Every finding on record at Willowbrooke Court at Lanier Village Estates

Based on observations, staff interviews, and review of the facility policy titled, Guidelines for Isolation Precautions, the facility failed to follow Enhanced Barrier Precautions (EBP) for two of four residents (R) (R6 and R8) on EBP while providing high-contact care. This deficient practice had the potential to increase the spread of infection due to cross-contamination.Findings include: A review of the facility policy, Guideline for Isolation Precautions revised 3/23/2023, revealed staff were required to use Enhanced Barrier Precautions (EBP), which included wearing gowns and gloves when performing high-contact care activities. A further review indicated that high-contact resident care activities encompassed, but were not limited to wound care, urinary catheter care, and hygiene care. 1. A review of R6's care plan revealed that the resident was care planned for EBP related to wound care. An observation of R6's room on 9/20/2025 at 11:50 am revealed signage indicating the need for personal protective equipment (PPE) and Enhanced Barrier Precautions (EBP) was observed outside the R'6 door. The instructions on the signage directed all staff to wear gowns and gloves when providing direct care. During an interview with the Infection Control Preventionist (ICP) on 9/20/2025 at 11:02 am, she stated that all staff members were trained on the proper use of PPE for residents on EBP. According to the facility's Infection Control Plan (ICP), a PPE cart was placed in front of the door for each resident on EBP, and staff were required to put on PPE before providing high-contact care, which included wound care. Education on EBP was provided annually, as well as during in-service training throughout the year. During an observation of wound care on 9/20/2025 at 11:51 am, Registered Nurse (RN) CC provided wound care without using PPE in accordance with EBP. During an interview with RN CC on 9/20/2025 at 12:06 pm, she acknowledged that she did not don (put on) PPE before providing wound care to R6. According to RN CC, R6 was on EBP, and she should have donned PPE; it was an oversight. During an interview with the Director of Nursing (DON) on 9/20/2025 at 12:18 pm, she stated it was her expectation that staff should wear PPE for residents on EPA when providing high-contact care, including wound care. 2. Review of the admission Record for R4 revealed diagnoses included, but were not limited to, urinary retention and renal insufficiency. Review of the Annual MDS for R4, dated 7/19/2025, revealed in Section GG (Functional Abilities and Goals) R4 was dependent on staff for lower body dressing and toileting, and required substantial to maximal assistance for personal hygiene and chair to bed transfers. Section H (Health Conditions) documented that the resident had an indwelling urinary catheter. Review of the care plan for R4 revealed a Focus, initiated 7/18/2024, of an indwelling catheter. Interventions included, but were not limited to, EBP, initiated 8/1/2024, and indwelling catheter care, CNA (Certified Nurse Aide) may perform. Review of the physician's orders for R4 revealed an order dated 3/7/2025 for EBP two times a day for prevention of transmission of MDRO (multi-drug-resistant organism) infections. Further review revealed an order dated 3/7/2025 for indwelling urinary catheter care, CNA may perform two times a day for indwelling urinary catheter care maintenance. Observation on 9/20/2025 at 11:45 am of CNA AA and CNA BB providing urinary catheter care for R8 revealed that CNA AA and BB performed hand hygiene, donned gloves, did not don gowns, transferred the resident to the bed, positioned R8, repositioned her pants, and removed her brief. CNA AA and BB provided catheter care, placed a clean brief on R4, repositioned her pants, and transferred R4 to her wheelchair. Observation revealed an EBP instructional sign, instructing staff to don gloves and gowns when providing high-contact care, and a cart with PPE supplies, including gowns, gloves, and masks, just outside of R4's room. In an interview on 9/20/2025 at 12:05 pm, CNA BB verified the EBP signage and PPE supply cart outside of R8's door. She stated that she was aware R8 was on EBP, and she should have worn a gown while providing catheter care. She further stated that she had just forgotten to. In an interview on 9/20/2025 at 12:10 pm, CNA AA verified the EBP signage and PPE supply cart outside of R8's door. She stated she always wore gloves but normally did not wear a gown while providing urinary catheter care or ADL care to residents on EBP. She stated she thought wearing gloves was all that was needed. In an interview on 9/20/2025 at 12:15 pm, the DON stated nursing staff had received education on EBP, and she expected them to follow EBP when providing high-contact care to residents who were on EBP.

Based on observations, staff interviews, record review, and review of the facility's policy titled Baseline Care Plan, the facility failed to implement interventions for oxygen therapy for one of seven residents (R) (R290) receiving oxygen therapy. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility's policy titled Baseline Care Plan, last review date of 5/2018 under Policy revealed, To strive to initiate a baseline care plan for a resident based upon the medical plan and nursing assessment, which includes the instructions needed to provide person-centered care and meets the professional stands of quality care. Under the section titled Procedure revealed, Number two. The baseline care plan should address the residents' immediate needs and include the minimum healthcare information necessary to properly care for the resident including, but not limited to: b. physician orders and d. therapy services. Review of the electronic medical record (EMR) revealed R290 admitted to the facility on [DATE] with diagnoses that included but not limited to dyspnea, interstitial pulmonary disease, chronic respiratory failure with hypoxia, and syncope and collapse. Review of R290's care plan indicated a focus of receiving oxygen therapy related to chronic respiratory failure with interventions that included but not limited to oxygen via nasal cannula at two liters per minute, initiated on 4/19/2024. Observation on 4/26/2024 at 10:35 am revealed R290 was observed wearing a nasal cannula and receiving oxygen via concentrator with flow meter set at three liters per minute. Observation on 4/26/2024 at 1:49 pm revealed R290 sitting up in a recliner in her room wearing a nasal cannula and receiving oxygen via concentrator with flow meter set at three liters per minute. Observation on 3/27/2024 at 8:01 am revealed R290 sitting up in her recliner eating breakfast wearing a nasal cannula and receiving oxygen via concentrator with flow meter set at three liters per minute. Observation and Interview with Licensed Practical Nurse (LPN) AA on 4/27/2024 at 8:15 am revealed R290 sitting up in recliner wearing a nasal cannula and receiving oxygen via concentrator with flow meter set at three liters per minute. LPN AA verified R290's oxygen flow meter was set at three liters per minute and that the physician order for oxygen was for two liters per minute via nasal cannula. LPN AA confirmed that it was the nurses responsibility to check and verify the flow meter was set to the setting specified by the physician orders. Interview on 4/27/2024 at 10:45 am with the Director of Nursing (DON) revealed her expectation was for the nursing staff to monitor and verify the concentrator flow rate to be set at the rate ordered by the physician. Interview on 4/28/2024 at 8:30 am with Registered Nurse (RN) Care Coordinator BB revealed that the nurses are expected to review and implement the interventions listed on the resident's care plan. Interview on 4/28/2024 at 8:45 am with RN CC revealed that the floor nurse's responsibility related to the care plan was to initiate the baseline care plan on admission, this includes review orders and family and resident requests, to assist with the development of the baseline care plan. She stated the floor nurse was expected to follow the care plan and verify the care provided was included in the care plan. She stated she usually reviewed orders and care plans prior to the start of her shift to verify and reconcile orders with the care plan. Interview with RN DD on 4/28/2024 at 9:00 am revealed the care plan was a communication tool, which opened communication with all staff, so everyone would be on the same page when providing care for each resident. She stated the care plan communicates with nurses, Certified Nursing Assistants (CNAs), and other staff what interventions are needed in relationship to the residents' orders and needs. She revealed nurses should update the care plan to include new interventions. Interview on 4/28/2024 at 9:25 am with the Assistant Director of Nursing (ADON) revealed care planning was addressed every morning during stand-up meetings. She stated the nursing supervisor rounded every morning and discussed with the floor nurses any resident concerns or needs and that they review the 24-hour report. She revealed that during the morning stand up meeting any concerns, issues, resident needs, and updates from the 24-hour report are communicated with the entire interdisciplinary team (IDT). She stated the care coordinator in the past would update the care plan immediately during this meeting as needed. She stated implementation of the care plan included addressing the Treatment Administration Record (TAR) for nurses and the task list for the CNAs. She also stated the care profile was updated and all staff were able to see this in the banner of the EMR. She stated nurses are expected to implement the interventions identified in the care plan and follow physician orders related to the oxygen flow rates. Cross Reference F695

Based on observations, staff interviews, record review, and review of the facility's policies titled Person Centered, Interdisciplinary Care Planning and Care Conference, and Catheter Care, Indwelling, the facility failed to develop a person-centered care plan with interventions that addressed performing catheter care for one of three residents (R) (R24) with an indwelling urinary catheter. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility's policy titled Person Centered, Interdisciplinary Care Planning and Care Conference last revised date 10/2022, under the section titled, Policy revealed, To strive to develop, review, and revise the person-centered interdisciplinary care plan for each resident in order to identify resident needs, establish measurable goals/objectives, interventions, and timeframes to enable the resident to attain/maintain his/her optimal level of physical, mental, and psychosocial functioning. Person Centered The focus on the resident as the center of control. Each resident is supported in making his/her own choices in identifying what is important to him/her regarding daily routines, preferred activities, and a meaningful life. Under the section titled, Procedure revealed, Number five. Ensures that the interdisciplinary person-centered care plan addresses the following: Residents personal and cultural preferences, Residents' preferences and potential for future discharge. Review of the facility's policy titled Catheter Care, Indwelling last revised date 7/2022, under the section titled Procedure, Number 22 revealed, Ensure the care plan reflects the following: a. Type of catheter tubing. b. Routine care of catheter, tubing, drainage bag. c. Interventions to minimize catheter-related injury, pain, encrustation, excessive urethral tension, accidental removal, or obstruction of urine overflow. d. Outcomes and/or effects of goals and interventions. e. Complications associated with catheter usage. f. Urology consult if indicated. Review of the electronic medical record (EMR) revealed R24 was admitted to the facility with diagnoses that included but not limited to hydronephrosis with renal and ureteral calculous obstruction, urinary tract infections (UTI), methicillin resistant staphylococcus aureus (MRSA) infection, artificial openings of the urinary tract, chronic kidney disease, urethral stricture, and obstructive and reflux uropathy. Review of R24's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated R24 was cognitively intact. Section GG (Functional status) revealed R24 required partial/moderate assistance during self-care admission performance of toileting. Section H (Bowel and Bladder) revealed R24 had an indwelling urinary catheter and an ostomy. Review of R24's care plan indicated a focus on bilateral nephrostomy tubes (initiated 4/1/2024) Interventions included: empty nephrostomy tubes as ordered, enhanced barrier precautions, follow up with MD (Medical Doctor) as ordered, monitor for s/sx (signs and symptoms) of infection. Further review of care plans revealed a focus for an indwelling catheter (initiated on 3/26/2024) Interventions included: monitor for s/sx of discomfort on urination and frequency, monitor/document pain/discomfort due to catheter and monitor/record/report to MD for s/sx UTI. There were no care plan interventions that addressed performing catheter care. Observation on 4/27/2024 at 9:29 am of R24 in the shower performing self-catheter care with Certified Nursing Assistant (CNA) EE standing on the other side of shower curtain observing R24 perform catheter care. Interview on 4/27/2024 at 9:24 with CNA EE revealed that R24 was documented as stand-by assist for catheter care. She stated he usually did his own catheter care while he showered. She revealed that while R24 showers she observes him performing his catheter care to verify that he completes the care correctly. She stated that if she notices him doing anything incorrectly, she redirects him in his care. She further stated once the catheter care was completed the CNA would report to the nurse and the nurse would document catheter care was completed in R24's eTAR. Interview on 4/27/2024 at 11:45 am with Licensed Practical Nurse (LPN) AA revealed she reviewed R24's care plan, latest MDS assessment, and the task tab in the EMR. She verified and confirmed she could not locate documentation that R24 had been assessed as stand-by assistance for catheter care. She verified and confirmed that the nurse document catheter care three times a day on the eTAR. She stated the CNA's have a tablet which they document in the EMR which may indicate the type of assistance R24 required for catheter care. Interview on 4/27/2024 at 11:45 am with CNA EE revealed that the tablet she uses to document care for residents listed catheter care as a task. She verified and confirmed the task did not indicate the type of assistance R24 required for catheter care. She stated she knew he was stand-by assist for catheter care because she knew R24. She stated she could not identify how the CNA determines the type of assistance R24 required for catheter care in the EMR. Interview on 4/27/2024 at 12:50 pm with the Registered Nurse (RN) Care Coordinator BB confirmed there was no care plan developed for R24 to self-perform catheter care. She stated that she runs a report everyday of new orders obtained from the physician and she develops/revises care plans based on the new orders entered in the EMRs for the facility's residents. She stated she has only been working in the facility since 4/22/2024 and was unaware R24 was performing self-catheter care. Interview with the Director of Nursing (DON) on 4/27/2024 at 12:54 pm revealed her expectation related to development of care plans was for the Care Coordinator to run a report of new orders and develop/revise care plans based upon new orders entered into resident's medical records. Cross Reference F690

Based on observations, staff interviews, record review, and review of the facility's policy titled Catheter Care, Indwelling, the facility failed to assess one out of three residents (R) (R24) with an indwelling urinary catheter for self-performance of catheter care prior to allowing the resident to perform catheter care without staff direct assistance. Findings include: Review of the facility's policy titled Catheter Care, Indwelling last revised date 7/2022 under the section titled Policy revealed, To strive to prevent contamination and catheter associated urinary tract infections and complications. Under the section titled Procedure number five revealed, Catheter care can be given during am or pm care as follows: a. Assist the resident into a supine position. b. Inspect the outside of the catheter where the catheter enters the meatus. Look for encrusted material or suppurative drainage and report any findings to the nurse. c. Inspect the tissue around the urinary meatus for irritation or swelling and report any findings to the nurse. d. Wash the meatal catheter junction and catheter tubing with soap and water, rinse and dry well. f. Draw back the foreskin, wash carefully around the catheter and replace the fore skin on the male resident. Review of R24's electronic medical record (EMR) revealed he was admitted to the facility with diagnoses that included but not limited to hydronephrosis with renal and ureteral calculous obstruction, urinary tract infections (UTI), methicillin resistant staphylococcus aureus (MRSA) infection, artificial openings of the urinary tract, chronic kidney disease, urethral stricture, and obstructive and reflux uropathy. Review of R24's most recent Minimum Data Set (MDS) assessment (Medicare five -day) dated 4/18/2024 revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated R24 was cognitively intact. Section GG (Functional) revealed no functional limitations of upper and lower extremities, he was assessed to require partial/moderate assistance with toileting and lower body dressing. Section H (Bowel and Bladder) revealed R24 had an indwelling catheter and ostomy. Review of the EMR revealed physician's orders for R24 included but were not limited to flush nephrostomy tubes with 10 milliliters of normal saline daily as needed for blockage (start date 4/26/2024), clean both nephrostomy sites with warm water, pat dry, apply drain sponge to nephrostomy and cover with transparent dressing daily on Tuesday and as needed, assess for warmth, leakage, pus, breaks in tube every shift on Tuesdays (start date 4/30/2024), empty and document output from catheter and bilateral nephrostomy tubes three times a day, monitor urine output and document nephrostomy drain output three times a day (start date 4/16/24). There were no orders for R24 to perform self-catheter care. Review of the EMR revealed there was no evidence that an assessment had been completed for R24 to self-perform catheter care. Review of the April 2024 Electronic Treatment Record (eTAR) revealed documentation of urinary catheter care documented three times a day and enhanced barrier precautions documented each shift by the nurse. Observation made on 4/27/2024 at 9:29 am of R24 in the shower with Certified Nursing Assistant (CNA) EE standing outside of the curtain watching R24 self-perform catheter care. R24 used soap and water to clean the urinary meatus and catheter tubing from the meatus to the bifurcation in the tube at the balloon port and the urine drainage port. He thoroughly rinsed the area with clean water using a handheld shower head. Interview on 4/27/2024 at 9:24 am with CNA EE stated R24 was stand-by assist for catheter care. She stated he usually did his own catheter care while he showered. She stated once the catheter care was completed the CNA reported the activity to the nurse who would document the care in R24's medical record. Interview on 4/27/2024 at 11:45 am with Licensed Practical Nurse (LPN) AA revealed that R24's care plan, latest MDS assessment, and the task list located in the EMR did not specify R24 was assessed as stand-by assist for catheter care. She confirmed and verified she could not locate any documentation in the EMR that stated R24 had been assessed as stand by assist for catheter care. She stated the care was documented each shift by the nurse on the electronic Treatment Administration Record (eTAR). Interview on 4/27/2024 at 11:50 am with the Director of Nursing (DON) verified the e-TAR indicated catheter care was to be completed each shift for R24. She stated her expectation was when a resident requests to perform their own catheter care, the nurse on the floor should call the physician to request an order for self-care. She further stated that nursing should perform an assessment to verify the resident was able to perform self-catheter care. Interview on 4/27/2024 at 12:50 pm with Registered Nurse (RN) Care Coordinator BB revealed if a resident request to perform self-catheter care, the nurse should assess and educate the resident regarding signs and symptoms of infection and proper performance of catheter care. She stated the nurse should then notify the physician to obtain an order and enter the order into the EMR. She stated her first day in the facility was Monday 4/22/2024, therefore she was unaware of R24's performance of self-catheter care. A request was made for a policy related to resident assessment for self-catheter care but was not provided by the facility. Cross Reference F656

