treatment scheduled at 8:00 AM and 9:50 AM by RT #1. Continued review revealed Resident #6 was suctioned by RT #1 at 9:50 AM on 7/26/17 and received a moderate amount of thick pale yellow secretions. Interview with the Director of Nursing (DON) on 9/20/17 at 3:36 PM in the conference room confirmed the facility failed to respond to ventilator and oxygen saturation alarms timely, failed to provide care and assistance to Resident #6 timely, and failed to follow the Comprehensive Care Plan. Medical record review revealed Resident #7 was admitted with [DIAGNOSES REDACTED]. Review of a quarterly MDS dated [DATE], revealed the resident was moderately cognitively impaired, totally dependent on staff for transfer, and required extensive assistance with bed mobility. The resident did not walk and required either supervision or limited assistance from staff with locomotion in her wheelchair. Review of Resident #7's Progress Notes revealed the resident had a history of [REDACTED]. Review of Resident #7's Comprehensive Care Plan, dated 9/7/17, revealed the resident has impaired/potential for impaired skin integrity r/t impaired mobility, incontinence of bowel and bladder, age related skin changes, ASA (aspirin) in use. [MEDICAL CONDITION], chronic [MEDICAL CONDITION]. Approaches to help the resident meet the goal of avoidable skin breakdown included 8/21/16 - Geri-sleeves to be in place. Review of the Safety Care Plan used by direct care staff and posted in the resident's closet also revealed the instructions: Geri-sleeves to be in place at all times d/t (due to) frequent STs (skin tears) - 8/21/16. Observation of Resident #7 on 9/18/17 at 8:48 AM, 3:00 PM., 5:06 PM., and on 9/19/17 at 8:10 AM., 8:26 AM, and 3:15 PM, revealed the resident was not wearing geri-sleeves. Bruising was noted on the resident's right hand, which extended from the index finger to the thumb, across the back of the hand. Interview on 9/19/17 at 8:26 AM with CNA #1 in the third floor dining/dayroom confirmed the resident was not wearing geri-sleeves at that time, and her arms were bare from below her elbow. CNA #1 stated, No, she doesn't use them. Interview with CNA #1 revealed she used the Care Plans posted in each resident's closet to know what care needed to be provided. After a review of the Care Plan posted in Resident #7's closet, CNA #1 confirmed it called for the use of geri-sleeves at all times, and she stated she had not known this intervention was listed on the Care Plan. Interview on 9/19/17 at 3:15 PM with LPN #1 in the third floor dining/dayroom, confirmed Resident #7 was not wearing geri sleeves. She stated the facility had geri-sleeves available, and they should be in place if the Care Plan called for their use. Interview on 9/19/17 at 3:22 PM with Unit Manager (UM) #1 in his office also confirmed the facility had geri-sleeves available for the resident's use and stated, If it's on the Care Plan, they should have been used. Review of Resident #8's Comprehensive Care Plan, initiated 11/10/16, was reviewed on 9/18/17. The Care Plan indicated the resident is at risk for falls r/t dependent on staff for ADLs, limited mobility, antihypertensive and [MEDICAL CONDITION] medications in use. To meet the goal of no avoidable falls, interventions since 12/20/16 included Floor mats at bedside. Interview on 9/18/17 at 1:52 PM with CNA #3 on the third floor hallway revealed the facility posted Care Plans in each resident's closet so direct care staff knew what care the resident needed. She stated the Care Plans included the amount of ADL assistance the resident needed, as well as any special devices or equipment that were to be used. Observation on 9/18/17 at 5:34 PM revealed Resident #8 was in his bed, which was in a high position. A fall mat was observed on the left side of the bed. However, no fall mat was present on the right side of the bed. Observation in Resident #8's closet revealed there was no Care Plan posted to provide information on the resident-specific approaches to be implemented. Review of Resident #9's Admission MDS, dated [DATE], revealed the resident was moderately cognitively impaired, was bedfast, had a [MEDICAL CONDITION], and was totally dependent on staff for all care, including transfers and bed mobility. Review of an Event Report revealed, on 9/17/17 at 2:20 AM, the resident had a fall from the bed and was found on the floor between the two beds in the room. The Event Report noted injuries from the fall, as the resident was decannulated ([MEDICAL CONDITION] came out), complained of pain after the fall, and had to have a [MEDICAL CONDITION]. In response to this fall, Resident #9's Care Plan for fall risk, initiated 8/23/17, was revised on 9/17/17 to include a Low bed when unattended. Observation on 9/18/17 at 5:24 PM, revealed the resident was asleep in bed, with his [MEDICAL CONDITION] in place, and nutrition infusing via gastrostomy tube. No staff were present in the room. The resident's bed was not in a low position and was higher than that of his roommate in the next bed. Interview on 9/19/17 at 3:22 PM with UM #1 in his office revealed if an intervention was listed on the Care Plan, it should have been used.

Based on review of facility policy, medical record review, review of Event Report, review of hospital record, interview, and observation, the facility failed to provide an environment free of accident hazards and the supervision needed to prevent accidents for 5 residents (#2, #4, #7, #8, #9) of 11 residents reviewed. Resident #2 sustained HARM (laceration to head which required stitches) during a fall when the facility failed to follow his care plan by using 2 staff to provide care. In addition, the facility failed to provide assistive devices such as low beds, fall mats, and call lights in reach to prevent falls for 4 residents (#4, #7, #8, #9). The facility failed to ensure devices to prevent accidents, such as geri-sleeves to prevent skin tears, were provided for Resident #7. The facility failed to ensure interventions resulting from an investigation were acted upon for 4 residents (#2, #4, #7, #9). The facility failed to ensure the environment was free of accident hazards such as side rails for which there was no assessment and were a factor in Resident #4's fall from the bed. The findings included: Review of facility policy, Fall Risk Reduction and Management, revised 9/16 revealed .A 'fall' is when a resident comes to rest unintentionally on the floor. An intercepted fall is a fall. A fall without injury is a fall. When a resident is found on the floor, the conclusion is that a fall has occurred. If a resident rolls or 'scoots' off a bed or mattress on the floor, this is a fall .Complete side rail assessment at time of admission, quarterly, at time of significant change Interventions appropriate to individual resident and their risk for falls will be implemented based on recognized standards of practice .MDS (Minimum Data Set)/Care Plan Coordinator is responsible for updating care plan related to fall risks, interventions and/or injury related to falls .Interdisciplinary staff will make suggestions for appropriate interventions to decrease likelihood of recurrent fall/fall with injury .The MDS/Care Plan Coordinator will be responsible for making sure that the care plan is updated accordingly .If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant .If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable . Review of a facility policy, Incident/Accident, revised 9/10/16, revealed .Incidents, accidents, or injury of unknown origin will be investigated and appropriate interventions taken as needed .Residents are assessed through the routine assessment and care planning process for factors that may place them at risk for incidents or accidents. Interventions will be implemented based on the assessment findings .The facility will investigate the incident, accident or injury to identify potential contributing factors .Based on investigative findings, the care plan will be reviewed and revised to include preventative interventions to decrease potential for recurrence . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident had a tracheostomy and was dependent on supplemental oxygen. Review of an Event Report dated 1/1/16 revealed the resident was lowered to floor. Review of the facility investigation revealed staff stated while she was giving him a bed bath, resident coughed violently multiple times that had him leaning off bed. For safety, resident was lowered to floor to keep from falling off bed .Care Plan to reflect x2 (2 person) assist for all care. Continued review of the note, staff were educated to use x2 assist for ADLs (Activities of Daily Living) and turning. Review of hospital records dated 11/2/16, revealed the resident was admitted to the hospital with [REDACTED]. Review of Progress Notes revealed the resident was readmitted to the facility on [DATE]. Review of an admission Fall Risk assessment completed on 11/9/16 revealed the resident was at risk for falls based on factors including decreased muscular coordination, impaired mobility, continent, medication use, length of stay, and his neuromuscular/functional status. Review of an Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 continued to require total assistance of 2 staff for ADLs including bed mobility, transfer, dressing and toilet use. Continued review of the assessment revealed the resident was bedfast, severely cognitively impaired, and had no recent falls. Review of Resident #2's fall risk Care Plan last updated on 12/4/16, revealed upon his return to the facility, the documentation remained the resident at risk for falls r/t (related to) impaired mobility, need for 2 staff members with ADL assistance. Review of an Event Report dated 12/4/16 revealed at 6:00 AM staff had resident turned twards (towards) herself as she was providing incontinent (incontinence) care. Resident began to forcefully cough multiple times. Resident's body came off the bed and (staff) was unable to stop him from falling due to weight. The Event Report noted the resident had a 2-inch gash above the right eye. Review of the Progress Notes attached to the facility investigation revealed swelling was present to the area and neurochecks were started due to suspected head trauma. Review of the fall investigation revealed the resident was transferred to the hospital at approximately 9:15 AM, at the sister's request. Review of the 12/4/16 hospital record revealed the resident had stitches applied to the laceration above his right eye. Continued review of a computerized tomography (CT) scan of the resident's head revealed there was a small amount of new intraventricular hemorrhage within the atria of both lateral ventricles, greatest on the left. Review of the 12/4/16 Progress Notes dated 12/4/16 revealed the resident returned from the Emergency Department at approximately 2:30 PM. Review of Progress Notes on 12/5/16, revealed the resident continues to have edema (swelling) to right side of face and eye (the same side of the head as the craniectomy). Continued review of the Progress Notes revealed the Resident is noted to have blood present in trachea and is present when being suctioned, that was initially noted after returning from hospital. Review of a CNA (Certified Nurse Aide) Observation form dated 12/4/16 and a witness statement from the CNA that was present at the time of the fall revealed, I was turning (Resident #2) towards the window .to reposition him and change him. (Resident) coughed and coughed very hard two - 3 times. He threw himself out of the bed and I was unable to catch him. He fell out and had hurt himself. Review of her statement revealed that she had marked Yes to the question, Were all intervention(s) in place? Interview with the Director of Nursing (DON) on 9/19/17 at 10:48 AM on the first floor administrative wing revealed the Quality Assurance (QA) Nurse completed the investigation of this fall with injury, and she would be able to answer questions about it. The DON related the CNA involved in the incident had been disciplined for failing to follow the resident's Care Plan a second time in February 2017, and no longer worked at the facility. Interview with the QA Nurse on 9/19/17 at 11:04 AM revealed the CNA's witness statement was not accurate. She stated all interventions were not in place, as the Care Plan called for 2 staff to be present whenever ADL care was given. The QA Nurse confirmed There were supposed to be 2 staff present at the time of the fall. She stated the CNA was aware of the resident's Care Plan and knew that there were supposed to be 2 people in the room but she was in a hurry. She made a big mistake. Medical record review revealed