Granbury Care Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that a resident received CPR in accordance with professional standards of practice for one (Resident #1) of six resident's reviewed for CPR. On [DATE] at 12:20 am, LVN A failed to initiate CPR on Resident #1 who was a full code status. Resident #1 expired on [DATE]. An Immediate Jeopardy was identified on [DATE] at 5:00 pm. The noncompliance began on [DATE] and ended on [DATE]. It was determined to be past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the investigation. This failure could affect residents who are full code status and could need CPR by placing them at risk of death. Findings included: Record review of Resident #1's admission Record, dated [DATE] revealed an [AGE] year-old female, with an original admission date of [DATE] and the latest readmission date of [DATE]. The resident expired on [DATE]. The resident had a primary diagnoses of unspecified dementia (the specific type of dementia cannot be clearly identified, despite the presence of cognitive decline and memory loss) and congestive heart failure (hearts ability to pump blood is compromised). The resident was under the care of hospice. Resident #1 was a full code. Resident #1 had a BIMS score of 14 indicating she was cognitively intact. Record review of Resident #1's Physician's Orders, dated [DATE], revealed an active order with a start date of [DATE] for full code. Record review of Resident #1's Care Plan, last revised on [DATE] revealed the following: Focus: Full Code/CPR in place. Goal: Resident has an order for CPR to be initiated will be followed. Interventions: Initiate CPR if the resident is without a heartbeat or not breathing. Notify EMS. Record review of Resident #1's progress noted, dated [DATE] at 3:40 am, by LVN A, revealed the following [in part]: [12:05 am] aide at this time has reported that patient is noted breathing abnormally. [12:07 am] This nurse went to assess pt and pt was noted semi-Fowlers (30 to 45 degree angle with the head elevated) in bed with head cocked to left side, pt appears to be taking deep breaths for air constantly at this time with eyes fixed as if she is imminent to passing. palpated for pulse and pulse is faint. skin is still warm to touch. [12:10 am to 12:15 am] Went to verify advance directive and was not found in hospice binder but did verify in PCC full code only. [12:20 am] returned to pt bedside and pt was noted unresponsive. aide prepared body immediately. A record review of Resident #1's vitals revealed there were no vitals documented in the Electronic Health Record on [DATE]. In an interview on [DATE] at 11:00 am, the DON said she did not know why LVN A did not initiate CPR on Resident #1. She said LVN A told her she was distracted by a phone call from her family member. In an interview on [DATE] at 1:40 pm, LVN A she said at the time of the incident on [DATE] at approximately 12:00 am, she had a lot going on, and said I had an emergency with my kids who were home alone and was distracted. In my head, all hospice patients have DNR's. My aide came and told me [Resident #1] took a turn, I went and saw her, and she was already basically gone. I went and looked at the hospice binder and did not see an advance directive. I looked in PCC (Electronic Health Record) and it said full code. I thought it was a mistake. I did not honor her code status. In an interview on [DATE] at 1:50 am, CNA B said on [DATE] at about 12:00 am, I went to check on and change [Resident #1] and she was having trouble breathing, I went and told [LVN A], the nurse went down with me to check her. [LVN A] said she didn't look good, and she went back to the nurses' station to look at computer. I stayed with [Resident #1], she got worse, she stopped breathing and had a blank staring off look. I went and got [LVN A] again. She came and took her vitals, told me she stopped breathing and passed, and told me to perform post-mortem care. [LVN A] did not initiate CPR. In an interview on [DATE] at 2:15 pm, the Medical Director said Resident #1 had an order for full code. He said it was his expectation for staff to follow the physician's orders. He said in this instance, failing to follow physician's orders had the potential that the resident's life could have been saved. In an interview on [DATE] at 3:19 pm, Resident #1's Family Member, he said LVN A called him sometime after midnight on [DATE] telling him that Resident #1 stopped breathing and did not have a DNR in place. He thought LVN A had told him CPR had been attempted but was too distraught to know for sure. In interview and record review on [DATE] at 10:30 am, the Administrator said he was no longer the Administrator of the facility since [DATE]. He said he was the Administrator of the facility during the time of the incident. He said he reported the incident and the LVN should have initiated CPR on Resident #1 who was a full code status. Record review of the facility policy Cardiopulmonary Resuscitation, not dated, revealed the following [in part]: Cardiopulmonary resuscitation (CPR) is a method of providing systemic circulation by manual chest compression and oxygen by mouth-to-mouth breathing or providing air to the lungs via ambu-bag. The procedure is preformed to prevent death following cardiac or pulmonary arrest . Record review of the facility policy Self Determination End of Life Measures, not dated, revealed the following [in part]: Policy: 2. Upon admission, the facility will provide the individual with a copy of her/her rights under Texas law concerning the right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives.3.The facility will respect the wishes of the resident as outlined in the advanced directive . A record review of the facility policy Resident Rights, not dated, revealed the following [in part]: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her equality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Planning and Implementing Care - the Resident has the right to be informed of, participate in, his or her treatment including:b. The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and d uratin of care and any other factors related to the effectiveness of the plan of care. Self-Determination: The resident has the right to and the facility must promote and facilitate resident self-determination through support of the resident choice. 2. The Resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. 12. The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). The facility prior to investigator entrance on [DATE] completed the following corrections/interventions. The facility was evaluated to be in past noncompliance based on the corrections implemented prior to entrance. 