Based on observations, staff and resident interviews, record review, and review of the facility's policies titled Oxygen Administration/Safety and Use and Care of Equipment, the facility failed to follow physician's order for oxygen therapy and failed to ensure the oxygen concentrator had a filter while in use for one out of seven residents (R) (R290) who receive oxygen via the concentrator. Findings include: Review of the policy titled Oxygen Administration/Safety with review date of 10/18, revealed the policy was to strive to improve oxygenation, provide comfort to resident's experiencing respiratory difficulties and provide safety precautions during the administration of oxygen. The section titled Procedure, step number one revealed obtain a physicians' order for the use of oxygen (i.e., continuous, as needed, number of liters, etc.). Step number four stated adjust the oxygen flow as ordered by the resident's physician. Step number nine revealed check the resident and oxygen flow frequently to assure the maintenance of the correct flow rate and proper functioning of the concentrator/cylinder. Review of the policy titled Use and Care of Equipment reviewed 11/20, revealed the policy was to strive to provide clean or sterile resident care equipment in order to reduce the possibility of equipment becoming contaminated that may cause infections. Under the section titled Clean Equipment Protocols, number nine addressed Respiratory Equipment and sub-section a addressed Oxygen Materials, number five revealed oxygen concentrator filters are cleaned and or replaced weekly. Review of the electronic medical record (EMR) revealed R290 was admitted to the facility with diagnoses that included but were not limited to dyspnea, interstitial pulmonary disease, chronic respiratory failure with hypoxia, and syncope and collapse. Review of R290's EMR revealed the Admission Minimum Data Set (MDS) assessment dated [DATE] was in process and had not been completed related to the resident's recent admission. Review of the EMR revealed a nursing assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated R290 was cognitively intact. Review of R290's care plan indicated a focus of care on receiving oxygen therapy related to chronic respiratory failure which included an intervention but was not limited to oxygen settings: Oxygen via nasal cannula at two liters per minute (initiated on 4/19/2024). Review of R290's EMR revealed physician's orders that included but was not limited to oxygen at two liters per minute via nasal cannula (started 4/18/2024). Review of the EMR revealed nurses documented on the electronic medication administration record (eMAR) oxygen saturations twice a day ranging from 94 to 98 percent on oxygen via nasal cannula. Observations and Interview on 4/26/2024 at 10:35 am of R290 working with physical therapy in her room. R290 was wearing nasal cannula with oxygen infusing from the concentrator at three liters per minute. R290 revealed she had worn her oxygen continuously since her admission into the facility. She revealed prior to admission, she only wore oxygen when walking because she became short of breath easily. Observation on 4/26/2024 at 12:30 pm revealed R290's oxygen concentrator was missing the filter on the back of the machine. Observations on 4/26/2024 at 1:49 pm revealed R290 sitting up in a recliner in her room wearing a nasal cannula and the flow meter on the oxygen concentrator was set at three liters per minute with the filter missing from the back of the concentrator. Observations made on 4/27/2024 at 8:01 am observed R290 sitting up in a recliner in her room wearing a nasal cannula and eating breakfast. The oxygen concentrator flow meter was set at three liters per minute with the filter missing from the back of the oxygen concentrator. Observation and interview on 4/27/2024 at 8:15 am with Licensed Practical Nurse (LPN) AA, confirmed R290's orders for oxygen at two liters via nasal cannula. LPN AA observed and confirmed R290's oxygen concentrator flow meter was set at three liters per minute in addition to the oxygen concentrator not having a filter. She revealed that all oxygen tubing and humidifier bottles were changed weekly on night shift. She stated she thought filters were cleaned one to two times a week but was not sure. She stated she was not sure which night this task was completed on but when tubing and humidifier bottles are changed the nurse should label them with the date. She further stated she was not sure where this task was documented because it was not on her eMAR. Interview on 4/27/2024 at 10:05 am with the Director of Nursing (DON) confirmed R290 had physician orders for oxygen at two liters per minute via nasal cannula. She confirmed the admitting nurse should obtain the oxygen concentrator for newly admitted resident and verify the filter was in place and clean before placing the concentrator in use. She stated oxygen tubing should be changed on Sunday nights. She revealed the admission nurse should initiate the change tubing orders and when tubing was changed, the nurse should document this on the eMAR. She stated each disposable component of the oxygen concentrator (nasal cannula and humidifier bottle) should be labeled with the date it was changed. She stated her expectation of staff was upon admission if a resident has an order for oxygen to initiate oxygen by obtaining a concentrator with a clean filter and set up with a nasal cannula and humidifier if needed and to label each component and the date initiated. She stated she expected the flow meter to be set on the rate ordered by the physician. She also stated she expected during nursing rounds the nurses should be checking the flow meter rate and verifying the rate was set at the physician's ordered rate. She stated she expected the night shift nurse on Sundays to change the tubing set up and clean the filter each week. Cross Reference F655

Based on observation, interviews, and review of facility policy titled, Personal Food in Willowbrooke Court the facility failed to ensure that a policy regarding resident personal food included procedure for safe consumption/safe reheating to prevent food borne illness. The deficient practice had the potential to affect 60 of 60 residents receiving an oral diet. Findings include: Review of the fcility policy titled, Personal Food in Willowbrooke Court dated 2/2017 revealed directions for food storage. The policy had no guidelines regarding safe consumption of hot foods if re-heated. Interview on 2/11/2023 at 11:45 a.m. with the Director of Dietary Services (DDS) revealed that he was not sure about a policy that included safe consumption or reheating of food items bought in from outside. The DDS stated that he would expect staff to re-heat to 165 degrees. During an interview on 2/11/2023 at 12:45 p.m. the Certified Dietary Manager (CDM) confirmed that the current policy regarding personal food brought in the facility did not cover safe consumption/reheating procedure. The CDM revealed that she had conducted a quick stand-up in-service a few months ago with some nursing staff on using the microwave for re-heating food items brought in the facility, but did not have staff sign an in-service form due to the information was presented on the spot. The CDM revealed that she did not educate all nurses and all shifts about re-heating foods properly. Observation on 2/11/2023 at 1:20 p.m. of all four resident nourishment areas revealed no food thermometer found for staff to use when reheating resident food items. During interview on 2/11/2023 at 1:20 p.m. the CDM confirmed that there are no food thermometers in any of the resident nourishment areas for staff to use when reheating resident food.

Based on record review, staff interview, and review of the facility policy titled, Psychotropic Medications, the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for one Resident (R) (R#28) reviewed for unnecessary medications. Specifically, the facility failed to ensure a stop date was implemented for antianxiety medication ordered as needed (PRN) for R#28. Findings Include: A review of the medical record revealed that R#28 was admitted to the facility with a past medical history of right femur fracture, hypokalemia, dementia with behaviors, HTN, heart disease, CHF, and abdominal aortic aneurysm. A review of the facility policy, Psychotropic Medications, number M-04.16, revised 10/2022, revealed the use of a psychotropic medication ordered on an as needed (PRN) basis was limited to 14 days, except when the prescribing practitioner believed it was appropriate for the order to be extended and documented the rationale and duration in the health record. A review of the Medical Doctor (MD) orders dated 12/22/2022 at 4:15 p.m. revealed R#28, the MD ordered Lorazepam Solution 2 MG/ML, lorazepam Solution 2 MG/ML, 0.5 (Milliliters) ml intramuscularly (IM) every six hours as needed for refusing care, hitting, kicking, or attempting to elope. The order had a start date of 12/22/2022, but the order had no stop date. A review of the Medication Administration Record (MAR) dated 1/27/2023 at 11:56 p.m., revealed R#28 was administered 0.5 milligrams of Lorazepam IM. A review of the Nursing Notes dated 1/27/2023 at 11:56 p.m. revealed staff administered Lorazepam Solution 2 MG/ML, 0.5 ml intramuscularly (IM) to R#28 for refusing care, hitting, kicking, and attempting to elope. The resident was screaming and combative. The staff had R#28 speak with his daughter by phone, and he would not calm down. The staff could not get him to return to his room and watch a ballgame on TV. He declined an offer to go on a walk. He could not be re-directed, called staff slang names, and struck out at staff. During an interview with the Nursing Supervisor (NS) AA on 2/11/2023 at 2:07 p.m., she stated that the consultant pharmacist reviewed all resident medications, and any recommended changes or modifications were sent to the Nursing Home Administrator (NHA) and the Director of Nursing (DON). NS AA stated the DON would notify the physician and alert them to any medication changes. NS AA acknowledged R#28's lorazepam, 0.5 mg IM, every six hours, as needed, should have been assigned a 14-day end date, and the medication did not have one.

Based on observation, interview, and review of facility policy titled, Holding Hot and Cold Potentially Hazardous Foods the facility failed to maintain hot food items on the portable steam table above 135 degrees to prevent food borne illness. This deficient practice affected 10 of 14 residents on the Reflections Hall consuming a regular textured diet. Findings included: Review of the facility policy titled Holding Hot and Cold Potentially Hazardous Foods revised 11/2013 revealed that for hot foods held for service, all hot potentially hazardous food should be 135F or above before placing the food out for service. Observation on 2/11/2023 at 12:35 p.m. of the portable steam table on the Reflection Hall revealed the grilled chicken breasts had a temperature of 115 degrees and the special request order of fried chicken tenders had a temperature of 116 degrees. Temperatures were obtained by the Certified Dietary Manager (CDM) using the facilities calibrated thermometer. During an interview on 2/11/2023 at 12:35 p.m. the CDM confirmed that the grilled chicken breast was at 115 degrees and the special order of fried chicken tenders were at 116 degrees. The CDM stated that food items should be held on the portable steam table above 135 degrees.

Based on observations, staff interviews, and policies Operational Standards Storeroom and Date Marking Ready-to-Eat Foods reviewed, the facility failed to discard expired food items in the freezer, label and date items in the main kitchen pantry, label and date items in the resident's pantry, and keep the ice machine clean. These deficient practices had the potential to affect 58 of 59 residents receiving an oral diet. Findings include: Review of Operational Standards Storeroom policy, dated ,d+[DATE], revised ,d+[DATE] revealed procedure is all items are organized for easy inventory, foods are stored properly, ensuring opened containers are properly sealed and labeled with the date of opening and the use-by date (month, day and year), all foods are stored in the delivery box with the delivery date or individually with a delivery date on the individual food item, and items that have a manufacture's expiration date do not need additional dating unless it is required by stated regulations. Review of Date Marking Ready-to-Eat Foods policy, dated ,d+[DATE], revised ,d+[DATE] revealed the procedure is for all ready-to-eat foods will be labeled to include the following information: product name and date (month, day and year) the product was prepared or opened and the date the product should be used by. Further review revealed the procedure is to label all ready-to-eat, potentially hazardous foods that are prepared on-site with date of three days from the date it was prepared. Continued review revealed the procedure is to label any processed, ready-to-eat, potentially hazardous foods when opened with a use-by-date based on the Food Storage Chart. 1. During initial tour observation of the main kitchen accompanied by the Sous Cook (SC) on [DATE] at 11:20 a.m. of walk-in freezer #2, revealed, an opened, one gallon of Tartar Sauce was without a received date or use by label. During continued observation tour of the main kitchen in the dry food storage pantry on [DATE] at 11:30 a.m. revealed three, seven pound cans of hot fudge topping with an expiration date of [DATE] on the label. Continued observation of the pantry revealed a 16 oz. jar of honey was open, unlabeled, and half of the contents were consumed and a 16 oz jar of unsalted almond butter was open, half of the contents were consumed and a label with an expiration date of [DATE] was on the lid. On [DATE] at 11:30 a.m. the SC verified the tartar sauce was missing the appropriate label, the hot fudge topping had expired on [DATE], the jar of honey was unlabeled, and the jar of almond butter had expired in [DATE]. An interview conducted with the SC on [DATE] at 11:30 a.m. revealed the process for rotating food in the main kitchen is to rotate most recent dated items to the front and when new food items are received they are placed in the back on the shelf. He stated once food items are received, a label will be created and the received date and discard date are noted before placing the food on the shelf or in the freezer. SC continued to state it is his responsibility to ensure the food items are used or discarded on or before the discard date. An interview conducted with Dietary Manager (DM) on [DATE] at 5:00 p.m. revealed she has provided in-service training on Date Marking for the kitchen staff to ensure the process of rotating food is followed. 2. During observation of the first floor kitchen on [DATE] at 10:00 a.m. the Dietary Aid (DA), revealed the ice machine has a black, wet substance located inside, underneath the door opening. Continued observation revealed one, 5.5 oz (ounce) pack of 6, V8 vegetable juice is unlabeled. Further observation of the first floor pantries on [DATE] at 10:15 a.m. with the DA revealed: Pantry #1 had one snack basket missing a use by label. Pantry #2 had an opened pitcher of lemonade in the refrigerator with a use-by [DATE] label. Observation and interview on [DATE] at 10:20 a.m. the DA verified the black substance located in the ice machine, the vegetable juice was missing the appropriate label, the snack basket was missing the use by label and the lemonade in the refrigerator had expired on [DATE]. An interview conducted with DM on [DATE] at 10:30 a.m. revealed that the facility has a contract with a repair service company to come into the building and clean the ice machines quarterly.

Based on record review, observations, staff interviews and review of the facility policy titled Side Rail/Bed Rail Usage, the facility failed to assess for the risk of entrapment from bed rails, for two residents (R) (#48) and (R#4); and failed to obtain informed consent, Physician Orders and attempt alternative methods for 36 of 39 residents prior to the use of assist rails (R#1, R#2, R#6, R#7, R#8, R#10, R#12, R#13, R#15, R#16, R#17, R#19, R#20, R#22, R#23, R#25, R#26, R#27, R#28, R#29, R#30, R#33, R#37, R#38, R#40, R#41, R#43, R#45, R#46, R#51, R#52, R#57, R#58, R#59, R#610, and R#613). The findings include: Review of the Facilities Policy titled Side Rail/Bed Rail Usage, revised 6/2018, revealed to strive to ensure that a side/bed rail is used only as necessary, and if used is installed correctly and routinely maintained. All residents will be assessed for the use of side rails upon move-in to the community. The community will attempt to offer side rail alternatives prior to using or installing a side rail. Review the risks and benefits of side/bed rail with the resident or resident's representative. Provide written documentation describing the risks/benefits and safety of side rail use. Look for risk of entrapment from the side (bed) rails at the time of the installation and ongoing with the use of one or more rails. 1. A review of the clinical record revealed R#48 was readmitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed R#48 had a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The resident was also assessed to require limited assistance of one person with bed, transfer and toileting. Observations of R#48 on 6/22/21 at 11:00 a.m., 6/22/21 at 3:30 p.m., 6/23/21 at 1:35 p.m. and 6/24/21 at 11:30 a.m. revealed the resident laying in her bed sleeping with bed rails in the up position. The bedrails can pivot to an upright position (grab bar) then pivoted for use as a side rail, the staff reference this position as down. Review of Physician Orders, and Progress Notes, for R#48 between admission through 6/24/2021 revealed no documentation related to the use or need for assist/bedrails. Further review revealed there were no Physician Orders, no documented informed consent and no evidence that alternatives or risk for bedrail entrapment were completed prior to the installation of bed rails. An interview on 6/24/21 at 9:50 a.m. with Certified Nursing Assistant (CAN) EE revealed that side rails stay down (pivoted for use as a side rail) when the resident is in bed in order to prevent resident's from failing and for safety. CNA EE stated that a lot of residents on the locked Alzheimer's/Dementia unit have them for safety. CNA EE revealed that she does not know of another use the side rails except to ensure safety of the resident. CNA EE stated the days she provides care to R#48 she enters the resident's room and asks her of she's ready to get up and if the resident is ready to get up, she lifts (pivots) the bed rail and places it in the locked-up position and assists R#48 with transferring from her bed to her wheelchair. CNA EE stated she assists R#48 with toileting and then takes her to breakfast. CNA EE revealed that that after the resident eats she always insists on returning to her bed. CNA EE stated that staff try to encourage R#48 to stay and interact with staff and other resident's but R#48 prefers to be in her bed. CNA EE stated when she returns the resident to her bed, she assists with transferring the resident to the bed, puts bed in low position and puts side rail in place. CNA EE stated she always places the call within reach but admitted that R#48 does not know what the call light is. CNA EE revealed that not all residents use bed rails but the ones that do it is for safety. CNA EE stated that all staff know that the rails are for safety and to prevent falls. CNA EE stated staff have discussed rails but that she is unaware of any in-service or training related to bedrail safety. An interview with Registered Nurse (RN) FF on 6/24/21 t 10:29 a.m. revealed that side rails are used for safety on the locked unit. RN FF revealed that when residents are out of bed, the side rails are in the up position (pivoted to grab bars) and when residents are in bed they are in the down position (pivoted to side rail position). RN FF stated that during admission a bedrail assessment is completed for all residents but is unsure of how often they are completed after admission or of any ongoing assessments. RN FF stated that she is not sure if any of the residents that currently have bedrails have an active Physician's Order for side rails because she has never been told to check for one. RN FF stated that the resident has bedrails on her bed currently and that they should always be in the down position (side rail position) when she is in the bed. RN FF stated that the resident is not compliant and will try to get out of bed without assistance and therefore the bed rails are there to keep her safe and is not able to release them by herself. RN FF stated they are not used for grab bars for the resident because she is unable to use them to pull herself or for repositioning. RN FF stated that she monitors the locked unit throughout her shift to ensure when residents, including R#48, are in bed and that the bed rails are in the down position (side rail position). 2. A review of the clinical record revealed Resident (R)#4 was readmitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Admission MDS, dated [DATE], revealed R#4 had a BIMS score of 10, indicating moderately cognitive impairment. The resident was also assessed to require extensive assistance of two person with bed mobility, transfer and toileting. The resident was assessed as having a history of falls prior to admission to the facility. An observation on 6/23/21 at 1:35 p.m. revealed R#4 lying in the bed with her eyes closed with a removeable mesh side rail covering the length of the bed and the bed was pushed against the wall on the other side. An observation on 6/24/2021 at 10:21 a.m. with RN PP revealed that the resident was unable to independently remove the mesh side rail on command throughout the observation without assistance from the RN. Review of the Physician Orders for R#4 dated 4/1/21 through 6/24/21 revealed no documented Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the progress notes for the resident dated 4/8/21, 5/13/21, and 6/10/21 revealed no documentation to use or need for the removable mesh side rail. Review of the document Side Rail assessment dated ,d+[DATE] revealed no documented evidence of appropriate alternatives to the removable mesh side rail use were attempted. An interview was conducted on 6/24/21 at 12:26 p.m. with the Administrator and Director of Nursing (DON) both confirmed that a Physician Order is not obtained for the use of side rails. The DON stated R#4 has not been assessed for the removable mesh side rail and does not have a Physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of medical records for residents R#1, R#2, R#6, R#7, R#8, R#10, R#12, R#13, R#15, R#16, R#17, R#19, R#20, R#22, R#23, R#25, R#26, R#27, R#28, R#29, R#30, R#33, R#36, R#37, R#38, R#40, R#41, R#43, R#45, R#46, R#51, R#52, R#57, R#58, R#59, R#610, and R#613 revealed no documented evidence of appropriate alternatives for bed rail use were attempted prior to a bedrail being assigned. Further review revealed no assessment for risk of entrapment, no documentation of a benefits verses risk analysis being completed, no documented signed informed consent by either the resident or the resident's representative prior to installing bedrails. And lastly there were no Physician Orders for bedrails for any of these residents.

