Every finding on record at Willow Haven Health and Rehab, LLC

Based on observation, interview, record review, and document review, the facility failed to ensure a resident was free from abuse. A thorough investigation of a resident-to-resident sexual abuse allegation was not conducted, and the resident was not promptly protected or monitored following the allegation for 1 of 52 sampled residents (Resident 45). This deficient practice had the potential to place the resident at risk for continued abuse, emotional distress, fear, anxiety, a diminished sense of safety, and delayed implementation of interventions necessary to protect the resident from further abuse.Findings include:Based on observation, interview, and document review, the facility failed to ensure the protection of a resident's privacy and confidentiality for 1 of 52 residents (Resident 58). This practice had the potential to violate resident rights related to privacy, expose protected health information, and result in unauthorized disclosure to visitors, other residents, or nonclinical personnel.Findings include: Resident 58 (R58) was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease. On 07/28/2026 at 11:45 AM, a handwritten sign was observed posted above R58's bed stated, Attention please no briefs chucks only!! On 07/29/2026 at 7:33 AM, a second observation was conducted, and the same handwritten sign was noted above R58's bed. On 07/29/2026 at 7:36 AM, a Respiratory Therapist confirmed the sign was present and it was a privacy issue and should not be posted above R58's bed. On 07/29/2026 at 7:39 AM, a Licensed Practical Nurse indicated the handwritten sign above R58's bed was a privacy concern and was against facility policy.On 07/29/2026 at 8:40 AM, a Registered Nurse acknowledged the handwritten sign was placed above R58's bed and indicated it was a dignity issue, which was against facility policy.On 07/29/2026 at 7:45 AM, a Certified Nursing Assistant confirmed the sign was above R58's bed and expressed that the sign was a privacy issue, was against facility policy, and should not have been placed.A facility policy titled Residents Rights (undated) documented residents have the right to privacy and confidentiality with personal care and medical records. The policy further stated residents' medical and personal care information is private, and facility staff are required to respect and uphold resident privacy at all times.

Based on interview, the facility failed to submit a final investigative report to the state agency following an alleged abuse incident for 2 of 37 residents (Resident 84 and resident 85). This deficient practice had the potential to delay state agency review, impede regulatory oversight, and result in noncompliance with mandated abuse reporting requirements. Findings include: Resident 85 (R85) was readmitted to the facility on [DATE] with diagnoses including epilepsy, dementia, schizophrenia and reduced mobility. An initial facility report was submitted to the state agency (SA) on 06/13/2026 documenting physical abuse. The facility did not submit a final report to the SA. The initial report documented on 06/10/2026 at 2:15 AM, a certified nursing assistant (CNA) witnessed and reported a disagreement over the television led to a resident slapping their roommate on the face. The residents were immediately separated, a room change implemented, the administrator notified, and law enforcement called. No injuries, no changes in condition or behavior noted. An investigation and interviews were conducted, and the incident was verified. Law enforcement, the public guardian and the physician were notified. On 07/28/2026 at 3:18 PM, the administrator indicated the facility report process required the initial report to be started within two hours of the incident and clarified the final report must be submitted within 5 days. The administrator reported that social services had been responsible for completing and submitting the initial and final reports; until 05/03/2026 but as of 05/18/2026 they had assumed responsibility for submitting the facility reports. The administrator confirmed there were no barriers or circumstances, which would have delayed the submission of a final report. The administrator acknowledged the final report regarding the incident involving R85 was not submitted due to selecting the incorrect submission button. The facility policy titled Compliance with Reporting Allegations of Abuse, Neglect and Exploitation dated 07/16/2026 documented the requirement to report, within five working days of an incident, sufficient information describing the results of the investigation, indicating any corrective actions taken, and specifying whether the allegation was verified. Resident 84 (R84) was admitted on [DATE] with diagnoses including schizoaffective disorder, bipolar type, schizophrenia and dementia. On 07/28/2026 at 4:00 PM, the Director of Social Services acknowledged the investigation regarding the abuse incident had been completed; however, no final report had been submitted for R84. The Social Services Director confirmed a final report should have been completed and submitted within the required five-day timeframe. A facility policy titled Compliance with Reporting Allegations of Abuse, Neglect and Exploitation revised 07/16/2026 documented the requirement to report, within five working days of an incident, sufficient information describing the results of the investigation, indicating any corrective actions taken, and specifying whether the allegation was verified. FRI 3039396

Based on interview, record review and document review the facility failed to ensure a comprehensive care plan was completed for 1 of 6 sampled residents (Resident 1). The deficient practice had the potential for a resident not to have a person-centered intervention to assist with health care needs.Findings include:Resident 1 (R1) was admitted on [DATE], with diagnoses including schizophrenia and bipolar disorder. An Initial Psychiatric Evaluation dated 04/30/2026, documented the resident has not exhibited any physical or verbal aggressive behaviors but does exhibit inappropriate behaviors needing redirection, per staff: Resident was sarcastic in nature. A Behavior/Psych Change of Condition dated 05/06/2026 documented, R1 exhibited inappropriate behaviors, including making sexual comments toward a nurse, including asking the nurse to sit on their lap. The note included redirecting the resident remaining calm and boundaries reinforced. R1 also grabbed this nurse's hair clip and clipped hair clip to hairy nipple area. When attempted to redirect resident behavior, R1 stated just clean the hair clip. A Social Service Note dated 05/11/2026 documented R1 was followed by Social Services regarding allegations of sexually inappropriate behavior toward staff. R1denied allegations of exposing his private areas to female kitchen staff. Social Services discussed the importance of maintaining appropriate boundaries and respectful behavior toward all staff members. R1 verbalized understanding and agreed to refrain from disturbing kitchen staff or making any inappropriate gestures, comments, or behaviors toward staff moving forward. Facility staff will continue to monitor and report any further concerns. Talk therapy offered, resident declined. Behavior/Psych Change of Condition dated 05/06/2026 documented R1 approached the nursing station requested medication and upon looking at resident, their genitals were out. This nurse quietly told resident that they were exposed, and the resident responded, No I'm not, I have a brief on see and grabbed self. The nurse you informed the resident they needed to cover up to which R1 responded no. The nurse reported the incident to the reported to ADON. A Psychiatry Follow Up visit was completed on 05/14/2026 including a plan and recommendations to monitor hours of hours of sleep, practice sleep hygiene, and to monitor inappropriate sexual behaviors. R1's medical record lacked documented evidence the Psychiatrist's recommendation to monitor target behavior for inappropriate sexual behavior. The documented behavioral incidences did not trigger the facility to create a care plan to address the behavior. A Social Service Note dated 05/18/2026 documented Social Services was notified of an alleged sexual abuse incident involving the resident with another resident that had reportedly occurred this morning. R1's care plan was updated on 05/18/2026 to include a care plan for inappropriate sexual behavior. On 05/26/2026 at 2:05 PM, the assistant director of nursing (ADON) indicated all nursing staff were responsible for creating a resident's care plan. Change in behavior, inappropriate behavior and recommendations should have cued the staff in creating a care plan. On 05/26/2026 at 2:35 PM, the director of nursing (DON) reviewed the medical record and agreed a care plan should have been created to address the inappropriate behavior. The DON indicated creation of a care plan ensures interventions were put into place to address the resident's needs. The facility policy titled Comprehensive Care Plan (undated), documented it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent to meet a resident's medical, nursing and mental and psychological needs and all services that are identified. FRI 3017458

Based on interview, record review and document review, the facility failed to ensure common side effects monitoring for psychotropic medications were initiated for 1 of 6 sampled residents (Resident 1). The deficient practice had the potential for a resident not to be monitored for serious adverse reactions of medication preventing the prompt implementation of interventions.Findings include:Resident 1 (R1) was admitted on [DATE], with diagnoses including schizophrenia and bipolar disorder. A physician order dated 04/16/2026, documented Quetiapine Fumarate (Seroquel) 200 milligrams (mg)two times a day for schizophrenia. The prescription was flagged with a black box warning (warnings are mandated only when clinical data shows a drug carries a significant risk of severe adverse events). The medication Seroquel (quetiapine) carried a warning (the most serious safety alerts): an increased risk of death in elderly patients with dementia-related psychosis and a higher risk of suicidal thoughts and behaviors in children, teens, and young adults A physician order dated 04/30/2026, documented Trazodone HCL 100 mg give 1 tablet by mouth one time a day for sleep. The prescription was flagged with a black box warning. The warning on trazodone suggests the increased risk of suicidal thoughts and behaviors in children, teenagers, and young adults (under [AGE] years old). R1's medical record lacked documented evidence of side effect monitoring for the specified medications. The medication administration record (MAR) or the comprehensive care plan lacked documentation of the side effect monitoring. On 05/26/2026 at 2:05 PM, the assistant director of nursing (ADON) indicated residents receiving psychotropic medications should have had side effect monitoring completed on the MAR. The nurse entering the psychotropic medication on the physician order should have entered side effect monitoring orders in the MAR as well. On 05/26/2026 at 2:35 PM, the director of nursing (DON) reviewed the medical record and agreed there was no side effect monitoring was completed for the two psychotropic medications prescribed to R1. The DON confirmed side effect monitoring should have been completed on the MAR. The facility policy titled Use of Psychotropic Medication(s) dated 04/28/2026, documented the resident's response to the medication, including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record. FRI 3017458

Based on observation, interview, record review, and document review, the facility failed to ensure:1) a resident was readmitted to the facility following hospitalization for 1 of 8 sampled residents (R1), and2) written criteria addressing residents hospitalized under a legal hold (L2K) was formulated and implemented. The deficient practice resulted in R1, who required medication management, assistance with activities of daily living, and nursing supervision, being left without housing, care, and access to prescribed medications, placing the resident at risk for serious harm, including deterioration in condition, hospitalization, or death.The deficient practice had the potential to affect other residents in the facility who required similar services if the practice continued.Findings include:Resident 1 (R1) was admitted on [DATE], with diagnoses including diabetes mellitus, long-term insulin use, chronic ulcer of right lower leg, cellulitis, infective myositis, muscle weakness, difficulty in walking, reduced mobility, pulmonary embolism, hypertension, chronic pain and anxiety disorder.R1's Quarterly Minimum Data Set, dated [DATE], documented a brief interview of mental status (BIMS) score of 15/15, indicating R1's cognition was intact.Nursing progress notes dated 02/03/2026, documented R1 was involved in a resident-to-resident altercation in the designated smoking area with two other residents. R1 was verbally aggressive toward one resident and threw a red ashtray at another resident. The physician was notified and ordered R1 to be placed on a L2K for further evaluation. R1 was sent to the hospital under a L2K. R1 left the facility via gurney with transportation at 9:30 PM.A physician order dated 02/03/2026, documented transfer of R1 to the hospital under L2K.Hospital records dated 02/03/2026 documented that R1's behavioral symptoms stabilized while in the emergency department and were assessed as secondary to psychiatric illness. R1 was medically cleared and deemed appropriate for further psychiatric evaluation. The records indicated R1 remained a danger to self and unable to care for self, with repeated evaluations showing ongoing psychotic behavior without significant improvement. The hospital disposition documented R1's discharge with a final diagnosis of acute situational disturbance. On 03/19/2026 at 11:30 AM, a Physician Assistant indicated a resident may be placed on a legal hold or L2K when a danger to self or others. The Physician Assistant indicated a resident discharged under an L2K could be readmitted to the facility on ce hospital discharge clearance or disposition was obtained.On 03/19/2026 at 11:43 AM, a Registered Nurse (RN) familiar with R1 during day shift, confirmed R1 was transferred to the hospital under an L2K, returned to the facility the next day, and was denied readmission. The RN indicated an L2K was initiated when a resident was considered a danger to others, including behaviors such as physical aggression, threats, or uncontrolled behavior. The RN indicated the physician determined whether to proceed with an L2K. The RN indicated a resident transferred to the hospital was considered discharged from the facility once admitted . The RN indicated if a resident returned within 24 hours, the determination of discharge or readmission depended on the administrator and the situation. On 03/19/2026 at 12:30 PM, the Director of Nursing (DON) explained the basis for an L2K was when a resident was a danger to self or other residents, and the physician provided the order with RN sign-off. The DON indicated R1 was placed on an L2K following a three-person altercation, during which R1 pushed another resident and attempted to throw an ashtray multiple times, and was very aggressive and posed a danger to others. The DON indicated that a resident returning from the hospital required readmission clearance and verbal report prior to return. R1 arrived at the facility without notification, documentation, or confirmation of discharge and arrived at the facility. Staff did not attempt to contact the hospital because R1 refused and did not want to go back to the hospital. R1 was very upset and law enforcement was contacted and the resident was trespassed.The DON explained when residents were sent to the hospital, staff packed and completed an inventory of their belongings, as rooms could be reassigned. The DON verbalized a bed hold was available for a fee; however, residents under an L2K were not typically offered a bed hold. The DON was unsure if it was offered in this case. The DON explained medications were not provided as R1 was not readmitted and no physician order was available. On 03/19/2026 in the afternoon, during a telephone interview R1 indicated not being admitted to the hospital due to no criteria for the psychiatric hold. R1 was treated in the emergency department prior to discharge. The hospital arranged transportation back to the facility and upon arrival, R1 was told readmission would not occur, and their previous room was occupied by another resident. The facility staff refused to accept R1's hospital discharge papers. R1 indicated facility staff were aware they had no home, no family in the area, and no resources. R1 indicated law enforcement was contacted by the facility, and they were trespassed from the property. R1 verbalized staying at a bus stop near the facility for several days following the refusal of readmission. R1 indicated, During that time, I was hungry, had no money, was cold, and had no medications, which resulted in hospitalization.On 03/19/2026 at 1:25 PM, a case manager (CM) indicated the facility was aware R1 had no home and no resources. The CM explained that R1 received custodial care while in the facility and applied for Medicaid after their insurance lapsed in January. The CM indicated the discharge plan was for R1 to obtain a weekly apartment or shared housing; however, was waiting for financial resources. The CM explained not being responsible for ensuring placement or discharge needs when R1 was not readmitted . The CM explained R1's belongings were packed once discharged , which occurred when the resident was admitted to the hospital. R1's room was reassigned to another resident.On 03/19/2026 at 4:27 PM, a receptionist indicated the facility received multiple calls from the hospital prior to R1's arrival regarding the transfer. The receptionist indicated the calls were transferred to case management, then the receptionist was informed the facility would not readmit R1. The receptionist confirmed the hospital called three times, and denial of readmission was confirmed by case management and the marketing director.The receptionist indicated R1 arrived at the facility via hospital transportation with two Emergency Medical Technicians, and R1 was in a wheelchair. The receptionist indicated R1 was positioned near the nurse's station and requested to return to the previous room. Nursing staff informed R1that readmission would not occur, their belongings had been packed, and another resident had been assigned to the room.The receptionist indicated R1 became verbally aggressive after being informed readmission would not occur and their previous room was occupied by another resident. The receptionist indicated Metro Police were contacted, issued a trespass notice, and escorted R1 off the property.On 03/20/2026 at 10:44 AM, during a telephone interview, an attending physician confirmed R1 was transferred to the hospital under a L2K following an altercation involving multiple residents. The physician indicated readmission decisions were determined by the administrator. The physician indicated R1 required assistance and was unable to safely care for self independently. The physician conveyed discharge without appropriate placement and access to medications placed R1 at risk for serious harm, including unmet medical needs, rapid deterioration in condition, hospitalization, or death. On 03/20/2026 in the afternoon, the marketing director indicated R1 was sent to the hospital under a L2K following an altercation involving other residents. The marketing director indicated facility's policy was to deny readmission for residents sent out under an L2K and indicated residents out of the facility for more than 24 hours were considered discharged from the system.The marketing director indicated the decision not to readmit R1 was made prior to R1's return and was based on direction from the administrator. The marketing director indicated once advised not to accept R1 back, the bed was filled and was no longer available for R1 upon return. The marketing director indicated exceptions to this practice occurred and confirmed another resident involved in a similar incident was readmitted due to long-term residency status.On 03/20/2026 at 1:00 PM, the Director of Nursing (DON) indicated the facility was licensed for 144 beds, with 133 occupied on 02/04/2026, confirming space was available. The DON confirmed there was no policy governing L2K or hospital readmissions and described existing procedures as vague. Staff followed verbal direction from leadership. The DON indicated the administrator was on leave and unavailable for interview.Hospital records dated 02/11/2026, documented R1 presented with worsening leg swelling. The records indicated R1 had a history of deep vein thrombosis (DVT) and pulmonary embolism. The records indicated R1 resided in a long-term-care facility and was not accepted for readmission. The records revealed R1 was not receiving prescribed medications and experienced worsening leg swelling, which prompted R1 to seek medical care. Ultrasound confirmed a positive DVT. The facility policy titled Transfer and Discharge, dated 04/11/2025, documented residents transferred to an acute care setting were permitted to return to the facility upon discharge.The facility policy titled Behavioral Health Services, revised 03/20/2026, was updated following identification of the deficient practice. The policy revision included processes for psychiatric holds, resident return rights, and readmission upon medical or psychiatric clearance. The policy documented support for appropriate use of psychiatric holds in accordance with applicable laws and regulations, that residents transferred under psychiatric hold retained resident rights, including the right to return to the facility, and that residents were readmitted upon medical or psychiatric clearance from the receiving provider or hospital.

Based on observation, interview, record review and document review the facility failed to ensure 1) staff re-assessed the smoking status and updated the care plan after a significant change of condition was completed regarding a decline in cognition and accurately assess the tobacco use section of the Minimum Data Set (MDS); 2) complete a safe smoking assessment and update the plan of care for a resident was found smoking inside room; and 3) ensure a resident lighter and cigarettes were secured for 1 of 38 sampled residents (Resident 1). The deficient practice resulted in a resident smoking in the room causing a fire, and hospitalization for burns and smoke inhalation.Findings include:Resident 1 (R1) was admitted on [DATE] and discharged on 12/10/2025 with diagnoses including hypertensive heart and chronic kidney disease with heart failure, chronic obstructive pulmonary disease, and emphysema.1. A Care Plan dated 10/17/2025 documented R1 was admitted as a cigarette smoker and may be at risk for injury and inappropriate behaviors. R1 was an independent smoker.A Significant Change Minimum Data Set (MDS) dated [DATE] documented R1's Brief Interview for Mental Status (BIMS) was a score of 11 indicating moderate cognitive impairment and documented no tobacco use.On 12/11/2025 at 12:10PM, the MDS Coordinator explained R1's BIMS score was previously 15 but due to exhibited behaviors and a decline in cognition a significant change assessment was completed on 10/09/2025. The MDS Coordinator verbalized R1's smoking safety should have been re-assessed and care plan revisions made when the significant change occurred.R1's medical record lacked a Smoking Safety evaluation to correlate with the documented 10/09/2025 significant change assessment.On 12/11/2025 at 12:58 PM, the Activity Director explained being responsible for completing resident smoking assessments upon admission, quarterly and during significant changes. The Activity Director confirmed R1's smoking safety should have been re-assessed and a Smoking Safety evaluation completed when the significant change of condition was identified on 10/09/2025.On 12/11/2025 at 2:28PM, the MDS Director explained the MDS should accurately reflect the resident's condition and confirmed R1's tobacco use on the 10/09/2025 Significant Change MDS was inaccurate.2. A Nursing Progress Note dated 10/23/2025, documented at 5:10 AM while making rounds, the writer smelled cigarette smoke coming from R1's room. R1 was noted to be sitting on the edge of the bed with oxygen on and oxygen tubing in both nostrils. R1 was asked if the resident had been smoking and R1 stated, I'm not going to lie to you, I just finished smoking, I only took a few puffs and then I placed it in here. R1 proceeded to show how R1 had placed the cigarette inside a water bottle that was in the trash can, next to bed. The writer informed the Director of Nursing (DON) and Administrator.R1's medical record lacked a Smoking Safety evaluation and care plan revisions to correlate with the documented 10/23/2025 event.R1's Smoking Safety evaluation dated 11/25/2025 documented no history of smoking related incidents.On 12/11/2025 at 12:58 PM, the Activity Director was unaware of R1 smoking in the resident's room on 10/23/2025 and generally Social Services or Nursing would alert Activities of such an event. The Activity Director confirmed R1's smoking safety should have been re-assessed and a Smoking Safety evaluation completed after an event of this nature.On 12/11/2025 at 2:15 PM, the DON explained when R1 was found to be smoking in room with oxygen on 10/23/2025 the facility protocol should have been followed such as re-assessing smoking safety and updating the care plan. The DON confirmed R1's smoking safety was not re-assessed, care plan revisions were not completed, and the facility protocol was not followed.3. On 11/25/2025 a facility Smoking Program Changes protocol was implemented. The protocol documented that no smoking paraphernalia was to be retained by residents.On 12/11/2025 at 10:28AM, the Activity Director explained an Activity Aide was assigned daily to be the Smoking Aide. The Smoking Aide would have a key, provided by the Activity Director, to the locked smoking cart. The cart contained residents smoking items such as lighter, cigarettes, and vapes.On 12/11/2025 at 12:28PM, an Activity Aide explained when assigned to be the Smoking Aide would take the smoking cart to the designated smoking area and provide a cigarette to the residents and light the cigarette for the residents. The Activity Aide expressed no residents were allowed to keep lighters or cigarettes, they were to be locked in the smoking cart when not in use. A Smoking Safety evaluation dated 12/08/2025 documented R1 safe to smoke with supervision and the plan of care was used to assure resident was safe while smoking.A Care Plan dated 10/17/2025 documented R1 was admitted as a cigarette smoker and may be at risk for injury and inappropriate behaviors. R1 was an independent smoker. Interventions included smoking materials were to be kept in a lock box.A Nursing Progress Note dated 12/10/2025, documented at approximately 1:17 AM administration was notified by staff of a fire in R1's room. The fire alarm had been activated at approximately 1:07 AM, at which time staff observed smoke and flames coming from R1's room. R1 appeared to have been smoking in room while using oxygen via nasal cannula, resulting in bed, sheets, and concentrator catching fire. R1 was transferred to emergency room (ER) for evaluation and treatment.A Change in Condition Note dated 12/10/2025, documented trauma, smoking in room with oxygen resulting in fire, send to ER post smoke inhalation and burn to face.The Hospital Burn Surgery History and Physical dated 12/10/2025, documented R1 reported went to light a cigarette and forgot oxygen was on. Noted that it flared up and burned face. Clinical impression: burn and inhalation injury.The facility policy titled Resident Smoking Safety Independent and Unsupervised, updated 01/2025, documented residents were reassessed on at least a quarterly basis, or more frequently as dictated by any significant changes in condition. Should any incident of unsafe smoking occur, a new smoking evaluation would be completed.FRI 2689771

Based on observation, interview and document review, the facility failed to ensure the fire alarm system, portable fire extinguishers and fire safety plan were maintained in accordance with the following National Fire Protection Association (NFPA) standards:NFPA 72 National Fire Alarm and Signaling Code, the 10 Standard for Portable Fire Extinguishers, and the 101 Life Safety Code. The deficient practice affected 36 residents in one of six smoke compartments. The facility was licensed for 144 nursing beds with a census of 137 the day of survey. Findings include: 1) On 12/11/2025, during a tour of the facility, the main fire alarm panel displayed a system trouble alarm. The panel display indicated MISSING DUCT DECTECTOR H20 HEATER ROOM. The fire alarm panel displayed an incorrect date of 03/03/2011 @ 1547 hrs.During an interview, the Maintenance Director (MD) indicated the facility was aware of the trouble alarm and had contacted the vendor to schedule future repairs. In addition, the MD indicated the facility recently suffered a power outage and the fire alarm panel had a hard reset and upon reactivation displayed the wrong date and time.2) On 12/11/2025, document review revealed the facility failed to provide evidence that the portable fire extinguishers had been inspected annually.The Administrator and Maintenance Director were informed of the deficient practice at the exit interview3) On 12/11/2025, during a review of the facility's evacuation / fire safety plan, the facility provided a policy titled, Responding to a Fire. The following deficiencies were identified:The plan failed to identify the protocol and functional requirements of utilizing a portable fire extinguisher (i.e P.A.S.S.)The fire safety plan did not include a procedure for reviewing the fire alarm annunciator panel during an alarm condition, nor did it describe how this action supports effective fire response operations or facilitates overhead communication during a fire event. During an interview, the Maintenance Director indicated being responsible for fire safety training and further indicated being aware of all code section requirements for maintaining an evacuation/ fire safety plan.