1. Self-reporting protocol initiated on [DATE]. 2. [DATE] at 2:15 am, the Administrator was notified by the hospice nurse of Resident #1 passing that was full code and LVN A did not initiate CPR or contact emergency services. 3. Ad Hoc QAPI on [DATE] for Resident who was on hospice services but chose to have full code status, had passed away and the nurse did not initiate a code. 4. LVN A was immediately suspended on [DATE].5. The Administrator notified the DON, ADON, MD, Responsible Party, Social Services, Ombudsman, and Regional Team notified on [DATE]. Investigation started by the facility on [DATE]. Obtained witness statements. 7. The DON audited all resident code status on [DATE] - reviewed orders, care plans, DNRs. No errors were found. 8. Staff in-services were initiated on abuse/neglect, CPR, Advanced Directives, Resident Rights, Notification of Change, How to identify code status, and Following Physician Orders. Sign-in sheets observed. Quizzes were completed. The DON said all staff have been in-serviced except for a few PRN staff that hasn't worked in a while and before they return to work, they will have to complete the in-services before they will be allowed to work. Initiated [DATE]. 9. Safe surveys were conducted with residents on the LVNs hallway on [DATE], no further concerns were identified. 10. LVN A was terminated, and her nursing license was referred to the Texas Board of Nursing on [DATE]. 11. Daily monitoring by DON was ongoing. Verification of Correction 1: In an interview on [DATE] at 11:00 am, the DON said she received a call from the Administrator on [DATE] at 4:30 am in the morning about the incident. The LVN was immediately suspended and terminated after an investigation and her nursing licenses was referred to the Texas Board of Nursing all on [DATE]. The DON audited all residents' code status', making sure they were completed, care plans were correct, and physician's orders were reviewed. There were no errors found. A memo was put out for staff to not assume if a resident was on hospice care that did not mean they were not full code and how to find the code status in PCC (Electronic Health Record). In-servicing staff with a competency quiz was initiated. All staff had been in-serviced except for a few PRN staff who hadn't worked in a while. When they returned to work, they would be required to complete the in-services before being able to work. Hospice services had been contacted regarding the incident and reviewed with them the 2 residents that were currently under hospice care who were also full codes in the facility. Daily monitoring was ongoing at this time by the DON, including during the stand-up meetings to identify any evidence of any potential neglect, and during facility rounds were there any signs of staff performing or not performing their duties in a neglect manner. At the facility, per policy, CNAs were not CPR certified, only the nurses were. The facility policy states only 1 person must be in the facility per shift that is CPR certified. LVNs could not pronounce death, only RNs could do that. In this instance the LVN contacted hospice who came and pronounced death. Record review of the facility reporting protocol template indicated all areas of the self-reporting protocol had been completed, dated and signed by staff. Verification of Correction 2:In an interview on [DATE] at 2:20 pm, the Hospice DON said the incident was reviewed in their morning stand up meeting on [DATE]. She said the hospice nurse arrived at the facility an hour after the incident at approximately 1:00 am and noted that Resident #1 was full code status, and that CPR had not been initiated. The hospice nurse did contact Resident #1's family member and he did not want anything else done at that time. She contacted the Administrator of the facility on [DATE] at 2:15 am and reported the incident to him. Verification of Correction 3:Record review of the Ad Hoc QAPI meeting revealed the meeting was conducted on [DATE] with the following members attended: Medical Director, Administrator, DON, ADON #1, ADON #2 , MDS Nurse #1, MDS Nurse #2, Area Director of Operations, and the Regional Compliance Nurse. Verification of Correction 4:Record review of the Employee Disciplinary Report dated [DATE] revealed the LVN A was suspended for investigation of failing to do CPR. Verification of Correction 5:Record review of the Provider Investigation Report, dated [DATE] revealed the Administrator, DON, ADON, Medical Director, the Resident Representative, Social Services, Ombudsman and the facility Regional Team were notified that LVN A failed to initiate CPR or notify EMS for Resident #1 that was full code status. Verification of Correction 6:Record review of documentation including the Provider Investigation Report dated [DATE] and the Self-Reporting protocol dated [DATE] revealed the facility investigation of the incident was started on [DATE] at 2:15 am by the Administrator. Verification of Correction 7:Record review of the 13 sampled Resident Code Status' were reviewed that included the advanced directives, physician's orders, and care plans. No errors were found. Verification of Correction 8:Record review in-service training records sign-in sheets and quizzes revealed completion by all active staff. Interviews with the following 12 sampled staff revealed all stated they had received in-service training including abuse/neglect, advance directives, CPR, resident rights, code status' and following physician's orders that included completing a competency quiz. They were not allowed to work until the in-services had been completed. [DATE] at 1:50 pm, CNA BXXX[DATE] at 11:29 am, CMA CXXX[DATE] at 11:55 am, Social WorkerXXX[DATE] at 11:12 am, CMA DXXX[DATE] at 11:24 am, CNA E.9/11.25 at 11:27 am, CNA FXXX[DATE] at 11:34 am, LVN GXXX[DATE] at 11:38 am, LVN HXXX[DATE] at 11:44 am, Rehabilitation ManagerXXX[DATE] at 11:48 am, CNA IXXX[DATE] at 11:52 am, CMA JXXX[DATE] at 11:57 am, CNA K. Verification of Correction 9:Record review revealed the residents on LVN A's hallway were interviewed with no additional concerns identified regarding the LVN. The resident's all said staff were respectful and appropriate, denied staff were rude or spoken abusively to, felt safe, knew how to report abuse, who the abuse coordinator was and did not express any concerns with their treatment and care. In interviews with the following sampled residents revealed none of them expressed concerns with staff. [DATE] at 11:27 am, Resident #2XXX[DATE] at 11:31 am, Resident #4XXX[DATE] at 11:35 am, Resident #3XXX[DATE] at 11:41 am, Resident # 5XXX[DATE] at 11:45 am, Resident #6. Verification of Correction 10:Record review of LVN A's employee file revealed a termination date of [DATE]. Record review of referral to Texas Board of Nursing was completed on [DATE] at 2:54 pm. Record review revealed LVN A's CPR certification was current, expiring on 03/2027. Verification of Correction 11:Record review of documentation monitoring revealed it was on-going daily since [DATE]. No further concerns have been identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #1, Resident #2, and Resident #3) of 10 residents reviewed for comprehensive person-centered care plans. <BR/>The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in areas such as impaired visual function, Seizure Disorder, and risk for falls for Resident #1.