Based on observation, record review and staff interview the facility failed to ensure that one resident (R) #30 received chopped meats at the lunch meal on two of three days of the survey. This affected one of six residents who were observed for dining. Findings include: Record review revealed that R#30 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of seven indicating that the resident was cognitively impaired, the resident was assessed as needing set-up help and supervision only for eating. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Registered Dietician's (RD) Note for the resident, dated 4/30/2021, revealed a recommendation for a mechanical soft/chopped meat. Review of the resident's care plan revealed that the resident was care planned for mechanical soft diet with chopped meats. Review of an electronic Rehab Screen, dated 6/24/2021, documented an evaluation was recommended for coughing with a meal. An observation of R#30 on 6/21/21 at 12:50 p.m. while eating in the main dining room revealed the resident coughing several times while eating a hot dog which was slice length wise but not chopped along with pinto beans. An observation and family interview on 6/23/21 at 11:25 a.m. revealed the resident sitting in a wheelchair in his room with his spouse visiting. The spouse revealed that the resident chokes sometimes while eating because he puts too much on his fork. An observation on 6/23/21 at 12:41 p.m. revealed R#30 at table a table, in the dining room, with his spouse. The resident was served asparagus soup, approximately quarter size breaded fried whole shrimp, not chopped, sweet potatoes, and cranberry juice. The resident was observed to experience some difficulty eating the food, recovered by self and was able to answer questions asked by the nurse who noticed his difficulty eating. Observation on 6/24/21 at 5:41 p.m. of the resident seated at a table and was served mashed sweet potatoes, chopped brussels sprouts, chopped pork with sauce, applesauce, cranberry juice, chocolate ice cream. No observation of coughing or choking. An interview on 6/23/21 at 1:10 p.m. with the Rehabilitation Director OO revealed that she was familiar with R#30 for physical therapy and that the resident was on a mechanical soft with chopped meats due to moderate dysphagia. She had not been aware of the resident having difficultly eating over the last year. She revealed that if this had been reported by nursing, a speech therapy screen would have been completed. An interview with Licensed Practical Nurse (LPN) II on 6/23/21 at 2:43 p.m. revealed that she is familiar with the resident and that he usually does very well with his meals of mechanical soft with chopped meats. LPN II further revealed that it was unusual for him to cough during meals as he did today. LPN II further revealed that the resident had been screened by Speech Therapy in the past because he eats fast and will put a lot of food in his mouth at one time. Due to his dementia, the resident needs to be reminded to eat slower and take smaller bites. An interview Dietary Manager (DM) AA on 6/24/21 at 9:43 a.m. revealed that the resident is on a mechanical soft diet with chopped meats. DM AA further stated on 6/21/21 the resident had a hot dog we would have cut it lengthwise. DM AA revealed on 6/23/21 that the resident had the shrimp, and it should have been chopped although it is a resident right to have the food the way he wants it. The process is we have host round sheets, are posted in the kitchen and a notebook for Certified Nursing Assistants (CNA's) which is kept by the coffee machine. The dietary aide is responsible to ensure it was chopped but he probably would not have eaten it. The DM AA further revealed it is all staff's responsibility to ensure it is the right consistency. DM AA further revealed that if a resident prefers to not have the ordered consistency that there is a waiver which should be signed. An interview with Dietary Aide (DA) NN on 6/24/21 at 10:08 a.m. revealed that the type of diet the resident is on is posted on a sheet hanging on the bulletin board in the kitchen and is visible so all kitchen staff can see it. DA NN revealed that R#30's diet is mechanical soft with chopped meat and confirmed that on 6/23/21 the resident's meat was not chopped. An interview with the Director of Nursing (DON) on 6/24/21 at 10:38 a.m. revealed that the facility does not have a waiver form for refusing chopped meats for R#30. An interview with CNA MM on 6/24/21 at 10:57 a.m. revealed that she is aware that R#30 is on mechanical soft with chopped meets. CNA MM revealed that she worked with the resident on 6/20/21 and that the resident had flounder, it was broken into small pieces and that the resident did not cough or choke while eating lunch that day. CNA MM further revealed that the resident's diets are posted on a list at the kitchen station or staff can asked and if the food consistency is not correct, they should have it remade. An interview with the Dietary Manager AA on 6/24/21 at 12:05 p.m. revealed that the shrimp was looked at as mechanical soft although the shrimp should have been chopped. An interview with the DON on 6/24/21 at 4:25 p.m. revealed that any agency staff are oriented by a CNA and are educated on how to determine what type of diet the resident is on and were to find that information. A telephone interview with CNA JJ on 6/24/21 at 4:54 p.m. revealed that she worked for an agency and was working with R#30 on 6/23/21. She was aware of where to find what type of diet the residents are on although she could not recall if the shrimp served to R#30 were chopped. A telephone interview with the Registered Dietitian (RD) on 6/24/2021 at 7:41 p.m., revealed that she is familiar with R#30 and is aware of his eating history and he is monitored quarterly. The RD confirmed that both the hot dog and the shrimp should have been chopped before serving them to R#30. She revealed that staff had not reported any issues with eating difficulties for this resident.

Based on observation, record review, policy review and staff interview the facility failed to follow the care plan for two (2) dependent residents (R) #19 for grooming: nail care and R #8 for administering [MEDICATION NAME] for weight gain. The sample size was 33. Findings include: Review of the facility policy titled Person Centered, Interdisciplinary Care Planning and Care Conference with revision date of 11/17, revealed the policy is to strive to develop, review and revise the person-centered interdisciplinary care plan for each resident in order to identify resident needs, establish measurable goals/objectives, interventions and timeframe's to enable the resident to attain/maintain his/her optimal level of physical, mental and psychosocial functioning. Procedure number five: Ensure the interdisciplinary person-centered care plan addresses the following: Measurable goals and timeframe's to meet a residents medical, nursing and psychosocial needs identified in the comprehensive assessment. Procedure number six revealed the interdisciplinary care plan team members follow through with their responsibilities to establish specific approaches fro each resident problem/need. 1. A review of the clinical record for R#19 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated mild cognitive impairment. Section G revealed that the resident was assessed for limited assistance with personal hygiene. Review of the care plan updated on 6/28/2018, revealed that R#19 has self-care deficient related to advanced age. Interventions include total dependence for bath/shower, requires extensive assistance of one (1) staff with bed mobility, transfers, and dressing, requires assistance from staff for personal hygiene and oral care. Observation on 9/14/18 at 4:37 p.m., 9/15/18 at 8:32 a.m. and 9/16/18 at 8:01 a.m. revealed resident had long fingernails with dark material underneath nails on both hands. On 9/21/18 at 9:51 a.m., Licensed Practical Nurse (LPN) Unit Manager BB, verified R#19 fingernails remained dirty and untrimmed. Interview on 9/15/18 at 9:30 a.m. with Certified Nursing Assistant (CNA) AA stated that she does nail care for residents on their shower days and as needed (PRN). She stated that she did not notice R#19 nails being dirty, or needing to be trimmed. Interview on 9/15/18 at 3:46 p.m. with Director of Nursing (DON) stated that she expects for personal care be done for any resident when it is needed, or requested. She stated that she would get someone to clean and trim R#19 nails. On 9/16/18 at 9:51 a.m., Licensed Practical Nurse (LPN) Unit Manager BB verified R #19 fingernails were dirty and untrimmed. She asked CNA AA to clean and trim them this morning. cross refer to F677 2. A review of the clinical record for R#8 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Section N revealed that the resident received diuretics seven out of seven days. Review of the care plan updated on 8/6/18, revealed that R#8 is on diuretic therapy related [MEDICAL CONDITIONS]. Interventions include 1800 cc fluid restriction per 24 hours, monitor and document fluid intake every shift, administer meds as ordered and monitor and document for effectiveness, weigh daily and report weight gain greater than (>) 2 pounds per day and administer extra [MEDICATION NAME] for weight gain of two pounds per 24 hours. Review of monthly weight values reveal weight gain on 5/17/18 from 170.2 to 172.4 for a 2.2 pound weight gain; 5/21/18 from 169.2 to 171.4 for a 2.2 pound weight gain; 7/11/18 from 167.2 to 169.4, for a 2.2 pound weight gain; 7/12/18 from 169.4 to 171.8 for a 2.4 pound weight gain. Review of the (MONTH) (YEAR) Physician order for [REDACTED]. Review of Medication Administration Record [REDACTED]> than two pounds. Review of Medication Administration Record [REDACTED]> than two pounds. Interview on 9/16/18 at 11:38 a.m. with DON stated that it is her expectation for all staff to follow care plans for providing care. She stated that staff go through yearly competency/skills checklist. She further stated that the leadership staff do random spot checks looking at personal care. cross refer to F684

Based on observation, record review and staff interviews, the facility failed to ensure that activities of daily living (ADL) was provided for one dependent resident (R) R#19 related to nail care. The sample size was 33. Findings include: A review of the clinical record for R#19 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated mild cognitive impairment. Section G revealed that the resident was assessed for limited assistance with personal hygiene. Review of the care plan updated on 6/28/2018, revealed that R#19 has self-care deficient related to advanced age. Interventions include total dependence for bath/shower, requires extensive assistance of one (1) staff with bed mobility, transfers, and dressing, requires assistance from staff for personal hygiene and oral care. Observation on 9/14/18 at 4:37 p.m., 9/15/18 at 8:32 a.m., 9/16/18 at 8:01 a.m. and 9/16/18 at 9:51 a.m. revealed resident had long fingernails with dark material underneath nails on both hands. On 9/21/18 at 9:51 a.m., Licensed Practical Nurse (LPN) Unit Manager BB, verified R#19 fingernails remained dirty and untrimmed. Interview on 9/15/18 at 9:30 a.m. with Certified Nursing Assistant (CNA) AA stated that she does nail care for residents on their shower days and as needed (PRN). She stated that she did not notice R#19 nails being dirty, or needing to be trimmed. Interview on 9/15/18 at 3:46 p.m. with Director of Nursing (DON) stated that she expects for personal care be done for any resident when it is needed, or requested.

Based on observation, record review and staff interviews, the facility failed to follow the Physician order [REDACTED].#8 related to as needed (PRN) [MEDICATION NAME] for weight gain of two (2) pounds in 24 hours. The sample size was 33. Findings include: A review of the clinical record for R#8 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Section N revealed that the resident received diuretics seven out of seven days. Review of the Physician order [REDACTED]. Review of monthly weight values reveal weight gain on 5/17/18 from 170.2 to 172.4 for a 2.2 pound weight gain; 5/21/18 from 169.2 to 171.4 for a 2.2 pound weight gain; 7/11/18 from 167.2 to 169.4, for a 2.2 pound weight gain; 7/12/18 from 169.4 to 171.8 for a 2.4 pound weight gain. Review of Medication Administration Record [REDACTED]> than two pounds. Review of Medication Administration Record [REDACTED]> than two pounds. Interview on 9/16/18 at 10:10 a.m. with Unit Manager Licensed Practical Nurse (LPN) BB, verified in electronic medical record that PRN order for [MEDICATION NAME] had not been given as ordered for weight gain > 2 pounds per 24 hours. She stated that she tracks the weight each day that she works, but has not been checking Medication Administration Records to see if medications have been given for the weight gain. She stated that she has periodic discussions with the staff about documentation about medication administration and she believes that it is getting better, but still has some more improvement to go. Interview on 9/16/18 at 11:38 a.m. with Director of Nursing (DON) stated that it is her expectation for all staff to follow physician orders.

Based on record review and interviews, the facility failed to file a claim when requested by the beneficiary for three residents (R) #59; #41; #263 of five residents during the Beneficiary Protection Notification review. Findings include: During record review for R #59 that was conducted on 9/15/18, the facility provided a copy of the resident's Centers for Medicaid and Medicare (CMS) form and the CMS NOMNC (Notice of Medicare Non-Coverage) which indicated that the effective date coverage for current skilled services will end on 3/26/18. The notice was signed as being received by the resident representative on 3/22/18. The resident representative marked YES opting for the resident to continue to receive the services; requesting an appeal. During record review for R #41 that was conducted on 9/15/18, the facility provided a copy of the resident's CMS form and the CMS NOMNC which indicated that the effective date coverage for current skilled services will end on 5/30/18. The notice was signed as being received by the resident on 5/27/18. The resident marked YES opting to continue to receive the services; requesting an appeal. During record review for R#263 that was conducted on 9/15/18, the facility provided a copy of the resident's CMS form and the CMS NOMNC which indicated that the effective date coverage for current skilled services will end on 5/11/18. The notice was signed as being received by the resident on 9/5/18. The resident marked YES opting to continue to receive the services; requesting an appeal. Interview with the Social Services Director (SSD) on 9/15/18 at 9:17 am she stated that she is responsible for providing the NONMNC notices to the residents. She was asked to provide the appeal information for R #59, #41, and #263 seeing as they had opted to continue to receive the services. She stated that the residents had never requested an appeal and that they were not provided the services beyond the end of services date. Interview with the Nursing Home Administrator (NHA) on 9/15/18 at 11:05 a.m. she stated that the facility does not admit residents outside of this community and so they never have anyone who requests to continue to receive the therapy services when they recommend for services to end. A subsequent interview was conducted with the NHA and the SSD on 9/15/18 at 11:45 am. SSD stated that she had a misunderstanding of the forms. She stated that when she provided the NOMNC forms to the residents/families she explained it inaccurately, so the residents were checking yes that they wanted to continue to receive medications and treatments. She stated that this was not an indication that they wanted to continue to receive therapy services. She stated that from this point forward, they are going to use the new forms and go back and speak to all the residents that are currently still in the facility and explain the process.