Based on interview, record review and document review, the facility failed to ensure staff requested permission from a resident prior to removing the battery of the motorized wheelchair for 1 of 37 sampled residents (Resident (R) 31). The deficient practice had the potential for inhibiting a resident from utilizing a motorized wheelchair for independent movement in the facility. Findings include:Resident 31 (R31) was admitted on [DATE], with diagnoses including multiple sclerosis, generalized anxiety disorder, and pain.The Progress Notes dated 07/15/2025, documented R31 was notified the resident would be transferring to a manual wheelchair from the resident's electric (motorized) wheelchair due to running over another resident's foot on accident.On 07/29/2025 at 10:10 AM, R31 was sitting in a motorized wheelchair by the nurse's station. R31 revealed previously using a manual wheelchair for seven to ten days. R31 indicated the facility returned the resident's motorized wheelchair after R31 talked to the Compliance Officer yesterday (07/28/2025). R31 indicated somebody went to the resident's room and took the battery of the motorized wheelchair. R31 confirmed being upset because nobody from the facility had asked the resident's permission for the battery to be removed. R31 indicated the facility removed the battery so the resident could not use the motorized wheelchair.On 07/29/2025 at 12:52 PM, R31 indicated the Maintenance Director took the battery of the motorized wheelchair about two weeks ago without the resident's permission.On 08/01/2025 at 10:00 AM, the Administrator revealed R31 was involved in an incident on 07/15/2025 where R31 accidentally ran over another resident's foot with the motorized wheelchair. The Administrator explained R31 used a manual wheelchair after the incident for the resident's safety. R31 used a manual wheelchair for one week.The Administrator confirmed the Maintenance Director removed the battery of R31's motorized wheelchair the next day after the incident, or on 07/16/2025, per the Administrator's instruction. The Administrator indicated the battery was removed for the resident's safety, so the resident could not use the motorized wheelchair. The Administrator confirmed not talking to R31 to ask permission from the resident the battery of the motorized wheelchair would be removed. The Administrator acknowledged the resident's permission should have been obtained prior to removing the battery. The reason for removing the battery of the motorized wheelchair should have been explained to R31.On 08/01/2025 at 10:35 AM, the Maintenance Director confirmed removing the battery of R31's motorized wheelchair a couple of weeks ago per the instruction of the Administrator. The Maintenance Director indicated the motorized wheelchair was located inside R31's room. The Maintenance Director revealed R31 was not inside the room when the battery was removed. The resident was at a doctor's appointment. The Maintenance Director confirmed not asking permission from R31 prior to removing the battery.The facility's Notice of Resident Rights Under Federal Law updated in July 2025, documented the resident had the right to a dignified existence and self-determination, and to be treated with respect and dignity.

Based on interview, record review and document review the facility failed to ensure informed consent was obtained prior to administration of psychotropic medications for 1 of 37 sampled residents (Resident 8). The deficient practice potentially deprived residents of the right to be informed of the medications' risks, benefits and potential side effects.Findings include: Resident 8 (R8) was admitted on [DATE] with diagnoses including type 2 diabetes mellitus, schizoaffective disorder bipolar type, major depressive disorder, and anxiety disorder. A Physician Order dated 07/17/2025 documented Seroquel Oral Tablet 50 milligrams (mg), give one tablet by mouth one time a day for paranoia, agitation, and irritability related to schizoaffective disorder, bipolar type.R8's medical record lacked documented evidence an informed consent was obtained prior to the first administration of Seroquel on 07/17/2025. On 08/01/2025 at 3:20 PM, a Registered Nurse (RN) explained psychotropic medications required an informed consent to be signed prior to administration.On 08/01/2025 at 3:51 PM, the Director of Nursing (DON) explained when a resident had orders for psychotropic medications a consent would need to be obtained from the resident or responsible party prior to administration of the first dose. The DON reviewed R8's medical record and confirmed R8 lacked an informed consent for the administration of Seroquel. The facility policy titled Psychoactive Medications, updated June 2025, documented prior to the administration of psychotropic medication, consent is obtained from the resident or resident representative.

Based on interview, record review and document review, the facility failed to ensure an advance directive and/or public guardianship was initiated and obtained for 1 of 37 sampled residents (Resident (R)12). The deficient practice had the potential for the resident, who was evaluated as not having the capacity to manage medical and financial decisions, to have a proper representation in health care decision-making.Findings include:Resident 12 (R12) was admitted on [DATE], with diagnoses including dementia, schizophrenia, major depressive disorder, and history of traumatic brain injury.The Clinical admission notes dated 11/05/2024, documented the following:- R12's Family / support person was not in attendance.- Living situation prior to admission: R12 lived alone.- Mental Status: R12 was disoriented, disorganized in thinking, and oriented to person.R12's History and Physical dated 11/05/2024, documented the physician's assessment of the resident included altered mental status and schizophrenia.The medical record contained the following consents which were signed by R12:- Consent To Treat (undated)- Psychotropic Drugs Disclosure dated 11/05/2024- Informed Consent for Immunization with Covid-19 dated 11/05/2024- Influenza Vaccine Informed Consent dated 11/05/2024- Pneumococcal Vaccine Informed Consent dated 11/05/2024The admission Minimum Data Set (MDS) dated [DATE], documented R12's Brief Interview for Mental Status (BIMS) score was 06 (severe impairment).The Cognitive Evaluation dated 12/02/2024, documented the following:- History of Present Illness: R12 was seen on facility request to assess the resident's capacity to manage medical and financial decisions. R12 was unable to list the medications and/or diagnoses with basic understanding. R12 was unable to detail income, financial matters and/or financial obligations with basic understanding. The resident was not able to discuss the role of a Power of Attorney (POA) with superficial understanding. R12 did not understand the process of instating and rescinding POA. The resident was informed of these concepts but was unable to paraphrase these concepts after some time. The resident did not understand the scope of authority granted to a POA including the ability to overrule the resident's decisions. The resident did not understand when decision making would be deferred to a POA. The resident was informed of these concepts but was unable to paraphrase these concepts after some time. The resident did not identify a potential POA.- Assessment / Plan: R12 did not have the capacity to manage medical andfinancial decisions. Overall, the resident demonstrated insufficient understanding of the financial situation and obligations as well as the medical diagnoses andmedications to make informed decisions and manage these safely. A decision maker should be implemented. R12 did not have the capacity to identify, instate, and rescind a POA. Overall, R12 demonstrated insufficient understanding of a POA and did not appear to understand the primary components and the impact on the resident's life.The Quarterly MDS dated [DATE], documented R12's BIMS score was 03 (severe impairment).R12's medical record lacked documented evidence an advance directive and / or public guardianship was initiated and obtained for R12.On 08/01/2025 at 12:03 PM, the Director of Nursing (DON) revealed R12 had a BIMS score of 03. R12 was alert and oriented to self and current location but not oriented to time or situation / event with episodes of confusion.The DON explained R12's Cognitive Evaluation dated 12/02/2024, documented the resident had no capacity to manage medical and financial decisions. The DON confirmed R12 signed all the consents. The DON indicated R12 should not have signed the consents.The DON revealed R12 had no public guardian or family. The DON explained the nurses should have contacted the providers because two doctors could have signed the consents. The DON revealed the facility should have initiated the process to obtain a guardian or POA when the cognitive evaluation was completed on 12/02/2024. Social services were responsible for obtaining a public guardian or POA for R12. The DON confirmed Resident 12's medical record did not contain an advanced directive and there was no documented evidence of the discussion regarding advanced directive.On 08/01/2025 at 1:09 PM, a Registered Nurse (RN) revealed R12 was alert and oriented times two with episodes of confusion. The RN explained that the nurses obtained consents upon a resident's admission.The RN indicated on admission R12 was alert and oriented to person only based on the Clinical admission notes dated 11/05/2024. The RN explained the resident's emergency contact should have been called to obtain consents. If the resident had no POA or family, the RN would have referred to the supervisor. The RN confirmed R12 should not have signed the consents due to the resident's mental status. The RN acknowledged R12 could not understand the risks and benefits of the medications.The facility's policy titled Advance Directive dated 01/01/2025, documented during the admission process, the facility would identify the resident's primary decision maker or appropriate legal representative and invoked this person at any time the resident was assessed as unable to make relevant health care decisions.During the admission process, quarterly, annually, and when significant changes in condition occurred, the resident was evaluated for decision making capacity and invoked the health care agent or legal representative if the resident was determined not to have decision making capacity.

Based on interview, record review, and document review, the facility failed to ensure residents were kept safe from physical abuse for 4 of 37 sampled residents (Resident (R) 3, 53, 113, and 151). The deficient practice had the potential for the residents to experience emotional and physical harm.Findings include:1) Resident 3 (R3) was admitted on [DATE] with diagnoses including metabolic encephalopathy, dementia with behavioral disturbance, and delusional disorders. Resident 113 (R113) was admitted on [DATE] and discharged on 7/27/2025 with diagnoses including Parkinsonism, major depressive disorder, and dementia with mood disturbance.A facility reported incident (FRI) dated 06/25/2025 documented the following:-On 06/21/2025 at approximately 11:30 AM, R113 became agitated by noise made by R3 and threw a book at R3, resulting in a minor laceration to R3's forehead and redness in the right eye.-R3 and R113 were immediately separated and R113 was placed on one-to-one supervision.-Conclusion: The incident was verified and R3 was transferred to an acute care hospital for medical evaluation and returned with treatment orders for traumatic iritis.A Behavior / Psychiatric Change of Condition Progress Note dated 06/21/2025 documented R113 had a room change for safety and security and remained on one-to-one supervision.A Daily Skilled Progress Note dated 06/22/2025 documented R113 remained in room with one-to-one supervision. No complaints.A Care Plan dated 06/25/2025 documented R113 was involved in a resident-to-resident altercation with interventions to include one-to-one supervision, and to provide a calm, quiet space when R113 appears agitated. A Fall / Accident / Injury Progress Note dated 06/21/2025 documented R3 returned to the facility with no complaints, resting in bed and safe.A Care Plan dated 06/25/2025 documented R3 was involved in a resident-to-resident altercation with interventions to include providing redirection when agitation was observed.During the onsite investigation on 07/29/2025 through 08/01/2025, the facility correction of past non-compliance related to the incident occurred as evidenced by:-Observation of resident-to-resident interactions were polite and courteous.-R113 was discharged from the facility on 07/27/2025 and had not returned.-Staff indicated the facility provided continuing education regarding abuse.-Review of the facility's training records corroborated the staff interviews regarding training.-Review of facility schedules corroborated one-to-one supervision occurred for R113 until discharge on [DATE].On 08/01/2025 at 11:10 AM, the Administrator reviewed the information reported in the FRI and explained R113 purposefully threw the book at R3 resulting in the injury. The Administrator explained R113 was placed on one-to-one supervision for resident safety.2) Resident 53 (R53) was admitted on [DATE] with diagnoses including schizophrenia, atherosclerotic heart disease, and chronic obstructive pulmonary disease. Resident 151 (R151) was admitted on [DATE] and discharged on 06/07/2025 with diagnoses including atherosclerotic heart disease, type 2 diabetes mellitus, and chronic embolism and thrombosis of unspecified deep veins of bilateral lower extremity. A facility reported incident (FRI) dated 06/10/2025 documented the following:- On 06/07/2025 at approximately 9:30 AM, R151 kicked R53 after becoming agitated due to R53 moving slowly and not clearing the path to the smoking area. The altercation was witnessed and immediately reported.-Both residents were immediately separated to prevent further incidents.-Skin assessment was completed on R53 to evaluate for injury.-R151 was placed on legal hold due to the threat of harm to self or others and metro police were notified.-Conclusion: The allegation of physical abuse between R53 and R151 was verified based on the admission of R151 and corroborating witness report. Immediate action was taken to ensure the safety of all residents and staff, and ongoing monitoring was implemented for R53. R151 was removed from the facility on a legal hold. During the onsite investigation on 07/29/2025 through 08/01/2025, the facility correction of past non-compliance related to the incident occurred as evidenced by:Observation of resident-to-resident interactions was polite and courteous.On 07/29/2025 at 12:30 PM, R53 explained no issues and gets along with others, had no concerns. A Nursing Progress Note dated 06/07/2025 documented R151 kicked R53 in the leg. When asked what happened R151 stated, Yeah, I kicked R53 because would not move out of my way.A facility document titled Police Contact Card dated 06/07/2025 documented R151caused a disturbance in facility, R151 placed under legal hold.A Resident Notice of Transfer of discharge date d 06/07/2025 documented discharge to a local correctional facility.A Nursing Progress Note dated 06/08/2025 documented R53 had no acute distress noted and no bruising observed. A Skin / Wound Progress Note dated 06/10/2025 documented R53's skin was clear with no signs of injury noted. R53 alert with confusion and denied pain or discomfort.A Care Plan dated 06/10/2025 documented R53 was the victim in a resident-to-resident altercation, causing R53 to be kicked, resulting in no injuries with interventions including encourage R53 to participate in activities throughout the day.On 08/01/2025 at 11:05 AM, the Administrator explained R151 was removed from the facility by local law enforcement. The Administrator explained based on R151's behaviors, statements, and past interactions with other residents, R151's interactions were willful. Facility Reported Incident 2294603Facility Reported Incident 2294610

Based on interviews, record review and document review, the facility failed to ensure a resident with moderate cognitive impairment was adequately supervised and was not able to elope from the facility for 1 of 37 sampled residents (Resident 113). The deficient practice had the potential for physical and psychosocial harm to a resident. Findings include:Resident 113 (R113) was admitted on [DATE] and discharged on 7/27/2025 with diagnoses including Parkinsonism, major depressive disorder, and dementia with mood disturbance.The Quarterly Minimum Data Set (MDS) dated [DATE] documented a brief interview for mental status (BIMS) assessment score of nine indicating R113 had moderate cognitive impairment. The Annual MDS dated [DATE] documented a BIMS assessment score of three indicating R113 had severe cognitive impairment. A facility reported incident (FRI) dated 05/31/2025 documented the following:On 05/27/2025 at 9:00 AM, the Administrator was notified that R113 eloped from the facility this morning and was found at or around 8:00 AM and brought back to the facility. Upon R113's return, the nursing staff did a skin assessment and found no injuries. The following timeline was based on the investigation notes and interviews from the facility:-On 05/26/25 at 7:00-7:30 PM, a Certified Nurse Assistant (CNA) took R113's vital signs.-On 05/26/25 at 7:41 PM, a registered nurse (RN) administered medications to R113.-On 05/27/25 at 2:05 AM, security footage showed R113 exited through door #5 independently.-On 05/27/25 at 6:40 AM, a CNA noted R113 was not in the room and began a search of the facility.-On 05/27/25 at 7:00 AM, the Assistant Director of Nursing (ADON) and a Registered Nurse (RN) were notified.-On 05/27/25 at 7:33 AM, an elopement Code Pink was initiated and a search was conducted by staff.- On 05/27/25 at 8:00 AM, a staff member saw R113 walking on cross streets near the facility while on the way to work.-On 05/27/25 at 8:05 AM, staff confirmed via internal communication that R113 had been located, and a facility driver was dispatched.-On 05/27/25 at 8:15 AM, R113 was safely returned to the facility.-On 05/27/25 at 8:40 AM, a post-elopement assessment was performed. R113 was noted to be unharmed and wearing a wander guard bracelet.-On 05/27/25 at 1:05 PM, R113's guardian and physician were notified, and an order placed to move R113 to the secured unit.-On 05/27/25 at 3:34 PM, R113 continued to exhibit no signs of injury or distress.-On 05/27/25, 3:52 PM, R113 moved to secured unit.The facility findings documented:-Upon return, R113 was found to be wearing a wander guard bracelet on right wrist.-The wander guard did not trigger an alert at the time of exit, and further evaluation of the system was initiated. -The facility will conduct in-services on elopement prevention for staff.During the onsite investigation on 07/29/2025 through 08/01/2025, the facility correction of past non-compliance related to the incident occurred as evidenced by:A Physician Order dated 05/27/2025 documented admit R113 to secure unit, for high elopement risk.A Physician Order dated 05/27/2025 documented wear wander guard for elopement.A Care Plan dated 05/27/2025 documented R113 was an elopement risk due to cognitive impairment, episodes of wandering, and psychiatric diagnosis with interventions including wander guard check for placement at least daily and ensure the exit door alarms on the secured unit activates after entering or exiting the unit.Review of the R113's Treatment Administration Record (TAR) for July 2025 provided documented evidence the wander guard was checked daily as per physician orders.On 07/29/2025 at 1:06 PM, upon entry and exit of the secured unit the alarm was activated.On 08/01/2025 at 8:26 AM, a Registered Nurse (RN) explained had a machine in the medication cart that allows staff to test the functioning of the residents wander guard bracelet to ensure it is activated. The RN explained staff could also walk the resident to the door to ensure the device was activated. The RN explained that the nurses would check each shift to ensure the wander guard device was applied to the resident and the device was functional.On 08/01/2025 at 11:20 AM, the Administrator explained an oversight had occurred for not ensuring testing of the functionality for R113's wander guard bracelet / device. The Administrator explained that the maintenance department performed checks of the wander guard system routinely to ensure it was functioning properly at the doors. The maintenance department provided the monthly wander guard testing log that documented each door of the facility equipped with the wander guard system was checked Monday through Friday of each week throughout the month. The logs documented the system was functioning. The facility training records provided documented evidence training for elopement was conducted on 5/31/2025.Facility Reported Incident 2294607

Based on interviews, record review, and document review, the facility failed to ensure education regarding the risks and benefits of the pneumococcal, influenza, and covid-19 vaccines, and failed to ensure administration or obtain documented declinations for 2 of 5 residents sampled for infection control (Residents 95 and 155). The deficient practice compromised the facility infection prevention and control program and placed residents at increased risk for vaccine-preventable disease outbreaks, including respiratory illnesses with serious health consequences in vulnerable populations.Findings include:1) Resident 95 (R95) was admitted on [DATE] with diagnoses including infection of amputation stump, left lower extremity and cellulitis of the left limb.On 08/01/2025 in the afternoon, R95 could not recall being offered any immunizations or if staff explained the risk and benefits.2) Resident 155 (R155) was admitted on [DATE] with diagnoses including depression and chronic systolic heart failure.On 08/01/2025 in the afternoon, R155 could not recall being offered any immunizations or if staff explained the risk and benefits.The facility failed to provide evidence that R95 and R155 had been provided education on the risk and benefits of pneumococcal, influenza, and covid-19 immunizations.The facility failed to provide evidence the immunization status and / or immunizations were provided for R95 and R155.On 08/01/2025 at 3:22 PM, a Registered Nurse explained for new admissions that the nurse would interview resident, review discharge summary for immunization status, ask if the resident would like to have the immunization and obtain a signed consent from the resident and / or responsible party accepting or declining the immunization. Once consent obtained input physician order and administer.On 08/01/2025 at 1:00 PM, the Infection Preventionist (IP) verbalized after admission the IP would verify if a vaccine was administered previously. The admission packet contained information regarding vaccine status and the admission nurse would review with the resident. The IP would follow up generally within 48 hours after admission. The IP indicated there was no documented evidence of the vaccination status for R95 or R155.On 08/01/2025 at 3:40 PM, the Director of Nursing acknowledged there was no documented evidence of the vaccination status for R95 or R155.The facility policy titled Vaccination of Residents (revised 06/19/2025) documented immunization status was determined upon admission or soon afterword and was documented in the resident medical record.