<BR/>The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in areas such as hypertension, Diabetes Mellitus, and risk for falls for Resident #2. <BR/>The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in areas such as Anticoagulant and Antiplatelet therapy, hypertension, and risk for falls for Resident #3.<BR/>This failure could place the residents at risk for decreased quality of life and not having their needs met.<BR/>Findings include:<BR/>Resident #1 <BR/>Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted to facility on 08/24/2021 with diagnoses to include: dementia, depression, schizophrenia, and repeated falls. <BR/>Review of Resident #1's Quarterly MDS assessment, dated 01/18/2024, revealed a BIMS score of 15 which indicated no impaired cognition. <BR/>Review of Resident #1's Comprehensive Care Plan initiated on 08/24/2021 revealed the lack of measurable objectives to be evaluated or quantified were in the order of the problems listed above: The Resident will maintain optimal quality of life within limitation imposed by visual function, The resident will remain free from injury related to seizure activity, The resident will be free of falls The resident will not sustain serious injury.<BR/>Resident #2<BR/>Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to facility on 09/28/2022 with diagnoses to include: dementia, depression, anxiety, and unsteadiness on feet. <BR/>Review of Resident #2's Quarterly MDS assessment, dated 11/03/2023, revealed no BIMS score. <BR/>Review of Resident #2's Comprehensive Care Plan initiated on 09/29/2022 revealed the lack of measurable objectives to be evaluated or quantified were in the order of the problems listed above: The resident will remain free of complication related to hypertension, The resident will be free from any s/sx of hyperglycemia, The resident will have no complications related to diabetes, The resident will be free from any s/sx of hypoglycemia, and The resident will not sustain serious injury.<BR/>Resident #3<BR/>Review of Resident #3's electronic face sheet revealed an [AGE] year-old male admitted to facility on 11/13/2023 with diagnoses to include: depression, kidney failure, and heart disease. <BR/>Review of Resident #3's Significant Change MDS assessment, dated 01/31/2024, revealed a BIMS score of 01 which indicated severely impaired cognition. <BR/>Review of Resident #3's Comprehensive Care Plan, initiated 11/14/2023, revealed the lack of measurable objectives to be evaluated or quantified were in the order of the problems listed above: The resident will be free from discomfort or adverse reactions related to anticoagulant and antiplatelet medication use, The resident will remain free of complication related to hypertension, The resident will be free of falls, and The resident will not sustain serious injury.<BR/>During an interview on 02/15/2024 at 10:40 am, the DON stated the facility had clinical meeting every morning to discuss day to day updates on all residents. She stated it was her responsibility to update the care plan with acute issues and new interventions. The DON stated the importance of measurable objectives in an accurate care plan were for residents to receive the care needed. The Comprehensive care plans were necessary for the staff to know the residents. The care plans that were not resident centered and lack of measurable objectives could be detrimental to the resident's health and well-being. The DON stated she expected care plans to address each resident's problems with measurable objectives and have a way to determine when the problem was resolved or needed to be re-evaluated. <BR/>During an interview on 02/15/2024 at 3:30 pm, the MDS Nurse stated she was not responsible for updating the care plan with acute or new issues. She stated she performed quarterly care plan conferences based on what was documented in the chart. She stated if the falls had been added to the care plan when they occurred and new interventions had been added then she would have discussed it in the care plan conferences. She stated it was not her responsibility to update the care plan.<BR/>Record review of the facility's policy, Comprehensive Care Planning, not dated, revealed; The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights that includes measurable objectives and timeframes to meet a residents needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, and record reviews, the facility failed to ensure the comprehensive care plan were prepared by an interdisciplinary team, that included but not limited to, a nurse aide or a registered nurse with responsibility for the resident for 3 (Resident #1, Resident #2, and Resident #3) of 10 residents reviewed for care plans.<BR/>The facility failed to invite and include the input of the nursing staff as members of the interdisciplinary team after the completion of the comprehensive assessment for Resident #1, Resident #2, and Resident #3.<BR/>This failure could place the residents at risk for decreased quality of life and not having their needs met.<BR/>Findings include:<BR/>Resident #1<BR/>Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted to facility on 08/24/2021 with diagnoses to include: dementia, depression, schizophrenia, and repeated falls. <BR/>Review of Resident #1's Quarterly MDS assessment, dated 01/18/2024, revealed a BIMS score of 15 which indicated no impaired cognition. Section J Health Conditions: Falls revealed no falls since admission or prior assessment. <BR/>Review of Resident #1's Significant Change MDS assessment, dated 02/14/2024, revealed a BIMS score of 11 which indicated moderate impaired cognition. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. Further review revealed: 0 falls with no injury, 0 falls with injury, and 1 fall with major injury. <BR/>Review of Resident #1's Comprehensive Care Plan, initiated 08/24/2021, revealed the care plan was not changed or updated during the quarterly care plan meeting on 01/11/2024. Further review of Comprehensive Care Plan revealed no new interventions added or implemented since 08/24/2022.<BR/>Review of Resident #1's Care Plan Conference, dated 01/11/2024 at 9:44 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Family did not attend. RN unable to attend. Nurse aide did not attend. The documentation revealed: Went over care plan, with no changes at this time. Continue current plan of care. Participants included LVN F and Social Worker. <BR/>Resident #2<BR/>Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to facility on 09/28/2022 with diagnoses to include: dementia, depression, anxiety, and unsteadiness on feet. <BR/>Review of Resident #2's Significant Change MDS assessment, dated 12/15/2023, revealed no BIMS score. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. 0 with no injury, 1 with injury, 1 with major injury. <BR/>Review of Resident #2's Quarterly MDS assessment, dated 11/03/2023, revealed no BIMS score. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. 0 with no injury, 1 with injury, 0 with major injury. <BR/>Review of Resident #2's Comprehensive Care Plan, initiated 09/29/2022, revealed the care plan was not changed or updated during the quarterly care plan meeting on 12/26/2023. Further review of Comprehensive Care Plan revealed no new interventions added or implemented since 09/29/2022.<BR/>Review of Resident #2's Care Plan Conference, dated 12/26/2023 at 11:29 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Resident #2's family did attend. RN unable to attend. Nurse aide did not attend. The documentation revealed: Went over care plan, with no changes at this time. Continue current plan of care. Participants included LVN F and Social Worker and Resident #2's family member.<BR/>Resident #3's <BR/>Review of Resident #3's electronic face sheet revealed an [AGE] year-old male admitted to facility on 11/13/2023 with diagnoses to include: depression, kidney failure, and heart disease. <BR/>Review of Resident #3's Significant Change MDS assessment, dated 01/31/2024, revealed a BIMS score of 01 which indicated severely impaired cognition. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment which was 11/17/2023. Further review revealed: 0 falls with no injury, 0 falls with injury, and 1 fall with major injury. <BR/>Review of Resident #3's Comprehensive Care Plan, initiated 11/14/2023, revealed the care plan was not changed or updated during the quarterly care plan meeting on 02/13/2024. Further review of Comprehensive Care Plan revealed no new interventions added or implemented since 11/14/2023.<BR/>Review of Resident #3's Care Plan Conference, dated 02/13/2024 at 11:12 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Resident #3's family did attend. RN unable to attend. Nurse aide did not attend. The documentation revealed: No changes made to plan of care. Continue current plan of care. Participants included LVN F and Social Worker and Resident #3's family member via phone.<BR/>During an interview on 02/15/2024 at 3:30 pm, the MDS Nurse stated she was not responsible for updating the care plan with acute or new issues. She stated she performed quarterly care plan conferences based on what was documented in the chart. She stated if the falls had been added to the care plan when they occurred and new interventions had been added then she would have discussed it in the care plan conferences. She stated it was not her responsibility to update the care plan. The MDS nurse stated nurse aides and registered nurses were not invited to the care plan conferences because it was just not feasible. She stated direct care staff did not have time to participate. She stated the social worker schedules the conferences and invites the attendees. The MDS nurse stated she was aware of the facilities policy that nurse aides and registered nurses were supposed to attend care conferences and she was aware the facility was cited for this in November. She stated there was a performance improvement plan in place but once again it just was not feasible. <BR/>During an interview on 02/15/2024 at 5:40 pm, LVN A said she had not attended or been invited to a care plan meeting. LVN A said the direct care staff should be able to attend the care plan meetings because they were the staff with key input to the residents' behaviors, monitoring and preventing behaviors and the CNAs knew what interventions worked and did not work. LVN A said the CNAs also knew the concerns and conditions of the residents they work with every day.<BR/>During an interview on 02/15/2024 at 5:50 pm, CNA B said he had never attended a care plan meeting or was asked for input for the care plan for Resident #1 or any other resident on the locked unit.<BR/>During an interview on 02/15/2024 at 6:00 pm, the Administrator stated he was unaware the facility had been cited in November for the same issue. He stated he was ultimately responsible for ensuring the previous plan of correction was being implemented. <BR/>Record review of the facility's policy, Comprehensive Care Planning, not dated, revealed the interdisciplinary team included but was not limited to - <BR/>- <BR/>The attending physician<BR/>- <BR/>A registered nurse with responsibility for the resident<BR/>- <BR/>A nurse aide with responsibility for the resident<BR/>- <BR/>A member of food and nutritional services staff<BR/>- <BR/>The resident and the resident's representative<BR/>- <BR/>Other appropriate staff or professionals determined by the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 3 (Resident #1, Resident #3 and Resident # 7) of 7 residents reviewed for resident records.<BR/>The facility failed to ensure weekly skin assessments were documented in the medical record for Resident #1, Resident #3, and Resident # 7.<BR/>This failure could place residents at risk of having errors in care and treatment.