Based on observations, record review, and staff interviews the facility failed to have an effective Quality Assessment and Assurance Committee (QAA) that developed and implemented a process to ensure food items were properly labeled, dated and stored by the Plan of Correction Date of 06/30/16 and failed to report the findings of weekly monitoring related to properly labeling, dating and storing food to the QAA Committee. Refer F371 Findings Include: Review of the Policy Titled Quality Assurance, Performance Improvement and Compliance Manual Rev-01; Quality Assurance, Performance Improvement and Compliance Review Procedure documented Overview: The Quality Assurance, Performance Improvement and Compliance Team focuses on general and specific resident care areas identified from audit, resident care or staff concerns, areas focusing on continuously improving resident care and services and the environment. Review of the weekly monitoring tool for the Food Store room titled Labeling and Dating of All Food Products for dates 07/04/16 through 07/10/16 reveals manager comments: Lentils not labeled. Review of the weekly monitoring tool for the Walk in Freezer Main Kitchen titled Labeling and Dating of All Food Products for dates 07/04/16 through 07/10/16 reveals manager comments: Ice Cream not labeled. Review of the weekly monitoring tool for the Food Storeroom titled Labeling and Dating of All Food Products for dates 06/27/16 through 07/03/16 reveals manager comments: Labeled Thick and Easy. Review of the weekly monitoring tool for the Produce Walk-in Refrigerator titled Labeling and Dating of All Food Products for dates 06/27/16 through 07/03/16 reveals manager comments: Labeled Romaine. Review of the weekly monitoring tool for the Dairy Walk-in Refrigerator titled Labeling and Dating of All Food Products for dates 06/27/16 through 07/03/16 reveals manager comments: Talked to employee about raw overcooked! Best Label and Dating. Review of Quality Assurance Meeting dated 07/06/16 reveals no culinary, dietary or kitchen representatives were in attendance. Kitchen tour and observation on 08/01/2016 at 5:29 p.m. of the Willowbrooke I Kitchen, with the Director of Culinary Services revealed three (3) undated, unlabeled, uncovered pie slices on plastic saucers, on a metal shelf in the holding refrigerator and one (1) open, unlabeled, undated box of eighteen (18) Blue Ribbon Classic Vanilla Ice Cream Sandwiches in an unlabeled and undated cardboard box in the stand-up freezer. Kitchen tour and observation on 08/01/2016 at 7:00 p.m. in the Willowbrooke II Kitchen, with the Director of Culinary Services revealed two (2) loaves of sliced raisin bread (no brand) in the refrigerator with a use by date of 07/28/16, and three (3) loaves of sliced European Bakers Roundtop Bread with no use by date. Observation on 08/01/16 at 7:28 p.m. of the Willowbrooke III Main Kitchen with the Director of Culinary Services revealed one (1) 8 ounce (oz) bag of Calorie Control Brand Instant Banana Pudding Mix with no use by date and two (2) 5 oz bags of Butterscotch Pudding and Pie Filling Mix with no use by date stored in a box labeled, Orange Gelatin Mix dated 12/01/2014. Interview on 08/01/16 at 6:09 p.m. with the Nutrition Services Manager revealed that monitoring, labeling and dating is not being done on a daily basis. Staff initially set it up that the form mentioned in the Plan of Correction (POC) would be used daily, but there are times when items come over during the day which have not been checked by management staff. Interview on 08/01/16 at 7:38 p.m. with the Director of Culinary Services (DCS) revealed the Daily Routines/Cleaning Checklists combine all the freezers and coolers so staff only have to look at one monitoring sheet. There are a total of twelve (12) to fourteen (14) coolers, two (2) small freezers and one (1) walk-in freezer in the facility. The DCS revealed labeling, dating and storage errors are corrected as monitoring is done. Interview on 08/01/16 at 8:08 p.m. with the facility Administrator revealed that the Quality Assurance (QA) Committee meets quarterly and last met on July 6, 2016. The facility Administrator revealed no Dietary, Nutrition or Culinary Staff were present at the meeting and the next meeting is for October, 2016. The Administrator added, the QA team has not yet compiled or looked at the data gathered from the daily monitoring. Continued interview revealed that monitoring issues were not presented at the QA meeting on July 6, 2016 as none were reported to her. The Administrator advised that she was only made aware of the issues listed on the daily monitoring tools when they were presented to her today during the follow-up visit survey. The Administrator acknowledged that the monitoring tool was not effective and the next steps in resolving the food labeling, dating and storage issues will involve a higher level of authority from the facility corporate office.

Based on observation, staff interview and review of facility guidelines, the facility failed to label and date opened food items in one (1) of one (1) walk-in freezers, in (1) of two (2) walk-in refrigerators, and in the dry storage area. The facility also failed to discard expired yogurt in one (1) of four (4) resident nourishment refrigerators. This deficient practice had the potential to effect all sixty (60) residents that received an oral diet. Findings include: Observation on 06/06/16 at 8:00 a. m. of the walk-in freezer with the Director of Culinary Services (DCS) revealed a food item that was wrapped in plastic, the size and shape of a grapefruit, deep red in color found in an aluminum pan that was twenty (20) inches in length, twelve (12) inches in width and two (2) inches in depth with no label or date. Continued observation revealed that a brown food item that was tubular in shape, twelve (12) inches in length and two (2) inches in diameter with no label or date. There was a second aluminum pan that was twelve (12) inches in width, ten (10) inches in length, and four (4) inches in depth that a food item that was brown and red in color covered with plastic with a light layer of frost under the plastic wrap touching the food with no label or date. On top of this pan were 2 plastic wrapped food items that were brown in color and the size and shape of a grapefruit with no label or a date. Observation on 06/06/16 at 8:15 a.m. of the produce walk-in refrigerator with the DCS revealed an aluminum pan that was ten (10) inches in length, four (4) inches in width, and four (4) inches in depth that contained five (5) zucchini squash that had the ends trimmed and covered with plastic wrap and did not have a label or date. Continued observation revealed an opened five (5) pound bag of baby carrots that was wrapped in plastic and did not have a label or date. Observation on 06/06/16 at 8:20 a.m. of the dry storage area with the DCS revealed a thirty two ounce (32 oz.) bag of sunflower seeds that was opened, wrapped in plastic with no label or date. Interview on 06/06/16 at 8:30 a.m. with the DCS confirmed the observations and stated he expects staff to label and date all food items before storing in freezers, refrigerators, and dry storage. Observation on 06/07/16 at 9:45 a.m. and at 4:55 p.m. of the second floor (Overlook Unit) resident refrigerator revealed one (1) eight ounce (8 oz.) container of Blueberry Dannon Light and Fit yogurt and one (1) 8 oz. container of Peach Dannon Light and Fit yogurt both with a use by date of May 19, 2016. Interview on 06/07/16 at 5:00 p.m. with Nutrition Services Manager confirmed that both containers of yogurt were in the resident refrigerator with a use by date of May 19, 2016. Continued interview revealed dietary staff stock the resident refrigerators on each unit and she expects the staff to review dates on food items and discard when items are past their use by date. Review of the facility guideline titled Guide to Proper Food Storage Techniques documented that all food items outside of the original container must be covered, labeled and dated. The label must include the name of the food (even if it is obvious), the date of preparation, and the date it should be discarded. Expiration dates should be checked on a regular basis. Review of the in-service sign-in sheet conducted on 12/29/15 revealed dietary staff was educated on state audit-compliance, recipes, temperatures, food safety, sanitation, uniform, and cleanliness. Review of the in-service sign-in sheet conducted on 03/01/16 revealed that dietary staff was educated on the label and dating policy. Dietary staff were educated that all food items will be labeled with the item name, and the date (month, day, and the year) the food item is opened or prepared.

Based on observation and staff interview the facility failed to ensure that the temperature of foods served to residents was held at or above the level necessary to prevent potential foodborne illnesses. This affected all residents on oral alimentation (census = 60). Findings include: During a measurement of temperatures of food items held on the steamtable which were being served to residents in the 1st floor dining room at the lunch meal on 2/27/12 at 12:15 p.m., the following items were found to be below the minimum safe temperature level of one hundred and thirty-five degrees Fahrenheit (135 F): Pureed Ground Beef Patties at 110 degrees F Ground Beef Patties at 120 degrees F Pureed Bean Soup at 100 degrees F During a measurement of temperatures of food items held on the steamtable which were being served to residents in the 2nd floor dining room at the lunch meal on 2/27/12 at 12:25 p.m., the following items were found to be below the minimum safe temperature level of one hundred and thirty-five degrees Fahrenheit (135 F): Ground Beef Patties at 120 degrees F Apple Crisp at 130 degrees F The above observation was made using the food service department's calibrated dial thermometer and was confirmed by the facility's Food Service Director.

Based on record review and staff interview the facility failed to accurately assess skin condition on the Admission Minimum Data Set (MDS) Assessment for one (1) resident (# 6) of twenty-five (25) sampled residents. Findings include: Review of the Admission MDS dated [DATE] revealed the resident did not have any pressure sores or other skin conditions upon admission to the facility on [DATE]. However; review of the Acute Care Facility's Nursing Transfer Record of the resident's status from 10/24/11 at 9:42 a.m. to 10/25/11 at 9:42 a.m. revealed the resident had a blister on the right upper lateral. Review of the facility's Resident Status Information Record upon admitted d 10/25/2011 revealed the resident was assessed as having a blister located on the right lateral upper thigh and reddened areas on the gluteal folds on the buttocks. 2/29/2012 at 10:00 a.m. interviewed with MDS/Care Coordinator stated she was not aware of the blister on the thigh, but did recall the resident had a reddened sacrum. The Assistant Director of Nursing (ADON), also the Wound Care Nurse, was interviewed on 2/29/2012 at 10:15 a.m. and revealed she expected a full head to toe assessment to be conducted upon the resident's admission to the facility. Areas identified should have been included in the initial MDS assessment.

Based upon record review and staff interview the facility failed to accurately assess upon admission or failed to begin treatment and document progress for pressure sores which were present on admission for two (2) residents (# 6 and # 76) of twenty five (25) sampled residents. The census was fifty seven (57). Findings include: 1. Resident #76 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Record review of the initial nursing assessment [DATE], revealed documentation that the resident had a abdominal surgical wound and an old scar and fistula of the left arm. The resident's Braden Scale assessment on admission was for low risk of developing a pressure ulcer with score of: [DATE]=19 and [DATE]=22 (a score of 12 or less=high risk). Record review on an initial wound assessment for [DATE] revealed the resident had an open blister on the right heel measuring three (3) centimeters (cm) by three (3) cm. The initial wound assessment is signed by Registered Nurse (RN) "EE", the Treatment Nurse. Record review of the fourteen (14) day MDS assessment revealed the resident had one (1) stage II pressure ulcer but was not coded as admitted with the pressure ulcer. The discharge MDS assessment on [DATE] revealed the Stage II pressure ulcer was present on admission to the facility on [DATE]. An interview on [DATE] at 10:15 a.m. with Treatment Nurse "EE" revealed that she was made aware of the blister several days after the resident was admitted . She did not know why it was not identified on admission and stated the nurse just missed it. 2. Review of the initial Minimum Data Set (MDS) assessment dated [DATE] revealed resident # 6 was at risk for developing pressure sores, but did not have any pressure sores upon admission to the facility. However; review of the Acute Care Facility's Nursing Transfer Record of the resident's status from [DATE] at 9:42 a.m. to [DATE] at 9:42 a.m. revealed the resident had a blister on the right upper lateral thigh. In addition, review of the facility's Resident Status Information Record dated [DATE] revealed the resident was assessed as having a blister located on the right lateral upper thigh and reddened areas on the buttocks. Review of Nursing Progress Notes dated [DATE], but referencing the resident's condition on admission [DATE] at 8:07 p.m. revealed no documentation of the blister or other skin conditions. Physician admission orders [REDACTED]. Review of the Interim Care Plan and the Comprehensive Care Plan also revealed no mention of the blister or reddened areas. The Minimum Data Set (MDS) Care Coordinator was interviewed on [DATE] at 10:00 a.m. and stated she was not aware of the blister on the thigh, but did recall the resident had a reddened sacrum. On [DATE] at 10:15 a.m. the Wound Nurse stated she was not aware of the right thigh blister or reddened areas. She further stated a full head to toe assessment should be done on admission and if areas were identified the physician should have been called and the wound nurse made aware. The Wound Care Nurse also provided a copy of the facility's policy for the staging of pressure areas. If pressure related, reddened areas would be Stage 1 and a blister would be considered Stage 2. Review of the resident's Admission physician's orders [REDACTED]. Further review of the Clinical Record revealed no documentation of either area during the resident's admission from [DATE] to [DATE] when the resident expired.