Based on interview, record review and document review, the facility failed to ensure a resident was kept safe from physical abuse for 1 of 12 sampled residents (Resident 10). The deficient practice had the potential for the resident to experience emotional and physical harm. Findings include: Resident 10 (R10) R10 was admitted on [DATE] with diagnoses including acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and diabetes mellitus type 2. The facility reported incident (FRI) dated 12/23/2024 documented the following: -On 12/19/2024 at approximately 1:15 PM, R10 was in bed being cared for by two Certified Nurse Assistants (CNA), Employee 9 and 10 (E9 and E10). - Per E10 an exchange of inappropriate and abusive language occurred between E9 and R10. This verbal altercation escalated, leading to E9 striking R10 in the rib area with a closed fist. -Conclusion: The allegation of physical abuse by E9 against R10 was substantiated. The police department was contacted and responded to the incident. Subsequently E9 was taken into custody. A progress note dated 12/19/2024 documented R10 had a Head-to-toe assessment performed to check for bruising/wound progression. At that time no bruising or discoloration noted in patient chest & rib area. Patient has no complaints of pain or discomfort. A Social Service visit note dated 12/23/2024 documented the Social Services Director and Administrator visited R10 regarding the self-report. R10 was provided emotional support and offered Behavioral Health Services psych services, R10 denied the need for services. R10 reported no psychosocial harm from the incident and reported were not experiencing any emotional distress from the incident. A Care Plan dated 12/23/2024 documented R10 was involved in an altercation with a staff member. Interventions included the following: -Provide a safe environment for R10. -Ensure employees are aware of policies and procedures for Abuse prevention and reporting. -Encourage R10 to verbalize concerns. -Monitor R10 for behaviors associated with the incident. -Notify MD of any changes. On 02/13/2025 at 9:10 AM, R10 stated they share a room with their spouse. R10 stated had an incident with one CNA punching them in the left side of their ribs. The resident shared had started screaming and asked their spouse to get the Director of Nursing, another CNA was present in the room, and had stood there looking as if afraid. The staff intervened and handled the situation, and the CNA was arrested by the police. R10 verbalized were happy with how management handled the situation, and they feel safe in the facility. On 02/13/2025 at 1:15 PM the Director of Nursing (DON) confirmed E9 was immediately removed from R10's room and was suspended pending the investigation. The allegation of abuse was substantiated and was witnessed by another CNA resulting in termination and arrest of E9. The DON confirmed E9 was reported to the State Board of Nursing regarding the incident. During the onsite investigation on 02/13/2025, the facility's correction of the past non-compliance related to the incident occurred as evidenced by: -Observation of staff and resident interactions were professional and courteous. -Interviews with residents revealed the residents were happy with staff and were treated in a polite manner. - CNA's and Licensed Nurses indicated the facility provided continuing education regarding Abuse and Neglect. -Review of the facility's employee file for E9 revealed reference and background checks were completed. -Review of the facility's training records corroborated the staff interviews regarding training. Facility Reported Incident #NV00073005

Based on interview, record review and document review, the facility failed to ensure an alleged incident of verbal abuse was reported to the State Agency (SA) within the required timeframes for 1 of 12 sampled residents (Resident #11). The deficient practice had the potential to place residents at risk for incidents of verbal abuse to not be adequately protected. Findings include: Resident #11 (R11) was admitted to the facility 03/09/2023 with a diagnosis including parkinsonism, dysphagia, cognitive communication deficit, and depression. A Behavior Note dated 10/10/2024, documented R11 was standing in the hallway with a butter knife in their sleeve threatening to harm another resident. A Facility Reported Incident (FRI) was submitted to the SA on 10/15/2024, documenting the resident's alleged verbal abuse on 10/10/2024. On 12/18/2024 at 3:46 PM, the Administrator/Abuse Coordinator verbalized abuse without serious bodily harm should be reported to the SA within 24 hours of the incident. The Abuse Coordinator confirmed the FRI was not reported to the SA within the required timeframes. The facility policy titled Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, revised 10/2022, documented allegations of verbal abuse, which include threats, would be reported to the appropriate State or Federal agencies within two hours if the allegation involves abuse.

Based on observation, interview, and record review, the facility failed to ensure physician's orders for the application of heel protectors were followed for 1 of 12 sampled residents (Resident 5). The deficient practice had the potential to lead to the development of skin breakdown. Findings include: Resident 5 (R5) was admitted on [DATE], with diagnoses including [NAME] syndrome and peripheral vascular disease. Physician's orders dated 09/02/2023 documented: -Bilateral heel protectors on at all times when in bed every shift for pressure relief and skin prophylaxis. The wound care progress note dated 11/12/2024, documented R5 was treated for a chronic non-healing arterial ulceration of the left anterior fifth toe. This was a 30 day follow up for a previously healed wound. Wound remains healed. Please continue using preventive measures which can include turning and repositioning, offloading, and nutritional supplementation. On 12/18/2024 at 11:15 AM, R5 was noted to be lying on their back, on an air mattress in bed. One pair of blue heel protectors, a device used to minimize pressure to heels, was sitting on top of a three-drawer organizer located at the foot of R5's bed. On 12/18/2024 at 11:30 AM, R5's room door was closed, at 11:32 AM, two Certified Nurse Aides (CNA's) exited the room and R5 was noted to be lying on their back, slightly tilted to left side, with a wedge-shaped pillow under R5's right shoulder. One pair of blue heel protectors were sitting on top of a three-drawer organizer located at the foot of R5's bed. On 12/18/2024 at 2:02 PM, R5 was lying in bed on their back. One pair of blue heel protectors were sitting on top of a three-drawer organizer located at the foot of R5's bed. On 12/18/2024 at 11:43 AM, a CNA expressed R5's heel protector boots are applied and removed at different times during the day. On 12/18/2024 at 11:50 AM, a Licensed Practical Nurse (LPN) expressed R5 does not currently have wounds, the heel protectors were to be applied at night if a resident had wounds. On 12/18/2024 at 12:05 PM, the Wound Treatment Nurse expressed R5 was seen by wound care providers once a week. R5 previously had an area to the left pinky toe that was being treated but was currently healed as of 11/12/2024. The Wound Treatment Nurse verified R5 had a current order for bilateral heel protectors at all times and confirmed due to R5's history of prior wounds to their foot and R5's risk for skin breakdown, the heel protectors should be applied as ordered. On 12/18/2024 at 2:05 PM, the Director of Nursing (DON) verbalized the CNA's role for wound care prevention was to anticipate resident needs and provide turning and repositioning, place any supportive equipment such as heel protectors, and report any new skin issues to the licensed nurse. The DON verified R5 would require heel protectors to be in place as indicated in the physician's orders.

Based on observation, interview and document review, the facility failed to ensure it maintained an effective pest control program as evidenced by the presence of live cockroaches in the kitchen. The deficient practice had the potential to maintain the kitchen in a clean and sanitary manner. On 08/21/2024 in the morning during the kitchen inspection, two live baby cockroaches were identified in a corner behind the stove area near the triple compartment sink. Several dead baby cockroaches were seen in the same area. The floor surface behind the stove and under the sink were soiled with food debris and grease. The [NAME] and the Maintenance Director confirmed the observation. The [NAME] indicated pest control was conducted a couple weeks ago. On 08/22/2024 in the afternoon, the Maintenance Director provided proof of pest control performed on 08/07/2024. The Director acknowledged the report did not document if live insects were detected during the pest control visit. The facility policy titled Pest Control and last revised May 2024, documented the facility would maintain an ongoing pest control program to ensure the facility was kept free of insects.

Based on observation, interview, record review, and document review, the facility failed to establish a process to identify residents with newly found changes or diagnosis to be referred for Preadmission Screening and Resident Review (PASRR) Level 2 evaluation for 1 of 27 sampled residents (Resident 98). The deficient practice had the potential to place residents at risk of not being evaluated for appropriate determination of necessary behavioral health services. Findings include: Resident 98 (R98) Resident 98 was admitted on [DATE] and readmitted on [DATE], with diagnosis including encounter for orthopedic aftercare following surgical amputation, type 2 diabetes, and peripheral vascular disease. On 08/20/2024 at 9:42 AM, R98 was observed sitting upright in bed while watched television. R98 was welcoming, calm and did not display concerning or withdrawn behaviors when interviewed. A Nevada PASRR Level I Identification Determination dated 09/22/2017, revealed R98 did not have dementia, mental illness (MI), mental retardation (MR) or any related condition (RC), and was deemed appropriate for nursing facility placement. R98's Admission Record Diagnosis Information documented a new diagnosis of bipolar disorder with an onset date of 08/13/2024. R98's medical record lacked documented evidence a referral was made for PASRR level 2 evaluation after the newly found diagnosis of bipolar disorder on 08/13/2024. On 08/21/2024 at 4:18 PM, the Assistant Director of Nursing (ADON) reported not knowing the facility process to request a PASRR level 2 evaluation after a resident had a new diagnosis of mental illness. On 08/22/2024 at 9:55 AM, the Minimum Data Set (MDS) Coordinator explained R98's medical record should have been reviewed after the new diagnosis and a referral for evaluation for PASRR level 2 should have been completed. The evaluation would have let the facility know if the resident was in the correct level of care. The MDS Coordinator reported there was no system in place after a new diagnosis to evaluate for PASRR level 2, due to new management and new staff. A facility policy titled PASRR Completion Policy (undated), documented the center was to make sure that all admissions had the appropriate Patient Assessment and Resident Review (PASRR) completed.

Based on observation, interview, record review, and document review, the facility failed to formulate a person-centered care plan addressing fluid restrictions and resident's non- and to develop and implement a care plan for hydration for a resident at risk of dehydration for 2 of 27 sampled residents (Resident 112 and 93). This deficient practice had the potential to lead to fluid overload, inadequate management of fluid restrictions, an increased risk of dehydration, and further complications Findings include: A facility policy titled Care Plans, Comprehensive Person-Centered revised March 2022, documented a comprehensive, person-centered care plan included the measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident. Resident 112 (R112) R112 was admitted on [DATE], with diagnoses including end stage renal disease, dependence on renal dialysis and history of sudden cardiac arrest. The History and Physical dated 07/11/2024, documented R112's work up revealed possible fluid collection and R112 underwent fluid aspiration. The Minimum Data Set, dated dated dated [DATE], documented R112 was on hemodialysis treatment. A Physician Order dated 08/14/2024, documented Fluid Restriction 1000 milliliter (ml) diet. On 08/21/2024 at 9:10 AM, R112 was in bed, verbally alert, and oriented. R112's stomach was severely distended. A yellow pitcher with ice water approximately 1000 ml was in place, along with an extra-large colored drink approximately 887 ml, which the cup was almost empty. There was also a covered disposable cup containing a yellow-colored drink (approximately 100 ml) and a carton of Nephro approximately 237 ml. R112 indicated the drink was ordered from a food chain. R112 indicated being thirsty most of the time and being able to go to the bathroom to urinate. R112 indicated fluids were restricted to a liter a day, the kitchen was strict and adhered to the order. R112 indicated the Certified Nursing Assistants (CNAs) were providing the ice water. R112 indicated had undergone paracentesis previously due to fluid overload. R112's medical records lacked documented evidence a person-centered care plan for fluid restriction and R112's non-compliance were formulated. On 08/21/2024 at 10:11 AM, a Licensed Practical Nurse (LPN) indicated R112 was receiving dialysis treatments and on fluid restrictions. The LPN confirmed the observation, a pitcher of ice water was at bedside, juices and a carton of supplement. The LPN indicated R112 was non-compliant with fluid restriction and indicated R112 ordered outside food and drinks. The LPN indicated with R112's non-compliance, the physician should have been notified and care planned. The LPN confirmed there was no documentation of R112's fluid restriction and non-compliance. On 08/21/2024 at 11:49 AM, a Registered Nurse (RN) Supervisor, indicated the fluid restriction required a physician order, which should have been transcribed and implemented. The RN Supervisor verbalized non-compliance with the fluid restriction could lead to edema and congestive heart failure. The RN Supervisor indicated there should have been a care plan for the fluid restriction and R112's non-compliance, but the care plans were not formulated. On 08/21/2024 at 4:27 PM, the Director of Minimum Data Set (MDS) indicated the staff who admitted R112 or the Licensed Nurses who received the new order was responsible for formulating the person-centered care plan for the fluid restriction or non-compliance. 29141 Resident 93 (R93) R93 was admitted on [DATE], with diagnoses including dementia. R93's medical record documented the following laboratory results: Sodium levels: 08/18/2024: 146 milliequivalents per liter (mEq/L). 08/07/2024: 146 mEq/L. 07/22/2024: 147 mEq/L. 07/07/2024: 146 mEq/L. The normal blood sodium level was between 135 and 145 mEq/L. Creatinine levels: 08/18/2024: 1.56 milligram over deciliter (mg/dL) (A normal range for creatinine levels in men was 0.7-1.3 mg/dL). On 08/21/2024 at 12:20 PM, R93 was eating in the dining room. The meal consisted in a hamburger and potato salad. The resident declined the beverage offered, as expressed a preference to not consume any beverage. The nursing staff supervising the meal experience did not encourage fluids. On 08/21/2024 at 1: 00 PM, a Certified Nursing Assistant (CNA) explained R93 disliked water or any other drinks, some cases drink juice but nurses gave water during medication administration. A Physician Order dated 08/11/2024, indicated to encourage more fluid intake every shift for hypernatremia. A Dietitian visit note dated 08/21/2024, documented R93 refused to consume any fluids provided and only consumed a few drops for medications. The note revealed despite having intravenous fluids, R93 was unable to maintain hydration. R93 had a no-added-salt (NAS) renal diet with a regular composition and thin liquids, and their oral intake was moderate to fair, but high-moisture foods were provided. The note indicated if the resident could not maintain hydration, a percutaneous endoscopic gastrostomy (PEG - a feeding tube inserted through the skin into the stomach to provide nutrition and hydration when inability to eat or drink is present) could be necessary to address their nutritional requirements. The medical record lacked documented evidence a care plan for hydration was initiated. On 08/21/2024 at 2:00 PM, a License Practical Nurse (LPN) assigned to provide care to R93, confirmed the record did not contain a care plan for hydration. The LPN acknowledged a care plan could provide different approaches to ensure R93 was hydrated. The facility policy titled Nutrition and Hydration to Maintain Skin Integrity with the last revision performed in October 2010, documented the purpose of the procedure was to provide guidelines for the assessment of resident nutritional needs, to aid in the development of an individualized care plan for nutritional interventions, and to help support the integrity of the skin through nutrition and hydration. The policy indicated dehydration risk factors included functional impairments, dementia, and/or fluid refusal, and a care plan should be documented in the medical record to address the risk factors.

Based on observation, record review, interview, and document review, the failed to provide oral care for a patient with total dependent functional status for 1 of 27 sampled residents (Resident 26). The deficient practice had the potential to place residents at risk for infection, aspiration pneumonia, and affecting residents' quality of life. Findings include: Resident 26 (R26) R26 was admitted on [DATE], with diagnoses including Alzheimer's, hypothyroidism, hypertension, dysphagia, and schizoaffective disorder. R26 was receiving hospice care. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed R26 was dependent for oral care and helper would do all of the effort, requiring the assistance of 2 or more helpers. On 08/20/24 at 3:42 PM, R26 was observed with a dry mouth with white stringy material in the mouth. A Licensed Practical Nurse (LPN) confirmed the observation and indicated the Certified Nursing Assistant should have provided oral care. A Care plan dated 07/25/2024, documented R26 had potential for oral/dental health problems without teeth or dentures and should have daily mouth care. A review of the Oral Care Record from 07/24/2024 through 08/22/2024, revealed the oral care was provided inconsistently. On 08/22/2024 at 1:45 PM, the Director of Nursing (DON) explained oral care should have been provided by the staff regardless of the resident receiving hospice care. The DON indicated oral care should have been provided at least twice daily, once in the morning prior to breakfast, and before bedtime, or more often if it was needed. The facility undated policy titled Mouth Care documented the purpose of the oral care was to keep the resident's lips and oral tissue moist, to clean and fresh resident's mouth, and to prevent oral infections.

Based on interview and record review, the facility failed to ensure professional standards were followed for a choking resident by administering emergency first aid such as abdominal thrust, for 1 of 8 sampled residents (Resident #1). The deficient practice resulted in the resident being unable to expel the foreign object from their airway. Resident #1 (R1) R1 was originally admitted on [DATE] and readmitted on [DATE], with diagnoses including cerebral vascular accident (CVA), vascular dementia, aphasia (disorder that affects the ability to communicate), dysphagia (swallowing difficulties), and esophageal stricture (an abnormal narrowing of the esophageal lumen). R1's history and physical dated [DATE], documented R1 had history of CVA with aphasia and dysphagia. R1 was on mechanical soft diet with thin liquids. Medical record revealed R1 was under hospice care and had a physician order for life-sustaining treatment (POLST) dated [DATE] that indicated to allow natural death, do not attempt resuscitation, no intubation, no mechanical ventilation, and no defibrillation. The order indicated when not in cardiopulmonary arrest, life-sustaining treatment could be ordered for a trial period to determine if there was benefit to the patient. A physician order dated [DATE], documented a Registered Nurse (RN) may pronounce the resident deceased and release the body to mortuary. The order was effective for 120 days and expired on [DATE]. The medical record did not document a new RN to pronounce order. Nursing SBAR (Situation, Background, Assessment, Recommendation) note dated [DATE] documented R1 was choking at the nursing station and was unable to expel dislodged food from throat. The SBAR note stated R1 was a hospice patient and had orders for do not resuscitate (DNR). The documented action requested or recommended to solve R1's choking situation, R1 was taken to their room from wheelchair to lay in bed and notify the Hospice agency. The SBAR note did not document if a physician or emergency medical services were called to provide R1 with emergency treatment to clear their airway. There is no documented evidence first aids were provided to R1. Nursing progress note dated [DATE], revealed R1 did not have sign of pulse, respiration, heartbeat, and pupil reaction. Resident was pronounced at 5:50 PM by the Director of Staff Development (DSD). The nursing progress note lacked documented evidence emergency treatment was administered to R1. The medical record lacked documented evidence about the details of the choking incident, the exact time when occurred, the type of food the resident was consuming, and the type of first aid dispensed. Care Plan for dysphagia initiated on [DATE], revealed R1 was at risk for aspiration. Interventions included staff to be informed of R1 special dietary and safety needs, alternate small bites, and sips, using a teaspoon for eating, monitor for shortness of breath, choking, labored respirations. On [DATE] at 2:30 PM, the Medical Director explained residents in hospice care were treated to have comfortable end of life. If a resident was choking with food, the situation was not comfortable and required immediate interventions to dislodge the food. If the nurses were not able to dislodge the food by encouraging cough or by abdominal thrusts, the emergency medical services should have been activated regardless of whether the patient was in hospice care or had order for do not resuscitate. The Medical Director verbalized a resident choking should not be put on a bed as it makes it difficult to apply lifesaving measures. The medical Director agreed a resident choking was not close to dying from a natural cause, and there was an obvious problem that required an emergency intervention. On [DATE] at 3:40 PM, a Licensed Practical Nurse (LPN), explained if a resident was choking on food, first aid should be provided immediately including abdominal thrusts maneuver to attempt to dislodge the food. If the maneuver was unsuccessful, 911 should be called to activate the emergency medical services regardless of the resident code status or hospice care. On [DATE] at 4:00 PM, an LPN outlined the first aid protocol for a resident who was choking included performing abdominal thrusts method to dislodge the food. If the maneuver was unsuccessful, the resident's code status or hospice care status made no difference and 911 must be contacted to summon emergency medical help. The LPN verbalized residents had the right for care and choking on food was far from being a comfortable situation. On [DATE] at 4:15 PM, the Director of Nursing (DON) indicated choking on food was an uncomfortable event that required immediate lifesaving intervention provided in the place where the incident occurred. The DON explained whether a resident is in a DNR status or receiving hospice care, a call to 911 should be made to activate emergency medical services if the first aids applied were unsuccessful. The DON confirmed the medical record did not document the interventions implemented during the event and the details of the incident. On [DATE] at 4:30 PM, the DSD explained the day of the incident R1 was receiving assistance with dinner at the nursing station in the rehabilitation unit. The DSD reported seeing a Certified Nursing Assistant (CNA) assisting R1 with the meal on their walk to the office of the House Supervisor. After around 10 to 15 minutes, the DSD was summoned to R1's room. The DSD found R1 unresponsive in bed. After the DSD assessed the resident, it was determined that R1 had no vital signs and proceeded to pronounce R1's death. The DSD was unaware of any life-saving measures implemented by the staff during the incident prior to arrival to R1's room. The DSD verbalized emergency medical services should have been activated to provide medical care to the resident regardless of whether the resident was receiving hospice care or a DNR status. On [DATE] at 4:40 PM, an attempt to contact the CNA who was assisting R1 with the dinner the day the incident occurred via phone call. The CNA was not available, and a message was left. The phone call was performed by the DSD. On [DATE] at 5:00 PM, an on-call nurse representative of the hospice agency was contacted via phone call. The nurse confirmed if a resident choked on food, first aid should be administered immediately, including abdominal thrust maneuvers to dislodge the food. If the maneuver fails, call 911 to activate emergency medical services regardless of whether the resident was receiving hospice care or a code status. The facility policy titled Emergency Procedure- Choking, dated [DATE], documented choking residents would be helped by trained staff to remove the foreign body from the throat. If the resident was aware, standing or seated, check the resident for choking and ask the resident to cough to eliminate any foreign item if they can. The policy indicated to execute abdominal thrusts if the resident could not cough and continue thrusting until the foreign body was evacuated or the resident lost consciousness. If the resident was unconscious, gently lower the resident and call for aid if needed. Place the resident on their back with arms at their sides and perform abdominal thrusts by putting one hand's heel on the resident's upper mid-abdomen, below the rib cage and above the navel, with fingers directed toward the chest, overlap the other hand, and quickly push your hands inside the resident's upper abdomen. Check for foreign bodies with the finger sweep. If unable to clear the foreign body from obstructing the airway, arrange emergency transport of the resident to the nearest acute care medical facility. The policy revealed documentation should be included in the resident's medical record by the individual performing this procedure that included the date and time the procedure was carried out, the name and title of the person or persons who performed the treatment, the exact time the choking started, the exact timing of any unconsciousness, all assessment information gathered during the operation, the beginning and ending times of the process, the resident's response to the treatment, and the signature and position of the individual recording the data. Complaint #NV00067675