<BR/>The Findings included: <BR/>Resident #1<BR/>Record review of Resident #1's face sheet dated 05/02/2025 revealed a [AGE] year-old-female admitted on [DATE], with the most recent admission on [DATE] and with the following diagnoses: Alzheimer's disease, respiratory failure, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (weakness and partial paralysis of left side following a stroke). <BR/>Record review of Resident #1's Significant Change MDS assessment dated [DATE] revealed, Section C- Cognitive Patterns: Resident #1 had a BIMS score of 5 (meaning severe cognitive impairment); Section GG-Functional Abilities: Resident #1 required substantial/maximal assistance for activities of daily living. Section M-Skin Conditions: Resident #1 had the risk of developing pressure ulcers/injuries and Resident #1 did not have pressure ulcers, wounds, or skin problems. <BR/>Record review of Resident #1's care plan dated 02/18/2025 revealed Resident #1 required extensive assistance of 1 staff with transfers and activities of daily living. <BR/>Record review of Resident #1's electronic medical chart revealed no evidence of weekly skin inspections completed weekly for the weeks of: 03/10/2025, 03/17/2025, 03/24/2025, 03/31/2025, 04/21/2025 and 04/28/2025. Further record review revealed Resident #1 did not have any skin issues and was admitted to hospital on [DATE] due to an abscess to her tooth. <BR/>Resident #3<BR/>Record review of Resident #3's face sheet dated 05/02/2025 revealed an [AGE] year-old-female admitted on [DATE], with the most recent admission on [DATE] and the following diagnoses: Alzheimer's disease, Type 2 diabetes, age-related osteoporosis, and high blood pressure. <BR/>Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed, Section C- Cognitive Patterns: Resident #3 had a BIMS score of 14 (meaning cognitively intact); Section GG-Functional Abilities: Resident #3 required substantial/maximal assistance or was dependent for activities of daily living. Section M-Skin Conditions: Resident #3 had the risk of developing pressure ulcers/injuries and Resident #3 had a stage 4 pressure ulcer, (open wound through multiple layers of skin and tissue) to right heel and sacrum (large triangular bone at the base of the spine). <BR/>Record review of Resident #3's care plan dated 03/04/2025 revealed Resident #3 had a stage 4 pressure ulcer to her sacrum area and right l heel. Resident #3 was receiving hospice care. <BR/>Record review of Resident # 3's physician's orders dated 05/02/2025 revealed: Start date: 08/19/2024 admit to {name} service. Start date: 01/30/2025: {Name wound care company} to consult for skin and wound conditions/prevention. Start date 04/04/2025: Cleanse stage 4 pressure wound to sacrum with wound cleanser, pat dry with gauze, pack with calcium alginate with silver, cover with non-border foam dressing 3 times a week and PRN as needed for Stage 4 pressure wound of the sacrum. Start date: 04/04/2025 Cleanse stage 4 pressure wound to sacrum with wound cleanser, pat dry with gauze, pack with calcium alginate with silver, cover with non-border foam dressing 3 times a week and PRN one time a day every Monday, Wednesday, Friday for Stage 4 pressure wound of the sacrum.<BR/>Record review of Resident #3's electronic medical chart revealed no evidence of weekly skin inspections completed weekly for the weeks of 03/17/2025, 03/24/2025, 03/31/2025, 04/21/2025 and 04/28/2025.<BR/>During an observation and interview on 05/01/2025 at 11:00 AM revealed Resident #3 was sitting up in her bed. Resident #3 stated the staff did frequent checks on her and changed her often. Resident #3 stated she did not have any concerns with her care from the staff. Resident #3 stated that she had some issues with her skin, but the facility was treating them and they were getting better. <BR/>Resident #7<BR/>Record review of Resident #7's face sheet dated 05/02/2025 revealed a [AGE] year-old-female admitted on [DATE], and with the following diagnosed: Alzheimer's disease and high blood pressure. <BR/>Record review of Resident #7's Significant Change MDS assessment dated [DATE] revealed, Section C- Cognitive Patterns: Resident #7 had a BIMS score of 4 (meaning severe cognitive impairment); Section GG-Functional Abilities: Resident #7 required Partial/moderate to substantial/maximal assistance for activities of daily living. Section M-Skin Conditions: Resident #7 had the risk of developing pressure ulcers/injuries and Resident #7 did not have pressure ulcers, wounds, or skin problems. <BR/>Record review of Resident #7's care plan dated 03/31/2025 revealed Resident #7 required extensive assistance of 1 staff with transfers and activities of daily living. Resident #7 had potential for pressure ulcer development. <BR/>Record review of Resident #7's electronic medical chart revealed no evidence of weekly skin inspections completed weekly for the weeks of 02/24/2025, 03/03/2025, 03/10/2025, 03/17/2025, 03,24,2025, 03/31/2025, 04/21/2025 and 04/28/2025. <BR/>During an observation and interview on 05/02/2025 at 8:45 AM revealed Resident #7 received incontinent care and her skin was observed to have no redness or drainage. Resident #7 stated she did not have any concerns with her care at the facility. <BR/>During an interview on 05/02/2025 at 1:15 PM the ADON stated charge nurses were responsible to complete skin assessments weekly. The ADON stated the CNAs completed shower sheets when they gave residents their showers. The ADON stated the CNAs were good about letting the nurses know when there was a change in the resident's skin. The ADON stated the weekly skin assessments were triggered for the charge nurses to complete weekly. The ADON did not have an explanation as to why skin assessments were not complete. <BR/>During an interview on 05/02/2025 at 1:26 PM CNA A stated she completed skin sheets when providing showers for residents. CNA A stated if during showers she noticed a problem she would contact the charge nurse. CNA A stated Resident #1, Resident #3, and Resident #7 were on her hall, and she had completed skin sheets for each resident. CNA A stated Resident #1, Resident #3 and Resident #7 did not have any new concerns with their skin. <BR/>During an interview on 05/02/2025 at 1:39 PM RN B stated the charge nurses were responsible for completing skin assessments weekly and were to be documented under Assessments in the electronic medical record. RN B stated Resident #1 and Resident # 7 were residents on her hall. RN B stated Resident #3 had been treated for a pressure ulcer on her sacrum and her left buttock. RN B stated Resident #3's wounds had gotten smaller. RN B stated she did not know why skin assessments had been missed. RN B stated the skin assessments would populate on the electronic medical system. RN B stated she would make sure to complete them before she ended her shift. RN B stated CNAs completed shower sheets, when they gave showers, and would document any new skin issues and would turn them into the charge nurse. RN B stated the nurses would sign the sheets after reviewing them. RN B stated she did not see any negative impact on the residents from skin assessments not being documented in the system, because the residents' skin was being assessed. <BR/>During an interview on 05/02/2025 at 1:40 