Based on observations, record reviews and staff interviews the facility failed to develop or implement interventions to provide a safe environment and prevent accidents for residents with multiple falls. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for seven (7) residents ("Q", #24, #23, #34, #7, #47,and #13) on a sample of Twenty-Five (25) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of March 21, 2011 and continues. Findings include: 1. Review of the Nursing Progress Notes for resident #34 during the year 2010 revealed the resident was admitted on [DATE] at 2:30 p.m. He was using a walker and was evaluated by therapy upon admission. The Progress Note written at 5:38 p.m. revealed the resident was alert, but mildly confused and shortly after admission to the facility sustained a fall at 3:00 p.m. when he was found in his room on the floor by his bed. No injury was noted and the intervention was to monitor him. Further review of the Progress Notes revealed documentation on 1/29/2010 at 9:44 p.m. that the resident had poor balance and was at risk for falls. Subsequent notes on 1/30/2010 at 3:02 p.m. and 1/31/2010 at 5:52 a.m. revealed the resident needed the assist of one due to an unsteady gait and that he would forget to use his walker. On 2/08/2010 at 6:15 a.m. he was found on the floor by his bed. He was leaning up against the bottom of the bed and told staff he hit his forehead. He had an abrasion to his forehead and to the bridge of his nose. Neurochecks were initiated. Review of the Incident Report for this fall revealed the resident was confused. He had a personal alarm on but it was not sounding and the resident was known to remove it. The report also revealed the resident required assist, but does not call for it. Intervention was to monitor and educate resident to call for help before getting up. The Incident Report indicated the problem was resolved. The resident fell again on 3/21/2010 at 10:40 p.m. in his room. He was found on the floor with a laceration to the right ear and signs and symptoms that suggested a right hip fracture. He was sent to the emergency room and was admitted with a right hip fracture and subsequently had surgery to repair it. The right ear laceration required sutures. The resident returned to the facility on [DATE]. Review of the Incident Report for this fall with injury revealed the resident was ambulating with a walker and the bed was in low level position. Two upper side rails were up. The staff heard a noise. When they entered the room they found the resident lying on floor in front of the wardrobe with bare feet. The identified cause of the incident on the report was unsteady gait and a change in mental status. Several days earlier the resident went to the emergency room and returned to the facility with a [DIAGNOSES REDACTED]. The resident fell again on 4/28/2010 at 9:00 a.m. in his room. Review of the Incident Report revealed the resident was alert, but confused, and climbed out of bed over the two upper siderails which were up because he wanted to get in his recliner. His status was identified as non-ambulatory and the cause of this fall was identified again as a change in mental status and unsteady gait. Intervention was to monitor. The resident also fell on [DATE] at 10:00 a.m. The Incident Report revealed he had no apparent injury and was confused. He had gotten out of his chair to get his walker which was at a distance. This happened in the activity room. He was found on the floor in front of the walker by staff. His personal alarm was on. The cause of the incident was a change in mental status. Interventions were monitoring and care plan review. Further review of the clinical record revealed the resident had fall risk assessments completed on 1/28/10, score 10; 2/4/10, score 14; 2/11/10, score 17; and 2/18/10, score 16. A score of 10 or above is considered a high risk for falls. There were no further fall risk assessments in the Clinical Record although the resident had falls after 2/18/10 Review of the facility policy for Fall Reduction and Management indicated all residents would be assessed for falls on admission and then quarterly. The policy also indicated A Falls Risk Committee would be formed with responsibilities which included: investigation regarding the cause of the fall, review appropriate strategies to reduce falls, determine the pattern of falls, develop individual interventions and approaches, make recommendations to prevent future occurrences. This would also Include a weekly review of all incident reports. Interview with the Director of Nursing (DON) on 2/2/2011 at 4:00 p.m. revealed that the facility did not have a Fall Risk Committee. They do have a Standards of Care (SOC) meeting every other week where they discuss residents who have fallen. Continued interview revealed that the person who had been responsible for tracking falls was no longer there and that the person who was tracking falls now was not doing a complete job. Since these staff members left, meetings of the SOC Committee have been less often. Prior to this decrease in staff, the Director of Nursing (DON) was only receiving monthly summary reports on falls. She stated these reports were retrospective and had no impact on prevention. She further stated personal alarms for chairs and beds tracked resident movement but were not effective for fall prevention. 2. Review of the Clinical Record for resident #13 revealed that the resident was admitted to the facility February 01, 2006. Continued review revealed that the resident fell twelve (12) times between 2/01/2010 to 1/30/2011. The last Fall Risk Assessment was done on 5/22/2010 and the score was 20 which indicated he was a high risk for falls. Further review of the Clinical Record revealed the resident had a Tinetti Balance Assessment Tool completed by therapy on 3/8/10 and his score indicated at high risk for falls Review of the facility's fall log, Incident Reports and Progress Notes revealed the following falls beginning 2/01/2010 and any interventions put in place to prevent further falls: -2/01/2010 (time unknown) The resident was found on floor in his room. Intervention was to monitor. -2/02/2010 (time unknown) The resident was found on floor in his room. Intervention was to monitor. -2/14/2010 (time unknown) The resident was found on floor in hallway. Intervention was to monitor. -3/04/2010 (time unknown) The resident was found on floor in hallway. Intervention was to monitor. -8/20/2010 at 8:45 p.m. The resident's wife informed staff he fell out of his chair. Staff found the resident on the floor. Interventions were to monitor the resident and provide resident and staff education. -10/19/2010 at 7:45 p.m. The resident was found on the floor in the day room. The resident told staff he was on his way to bed and sat on the floor. He had removed his personal alarm. Intervention was to monitor and do staff and resident education. -11/21/2010 (time unknown) Resident was found on floor in the day room by a staff member making rounds who heard an alarm ringing. The resident was on the floor in front of his wheelchair. Intervention was to monitor. -12/13/2010 at 2:00 a.m. Resident was found on floor in his room. He had an abrasion to the left great toe and a skin tear to the left hand ring finger which measured 1.0 cm x 0.5 cm. The bed alarm was sounding. Intervention was to monitor. -1/2/2011 at 11:05 p.m. The resident was attempting to go to wife's room, which is adjoining to his from the hallway, when he lost his balance. He was observed sitting on the floor. His alarm was not sounding. His wife alerted staff to the fall by pressing her call light. Intervention was to monitor. -1/07/2011 at 10:30 p.m. Resident was found on floor and no injury noted. Bed alarm was sounding. Incident report revealed resident was independent with ambulation however an undated Certified Nursing Assistant (CNA) Care Plan revealed he needed assistance. Resident was going to the bathroom without his walker. -1/15/2011 at 7:15 p.m. Resident was found by staff sitting on the floor in another resident's room. He was alert but disoriented. Intervention was to monitor. -1/30/2011 at 11:20 a.m. The resident fell in the activity lounge. Staff noted the resident was laying on floor. Intervention was to monitor. 3. Review of the Initial Nursing Admission assessment dated [DATE], the date of admission, for resident # 47 revealed she had fallen four times in the four months prior to admission, and was being admitted to the nursing facility due to debility and increased care needs her husband could no longer provide at home. Her fall risk assessment on 1/21/2011 was 13 indicating she was a high risk for falls. Further review of the admission assessment revealed the resident had an unsteady gait and needed assist with transferring and ambulating. Review of a Nursing Progress Note dated 1/30/2011 at 5:40 p.m. revealed resident #47 was found on the floor in her room by a family member. She was lying on her side by her wheelchair in the bathroom when he entered the room. Resident stated she was trying to shut the room door. The documentation revealed the resident was alert and oriented, but confused, and at the time of the fall, the resident had an alarm on her bed, but not on her chair. Review of the incident report for the fall on 1/30/2011 revealed the resident was observed by staff on the floor in her bathroom after a family member alerted them. Therapy Staff Member "HH" was interviewed on 2/03/2011 at 1:00 p.m. and stated the resident had falls prior to admission and was admitted to the facility due to increasing need for care the family was unable to provide. They further stated they were unsure how care needs for residents were communicated to the nursing assistants and had difficulty establishing a system of communication with nursing. 4. Review of the clinical record for resident "Q" revealed that the resident was readmitted to the facility on [DATE] after a fall resulting in a hip fracture. Continued review revealed that from January 2010 to August 2010 the resident had 5 falls: -01/31/10 at 9:15 pm the resident was found on the floor in her room, facing the bed, wrapped in covers, asleep. Family member present did not see the incident; -06/21/10 at 11:30 pm the resident was found on the floor in the hallway between her room and the bathroom. Resident "Q" said she was going to the bathroom because she felt nauseous; - 08/15/10 at 1:15 am resident "Q" was calling out for help from the hallway between the bathroom and her room. The resident was reminded to use the call light and not take off her personal alarm.; -08/26/10 on the night shift, the resident was found on the floor in the hallway between her room and the bathroom; -01/14/11 at 3:50 pm resident "Q" was walking behind her wheelchair with her husband, got tired, attempted to sit in the wheelchair and fell . Injuries from the fall included a lump on the left forehead, a red abrasion to the left cheek by the lower left eyelid. The resident was sent to the emergency room for evaluation. A Cat Scan dated 5:32 pm revealed there was a large soft tissue injury overlying the forehead; no evidence of a fracture and no acute abnormalities seen. Review of the resident care plan dated 11/18/10 revealed that the there were no interventions related to falls, including the use of the bed and chair alarm. 5. Resident #7 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]., abnormal gait, muscle weakness, Osteoarthrosis, urinary urgency and visual hallucinations. Review of the Fall Risk assessment performed on admission indicated the resident was at a high risk for falls. On 6/8/10 the resident had a score of 19 and a score of 10 or above represented high risk. Further review revealed there had been no evidence of additional fall risk assessments being performed on the resident since 7/27/10. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had falls within the past 30 days. Review of the Nurse's Progress Notes and the Fall/Incident log revealed the resident had thirty-four (34) falls from admission on 6/8/10 until 1/31/2011. The resident had 2 falls during the month of June 2010, with the first fall being the day of admission to the facility. Review of the Nurses Progress Notes revealed on 6/8/10 at 7:30 p.m., the resident reported to the staff she fell off the shower bench. The note also indicated the resident was confused and forgetful. Corrective actions on the Incident/Accident Report indicated to monitor the resident and instruct her to use the call light. The resident was also to be placed on a toileting schedule. Review of the Bladder Retraining Schedule revealed this was to be done from 6/30/10 through 7/31/10. However documentation revealed the resident was only on the program for 2 weeks. There was no indication her success on the program had been evaluated. Further review of the schedule indicated the resident had only 2 episodes of incontinence during the 2 week period. -On 6/22/10 at 5:30 p.m. the resident fell in the hallway, backing up with her walker. The resident hit the water fountain and rolled to the floor onto her right hip and side. Corrective action on the Incident/Accident Report indicated the staff was to walk beside the resident to and from the dining room and to encourage the resident not to turn and sit on the walker. There were no injuries. Review of a physician orders dated 7/9/10 revealed the resident was started on Seroquel (an antipsychotic) 12.5 milligrams (mg) three times a day. The resident had a total of 2 falls during the month of July 2010. -7/10/10 at 2:15 a.m. and on 7/13/10 11:00 p.m. the resident was observed on the floor in her room. There was no evidence of new interventions. Review of a nurses progress noted dated 7/24/10 indicated the Seroquel was increased from 37.5 mg. per day to Seroquel XL 50mg. at 6:00 p.m. each day. A note in the nurses progress note dated 7/25/10 indicated distraction and redirection were not helpful. The resident had 4 falls during the month of August 2010 - 8/13/10 at 10:05 p.m. the resident was observed lowering herself to her knees and then lying on her right side on the floor. There were no injuries and no new interventions. The facility Incident/Accident Report did not consider this a fall. -8/14/10 at 12:25 p.m. the resident slid to the floor in the bathroom, on 8/24/10 the resident reported to the staff she fell during the night. On 8/28/10 at 7:20 a.m., the staff found the resident on the floor. Review of the Incident/Accident Report indicated the only intervention was to monitor the resident, however further review indicated the resident began receiving Physical Therapy on 8/16/10. The resident received the Physical Therapy services until 9/1510. The resident had 12 falls during the month of September 2010. -9/2/10 at 8:40 a.m., the resident reported to the Certified Nursing Assistant (CNA) she fell in her room. There were no evidence of new interventions. - 9/6/10 at 2:07 a.m. the staff found the resident on the floor, leaning against the chair in her room. Again, the facility did not consider this to be a fall. She was assisted to stand and sit in her chair. -9/6/10 at 5:15 p.m., the resident fell in the hallway, the note indicated the resident was going to dinner and lost her balance and fell against the wall and slid to the floor. There were 2 abrasions to the right side of the head and a knot on the top of the head. There was no evidence of new interventions. -9/7/10 at 5:05 p.m. The resident fell in the shower. The CNA was with the resident assisting her with a shower and the resident demanded the CNA leave the room. The CNA left the resident and the resident fell in the shower. The resident sustained [REDACTED]. There was no evidence of new interventions -9/9/10 at 6:15 a.m.,and on 9/11/10 at 6:15 a.m., the resident was found in the floor in her room next to the bed. Again there were no new interventions. -On each of the following occasions: 9/13/10 at 9:10 p.m., 9/16/10 at 2:00 a.m.,and 9/17/10 at 1:30 a.m., the resident was found on the floor by the staff. There was no evidence of new interventions. -9/19/10-at 5:00 p.m. the resident was found on the floor in the her room, The note indicated she slid out of the wheelchair. On 10/29/10, Physical Therapy was ordered to fit the resident for a new wheelchair. -9/29/10 at 12:15 am the resident was again found sitting on the floor in her bathroom. She complained of left buttock pain, the physician was notified and an x-ray of the hip was ordered and was negative. There was no evidence of new interventions put in place. -9/30/10 at 7:00 a.m., the resident was found on the floor in her room. Review of the Incident/Accident Report indicated the resident removed her personal alarm. The resident had 9 falls during October 2010. -10/02/10 at 4:30 p.m. the resident was found on the floor in her room. Interventions included monitoring and staff education, however there was no evidence of the type of education which was provided. -10/07/10 on the 3:00 p.m. to 11:00 p.m. shift, the resident was found on the floor in her room. Review of the Incident/Accident Report indicated the incident was resolved and there was no follow-up required. -10/9/10 at 1:56 p.m.,the resident was found sitting in her bathroom floor. Her personal alarm had been removed and was wrapped around her wheelchair. There were no injuries and no evidence of new interventions. -10/15/10 at 9:24 a.m. The resident was found on the floor in the bathroom. The resident had removed the alarm and gotten out of bed. There were no injuries. Interventions were to view her more often and educate the resident to leave the alarm on and call for assistance when she needed to go to the bathroom. Review of the Nurses Progress Notes revealed the resident was confused. -10/26/10 at 8:00 p.m. The resident was found on the floor in her room. The resident was asking the staff to take her to the bathroom. Review of the Incident/Accident Report revealed the resident removed the alarms, it even indicated the resident demonstrated ability to disconnect the tab alarm,but was unable to disconnect the bed alarm. -10/27/10 at 7:29 p.m. and 10/28/10 at 12:22 a.m. the resident was found on the floor in her room. There was no evidence of new interventions. -10/30/10 at 7:15 p.m. The Nurses Progress Note indicated the resident was confused. The resident reported to the CNA she hit her head. There was a red, raised area 3 centimeters by 0.5 centimeters on the back of the head. Interventions were to adjust the volume on the chair alarm and the staff was also advised to put the chair alarm on the resident while she was in bed. -10/31/10 at 5:30 a.m., the resident was again found in the floor in the her room. There were no injuries and no evidence of new interventions. During the month of November 2010 the resident had 2 falls -11/13/10 at 7:30 a.m., The resident was found on the floor in the bathroom on her hands and knees. The alarm was on low volume. -11/21/10 at 4:00 p.m., The resident was found on the floor in the bathroom/shower- The bed alarm was on the mattress, but was not connected to the monitor. During the month of December 2010 the resident had 5 falls. -12/6/10 at 7:45 p.m. The staff found the resident on the floor in her room. There was a bruise and 0.5 centimeter cut on the side of the head. There was no evidence of new interventions to address the fall. -12/11/10 at 3:45 p.m., the resident was sitting on floor and leaning against the wall. The monitor had been removed by the resident The Incident/Accident Report indicated an inservice was conducted to educate staff that both alarms should be in place when in bed and in the wheelchair. -12/10 at 10:30 p.m., the resident slid to the floor. The corrective action was to remind the resident to use the call light. -12/14/10 at 3:05 p.m. the resident was found in the floor. The only corrective action at this time was to monitor the resident. -12/23/10 at 9:00 p.m., the resident was found on the floor by the staff. The resident had removed the alarm and placed it in a pillow. There was no evidence of new interventions. There was one fall during the month of January 2010. On 1/31/11 at 5:14 a.m. the resident was found on the floor. There was no evidence of new interventions.- During an observation on 2/1/11 3:15 p.m., the resident was observed sitting on the side of the bed, a wheelchair was noted beside the bed. The resident got up off the bed. There was a monitor box for a bed alarm on the bedside table, however the alarm did not sound when the resident got up. The resident became very unsteady on her feet and was loosing her balance. The surveyor had to hold under the resident's arms and assist her to the chair. There was no staff available in the area. This was immediately reported to Licensed Practical Nurse "QQ" on the unit. During an interview on 2/1/11 at 3:50 p.m. LPN "QQ" stated the resident was supposed to have a pressure alarm on her bed and in her wheelchair and she also is supposed to have a tab alarm on the back of the wheelchair. She stated the resident had learned to take them off and will pack them everyday. LPN "QQ" stated at the time of the near fall the resident had been in the bed, so the pad was moved from the wheelchair to the bed. She stated the pad was on the bed, however the resident had disconnected the alarm. Observation of the resident 2/2/11 at 10:45 a.m., revealed the resident was sitting up in the wheelchair. There was no evidence of an alarm on the resident's wheelchair, This was again reported to LPN "QQ". She placed the alarm on the wheelchair at that time and stated she did not know why the alarm was not in place. Observation of the resident on 2/3/11 at 10:00 a.m. revealed the resident with a tab alarm on the wheelchair, however there was no evidence of a pressure alarm in the chair. LPN "QQ" stated at this time she was not sure if the resident was supposed to have the pressure alarm in the wheelchair. During an interview on 2/4/10 at 2:00 p.m. the MDS coordinator stated she could not find at what point the alarms began being placed on the resident. She further stated the resident was supposed to have a pressure alarm on the bed when in bed and a tab alarm and pressure alarm in the chair when up in the wheelchair. Further review of the medical record indicated the resident received an Interdisciplinary Therapy Screen on 8/3/10. It was recommended at that time for the resident to receive Physical Therapy services due to multiple falls and many additional "near falls". The screen indicated the resident was more confused and delusional. The resident began receiving Physical Therapy (PT) on 8/16/10 and ended on 9/15/10. The resident received PT for balance and gait training. During an interview on 3/2/10 at 1:00 p.m. therapy staff "HH" stated the resident had poor safety awareness, she stated no matter how often she was told not to get up she would get up anyway. She stated they were alerted to one fall, but unsure about others that had occurred since she was discharged . In addition, she stated when she was the therapy program manager,over a year ago,they would discuss anyone who had a fall weekly. She stated they would discuss interventions and and would follow-up till the problem with falls had resolved. She indicated they now get a log of incidents monthly. During an interview on 2/3/11 at 12:00 noon therapy staff "FF" indicated the therapists have had some restrictions on the interventions they can use. She stated they are restricted on types of devices they can implement after falls such as self release belts, merri-walkers and other types of safety devices. She also stated she had asked the CNA's if they have a way to communicate interventions and types of assistance required for the residents. She stated the CNA's told her there was no method to communicate information. Interview with the Director of Nursing on 2/04/2011 at 3:00 p.m. revealed that the facility had no system for identifying which residents were at risk for falls nor had they identified trends and /or causes of falls. 6. Review of the clinical record for resident #24 revealed that that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Continued review revealed that the resident had eight (8) falls from 9/16/10 to 12/5/10. On 9/16/10 at 7:30 a.m. the resident was found on the floor beside the bed. The resident stated he/she slipped off the bed and thought his right shoulder was broken. The doctor was notified and ordered a portable X-ray. The X-ray company was contacted and at 12:15 p.m. the X-ray results were called in with a [DIAGNOSES REDACTED]. An order was received to send the resident to the hospital for treatment and the resident was transported to the hospital. The resident returned to the facility on the same day. No new interventions were put into place to prevent further falls. -9/18/10 at 8:50 a.m. found on floor in hallway. Resident stated that he/she saw an animal and tried to go over it, tripped and fell . A Physical Therapy (PT) screen was done but the resident refused PT. A personal alarm was put in place on 9/20/10 with reminders to use call light for assistance. -11/9/10 at 12:40 a.m. resident was calling out for help then found on floor in room. Personal electric bed was in the lowest position. Interventions were to use call light and monitor resident. Resident continued to be alert and confused. -11/29/10 at 1:50 a.m. resident was found on the floor in the resident's room with no injuries. Resident continued to be confused but was reminded to use call light staff will monitor resident. -12/5/10 at 1:25 p.m. resident fell at nurses station. Resident fell backwards on his back and head. No injuries noted. Blood pressure at this time was 83/52 and neurological checks were begun and monitoring continued. Information was faxed to physician for notification. An interview with the Director of Nursing on 2/2/11 at 5:00 p.m. revealed that monitoring means different things to different staff and realizes this should be made clearer. 7. Review of the clinical record for resident #23 revealed that the resident was admitted to the facility on [DATE]. Continued review revealed that the resident had twelve (12) falls between 1/22/10 to 1/26/11. Review of the Nursing progress notes revealed the resident was found 1/22/10 at 6:15 a.m. lying on the floor, behind the door on the his/her right side with the walker at the resident's feet. No injury noted. Resident was being seen by Physical Therapy (PT) at this time. No new interventions but to monitor resident. -4/20/10 the resident fell at 5:30 p.m. Resident had a small round raised area to the right side of the head. Ice packs were applied and the on call physician was notified. The resident was on Risperdal 0.25 milligrams (mg) at 11:00 a.m. and 5:00 p.m. and the on call physician discontinued the 5:00 p.m. dose. -4/15/10 at 11:05 a.m. resident was walking without a walker and fell backwards hitting the back of the resident's head. No injury or new interventions. The nursing progress notes for 4/16-4/18/10 reveal the resident had bruising on the right side of face. The resident was confused and had symptoms of anxiety. Interventions were to remind the resident to call for help and to use the walker. Continue to monitor. -7/6/10 at 1:45 p.m. Certified Nursing Assistant (CNA) was assisting the resident to the bathroom and left the resident in the bathroom to get a clean brief. During this time the resident attempted to stand by herself, slipped and fell to the floor. Injury to the resident's forehead: a large hematoma 2 cm by 2.5 cm on anterior forehead and a skin tear to the this area. Neurological checks were done and the resident was monitored. -9/24/10 at 9:35 p.m. Resident found on floor in the room. Alert but unable to say how the fall occurred. No injury. No intervention but to monitor resident. -9/27/10 Resident found on floor in 2nd floor activity room after activity this morning (no specific time noted). No injury noted. No interventions other than monitor resident. -10/1/10 at 6:02 p.m. resident sitting in wheelchair in activity room. The resident stood up and started to walk and fell on the left side. No injury noted-monitor resident. 10/8/10 at 6:00 a.m. bruise and slight swelling noted to left hip, no problems weight bearing. -10/12/10 at 4:30 p.m. Resident found on the floor in the hallway with the wheelchair in front them. Small raised lump at back of the head. Chair alarm placed in wheelchair, neurological checks and monitor resident. Note on 10/15/10 at 6:46 p.m. resident trying to stand up from wheelchair without assistance. Will continue to monitor. -11/11/10 at 3:55 p.m. Resident sitting in dayroom in wheelchair with chair locked and alarm in place. Resident pushed wheelchair away from table, stood and started to walk and lost her balance and fell . Bump found on back of head with ice applied. Neurological checks. -1/26/11 at 3:45 p.m. fell in activity room from wheelchair. Alarm on, stood and fell . No apparent injury. Interventions: Monitor resident. The resident was being seen by Physical Therapy (PT) between 1/5-1/28/10 and had been discharged from this service on 1/28/10 as having met goals. The resident had a PT screen done on 9/17/10. The resident received PT services from 11/4/10-11/11/10 and was discharged after meeting goals. A chair alarm was added 10/12/10. The facility fall risk assessment had not been updated since 9/8/10 when the resident was assessed with [REDACTED].