Based on interview and record review, the facility failed to ensure emergency medical services were activated to transport a choking resident to an acute care facility when staff were unable to clear the foreign body obstructing the airway, for 1 of 8 sampled residents (Resident #1). The deficient practices resulted in the deprivation of emergency procedures to clear the resident's airway. Findings include: Resident #1 (R1) R1 was originally admitted on [DATE] and readmitted on [DATE], with diagnoses including cerebral vascular accident (CVA), vascular dementia, aphasia (disorder that affects the ability to communicate), dysphagia (swallowing difficulties), and esophageal stricture (an abnormal narrowing of the esophageal lumen). R1's history and physical dated [DATE], documented R1 had history of CVA with aphasia and dysphagia. R1 was on mechanical soft diet with thin liquids. Medical record revealed R1 was under hospice care and had a physician order for life-sustaining treatment (POLST) dated [DATE] that indicated to allow natural death, do not attempt resuscitation, no intubation, no mechanical ventilation, and no defibrillation. The order indicated when not in cardiopulmonary arrest, life-sustaining treatment could be ordered for a trial period to determine if there was benefit to the patient. A physician order dated [DATE], documented a Registered Nurse (RN) may pronounce the resident deceased and release the body to mortuary. The order was effective for 120 days and expired on [DATE]. The medical record did not document a new RN to pronounce order. Nursing SBAR (Situation, Background, Assessment, Recommendation) note dated [DATE] documented R1 was choking at the nursing station and was unable to expel dislodged food from throat. The SBAR note stated R1 was a hospice patient and had orders for do not resuscitation (DNR). The documented action requested or recommended to solve R1's choking situation was R1 was taken to their room from wheelchair to lay in bed and notify the Hospice agency. The SBAR note did not document if a physician or emergency medical services were called to provide R1 with emergency treatment to clear their airway. There is no documented evidence first aids were provided to R1. Nursing progress note dated [DATE], revealed R1 did not have sign of pulse, respiration, heartbeat, and pupil reaction. Resident was pronounced at 5:50 PM by the Director of Staff Development (DSD). The nursing progress note lacked documented evidence emergency treatment was administered to R1. The medical record lacked documented evidence about the details of the choking incident, the exact time when occurred, the type of food the resident was consuming, and the type of first aid dispensed. Care Plan for dysphagia initiated on [DATE], revealed R1 was at risk for aspiration. Interventions included staff to be informed of R1 special dietary and safety needs, alternate small bites, and sips, using a teaspoon for eating, monitor for shortness of breath, choking, labored respirations. On [DATE] at 2:30 PM, the Medical Director explained residents in hospice care were treated to have comfortable end of life. If a resident was choking with food, the situation was not comfortable and required immediate interventions to dislodge the food. If the nurses were not able to dislodge the food by encouraging cough or by abdominal thrusts, the emergency medical services should have been activated regardless of whether the patient was in hospice care or had order for do not resuscitate. The Medical Director verbalized a resident choking should not be put on a bed as it makes it difficult to apply lifesaving measures. The medical Director agreed a resident choking was not close to dying from a natural cause, and there was an obvious problem that required an emergency intervention. On [DATE] at 3:40 PM, a Licensed Practical Nurse (LPN), explained if a resident was choking on food, first aid should be provided immediately including abdominal thrusts maneuver until able to dislodge the food. If the maneuver was unsuccessful, 911 should be called to activate the emergency medical services regardless of the resident code status or hospice care. On [DATE] at 4:00 PM, an LPN outlined the first aid protocol for a resident who was choking included performing abdominal thrusts method to dislodge the food. If the maneuver was unsuccessful, the resident's code status or hospice care status made no difference and 911 must be contacted to summon emergency medical help. The LPN verbalized residents had the right for care and choking on food was far from being a comfortable situation. On [DATE] at 4:15 PM, the Director of Nursing (DON) indicated choking on food was an uncomfortable event that required immediate lifesaving intervention provided in the place where the incident occurred. The DON explained whether a resident is in a DNR status or receiving hospice care, a call to 911 should be made to activate emergency medical services if the first aids applied were unsuccessful. The DON confirmed the medical record did not document the interventions implemented during the event and the details of the incident. On [DATE] at 4:30 PM, the Director of Staff Development (DSD) explained the day of the incident R1 was receiving assistance with the dinner at the nursing station in the rehabilitation unit. The DSD reported seeing a Certified Nursing Assistant (CNA) assisting R1 with the meal on their walk to the office of the House Supervisor. After around 10 to 15 minutes, the DSD was summoned to R1's room. The DSD found R1 unresponsive in bed. After the DSD assessed the resident, it was determined that R1 had no vital signs and proceeded to pronounce R1's death. The DSD was unaware of any life-saving measures implemented by the staff during the incident prior to arriving at R1's room. The DSD verbalized emergency medical services should have been activated to provide medical care to the resident regardless of whether the resident was receiving hospice care or a DNR status. On [DATE] at 4:40 PM, an attempt was made to contact the CNA who was assisting R1 with the dinner the day the incident occurred via phone call. The CNA was not available, and a message was left. The phone call was performed by the DSD. On [DATE] at 5:00 PM, an on-call nurse representative of the hospice agency was contacted via phone call. The nurse confirmed if a resident choked on food, first aid should be administered immediately, including abdominal thrust maneuvers to dislodge the food. If the maneuver fails, call 911 to activate emergency medical services regardless of whether the resident was receiving hospice care or a code status. The facility policy titled Emergency Procedure- Choking, dated [DATE], documented choking residents would be helped by trained staff to remove the foreign body from the throat. If unable to clear the foreign body from obstructing the airway, arrange emergency transport of the resident to the nearest acute care medical facility. Complaint #NV00067675

Based on observation, interviews, clinical record review, and document review, the facility failed to ensure adequate supervision and 15-minute safety checks were implemented to prevent an elopement for 1 of 11 sampled residents (Resident #1). Findings include: Resident #1 (R1) was admitted on [DATE], with a primary [DIAGNOSES REDACTED]. A facility report dated 01/18/2020, documented R1 had eloped from the facility and was found outside in the parking lot unharmed. A physician's orders [REDACTED]. R1's care plan dated 01/22/2020, documented R1 would be monitored by staff to ensure the resident did not leave the facility unattended and to monitor the resident's location every 15 minutes while awake. A review of R1's clinical record revealed 15-minute safety checks were not completed from 02/19/2020 to 05/19/2020. A behavior chart used for behavior monitoring dated 05/12/2020 documented R1 escaped from the facility at 5:00 PM, and a search was conducted. R1 was found trying to enter an apartment complex located next to a major intersection at 6:30 PM. A Progress Note dated 05/12/2020, documented at approximately 6:00 PM, a Certified Nursing Assistant (CNA) alerted, a Licensed Practical Nurse (LPN) R1 was missing. The LPN instructed all CNAs on the unit to check residents' rooms, bathrooms, common areas, and utility rooms. R1 was not found in those areas. A facility report dated 05/12/2020, documented at approximately 6:00 PM a CNA alerted the LPN, R1 was missing. The Resident Care Coordinator (RCC) was notified and contacted 911. At 6:30 PM, R1 was found by staff unharmed walking into a nearby apartment complex, and the 911 call was canceled. On 05/15/2020 at 12:27 PM, the LPN who was working on the unit at the time of R1's elopement revealed she was charting at the nurse station located approximately 14 feet (ft) from the door R1 used to elope. The LPN indicated a CNA redirected a different resident away from the door at the time of the incident. The LPN was first notified R1 was missing on 05/12/2020 at approximately 6:00 PM. The LPN indicated R1 had eloped at approximately 5:00 PM. The LPN confirmed R1's location was not monitored every 15 minutes, per the physician's orders [REDACTED]. On 05/19/2020 at 3:55 PM, a CNA who was caring for R1 at the time of the incident indicated R1 had eloped from the facility at approximately 5:00 PM on 05/12/2020 and notified the LPN, R1 was missing at 6:00 PM on 05/12/2020. The CNA confirmed 15-minute checks to monitor R1's location were not completed on 05/12/2020. On 05/15/2020 at 1:58 PM, the RCC indicated video footage of the incident revealed a CNA and an LPN were sitting at the nurse's station charting at the time of the incident. The RCC explained a different resident was observed pushing on the secured unit door until it eventually opened. The RCC indicated when pushed consecutively for 15 seconds, the door would open, and an alarm would sound. The RCC verbalized once the door opened, R1 eloped through the door. The RCC explained after R1 eloped, the CNA looked up and intervened by redirecting the resident who was observed pushing on the door, and ensured the door was secured. The RCC verbalized the CNA should have walked the hallways outside of the secured unit to ensure no residents had eloped unobserved. The RCC confirmed the video footage documented R1 eloped through the door on 05/12/2020 at 4:57 PM. On 05/15/2020 at 3:56 PM, the Director of Nursing (DON) indicated 15-minute safety checks to monitor R1's location were not completed from 02/19/2020 to 05/15/2020. The DON explained the 15-minute safety checks should have been completed. The DON indicated a physician's orders [REDACTED]. On 05/19/2020 at 10:06 AM, one-to-one supervision for R1 was not observed. R1's clinical record lacked documented evidence a physician's orders [REDACTED]. On 05/19/2020 at 10:11 AM, an LPN confirmed 15-minute safety checks for R1 had not been completed from 05/12/2020 to 05/19/2020. The LPN was unaware of any new interventions put into place since R1 eloped on 05/12/2020. On 05/19/2020 at 3:57 PM, a CNA who provided care for R1 on 05/17/2020 revealed R1 had not received one-to-one supervision. The Medical Records Supervisor acknowledged the clinical record lacked documented evidence 15-minute checks were completed from 02/19/2020 through 05/18/2020. R1's care plan lacked documented evidence a new intervention for R1's elopement risk to include one on one supervision was developed. The facility's policy titled 15-minute Checks revised on 05/19/2020, documented CNAs would document the 15-minute check activity every 15 minutes. The facility's policy titled Elopement/Wandering/Exit Seeking, Unsafe Resident revised on 05/19/2020, documented residents who were an elopement/wandering/exit seeking would be on 15-minute checks unless other orders were written. The nurse who received the order for 15-minute checks would be responsible for entering the order on the treatment sheet, filling out a 15-minute log, give to assigned CNA, and place a green band on the resident. On 05/19/2020 in the afternoon, R1's clinical record was reviewed with the Medical Records Supervisor for previous documentation regarding the 15-minute checks ordered on [DATE]. The current physician order [REDACTED]. The overflow chart review revealed a pattern of failing to document the 15-minute checks. The Medical Records Supervisor acknowledged the clinical record lacked documented evidence 15-minute checks were completed from 02/19/2020 through 05/18/2020. R1's care plan lacked documented evidence new interventions for R1's elopement risk tendencies. Facility Reported Incident #NV 059

Based on observation, record review, interview and document review, the facility failed to ensure a prescribed feeding formula was properly administered to a resident in order to provide the calories and protein recommended by a dietitian, failed to follow facility policies of weight management, promptly implement dietary recommendations for weight loss, failed to promptly notify the Attending Physician regarding the severe weight loss and failed to initiate and implement a care plan for weight loss for 1 of 24 sampled residents (Resident #5). Findings include: Facility policy titled Weight Monitoring- Identifying Residents at Nutritional Risk dated October 2015, indicated a resident that weighs over 100 pounds (Lbs) would be reweighed within 24 hours if the monthly weight showed a change greater than 5 Lbs. The policy directed the Dietary Manager to document significant weight changes (more than 3 % in a week, more than 5 % in a month, more than 7.5 % in 90 days and more than 10 % in 180 days. The policy documented a resident would require a higher degree of interventions if the resident had a tube-feeding, pressure ulcer and [MEDICAL CONDITION]. Facility policy titled Weight Assessment and Intervention documented that weight changes 5 % or greater identified since the last weight assessment should be retake the next day to confirm the change and the Registered Dietitian should be notified immediately in writing by nursing if weight change was verified. The policy defined the following criteria for significant weight loss; in one month, 5 % of weight loss was significant and greater than 5 % was severe. In 3 months, 7.5 % of weight loss was significant and greater than 7.5 % was severe and in six months, 10 % of weight loss was significant and greater than 10 % was severe. The policy documented a care plan for weight loss would be a multidisciplinary effort and addressed the identification of the cause of the weight loss, goals for improvement and time frame and parameters for monitoring and reassessment. Resident #5 Resident #5 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #5's admission assessment dated [DATE], revealed an initial weight of 141 pounds (Lbs.). The assessment documented the resident did not have [MEDICAL CONDITION]. Nurses notes dated 11/17/16 at 1:33 AM and 11/18/16 at 1:13 AM, documented the resident had a +1 [MEDICAL CONDITION] in the left upper extremity (scale to determine the severity of the [MEDICAL CONDITION]. Pressure is applied to the swollen area with a finger. The scale number indicated the persistence of the skin indentation. +1 [MEDICAL CONDITION] is a barely detectable impression when finger is pressed into skin). There was not other body area identified with [MEDICAL CONDITION]. The record did not document the resident was receiving diuretics due to the left upper extremity [MEDICAL CONDITION]. 1) Admission order dated 11/15/16, documented an order for [REDACTED]. The resident should have received about 2,500 cc of fluids (formula plus water) in a daily basis from 12/1/16 through 12/8/16. Medication Administration Record (MAR) documented the following intakes while the resident was receiving the formula [MEDICATION NAME]: 12/1/16: 2,300 cc (200 cc less than ordered). 12/6/16: 2,300 cc (200 cc less than ordered). 12/7/16: 2,300 cc (200 cc less than ordered). 12/8/16: 2,200 cc (300 cc less than ordered). The MAR documented the resident did not receive the prescribed amount of fluids. Physician order [REDACTED]. The resident should have received about 2100 cc of fluids (formula plus 1,500 cc of water) in a daily basis from 12/9/16 through 12/13/16. MAR documented the following intakes while the resident was receiving the formula [MEDICATION NAME] Renal: 12/9/16: 1,900 cc (200 cc less than ordered). 12/10/16: 1,770 cc (330 cc less than ordered). 12/11/16: 1,800 cc (300 cc less than ordered). 12/12/16: 1,990 cc (110 cc less than ordered). 12/13/16: 1,210 cc (890 cc less than ordered). On 12/14/16 at 10:14 AM, an inspection was conducted in Resident #5's bedroom. A Kangaroo (trade mark) tube-feeding bag was observed hanging in a pole and connected to a infusion pump. The bag contained about 300 ml of formula. The label of the bag indicated [MEDICATION NAME] Renal at 30 ml per hour started at 10 AM on 12/13/16. The pump was off and the infusion set disconnected from the [DEVICE]. On 12/14/16 at 12:09 AM, a medication pass observation was conducted with a Registered Nurse (RN). The RN explained two cans of Novasourse were put into the tube-feeding bag at 10 AM but the feeding was not initiated due to a gastric residual of 60 ml. The RN indicated at 11:50 AM, the gastric residual was checked again and the tube-feeding initiated. The RN said the residual had to be checked after an hour and if there was no residual, the tube feeding had to be started. The RN acknowledged the residual was checked two hours later and the feeding started at 11:50 AM instead at 11:00 AM. The RN confirmed she always put two cans of the formula to be administered in 20 hours. Review of the label of a [MEDICATION NAME] Renal indicated a can contained 237 ml of formula. The RN was providing 474 ml of formula instead 600 ml as prescribed. On 12/14/16 at 1:55 PM, Resident #5's infusion pump was check with the RN. The pump history indicated that for the last 72 hours the resident received 1,394 ml of formula instead 1,800 ml (600 ml per day). The resident missed about 406 ml of formula in 72 hours that represent 812 calories and 36.8 grams of protein. On 12/15/16 at 7:00 AM, Resident #5's infusion pump was check with the RN. The pump was off and the history indicated that for the last 24 hours the resident received 503 ml of formula instead 600 ml as prescribed. Resident #5' medical record revealed a discrepancy between the MAR and the data recorded in the history of the infusion pump. The MAR documented 5,000 ml of fluids (formula and water) were administered from 12/11/16 through 12/13/16, while the infusion pump documented 3,878 ml in the same period of time (a discrepancy of 1,122 ml). The resident had to receive 6,300 ml of prescribed fluids, including water and formula. Initial dietary nutritional assessment dated [DATE], documented the following parameters: Weight: 142 Lbs. Ideal Body Weight (IBW): 99-126 (113) Lbs. Resident Usual Body Weight: 150 Lbs Body Mass Index (BMI): 27 Adjusted IBW due to left above knee amputation: 89-115 (93) Lbs. Calories needed: 1936. Protein needed: 65-77 grams Fluids needed: 2275 ml. Resident 5#'s medical record revealed a discrepancy between the daily calories calculated by the Registered Dietitian (RD) in the initial dietary assessment and the calories provided by the prescribed feeding formulas. Dietary progress note dated 11/29/16, documented the RD was notified about weight loss of 4.6 Lbs in seven days, from 11/22/16 to 11/29/16. RD progress note dated 12/6/16, documented a recommendation to change the formula to [MEDICATION NAME] Renal due to high blood levels of potassium. The recommendation indicated the new formula should be administered at 30 ml per hour for 20 hours to provide 600 ml of formula at day, 1,200 calories and 54 grams of protein. The note documented the resident lost 5 Lbs in one week and recommended to increase the TF formula from 600 ml to 900 ml to provide 1,800 calories if weight loss continued. Physician order [REDACTED]. Weight and vital summary dated 12/7/16, documented a weight of 128.4 Lbs. The summary indicated the resident had a weight loss of 5.9 % from 11/29/16 ( 8.1 Lbs) and 9.6 % over 30 days from 11/17/16. There was not documented evidence the resident was reweighed within 24 hours after the severe weight loss was identified and the Attending Physician notified about the weight change. Dietitian progress note dated 12/14/16, revealed 13 pounds weight loss since admission was identified. Current weight of 128.6 Lbs. The dietitian documented less [MEDICAL CONDITION] per nursing notes and a recommendation to increase the tube-feeding formula to 45 ml per hour for 20 hours to provide 900 ml of formula, 1,800 calories and 81 grams of protein. Weight change note dated 12/15/16 at 4:31 PM, documented the severe weight loss and the notification to the Attending Physician about weight change and Dietitian recommendation to increase the tube-feeding formula. The Physician was notified eight days after the weight change was identified on 12/7/16. Laboratory reports documented the following results: 11/16/16: [MEDICATION NAME] 2.3 grams over deciliter (g/dL). Reference range: 3.5 - 5.7 Pre-[MEDICATION NAME]: 9.7 milligram over deciliter (mg/dL). Reference range: 17.0 - 40.0 12/01/16: [MEDICATION NAME]: 2.7 g/dL. Reference range: 3.5 - 5.7 Pre-[MEDICATION NAME]: 12.8 mg/dL. Reference range: 17.0 - 40.0 The medical record did not document newest [MEDICATION NAME] test. On 12/16/16 at 10:25 AM, the Dietary Manager explained she performed the weight evaluation and determined the percent of weight changes in resident. The data was revised by the Registered Dietitian who made diet change recommendations. The RD would be notified when significant weight changes were identified. On 12/16/16 at 2:36 PM, the RD explained the tube feeding formula was recommended based on the residents nutritional needs and medical conditions and calories were calculated based on the resident weight. The RD indicated to monitor the residents intake was based on whatever order for tube feeding the residents had. The RD confirmed she did not check the MAR and typically did not review the residents daily intake documentation. The RD verbalized she was aware about Resident #5's weight loss and recommendations were made recently to increase the tube feeding formula. The RD acknowledged she was not aware about the discrepancies in the intake data that showed the resident was not receiving the prescribed amount of fluids and feeding formula. Care plan dated 11/23/16, indicated Resident #5 required tube feeding related to swallowing problem and was dependent with tube feeding and water flushes. The care plan documented approaches including the RD to evaluate quarterly and as needed and monitor caloric intake. The medical record lacked documented evidence a care plan for weight loss was initiated.