PM the DON stated her expectation was that skin assessments should have been completed weekly and documented on the weekly skin assessment in the electronic medical system. The DON stated the charge nurses were responsible to complete the weekly skin assessments. The DON stated herself and the ADON would help the nurses with completing the skin assessments. The DON stated the ADON was responsible to monitor the completion of weekly skin assessments by running reports. The DON stated there had been some changes with the electronic medical record system and that had made it harder to catch the missed assessments. The DON stated what led to the failure was the updates to the electronic medical record system and nurses having to help with other duties. The DON stated she did not think there was a negative effect on residents because she felt nurses were assessing residents' skin and they were failing to document. <BR/>During an interview on 05/02/2025 at 1:55 PM the ADMN stated her expectation was that skin assessments were to be completed upon admission and weekly. The ADMN stated skin assessments should have been documented under the assessment tab in the electronic medical chart. The ADMN stated the weekly skin assessment was to be completed by the charge nurse for the residents on their hall. The ADMN stated the DON and ADON were supposed to have been monitoring to ensure the weekly skin assessments were completed. The ADMN stated the skin assessments were to have been monitored during the standard of care meeting. The ADMN stated the effect on residents could have been missed skin breakdown. The ADMN stated the failure of skin assessments not being completed could have been changes in the electronic medical record system. The ADMN stated the electronic medical record system failed to notify nurse that assessments were needed to be done.<BR/>Record review of the facility policy titled, Skin Assessment dated 08/15/2016, revealed: All residents should have a skin assessment on a weekly basis completed in {name of electronic medical system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 2 (Resident #1 and Resident #2) of 10 residents reviewed for multiple falls.<BR/>The facility failed to implement a system for identifying fall patterns and implementing interventions to prevent falls that lead to emergency room visits with serious injury on 12/17/2023 and 02/07/2024 for Resident #1 and 12/10/2023 and 01/04/2024 for Resident #2.<BR/>An IJ was identified on 02/16/2024. The IJ template was provided to the facility on [DATE] at 10:25 am. While the IJ was removed on 02/16/2024, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. <BR/>These failures could place the residents at risk for falls, serious injuries, hospitalizations, and death. <BR/>Findings include:<BR/>Resident #1<BR/>Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted to facility on 08/24/2021 with diagnoses to include: dementia, depression, schizophrenia, and repeated falls. <BR/>Review of Resident #1's Quarterly MDS assessment, dated 01/18/2024, revealed a BIMS score of 15 which indicated no impaired cognition. Section J Health Conditions: Falls revealed no falls since admission or prior assessment. <BR/>Review of Resident #1's Significant Change MDS assessment, dated 02/14/2024, revealed a BIMS score of 11 which indicated moderate impaired cognition. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. Further review revealed: 0 falls with no injury, 0 falls with injury, and 1 fall with major injury. <BR/>Review of Resident #1's Comprehensive Care Plan, initiated 08/24/2021, revealed: Focus: The resident is at risk for falls. Goal: The resident will be free from falls through the review date. The resident will not sustain serious injury through review date. Interventions: Anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed., ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, keep furniture in locked position, Keep needed items, water in reach. Staff to make frequent visual checks to promote safety and reduce risk of fall, Physical therapy evaluate and treat as ordered or as needed, the resident needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side fails as ordered, handrails on walls, personal items within reach. The resident needs activities that minimize the potential for falls while providing diversion and distraction. Further review of the Comprehensive Care Plan revealed no new interventions added or implemented since 08/24/2021.<BR/>Review of Resident #1's Fall Event Nurses' Note, dated 02/07/2024 at 4:48 PM, signed by LVN D, revealed: Resident #1 had an unwitnessed fall where he hit his head. Resident #1 was ambulating in hallway, and he fell in hallway face first. He bloodied his nose and received a bruise to the right side of his forehead. Doctor was notified and Resident #1 was sent to the emergency room for evaluation and treatment. <BR/>Review of Resident #1's hospital clinical record, dated 02/07/2024, revealed: Injuries: Subdural hematoma (blood around the brain), Hemorrhagic contusion right inferior temporal region (bleeding brain bruise), left periorbital hematoma (bruise around the eye), and left 7th, 9th, and 10th rib fractures. Resident #1 was discharged back to facility on 02/08/2024.<BR/>Review of Resident #1's Fall Event Nurses' Note, dated 12/17/2023 at 6:48 PM, signed by RN E, revealed: Resident #1 had an unwitnessed fall. Resident #1 fell and hit head on floor with laceration. Resident #1 was transferred to the emergency room.<BR/>Review of Resident #1's hospital clinical record, dated 12/17/2023, revealed: Injury: Laceration sustained to left parietal area (top rear of head) is clean, jagged, superficial, 2.6 by 7.5 centimeters. Wound care applied 5 stiches. Resident #1 was discharged back to facility on 12/17/2023.<BR/>Review of the facility's incident log from 11/16/2023-02/07/2024, revealed Resident #1 had falls on 12/17/2023 at 3:09 pm no injury, 12/17/2023 at 6:15 pm with injury, 01/25/2024 at 2:30 pm no injury, 01/29/2024 at 4:40 pm no injury, 01/30/2024 at 4:21 pm no injury, 02/01/2024 at 4:07 pm no injury, 02/06/2024 at 3:22 pm no injury, and 02/07/2024 at 4:46 pm with injury. <BR/>Review of Resident #1's Fall Risk Assessments dated 12/17/2023 revealed a score of 13 High Risk, 01/25/2024 score 18 High Risk, 01/29/2024 score 21 High Risk, 01/30/2024 score 21 High Risk, 02/01/2024 score 18 High Risk, 02/06/2024 score 20 High Risk, and 02/07/2024 score 23 High Risk.<BR/>Review of Resident #1's Care Plan Conference, dated 01/11/2024 at 9:44 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Family did not attend. Went over care plan, with no changes at this time. Continue current plan of care.