Although the facility alleged compliance on 2/16/11 related to jeopardy situation, record review revealed one (1) resident (#1) from a sample of nine (9) continued to have falls from 2/06/11 through 2/18/11. Three additional residents (#2, #3, and #4) experienced falls between 2/06/11 and 2/16/11. Although the facility developed preventative interventions for these residents, insufficient time had lapsed to determine effectiveness of these interventions; therefore, non compliance continues at a lesser scope and severity of "E". Findings include: Record review for resident #1 revealed the resident was identified as having a history of fall, assessed as a high risk of continued falls. The resident experienced a fall on 2/07/11 and again on 2/18/11. Interventions were identified to address the falls but there was no evidence these interventions had been implemented. Record review revealed resident #2 was assessed as having falls and at risk for falls. On 2/07/11 the resident was found in the hallway on their knees with a head laceration. The resident was sent to the hospital for evaluation/treatment of [REDACTED]. Record review revealed resident #3 was assessed as having falls and at risk for falls. On 2/12/11 the resident fell in their room. The resident experience no obvious injury from the fall but was sent to the hospital for evaluation. The resident was admitted to the hospital with [REDACTED]. After return to the facility on [DATE] appropriate interventions were added to the resident's care plan. Record review for resident #4 revealed the resident was assessed by the facility as having falls and at risk for falls. On 2/14/11 the resident fell in the bathroom of their room. Interventions were added to the care plan on 2/15/11, however the interventions did not address the issue of falling in the bathroom. The following documentation was from 2/04/11 survey: Based on observations, record reviews and staff interviews the facility failed to develop or implement interventions to provide a safe environment and prevent accidents for residents with multiple falls. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for seven (7) residents ("Q", #24, #23, #34, #7, #47,and #13) on a sample of Twenty-Five (25) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of March 21, 2011 and continues. Findings include: 1. Review of the Nursing Progress Notes for resident #34 during the year 2010 revealed the resident was admitted on [DATE] at 2:30 p.m. He was using a walker and was evaluated by therapy upon admission. The Progress Note written at 5:38 p.m. revealed the resident was alert, but mildly confused and shortly after admission to the facility sustained a fall at 3:00 p.m. when he was found in his room on the floor by his bed. No injury was noted and the intervention was to monitor him. Further review of the Progress Notes revealed documentation on 1/29/2010 at 9:44 p.m. that the resident had poor balance and was at risk for falls. Subsequent notes on 1/30/2010 at 3:02 p.m. and 1/31/2010 at 5:52 a.m. revealed the resident needed the assist of one due to an unsteady gait and that he would forget to use his walker. On 2/08/2010 at 6:15 a.m. he was found on the floor by his bed. He was leaning up against the bottom of the bed and told staff he hit his forehead. He had an abrasion to his forehead and to the bridge of his nose. Neurochecks were initiated. Review of the Incident Report for this fall revealed the resident was confused. He had a personal alarm on but it was not sounding and the resident was known to remove it. The report also revealed the resident required assist, but does not call for it. Intervention was to monitor and educate resident to call for help before getting up. The Incident Report indicated the problem was resolved. The resident fell again on 3/21/2010 at 10:40 p.m. in his room. He was found on the floor with a laceration to the right ear and signs and symptoms that suggested a right hip fracture. He was sent to the emergency room and was admitted with a right hip fracture and subsequently had surgery to repair it. The right ear laceration required sutures. The resident returned to the facility on [DATE]. Review of the Incident Report for this fall with injury revealed the resident was ambulating with a walker and the bed was in low level position. Two upper side rails were up. The staff heard a noise. When they entered the room they found the resident lying on floor in front of the wardrobe with bare feet. The identified cause of the incident on the report was unsteady gait and a change in mental status. Several days earlier the resident went to the emergency room and returned to the facility with a [DIAGNOSES REDACTED]. The resident fell again on 4/28/2010 at 9:00 a.m. in his room. Review of the Incident Report revealed the resident was alert, but confused, and climbed out of bed over the two upper siderails which were up because he wanted to get in his recliner. His status was identified as non-ambulatory and the cause of this fall was identified again as a change in mental status and unsteady gait. Intervention was to monitor. The resident also fell on [DATE] at 10:00 a.m. The Incident Report revealed he had no apparent injury and was confused. He had gotten out of his chair to get his walker which was at a distance. This happened in the activity room. He was found on the floor in front of the walker by staff. His personal alarm was on. The cause of the incident was a change in mental status. Interventions were monitoring and care plan review. Further review of the clinical record revealed the resident had fall risk assessments completed on 1/28/10, score 10; 2/4/10, score 14; 2/11/10, score 17; and 2/18/10, score 16. A score of 10 or above is considered a high risk for falls. There were no further fall risk assessments in the Clinical Record although the resident had falls after 2/18/10 Review of the facility policy for Fall Reduction and Management indicated all residents would be assessed for falls on admission and then quarterly. The policy also indicated A Falls Risk Committee would be formed with responsibilities which included: investigation regarding the cause of the fall, review appropriate strategies to reduce falls, determine the pattern of falls, develop individual interventions and approaches, make recommendations to prevent future occurrences. This would also Include a weekly review of all incident reports. Interview with the Director of Nursing (DON) on 2/2/2011 at 4:00 p.m. revealed that the facility did not have a Fall Risk Committee. They do have a Standards of Care (SOC) meeting every other week where they discuss residents who have fallen. Continued interview revealed that the person who had been responsible for tracking falls was no longer there and that the person who was tracking falls now was not doing a complete job. Since these staff members left, meetings of the SOC Committee have been less often. Prior to this decrease in staff, the Director of Nursing (DON) was only receiving monthly summary reports on falls. She stated these reports were retrospective and had no impact on prevention. She further stated personal alarms for chairs and beds tracked resident movement but were not effective for fall prevention. 2. Review of the Clinical Record for resident #13 revealed that the resident was admitted to the facility February 01, 2006. Continued review revealed that the resident fell twelve (12) times between 2/01/2010 to 1/30/2011. The last Fall Risk Assessment was done on 5/22/2010 and the score was 20 which indicated he was a high risk for falls. Further review of the Clinical Record revealed the resident had a Tinetti Balance Assessment Tool completed by therapy on 3/8/10 and his score indicated at high risk for falls Review of the facility's fall log, Incident Reports and Progress Notes revealed the following falls beginning 2/01/2010 and any interventions put in place to prevent further falls: -2/01/2010 (time unknown) The resident was found on floor in his room. Intervention was to monitor. -2/02/2010 (time unknown) The resident was found on floor in his room. Intervention was to monitor. -2/14/2010 (time unknown) The resident was found on floor in hallway. Intervention was to monitor. -3/04/2010 (time unknown) The resident was found on floor in hallway. Intervention was to monitor. -8/20/2010 at 8:45 p.m. The resident's wife informed staff he fell out of his chair. Staff found the resident on the floor. Interventions were to monitor the resident and provide resident and staff education. -10/19/2010 at 7:45 p.m. The resident was found on the floor in the day room. The resident told staff he was on his way to bed and sat on the floor. He had removed his personal alarm. Intervention was to monitor and do staff and resident education. -11/21/2010 (time unknown) Resident was found on floor in the day room by a staff member making rounds who heard an alarm ringing. The resident was on the floor in front of his wheelchair. Intervention was to monitor. -12/13/2010 at 2:00 a.m. Resident was found on floor in his room. He had an abrasion to the left great toe and a skin tear to the left hand ring finger which measured 1.0 cm x 0.5 cm. The bed alarm was sounding. Intervention was to monitor. -1/2/2011 at 11:05 p.m. The resident was attempting to go to wife's room, which is adjoining to his from the hallway, when he lost his balance. He was observed sitting on the floor. His alarm was not sounding. His wife alerted staff to the fall by pressing her call light. Intervention was to monitor. -1/07/2011 at 10:30 p.m. Resident was found on floor and no injury noted. Bed alarm was sounding. Incident report revealed resident was independent with ambulation however an undated Certified Nursing Assistant (CNA) Care Plan revealed he needed assistance. Resident was going to the bathroom without his walker. -1/15/2011 at 7:15 p.m. Resident was found by staff sitting on the floor in another resident's room. He was alert but disoriented. Intervention was to monitor. -1/30/2011 at 11:20 a.m. The resident fell in the activity lounge. Staff noted the resident was laying on floor. Intervention was to monitor. 3. Review of the Initial Nursing Admission assessment dated [DATE], the date of admission, for resident # 47 revealed she had fallen four times in the four months prior to admission, and was being admitted to the nursing facility due to debility and increased care needs her husband could no longer provide at home. Her fall risk assessment on 1/21/2011 was 13 indicating she was a high risk for falls. Further review of the admission assessment revealed the resident had an unsteady gait and needed assist with transferring and ambulating. Review of a Nursing Progress Note dated 1/30/2011 at 5:40 p.m. revealed resident #47 was found on the floor in her room by a family member. She was lying on her side by her wheelchair in the bathroom when he entered the room. Resident stated she was trying to shut the room door. The documentation revealed the resident was alert and oriented, but confused, and at the time of the fall, the resident had an alarm on her bed, but not on her chair. Review of the incident report for the fall on 1/30/2011 revealed the resident was observed by staff on the floor in her bathroom after a family member alerted them. Therapy Staff Member "HH" was interviewed on 2/03/2011 at 1:00 p.m. and stated the resident had falls prior to admission and was admitted to the facility due to increasing need for care the family was unable to provide. They further stated they were unsure how care needs for residents were communicated to the nursing assistants and had difficulty establishing a system of communication with nursing. 4. Review of the clinical record for resident "Q" revealed that the resident was readmitted to the facility on [DATE] after a fall resulting in a hip fracture. Continued review revealed that from January 2010 to August 2010 the resident had 5 falls: -01/31/10 at 9:15 pm the resident was found on the floor in her room, facing the bed, wrapped in covers, asleep. Family member present did not see the incident; -06/21/10 at 11:30 pm the resident was found on the floor in the hallway between her room and the bathroom. Resident "Q" said she was going to the bathroom because she felt nauseous; - 08/15/10 at 1:15 am resident "Q" was calling out for help from the hallway between the bathroom and her room. The resident was reminded to use the call light and not take off her personal alarm.; -08/26/10 on the night shift, the resident was found on the floor in the hallway between her room and the bathroom; -01/14/11 at 3:50 pm resident "Q" was walking behind her wheelchair with her husband, got tired, attempted to sit in the wheelchair and fell . Injuries from the fall included a lump on the left forehead, a red abrasion to the left cheek by the lower left eyelid. The resident was sent to the emergency room for evaluation. A Cat Scan dated 5:32 pm revealed there was a large soft tissue injury overlying the forehead; no evidence of a fracture and no acute abnormalities seen. Review of the resident care plan dated 11/18/10 revealed that the there were no interventions related to falls, including the use of the bed and chair alarm. 5. Resident #7 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]., abnormal gait, muscle weakness, Osteoarthrosis, urinary urgency and visual hallucinations. Review of the Fall Risk assessment performed on admission indicated the resident was at a high risk for falls. On 6/8/10 the resident had a score of 19 and a score of 10 or above represented high risk. Further review revealed there had been no evidence of additional fall risk assessments being performed on the resident since 7/27/10. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had falls within the past 30 days. Review of the Nurse's Progress Notes and the Fall/Incident log revealed the resident had thirty-four (34) falls from admission on 6/8/10 until 1/31/2011. The resident had 2 falls during the month of June 2010, with the first fall being the day of admission to the facility. Review of the Nurses Progress Notes revealed on 6/8/10 at 7:30 p.m., the resident reported to the staff she fell off the shower bench. The note also indicated the resident was confused and forgetful. Corrective actions on the Incident/Accident Report indicated to monitor the resident and instruct her to use the call light. The resident was also to be placed on a toileting schedule. Review of the Bladder Retraining Schedule revealed this was to be done from 6/30/10 through 7/31/10. However documentation revealed the resident was only on the program for 2 weeks. There was no indication her success on the program had been evaluated. Further review of the schedule indicated the resident had only 2 episodes of incontinence during the 2 week period. -On 6/22/10 at 5:30 p.m. the resident fell in the hallway, backing up with her walker. The resident hit the water fountain and rolled to the floor onto her right hip and side. Corrective action on the Incident/Accident Report indicated the staff was to walk beside the resident to and from the dining room and to encourage the resident not to turn and sit on the walker. There were no injuries. Review of a physician orders dated 7/9/10 revealed the resident was started on Seroquel (an antipsychotic) 12.5 milligrams (mg) three times a day. The resident had a total of 2 falls during the month of July 2010. -7/10/10 at 2:15 a.m. and on 7/13/10 11:00 p.m. the resident was observed on the floor in her room. There was no evidence of new interventions. Review of a nurses progress noted dated 7/24/10 indicated the Seroquel was increased from 37.5 mg. per day to Seroquel XL 50mg. at 6:00 p.m. each day. A note in the nurses progress note dated 7/25/10 indicated distraction and redirection were not helpful. The resident had 4 falls during the month of August 2010 - 8/13/10 at 10:05 p.m. the resident was observed lowering herself to her knees and then lying on her right side on the floor. There were no injuries and no new interventions. The facility Incident/Accident Report did not consider this a fall. -8/14/10 at 12:25 p.m. the resident slid to the floor in the bathroom, on 8/24/10 the resident reported to the staff she fell during the night. On 8/28/10 at 7:20 a.m., the staff found the resident on the floor. Review of the Incident/Accident Report indicated the only intervention was to monitor the resident, however further review indicated the resident began receiving Physical Therapy on 8/16/10. The resident received the Physical Therapy services until 9/1510. The resident had 12 falls during the month of September 2010. -9/2/10 at 8:40 a.m., the resident reported to the Certified Nursing Assistant (CNA) she fell in her room. There were no evidence of new interventions. - 9/6/10 at 2:07 a.m. the staff found the resident on the floor, leaning against the chair in her room. Again, the facility did not consider this to be a fall. She was assisted to stand and sit in her chair. -9/6/10 at 5:15 p.m., the resident fell in the hallway, the note indicated the resident was going to dinner and lost her balance and fell against the wall and slid to the floor. There were 2 abrasions to the right side of the head and a knot on the top of the head. There was no evidence of new interventions. -9/7/10 at 5:05 p.m. The resident fell in the shower. The CNA was with the resident assisting her with a shower and the resident demanded the CNA leave the room. The CNA left the resident and the resident fell in the shower. The resident sustained [REDACTED]. There was no evidence of new interventions -9/9/10 at 6:15 a.m.,and on 9/11/10 at 6:15 a.m., the resident was found in the floor in her room next to the bed. Again there were no new interventions. -On each of the following occasions: 9/13/10 at 9:10 p.m., 9/16/10 at 2:00 a.m.,and 9/17/10 at 1:30 a.m., the resident was found on the floor by the staff. There was no evidence of new interventions. -9/19/10-at 5:00 p.m. the resident was found on the floor in the her room, The note indicated she slid out of the wheelchair. On 10/29/10, Physical Therapy was ordered to fit the resident for a new wheelchair. -9/29/10 at 12:15 am the resident was again found sitting on the floor in her bathroom. She complained of left buttock pain, the physician was notified and an x-ray of the hip was ordered and was negative. There was no evidence of new interventions put in place. -9/30/10 at 7:00 a.m., the resident was found on the floor in her room. Review of the Incident/Accident Report indicated the resident removed her personal alarm. The resident had 9 falls during October 2010. -10/02/10 at 4:30 p.m. the resident was found on the floor in her room. Interventions included monitoring and staff education, however there was no evidence of the type of education which was provided. -10/07/10 on the 3:00 p.m. to 11:00 p.m. shift, the resident was found on the floor in her room. Review of the Incident/Accident Report indicated the incident was resolved and there was no follow-up required. -10/9/10 at 1:56 p.m.,the resident was found sitting in her bathroom floor. Her personal alarm had been removed and was wrapped around her wheelchair. There were no injuries and no evidence of new interventions. -10/15/10 at 9:24 a.m. The resident was found on the floor in the bathroom. The resident had removed the alarm and gotten out of bed. There were no injuries. Interventions were to view her more often and educate the resident to leave the alarm on and call for assistance when she needed to go to the bathroom. Review of the Nurses Progress Notes revealed the resident was confused. -10/26/10 at 8:00 p.m. The resident was found on the floor in her room. The resident was asking the staff to take her to the bathroom. Review of the Incident/Accident Report revealed the resident removed the alarms, it even indicated the resident demonstrated ability to disconnect the tab alarm,but was unable to disconnect the bed alarm. -10/27/10 at 7:29 p.m. and 10/28/10 at 12:22 a.m. the resident was found on the floor in her room. There was no evidence of new interventions. -10/30/10 at 7:15 p.m. The Nurses Progress Note indicated the resident was confused. The resident reported to the CNA she hit her head. There was a red, raised area 3 centimeters by 0.5 centimeters on the back of the head. Interventions were to adjust the volume on the chair alarm and the staff was also advised to put the chair alarm on the resident while she was in bed. -10/31/10 at 5:30 a.m., the resident was again found in the floor in the her room. There were no injuries and no evidence of new interventions. During the month of November 2010 the resident had 2 falls -11/13/10 at 7:30 a.m., The resident was found on the floor in the bathroom on her hands and knees. The alarm was on low volume. -11/21/10 at 4:00 p.m., The resident was found on the floor in the bathroom/shower- The bed alarm was on the mattress, but was not connected to the monitor. During the month of December 2010 the resident had 5 falls. -12/6/10 at 7:45 p.m. The staff found the resident on the floor in her room. There was a bruise and 0.5 centimeter cut on the side of the head. There was no evidence of new interventions to address the fall. -12/11/10 at 3:45 p.m., the resident was sitting on floor and leaning against the wall. The monitor had been removed by the resident The Incident/Accident Report indicated an inservice was conducted to educate staff that both alarms should be in place when in bed and in the wheelchair. -12/10 at 10:30 p.m., the resident slid to the floor. The corrective action was to remind the resident to use the call light. -12/14/10 at 3:05 p.m. the resident was found in the floor. The only corrective action at this time was to monitor the resident. -12/23/10 at 9:00 p.m., the resident was found on the floor by the staff. The resident had removed the alarm and placed it in a pillow. There was no evidence of new interventions. There was one fall during the month of January 2010. On 1/31/11 at 5:14 a.m. the resident was found on the floor. There was no evidence of new interventions.- During an observation on 2/1/11 3:15 p.m., the resident was observed sitting on the side of the bed, a wheelchair was noted beside the bed. The resident got up off the bed. There was a monitor box for a bed alarm on the bedside table, however the alarm did not sound when the resident got up. The resident became very unsteady on her feet and was loosing her balance. The surveyor had to hold under the resident's arms and assist her to the chair. There was no staff available in the area. This was immediately reported to Licensed Practical Nurse "QQ" on the unit. During an interview on 2/1/11 at 3:50 p.m. LPN "QQ" stated the resident was supposed to have a pressure alarm on her bed and in her wheelchair and she also is supposed to have a tab alarm on the back of the wheelchair. She stated the resident had learned to take them off and will pack them everyday. LPN "QQ" stated at the time of the near fall the resident had been in the bed, so the pad was moved from the wheelchair to the bed. She stated the pad was on the bed, however the resident had disconnected the alarm. Observation of the resident 2/2/11 at 10:45 a.m., revealed the resident was sitting up in the wheelchair. There was no evidence of an alarm on the resident's wheelchair, This was again reported to LPN "QQ". She placed the alarm on the wheelchair at that time and stated she did not know why the alarm was not in place. Observation of the resident on 2/3/11 at 10:00 a.m. revealed the resident with a tab alarm on the wheelchair, however there was no evidence of a pressure alarm in the chair. LPN "QQ" stated at this time she was not sure if the resident was supposed to have the pressure alarm in the wheelchair. During an interview on 2/4/10 at 2:00 p.m. the MDS coordinator stated she could not find at what point the alarms began being placed on the resident. She further stated the resident was supposed to have a pressure alarm on the bed when in bed and a tab alarm and pressure alarm in the chair when up in the wheelchair. Further review of the medical record indicated the resident received an Interdisciplinary Therapy Screen on 8/3/10. It was recommended at that time for the resident to receive Physical Therapy services due to multiple falls and many additional "near falls". The screen indicated the resident was more confused and delusional. The resident began receiving Physical Therapy (PT) on 8/16/10 and ended on 9/15/10. The resident received PT for balance and gait training. During an interview on 3/2/10 at 1:00 p.m. therapy staff "HH" stated the resident had poor safety awareness, she stated no matter how often she was told not to get up she would get up anyway. She stated they were alerted to one fall, but unsure about others that had occurred since she was discharged . In addition, she stated when she was the therapy program manager,over a year ago,they would discuss anyone who had a fall weekly. She stated they would discuss interventions and and would follow-up till the problem with falls had resolved. She indicated they now get a log of incidents monthly. During an interview on 2/3/11 at 12:00 noon therapy staff "FF" indicated the therapists have had some restrictions on the interventions they can use. She stated they are restricted on types of devices they can implement after falls such as self release belts, merri-walkers and other types of safety devices. She also stated she had asked the CNA's if they have a way to communicate interventions and types of assistance required for the residents. She stated the CNA's told her there was no method to communicate information. Interview with the Director of Nursing on 2/04/2011 at 3:00 p.m. revealed that the facility had no system for identifying which residents were at risk for falls nor had they identified trends and /or causes of falls. 6. Review of the clinical record for resident #24 revealed that that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Continued review revealed that the resident had eight (8) falls from 9/16/10 to 12/5/10. On 9/16/10 at 7:30 a.m. the resident was found on the floor beside the bed. The resident stated he/she slipped off the bed and thought his right shoulder was broken. The doctor was notified and ordered a portable X-ray. The X-ray company was contacted and at 12:15 p.m. the X-ray results were called in with a [DIAGNOSES REDACTED]. An order was received to send the resident to the hospital for treatment and the resident was transported to the hospital. The resident returned to the facility on the same day. No new interventions were put into place to prevent further falls. -9/18/10 at 8:50 a.m. found on floor in hallway. Resident stated that he/she saw an animal and tried to go over it, tripped and fell . A Physical Therapy (PT) screen was done but the resident refused PT. A personal alarm was put in place on 9/20/10 with reminders to use call light for assistance. -11/9/10 at 12:40 a.m. resident was calling out for help then found on floor in room. Personal electric bed was in the lowest position. Interventions were to use call light and monitor resident. Resident continued to be alert and confused. -11/29/10 at 1:50 a.m. resident was found on the floor in the resident's room with no injuries. Resident continued to be confused but was reminded to use call light staff will monitor resident. -12/5/10 at 1:25 p.m. resident fell at nurses station. Resident fell backwards on his back and head. No injuries noted. Blood pressure at this time was 83/52 and neurological checks were begun and monitoring continued. Information was faxed to physician for notification. An interview with the Director of Nursing on 2/2/11 at 5:00 p.m. revealed that monitoring means different things to different staff and realizes this should be made clearer. 7. Review of the clinical record for resident #23 revealed that the resident was admitted to the facility on [DATE]. Continued review revealed that the resident had twelve (12) falls between 1/22/10 to 1/26/11. Review of the Nursing progress notes revealed the resident was found 1/22/10 at 6:15 a.m. lying on the floor, behind the door on the his/her right side with the walker at the resident's feet. No injury noted. Resident was being seen by Physical Therapy (PT) at this time. No new interventions but to monitor resident. -4/20/10 the resident fell at 5:30 p.m. Resident had a small round raised area to the right side of the head. Ice packs were applied and the on call physician was notified. The resident was on Risperdal 0.25 milligrams (mg) at 11:00 a.m. and 5:00 p.m. and the on call physician discontinued the 5:00 p.m. dose. -4/15/10 at 11:05 a.m. resident was walking without a walker and fell backwards hitting the back of the resident's head. No injury or new interventions. The nursing progress notes for 4/16-4/18/10 reveal the resident had bruising on the right side of face. The resident was confused and had symptoms of anxiety. Interventions were to remind the resident to call for help and to use the walker. Continue to monitor. -7/6/10 at 1:45 p.m. Certified Nursing Assistant (CNA) was assisting the resident to the bathroom and left the resident in the bathroom to get a clean brief. During this time the resident attempted to stand by herself, slipped and fell to the floor. Injury to the resident's forehead: a large hematoma 2 cm by 2.5 cm on anterior forehead and a skin tear to the this area. Neurological checks were done and the resident was monitored. -9/24/10 at 9:35 p.m. Resident found on floor in the room. Alert but unable to say how the fall occurred. No injury. No intervention but to monitor resident. -9/27/10 Resident found on floor in 2nd floor activity room after activity this morning (no specific time noted). No injury noted. No interventions other than monitor resident. -10/1/10 at 6:02 p.m. resident sitting in wheelchair in activity room. The resident stood up and started to walk and fell on the left side. No injury noted-monitor resident. 10/8/10 at 6:00 a.m. bruise and slight swelling noted to left hip, no problems weight bearing. -10/12/10 at 4:30 p.m. Resident found on the floor in the hallway with the wheelchair in front them. Small raised lump at back of the head. Chair alarm placed in wheelchair, neurological checks and monitor resident. Note on 10/15/10 at 6:46 p.m. resident trying to stand up from wheelchair without assistance. Will continue to monitor. -11/11/10 at 3:55 p.m. Resident sitting in dayroom in wheelchair with chair locked and alarm in place. Resident pushed wheelchair away from table, stood and started to walk and lost her balance and fell . Bump found on back of head with ice applied. Neurological checks. -1/26/11 at 3:45 p.m. fell in activity room from wheelchair. Alarm on, stood and fell . No apparent injury. Interventions: Monitor resident. The resident was being seen by Physical Therapy (PT) between 1/5-1/28/10 and had been discharged from this service on 1/28/10 as having met goals. The resident had a PT screen done on 9/17/10. The resident received PT services from 11/4/10-11/11/10 and was discharged after meeting goals. A chair alarm was added 10/12/10. The facility fall risk assessment had not been updated since 9/8/10 when the resident was assessed with [REDACTED].