Based on observation, interview and document review, the facility failed to ensure prescribed amount of feeding formula to moderate the potassium intake was administered to a resident with high levels of serum potassium for 1 of 24 sampled residents (Resident #18), ensure water and tube feeding formula were infused through gastric tubes ([DEVICE]) in correct amounts on a daily basis as ordered by the physician for 5 of 24 sampled residents (Resident #18, #5, #17, #7 and #15) . 2. Ensure formula was administered per manufacturers instructions within 24 hours of opening for 2 of 24 residents (Resident #7 and #17). Findings include: Facility policy titled Enteral Tube Feeding via Continuous Pump dated December 2011, documented the following procedures: -When checking gastric residual in a patient with [DEVICE] and the residual was more than 250 milliliters (ml), the feeding had to be withhold and rechecked in one hour and notified the physician if the second check was more than 250 ml. -When checking gastric residual in a patient with [DEVICE] and continuous tube feeding, the stomach should not have more than the total intake from the last hour, if so, the feeding would be hold and the physician notified. - The person that performed the tube feeding procedure should record information that included the date and time of the procedure, the amount and type of enteral feeding, the name and title of the person who performed the procedure and all assessment data during the procedure. Facility policy titled Enteral Feeding - Safety Precautions dated December 2011, documented the following: - Sterile formulas decanted in open system should be hung for eight hours and closed-system enteral formulas could be hung between 24 to 48 hours following the manufacturer's recommendations. - Administration sets for open system enteral feeding should be changed at least every 24 hours and sets for close-systems should be changed following the manufacturer's recommendations. - The date and time the formula was hung and the initials of the person who performed the procedure had to be documented in the formula label. Kangaroo (trade mark) feeding bag instructions documented in the bag packet and in the bag label, indicated the bag could not be used for more than 24 hours. Enteral tube feeding pump operating manual dated 2009, recommended the hanging time for the formulas to do not exceed 24 hours but extended up to 48 hours for closed system. The manual indicated that using a set for more that 24 hours could impact the accuracy of the feeding pump. Resident #18 Resident #18 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #18 had an order for [REDACTED]. In addition, there was an order dated 10/21/16, to flush the [DEVICE] with 200 cc of water every six hours (800 cc/day). The total amount of fluid intake (formula and water) prescribed for Resident #18 was 2,500 cc per day. Monitor intake and output record documentation for November 2016, did not include an assessment tool to confirm the correct volume of enteral formula and or water was infused every 24 hours as ordered by the physician. The record evidenced Resident #18 was receiving more fluids than the prescribed as follow: 11/1/2016: 3,121 cc (621 cc more than ordered). 11/2/2016: 3,899 cc (1,399 cc more than ordered). 11/3/2016: 3,130 cc (630 cc more than ordered). 11/4/2016: 2,713 cc (213 cc more than ordered). 11/5/2016: 2,795 cc (295 cc more than ordered). 11/6/2016: 3,098 cc (598 cc more than ordered). 11/7/16: 2,873 cc (373 cc more than ordered). 11/8/16: 3,187 cc (687 cc more than ordered). 11/9/16: 3,400 cc (900 cc more than ordered). 11/11/2016: 3,080 cc (580 cc more than ordered). 11/12/2016: 2,880 cc (380 cc more than ordered). 11/13/2016: 3,115 cc (615 cc more than ordered). 11/14/2016: 3,151 cc (651 cc more than ordered). 11/15/2016: 3,153 cc (653 cc more than ordered). 11/16/2016: 3,728 cc (1,228 cc more than ordered). 11/17/2016: 3,045 cc (545 cc more than ordered). 11/18/2016: 3,450 cc (950 cc more than ordered). 11/19/2016: 2,800 cc (300 cc more than ordered). 11/20/2016: 2,860 cc (360 cc more than ordered). 11/21/2016: 2,830 cc (330 cc more than ordered). 11/22/2016 : 3,251 cc (751 cc more than ordered). 11/23/2016: 3,979 cc (1,479 cc more than ordered). 11/27/2016: 2,695 cc (195 cc more than ordered). Medical record revealed that on 11/23/16, the RD was consulted due to the high levels of potassium in blood and recommended to change the formula [MEDICATION NAME] to [MEDICATION NAME] at 85 cc per hour for 10 hours to provide 803 mg of potassium. The new formula order was signed on 11/30/16 and started on 12/3/16. Review of Resident #18's medical record revealed an enteral feed order dated 11/30/16, for [MEDICATION NAME] Renal 85 cc per hour for 10 hours to provide 850 cc of formula and 1,700 calories to be started at 8:00 PM and stopped at 6:00 AM. In addition, there was an order dated 10/21/16, to flush the [DEVICE] with 200 cc of water every six hours. The total amount of fluid intake (formula and water) prescribed for Resident #18 was 1,650 cc at day. Monitor intake and output record documentation for December 2016, did not include an assessment tool to confirm the correct volume of enteral formula and or water was infused every 24 hours as ordered by the physician. The record evidenced Resident #18 was receiving more fluids than the prescribed as follow: 12/1/16: 2,995 cc (1,345 cc more than ordered). 12/2/16: 2,620 cc (970 cc more than ordered). 12/3/16: 2,445 cc (795 cc more than ordered). 12/4/16: 2,225 cc (575 cc more than ordered). 12/5/16: 2,295 cc (645 cc more than ordered). 12/6/16: 2,145 cc (495 cc more than ordered). 12/7/16: 2,480 cc (830 cc more than ordered). 12/8/16: 2,290 cc (640 cc more than ordered). 12/9/16: 2,190 cc (540 cc more than ordered). 12/10/16: 2,300 cc (650 cc more than ordered). 12/11/16: 2,330 cc (580 cc more than ordered). 12/12/16: 2,362 cc (712 cc more than ordered). 12/13/16: 2,195 cc (545 cc more than ordered). 12/14/16: 1,995 cc (345 cc more than ordered). On 12/14/16 at 4:46 PM, observation of tube feeding conducted with a RN evidenced the infusion pump was on and running at 85 cc per hour. The label of the feeding bag indicated the feeding was started on 12/13/16 at 8:00 PM. The RN confirmed the tube feeding was started the night before at 8 PM and could not explain why the feeding was not turned off at 6:00 AM as ordered. The RN explained the amount of Review of the infusion pump revealed that since the tube feeding was started on 12/13/16 at 8:00 PM, the the resident received 1,527 cc of formula (677 cc more than ordered) and 788 cc of water flush. The pump ran for over 20 hours instead 10 hours as prescribed and the resident received a total of 2,315 cc (665 cc more than ordered). The RN confirmed the observation. [MEDICATION NAME] Renal label documented 237 cc of the formula contained 225 mg of potassium. From 12/13/16 at 8:00 PM to 12/14/16 at 4:45 PM, the resident received 1,527 cc of formula that provided about 1,449 mg of potassium. Laboratory reports showed the potassium levels were over the normal limits as follow: 8/12/16: 3.9 milliequivalents over liter (mEq/L). Reference range: 3.5 - 5.1 9/9/16: 4.9 mEq/L 10/19/16: 5.7 mEq/L 10/21/16: 6.2 mEq/L 10/24/16: 5.8 mEq/L 11/02/16: 6.0 mEq/L 11/07/16: 5.6 mEq/L 11/21/16: 6.3 mEq/L 12/12/16: 5.4 mEq/L On 12/14/16 at 4:46 PM, a RN explained the procedure to collect data and document the total amount of fluids every shift. The RN indicated the prescribed hourly tube feeding rate was multiplied by the numbers of hours of each shift and added the water flushes and fluids administered during the medication administration Care Plan dated 8/19/16, documented interventions that included monitor and document intake and output as per facility policy. Resident #5 Resident #5 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #5's admission assessment dated [DATE], revealed an initial weight of 141 pounds (Lbs.). The assessment documented the resident did not have [MEDICAL CONDITION]. Nurses notes dated 11/17/16 at 1:33 AM and 11/18/16 at 1:13 AM, documented the resident had a +1 [MEDICAL CONDITION] in the left upper extremity (scale to determine the severity of the [MEDICAL CONDITION]. Pressure is applied to the swollen area with a finger. The scale number indicated the persistence of the skin indentation. +1 [MEDICAL CONDITION] is a barely detectable impression when finger is pressed into skin). There was not other body area identified with [MEDICAL CONDITION]. The record did not document the resident was receiving diuretics due to the left upper extremity [MEDICAL CONDITION]. Admission order dated 11/15/16, documented an order for [REDACTED]. The resident should have received about 2,500 cc of fluids (formula plus water) in a daily basis from 12/1/16 through 12/8/16. Medication Administration Record (MAR) documented the following intakes while the resident was receiving the formula [MEDICATION NAME]: 12/1/16: 2,300 cc (200 cc less than ordered). 12/6/16: 2,300 cc (200 cc less than ordered). 12/7/16: 2,300 cc (200 cc less than ordered). 12/8/16: 2,200 cc (300 cc less than ordered). The MAR documented the resident did not receive the prescribed amount of fluids. Physician order [REDACTED]. The resident should have received about 2100 cc of fluids (formula plus 1,500 cc of water) in a daily basis from 12/9/16 through 12/13/16. Monitor intake and output record documentation for December 2016, did not include an assessment tool to confirm the correct volume of enteral formula and or water was infused every 24 hours as ordered by the physician. The record evidenced Resident #5 was receiving less fluids than the prescribed as follow: 12/9/16: 1,900 cc (200 cc less than ordered). 12/10/16: 1,770 cc (330 cc less than ordered). 12/11/16: 1,800 cc (300 cc less than ordered). 12/12/16: 1,990 cc (110 cc less than ordered). 12/13/16: 1,210 cc (890 cc less than ordered). On 12/14/16 at 10:14 AM, an inspection was conducted in Resident #5's bedroom. A Kangaroo (trade mark) tube-feeding bag was observed hanging in a pole and connected to a infusion pump. The bag contained about 300 cc of formula. The label of the bag indicated [MEDICATION NAME] Renal at 30 cc per hour started at 10 AM on 12/13/16. The pump was off and the infusion set disconnected from the [DEVICE]. On 12/14/16 at 12:09 PM, a medication pass observation was conducted with a Registered Nurse (RN). The RN explained two cans of Novasourse were put into the tube-feeding bag at 10 AM but the feeding was not initiated due to a gastric residual of 60 cc. The RN indicated at 11:50 AM, the gastric residual was checked again and the tube-feeding initiated. The RN said the residual had to be checked after an hour and if there was no residual, the tube feeding had to be started. The RN acknowledged the residual was checked two hours later and the feeding started at 11:50 AM instead at 11:00 AM. The RN confirmed she always put two cans of the formula to be administered in 20 hours. Review of the label of a [MEDICATION NAME] Renal indicated a can contained 237 cc of formula. The RN was providing 474 cc of formula instead 600 ml as prescribed. On 12/14/16 at 1:55 PM, Resident #5's infusion pump was check with the RN. The pump history indicated that for the last 72 hours the resident received 1,394 cc of formula instead 1,800 cc (600 cc per day). The resident missed about 406 cc of formula in 72 hours. On 12/15/16 at 7:00 AM, Resident #5's infusion pump was check with the RN. The pump was off and the history indicated that for the last 24 hours the resident received 503 cc of formula instead 600 cc as prescribed. Resident #5' medical record revealed a discrepancy between the MAR and the data recorded in the history of the infusion pump. The MAR documented 5,000 cc of fluids (formula and water) were administered from 12/11/16 through 12/13/16, while the infusion pump documented 3,878 cc in the same period of time (a discrepancy of 1,122 ml). The resident had to receive 6,300 cc of prescribed fluids, including water and formula. On 12/14/16 at 12:09 PM, during the medication pass observation performed with a RN, Resident #5 was receiving tube feeding formula [MEDICATION NAME] Renal at 30 cc per hour. The label on the tube feeding bag indicated the formula was started on 12/13/16 at 10 :00 AM. The RN explained the information in the label indicated the date and time the tube feeding bag was changed. The RN indicated the formula and the tube feeding bag could be used up to 48 hours per training provided by an infusion pump vendor. Novosource Renal feeding formula documented in the can label that once open, the unused portions of the formula should be used within 24 hours. Resident #17 Resident #17 was admitted on [DATE], with [DIAGNOSES REDACTED]. Physician order [REDACTED]. The resident should have received about 3,204 cc of fluids (formula and water). Monitor intake and output record documentation for December 2016, did not include an assessment tool to confirm the correct volume of enteral formula and or water was infused every 24 hours as ordered by the physician. The record evidenced Resident #17 was receiving less fluids than the prescribed as follow: 12/1/16: 3,050 cc (154 cc less than ordered). 12/2/16: 2,775 cc (429 cc less than ordered). 12/3/16: 2,500 cc (704 cc less than ordered). 12/4/16: 2,412 cc (792 cc less than ordered). 12/5/16: 2,100 cc (1,104 cc less than ordered). 12/6/16: 2,270 cc (934 cc less than ordered). 12/7/16: 2,334 cc (860 cc less than ordered). 12/8/16: 2,324 cc (880 cc less than ordered). 12/9/16: 2,324 cc (880 cc less than ordered). 12/10/16: 2,524 cc (680 cc less than ordered). 12/11/16: 2,211 cc (993 cc less than ordered). 12/12/16: 2,198 cc (1,006 cc less than ordered). 12/13/16: 1,800 cc (1,404 cc less than ordered). On 12/14/16 at 5:15 PM, Resident #17's tube feeding infusion pump was check with the RN. The pump history indicated that for the last 72 hours the resident received 3,430 cc of formula instead 4,212 cc (1,404 cc per day) and 3163 cc of water instead 5,400 cc (1800 cc per day). The resident missed about 782 cc of formula in 72 and 2,237 cc of water in 72 hours. On 12/14/16 at 5:15 PM, tube feeding system for Resident #17 was inspected with a RN. 300 cc of formula remained in the tube feeding bag. The bag label was dated 12/13/16 at 4:00 PM. The RN added two cans of formula to the formula that was previously hanging. The RN indicated the remaining formula was decanted the day before at 4:00 PM and confirmed it was hanging for more than 24 hours bud could be reused up to 48 hours as per the information obtained in a training. The label of formula's can was written with the RN. The label documented that once open, the unused portions of the formula should be used within 24 hours. The RN acknowledged she did not read the label of the can before using the formula. The RN indicated the tube feeding bag had to be changed every 48 hours. The RN was not aware about the instructions printed in the tube feeding bag by the manufacturer that indicated the bag could not be used for more than 24 hours. On 12/16/16 at 8:30 AM, the Director of Nursing (DON), indicated she was not aware the tube feeding bag could not be used for more than 24 hours. The DON verbalized the enteral feeding pump vendor explained the bag could be used up to 48 hours. The DON acknowledged there were issues regarding the intake documentation since the pumps were not cleared prior to start the tube feeding and formula hung over 24 hours with open-systems should not be reused. On 12/16/16 at 2:36 PM, the RD explained the tube feeding formula was recommended based on the residents nutritional needs and medical conditions and calories were calculated based on the resident weight. The RD indicated to monitor the residents intake was based on whatever order for tube feeding the residents had. The RD confirmed she did not check the MAR and typically did not review the residents daily intake documentation. The RD acknowledged she was not aware about the discrepancies in the intake data that showed the residents were not receiving the prescribed amount of fluids and feeding formula. The RD confirmed it was not acceptable to use feeding formulas for more than 24 hours in open-system tube feeding. Resident #7 Resident #7 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 12/8/16, Resident #7's physician ordered [MEDICATION NAME] at 65 cubic centimeters (cc's) per hour to provide a total of 1,560 cc's continuously via enteral feeding in 24 hours. A 250 cc water flush was also ordered to be given via gastrostomy tube every 6 hours which would equal 1000 cc's in 24 hours. The resident should have received 2,560 cc's per day. Resident #7's Medication Administration Record (MAR) indicated total intakes were entered each shift (day, evening and night). The record did not include an assessment tool to confirm the correct volume of enteral formula and or water was infused every 24 hours as ordered by the physician. MAR entries on the following dates were added and showed: 12/8/16 = 1,650 cc's (910 cc's less than ordered). 12/9/16 = 3,430 cc's (870 cc's greater than ordered). 12/10/16 = 2,595 cc's (35 cc's less than ordered). 12/11/16 = 2,640 cc's (80 cc's greater than ordered). 12/12/16 = 2,620 cc's (60 cc's greater than ordered). 12/13/16 = 3,105 cc's (545 cc's greater than ordered). 12/14/16 = 2,050 cc's (510 cc's less than ordered). The volumes documented on the MAR did not specify whether the enteral formula or the water was within the parameters ordered by the physician every 24 hours. On 12/15/16 at 1:30 PM, the Registered Nurse confirmed the MAR did not include a process to evaluate the total volume of formula and water infused in a 24 hour period. The nurse indicated the process to identify the total volume to enter on the MAR every shift is to read the amount on the infusion pump and clear the pump at the end of every shift. The nurse indicated the volume documented on the MAR each shift is a combined total of water and formula. On 12/15/16 at 1:55 PM, the Licensed Practical Nurse (LPN) reported the process for determining the amount to enter on the MAR for fluid intake is to use the calculation of the rate times the number of hours infused which equals the volume amount infused each shift. The LPN confirmed this was the process for determining the volume to be entered in the resident's MAR for gastrostomy intakes each shift. The LPN confirmed she did not use the numbers on the infusion pump or look at volumes in the infusion bag. On 12/15/16 at 4:25 PM, the LPN indicated the total volume infused via a gastrostomy tube each shift is based on the total number indicated on the infusion pump. A physician order [REDACTED]. The nurse explained many times during a shift an infusion can be delayed for multiple reasons and this will alter the total volume infused during the shift. The LPN indicated the nurse on each shift is responsible for the volume infused on their shift and the last shift of the day should total the volume and clear the pump at the end of their shift. The nurse was unsure who was responsible to assess weather the resident received the total volume of formula and water ordered by the physician on a daily basis. On 12/16/16 at 9:45 AM, the LPN confirmed the total volume of fluid intake each 24 hours is not included in residents records but it is identified in the physician order. The nurse indicated it is important to confirm the resident receives the correct volume of formula on a daily basis to ensure the resident gets the right calories. Resident #7's [MEDICATION NAME] formula container held 250 cc's and the label indicated once the container was opened the formula should be used within 24 hours. On 12/15/16 at 1:30 PM, the Registered Nurse indicated a feeding tubing bag can be used for up to 48 hours and each nurse on every shift can just add 2 containers of formula to the existing formula in the bag. Resident #15 Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/19/16, Resident #15's physician ordered Fibersource HN (high nitrogen) enteral formula to be given via gastrostomy tube at 80 cc's (cubic centimeters) for 18 hours per day. A 200 cc water flush was also ordered to be given via gastrostomy tube every 6 hours. The resident should have received 2,240 milliters per day with the flexibility of plus or minus 150 milliliters. The resident's total intake on the following dates was as follows: -12/14/16 = 2,740 milliters -12/15/16 = 2,560 milliters -12/16/16 = 3,010 milliters -12/11/16 = 2,410 milliters -12/10/16 = 2,140 milliters -12//9/16 = 2,960 milliters On 12/16/16 at 11:50 AM, Resident #15's nurse was interviewed and the recorded intake values were reviewed with the inspector. The nurse stated the medications given each medication pass may account for an extra 60 milliters of water, however the the pumps used were for the enteral feedings were new and the staff was still learning and had made mistakes in calculating the intake values and the documented values were not within the limits of the physician's orders [REDACTED].>

Based on interview, clinical record review and document review, the facility failed to ensure 1 of 24 sampled residents (Resident #17), was assessed for their nutritional status upon admission; failed to ensure a significant weight loss was reported to the Physician, Registered Dietician and the resident's Responsible Party for 2 of 24 sampled residents (Resident #17, #9 ); failed to ensure 2 of 24 sampled residents (Resident #17, #9) was assessed after a significant weight loss; failed to ensure 2 of 24 sampled residents (Resident #17, #9) were provided with interventions to stop or slow down weight loss after a significant weight loss; failed to ensure dietary consultation was performed in accordance with a resident's care plan for 1 of 24 sampled residents (Resident #9). Findings include: Documentation entitled, Weight Monitoring-Identifying Residents at Nutritional Risk dated 5/06, documented the facility's policy was "To monitor residnet's with weight loss, and identify resident's who may be at nutritional risk to help prevent further decline."... The policy revealed the RA (Restorative Aide) would report weekly weights at the Risk Management meeting. Interventions will be discussed by team members and implemented as needed with physician approval. Residents with any of the following conditions should be considered at nutritional risk: Residents with a 2% weight loss in one week, 5% loss in 30 days, intake of less than 50% of meals for 3 days or more, tube fed residents, residents with pressure sores or non healing wounds and residents with [MEDICAL CONDITION]. Procedure included in part: The dietary manager will document significant weight changes and notify the dietitian if further intervention is necessary. All residents at nutritional risk will be reviewed by the dietician. Residents at nutritional risk will be discussed weekly at the Risk Management meeting. All interventions made by the dietary manager and/or dietitian must be approved by the physician. Resident # 17 Resident # 17 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #17's admission orders [REDACTED]. Physical Therapy, Occupational therapy and Speech Therapy evaluation and treatment. A care plan initiated 2/24/14, documented the focus areas for Resident #17 were PICC line (peripherally inserted central catheter), [DIAGNOSES REDACTED]. The documented interventions included: provide and encourage consumption of a pureed, low sodium, low fat diet, and nectar thick liquids; monitor vital signs, lab values and weight per the facility policy or as ordered by the physician. A Physician's progress note dated 2/26/14, documented the resident wanted solid foods. Advance diet to mechanical soft. On 2/26/14 a physician's orders [REDACTED].#17's diet changed from pureed and nectar thick liquids to mechanical soft with thin liquids. The Height/Weight Record documented Resident #17's admission weight was 166.4 pounds and the resident's height was 59 inches. The Height/Weight Record documented the following: On 2/27/14, 167.0 pounds On 3/4/14, 156.0 pounds (down 11.0 pounds or 5% weight loss). On 3/4/14, a re-weight was completed with a Licensed Nurse (LN). The documented weight was 156.0 pounds. On 3/11/14 152.0 pounds (down 15 pounds or greater than 7.5% weight loss). On 3/11/14, a re-weight was completed with a LN. The documented weight was 152.0 pounds. The Physician's progress note dated 3/2/14, lacked documented evidence the physician had was notified of Resident #17's weight loss. Medicare Meeting Note dated 3/4/14, lacked evidence of Resident #17's 11 pounds weight loss. Resident Summary dated 3/7/14, indicated Resident #17 was on a mechanical soft diet and consumed 25% at each meal; however, weight loss from 166.4 pounds to 156.0 pounds was not documented in the summary. Resident #17's clinical record lacked documentation of the following: 1. The resident's nutritional needs had been assessed by the Dietary Manager (DM) or the Registered Dietician (RD) upon admission to the facility. 2. The Physician, DM, RD or Responsible party had been notified of the 11 pounds/ or 5% weight loss. 3. The resident's care plan had been updated to reflect the new diet order on 2/26/14, or the 11 pound/ or 5% weight loss on 3/4/14. 4. Documentation the resident had been assessed and intervention put into place after the 11 pounds/ or 5% weight loss. 5. The Physician, DM, RD or Responsible party had been notified on 3/11/14, the resident's weight was down to 152.0 pounds (down 15 pounds or greater than 7.5% weight loss). 6. Documentation the resident had been assessed and interventions implemented after the resident's weight went down to 152.0 pounds on 3/11/14. On 3/14/14 at 10:05 AM, the Director of Nursing (DON ) and DM verbalized the weekly weight sheets were put into the RD's box every week for review. The DON revealed in February 2014, Resident #17's meal percentage intake for breakfast and lunch were from 51% to 75%, and dinner was from 26% to 50%. The DON revealed in March 2014, Resident #17's meal percentage intake for breakfast was from zero to 25% , for lunch from 51% to 75% and for dinner from 26% to 50% . During the interview on 3/14/14, the DON and DM confirmed the resident's nutritional needs should have been re-assessed and interventions put in place after the weight loss. The DON and DM revealed the Physician, DM, RD and Responsible party should had been notified of Resident #17's weight loss. On 3/14/14 at 10:05 AM, the Director of Nursing (DON ) and DM confirmed the following: 1. The clinical record lacked documented evidence the Physician, DM, RD or Responsible party had been notified of the 11 pound weight loss or subsequent weight loss. 2. There was no documented evidence Resident #17's nutritional needs had been assessed by the DM or RD before or after the resident's weight loss. 3. There was no documented evidence intervention put into place after the weight loss. On 3/14/14, the DON verbalized the facility's policy for weight loss had not been followed. Resident #9 Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #9's Weight Record indicated the following: 8/13/13 97.4 lbs (pounds) 9/9/13 94.4 lbs 10/14/13 91.2 lbs 10/29/13 89.2 lbs 11/11/13 88.8 lbs 11/18/13 88 lbs 12/9/13 87.4 lbs 1/13/14 87.4 lbs 2/10/14 86.6 lbs 2/17/14 85.6 lbs 2/24/14 85.4 lbs 3/3/14 81.4 lbs 3/11/14 81.8 lbs From 8/12/13 through 2/10/14, the resident lost 10.8 lbs which constituted a severe weight loss of 11%. From 2/10/14 through 3/11/14, the resident lost 4.8 lbs which constituted a severe weight loss of 5.5%. The Dietician evaluated Resident #9 as listed below: Dietician review dated 6/16/13, documented the resident consumed 50% of food orally and needed the bolus feedings for extra nutrition. The resident had a 14 lb (pound) desirable weight gain since 12/11/12. Dietician review dated 12/16/13, documented Resident #9 required 1400 calories, 40-48 grams of protein daily and the resident lost 1.3 lbs since 11/11/13, lost 7 lbs since 9/9/13 which was near a significant change and 8 lbs since 6/10/13. The weight loss was undesirable because the resident remained less than 90% of her IBW (ideal body weight) with a BMI (body mass index) of 18 which increased her nutritional risk. The resident had poor oral intake less than 25% consumed and more frequent refusals. The Dietician decreased the Resource 2.0 from 8 oz (ounces) to 6 oz. The Dietary Manager (DM) documented on 2/11/14, Resident #9's IBW was 92-117 lbs and the resident lost 10 lbs since 8/12/13 which would be a significant weight loss. The DM called the physician to obtain an order for [REDACTED]. On 3/12/14 at 10:20 AM, the DM was unable to locate a quarterly assessment from June 2013 through December 2013. The DM reported the Dietician last evaluated the resident on 12/16/13 and was not contacted regarding the 10 lb weight loss identified on 2/11/14. On 3/14/13 at 4:00 PM, the DON acknowledged nursing staff or the DM should have contacted the Dietician, MD, and POA regarding Resident #9's severe weight loss identified in February and March 2014. Resident #9's physician progress notes [REDACTED]. Resident #9's Care Plan dated 6/11/13, identified problems related to swallowing. Interventions included the following: - Monitor/record/report to MD PRN (as needed) signs/symptoms of malnutrition, significant weight loss, more than 5% in 1 month, more than 7.5% in 3 months, more than 10% in 6 months. - RD (Registered Dietician) to evaluate quarterly and PRN. Monitor caloric intake, estimate diet needs. Make recommendations for changes to tube feeding as needed. Resident #9's Care Plan dated 2/11/14, documented due to a swallowing deficit, resident was unable to consume little nourishment or hydration via mouth. The resident's weight remained below her IBW and the resident will be weighed weekly for four 4 weeks due to a significant weight loss (10.6 lbs from 8/12/13 to 2/10/14). Resident #9's March 2014 eating record from 3/1/14 through 3/12/14, revealed the following: - The resident refused to eat 16 of 36 total meals - The resident consumed between 0% - 25% 10 of 36 total meals Resident #9's February 2014 eating record from 2/1/14 through 2/28/14 revealed the following: - The resident refused to eat 50 of 84 total meals - The resident consumed between 0% - 25% 20 of 84 total meals Resident #9's Resource was not administered or smaller amounts were administered from 3/1/14-3/11/14 as indicated: - The resident refused or missed 9 of 44 total feedings - The resident received less than 180 CC (Cubic Centimeters) 3 of 44 total feedings.