Resident #4's was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed the resident was cognitively impaired and required limited assistance with bed mobility, transfers and walking in her room. Continued review revealed the resident had no functional limitations to range of motion, but was not steady in transfers and was only able to stabilize herself during transfers with staff assistance. She was assessed as at risk for falls and the problem was Care Planned. Review of Resident #4's clinical record revealed no Physician Orders for any type of restraints, including side rails. Review of x-ray results dated 5/19/17 revealed Resident #4 was diagnosed with [REDACTED]. Review of Progress Notes dated 5/19/17 revealed the resident required hospitalization and a hip replacement. Review of the facility investigation revealed the facility was unable to determine the etiology of this fracture. Resident #4 returned to the facility on [DATE] and remained at risk for falls and the problem continued to be Care Planned. Fall 1 - Review of an Event Report dated 6/20/17 revealed at 11:00 PM the resident had an unwitnessed fall, and was found sitting next to bed on floor. Patient still had blankets on. Continued review of the Event Report revealed bilateral hip and sacral x-rays were ordered on [DATE] due to the resident's increased pain after the fall; however, no new fractures were found. The Probable Cause of the fall was listed as resident attempted to ambulate without assistance. Review of the Event Report revealed the Care Plan was updated; however, review of the Care Plan, initiated on 4/19/17, revealed no interventions were added to the Care Plan. Review of hospital records revealed the resident was hospitalized from [DATE] - 7/3/17, when she required a below the knee amputation (BKA) of her left leg due to a gangrenous great toe. Resident #4 returned to the facility on [DATE]. The resident's Comprehensive Care Plan continued to indicate she was at risk for falls. Medical record review of a comprehensive assessment dated [DATE], was completed for a significant change in the resident's condition. After the amputation, the resident no longer walked, and needed extensive staff assistance with bed mobility and transfers. After completion of the Comprehensive Assessment, the resident's Comprehensive Care Plan was updated and a Care Conference was held on 7/19/17. Review of Resident #4's Care Plan revealed approaches were not revised to reflect the resident's current status. Review of the Care Plan revealed the resident was at risk for infection r/t Left BKA. Approaches to meet the goal of remaining free of infection revealed the resident was to have Shoes on only during therapy r/t L (left) heel blister. The care plan also noted the resident is a fall risk r/t S/P (status [REDACTED]. Both of these approaches had previously been on the resident's Care Plan and were not revised/deleted after the amputation of the resident's leg. Fall 2 - Review of an Event Report dated 7/13/17 revealed the resident's next fall occurred on 7/13/17 at 1:35 AM. The resident was found by staff Sitting on floor at bedside with legs extended in front of her. Resident stated she slid out of bed once her leg went over the side. Medical record review of a x-ray Report of the resident's left hip (which was previously fractured and replaced) revealed no new fractures. Review of Physician Orders attached to the Event Report revealed, on 7/13/17, the Physician gave new orders for Fall mats beside pt's (patient's) bed. Bed in lowest position at ALL times. Continued review of the Event Report revealed the resident's Care Plan was updated in response to the fall on 7/13/17. Further review of the Care Plan revealed the approach of the bed in the lowest position was not added to the Care Plan until 8/1/17. Continued review of the Care Plan revealed, as of 9/18/17, the approach of fall mats at the bedside had never been added to Resident #4's Care Plan. Fall 3 - Review of an Event Report dated 8/1/17 revealed, at approximately 4:30 PM, the resident was found sitting on the floor .When asked what happened, the resident stated, I just wanted to get in the chair. Continued review of the Event Report revealed the Probable cause of the fall was the Resident has intermittent confusion, is a fall risk, and doesn't always remember to use call light. Although the investigation identified the resident's [DIAGNOSES REDACTED]. Fall 4 - Review of an Event Report dated 8/25/17 revealed at 4:15 PM, the resident attempted to transfer herself from the chair to the bed without assistance and fell , did not call and ask for help. The root cause was described as transferring without assistance, not using call light. The Care Plan was updated on 8/25/17 with an intervention for, Remind resident to use the call light for assistance. Continued review revealed there was no evidence of identification that the use of the call light was already on the Care Plan and was not successful in preventing this fall. Further review revealed there was no evidence of an investigation as to why the previous intervention of the call light was not successful, and the facility did not assess factors such as whether the call light was out of reach, or if the resident could not remember to use it due to cognitive function. Fall 5 - Review of an Event Report dated 9/11/17 revealed at 11:20 AM, staff walked into resident's room to find resident at the end of bed with legs hanging off bed touching floor. Resident began to slide, (staff) assisted resident to floor. Review of the Probable Cause was listed as resident scooted to foot of bed and lost her balance and fell off bed. Continued review revealed there was no evidence the facility assessed the root cause of why the resident scooted to the foot of the bed. Medical record review of the resident's Care Plan revealed, since 7/26/17, the resident was to have a lower bedrail raised on the amputation side (left side) of the bed. Further review of the Care Plan revealed with the use of the one lower side rail, the resident will still be able to get OOB (out of bed) to her strong side. Review revealed there was no evidence the facility investigated whether one (or more) side rails were in use at the time of this fall and whether their use restricted normal exit from the bed, forcing the resident to scoot to the end to try and get out of bed. Although the Event Report indicated there were no injuries noted from this fall, review of the facility investigation revealed the resident complained of pain to the left leg stump on 9/12/17 and 9/13/17, as well as knee pain on 9/14/17. Fall 6 - Review of Progress Notes dated 9/17/17 revealed at approximately 5:30 AM the resident was found sitting on floor on knee/stump, claims she forgot she only has one leg. Medical record review revealed the resident's stump was bleeding and she had a small bruise to the right knee. Continued medical record review revealed at 7:16 PM, the resident was complaining of pain in her right ankle from the fall and the nurse observed bruising across the top of the ankle. X-rays were obtained on 9/18/17, and no fracture was identified. Observation on 9/18/17 at 8:35 AM revealed Resident #4 was asleep in bed. The resident's Physician Orders for fall mats and the bed to be in the lowest position were not followed. Observation revealed the resident's bed was not lowered and the fall mats were not in use. The resident's Care Plan called for one lower side rail to be up when the resident was in bed. However,observation revealed all 4 one-half side rails were raised, creating the effect of 2 full side rails which restrained the resident in bed. Although the Care Plan called for the resident to use her call light to prevent falls, observation revealed the call light cord was looped through the middle bar of the top side rail, and was dangling under the bed, out of the resident's reach. Further observation on 9/18/17 at 1:49 PM revealed the resident was asleep in bed with the bed in the lowest position closest to the floor with no fall mats in use and the 4 side rails raised. Observation on 9/19/17 at 8:08 AM revealed Resident #4's right foot was bruised and purple-grey in color. The bruising extended over the top of the resident's foot from the ankle to the toe and around the back and side of the ankle. The resident was moaning, and when Licensed Practical Nurse (LPN) #1 asked Resident #4 if her foot hurt, she responded, Yes. Interview with CNA #3 on 9/18/17 at 1:52 PM, confirmed all 4 side rails were raised, and there were no fall mats in place. CNA #3 stated, She doesn't use any fall mats; not that I know of. CNA #3 stated the bed was always supposed to be in the lowest position; however, it had to be raised for meals to get the over-bed table in place. When told of the observation on 9/18/17 at 8:08 AM, she stated staff, may have forgotten to lower the bed after the resident's meal was finished. During the interview on 9/18/17 at 1:52 PM, CNA #3 stated she always used all 4 side rails for the resident when she was in bed. She stated the resident had a leg amputation earlier this year, and After she came back from the hospital, we was (were) told to use all 4 side rails with her because she's a fall risk. Further interview with CNA #3 revealed the resident doesn't try to climb over - she goes out the end (of the bed) instead. CNA #3 stated she was the staff who witnessed Fall #5 on 9/11/17, saying, Just last week, I found her sliding out the end of the bed when she could not exit the bed in a normal fashion because all 4 side rails were raised. Further interview with CNA #3 revealed each resident had a Care Plan posted in their closet and this information was used to know what type of assistance and devices were needed. She went to Resident #4's closet and showed there was a Care Plan posted on the left door of the resident's closet. Review of the documents which CNA #3 referred to revealed the Safety care plan included only one intervention - Mattress stops in place to prevent mattress from sliding down. CNA #3 reviewed the Safety Care Plan and confirmed it did not show the need for fall mats, low bed, and only 1 side rail to the lower left side of the bed. Interview with the DON about Resident #4 on 9/18/17 at 2:10 PM, the DON stated, She's fallen more times than you can count. When informed the Safety Care Plan provided by CNA #3 did not include multiple interventions which had been identified to prevent falls, the DON provided another document titled Safety Careplan and stated this was also posted in the resident's closet (on the right door of the closet.) Review of this Safety Careplan revealed the resident was supposed to have: Bed in lowest position at all times. Fall mats. Remind her to use call light. Raise Lower Bedrail on bed to help with safe sleep. Further interview with the DON at this same time revealed she was unaware staff were not consistently using a low bed and were not using fall mats when the resident was in bed. The DON stated historically the facility did not assess for the use of side rails. She stated, although the facility was in the process of adding side rail assessments to the admission packet, Resident #4 did not have a side rail assessment completed. The DON stated she had no evidence the facility had conducted a thorough assessment of the safety of this equipment relative to the resident's condition. Continued interview with the DON revealed after the fall in July 2017, the fall team decided the resident should only have 1 side rail (lower left) raised when she was in bed. She stated she was unaware staff were using all 4 side rails when the resident was in bed. The DON added she was unaware all 4 side rails were in use at the time of the 9/11/17 fall, and confirmed the investigation should have addressed this as a possible root cause and determined if the fall from the end of the bed occurred because all 4 side rails were raised and Resident #4 could not get out of bed in a routine manner. The DON was interviewed about other interventions listed on the investigations and care plans to prevent further accidents. She stated the repeated addition of the call light was not appropriate, based on the resident's cognition, which she stated had declined since admission. Interview with the Care Plan Coordinator on 9/19/17 at 9:50 AM revealed if the call light was already listed on the Care Plan, the Care Plan should have been revised with a different intervention - Not one that was already on there. Further interview with the Care Plan Coordinator on 9/19/17 at 4:35 PM revealed Anyone can update the Care Plan when the falls team meets. He could provide no explanation as to why Care