Based on observation, record review and staff interview, the facility failed to be administered in a manner that ensured staff members were trained appropriately regarding assessment of resident's at risk for falls, implementation of appropriate interventions for falls and monitoring to ensure safety devices were being used as appropriate and were functional. This affected seven (7) residents ("Q", #24, #34, #7, #23, #47,and #13) on a sample of twenty-five (25) residents. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for those seven (7) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of March 21,2010 and continues. Findings include: Review of the medical records resident "Q", #24, #34, #7, #23 , #47 and #13 revealed that care plans had not been developed and/or updated to reflect appropriate interventions for falls. Falls assessments were not done quarterly as per the facility policy for Fall Reduction and Management. Cross refer F278, F279 and F280 Review of the facility policy for Fall Reduction and Management revealed that a Falls Risk Committee would be formed with responsibilities which included: investigation regarding the cause of the fall, review appropriate strategies to reduce falls, determine the pattern of falls, develop individual interventions and approaches, make recommendations to prevent future occurrences. Interview with the Director of Nursing on 2/02/2011 at 4:00 p.m. and again on 2/04/2011 at 3:00 p.m. revealed that the facility had no Falls Risk Committee and had no plan to address residents with falls, no system for identifying which residents were at risk for falls nor had they identified trends and/or causes of falls. Interview with the Administrator on 2/4/2011 at 3:00 p.m. revealed that the facility had not identified a concern with falls and had not developed a plan to address safety and falls. The facility failed to ensure that residents were appropriately assessed for risk for falls, and residents who experienced falls had appropriate interventions in place. There were no systems to ensure that residents received needed supervision and assistance; that safety devices/interventions were in place to prevent falls and that bed and chair alarms were functional. Cross refer F 323

Although the facilty alleged compliance on 2/16/11, non compliance in F279, F282, F323 continues. Therefore, non compliance continues at a lesser scope and severity of "E". Cross referrence to F278 is deleted. The following documentation was from 2/04/11 survey: Based on observation, record review and staff interview, the facility failed to be administered in a manner that ensured staff members were trained appropriately regarding assessment of resident's at risk for falls, implementation of appropriate interventions for falls and monitoring to ensure safety devices were being used as appropriate and were functional. This affected seven (7) residents ("Q", #24, #34, #7, #23, #47,and #13) on a sample of twenty-five (25) residents. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for those seven (7) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of March 21,2010 and continues. Findings include: Review of the medical records resident "Q", #24, #34, #7, #23 , #47 and #13 revealed that care plans had not been developed and/or updated to reflect appropriate interventions for falls. Falls assessments were not done quarterly as per the facility policy for Fall Reduction and Management. Review of the facility policy for Fall Reduction and Management revealed that a Falls Risk Committee would be formed with responsibilities which included: investigation regarding the cause of the fall, review appropriate strategies to reduce falls, determine the pattern of falls, develop individual interventions and approaches, make recommendations to prevent future occurrences. Interview with the Director of Nursing on 2/02/2011 at 4:00 p.m. and again on 2/04/2011 at 3:00 p.m. revealed that the facility had no Falls Risk Committee and had no plan to address residents with falls, no system for identifying which residents were at risk for falls nor had they identified trends and/or causes of falls. Interview with the Administrator on 2/4/2011 at 3:00 p.m. revealed that the facility had not identified a concern with falls and had not developed a plan to address safety and falls. The facility failed to ensure that residents were appropriately assessed for risk for falls, and residents who experienced falls had appropriate interventions in place. There were no systems to ensure that residents received needed supervision and assistance; that safety devices/interventions were in place to prevent falls and that bed and chair alarms were functional. Cross refer to F279, F282 and F323

Based on observation, record review and staff interview the facility failed to have an effective Quality Assurance process that identified residents at risk for falls, needing supervision and monitoring to ensure safety, that developed effective interventions and determined the effectiveness of any interventions that were developed. This effected seven (7) residents ("Q",#24, #34, #7, #23, #47,and #13) on a sample of twenty-five (25) residents. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for those seven (7) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of March 21, 2010 and continues. Findings include: Interview with the Administrator on 2/04/2011 at 3:00 p.m. revealed that the facility conducts Quality Assurance meetings quarterly but that the Medical Director or a physician designee had not attended the meeting since July 2010. Continued interview revealed that the Quality Indicators for the facility were reviewed at each of the meetings and a trend with residents requiring more assistance had been identified, however, they had not identified a concern with falls and had not developed a plan to address safety and falls. Further interview revealed that the facility has a Standards of Care (SOC) meeting every other week and residents with specific needs, such as falls, are discussed. Cross Refer to F323

One QA meeting had been conducted on 2/15/11, although the facility alleged compliance on 2/16/11, non compliance continues due to the fact that insufficient time has lapsed to determine effectiveness of any interventions developed to address issues identified during the survey of 2/04/11. Therefore, non compliance continues at a lesser scope and severity of "E". The following documentation was from the 2/04/11 survey: Based on observation, record review and staff interview the facility failed to have an effective Quality Assurance process that identified residents at risk for falls, needing supervision and monitoring to ensure safety, that developed effective interventions and determined the effectiveness of any interventions that were developed. This effected seven (7) residents ("Q",#24, #34, #7, #23, #47,and #13) on a sample of twenty-five (25) residents. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for those seven (7) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of March 21, 2010 and continues. Findings include: Interview with the Administrator on 2/04/2011 at 3:00 p.m. revealed that the facility conducts Quality Assurance meetings quarterly but that the Medical Director or a physician designee had not attended the meeting since July 2010. Continued interview revealed that the Quality Indicators for the facility were reviewed at each of the meetings and a trend with residents requiring more assistance had been identified, however, they had not identified a concern with falls and had not developed a plan to address safety and falls. Further interview revealed that the facility has a Standards of Care (SOC) meeting every other week and residents with specific needs, such as falls, are discussed. Cross Refer to F323

Based on record review and staff interview, the facility failed to accurately assess falls for one (1) resident (#23) from a sample of twenty five (25) residents. This resulted in an immediate and serious threat to resident safety. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for the one (1 ) resident. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of March 21, 2010 and continues. Findings include: Review of the clinical record for resident #23 revealed that the resident had twelve (12) falls from 1/10/10. The falls occurred on: 1/22/10, 4/9/10, 4/15/10, 7/6/10, 9/24/10, 9/27/10, 10/1/10, 10/6/10, 10/12/10, 10/25/10, 11/11/10, and 1/26/11. Review of the quarterly MDS assessment dated [DATE] revealed that the resident was assessed as having had no falls in the last one hundred and eighty (180) days. An interview with the MDS Coordinator on 2/1/11 at 3:32 p.m. revealed that she had overlooked this assessment and that the resident had not had a facility quarterly falls assessment since 9/8/10.