Based on interview, clinical record review and document review, the facility failed to ensure the policy for falls was followed for 8 of 15 sampled residents (Resident #1, #2, #3, #4, #5, #7, #13, #15). The facility failed to ensure the policy for bowel monitoring was followed for 1 of 15 sampled residents (Resident #1). Findings include: The facility's policy entitled Fall-When a Fall Occurs (undated) documented...#2 In the event that a resident has a fall, the following will occur: For falls occurring between the hours of 8:00 AM and 4:00 PM Monday through Saturday... d. As a team, all members present will conduct the "Post Fall Evaluation" at the scene to determine the "Root Cause" for the fall. e. If the fall was un-witnessed or was witnessed and the resident hit his/her head, the team will conduct "neuro-checks." (neurological). Neuro checks will be conducted in the following manner: 1. Initially at the scene of the fall prior to getting the resident up; 2. Every 15 minutes times 2. 3. Every 30 minutes times 2. 4. Every 1 hour times 2. 5. Every 2 hours times 24. The facility's policy for Fall Risk (undated) documented... "a falling star symbol will be placed next to the resident's name plate outside his/her room door to indicate that he/she is a fall risk." Initiate a Care Plan identifying that the resident had a Potential for Falls." The facility's policy entitled, Neurological Signs, Observation of (undated), documented, observation of neurological signs was conducted on all residents who sustain a head injury or have had an unwitnessed fall. "The purpose of this observation is to detect clinical manifestations of increased intracranial pressure." Resident #1 Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Fall Risk Evaluation form dated 8/11/12 documented Resident #1's fall risk score was 16 (a score of 13 or above high fall risk). On the back of the form the documentation indicated resident was alert with confusion, one person assist when ambulating and unsteady gait. The Licensed Nurse Documentation Flow Sheet dated 8/27/12 indicated Resident #1 was alert, and orientated times 1, Foley catheter in place and no behaviors noted. The resident was not able to make needs known to staff or others, or able to cooperate with care/treatment plan. The documentation indicated on 8/27/12 at 5:30 AM, a Certified Nursing Assistant (CNA) reported the resident had a bruise on the right side of her forehead approximately "(2 x 3)" centimeters with "swollen tissue, pale bluish colored. Painful to touch." The resident was not able to "give correct answer how she got this injury, due to her mental status." At 7:15 AM, the physician on call was notified. Orders were received for a STAT (immediately) x-ray of the skull, neurological assessment every 2 hours times 24 hours. On 8/27/12, a physician's orders [REDACTED]. On 8/28/12, a physician's orders [REDACTED]. On 8/30/12, a physician's orders [REDACTED]. The clinical record contained documentation dated 9/3/12 11:00 PM to 7:00 AM. Resident received in bed, awake and alert with some confusion. Remains on bed rest for [MEDICAL CONDITION]" ([MEDICAL CONDITION]). Narrative Notes dated 9/3/12 (7:00 AM to 3:00 PM) documented "On w/c (wheelchair). Tried to get her to bed d/t [MEDICAL CONDITION] precaution. Kept "on w/c and elevated legs." Documentation dated 9/3/12 (3:00 PM to 11:00 PM) indicated the resident was alert and orientated times one. Up in wheelchair with bilateral lower extremities elevated. The Narrative Notes dated 9/4/12 documented resident received up in wheelchair in front of nurse's station. The 11:00 PM -7:00 AM shift Licensed Nurse reported they got her up in the wheelchair "due to resident was restless in bed. Climbing out of bed." The resident was assisted up on the wheelchair by the 11:00 PM -7:00 AM shift assigned Certified Nursing Assistant (CNA). The resident ate breakfast in dining and then was placed in front of the nurse's station for close supervision. Both lower extremities kept elevated. The clinical record lacked documentation on 9/4/12, Resident #1 had been assessed to determine why the resident did not want to stay in bed. The clinical record lacked documentation the physician was notified the resident did not want to stay in bed and was trying to climb out of bed. There was no documentation a physicians' order had been received to cancel the order for best rest or to get the resident up in the wheelchair. The CNA (Certified Nursing Assistant) Flow Sheet dated 9/4/12, documented the resident had a fall in front of the nurse's station while she was in a wheelchair with both her legs elevated at 11:15 AM. Nurse's Notes dated 9/4/12 documented the resident was sitting up in the wheelchair in the hallway with bilateral legs elevated with pillow support on the leg rests. The resident bent over causing the wheelchair to tilt forward and the resident fell on the floor on her right side face down. The resident sustained [REDACTED]. The resident was alert, awake, but very confused. The resident was assisted back into the wheelchair and then to bed. Cold compress applied to right forehead and right periorbital area. The physician was paged at 11:30 AM. At 11:40 AM, the physician was notified of the fall and a new order received for a geri-chair with lap tray on when out of bed for safety and fall precautions. The Post Fall Evaluation/Investigation form documented Resident #1 fell on [DATE] at 11:15 AM. The resident was in her wheelchair with both legs elevated on the leg rests with pillow support. The resident bent over causing the wheelchair to tilt forward. The tab alarm went off. The resident was on her right side and face down on the floor. The documented behavior was alert and confused. The documentation indicated "Suppose to be on bed rest" but did not stay in bed. The Neurological Assessment form lacked documentation the neurological assessments had been completed in accordance with the facility's policy. The Neurological Assessment form lacked documentation the checks had been completed every 15 minutes times two per the policy. The Neurological Assessment for lacked documentation a complete neurological assessment had been completed in regards to eye response, level of consciousness, speech and motor response from 9/4/12 at 4:30 PM to 10:30 PM on 9/4/12. The clinical record lacked documentation the every 15 minute activity log for safety and fall precautions had been completed from 8/27/12 through 9/4/12 in accordance with the physician's orders [REDACTED]. The clinical record contained an (undated) care plan for fall risk. The goal was for the resident to participate with her transfers and have no falls during transfers over the next 30 days. The documented approaches included offer verbal cues to assist in steps of transfer, assist with all transfers, document and report any decline in transfer ability. Restorative nursing for transfers every shift for 90 days. The undated care plan lacked documentation to indicated Resident #1 had physician's orders [REDACTED]. documented on the care plan. The Resident Data Collection form dated 8/11/12 at 9:30 PM, documented Resident #1 had a stage 4 pressure ulcer on her coccyx. On 8/16/12 a physician's orders [REDACTED]. Stage 4 pressure ulcer on the sacrum: cleanse with wound cleaner, pat dry, apply Santyl packed with Pericol, cover with bordered gauze daily times 21 days then re-evaluate. The Licensed Nurse Documentation Flow Sheet dated 8/27/12 indicated Resident #1 was alert, and orientated times 1, Foley catheter in place and no behaviors noted. The resident was not able to make needs known to staff or others, or able to cooperate with care/treatment plan. The documentation indicated on 8/27/12 at 5:30 AM, a Certified Nursing Assistant (CNA) reported the resident had a bruise on the right side of her forehead approximately "(2 x 3)" centimeters with "swollen tissue, pale bluish colored. Painful to touch." The resident was not able to "give correct answer how she got this injury, due to her mental status." At 7:15 AM, the physician on call was notified. Orders were received for a STAT (immediately) X-ray of the skull, neurological assessment every 2 hours times 24 hours. The August and September 2012, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The clinical record lacked documentation the resident had physician's orders [REDACTED]. The clinical record lacked documentation the resident's physician was notified the resident had not had a bowel movement from 8/23/12 -8/29/12. On 10/23/12 at 1:10 PM, a Registered Nurse (RN) stated the resident should have received something after 3 days with no bowel movement. The RN indicated physician's orders [REDACTED]. On 10/23/12 at noon, a Registered Nurse (RN) verbalized if a resident was trying to climb out of bed she would get an order for [REDACTED]. This information would be documented in the nurse's notes. On 10/23/12 in the afternoon, a RN stated per the facility policy a fall risk evaluation was done upon admission. The RN stated the care plan for high risk falls was not dated and was incomplete. The RN indicated if a resident was agitated the staff should find out why the resident wanted to get out of bed. The RN stated the clinical record lacked documentation to indicate the resident had been assessed as to why she had been trying to get out of bed. The RN confirmed a resident not having a stool for 4 days could have caused agitation with the behavior of trying to climb out of bed. The RN stated no other options were tried such as a low bed or releasing the side rails due to the resident's behavior. The RN stated there was no documentation the resident had been assessed as to why she wanted to get out of bed. On 11/1/12 at 1:43 PM, a Staff member in Medical Records verbalized the only documentation in the clinical record for the every 15 minute activity logs were for 8/15/12 through 8/16/12, 9/5/12 through 9/6/12 and 9/6/12 through 9/7/12. The facility failed to ensure staff followed the facility's policy on falls. The facility failed to follow Resident #1's physician' orders for bed rest and for the every 15 minute activity logs. Resident #13 Resident #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Documentation entitled, Resident Summary dated 9/3/12 indicated Resident #13 was alert, orientated times one to person and was confused. The resident had both long term and short term memory loss. The resident ambulated with a walker. The Fall Risk Evaluation form dated 9/13/12 documented the resident's fall risk score was 24 (high risk). Nurse's Notes dated 10/15/12 (7:00 AM -3:00 PM) documented the resident stated she had fallen early this morning and did not tell anyone. Upon examination the resident's right ankle was slightly swollen and tender to the touch. The physician was contacted and orders were received for an x-ray of the right ankle and to ice the right ankle for 20 minutes every 4 hours times 24 hours. The clinical record lacked documentation the neurological assessments had been completed in accordance with the facility's fall policy. The clinical record lacked documentation a Post Fall Evaluation Form had been completed in accordance with the facility's fall policy. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The clinical record contained an episodic care plan dated 10/15/12 for sustained fall. The documentation indicated the fall occurred during ambulation and was unwitnessed. The resident's right ankle was swollen and tender. The approaches documented included: make sure the bed pad alarm was on, x-ray right ankle and ice pack on 20 minutes every 4 hours times 24. The Episodic care plan lacked documentation new fall prevention interventions had been put into place or the bed needed to be in the lowest position. On 11/1/12 at 9:20 AM a Licensed Nurse (LN) stated if a resident was admitted to the facility with a high fall risk, then the high risk care plan should be completed. The LN indicated all the fall precautions from the physician's orders [REDACTED]. The LN stated the care plan should be updated after each fall and new fall prevention interventions put in place. On 11/1/12 at 9:45 AM, a LN was not able to locate documentation in the clinical record, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s policy. The LN stated the care plan lacked documentation the resident's bed was to be in the lowest position and no new fall interventions had been put into place after the resident's fall on 10/15/12. The LN stated the facility's fall policy had not been followed. Resident #3 Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 10/24/12 at 8:20 AM, the resident was observed in bed and the wheelchair was at the foot of the bed. The name plate outside the resident's room did not have a falling star to indicated the resident was a fall risk in accordance with the facility's policy. On 10/24/12 at 8:30 AM, a Certified Nursing Assistant (CNA) stated the resident was a fall risk. The CNA stated she was not sure if a falling star was placed outside the room if a resident was a fall risk. On 10/24/12 at 8:35 AM, a Licensed Nurse (LN) stated the resident was a high fall risk and probably should have a falling star outside the door. The admission orders [REDACTED] a. Toilet resident every 2 hours times 7 days b. Every 15 minute activity log checks times 7 days c. Tabs monitor in chair and bed times 7 days , then re-evaluate. The Resident Data Collection form dated 9/28/12 at 7:30 PM, documented the resident had no pain upon admission, skin warm, transferred with one person assist, and propels self in wheelchair. A Nurse's Note dated 9/28/12 documented the resident was alert and orientated times three with periods of confusion. The resident required limited assistance with Activity of Daily Living (ADL'S) and was continent of bowel and bladder. The resident used a wheelchair for locomotion. The clinical record documental on 9/29/12 at 9:10 PM, the resident had an unwitnessed fall. The resident was found lying on her left lateral side on the floor in her room. Denied hitting her head. Took the alarm off and was going to get the belongings in room. The High Risk Falls Worksheet dated 10/1/12 documented the following safety interventions to be put in place included: call light within reach, articles needed maintained in reach, falling star symbol outside the door, resident to wear non skid footwear in bed, signs posted to cue the resident, scheduled toileting program times 7 days, body pillow/positioning pillows, alarm in wheelchair times 7 days, alarm in bed times 7 days, full side rails bilaterally and ambulation aide-walker, cane etc. The Post Fall Evaluation/Investigation form dated 9/29/12 indicated Resident #3 had a fall on 9/29/12 at 9:10 PM. The resident was ambulating at the time in her room. The resident was found lying on her left lateral side on the floor. The resident was alert and orientated times 3, no signs of injury, and was wearing her own slippers. The documentation indicated the resident needed to be remained to use the call light for all needs, routinely, remind and check resident tab alarm in place. Wear non skid slippers/socks. The clinical record lacked documentation the Neurological checks had been completed in accordance with the facility's policy after an unwitnessed fall. The clinical record lacked documentation the resident had been charted on every shift times 72 hours status [REDACTED]. The clinical record lacked documentation the every 15 minute activity checks had been completed on 9/28/12 and 9/29/12 in accordance with the physician's orders [REDACTED]. The September 2012 Treatment Sheet lacked documentation the resident had scheduled toileting completed every 2 hours on the 3-11 shift on 9/28/12 and the 11-7 shift on 9/29/12 and 9/30/12. On 10/24/12 at 8:35 AM, a LN stated high fall risk resident's had care plans upon admission and if no care plan was completed upon admission there should be a care plan done after the first fall. The LN stated the care plan should be updated after each fall and contain additional measures after each fall. On 10/31/12 at 10:10 AM, a Registered Nurse (RN) verbalized the fall care plan was inaccurate and missing the physician's admission orders [REDACTED]. The RN was not able to locate documentation the every 15 minute activity checks were completed in accordance with the physician's orders [REDACTED]. The RN stated the facility's fall policy had not been followed. On 10/31/12 in the morning, a RN and a Staff Member from Medical records were not able to locate documentation the Neurological Assessments were done per the facility's policy after the resident's fall on 9/29/12. The clinical record documented on 10/6/12 at 7:35 AM, Resident #3 had an unwitnessed fall. The resident was found by staff sitting upright on her buttocks on the floor. The resident denied hitting her head. The resident stated she had transferred herself from the bed to the wheelchair independently and had removed her tab alarm. The Post Fall Evaluation/Investigation form dated 10/6/12 at 7:35 AM, documented the resident had an unwitnessed fall while transferring in her room. The resident was found sitting upright on the floor next to the bed with the wheelchair next to her. No signs of injury, the resident was alert and orientated times 3. The documentation indicated re-educate the resident in regards to the importance of tab alarm and using the call light. Remove wheelchair from side of bed. The Post Fall Evaluation form contained blank or areas not filled in for oxygen saturation level orthostatic blood pressure and the resident's use of glasses. The clinical record lacked documentation the Neurological checks had been completed in accordance with the facility's policy after an unwitnessed fall. The entries for 10/6/12 at 12:50 PM and 10:50 PM, lacked documentation in regards to the resident's pupil response, eye response, level of consciousness, speech and motor response. The entry for the Neurological Assessment on 10/6/12 at 3:50 AM lacked vitals signs along with the resident's pupil response, eye response, level of consciousness, speech and motor response. The clinical record lacked documentation the resident was charted on every shift times 72 hours status [REDACTED]. There was no documentation regarding the resident's condition status [REDACTED]. The Fall Risk Evaluation form dated 10/7/12, documented the resident's fall risk score was 26 (13 or above go to high risk fall form). The instructions documented on the form indicate the resident's status was to be assessed at admission and quarterly. The Post Fall Evaluation/Investigation form dated 10/7/12 at 11:10 PM, documented Resident #3 had a fall The resident was found sitting on the floor with bilateral lower extremities in front of her next to the bed. The documentation indicated the resident stated she was feeling nauseous and wanted to go to the trash can to throw up. The Post Fall Evaluation form contained blank or areas not filled in for orthostatic blood pressure and if the wheelchair was locked, positioned properly and the location of the wheelchair. On 10/31/12 at 10:40 AM, a RN stated the clinical record lacked documentation to show the neurological checks were done after an unwitnessed fall in accordance with the facility's policy. The RN stated the documentation was incomplete. The RN stated the resident had not been charted on status [REDACTED]. The RN confirmed there was no documentation regarding the resident status [REDACTED]. The RN confirmed the Post Fall Evaluation was incomplete. The RN confirmed no new fall precautions/interventions put into place after the resident's fall on 10/6/12. During the interview on 10/31/12 at 10:40 AM, a RN confirmed the clinical record lacked documentation the resident was charted on every shift times 72 hours after the fall on 10/7/12. The clinical record lacked nurse's notes regarding the resident's condition status [REDACTED]. The RN confirmed the Neurological checks had not been completed and the care plan had not been updated with new interventions put in place after the fall on 10/7/12. Resident #5 Resident # 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident's admission orders [REDACTED] Landing strip to right side of the bed for fall precaution. Left side of the bed against the wall for fall precaution. Anti-tippers on front of wheelchair for fall precautions. Bed pad alarm while in bed for fall precautions. Soft belt restraint in wheelchair. Put straps through wheelchair and loop to back for fall precautions. Toilet resident every 2 hours for fall precautions. Resident to have a low bed for fall precautions. Every 15 minute activity log checks. Tabs monitor in chair and bed times 7 days, then re-evaluate. A Nurse's Note dated 8/15/12 at 7:30 AM, documented the resident was found on her right side sitting on the landing strip on the floor at the side of the bed. The resident indicated "I got up". The responsible party and physician notified. The Post Fall Evaluation/Investigation form dated 8/15/12 lacked documentation regarding the ground surface at the time of the fall (such as uneven or wet floor) and what foot wear was in place at the time or the fall. The clinical record lacked documentation the resident had been charted on every shift times 72 hours after the fall on 8/15/12. The clinical record lacked entries for 8/16/12 night shift and day shift and 8/17/12 the day and evening shifts. The clinical record lacked documentation the neurological assessments had been done per the facility policy on 8/15/12. There was no documentation the neurological assessments were done every 15 minutes times 2 in accordance with the facility' fall policy. The Neurological Assessment form lacked complete documentation for 16 of the 17 assessments documented on 8/15/12 and 8/16/12. Areas on the form were blank or not filled in. A care plan dated 8/9/12 documented the resident was at risk for falls/injury related to a history of falls, [MEDICAL CONDITION] disorder, cognitive impairment including mental [MEDICAL CONDITION], alerted mental status with transient [MEDICAL CONDITION]. The care plan lacked specific measurable goals. The documented approaches on the care plan indicated the following: call light in place and remind to use, orient to surroundings and routine activities, keep needed articles within reach, encourage toileting every 2 hours, bed pad alarm in place on bed and always working, left side of bed against the wall, landing strips on floor, use of soft belt when out of bed, wheelchair with anti-tippers, re-assure staff here to assist, use calm approach and allow own space and freedom. The care plan lacked documentation to include the fall precaution measure for a low bed, every 15 minute activity log checks and tabs monitor in chair and then re-evaluate in accordance with the resident's admission orders [REDACTED] The clinical record lacked documentation the 8/15/12, fall had been care planned and new fall preventions measures put in place. On 11/1/12 at 10:20 AM, a Licensed Nurse (LN) verbalized Resident #5's fall risk score indicate she was a high risk with a score of 15. The LN stated the initial care plan for falls was not done timely. The LN stated the neurological assessments were not done every 15 minutes times 2 and an hourly neurological check was missing after the fall on 8/15/12. The LN stated the neurological assessments were incomplete. The LN indicated the Post Fall Evaluation Form was incomplete with missing information. The form should be filled out completely. The LN stated the clinical record lacked documentation the resident was charted on every shift times 72 hours after the fall. The LN confirmed the clinical record lacked entries for 8/16/12 night shift and day shift and 8/17/12 the day and evening shifts. The LN stated the fall had not been care planned and the falls care plan in the clinical record had not been updated. The LN stated the falls policy had not been followed. A Nurse's Note dated 9/2/12 documented at 1:40 PM, the resident attempted to get herself out of bed to get her money on the nightstand. The resident attempted to get up and fell her knees. No injuries noted. The physician was contacted and an order for [REDACTED]. A form entitled Episodic Care Plan-Post Fall dated 9/2/12, documented sustained fall during transfer. No apparent injury. The care plan did not contain the fall precaution measures for a low bed and every 15 minute activity log checks per the physician's admission orders [REDACTED]. On 11/1/12 at 10:40 AM, a LN stated the clinical record lacked documentation the resident had been charted on every shift times 72 hours after the 9/2/12 fall. The LN confirmed the clinical record lacked documentation in regards to the resident's fall on 9/3/12 for all 3 shifts, 9/4/12 day shift and 9/5/12 for evening and night shifts. The LN confirmed the care plan had not been updated after the 9/2/12 fall and new fall prevention measures put into place. The LN verbalized the facility's fall policy had not been followed. A Nurse's Note dated 9/13/12 documented at 6:00 AM, the resident was found sitting on the landing strip on the floor. The resident was noted to have a cut on her right eye lid. Treatment done as per facility policy. The physician and family were notified. On 11/1/12 at 10:45 AM, Licensed Nurse (LN) stated the neurological assessments were not done every 15 minutes times 2 and the 5:00 AM, neurological check was missing after the fall on 9/13/12. The LN stated the neurological assessments were incomplete. The LN indicated the Post Fall Evaluation Form was incomplete with missing information regarding the fall pattern, footwear in place during the time of the fall or any other external factors such as noise, change in routine, recent room change, anything different or unusual. The LN stated the form should be filled out completely. The LN stated the clinical record lacked documentation the resident was charted on every shift times 72 hours after the fall. The LN stated the fall had not been care planned and the falls care plan in the clinical record had not been updated. The LN verbalized none of the care plans in the clinical record contained all the fall precautions from the admission orders [REDACTED]. The LN stated the falls policy had not been followed. Resident #2 Resident #2 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. The clinical record contained a care plan dated 3/28/12 for [MEDICAL CONDITION] and generalized pain. The documented goal indicated the resident would be clean, comfortable and free from falls or tissue breakdown. The documented approaches included: maintain articles for use and call bell within reach, encourage and provide assistance with repositioning and toileting every 2-3 hours, maintain air mattress on bed and Gel cushion in wheelchair. The care plan lacked documentation it had been updated after the resident's fall on 10/6/12 or 10/7/12. The Fall Risk Evaluation dated 6/22/12 and 9/4/12 documented Resident #2's fall risk as 8. The form documented Resident #2 had no falls in the past 90 days, was alert and orientated times 3. The High Risk For Falls Worksheet dated 3/27/12 and 6/22/12 documented the safety interventions for the resident were call light in reach, articles needed maintained in reach, resident to wear non skid footwear in bed, lap buddy, lap tray and full bilateral side rails. The Restraint Evaluation Form dated 9/4/12 documented Resident #2 was alert and orientated times 3, required assistance with Activity of Daily Living (ADL'S), assistance of one with transfers, no falls continent of bowel and bladder and no attempts to transfer self. The October 2012 physician's orders [REDACTED]. The October 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] [MEDICATION NAME] 100 milligrams twice a day orally (8:00 AM and 12 Noon) [MEDICATION NAME] 100 mg (three tablets) orally at bedtime (8:00 PM) Elvail 25 mg orally at bedtime for neuropathic leg pain (8:00 PM) Trazadone 50 mg orally at hour of sleep (8:00 PM) [MEDICATION NAME] 7.5 mg orally at hour of sleep as needed. (time of administration unclear) [MEDICATION NAME] 0.5 mg orally every 6 hours as needed anxiety (Midnight) [MEDICATION NAME] 5/325 1 tablet orally every 4 hours as needed for pain ( No documentation of the time administered). The CNA (Certified Nursing Assistant ) Flow Sheet dated 10/6/12 documented the resident "was very drowsy all day, slumped in chair and slightly unresponsive" At 6:30 PM, the CNA took the resident to the bathroom changed him into night gown and attempted to assist the resident to bed but he refused. At 7:00 PM the resident fell from the wheelchair to floor and landed on right side of body, hitting his head on the ground. Vitals taken and nurse aware. The CNA Flow Sheet lacked documentation the Gel cushion was in place at the time of the fall. Nursing Progress Notes dated 10/6/12 at 7:00 PM, documented resident was found on the floor (side lying position) with bleeding laceration on right side of forehead, 4 centimeters in length. The resident had been seen all day drowsy but alert. He fell out of his wheelchair. Treatment done, wound cleansed with saline then wound cleanser, applied steri strips, Triple Antibiotic Ointment (TAO) and covered with gauze. Placed resident on neurological assessment. The Post Fall Evaluation/Investigation form indicated date of fall 10/6/12 at 7:00 PM. The fall was unwitnessed in the resident's bedroom. The resident was found in a side lying position. The form contained blank areas for documentation if the call light was on, an alarm sounded, the orthostatic blood pressure or the condition of the floor ( i.e.: liquid on floor, title lifted). The form documented the resident's injury was a laceration to the right side of his forehead. The behavior/mental status was alert/drowsy. The documentation indicated the resident was seen on the floor (side lying position) with bleeding laceration on the