Plan approaches were not updated per the Event Report documentation, and stated, It should have been done. Medical record review revealed Resident #7's with [DIAGNOSES REDACTED]. Review of the resident's most recent assessment, a Quarterly MDS dated [DATE], revealed the resident was moderately cognitively impaired, was totally dependent on staff for transfer, and required extensive assistance with bed mobility. The resident did not walk and required either supervision or limited assistance from staff with locomotion in her wheelchair. Medical record review revealed Resident #7 had a history of [REDACTED]. -11/10/16 skin tear to left lower extremity during transfer to wheelchair by staff -1/3/17 skin tear to back of right calf during transfer by staff -2/18/17 skin tear to right thigh -3/23/17 skin tear to left forearm -4/30/17 skin tear to right hand -6/22/17 skin tear to left upper extremity (x2) -7/19/17 skin tear to left lower extremity -7/19/17 skin tear to right lower extremity -8/6/17 skin tear to left wrist -8/21/17 skin tear to second knuckle of right hand Review of Resident #7's Comprehensive Care Plan, dated 9/7/17, revealed that since 11/30/15, the resident has impaired/potential for impaired skin integrity r/t impaired mobility, incontinence of bowel and bladder, age related skin changes, ASA (aspirin) in use. Venous insufficiency, chronic edema. Approaches to help the resident meet the goal of avoidable skin breakdown included 8/21/16 - Geri-sleeves to be in place. Review of the Safety Care Plan used by direct care staff and posted in the resident's closet also revealed the instructions: Geri-sleeves to be in place at all times d/t (due to) frequent STs (skin tears) - 8/21/16. Observation of Resident #7 on 9/18/17 at 8:48 AM, 3:00 PM, 5:06 PM, and 9/19/17 at 8:10 AM, 8:26 AM, and 3:15 PM revealed the resident was not wearing geri-sleeves. Bruising was noted on the resident's right hand, which extended from the index finger to the thumb, across the back of the hand. Interview on 9/19/17 at 8:26 AM with CNA #1 confirmed the resident was not wearing geri-sleeves at that time, and her arms were bare from below her elbow. CNA #1 stated, No, she doesn't use them. Interview with CNA #1 revealed she was unaware that the resident's Care Plan called for the use of geri-sleeves at all times. Interviews on 9/19/17 at 3:15 PM with LPN #1 and on 9/19/17 at 3:22 PM with UM #1 both confirmed that the facility had geri-sleeves available for use. Each confirmed that this assistance device to prevent injuries should have been used per Resident #7's care plan. Review of Resident #8's most recent Comprehensive Assessment (admission MDS of 11/17/16) revealed the resident was cognitively intact, as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The resident was bedfast and totally dependent on staff for all ADLs, including bed mobility and turning/repositioning. Review of a readmission History and Physical, dated 5/17/17 revealed the resident had a tracheostomy, and was ventilator and dialysis dependent. Demographic information revealed the resident also had [DIAGNOSES REDACTED]. Review of the most recent Fall Risk assessment form, completed 8/31/17, revealed the resident was at risk for falls based on intermittent confusion/poor recall/judgement/safety awareness, decreased muscular coordinator, incontinence, medication use, and neuromuscular//functional status. Resident #8's Comprehensive Care Plan, initiated 11/10/16, was reviewed on 9/18/17. The Care Plan stated the resident is at risk for falls r/t dependent on staff for ADLs, limited mobility, antihypertensive and psychotropic medications in use. To meet the goal of no avoidable falls, interventions since 12/20/16 included Floor mats at bedside. Observation on 9/18/17 at 5:34 PM revealed Resident #7 was in his bed, which was in a high position. A fall mat was observed on the left side of the bed. However, no fall mat was present on the right side of the bed. A fall mat was noted on the floor in the bathroom, underneath a reclining chair in storage. Additional observations on 9/19/17 at 8:30 AM and 10:04 AM also revealed, while the resident was in bed, there was no fall mat on the right side of the bed, which was in a high position. Interview on 9/19/17 at 10:04 AM with CNA #2 confirmed there was no fall mat on the right side of the resident's bed. She stated, I think it's family preference that there was no mat on one side of the bed. She stated if a Care Plan intervention was not being used, it should be reported to the nurse; however, she had not done so. CNA #2 was also asked about the height of Resident #7's bed, which increased the potential for injury, should a fall occur. She stated, Oh, he wants it that way. You can ask him. When interviewed at this time, Resident #7 responded No, he did not want his bed to be in a high position. When asked if he wanted his bed lower, he replied, Yes. CNA #2 then stated, Oh, well and did not lower the resident's bed before she left the room. Further review of Resident #8's Care Plan on 9/19/17 revealed the intervention of fall mats, which had been in effect since 2016, was no longer on the Care Plan. Review of the Care Plan History revealed the intervention of fall mats was deleted on 9/18/17 after surveyor intervention. The reason for the discontinuation of the mats on the Care Plan was listed as prior admit. Interview with the Care Plan Coordinator on 9/19/17 at 4:45 PM revealed he had deleted the intervention of fall mats after the survey team left the faciity on [DATE] because, I was just trying to make the Care Plans right and the fall mats had been in place on the Care Plan since the resident's last admission. He confirmed that each of the other interventions listed on the Care Plan were also in place since the last admission, and could provide no explanation as to why he had discontinued the one intervention on the Care Plan which the survey team identified was not being implemented by staff. Interview with a corporate representative who was present during this interview revealed the Care Plan approach of fall mats should not have been removed without an assessment of the resident's current needs and ongoing fall risk. Review of Resident #9's Admission Notes dated 8/7/17 revealed the resident was admitted to the facility with [DIAGNOSES REDACTED]. The admission note documented the resident's right side was flaccid, but he could move his left arm within the functional limitation. Demographic information revealed additional [DIAGNOSES REDACTED]. An Admission Fall Risk assessment completed 8/7/17 revealed the resident was at risk for falls, based on his incontinence, use of multiple medications, neuromuscular/functional status, and length of stay in the facility. Resident #9's admission MDS, dated [DATE] revealed the resident was moderately cognitively impaired, was bedfast, and was totally dependent on staff for all care, including transfers and bed mobility. Review of Resident #9's Comprehensive Care Plan revealed it was initiated on 8/23/17. The Care Plan noted the resident was at risk for falls r/t weakness S/P CVA (cerebrovascular accident - stroke). In response, 4 standard nursing interventions were listed as interventions - administer medications per orders, anticipate needs proactively, get assistance with ADLS to ensure safety as needed and observe for unsafe actions - intervene immediately. Review of Resident #9's Progress Notes revealed on 9/2/17, Nursing staff have had to assist resident back into proper position multiple times this shift. Resident has been found with legs out of bed. Progress Notes on both 9/8/17 and 9/9/17 documented the resident was in a low bed with call light in reach. Progress Notes on 9/15/17 documented the resident was noted with more activity, movement in legs, reaching, turning self from side to side .Bed currently in low position for patient safety. However, review of the Care Plan revealed it was not revised to reflect the fall risk related to the resident being found with portions of his body out of bed, his increased mobility and movement in legs, or the need for a low bed and call light that was identified by staff. Review of an Event Report revealed on 9/17/17 at 2:20 AM, a staff was walking hallway, noted resident OOB (out of bed) and yelled for assistance. Upon entering room, resident noted on R (right) side on floor between A and B bed. The report noted injuries from the fall, as the resident was decannulated (tracheostomy tube came out), complained of pain after the fall and had to have a .new trach placed . Per the Event Report, the facility was unable to determine the root cause of the fall, noting the resident was non-verbal/clean and dry. In response to this fall, the Care Plan was updated for a .Low bed when unattended . Observation on 9/18/17 at 5:24 PM revealed the resident was asleep in bed, with his tracheostomy in place, and nutrition infusing via gastrostomy tube. No staff were present in the room. The resident's bed was not in a low position. Interview on 9/18/17 at 5:29 PM with LPN #3 revealed, although he was aware Resident #9 had fallen from bed the previous day, he did not know the resident had been injured or required trach placement in response to the fall. He stated, He's been trying to get out of bed again today, especially this morning. LPN #3 stated, although the resident was totally dependent on staff for turning and repositioning, the resident had limited use of one arm and one foot, which he was using to wriggle himself across the bed. LPN #3 stated We put some pillows in to help keep the resident's position in the center of the bed to prevent further falls. Further observations of Resident #9 in bed on 9/18/17 at 5:33 PM, and on 9/19/17 at 8:33 AM and 2:03 PM revealed there were no pillows being used to

Based on facility policy review, medical record review, facility investigation review, interview and observation, the facility failed to update care plans for residents to reflect interventions to protect the residents and prevent future falls for 2 (#1, 14) of 8 residents reviewed for falls. This failure resulted in actual HARM to resident #1 who sustained a complicated femur fracture. The findings included: Review of the facility policy entitled Falls with the effective date of 11/1/10, revealed .It is the policy of this facility to provide a safe and hazard free environment as is possible. Further review revealed the Procedure.Identify residents at high risk for falls.Implement a plan of care based on identifying risk factors.In the event of a fall.Adjust plan of care as appropriate. Review of the facility Falls Clinical Practice Guidelines revealed .based on the analysis, preventative measures will be implemented as appropriate for residents identified at risk for falls.Based on findings, appropriate interventions will be developed in the comprehensive care plan. Implement an intervention to prevent further falls or injury, write the order, and place the device at that time. Ensure the new intervention is written on the Safety Care Plan. Review of the facility policy Careplan-Updating with an effective date of 8/2011 revealed.Objective.To ensure the careplans are updated timely.Purpose.To ensure resident careplans are kept current.Conditions indicated for careplan updates.Falls. Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident scored 7/15 on the Brief Interview for Mental Status (BIMS) indicating the resident was alert but moderately cognitively impaired. Continued review of the MDS revealed the resident required extensive assistance of one person for transfers, dressing, eating, and grooming; was dependent for bathing; and was occasionally incontinent of bowel and bladder. Medical record review of the Point of Care ADL (activities of daily living) Category Report, for the week immediately preceding the MDS, revealed from 10/13/14 - 10/22/14, the resident required extensive assistance of two staff for transfers. Review of the comprehensive care plan dated 11/11/10, revealed a problem of .Resident at risk for falls R/T (related to) limited mobility, cognitive deficits, dx (diagnosis) of [MEDICAL CONDITION], left humerus fracture, hx (history) of falls, [MEDICAL CONDITION] disorder, hx [MEDICAL CONDITION], and [MEDICAL CONDITION] Continued review of the care plan revealed an entry dated 5/30/13, with an approach of .Two person assist with transfers. Further review of the care plan revealed an entry dated 6/21/13, with an approach of .Gait belt with transfers. Continued review of the care plan revealed an entry dated 10/06/13, with an approach of .Non-skid footwear. Further review of the care plan revealed an entry dated 11/28/14, with an approach of .If resident's legs become weak during transfers, slowly lower resident to floor. Continued review of the care plan revealed an entry dated 12/20/14, with an approach of .Transfer to ER (emergency room ) for evaluation and treatment of [REDACTED]. Review of the Risk Management Incident Report dated 11/28/14, revealed .Pt (patient) was lowered to the floor because her knees became weak during transfer from bed to w/c (wheelchair). Continued review of the Incident Report revealed the resident did not sustain any injuries. Further review of the Incident Report revealed the Safety Intervention Initiated section was marked none. Review of the CNT (Certified Nursing Technician used interchangeably with Certified Nurse Aide, CNA) Observation dated 11/28/14, at 11:10 AM, revealed, .As I transferred (named Resident #1) from bed to chair her legs became weak. For safety reasons I lowered her to the floor and got (named nursing supervisor) for help. Review of the analysis and conclusion completed by the Unit Manager and dated 11/30/14, revealed .Resident is a frail elderly woman with multiple comorbidities (other illnesses) and primary [DIAGNOSES REDACTED]. Nursing staff has explained to both resident and son that resident is requiring more assistance and it is evident resident should not be gotten up and pivot to use BSC - that use of lift would be safer. Both resident and son did not want this done and request to continue with current plan of care. A brief synopsis of events as follows: resident had put call light on; CNT answered and got resident up to use BSC; resident became weak and legs gave out; CNT lowered resident to floor. Nurse notified of event. All paperwork and notification completed. Further review of the Incident Report revealed there were no new interventions put in place. Medical record review of the comprehensive care plan update of 11/28/14, revealed the only intervention documented was .If resident's legs become weak during transfers, slowly lower resident to floor. Review of the Risk Management Incident Report, dated 12/20/14, revealed .Resident lowered to floor. Tech was taking resident off bedside commode when resident's legs got weak. Tech then lowered resident to floor. Tech straightened out left leg for better positioning for this nurse and two tech to lift resident to bed when knee popped. Continued review of the Incident Report revealed the section on Safety Intervention Initiated revealed the section was blank. Further review of the Incident Report revealed there were no new interventions put into place. Interview with CNA #2 on 4/21/15, at 9:22 PM, in the conference room, revealed she was never assigned to care for Resident #1 since she was on another hall. Continued interview with CNA #2 revealed on 12/20/14, .the tech called for me that she had lowered Resident #1 to the floor and could I come help. She was going to put her on the bedside commode and had to lower her to the floor. The resident was on the floor beside the bed, just sitting on the floor. Her feet were as straight as could be, knees together, feet out. I did not see her leg bent. When I got there the nurse was already there. One CNA was on each side of the resident; the nurse got the feet; and we put her into bed. I did not hear any of her joints pop. I can't recall if she moaned or not. Further interview with CNA #2 revealed the resident would always tell you what she wanted but you couldn't touch her right shoulder. Further interview with CNA #2 revealed Resident #1 would pivot and you held her around the waist without using a gait belt. Telephone interview with the complainant on 4/23/15 at 3:45 PM, revealed the former manager of the third floor called him several times in May, 2014, about the resident becoming weaker to which he responded .if the staff can't lift her up safely then use two people and the lift to transfer her. Continued interview with the complainant revealed he never attended a care planning meeting where transfers were discussed. Continued interview revealed transfers depended on the CNA's ability and strength because the resident could not pivot but required the CNA to pull her buttocks around. Interview with the Administrator and DON on 4/30/15, at 11:30 AM, in the conference room, discussed the findings regarding Resident #1. Further interview revealed a fall investigation was considered complete when the Falls Assessment was completed; interventions were in place; and My Patient fell was finished. Further interview revealed the My Patient fell includes resident assessment; found root cause; apply intervention; completed fall observation; updated care plan; updated CNT care plan; notified MD; notified family; fill out Risk Management form; fill out CNT Observation form; place Alert Charting sticker on chart; notify supervisor and/or Unit Manager. Continued interview revealed .we may have to assume the cause and put interventions in place. If another fall occurs, then come up with another intervention. The failure of the facility to update care plans after resident falls resulted in actual HARM to Resident #1. Medical record review for Resident #2 revealed an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS dated [DATE], revealed the resident was moderately impaired cognitively; required extensive assistance and 2 people for transfers; required extensive assistance of one person for dressing and grooming; was dependent on one person for bathing; and was frequently incontinent of bowel and bladder. Fall investigations for Resident #14 revealed the following: 1. 7/29/14 @ (at) 7:30 PM - .found patient sitting on floor in room in front of wheelchair next to bed, found on buttocks removing shoes. Safety Intervention Initiated - blank Neuro checks every 15 minutes x 4 (times), hourly x 2, every 2 hours x 2, every 4 hours x 2, every shift x 3 Interventions: low bed, fall mats in place, pressure pad alarm (bed) tested and found to be in working order Care plan entry dated 7/29/14: enough safety devices are properly working. 2. 8/6/14 @ 8:50 PM - .witnessed fall; resident's alarm went off; resident found half-way out of geri-chair. When I attempted to put her back in chair resident resisted and buttocks slid onto floor mat. Safety Interventions Initiated: Fall precautions remain (chair/bed alarm, fall mats) Care plan: no new interventions. 3. 8/19/14 @ 5:00 PM - .observed resident in floor by rock n go (rocking wheelchair) chair in room; resident agitated and anxious; going in and out of other resident's rooms searching for male CNT; became agitated and aggressive when staff attempted to redirect; grabbed handrail and stood up, refusing to leave doorway; sat self on floor. Safety Interventions Initiated: blank Care plan entry dated 8/19/14: technician that resident calls Chester (what resident calls CNT) will be moved to another unit while medication management takes place. 4. 10/16/14 @11:20 AM - .patient was playing with her shoes when she slid out of her chair onto the gym mat next to her bed. Safety Intervention Initiated: chair alarm Care plan was not updated. 5. 11/24/14 @ 6:00 PM - .resident found in fetal position in hallway by staff. She had stuffed animal tucked under head and pillow tucked between legs. Safety Interventions Initiated: blank Care plan entry dated 11/24/14: offer resident assistance to bed when tired. 6. 12/3/14 @ 12 noon - .found on mat with legs in front of her on bedside mat. Safety Interventions Initiated: yes Care plan entry dated 12/3/14: continue with mats at bedside. 7. 12/7/14 @ 6:00 PM - .resident was found in front of rock n go in floor in hallway. Safety Intervention Initiated: blank Care plan entry dated 12/7/14: chair alarm. 8. 12/14/14 @ 1:00 PM - .resident observed in room on blue landing mat by bed after poss. (possibly)sliding out of w/c onto mat. Resident sitting on her bottom while laughing and shouting help. Safety Intervention Initiated: blank Care plan entry dated 12/14/14: Place resident near nursing station to be more observable. 9. 12/20/14 @ 4:00 PM - .resident observed on hands and knees on floor - in front of wheelchair in hallway. Safety Interventions Initiated: blank Care plan entry dated 12/20/14: Place resident to bed for frequent rest periods as needed. 10. 12/28/14 @ 11:30 AM - .resident found sitting on floor on buttocks in dining room in front of rock n go chair. Safety Interventions Initiated: blank Care plan entry dated 12/28/14: Toilet resident and place at nursing station after resident has completed eating lunch. There was no documentation the resident was wet or soiled. 11. 1/3/15 @ 11:30 AM - .resident was observed sitting on blue mat by floor at bedside. Resident laughed at situation stating Let me sit here. Daughter requested nurse contact supervisor about allowing resident to sit on floor mat safely with call light since resident will do things she is not allowed to do and if she's allowed to sit on floor, maybe she won't slip onto it. Safety Interventions Initiated: .no intervention required. Informed her and family that pt. cannot sit on mat. Care plan entry dated 1/3/15: Informed resident and family that resident cannot sit on the mat. 12. 1/12/15 @ 3:00 PM - .resident fell forward out of rock n go while CNT was pushing resident to room. Safety Intervention Initiated: Assist res (resident) to bed after lunch when leaning forward as tolerated by resident; keep rock n go reclined when not eating as tolerated. Care plan entry dated 1/12/15: Assist resident to bed after lunch when leaning forward as tolerated by resident. Keep rock n go reclined when not eating. 13. 1/29/15 @ 9:00 AM - .resident was in front of rock n go lying on rt. (right) side in hallway. Safety Interventions Initiated: continue with busy box while up in chair. Care plan entry dated 1/29/15: Continue to encourage and provide resident with busy boxes while up in rock n go chair. 14. 2/1/15 @ 10:00 AM - .this nurse was taking resident to dining room. Resident being resistive, scooted herself to edge of chair and hopped out onto floor. Safety Interventions Initiated: continue poc (plan of care) Care plan entry dated 2/1/15: Continue with current POC. 15. 2/2/15 @ 4:05 PM - .I was told by the Unit Manager this resident had fallen. I went to assist the pt back in her chair. The resident was found on the floor in the hallway. Safety Interventions Initiated: bed in low position. Offer assist to bed when tired. Care plan entry dated 2/2/15: Bed in low position and mats at bedside. Bed was already in low position and mats were on floor at bedside, but this incident occurred in the hallway. 16. 2/7/15 @ 4:00 PM - .resident observed in room [ROOM NUMBER] (res room [ROOM NUMBER]) lying in floor on left side. Safety Interventions Initiated: continue poc Care plan entry dated 2/7/15: Continue current POC. 17. 3/7/15 @ 3:30 PM - .observed resident laying on her back on the bedside mat. Safety Interventions Initiated: blank Care plan dated 3/7/15: Continued with mats at bedside. 18. 03/11/15 @ 10:00 AM - .res found to be sitting on bedside mat between A and B bed holding onto both A and B bed siderails. It appears resident had attempted to ambulate unassisted et (and) lowered self to floor. Safety Interventions Initiated: res to be checked/changed/toileted et gotten up after breakfast Care plan entry dated 3/11/15: frequent toileting and resident to be out of bed after breakfast. There was an entry for 3/15/15 to continue with mats at bedside. There is no documentation the resident was wet and/or soiled. 19. 4/18/15 @ 2:45 PM - .was notified by an emergency call light when a resident sitter heard her screaming. saw her sitting in floor on butt leaned against wall. Apparently fell out of rock n go. Resident stated she felt like getting up. Safety Interventions Initiated: chair alarm Care plan: no update. 20. 4/22/15 @ 2:45 PM - .resident was sitting on bottom on north hall in front of rock n go. Activities Director saw resident leaned over in her chair and saw her fall forward but did not hit head. New geri chair ordered. Safety Intervention Initiated: dycem to chair. Geri chair was determined not to be effective. Dycem (non-slip material) was ordered to be placed in chair to prevent sliding. Care plan entry dated 4/22/15: Dycem to be placed in the resident's chair. Bed in lowest position with floor/bed mats while the resident is in the bed. The resident's Safety Care Plan, located in resident's closet for CNA reference, dated 4/23/15, revealed .Resident to be out of bed in high back w/c - ensure gel cushion is in seat and chair reclined 25 - 40 degrees when resident is leaning forward. The findings were discussed with the DON and Administrator on 4/30/15, at 11:30 AM in the conference room.