<BR/>Observation on 02/14/2024 at 12:40 pm, revealed Resident #1 on the secure unit lying in bed no distress noted. Resident was alert but not oriented and not really communicating. Nurse and CNA were currently sitting at bedside.<BR/>Observation on 02/15/2024 at 9:30 am, revealed Resident #1 was lying in bed. The bed was in a low position. There was no siderail or handrails on the bed. Resident #1 had his eyes open and looked at the surveyor but did not speak. There were 3 CNAs in the resident's room.<BR/>Resident #2<BR/>Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to facility on 09/28/2022 with diagnoses to include: dementia, depression, anxiety, and unsteadiness on feet. <BR/>Review of Resident #2's Significant Change MDS assessment, dated 12/15/2023, revealed no BIMS score. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. 0 with no injury, 1 with injury, 1 with major injury. <BR/>Review of Resident #2's Quarterly MDS assessment, dated 11/03/2023, revealed no BIMS score. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. 0 with no injury, 1 with injury, 0 with major injury. <BR/>Review of Resident #2's Comprehensive Care Plan, initiated 09/29/2022, revealed: Focus: The resident is at risk for falls related to She has had actual falls since entering the facility due to poor gait and balance, dementia with poor safety awareness and judgment. Actual fall 12/10/23 Fall between bed and wall causing Right Rib Fracture and mild pneumothorax resulting in emergency room visit. Goal: The resident will not sustain serious injury through review date. Interventions: Anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, Ensure that the resident is wearing appropriate footwear when ambulating, Staff x 1 to assist with transfers, and the resident needs activities that minimize the potential for falls while providing diversion and distraction. Further review of the Comprehensive Care Plan revealed no new interventions added or implemented since 09/29/2022.<BR/>Review of Resident #2's Fall Event Nurses' Note, dated 12/10/2023 at 6:05 AM, signed by LVN G, revealed: Resident #2 had an unwitnessed fall. CNA reported that resident had fallen on the floor. This nurse went into residents' room and found her lying on the floor on her right side and screaming in pain and holding her right side at her rib cage. Having difficulty breathing at this time. Bedside toilet and table and walker all turned over on floor by her. Resident #2 was transferred to the emergency room.<BR/>Review of Resident #2's hospital discharge record, dated 12/10/2023, revealed: Diagnosis Fractured rib and head injury. Resident #2 was discharged back to the facility on [DATE].<BR/>Review of Resident #2's Fall Event Nurses' Note, dated 01/04/2024 at 9:50 PM, signed by LVN H, revealed: Resident #2 had an unwitnessed fall. CNA noticed blood on resident's shirt and observed blood in residents' hair and notified nurse. I assessed resident and observed laceration to right side of resident's head. Resident was guarding right shoulder as well. Resident #2 was transferred to the emergency room.<BR/>Review of Resident #2's hospital clinical record, dated 01/04/2024, revealed: Abrasion on the right scalp and shoulder pain. Resident #2 was discharged back to the facility on [DATE].<BR/>Review of the facility's incident log from 11/16/2023-02/07/2024, revealed Resident #2 had falls on 11/19/2023 at 11:00 pm with no injury, 12/10/2023 at 5:44 am with injury, 12/23/2023 at 10:00 am with no injury, and 01/04/2024 at 8:15 pm with injury.<BR/>Review of Resident #2's Fall Risk Assessments dated 11/19/2023 revealed score 16 High Risk, 12/10/2023 score 19 High Risk, 12/23/2023 score 15 High Risk, 01/04/2024 score 15 High Risk.<BR/>Review of Resident #2's Care Plan Conference, dated 12/26/2023 at 11:29 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Resident #2's [family member] did attend. Went over care plan, with no changes at this time. Continue current plan of care.<BR/>Observation on 02/15/2024 at 4:00 pm, revealed Resident #2 ambulating up and down the hall. Resident seemed unsteady on her feet. Resident was wandering in and out of other residents' rooms.<BR/>During an interview on 02/14/2024 at 12:45 pm, LVN A stated Resident #1 had a history of falling. She stated she had been sitting in his room since his return from the hospital as much as she could because she did not want him to fall again. She stated Resident had a history of wandering and was only oriented to his name. She stated she was trying to increase supervision. She stated she had not been instructed to sit or monitor Resident #1 by the facility. She stated she just was because she was concerned. She stated she had spoken to the DON and informed her that Resident #1 needed 1:1 supervision but she was told the facility did not have the staff for that. She stated there was always 2 CNAs on the secure unit. LVN A stated Resident #2 had a history of wandering and falls also. She stated Resident #2 walks the unit continuously and it was almost impossible to keep an eye on her all the time. She stated Resident #2 had no new fall interventions that she was aware of. <BR/>During an interview on 02/14/2024 at 12:50 pm, CNA B stated he was working with another resident the day Resident #1 fell and was injured. He stated his coworker was in a room and he was assisting the nurse with another resident when he heard a loud noise. He stated he turned around and Resident #1 was lying face down in his doorway covered in blood. He stated he had seen Resident #1 in his bed 15 minutes prior to the fall. He stated he always tried to watch Resident #1 closely and made sure to check on him every 15 minutes when possible. He stated he had asked for help and spoke to the DON and Administrator about not having adequate staff to meet Resident #1's needs. He stated Resident #2 was also a high fall risk. He stated Resident #2 continuously wandered and was very unsteady. CNA B stated he felt 2 CNAs was not enough to monitor the residents and to prevent falls. He stated he was not aware of any new fall prevention interventions put in place for Resident #1 or Resident #2. <BR/>During an interview on 02/14/2024 at 2:00 pm, the DON stated she did not know much about Resident #1. She stated she had 130 residents and could not keep up with all of them. She stated she was not aware of any clinical issues with Resident #1 prior to the fall. She stated she was not aware of how many falls he had had but she knew he had a history of falls. She stated when a fall occurred the staff assessed the resident, notified the physician and family member, then completed an incident report. She stated she was not always notified of all falls, only falls with major injury. She stated falls were reviewed every morning during morning meeting.