Based on interview, clinical record review and document review, the facility failed to ensure the policy for falls was followed for 7 of 14 sampled residents (Resident #1, #2 #3, #6, #9, #12, & #14). Findings include: The facility's policy entitled Fall-When a Fall Occurs (revised 12/07) documented. (d). As a team, staff present will complete the post fall evaluation at the scene to determine the "Root Cause" of the fall. (e). If the fall was un-witnessed or the resident hit his/her head, the team will conduct "neuro-checks." (neurological checks). The policy indicated neurological checks will be conducted as follows: - Every 15 minutes times 2. - Every 30 minutes times 2. - Every 2 hour times 2. - Every 4 hours times 6. The facility's policy entitled Fall-When a Fall Occurs documented after a fall: If a resident had just fallen, or was found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine and extremities. Nursing staff will observe for delayed complications of a fall for 72 hours after an observed or suspected fall, and will document findings in the clinical record. The facility's policy entitled Fall-When a Fall Occurs indicated when a resident falls, the following information should be recorded in the resident's clinical record: -The condition in which the resident was found. -Assessment data including vital signs and obvious injuries... -Completion of a post fall evaluation/investigation... Resident #3 Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 12/27/12, admission orders [REDACTED]. A Fall Risk Evaluation form dated 12/27/12, documented Resident #3's fall risk score was 18 (a score of 13 or above high fall risk). On the back of the form the documentation indicated resident was awake, alert and orientated to name only. The resident had intermittent confusion and had attempted to stand and walk per self. The resident was a high fall risk. The preliminary care plan dated 12/28/12, lacked documentation of every 15 minute activity checks and scheduled toileting per the facility's policy. The CNA (Certified Nursing Assistant) Flow Sheet dated 12/28/12, documented the resident had fallen in the hallway "at nurses station." On 12/28/12, a Nurses Note dated 12/28/12 at 4:00 PM, documented resident fell , skin tear to right arm, wound cleaned and dressing applied. The Physician's Assistant and Responsible party were notified. The Nurses Notes lacked documentation to indicate the location of the fall, if the fall had been witnessed or unwitnessed, if the resident had hit their head, vital signs and a complete assessment had been done after the fall. The nurses notes lacked documentation to indicate whether or not the resident's alarms were in place at the time of the fall. The clinical record lacked documentation the resident had been charted on every shift times 72 hours status [REDACTED]. There was no documentation regarding the resident's condition status [REDACTED]. The Treatment record lacked documentation the bed pad and wheelchair pad alarms were in place on 12/30/12 and 12/31/12 on the 3:00 PM-11:00 PM shift. The treatment record lacked documentation to indicate the resident had been toileted every 2 hours on 12/30/12 and 12/31/12 on the 3:00 PM-11:00 PM shift per the facility's policy. The clinical record lacked documentation a Post Fall Evaluation Form had been completed in accordance with the facility's fall policy. The Neurological Assessment form lacked documentation the neurological assessments had been completed every 15 minutes times two per the policy. The Neurological Assessment form lacked documentation a complete neurological assessment had been completed in regards to eye response, level of consciousness, speech and motor response for 2 entries on 12/29/12. On 1/9/13 in the afternoon, a Licensed Nurse (LN) was not able to locate documentation the post fall evaluation had been completed in accordance with the facility's policy. On 1/10/13 at 9:50 AM, a LN stated the neurological assessment had not been done per the facility's policy. The LN stated the neurological assessment should go for 24 hours and the areas on the form were blank. On 1/10/13 at 9:55 AM, a LN stated the post fall evaluation had not been completed after the fall on 12/28/12. On 1/10/13 at 10:20 AM, the Director of Nursing (DON) stated the documentation in the nurses notes lacked information on how the resident fell , who found the resident and if the resident had been assessed per the policy. The DON confirmed there was no documentation the bed pad and wheelchair pad alarms were in place on 12/30/12 and 12/31/12 on the 3:00 PM-11:00 PM shift. The DON stated there was no documentation in the nurses notes regarding the resident's condition status [REDACTED]. The DON indicated the neurological assessments were incomplete, missing an entry at 4:30 PM (a 15 minute check) and the times of the neurological checks were not per the facility's policy. The DON confirmed the preliminary care plan lacked documentation for the every 15 minute activity checks and scheduled toileting every 2 hours. On 1/10/13 at 11:40 AM, a LN stated after a resident falls the documentation in the Nurses notes should contain if the fall was witnessed or unwitnessed, location of fall, if there was any injury, if the resident hit their head, a fall assessment, initial interventions done, the Physician contacted regarding the fall and any new orders received, the responsible party/ emergency contact called regarding the fall. During the interview on 1/10/13, the LN stated all areas on the neurological check form should be completed. The LN indicated the section for memory, speech and sensory were vital to the assessment. The resident would be placed on 72 hours observation, where the resident was charted on every shift to monitor and assess to see if any injury was present after the fall. The facility's policy entitled, Falls and Risk (undated), documented upon admission every new resident will have orders for the following: 1. Every 15 minute checks times 7 days, scheduled toileting times 7 days, tabs monitor in chair and bed times 7 days. 2. Within 24 hours of the resident's admission the licensed nurse will conduct a fall risk evaluation on the resident. 5. If the resident scores a "13" or above proceed to care plan. 6. Each quarter the fall risk evaluation will be repeated. 7. If the resident experiences a fall you will complete the Post Fall Evaluation. Resident #2 Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Fall Risk Evaluation form dated 9/26/12, documented Resident #2's fall risk score was 24 (a score of 13 or above high fall risk). On the back of the form the documentation indicated resident was considered a high fall risk. The clinical record lacked documentation a Fall Risk Evaluation had been completed after 9/26/12. The Post Fall Evaluation form dated 12/31/12, documented at 3:10 PM, the resident was found sitting on the floor next to the bed. The resident's head was resting on the bed. The fall was unwitnessed. The Neurological Assessment form lacked documentation a complete neurological assessment had been completed in regards vitals signs (respirations normal, shallow/irregular) and level of consciousness (alert, drowsy, stuporous, comatose) for 4 entries dated 1/1/13. Resident #1 Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Documentation in the Nurses notes dated 1/8/13 at 4:25 PM, indicated the Licensed Nurse heard a call for help in a resident room. The resident and a Certified Nursing Assistant (CNA) were found sitting on the floor. The resident was on top of the CNA. During a transfer with 2 CNA's the resident did not bear weight during the transfer and landed on the CNA. The physician and responsible party were notified. On 1/8/13, a physician's order was received for neurological assessments every 2 hours times 24 hours. The Neurological Assessment form lacked documentation a complete neurological assessment had been completed in regards vitals signs (e.g., respirations normal, shallow/irregular) from 1/8/13 at 10:25 PM through 1/9/13 at 6:20 PM. Resident #6 Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #6's admission orders [REDACTED]. Resident to have a landing strip on the left side of the bed for fall precautions. A Fall Risk Evaluation form dated 12/29/12, documented Resident #6's fall risk score was 14 (a score of 13 or above high fall risk). On the back of the form the documentation indicated the resident continues to present as a high fall risk related to intermittent confusion, unsteady gait at times and current medications. The clinical record lacked documentation a care plan dated 12/30/12 for self care and mobility defect and history of falls contained the fall prevention/precautions ordered by the physician. The Treatment Record dated January 2013, indicated the tabs monitor in bed and in chair were circled as not done on 1/3/13 to 1/6/13 for the 3:00 PM to 11:00 PM shift. However, the documentation indicated the Tabs alarm for the wheelchair and bed were in place on the 11:00 PM to 7:00 AM, shift and the 7:00 AM to 3:00 PM shift on 1/3/13 to 1/6/13. The clinical record lacked documentation to explain why the tabs monitors (bed and chair) were not in place on 1/3/13. The admission orders [REDACTED]. On 1/10/13 at 8:45 AM, a LN stated because the resident was a high fall risk the care plan should contain the admission orders [REDACTED]. The LN stated the care plan did not have these documented. The LN indicated it was not clear why the tab monitors had been circled on the Treatment record for 1/3/13 through 1/6/13 on the 3:00 PM to 11:00 PM shift. The LN stated there was no documentation on the back of the Treatment record or in the Nurses notes to indicate why they were not in place. On 1/10/13 at 10:15 AM, the DON stated the order for the tabs monitors/alarm on the chair and bed were to be in place for 7 days (12/28/12 through 1/3/13) had been marked off incorrectly on the Treatment record. The DON verbalized she did not know why the tabs monitors for the chair and bed had been extended. The DON stated the resident did not need the monitor/alarms. The DON confirmed if the tabs monitor for the chair and bed were extended past the initial order for 7 days, then a physicians order was needed to continue the use of the monitors. The DON confirmed there was no physician's order to continue the chair and bed tabs monitor. The facility's policy entitled, Falls and Risk (undated), documented upon admission every new resident will have orders for the following: 1. Every 15 minute checks times 7 days, scheduled toileting times 7 days, tabs monitor in chair and bed times 7 days. 2. Within 24 hours of the resident's admission the licensed nurse will conduct a fall risk evaluation on the resident. 5. If the resident scores a "13" or above proceed to care plan. 6. Each quarter the fall risk evaluation will be repeated. 7. If the resident experiences a fall you will complete the Post Fall Evaluation. On 1/10/13 facility staff were interviewed regarding residents who were high fall risks. Some resident rooms had a falling star posted outside the room on the name plate. The current revised policy did not indicate a falling star would be posted outside a resident's room if they were a high fall risk. On 1/10/13 at 8:05 AM, a Certified Nursing Assistant (CNA) stated residents who were a high fall risk should have a falling star outside there door. On 1/10/13 at 8:45 AM, a LN stated the facility did not post the falling star outside the rooms of resident's who were high fall risks. On 1/10/13 at 10:15 AM, the DON verbalized the facility no longer posted the falling star outside a resident's room if they were a high fall risk. Resident #14: Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Upon admission, she was assessed to be at high risk for falls. On 12/26/2012, she sustained a fall. Her nurse documented "(Patient) at nursing desk in (wheelchair) as client would not stay in bed. observed by CNA stand up take diaper down then fall over, (large skin tear right) elbow, (large skin tear left forearm) steri strips applied...as per orders (by medical doctor. Director of Nurses) notified also. (Neurological) checks started. Will continue to monitor". On 01/09/2013, the Director of Nursing was interviewed. She stated that based on interview with the CNAs on duty, this entry was inaccurate. She stated the resident was in her room, and attempted to transfer herself from her bed to the wheelchair. When the CNA her her bed alarm sound, the CNA entered the room and found the resident was falling. The resident was assisted by the CNA to the wheelchair, and sustained a skin tear. The Director of Nursing (DON) further stated the resident later in the shift fell and hit her head. Neurological checks were conducted. The Neurological Record form that was completed for Resident #14 on 12/26/2012 and 12/27/2012, was reviewed with the DON. She indicated the documented frequency of the neurological checks for the resident was not in compliance with facility policy. The DON stated the nurse was terminated for inaccurate documentation. The DON stated on 01/09/2013, that when the physician was notified of the inaccurate report of Resident #14's fall, and that she sustained a fall in which she hit her head, he ordered neurological checks on 12/27/2012 "per protocol". The DON stated she did not write a physician's order to ensure neurological checks were conducted as ordered. The DON stated on 01/09/2013, she should have written a physician's order but did not. Resident #9: Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. She was assessed to be at high risk for falling. Her medical record was reviewed on 01/10/2013. She was not assessed quarterly for risk of falls according to facility policy. The charge nurse was interviewed on 01/10/2013. She reviewed the medical record with the inspector. The most recent documented fall risk evaluation occurred on 09/05/2012. The Director of Nursing acknowledged the resident was not assessed quarterly for risk of falls.