Based on facility policy review, medical record review, facility investigation review, and interview the facility failed to follow the care plan and interventions for residents with falls for 4 (#1, 2, 15, 18) of 8 residents reviewed for falls. The failure of the facility caused actual HARM to Resident #1 who sustained a complicated [MEDICAL CONDITION]. The findings included: Review of the facility policy entitled Falls with the effective date of 11/1/10, revealed .It is the policy of this facility to provide a safe and hazard free environment as is possible. Further review revealed the Procedure.Identify residents at high risk for falls.Implement a plan of care based on identifying risk factors.In the event of a fall.and Adjust plan of care as appropriate. Review of the facility Falls Clinical Practice Guidelines revealed .based on the analysis, preventative measures will be implemented as appropriate for residents identified at risk for falls.Based on findings, appropriate interventions will be developed in the comprehensive care plan. Implement an intervention to prevent further falls or injury, write the order, and place the device at that time. Ensure the new intervention is written on the Safety Care Plan. Review of the facility policy Careplan-Updating with an effective date of 8/2011 revealed .Objective.To ensure the careplans are updated timely.Purpose.To ensure resident careplans are kept current.Conditions indicated for careplan updates.Falls. Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident scored 7/15 on the Brief Interview for Mental Status (BIMS) indicating the resident was alert with confusion. Continued review of the MDS revealed the resident required extensive assistance of one person for transfers, dressing, eating, and grooming; was dependent for bathing; and was occasionally incontinent of bowel and bladder. Medical record review of the Point of Care ADL (activities of daily living) Category Report, for the week immediately preceding the MDS, revealed from 10/22/14 - 10/29/14, the resident required extensive assistance of two staff for transfers on four occasions. Review of the comprehensive care plan dated 11/11/10, revealed a problem of .Resident at risk for falls R/T (related to) limited mobility, cognitive deficits, dx (diagnosis) of [MEDICAL CONDITION], left humerus fracture, hx (history) of falls, [MEDICAL CONDITION] disorder, hx [MEDICAL CONDITION], and [MEDICAL CONDITION] Continued review of the care plan revealed an entry dated 5/30/13, with an approach of .Two person assist with transfers. Further review of the care plan revealed an entry dated 6/21/13, with an approach of .Gait belt with transfers. Continued review of the care plan revealed an entry dated 10/06/13, with an approach of .Non-skid footwear. Further review of the care plan revealed an entry dated 11/28/14, with an approach of .If resident's legs become weak during transfers, slowly lower resident to floor. Continued review of the care plan revealed an entry dated 12/20/14, with an approach of .Transfer to ER (emergency room ) for evaluation and treatment of [REDACTED]. Review of the Risk Management Incident Report dated 11/28/14, revealed .Pt (patient) was lowered to the floor because her knees became weak during transfer from bed to w/c (wheelchair). Continued review of the Incident Report revealed the Safety Intervention Initiated section was marked none. Review of the Certified Nursing Technician (CNT used interchangeably with Certified Nurse Aide - CNA)Observation dated 11/28/14, at 11:10 AM, revealed, As I transferred (named Resident #1) from bed to chair her legs became weak. For safety reasons I lowered her to the floor and got (named nursing supervisor) for help. Review of the analysis and conclusion completed by the Unit Manager and dated 11/30/14, revealed .Resident is a frail elderly woman with multiple comorbidities (other illnesses) and primary [DIAGNOSES REDACTED]. Nursing staff has explained to both resident and son that resident is requiring more assistance and it is evident resident should not be gotten up and pivot to use BSC - that use of lift would be safer. Both resident and son did not want this done and request to continue with current plan of care. A brief synopsis of events as follows: resident had put call light on; CNT answered and got resident up to use BSC; resident became weak and legs gave out; CNT lowered resident to floor. Nurse notified of event. All paperwork and notification completed. Further review of the Incident Report revealed there were no new interventions put in place. Medical record review of the comprehensive care plan update of 11/28/14, revealed the only intervention documented was .If resident's legs become weak during transfers, slowly lower resident to floor. Medical record review revealed no new interventions put into place after the fall; no root cause analysis of the incident completed; and failure to follow the care plan with an approach of two person assist with transfers. Review of the Risk Management Incident Report, dated 12/21/14, revealed .Resident lowered to floor. Tech was taking resident off bedside commode when resident's legs got weak. Tech then lowered resident to floor. Tech straightened out left leg for better positioning for this nurse and two tech to lift resident to bed when knee popped. Continued review of the Incident Report revealed the section on Safety Intervention Initiated revealed the section was blank. Further review of the Incident Report revealed there were no new interventions put into place. Interview with the Director of Nursing (DON) on 4/20/15, at 8:40 AM in the DON's office, revealed Resident #1 was a 1 person assist with transfers and the care plan was not updated to reflect 1 person. Continued interview with the DON revealed the son of Resident #1 wanted her to transfer with 1 person to have her do as much as she could for herself. Further interview with the DON revealed she had many meetings with the son over transfers. Interview with the DON on 4/20/15, at 3:25 PM in the conference room revealed the son insisted his mother be transferred with one person only and .we were following what (named son) wanted. Further interview with the DON revealed she had documented several communications with the son regarding transferring Resident #1 but she was unable to produce them throughout the survey. Telephone interview with CNA #1 on 4/21/15, at 9:10 AM, revealed the incident happened between 2 and 3 in the morning. Continued interview revealed CNA #1 had transferred Resident #1 to the bedside commode and was transferring her back to bed when the resident's legs gave out so she lowered the resident to the floor. Further interview revealed CNA #1 went to find the nurse to assist her. Continued interview revealed Resident #1 complained of left leg pain and wanted an x-ray done. Further interview revealed CNA #1 transferred Resident #1 using a stand-pivot move. Continued interview revealed CNA #1 felt .there should have been 2 people to transfer Resident #1. Telephone interview with the complainant on 4/21/15, at 9:30 AM revealed the fall on 12/20/14 broke the femur and dislocated the hip replacement from 2010 of Resident #1, and he told the facility they needed to use two people to transfer her, or use the lift. Continued interview revealed . I told them (Resident #1) was more dependent and needed to be transferred using 2 people or the lift. Telephone interview with Licensed Practical Nurse (LPN) #1 on 4/21/15, at 2:40 PM, revealed she transferred the resident with 2 people assisting because toward the end of her stay here (discharged [DATE]), the resident lost mobility and became more dependent. Interview with CNA #2 on 4/21/15, in the conference room, at 9:22 PM, revealed she was never assigned to care for Resident #1 since she was on another hall. Continued interview with CNA #2 revealed on 12/20/14, .the tech called for me that she had lowered Resident #1 to the floor and could I come help. She was going to put her on the bedside commode and had to lower her to the floor. The resident was on the floor beside the bed, just sitting on the floor. Her feet were as straight as could be, knees together, feet out. I did not see her leg bent. When I got there the nurse was already there. One CNA was on each side of the resident; the nurse got the feet; and we put her into bed. I did not hear any of her joints pop. I can't recall if she moaned or not. Further interview with CNA #2 revealed the resident would always tell you what she wanted but you couldn't touch her right shoulder. Further interview with CNA #2 revealed Resident #1 would pivot and you held her around the waist without using a gait belt. Telephone interview with the complainant on 4/23/15 at 3:45 PM, revealed the former manager of the third floor called him several times during the month of May about the resident becoming weaker to which he responded .if the staff can't lift her up safely then use two people and the lift to transfer her. Continued interview with the complainant revealed he never attended a care planning meeting where transfers were discussed. Further interview revealed the resident could not pivot but required the CNA to pull her buttocks around. The findings were discussed with the Administrator and DON during an interview on 4/30/15, at 11:20 AM in the conference room. The failure of the facility to follow the care plan to transfer the resident with two person assistance resulted in actual HARM to Resident #1. Medical record review for Resident #2 revealed an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Medical record review of 14 day MDS dated [DATE] revealed Resident #2 had a BIMS score of 14, indicating he was cognitively intact. Continued review revealed Resident #2 required extensive assistance of 2 persons for bed mobility and transfers. Medical record review of a Falls-Fall Risk (Acuity) with observation date of 11/17/14 and completion date of 11/18/14 revealed .Total Fall Risk Score: 15.score of 10 or higher represents a high risk for falls. Medical record review of a care plan with admitted [DATE], revealed .Problem Start Date: 07/11/2014.Category: Falls.Resident at risk for falls r/t (related to) impaired mobility, unable to sit/stand independently, hands on assist w (with)/ ambulation. Continued review revealed an approach dated 7/11/14 .low bed with bed side mats. Review of a facility a Risk Management Incident Report dated 11/30/14 at 9:30 PM revealed .Describe Incident.Resident observed lying on mat @ (at) bedside in supine position c (with) legs extended out. Resident bed noted to be in a high position. Review of a Safety Events - Fall assessment with event date and time of 11/30/14 at 9:30 PM revealed Resident #2 had an unwitnessed fall in his room. Continued review revealed .resident was observed on the floor on right side of bed.sitter did not put bed in lowest position prior to leaving. Telephone interview with LPN #4 on 4/22/15 at 9:17 AM, when asked about Resident #2's fall on 11/30/14 , after reviewing the incident, confirmed the resident fell out of bed and the bed was not in the lowest position per the care plan. Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician orders in the medical record dated 12/26/14 revealed .Falls precautions. Review of the Fall Risk Acuity MDS dated [DATE] revealed no history of falls and a score of 17 indicting Resident #15 was at high risk for falls. Review of the care plan problem with the start date of 12/27/14 revealed Resident #15 was .at risk for falls. Further review revealed the Goal .Resident will remain free of avoidable falls or related injury thru the next review 3/27/15. Further review revealed the approaches with the start date of 12/27/14 for the following: .make staff aware of resident's fall risk. Observe for unsafe actions and intervene as indicated. Observe/record unsafe actions and staff intervention. Provide reminders/verbal cues to resident regarding unsafe ambulation. Orient/educate resident to call light system and instruct/educate to call for assistance. Further review revealed an approach with the start date of 1/1/15 of .Q (every) 1 hour checks from 3am - 7am. Review of the nurses Progress Notes and the Risk Management Incident Report, both created by LPN #13, dated 1/1/15 with the .Time of the Incident 5:00 AM. revealed .Describe Incident: Resident was observed on the floor on his right side beside his bed.Safety Interventions Initiated: Floor mats. Review of the Safety Events-Falls, created by LPN #13, with the .Event date 1/1/15 6:33 AM. revealed the .Intervention-Immediate measures taken. Q1 hour checks from 3am-7am. Review of the nurses Progress Notes, created by LPN #13, and the CNT (Certified Nurse Technician used interchangeably with Certified Nurse Aide (CNA)) Observation form, created by CNA #7, dated 1/6/15 with the time of the incident at 3:35 AM revealed Resident #15 .was observed on the floor, lying on the right side. Review of the Safety Events-Falls, created by LPN #13, with the .Event date 1/6/15 4:24 AM. and the Risk Management Incident Report, created by LPN #13, dated 1/6/15 with the .Time of the Incident 3:40 AM. revealed the .Intervention- Immediate measures taken. low bed and floor mats. Review of the care plan problem with the start date of 12/27/14 revealed Resident #15 was .at risk for falls. with an approach start date of 1/6/15 .Floor mats at bedside and bed in low position when resident in bed. Review of the 1/2015 Medication Administration Record (MAR) revealed the floor mats at bedside and bed in low position when resident in bed with the .start date of 1/6/15 ongoing. Further review revealed nursing failed to initial the MAR from 1/6/15 through 1/10/15 indicating the fall interventions were in -place per the care plan intervention. Review of the nurses Progress Notes from 1/6/15 through 1/10/15, failed to document fall interventions in use. Interview with LPN #13 on 4/28/15 beginning at 6:30 AM, at the second floor nurses station, after reviewing the Fall Assessment, Safety Events, CNT Observation form, and nursing notes, when asked what the LPN could recall of the fall on 1/6/15 stated .same thing, rolled on side and out of bed.he did it all the time.I'm pretty sure mat was on floor.nothing else we could do.not sure why I didn't write the mat was in place in the description.not sure now. Telephone interview with CNA #7 on 4/29/15 at 8:25 AM, after reviewing the Fall Assessment, Safety Events, CNT Observation form, and nursing notes, when asked what the CNA could recall of the fall on 1/6/15 stated, the resident .fell between the bed and window if not mistaken, he was on the floor, not recall if a mat was there.I think we got mat for the other side where he fell , he had mat on the door side already. Review of the nurses Progress Notes dated 1/9/15 revealed .resident noted to be lying on floor between toilet and WC (wheel chair).Intervention added to care plan to ensure resident is not left unattended in bathroom. Review of the Fall Assessment with the .Observation date 1/9/15 2:29 PM. revealed .fall in resident's bathroom.describe measures taken to prevent future falls intervention added to care plan to ensure resident is not left unattended in bathroom. Review of the care plan problem with the start date of 12/27/14 revealed Resident #15 was .at risk for falls. with an approach start date of 1/9/15 .Staff to ensure resident is not left unattended in the bath room. Review of the nurses Progress Notes dated 1/10/15 revealed .resident observed on the floor next to bed at approximately (2:00 AM). floor mat in place.call button in reach. Review of the Safety Events-Falls, and the Risk Management Incident Report, created by LPN #12, revealed the .Event date 1/10/15 2:00 AM with the .Interventions-Immediate measures taken.low bed and floor mats. and .Safety Intervention Initiated: fall mat next to bed. Review of the CNT Observation form dated 1/10/15 with the time of incident at 2:00 AM, revealed .heard resident yelling for help, walked into room, patient was lying in the floor on right side of bed. Review of the care plan problem with the start date of 12/27/14 revealed Resident #15 was .at risk for falls. with an approach start date of 1/10/15 for .Continue floor mats at bedside and bed in low position when resident in bed. Review of the 1/2015 MAR revealed .continue floor mats at bedside and bed in low position when resident in bed with the.start date of 1/10/15 ongoing. Further review revealed nursing failed to initial the MAR from 1/10/15 through 1/15/15 indicating the interventions were in place per the care plan intervention. Telephone interview with LPN #12 on 4/28/15 at 10:55 AM, after reviewing the Fall Assessment, Safety Events, CNT Observation form, and nursing notes, when asked what the LPN could recall of the 1/10/15 fall stated .he was on the floor.mat not on side he fell .between the bed and the window.he always went toward the right side.I had to hunt one (mat) down.found one upstairs and put mat on right side of his bed. Review of the nurses Progress Notes dated 3/26/15 revealed .resident was in the bathroom, resident stated he slid off of the toilet. Review of the Safety Events-Falls, with the .Event date 3/26/15 11:30 PM. revealed the . Interventions-Immediate measures taken.Continue current Plan of Care. The facility failed to follow the care plan to ensure staff was present while the resident was in the bath room. The findings of the falls were discussed with the DON and Administrator in interview on 4/30/15 beginning at 11:20 AM. Medical record review for Resident #18 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 14 day MDS dated [DATE] documented a BIMS score of 10, indicating Resident #18 was moderately cognitively impaired. Continued review documented Resident #18 required extensive assistance of 2 for transfers, bed mobility, and toilet use; and extensive assistance of 1 for dressing. Medical record review of a care plan with a start date of 2/13/15 revealed an approach, with a start date of 3/8/15 .offer resident toileting assistance frequently to ensure needs are met. Continued review revealed an approach with a start date of 3/9/15 .frequent monitoring of resident r/t (related to) recent falls. Review of the Risk Management Incident Report dated 3/11/15 at 5:00 PM revealed .patient fell on to knees onto matt (mat) beside bed with upper body still in bed. Continued review revealed the fall was witnessed. Continued review revealed .list the Safety Care Plan interventions.continue current interventions with fall precautions in place. Interview with Registered Nurse (RN) #2 on 4/29/15 at 1:26 PM at the 2nd floor nursing station, after reviewing fall on 3/11/15, stated .he had multiple falls.almost like daily when I was working.hard to keep a watch on him. Continued interview with RN #2 confirmed the care plan was not followed for frequent monitoring. The findings were discussed with the Administrator and Director of Nursing on 4/30/15 at 11:20 AM in the conference room.