Based on observation, record review and staff interview the facility failed to develop a Comprehensive Care Plan with interventions for three (3) residents (#34, #13 and #7) assessed with [REDACTED]. This resulted in an immediate and serious threat to resident safety. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for the three (3 ) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of March 21, 2010 and continues. Findings include: 1. Review of the Clinical Record for resident #34 revealed the resident was admitted to the facility on [DATE]. Review of the initial Minimum Data Assessment ((MDS) dated [DATE] revealed that the resident was assessed as having falls within the last thirty (30) days and the Resident Assessment Protocol Summary (RAPS) indicated that a care plan would be developed for falls. A progress Note dated 1/29/2010 at 9:44 p.m. revealed the resident was at risk for falls related to poor balance and an unsteady gait. Review of the current care plan for this resident revealed that he was at increased risk of falls due to use of anti-depressant medications, a history of falls and unsteady gait. He needed reminders to use his Rolator and needed to request assistance if he felt unsteady. Interventions included: remind to ask for help, keep call light within reach at all times when in room, keep adaptive device/reacher in reach at all times and remind resident to use it, use personal alarm as necessary, place Rolator in reach at all times and do a fall risk assessment on admission, quarterly and after any falls as needed. This Care Plan was not developed until 12/27/2010 Interview on 2/03/2011 at 10:00 a.m. with the MDS/Care Plan Coordinator revealed that there was no Care Plan related to falls prior to 12/27/2010. Interview with Registered Nurse (RN) "BB" on 2/4/2011 at 11:00 a.m. revealed the facility's clinical records including Care Plans were not complete. Review of the facility's policy on Falls Reduction and Management revealed the residents were to be assessed upon admission for fall risk and then quarterly using the Fall Risk Assessment Form. Once risk was identified the Interdisciplinary Care Plan Team would identify appropriate preventive measures and interventions. 2. Review of the RAPS from a significant change MDS completed on 1/14/10 for resident #13 indicated that a care plan would be developed for falls. Review of the quarterly MDS dated [DATE] revealed that the resident was assessed with [REDACTED]. Review of the clinical record revealed that this resident had twelve falls between 2/01/2010 and 1/30/2011. There was no evidence a comprehensive care plan to address the resident's falls and safety needs was developed until 12/22/10. The last Fall Risk Assessment was done on 5/22/10 and the score was 20 indicating that the resident was a high risk for falls. Review of the current care plan revealed that he was at risk for falls due to being unsteady on his feet, poor safety awareness and history of falls. Interventions included: assistance from staff, chair alarm, and frequent safety reminders. 3. Resident #7 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]., abnormal gait, muscle weakness, [MEDICAL CONDITION], urinary urgency and visual hallucinations. Review of the Fall Risk assessment performed on admission indicated the resident was at a high risk for falls. Review of the initial Minimum Data Assessment ((MDS) dated [DATE] revealed that the resident was assessed as having falls within the last thirty (30) days and the Resident Assessment Protocol Summary (RAPS) indicated that a care plan would be developed for falls. There was no evidence a comprehensive care plan to address the resident's falls and safety needs was developed until 12/10/10. Review of the current care plan revealed that the resident was at increased risk of falls due to use of anti depressant medication, had a history of [REDACTED]. Continued review revealed interventions which were not appropriate for the resident such as reminding the resident to use the call light. During an interview on 2/3/10 at 3:00 p.m. the MDS coordinator confirmed the care plan had not been developed until 12/10/10.

Although the facility alleged compliance on 2/16/11, based on record review the facility failed to develop appropriate interventions for one (1) resident (#4) who experienced falls from a sample of nine (9) residents. Non compliance continues at a lesser scope and severity of "D". Findings include: Record review for resident #4 revealed the resident was assessed by the facility as having falls and at risk for falls. On 2/14/11 the resident fell in the bathroom of their room. Interventions were added to the care plan on 2/15/11. Interventions included a low bed and bed alarm, however these items were not available and would have to be ordered. In addition, the issue of a fall occurring while the resident attempted self toileting was not addressed with appropriate interventions. The following was documented on the 2/04/11 survey: Based on observation, record review and staff interview the facility failed to develop a Comprehensive Care Plan with interventions for three (3) residents (#34, #13 and #7) assessed with [REDACTED]. This resulted in an immediate and serious threat to resident safety. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for the three (3 ) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of March 21, 2010 and continues. Findings include: 1. Review of the Clinical Record for resident #34 revealed the resident was admitted to the facility on [DATE]. Review of the initial Minimum Data Assessment ((MDS) dated [DATE] revealed that the resident was assessed as having falls within the last thirty (30) days and the Resident Assessment Protocol Summary (RAPS) indicated that a care plan would be developed for falls. A progress Note dated 1/29/2010 at 9:44 p.m. revealed the resident was at risk for falls related to poor balance and an unsteady gait. Review of the current care plan for this resident revealed that he was at increased risk of falls due to use of anti-depressant medications, a history of falls and unsteady gait. He needed reminders to use his Rolator and needed to request assistance if he felt unsteady. Interventions included: remind to ask for help, keep call light within reach at all times when in room, keep adaptive device/reacher in reach at all times and remind resident to use it, use personal alarm as necessary, place Rolator in reach at all times and do a fall risk assessment on admission, quarterly and after any falls as needed. This Care Plan was not developed until 12/27/2010 Interview on 2/03/2011 at 10:00 a.m. with the MDS/Care Plan Coordinator revealed that there was no Care Plan related to falls prior to 12/27/2010. Interview with Registered Nurse (RN) "BB" on 2/4/2011 at 11:00 a.m. revealed the facility's clinical records including Care Plans were not complete. Review of the facility's policy on Falls Reduction and Management revealed the residents were to be assessed upon admission for fall risk and then quarterly using the Fall Risk Assessment Form. Once risk was identified the Interdisciplinary Care Plan Team would identify appropriate preventive measures and interventions. 2. Review of the RAPS from a significant change MDS completed on 1/14/10 for resident #13 indicated that a care plan would be developed for falls. Review of the quarterly MDS dated [DATE] revealed that the resident was assessed with [REDACTED]. Review of the clinical record revealed that this resident had twelve falls between 2/01/2010 and 1/30/2011. There was no evidence a comprehensive care plan to address the resident's falls and safety needs was developed until 12/22/10. The last Fall Risk Assessment was done on 5/22/10 and the score was 20 indicating that the resident was a high risk for falls. Review of the current care plan revealed that he was at risk for falls due to being unsteady on his feet, poor safety awareness and history of falls. Interventions included: assistance from staff, chair alarm, and frequent safety reminders. 3. Resident #7 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]., abnormal gait, muscle weakness, [MEDICAL CONDITION], urinary urgency and visual hallucinations. Review of the Fall Risk assessment performed on admission indicated the resident was at a high risk for falls. Review of the initial Minimum Data Assessment ((MDS) dated [DATE] revealed that the resident was assessed as having falls within the last thirty (30) days and the Resident Assessment Protocol Summary (RAPS) indicated that a care plan would be developed for falls. There was no evidence a comprehensive care plan to address the resident's falls and safety needs was developed until 12/10/10. Review of the current care plan revealed that the resident was at increased risk of falls due to use of anti depressant medication, had a history of [REDACTED]. Continued review revealed interventions which were not appropriate for the resident such as reminding the resident to use the call light. During an interview on 2/3/10 at 3:00 p.m. the MDS coordinator confirmed the care plan had not been developed until 12/10/10.

Based on observation, record reviews and staff interviews the facility failed to follow the Comprehensive Care Plan interventions related to fall prevention for three (3) residents,(#13, #20 and #34) of twenty-five (25) sampled residents. This resulted in an immediate and serious threat to resident safety. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for these three (3 ) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of March 21, 2010 and continues. Findings include: 1. Review of the Resident Care Plan for resident #13 revealed that the resident was having more trouble using walker, staff to evaluate daily whether it continues to be safe for him to use it. Review of the Clinical Record revealed that the resident had seven (7) falls from 10/19/10 until 1/30/11. There was no evidence in the clinical record or on the Incident Reports that the staff had been monitoring the resident's ability to use the walker safely. 2. Review of the current Care Plan dated 12/27/2010 revealed resident # 34 had an increased risk of falling due to use of anti-depressant medications, a history of falls, poor balance and an unsteady gait. The resident needed reminders to use his Rolator and to request assistance if he felt unsteady. Interventions included reminding the resident to ask for help, keeping the call light and adaptive devices, such as the reacher and Rolator, within reach at all times. Observation of the resident in the activity area on 2/2/11 at 9:08 a.m. revealed the resident in a chair reading. The Rolator was located away from the chair and the reacher was not visible. Continued observation at 1:30 p.m. on 2/2/11 revealed the resident again in the activity area near his room sitting in a gliding rocking chair watching television. His personal chair alarm and reacher were in his room. There were no staff members in the area of the activity room at this time. 2. Review of the current care plan for resident "Q" revealed that the resident was assessed as being a high risk for falls. Nursing interventions in the plan of care included a fall risk assessment was to be done quarterly. Staff was to assess the resident's gait, and balance and report any decline to the physician and therapy services for evaluation. Interview on 02/02/11 at 9:00 a.m. with Licensed Practical Nurse "CC" revealed that the intervention to assess gait and balance meant staff were to do a visual assessment to see if the resident had problems. If staff noticed any problems they would bring it to her attention and document it. Interview with an LPN on 01/31/11 at 3:45 pm revealed resident "Q" fell on [DATE]. The resident was noted lying on the floor near the front lobby. The resident was with her husband. The right side of her face was bruised, a knot was above her right eyebrow, and a bruise underneath the left eye. The fall on 01/14/11 occurred while resident "Q" was walking, but no assessment of the gait had been done as indicated in the care plan

Although the facility revised care plans for residents identified as having fall risk, during the visit of 2/18/11 the facility had not implemented interventions for one resident (#1) from a sample of nine (9) residents. Non compliance continues at a lesser scope and severity of "D". Finding include: Record review for resident #1 revealed the resident had a history of [REDACTED]. The resident experienced a fall on 2/06/11 and a notation of the fall was added to the 2/07/11 care plan. No additional intervention were included in this notation. On 2/18/11 the resident fell from bed without injury. Review of the resident's care plan revealed interventions were added on 2/18/11. Interventions included: every 30 minutes checks and to reeducate staff on use of bed alarms (specifically to ensure the alarm is turned on and/or reset before resident gets in bed). There was no evidence that these interventions had been implemented. The following was documented on the survey of 2/04/11: Based on observation, record reviews and staff interviews the facility failed to follow the Comprehensive Care Plan interventions related to fall prevention for three (3) residents,(#13, #20 and #34) of twenty-five (25) sampled residents. This resulted in an immediate and serious threat to resident safety. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for these three (3 ) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of March 21, 2010 and continues. Findings include: 1. Review of the Resident Care Plan for resident #13 revealed that the resident was having more trouble using walker, staff to evaluate daily whether it continues to be safe for him to use it. Review of the Clinical Record revealed that the resident had seven (7) falls from 10/19/10 until 1/30/11. There was no evidence in the clinical record or on the Incident Reports that the staff had been monitoring the resident's ability to use the walker safely. 2. Review of the current Care Plan dated 12/27/2010 revealed resident # 34 had an increased risk of falling due to use of anti-depressant medications, a history of falls, poor balance and an unsteady gait. The resident needed reminders to use his Rolator and to request assistance if he felt unsteady. Interventions included reminding the resident to ask for help, keeping the call light and adaptive devices, such as the reacher and Rolator, within reach at all times. Observation of the resident in the activity area on 2/2/11 at 9:08 a.m. revealed the resident in a chair reading. The Rolator was located away from the chair and the reacher was not visible. Continued observation at 1:30 p.m. on 2/2/11 revealed the resident again in the activity area near his room sitting in a gliding rocking chair watching television. His personal chair alarm and reacher were in his room. There were no staff members in the area of the activity room at this time. 2. Review of the current care plan for resident "Q" revealed that the resident was assessed as being a high risk for falls. Nursing interventions in the plan of care included a fall risk assessment was to be done quarterly. Staff was to assess the resident's gait, and balance and report any decline to the physician and therapy services for evaluation. Interview on 02/02/11 at 9:00 a.m. with Licensed Practical Nurse "CC" revealed that the intervention to assess gait and balance meant staff were to do a visual assessment to see if the resident had problems. If staff noticed any problems they would bring it to her attention and document it. Interview with an LPN on 01/31/11 at 3:45 pm revealed resident "Q" fell on [DATE]. The resident was noted lying on the floor near the front lobby. The resident was with her husband. The right side of her face was bruised, a knot was above her right eyebrow, and a bruise underneath the left eye. The fall on 01/14/11 occurred while resident "Q" was walking, but no assessment of the gait had been done as indicated in the care plan

Based on observation, record review and staff interviews the facility failed to provide sufficient staff to ensure appropriate supervision related to safety for one (1) resident ("Q") of fifteen (15) residents on a secured unit from a sample of twenty five (25) residents. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for one (1) resident ("Q")on a sample of twenty-five (25) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of March 21, 2011 and continues. Findings include: Observations on 1/31/2011 beginning at 4:15 p.m. of the Reflection (secured) Unit revealed a resident wandering in and out of rooms [ROOM NUMBER]. Two (2) Certified Nursing Assistants (CNAs) were watching the resident and redirected him//her. Licensed Practical Nurse (LPN) "KK" was administering medications. Observations continued until 5:30 p.m. and the surveyor attempted to leave the unit. Not knowing the code to exit the unit, the surveyor began to look for staff to assist her in exiting this unit. The surveyor went down all the halls and into the corner rooms and could not find any staff. The residents were sitting in the dayroom. At 5:50 p.m. the surveyor called the operator and spoke with security, explaining that she could not find any staff and did not have the code to get out of the secured unit. At 5:55 p.m. the surveyor exited the secured unit after getting the code from LPN "KK". All three of the staff persons seen on the secured unit were observed on the Blue Ridge unit, with the nurse administering medications and the 2 CNAs standing in the hallway near the day area. There had been no staff on the secured unit for at least 20 minutes. Review of the clinical record for resident "Q" who resides on the secured unit revealed that the resident was readmitted to the facility on [DATE] after a fall resulting in a [MEDICAL CONDITION]. Continued review revealed that from January 2010 to August 2010 the resident had 5 falls. Four (4) of these falls occurred after 8:00 p.m. and each time the resident was found on the floor. Interview on 2/04/2011 at 1:50 p.m. with CNA "NN" revealed that there was one (1) CNA and one (1) nurse assigned to both units (the secure unit and Blue Ridge) on the 11pm to 7 am shift. Continued interview revealed that when it was break time or lunch time for the staff only one (1) person was left to watch the residents on both units (30 residents) meaning that residents were left on the locked unit unattended. Further interview revealed that resident's who fall were found when rounds were made every two (2) hours Interview on 2/04/2011 at 2:00 p.m. with a Registered Nurse Supervisor revealed that on the 11-7 shift one (1) CNA and one (1) nurse was assigned to each floor. Interview on 02/0/2011 at 5:00 p.m. with the Director of Nursing (DON) confirmed that usually there is one (1) nurse and one (1) CNA for each floor on the 11pm to 7 am shift. The DON said the CNA covers both units (Reflections and Blue Ridge) on the 1st floor.

Review of staffing grids and postings in the facility on 2/18/11 revealed sufficient staff during 2/16/11, 2/17/11 and the night shift of 2/18/11. The supplemental staffing in the secured unit was reassigned from the Assisted Living Facility. Insufficient time has lapsed to determine if the supplemental staffing would be able to continue in sufficient numbers, therefore non compliance continues at a lesser scope and severity of "D". The following was documented on 2/04/11 survey: Based on observation, record review and staff interviews the facility failed to provide sufficient staff to ensure appropriate supervision related to safety for one (1) resident ("Q") of fifteen (15) residents on a secured unit from a sample of twenty five (25) residents. This failure resulted in the likelihood of an immediate and serious threat to resident health and safety for one (1) resident ("Q")on a sample of twenty-five (25) residents. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed as of March 21, 2011 and continues. Findings include: Observations on 1/31/2011 beginning at 4:15 p.m. of the Reflection (secured) Unit revealed a resident wandering in and out of rooms [ROOM NUMBER]. Two (2) Certified Nursing Assistants (CNAs) were watching the resident and redirected him//her. Licensed Practical Nurse (LPN) "KK" was administering medications. Observations continued until 5:30 p.m. and the surveyor attempted to leave the unit. Not knowing the code to exit the unit, the surveyor began to look for staff to assist her in exiting this unit. The surveyor went down all the halls and into the corner rooms and could not find any staff. The residents were sitting in the dayroom. At 5:50 p.m. the surveyor called the operator and spoke with security, explaining that she could not find any staff and did not have the code to get out of the secured unit. At 5:55 p.m. the surveyor exited the secured unit after getting the code from LPN "KK". All three of the staff persons seen on the secured unit were observed on the Blue Ridge unit, with the nurse administering medications and the 2 CNAs standing in the hallway near the day area. There had been no staff on the secured unit for at least 20 minutes. Review of the clinical record for resident "Q" who resides on the secured unit revealed that the resident was readmitted to the facility on [DATE] after a fall resulting in a [MEDICAL CONDITION]. Continued review revealed that from January 2010 to August 2010 the resident had 5 falls. Four (4) of these falls occurred after 8:00 p.m. and each time the resident was found on the floor. Interview on 2/04/2011 at 1:50 p.m. with CNA "NN" revealed that there was one (1) CNA and one (1) nurse assigned to both units (the secure unit and Blue Ridge) on the 11pm to 7 am shift. Continued interview revealed that when it was break time or lunch time for the staff only one (1) person was left to watch the residents on both units (30 residents) meaning that residents were left on the locked unit unattended. Further interview revealed that resident's who fall were found when rounds were made every two (2) hours Interview on 2/04/2011 at 2:00 p.m. with a Registered Nurse Supervisor revealed that on the 11-7 shift one (1) CNA and one (1) nurse was assigned to each floor. Interview on 02/0/2011 at 5:00 p.m. with the Director of Nursing (DON) confirmed that usually there is one (1) nurse and one (1) CNA for each floor on the 11pm to 7 am shift. The DON said the CNA covers both units (Reflections and Blue Ridge) on the 1st floor.