Based on interview, clinical record review and document review, the facility failed to ensure the resident's environment was free from accident, received adequate supervision and assistive devices to prevent accidents for 4 of 15 sampled residents (Resident #1, #2, #3 and #7) Findings include: The facility's policy entitled Fall-When a Fall Occurs (undated) documented...#2 In the event that a resident has a fall, the following will occur: For falls occurring between the hours of 8:00 Am and 4:00 PM Monday through Saturday... d. As a team, all members present will conduct the "Post Fall Evaluation" at the scene to determine the "Root Cause" for the fall. e. If the fall was un-witnessed or was witnessed and the resident hit his/her head, the team will conduct "neuro-checks." (neurological). Neuro checks will be conducted in the following manner: 1. Initially at the scene of the fall prior to getting the resident up; 2. Every 15 minutes times 2. 3. Every 30 minutes times 2. 4. Every 1 hour times 2. 5. Every 2 hours times 24. The facility's policy for Fall Risk (undated) documented... "a falling star symbol will be placed next to the resident's name plate outside his/her room door to indicate that he/she is a fall risk." Initiate a Care Plan identifying that the resident had a Potential for Falls." The facility's policy entitled, Neurological Signs, Observation of (undated), documented, observation of neurological signs was conducted on all residents who sustain a head injury or have had an unwitnessed fall. "The purpose of this observation is to detect clinical manifestations of increased intracranial pressure." Resident #1 Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident Data Collection form dated 8/11/12 at 9:30 PM, documented Resident #1 had a stage 4 pressure ulcer on her coccyx. A Fall Risk Evaluation form dated 8/11/12 documented Resident #1's fall risk score was 16 (a score of 13 or above high fall risk). On the back of the form the documentation indicated resident was alert with confusion, one person assist when ambulating and unsteady gait. The Licensed Nurse Documentation Flow Sheet dated 8/27/12 indicated Resident #1 was alert, and orientated times 1, Foley catheter in place and no behaviors noted. The resident was not able to make needs known to staff or others, or able to cooperate with care/treatment plan. The documentation indicated on 8/27/12 at 5:30 AM, a Certified Nursing Assistant (CNA) reported the resident had a bruise on the right side of her forehead approximately "(2 x 3)" centimeters with "swollen tissue, pale bluish colored. Painful to touch." The resident was not able to "give correct answer how she got this injury, due to her mental status." At 7:15 AM, the physician on call was notified. Orders were received for a STAT (immediately) x-ray of the skull, neurological assessment every 2 hours times 24 hours. Nurse's Notes dated 8/28/12 documented the resident had been attempting to get out of bed by herself and unaware of safety needs. The physician was notified and an order was received for pad alarm in bed for safety. On 8/27/12, a physician's orders [REDACTED]. On 8/28/12, a physician's orders [REDACTED]. On 8/30/12, a physician's orders [REDACTED]. The clinical record contained documentation dated 9/3/12 11:00 PM to 7:00 AM. Resident received in bed, awake and alert with some confusion. Remains on bed rest for DVT" (Deep Vein Thrombosis). Narrative Notes dated 9/3/12 (7:00 AM to 3:00 PM) documented "On w/c (wheelchair). Tried to get her to bed d/t DVT precaution. Kept "on w/c and elevated legs." Documentation dated 9/3/12 (3:00 PM to 11:00 PM) indicated the resident was alert and orientated times one. Up in wheelchair with bilateral lower extremities elevated. The Narrative Notes dated 9/4/12 documented resident received up in wheelchair in front of nurse's station. The 11:00 -7:00 AM shift Licensed Nurse reported to this writer they got her up in the wheelchair "due to resident was restless in bed. Climbing out of bed." The resident was assisted up on the wheelchair by the 11:00 PM -7:00 AM shift assigned Certified Nursing Assistant (CNA). The resident ate breakfast in dining and then was placed in front of the nurse's station for close supervision. Both lower extremities kept elevated. The clinical record lacked documentation on 9/4/12, Resident #1 had been assessed to determine why the resident did not want to stay in bed. The clinical record lacked documentation the physician was notified the resident continued with attempt to climb out of bed. There was no documentation a physicians' order had been received to cancel the order for bed rest or to get the resident up in a wheelchair. Nurse's Notes dated 9/4/12 documented the resident was sitting up in the wheelchair in the hallway with bilateral legs elevated with pillow support on the leg rests. The resident bent over causing the wheelchair to tilt forward and the resident fell on the floor on her right side face down. The resident sustained [REDACTED]. The resident was alert, awake, but very confused. The resident was assisted back into the wheelchair and then to bed. Cold compress applied to right forehead and right periorbital area. The physician was paged at 11:30 AM. At 11:40 AM, the physician was notified of the fall and a new order received for a geri-chair with lap tray on when out of bed for safety and fall precautions. The Post Fall Evaluation/Investigation form documented Resident #1 fell on [DATE] at 11:15 AM. The resident was in her wheelchair with both legs elevated on the leg rests with pillow support. The resident bent over causing the wheelchair to tilt forward. The tab alarm went off. The resident was on her right side and face down on the floor. The documented behavior was alert and confused. The documentation indicated "Suppose to be on bed rest" but does not stay in bed. The resident had a order for bilateral 1/2 side rails while in bed. The Neurological Assessment form lacked documentation the neurological assessments had been completed in accordance with the facility's policy. The Neurological Assessment form lacked documentation the neurological checks had been completed every 15 minutes times two per the policy. The Neurological Assessment for lacked documentation a complete neurological assessment had been completed in regards to eye response, level of consciousness, speech and motor response from 9/4/12 at 4:30 PM to 10:30 PM on 9/4/12. The clinical record lacked documentation the every 15 minute activity log for safety and all precautions had been completed from 8/27/12 through 9/4/12 in accordance with the physician's orders [REDACTED]. The clinical record contained an (undated) care plan for fall risk. The goal was for the resident to participate with her transfers and have no falls during transfers over the next 30 days. The documented approaches included offer verbal cues to assist in steps of transfer, assist with all transfers, document and report any decline in transfer ability. Restorative nursing for transfers every shift for 90 days. The undated care plan lacked documentation to indicated Resident #1 had physician's orders [REDACTED]. documented on the care plan. On 10/23/12 at noon, a Registered Nurse (RN) verbalized if a resident was trying to climb out of bed she would get an order for [REDACTED]. The RN stated she would assess the resident to see if they were in pain, uncomfortable, hungry or needed to go to the bathroom. This information would be documented in the nurse's notes. On 10/23/12 in the afternoon, a RN stated per the facility policy a fall risk evaluation was done upon admission. The RN stated the care plan for high risk falls was not dated and was incomplete. The RN indicated if a resident was agitated the staff should find out why the resident wanted to get out of bed. The RN stated the clinical record lacked documentation to indicate the resident had been assessed as to why she had tried to get out of bed. The RN confirmed a resident not having a stool for 4 days could have caused agitation with the behavior of trying to climb out of bed. The RN stated no other options were tried such as a low bed or releasing the side rails due to the resident's behavior. The RN stated there was no documentation the resident had been assessed as to why she wanted to get out of bed. On 11/1/12 at 1:43 PM, a Staff member in Medical Records verbalized the only documentation in the clinical record for the every 15 minute activity logs were for 8/15/12 through 8/16/12, 9/5/12 through 9/6/12 and 9/6/12 through 9/7/12. Resident #3 Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 10/24/12 at 8:20 AM, the resident was observed in bed and the wheelchair was at the foot of the bed. The name plate outside the resident's room did not have a falling star to indicated the resident was a fall risk in accordance with the facility's policy. On 10/24/12 at 8:30 AM, a Certified Nursing Assistant (CNA) stated the resident was a fall risk. The CNA stated she was not sure if a falling star was placed outside the room if a resident was a fall risk. On 10/24/12 at 8:35 AM, a Licensed Nurse (LN) stated the resident was a high fall risk and probably should have a falling star outside the door. The admission orders [REDACTED] a. Toilet resident every 2 hours times 7 days b. Every 15 minute activity log checks times 7 days c. Tabs monitor in chair and bed times 7 days , then re-evaluate. The Resident Data Collection form dated 9/28/12 at 7:30 PM, documented the resident had no pain upon admission, skin warm, transferred with one person assist, and propels self in wheelchair. A Nurse's Note dated 9/28/12 documented the resident was alert and orientated times three with periods of confusion. The resident required limited assistance with Activity of Daily Living (ADL'S) and was continent of bowel and bladder. The resident used a wheelchair for locomotion. The clinical record documental on 9/29/12 at 9:10 PM, the resident had an unwitnessed fall. The resident was found laying on her left lateral side on the floor in her room. Denied hitting her head. Took the alarm off and was going to get the belongings in room. The High Risk Falls Worksheet dated 10/1/12 documented the following safety interventions to be put in place include: call light within reach, articles needed maintained in reach, falling star symbol outside the door, resident to wear non skid footwear in bed, signs posted to sue the resident, scheduling toileting program times 7 days, body pillow/positioning pillows, alarm in wheelchair times 7 days, alarm in bed times 7 days, full side rails bilaterally and ambulation aide-walker, cane etc.. The Post Fall Evaluation/Investigation form dated 9/29/12 indicated Resident #3 had a fall on 9/29/12 at 9:10 PM. The resident was ambulating at the time in her room. The resident was found lying on her left lateral side on the floor. The resident was alert and orientated times 3, no signs of injury, and was wearing her own slippers. The documentation indicated the resident needed to be remained to use the call light for all needs, routinely, remind and check resident tab alarm in place. Wear non skid slippers/socks. The clinical record lacked documentation the Neurological checks had been completed in accordance with the facility's policy after an unwitnessed fall. The clinical record lacked documentation the resident had been charted on every shift times 72 hours status [REDACTED]. The clinical record lacked documentation the every 15 minute activity checks had been completed on 9/28/12 and 9/29/12 in accordance with the physician's orders [REDACTED]. The September 2012 Treatment Sheet lacked documentation the resident had scheduled toileting completed every 2 hours on the 3-11 shift on 9/28/12 and the 11-7 shift on 9/29/12 and 9/30/12. On 10/24/12 at 8:35 AM, a LN stated high fall risk resident's had care plans upon admission and and if no care plan was completed upon admission there should be a care plan done after the first fall. The LN stated the care plan should be updated after each fall and contain additional measures after each fall. On 10/31/12 at 10:10 AM, a Registered Nurse (RN) verbalized the fall care plan was inaccurate and missing the physician's admission orders [REDACTED]. The RN was not able to locate documentation the every 15 minute activity checks were completed in accordance with the physician's orders [REDACTED]. The RN stated the facility's fall policy had not been followed. On 10/31/12 in the morning, a RN and a Staff Member from Medical records were not able to locate documentation the Neurological Assessments were done per the facility's policy after the resident's fall on 9/29/12. The clinical record documented on 10/6/12 at 7:35 AM, Resident #3 had an unwitnessed fall. The resident was found by staff sitting upright on her buttocks on the floor. The resident denied hitting her head. The resident stated she had transferred herself from the bed to the wheelchair independently and had removed her tab alarm. The Post Fall Evaluation/Investigation form dated 10/6/12 at 7:35 AM, documented the resident had and unwitnessed fall while transferring in her room. The resident was found sitting upright on the floor next to the bed with the wheelchair next to her. No signs or injury, the resident was alert and orientated times 3. The documentation indicated re-educate the resident in regards to the importance of tab alarm and using the call light. Remove wheelchair from side of bed. The Post Fall Evaluation form contained blank or areas not filled in for oxygen saturation level orthostatic blood pressure and the resident's use of glasses. The clinical record lacked documentation the neurological checks had been completed in accordance with the facility's policy after an unwitnessed fall. The entry for 10/6/12 at 12:50 PM and 10:50 PM, lacked documentation in regards to the resident's pupil response, eye response, level of consciousness, speech and motor response. The entry for the Neurological Assessment on 10/6/12 at 3:50 AM lacked vitals signs along with the resident's pupil response, eye response, level of consciousness, speech and motor response. The clinical record lacked documentation the resident was charted on every shift times 72 hours status [REDACTED]. There was no documentation regarding the resident's condition status [REDACTED]. The Fall Risk Evaluation form dated 10/7/12, documented the resident's fall risk score was 26 (13 or above go to high risk fall form). The instructions documented on the form indicate the resident's status was to be assessed at admission and quarterly. The Post Fall Evaluation/Investigation form dated 10/7/12 at 11:10 PM, documented Resident #3 had a fall The resident was found sitting on the floor with bilateral lower extremities in front of her next to the bed. The documentation indicated the resident stated she was feeling nauseous and wanted to go to the trash can to throw up. The Post Fall Evaluation form contained blank or areas not filled in for orthostatic blood pressure and if the wheelchair was locked, positioned properly and the location of the wheelchair. On 10/31/12 at 10:40 AM, a RN stated the clinical record lacked documentation to show the neurological checks were done after an unwitnessed fall in accordance with the facility's policy. The RN stated the documentation was incomplete. The RN stated the resident had not been charted on status [REDACTED]. The RN confirmed there was no documentation regarding the resident status [REDACTED]. The RN confirmed the Post Fall Evaluation was incomplete. The RN confirmed no new fall precautions/interventions put into place after the resident's fall on 10/6/12. During the interview on 10/31/12 at 10:40 AM, a RN confirmed the clinical record lacked documentation the resident was charted on every shift times 72 hours after the fall on 10/7/12. The clinical record lacked nurse's notes regarding the resident's condition status [REDACTED]. The RN confirmed the Neurological checks had not been completed and the care plan had not been updated with new interventions put in place after the fall on 10/7/12. The clinical record documented a physician's orders [REDACTED]. Resident #2 Resident #2 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. The clinical record contained a care plan dated 3/28/12 for Neuropathy and generalized pain. The documented goal indicated the resident would be clean, comfortable and free from falls or tissue breakdown. The documented approaches included: maintain articles for use and call bell within reach, encourage and provide assistance with repositioning and toileting every 2-3 hours, maintain air mattress on bed and Gel cushion in wheelchair. The care plan lacked documentation it had been updated after the resident's fall on 10/6/12 or 10/7/12. The Fall Risk Evaluation dated 6/22/12 and 9/4/12 documented Resident #2's fall risk as 8. The form documented Resident #2 had no falls in the past 90 days, was alert and orientated times 3. The High Risk For Falls Worksheet dated 3/27/12 and 6/22/12 documented the safety interventions for the resident were call light in reach, articles needed maintained in reach, resident to wear non skid footwear in bed, lap buddy, lap tray and full bilateral side rails. The Restraint Evaluation Form dated 9/4/12 documented Resident #2 was alert and orientated times 3, required assistance with Activity of Daily Living (ADL'S), assistance of one with transfers, no falls continent of bowel and bladder and no attempts to transfer self. The October 2012 physician's orders [REDACTED]. The October 2012 Medication Administration Record (MAR) documented Resident #2's had received the medications listed below on 10/6/12: Neurontin 100 milligrams twice a day orally (8:00 AM and 12 Noon) Neurontin 100 mg (three tablets) orally at bedtime (8:00 PM) Elvail 25 mg orally at bedtime for neuropathic leg pain (8:00 PM) Trazadone 50 mg orally at hour of sleep (8:00 PM) Restoril 7.5 mg orally at hour of sleep as needed. (time of administration unclear) Ativan 0.5 mg orally every 6 hours as needed anxiety (Midnight) Percocet 5/325 1 tablet orally every 4 hours as needed for pain ( No documentation of the time administered). The CNA (Certified Nursing Assistant ) Flow Sheet dated 10/6/12 documented the resident "was very drowsy all day, slumped in chair and slightly unresponsive" At 6:30 PM, the CNA took the resident to the bathroom changed him into night gown and attempted to assist the resident to bed but he refused. At 7:00 PM the resident fell from the wheelchair to floor and landed on right side of body, hitting his head on the ground. Vitals taken and nurse aware. The CNA Flow Sheet lacked documentation the Gel cushion was in place at the time of the fall. Nursing Progress Notes dated 10/6/12 at 7:00 PM, documented resident was found on the floor (side lying position) with bleeding laceration on right side of forehead, 4 centimeters in length. The resident had been seen all day drowsy but alert. He fell out of his wheelchair. Treatment done, wound cleansed with saline then wound cleanser, applied steri strips, Triple Antibiotic Ointment (TAO) and covered with gauze. Placed resident on neurological assessment. The Post Fall Evaluation/Investigation form indicated date of fall 10/6/12 at 7:00 PM. The fall was unwitnessed in the resident's bedroom. The resident was found in a side lying position. The form contained blank areas for documentation if the call light was on, an alarm sounded, the orthostatic blood pressure or the condition of the floor ( i.e.: liquid on floor, title lifted). The form documented the resident's injury was a laceration to the right side of his forehead. The behavior/mental status was alert/drowsy. The documentation indicated the resident was seen on the floor (side lying position) with bleeding laceration on the right side of his forehead, 4 centimeters in length. The resident had been seen all day drowsy but alert. "He was believed that he fell from the wheelchair." The area under assessment documented the CNA "instructed to place resident on bed early when resident is drowsy/sleepy." The clinical record contained a Episodic Care Plan: Post Fall dated 10/6/12 for sustained fall from chair, unwitnessed. Laceration on forehead. The documented approaches included monitor resident's condition and vitals over the next 72 hours, assess for pain and other signs of physical injury/trauma, complete neurological assessment if actual of suspected head injury or unwitnessed fall. Notify family and physician of any change of condition. The care plan lacked documentation of any additional interventions were initiated after the fall. The care plan lacked documentation a gel cushion was to be in place when the resident was in the wheelchair. The care plan lacked documentation the resident was to have a tabs alarm in place. The clinical record contained an Episodic Care Plan: Post Fall dated 10/6/12 sustained unwitnessed fall during transfer. The area on the form to document no apparent injuries or signs of injury was blank. The documented approaches included monitor resident's condition and vitals over the next 72 hours, assess for pain and other signs of physical injury/trauma, complete neurological assessment if actual of suspected head injury or unwitnessed fall. Notify family and physician of any change of condition. The care plan lacked documentation of any additional interventions after the fall during transfer. The Post Fall Evaluation/Investigation form and Nursing Progress Notes lacked documentation the Gel cushion was in place at the time of Resident #2's fall on 10/6/12 at 7:00 PM. The Treatment Record dated October 2012 lacked documentation 10/6/12 on the 3:00 PM to 11:00 PM shift Resident #2 had the Gel cushion on place when in the wheelchair. The Nurse's notes dated 10/7/12 documented at 2:45 PM, the resident had an unwitnessed fall at 2:45 PM. The resident was found sitting upright on the floor. "admitted to hitting his head" and had a small laceration to left scalp temporal region. Vital signs obtained. Denied pain/discomfort. The resident was transferring self from wheelchair to bed. Had tab alarm on and wheels on wheelchair locked. On call physician notified along with family. A Urinalysis, Basic metabolic panel and Complete Blood Count were ordered for 10/8/12. Per the physician send to hospital if the resident falls again. The Post Fall Evaluation/Investigation documented Resident #2 fell on [DATE] at 2:45 PM while transferring in bedroom. The resident was found sitting upright on the floor. May have attempted to transfer self. Tab alarm on wheelchair. The documentation indicated the resident had a small laceration to left scalp temporal area. The back of the document indicated the resident had previous fall and head involvement on 10/6/12 at 7:00 PM. the assessment was to ensure the tab alarm was fastened and out of reach of the resident's grasp. Check on resident's status every 2 hours and toilet every 2 hours. Ensure call light within reach. The neurological checks for (for the 10/6/12 fall) dated 10/7/12 at 8:30 AM, 10:30 AM, 12:30 PM and 2:30 PM, lacked documentation a complete neurological check had been completed in accordance with the facility's policy. The form contained areas on the form which were blank/not filled out regarding the resident's respiratory rate (i.e.. normal, shallow/irregular). The Nurse's Progress Notes and Post Fall Evaluation/Investigation form dated 10/7/12, lacked documented Resident #2 had a gel cushion in his wheelchair at the time of the fall. The Treatment Record dated October 2012 lacked documentation 10/7/12 on the 3:00 PM to 11:00 PM shift Resident #2 had the Gel cushion on place when in the wheelchair. The Treatment record lacked documentation as to why the Gel cushion had not been in the wheelchair. The CNA Flow Sheets documented on 10/7/12, Resident #2 was very disorientated was talking about delusional things, and repeatedly attempted to get up out of chair. But did not want to go to bed or bathroom, nurse aware. The clinical record contained additional CNA notes dated 10/7/12. The documentation indicated the resident was very disorientated today and was talking to himself. At beginning of shift the resident fell from the wheelchair to the floor landing on left side sitting left side of head. The resident was still attempting to get out of wheelchair so he was placed in the hallway. The CNA Flow Sheet lacked documentation a Gel cushion was in place at the time of the fall. The October 2012 Medication Administration Record (MAR) documented Resident #2's had received the medications listed below on 10/7/12: Neurontin 100 milligrams twice a day orally (8:00 AM and 12 Noon) Neurontin 100 mg (three tablets) orally at bedtime (8:00 PM) Elvail 25 mg orally at bedtime for neuropathic leg pain (8:00 PM) Trazadone 50 mg orally at hour of sleep (8:00 PM) Restoril 7.5 mg orally at hour of sleep as needed. ( 9:00 PM) Ativan 0.5 mg orally every 6 hours as needed anxiety ( 3:45 PM and 9:45 PM) Percocet 5/325 1 tablet orally every 4 hours as needed for pain ( 4:00 PM). The Nurse's Note dated 10/7/12 at 11:00 PM documented "continued hallucinating and repeatedly attempting to get up from wheelchair to walk. One- one CNA with resident due to negative behaviors."No bleeding from left temporal wound. small bruising hematoma present. Denies pain. As needed Ativan administered for restlessness at 3:45 PM and 9:30 PM. The nurse asked the resident if the as needed sleeping medication was needed. The resident agreed. Refusing HS (hour of sleep) cares. "Psych eval" (psychological evaluation) ordered at 3:45 PM by physician with other orders. On 10/7/12 the resident was discharged to the acute care hospital due to behaviors and possible head trauma from falls. Resident confused alert and orientated times 1-2, hallucinating, refusing cares Resident non ambulatory and uses wheelchair for mobility. Propels elf short distances assist of one with transfers. Scalp lacerations right and left temporal area. Transported to the acute care hospital at 9:55 PM. The neurological assessments dated 10/7/12 after the second fall at 2:45 PM, lacked documentation a complete neurological checks had been completed in accordance with the facility's policy. The form contained areas on the form which were blank/not filled out. On 10/7/12 at 3:00 PM, the neurological assessment lacked documentation of the resident's vital signs. The 10/7/12 entries for 6:15 PM, 6:45 PM lacked documentation of the resident's blood pressure and respirations (i.e.. normal, shallow/irregular). The entries dated 10/7/12 at 7:45 PM and 8:45 PM lacked documentation regarding the resident's respiratory rate being normal or shallow/irregular. The clinical record lacked documentation the Fall Care Plan had been updated or revised after the resident's fall on 10/7/12 at 2:45 PM. The Resident Transfer Form dated 10/7/12 documented Resident #2 had recent falls involving hitting his head. The reason for the transfer was "Confusion, Behaviors". The documentation indicated impairments for mental and speech. The area for additional comments documented confused, hallucinating, combative, behaviors, generalized weakness, "Refusing to follow safety." On 10/23/12 at noon, a Registered Nurse (RN) stated if a resident falls and hits their head at 7:00 PM the policy was to assess the resident provide treatment if required, check vitals, neuro checks, call the physician, family and develop a care plan. The RN verbalized if a resident was trying to climb out of bed she would get an order for [REDACTED]. The RN stated she would assess the resident to see if they were in pain, uncomfortable, hungry or needed to go to the bathroom. The RN stated this would be documented in the nurse's notes. During the interview on 10/23/12, a RN indicated the Fall Risk Evaluation was not filled out completely. The blood pressure was not documented. Any change in the blood pressure would be added to the Fall Risk Evaluation score. The RN verbalized after a fall a care plan should be initiated with fall interventions. The RN stated there were no additional interventions documented on the care plan after the 10/6/12 and 10/7/12 fall. The RN confirmed the neurological checks were not complete per facility policy on 10/6/12 and 10/7/12. On 10/23/12 at 12:15 PM, a RN stated the side effect of Percocet, Trazadone, Restoril, Neurontin and Ativan were dizziness, sedation and drowsiness. The RN stated with all medications Resident #2 had ordered can cause a dizziness and drowsiness. The RN stated a resident being drowsy all day was a change of condition, the nurse's should have monitored the resident and called the physician. The physician should be told the resident was drowsy and what medications the resident had prescribed. The RN stated there was no documentation the physician had been notified the resident was drowsy. On 10/24/12 at 10:30 AM, a Licensed Nurse stated if in report she was told a resident had been drowsy all day "I don't think I would be giving all those medications (Ativan, Percocet, and Restoril). "I would try to focus on why the resident was drowsy and help resolve the issue and continue to assess the resident through the shift. The medications cause drowsiness and sedation and "may be need to hold the medications and tell the physician what's going on." The LN was asked if Ativan, Percocet, Neurontin, Elavil, Trazadone and Restoril could contribute to a fall. The LN stated "Yes, especially if the resident was drowsy and sedated."The LN stated it was her responsibility to know the right resident,right medication, right route, right time and right frequency. The LN stated it was the nurse's responsibility to assess the resident and determine were they alert, confused, was this normal or new confusion. On 11/1/12 in the morning, a RN stated the clinical record indicated on 10/6/12 the night shift documented Resident #2 was alert, no speech issues. The RN verbalized the clinical record did not contain documentation in the nurse's notes regarding the resident's cognitive status prior to the fall. The RN was not able to locate documentation in the nurse's notes for 10/4/12 and 10/512 to indicate what the resident's cognitive status was. The RN stated the clinical record did not contain documentation from the Day shift nurse on 10/6/12. The RN verbalized if routine medications were due for a resident who had been drowsy all day a complete head to toe assessment with vitals and denotation should be done. The RN indicated the physician should be called and advised what medications were due to see if the physician wanted to hold the medications, change the medication orders or give