Based on facility policy review, medical record review, facility investigation review, interview, and observation, the facility failed to investigate falls completely; failed to put interventions in place to prevent further falls and failed to supervise residents appropriately to prevent falls for 6 (#1, 2, 14, 15, 17, 18) of 8 residents reviewed for falls. This failure resulted in actual HARM to Resident #1 who sustained a complicated fracture of the femur. The findings included: Review of the facility policy entitled Falls with the effective date of 11/1/10, revealed .It is the policy of this facility to provide a safe and hazard free environment as is possible. Further review revealed the Procedure.Identify residents at high risk for falls.Implement a plan of care based on identifying risk factors.In the event of a fall, conduct an assessment to aid in identifying contributing Factors, complete Risk Management Form,.complete Pain Assessment.Post Fall Assessment. Review of the facility Falls Clinical Practice Guidelines revealed .based on the analysis, preventative measures will be implemented as appropriate for residents identified at risk for falls.Any episode of a fall must be recorded on a Post Fall Assessment,.Pain Assessment,.& (and) Risk Management Form. The documentation must record the episode in factual observed detail and not supposition of what occurred. The Post Event Nursing Assessment completed by the nurse responsible for the residents care during that time period. The CNT (Certified Nurse Technician interchangeable with Certified Nurse Aide (CNA)) who found the resident should record their findings on the CNT observation sheet.Each fall must be investigated/evaluated to determine the cause of the episode and include expansion of the care plan, as appropriate, to reduce risk of additional falls. A resident experiencing a head injury and or suspected head injury should receive a neurological review. Neurochecks (neurological assessment) should be repeated as ordered by the physician. If frequency is not specified by the physician, then complete in accordance with current professional standards.A resident experiencing a fall will be reviewed utilizing the Post Fall Assessment for the purpose of identifying contributing factors. Medical record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident scored 7/15 on the Brief Interview for Mental Status (BIMS) indicating the resident was alert but moderately cognitively impaired. Continued review of the MDS revealed the resident required extensive assistance of one person for transfers, dressing, eating, and grooming; was dependent for bathing; and was occasionally incontinent of bowel and bladder. Medical record review of the Point of Care ADL (activities of daily living) Category Report, for the week immediately preceding the MDS, revealed from 10/22/14 - 10/29/14, the resident required extensive assistance of two staff for transfers on 4 occasions. Review of the comprehensive care plan dated 11/11/10, revealed a problem of .Resident at risk for falls R/T (related to) limited mobility, cognitive deficits, dx (diagnosis) of Parkinson's, left humerus fracture, hx (history) of falls, seizure disorder, hx osteoporosis, and osteoarthritis. Continued review of the care plan revealed an entry dated 5/30/13, with an approach of .Two person assist with transfers. Further review of the care plan revealed an entry dated 6/21/13, with an approach of .Gait belt with transfers. Continued review of the care plan revealed an entry dated 10/6/13, with an approach of .Non-skid footwear. Further review of the care plan revealed an entry dated 11/28/14, with an approach of .If resident's legs become weak during transfers, slowly lower resident to floor. Continued review of the care plan revealed an entry dated 12/20/14, with an approach of .Transfer to ER (emergency room ) for evaluation and treatment of [REDACTED]. Review of the Risk Management Incident Report dated 11/28/14, revealed .Pt (patient) was lowered to the floor because her knees became weak during transfer from bed to w/c (wheelchair). Continued review of the Incident Report revealed the Safety Intervention Initiated section was marked none. Review of the CNT Observation dated 11/28/14, at 11:10 AM, revealed, .As I transferred (named Resident #1) from bed to chair her legs became weak. For safety reasons I lowered her to the floor and got (named nursing supervisor) for help. Review of the analysis and conclusion completed by the Unit Manager and dated 11/30/14, revealed .Resident is a frail elderly woman with multiple comorbidities (other illnesses) and primary [DIAGNOSES REDACTED]. Nursing staff has explained to both resident and son that resident is requiring more assistance and it is evident resident should not be gotten up and pivot to use BSC - that use of lift would be safer. Both resident and son did not want this done and request to continue with current plan of care. A brief synopsis of events as follows: resident had put call light on; CNT answered and got resident up to use BSC; resident became weak and legs gave out; CNT lowered resident to floor. Nurse notified of event. All paperwork and notification completed. Further review of the Incident Report revealed there were no new interventions put in place and a complete root cause analysis was not completed. Medical record review of the comprehensive care plan update of 11/28/14, revealed the only intervention documented was .If resident's legs become weak during transfers, slowly lower resident to floor. Medical record review revealed no new interventions put into place after the fall; no root cause analysis of the incident; and no extra precautions were implemented with a resident who has a [DIAGNOSES REDACTED]. Review of the Risk Management Incident Report, dated 12/20/14, revealed .Resident lowered to floor. Tech was taking resident off BSC when resident's legs got weak. Tech then lowered resident to floor. Tech straightened out left leg for better positioning for this nurse and two tech to lift resident to bed when knee popped. Continued review of the Incident Report Safety Intervention Initiated revealed the section was blank. Further review of the Incident Report revealed there were no new interventions put into place and a root cause analysis was not completed. Review of the Medication Administration Record (MAR) for the month of December 2014, revealed the resident received the following medications each evening: Neurontin (muscle relaxant) 400 milligrams (mg) at 8:00 PM; Phenobarbital (anti-seizures) 64.8 mg and Percocet (pain reliever) 5/325 mg at 9:00 PM; and the Fentanyl (pain management) patch 12 micrograms hourly and changed every 72 hours, was replaced at 9:00 PM. Review of an undated statement written by CNA #1 revealed .There was an incident that took place where (named Resident #1) ended up being hurt. It was around 3 AM and I helped her onto the commode. She transferred fine at that time. When it was time for her to transfer back to the bed her legs became weak. I told her lets sit back on the bed side commode. When she went to step back I felt her giving out so I lowered her to the floor and went and asked (named LPN #2, Licensed Practical Nurse) for assistance getting her up. We attempted to stand her up but again she was weak so we lowered her back down. At that time we heard bones crack but she showed no signs of pain so assuming it was just bones cracking I went and asked the other tech (named CNA #2) to assist us. We got her back in bed and she still showed no sign of pain nor did she have any bruising on her bottom or her legs at that time. Review of a statement written by LPN #2 dated 12/22/14, revealed .Saturday morning 12/20/14 around 3:30 AM the tech (named CNA #1) came and got me and said she had tried to get (named Resident #1) off the bedside commode to place her back in bed but when the resident's legs got weak she then had to lower her to the floor. When I arrived in the room the resident was seated in a sitting position in front of the bedside commode with her legs in front of her and her left knee slightly bent. We was about to place resident back into bed when tech went to straighten out left leg to a better position for lifting and her knee popped. Resident said I heard it pop, it's broke. I then assessed leg looking for any swelling or bruising. Review of a statement written by CNA #2 and dated 01/9/15, revealed .On 12/20/14 at approximately 0345 (3:45 AM), I was called to room 3060 by (named CNA #1) to assist her and (named LPN #2) with putting (named Resident #1) into bed after being lowered to the floor. Upon entering the room I observed (named Resident #1) in a sitting position with her back resting against (named LPN #2)'s legs. I did not witness (named Resident #1) being lowered to the floor and I exited the room immediately after assisting with the transfer. Review of a statement written by LPN #1 dated 12/20/14, revealed the night nurse (LPN #2), reported Resident #1 had been lowered to the floor during the night after getting off the bedside commode. Resident stated to night nurse, according to night nurse, that her knee popped when they were getting her back up after being lowered to the floor. When this nurse called resident's son to talk to him about res. left knee it seemed some swollen, maybe an x-ray. Son knew nothing about incident. Review of the event statement revealed the physician was notified of the resident's fall .in early AM when x-ray was ordered. Review of an undated statement written by the Nursing Supervisor, LPN #3, revealed .On Saturday morning 12/20/14 at app. (approximately) 7:05 AM, (named LPN #2) stopped by the third floor unit manager's office and informed me that (named Resident #1) had been lowered to the floor the previous night. I asked her what happened and she informed me that while the tech was transferring (named Resident #1) from the bedside commode to the bed that (named Resident #1) knees had given out and that the tech had lowered her to the floor. (named LPN #2) also informed me that when they were picking (named Resident #1) up that her left knee had popped. I asked (named LPN #2) if anyone had called (named Resident #1)'s son. She informed me that they had not called yet that they were going to make the call this morning. I told her to make sure to call. I also asked her if she had documented the fall and she informed me that she had, At app 8:15 AM the day shift nurse (named LPN #1) contacted me and said that (named Resident #1) was complaining of her left knee hurting and that the left knee looked slightly swollen. I told (named LPN #1) to write an order for [REDACTED]. At 9:14 AM the son of (named Resident #1) called me and I informed him of the situation that his mother had a fall the night before and that we had ordered an x-ray to be done. At app. 12:15 PM (named son) arrived as we were checking on his mother; we noticed that the left leg did not look in proper alignment. (named son) stated that his mother's leg was broken and that he wanted her to go to (named hospital). Since the mobile x-ray had arrived at the facility I changed the order with them to have an x-ray of the left leg. The x-ray did confirm that (named Resident #1) had a spiral fracture of the distal femoral diaphysis. (named Resident #1) was transported from the facility to (named hospital) at 1:10 PM. At app. 2:30 PM I spoke with ER (emergency room ) at (named hospital) and confirmed (named Resident #1) was being admitted . Review of the analysis and conclusion completed by the Director of Nursing (DON) dated 1/6/15, revealed .The resident is alert and oriented and able to make her needs known. The resident requests to utilize the bedside commode with toileting. Review of the resident's medical record for past 6 months showed an incident for 11/28/14 at 11:15 AM the resident was lowered to the floor because her knees legs became weak during a transfer from the bed to the w/c. The resident had no noted injuries. On 12/20/14, at approximately 3:30 AM the resident was lowered to the floor again when her legs became weak. The resident was utilized her bedside commode. The technician was assisting the resident from the bedside commode to bed. The resident's legs became weak and the technician lowered the patient to the floor. The resident was sitting on the floor with her right leg straight out and her left leg bent at the knee. The technician straightened out the resident's left leg for better positioning. This is when the knee popped. The incident report states that the knee popped when the nurse and two technicians attempted to lift the resident and place her in bed. I spoke directly with the nurse (named LPN #2) on 12/22/14 regarding this. The nurses note states that the pop occurred when the technician straightened out the resident's leg. (named LPN #2) stated that she assessed the resident for injuries and none were noted. (named LPN #2) also states the resident denies pain. (named LPN #2) assessed the patient 3 other times before the end of her shift at 7 AM. The oncoming nurse was notified of the incident. (named LPN #2) stated she didn't call the son because it was 4 in the morning and there wasn't any injuries noted. At approximately 8:15 AM the day shift nurse noted that the resident's left knee was swollen. The day shift nurse notified the MD (physician) and the resident's son. An x-ray was ordered and obtained. The resident was noted to have a left spiral fracture of the distal femoral diaphysis. The resident was transferred to (named hospital). On 12/22/14 I phoned the resident's son to inquire about her status. (named son) informed me that the fracture was inoperable and that his mother was going with (named hospice services) On 1/5/14 the Administrator and DON met with the son regarding his mother. I explained what the staff said occurred. At the present time I am unable to determine when the fracture occurred. There was not any injuries noted from 4 AM - 8:15 AM and the patient did not c/o pain until approximately 8:15 AM. Medical record review of nursing notes dated 12/20/14, from 3:30 AM to 8:30 AM, revealed no documentation of LPN #2 assessing the resident's left leg every two hours for pain and/or swelling as was stated in the analysis documented by the DON. Continued medical record review revealed no documentation of any swelling of the resident's left leg until noticed by LPN #1 at 8:30 AM on 12/20/14. Review of the discharge summary from the hospital dated 12/23/14, revealed the resident suffered a .comminuted (bone has broken into 3 or more pieces) oblique (angled line across the shaft) fracture through the distal femoral diametaphysis with moderate distraction (separation) of fracture segments. Continued review of the discharge summary revealed .Given the patient's severe debility at baseline and given the fact she is nonambulatory at baseline, the patient was not considered to be an operative candidate. The patient will be transferred to inpatient hospice today. Review of the admission note dated 12/23/2014, from Hospice revealed the resident arrived at 12:15 PM with a splint stabilizer on LLE (left lower extremity) from upper thigh to mid calf for left femur fracture. Continued review of hospice notes revealed the resident was moaning in pain and was started on pain medication. Further review of hospice notes at 6:50 PM revealed .son called nurse into pt room, stated he thought she stopped breathing. Assessed pt, at that time no radial pulse palpable and apical HR (heart rate) slowed and very faint. Informed him that death was imminent. Continued review of hospice notes at 7:05 PM revealed .nurse returned to room. Assessed pt and pronounced death. Telephone interview with LPN #2 on 4/14/15, at 3:15 PM, revealed she was in another resident's room when CNA #1 came to tell her she was getting Resident #1 up to the bedside commode when the resident's legs became weaker so she lowered the resident to the floor. Continued interview revealed LPN #2 told CNA #1 to get another CNA to help them. Further interview with LPN #2 revealed CNA #2 and LPN #2 would take the resident's torso while CNA #1 would take the legs. Continued interview with LPN #2 revealed CNA #1 was going to straighten the resident's legs before moving her when they heard a pop, .like when you sit too long and your joint cracks. Further interview with LPN #2 revealed .the resident started crying and saying the leg was broken, but there was no pain or swelling. Interview with the DON on 4/20/15, at 8:40 AM in the DON's office, revealed Resident #1 was a 1 person assist with transfers and the care plan was not updated to reflect 1 person. Continued interview with the DON revealed the son of Resident #1 wanted Resident #1 to transfer with one person to have her do as much as she could for herself. Further interview with the DON revealed she had many meetings with the son over transfers. Continued interview with the DON regarding LPN #1 documenting Resident #1 was dependent for transfers and required 2 person assist, stated .(named LPN #1) put two assist because she is old school and doesn't have a strong upper body. Continued interview with the DON revealed CNA #2 cared for Resident #1 almost exclusively. Further interview with the DON revealed Resident #1 was alert and oriented so could tell you what she wanted done and how. Interview with the DON on 4/20/15, at 3:25 PM in the conference room revealed the DON shared the investigation results with the son and did not see the facility did anything wrong. Continued interview with the DON revealed the son insisted his mother be transferred with one person only and .we were following what (named son) wanted. Further interview with the DON revealed she had documented several communications with the son regarding transferring Resident #1 but she failed to produce them during the survey. Telephone interview with CNA #1 on 4/21/15, at 9:10 AM, revealed the incident happened between 2 and 3 in the morning. Continued interview revealed CNA #1 had transferred Resident #1 to the bedside commode and was transferring her back to bed when the resident's legs gave out so she lowered the resident to the floor. Further interview revealed CNA #1 went to find the nurse to assist her. Continued interview revealed Resident #1 complained of left leg pain and wanted an x-ray done after a pop was heard when the resident's left leg was straightened. Further interview revealed CNA #1 transferred Resident #1 using a stand-pivot move. Continued interview revealed CNA #1 felt there should have been 2 people to transfer Resident #1. Telephone interview with the complainant on 4/21/15, at 9:30 AM, revealed the last five months have been a constant decline for Resident #1 with self care becoming more complicated and the resident becoming more dependent. Further interview revealed between 6/14 and 12/14 the resident became more feeble and could not stand well, and as a result the staff let her fall. Continued interview revealed the fall on 12/20/14 broke her femur and dislocated the hip replacement from 2010. Further interview with the complainant revealed he told the facility on several occasions between May 2014 and December 2014 they needed to use two people to transfer her, or use the lift. Further interview revealed Resident #1 had severe pain so took large doses of narcotics. Continued interview revealed when he met with the DON and Administrator he asked who the CNA was and the DON stated it was CNA #2, the best one they have. Further interview with the complainant revealed he was not notified of the fall until 9:00 AM when it had occurred at 3:00 AM. Continued interview revealed the complainant entered the room to find Resident #1 .scrunched at the foot of the bed with urine and stool all over. She was crying in pain. She said she had been hurting all night. Further interview revealed the resident's left thigh was twice its normal size and you could tell the leg was broken. Continued interview revealed the complainant felt .the facility dropped the ball in providing care to (named Resident #1). Further interview with the complainant revealed .one fall is a red flag and they needed to make a decision regarding the resident's care. Starting in May 2014 I told them (Resident #1) was more dependent and needed to be transferred using 2 people or the lift. Telephone interview with LPN #1 on 4/21/15, at 2:40 PM, revealed she heard about the incident in report. Continued interview revealed she checked the resident's left leg about 8:30 AM and noticed the knee was swollen so she called the son to ask him if he wanted an x-ray done. Further interview revealed the son acted as if he didn't know anything about the incident. Continued interview revealed the x-ray was ordered but before the mobile x-ray came the resident wanted to get up to the bedside commode but was told she would have to use the bedpan. Interview with LPN #1 on 4/23/15, at 8:30 AM on the 3000 hall revealed she transferred the resident with 2 people assisting because toward the end of the resident's stay here (discharged [DATE]), the resident lost mobility and became more dependent. Interview with CNA #2 on 4/21/15, at 9:22 PM, revealed she was never assigned to care for Resident #1 since she was on another hall. Continued interview with CNA #2 revealed on 12/20/14, .the tech called for me that she had lowered Resident #1 to the floor and could I come help. She was going to put her on the bedside commode and had to lower her to the floor. The resident was on the floor beside the bed, just sitting on the floor. Her feet were as straight as could be, knees together, feet out. I did not see her leg bent. When I got there the nurse was already there. One CNA was on each side of the resident; the nurse got the feet; and we put her into bed. I did not hear any of her joints pop. I can't recall if she moaned or not. Further interview with CNA #2 revealed the resident would always tell you what she wanted but you couldn't touch her right shoulder. Further interview with CNA #2 revealed Resident #1 would pivot and you held her around the waist without using a gait belt. Telephone interview with the complainant on 4/23/15 at 3:45 PM, revealed the former manager of the third floor called him several times during the month of May, 2014, about the resident becoming weaker to which he responded .if the staff can't lift her up safely then use two people and the lift to transfer her. Continued interview with the complainant revealed he never attended a care planning meeting where transfers were discussed. Continued interview revealed when he spoke with the Administrator after the incident, the Administrator stated the CNA was CNA #2 which was not what he was told originally and he knew CNA #2 always worked the east hall and had never cared for Resident #1. Further interview revealed on 12/20/14, the nurse called him about the resident not eating breakfast and she screamed when they put her on the bedpan. Continued interview revealed the complainant asked the nurse if an x-ray had been done and she said no. Continued interview revealed transfers depended on the CNA's ability and strength because the resident could not pivot but required the CNA to pull her buttocks around. Further interview with the complainant revealed the CNAs set themselves up for a fall if they didn't know the resident's routine. Interview with the Administrator and DON on 4/30/15, at 11:30 AM, in the conference room, revealed .a fall investigation is considered complete when the Falls Assessment is completed; interventions are in place; and My Patient fell is finished. Further interview revealed the My Patient fell includes resident assessment; found root cause; apply intervention; completed fall observation; updated care plan; updated CNT care plan; notified MD; notified family; fill out Risk Management form; fill out CNT Observation form; place Alert Charting sticker on chart;notify supervisor and/or Unit Manager. Continued interview revealed .we may have to assume the cause and put interventions in place. If another fall occurs, then come up with another intervention. The failure of the facility to supervise Resident #1 adequately and put appropriate interventions in place to prevent future falls resulted in actual HARM to Resident #1. Medical record review for Resident #2 revealed an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Medical record review of 14 day MDS dated [DATE] revealed Resident #2 had a BIMS score of 14, indicating he was cognitively intact. Continued review revealed Resident #2 required extensive assistance of 2 persons for bed mobility and transfers. Medical record review of a Falls - Fall Risk (Acuity) assessment with an observation and completion date of 5/13/14 revealed a fall risk score of 14, indicating Resident #2 was at high risk for falls. Medical record review of a care plan problem with start date of 7/11/14 revealed .resident at risk for falls r/t (related to) immobility, unable to sit/stand independently. Continued review revealed .approach start date: 04/18/2014.orient/educate resident to call light system and instruct/educate to call for assistance.observe/record unsafe actions and staff intervention. Provide reminders/verbal cues to resident regarding unsafe ambulation.Make staff aware of resident's fall risk, observe for unsafe actions and intervene as indicated. Continued review documented .approach start date: 7/11/2014.low bed with bed side mats. Medical record review of a Monthly Summary dated 7/9/14 revealed Resident #2 was total dependence of 2 person assist for bed mobility and transfers, and mode of transfer was lifted mechanically; total dependence for dressing with 1 person assistance; total dependence for personal hygiene and bathing, requiring 2 persons physical assistance. Medical record review of a nurses Progress Note dated 7/11/15 at 7:50 PM revealed .resident observed on the floor, on the right side of bed in prone position.unable to verbalize how fall occurred.assessment revealed a 3 cm (centimeter) hematoma to center forehead along with c/o (complaints of) cervical neck & (and) left shoulder pain.orders given to x-ray LUE (left upper extremity) & (and) C (Cervical spine)1-5. Review of a Risk Management Incident Report dated 7/11/14 at 8:00 PM revealed Resident #2 had an unwitnessed fall. Continued review revealed .resident observed on right side of bed lying in prone (lying face down) position on floor.hematoma to center forehead.cervical spine L (left) shoulder pain. Continued review revealed .safety intervention initiated.low bed c (with) mats. Continued review of a CNT Observation note attached to the investigation, dated 7/11/14, and unsigned by staff, revealed .looked in the room and saw (named Resident #2) on the floor. Medical record review of x-ray report dated 7/11/14 revealed .procedure.left shoulder, 2 views.fracture(s) and/or dislocation(s).none.Impression.degenerative changes. No acute fracture. Medical record review of x-ray report dated 7/11/14 revealed .procedure.cervical spine, 2 views. Continued review revealed .findings.study limited by positioning. Questionable lucency (a region in an image caused by an absorber of lower x-ray attenuation than its surrounding tissues) in the region of the odontoid (the odontoid process is a toothlike process projecting from the anterior end of the center of the vertebra on which it rotates). Continued review revealed .Impression.Limited exam.questionable lucency in the region of the odontoid. Further evaluation with CT (Computed Tomography) is suggested to fully exclude possibility of odontoid fracture if there is a clinical history of trauma. Interview with CNA #2 on 4/21/15 at 9:05 PM in the conference room, when questioned about the incident on 7/11/14, stated .I heard him.found him on the floor. When questioned if she could remember if the call light was on, CNA stated .no, it was not on. When questioned as to why the resident fell , CNA stated .the sitter was gone.she did not tell us she was leaving.bed was up really high.it was first time for that sitter.previous sitter always told us they were leaving. Telephone interview with LPN #4 on 4/22/15 at 9:15 AM, after reviewing Resident #2's fall investigation on 7/11/14, stated .he fell on the right side of the bed.used a lift to put him back to bed.had hematoma and did x-rays. When asked if she knew why the resident fell on [DATE], the LPN stated .we thought the sitter left the rail down. When asked if she determined the exact cause of the incident, the LPN confirmed .no, we did not. Medical record review of a Falls -Fall Risk (Acuity) assessment with an observation date of 11/17/14 and completion date of 11/18/14 revealed a fall risk score of 15, indicating Resident #2 was at high risk for falls. Review of a Risk Management Incident Report dated 11/30/14 at 9:30 PM revealed .resident observed lying on mat @ (at) bedside in supine (lying face upward) position c (with) legs extended out. Resident bed noted to be in a high position. Continued review of a CNT Observation note attached to the incident report, dated 11/30/14 at 9:30 PM, revealed .resident stated he was trying to get into bed & (and) fell on to the fall mat. Medical record review of a Safety Events - Fall assessment dated [DATE] at 9:30 PM revealed Resident #2 had an unwitnessed fall with no injury. Continued review revealed .interventions.will continue to keep low bed while in bed and mats at bedside.Did have unit manager speak to the sitter to instruct her to leave the bed in low position when she leaves. Medical record review of a nurses Progress Note dated 12/1/14 at 12:00 AM revealed .resident was observed on the floor lying on right side of bed on impact mat located on left side of bed.resident stated he dove into bed & completely missed the bed.sitter did not put bed in lowest position prior to leaving & impact (mat) was not placed on right side of bed. Medical record review of a nurse Progress Note dated 12/1/14 at 7:07 PM revealed .c/o (complained of) L knee pain this AM.upon moving him he cried out and c/o hip/thigh pain. X-rays ordered and done.new order for ice to knee. Review of x-ray reports dated 12/1/14 for left femur, left knee, and left hip revealed no visible fracture or dislocation. Interview with CNA #2 on 4/21/15 at 9:15 PM in the conference room, after reviewing Resident #2's fall investigation on 11/30/14 and questioned what she could remember, stated Z

Based on the "National Pressure Advisory Panel (NPUAP) Pressure Ulcer Prevention QUICK REFERENCE GUIDE", policy review, medical record review, observation and interview, it was determined the facility failed to prevent, identify and treat a pressure ulcer for 2 of 6 (Residents #4 and 17) sampled residents with pressure ulcers. The failure to identify and prevent skin breakdown prior to the development of a Stage 3 pressure ulcer resulted in actual harm to Resident #17. The findings included: 1. Review of the "National Pressure Advisory Panel Pressure Ulcer Prevention QUICK REFERENCE GUIDE" documented, "...p. 8...Category Stage III: Full thickness skin loss Full thickness tissue loss... slough may be present... p. 12... 3. inspect skin regularly for signs of redness... Ongoing assessment of the skin is necessary to detect early signs of pressure damage. 4. Skin inspection should include assessment for localized heat, [MEDICAL CONDITION], or induration (hardness)..." 2. Review of the facility's "SKIN ASSESSMENTS" policy documented, "Every floor nurse on 7a- (to) 7p has daily skin assessments that must be complete... For any skin problems the floor nurses are required to write an order and initiate tx (treatment)..." 3. Medical record review for Resident #17 documented an admission date of [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Weekly Skin Assessment sheet completed by the Certified Nursing Assistant (CNA) dated 4/21/11 documented, "blister" with a line pointing to the back of the left leg. Review of the "Progress Note" dated 4/25/11 at 3:12 PM documented, "Stage 3 noted to posterior calf area beneath brace. wound including redness surrounding wound measures approx (approximately) 4.5 cm (centimeters) x (by) 4.5 cm..." Review of the "NURSES DAILY SKILLED NOTES" dated 4/19/11 through 4/25/11 documented, "...SKIN ...Skin Color normal..." Review of the computerized "NURSES DAILY SKILLED NOTES" dated 4/26/11 documented, "...SKIN ...Skin Color normal... Decubitus Wound..." Review of the care plan dated 4/12/11 documented, "...APPROACH: On-going monitoring for s (signs) / (and) sx (symptoms) of skin breakdown. Skin assessment and Braden scale per policy and prn (as needed)..." Observations in Resident #17's room on 5/4/11 at 8:50 AM, revealed Resident #17 lying in bed on his back. Inspection of the wound to his left calf revealed, eschar with redness around the wound. During an interview in Resident #17's room on 5/4/11 at 8:50 AM, Nurse #2 was asked when Resident #17 developed the wound and what stage it was at that time. Nurse #2 stated, "...April 25th (date wound was found) ...it was Stage 3 due to slough in the wound bed..." During an interview in the 2nd floor Unit Manager's office on 5/4/11 at 1:13 PM, Nurse #11 was asked how often she expected skin assessments to be done on residents. Nurse #11 stated, "...every other day with shower... by the CNT (Certified Nursing Technician)..." When asked how often she expected the nurses to perform a skin assessment. Nurse #11 stated, "...daily as they're providing care..." During an interview at the 2nd floor nurses' station on 5/4/11 at 1:35 PM, CNA #14 was asked how often skin assessments are done by CNAs. CNA #14 stated, "...every shower day... and we give these (weekly skin assessment sheets) to the nurse..." CNA #14 was asked if she had noted any skin breakdown for Resident #17 on 4/25/11. CNA #14 stated, "...No, I was off for about 5 days and when I came back I heard some of the others talking about it (skin breakdown)..." During an interview at the second floor nurses' station on 5/4/11 at 1:42 PM, CNA #12 was asked if she had noted any skin breakdown for Resident #17 on 4/25/11. CNA #12 stated, "...a few days before I had seen a little blister on his leg..." During an interview in the Director of Nursing's office on 5/4/11 at 2:15 PM, Nurse #2 was asked when there was any indication of skin breakdown and when treatment was started for Resident #17. Nurse #2 presented the weekly skin assessment sheets completed by the CNAs at bath time and stated, "...No one (nurse) signed this sheet (weekly skin assessment sheet dated 4/21/11)... guarantee this CNT told someone... We don't have a skin assessment for 4/19 or 4/23... No treatment was started at this time..." Nurse #2 stated the "...Weekend Supervisor... treated it (the Stage 3 breakdown) on April 25th..." and that Nurse #2 saw Resident #17 on 4/26/11 and "...slough was present." The failure to identify and prevent skin breakdown prior to the development of a Stage 3 pressure ulcer resulted in actual harm to Resident #17. 4. Medical record review for Resident #4 documented an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Observations in Resident #4's room on 5/3/11 at 9:00 AM, Nurse #5 was asked to check Resident #4's drawers and closets for the heel protectors. Nurse #5 was unable to locate heel protectors in Resident #4's room. During an interview in the second floor hallway on 5/3/11 at 9:05 AM, CNA #13 was asked if she placed heel protectors on Resident #4 when he was in bed. CNA #13 stated, "No. I only float his heels on that pillow." During an interview in the second floor hallway on 5/3/11 at 9:15 AM, Nurse #5 was asked about the order for heel protectors for Resident #4. Nurse #5 stated, "If the order says there should be heel protectors there should be heel protectors in his room and they should be used."