<BR/>During an interview on 02/15/2024 at 9:35 am, CNA B stated he was told this morning by the DON to keep resident #1 in his line of site at all times. He stated they did not increase the staffing and he still had to do his normal work and watch resident. #1. He stated he had not received any in-service regarding increased supervision for Resident #1 or Resident #2.<BR/>During an interview on 02/15/2024 at 10:40 am, the DON stated the facility had clinical meeting every morning to discuss day to day updates on all residents. She stated if a resident fell it would be discussed in the clinical meeting and new interventions should be put into place. She stated it was her responsibility to update the care plan with acute issues and new interventions. The DON stated she did not have any documentation of what was discussed in the clinical meeting she just made herself a to-do list. She stated she had missed multiple clinical meetings lately due to having to work the floor. She stated she did not have a system where she tracked falls. She stated falls were discussed in QAPI meetings monthly. She stated the facility just stated how may falls they had each month. The DON stated she was unaware of any QAPI plan specifically for falls or any fall prevention programs in place. She stated the possibility of getting Resident #1 a helmet was brought up by the family on 02/07 prior to the fall. The DON stated since Residents #1's return from the hospital on [DATE], she placed the resident on increased supervision. She stated she verbally in-serviced the staff on the secure unit and instructed them to always keep Resident #1 in line of site. She stated she did not increase staffing and did not document, or care plan the new intervention. She stated she obtained an order to refer Resident #1 to a neurologist, but she was unsure where the facility was in the process of getting that done. The DON stated she was unable to perform her clinical duties because she was working the floor or constantly putting out fires and she had not had the time do her responsibilities. She stated she did not feel that any further interventions could have been put in place to prevent the falls but agreed that the facility did not attempt any new interventions.<BR/>Interview attempted on 02/15/2024 at 11:00 am with both Medical Directors via phone. Called office and left message with no returned phone call. <BR/>During an interview on 02/15/2024 at 11:45 pm, the Administrator stated he monitored the number of falls in QAPI meetings and looked for trends, but he just looked at overall fall numbers not resident specific. He stated more interventions should have been put into place for Resident #1 and Resident #2 and it was ultimately his responsibility to ensure this was done. The Administrator stated he was notified of all falls and ensured all documentation was done. He stated he only investigated falls with injury or unwitnessed or suspicious falls.<BR/>During an interview on 02/15/2024 at 1:00 pm, CNA C stated Resident #1 had always had multiple falls. She stated she was working the day he fell and the day he returned. CNA C stated she was not aware of any new interventions being put into place. She stated Resident #2 got up quickly and fell before staff even knew that he was out of bed. She stated she tried to watch him closely but most of the time there was only 2 CNAs on the unit, and it was hard to provide 1:1 supervision. CNA denied being in-serviced or told to increase monitoring or supervision when Resident #1 returned to the facility.<BR/>During an interview on 02/15/2024 at 3:30 pm, the MDS Nurse stated she was not responsible for updating the care plan with acute or new issues. She stated she performed quarterly care plan conferences based on what was documented in the chart. She stated if the falls had been added to the care plan when they occurred and new interventions had been added then she would have discussed it in the care plan conferences. She stated it was not her responsibility to update the care plan. She stated the failure occurred because the DON had not added new interventions when the falls occurred. <BR/>Review of facility policy titled, Preventive Strategies to Reduce Fall Risk, revised October 5, 2016, revealed in part: Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. Procedure: 1. After risk is assessed, individualized nursing care plans will be implemented to prevent falls. The resident and family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects .5. Incident Reporting: Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s).<BR/>This was determined to be an Immediate Jeopardy (IJ) on 02/16/2024. The Administrator, and Director of Nurses were notified on 02/16/2024 at 10:25 am that an Immediate Jeopardy was identified, and a Plan of Removal was requested at that time. <BR/>The Administrator was provided with the IJ template on 02/16/2024 at 10:25 am. <BR/>The following Plan of Removal was accepted on 02/16/2024 at 2:35 pm and included: <BR/>Problem: F689 Accidents/Hazards<BR/>Interventions:<BR/>Resident #1's care plan was reviewed for fall prevention interventions by the DON/Regional Compliance nurse on 2/16/24. <BR/>o <BR/>Helmet ordered for safety.<BR/>o <BR/>Refusal to use assistive devices.<BR/>o <BR/>PT/OT/ST<BR/>o <BR/>Offer diversions, activities, food, conversation, etc to reduce wandering.<BR/>o <BR/>Non-skid socks <BR/>o <BR/>Increased staff rounding<BR/>Resident #2's care plan was reviewed for fall prevention interventions by the DON/Regional Compliance nurse on 2/16/24. <BR/>o <BR/>Increase rounding to promote safety.<BR/>o <BR/>Ensure a safe environment free of clutter and obstructions.<BR/>All residents with falls in the last 30 days were reviewed by DON/Regional Compliance Nurse on 2/16/24 to ensure that appropriate fall interventions are listed on the care plan. There were 50 falls with 26 residents noted in the review.<BR/>A task on the POC Kiosk was added for all resident at high risk for easy identification by the DON, ADON, and Regional Compliance Nurse on 2/16/24.<BR/>The medical director was notified of the immediate jeopardy situation on 2/16/24 at 11:30pm by the Administrator. <BR/>Ad Hoc QAPI meeting will be held on 2/16/24 to discuss the IJ and review plan of removal.<BR/>In-services:<BR/>The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following in-services. <BR/>o <BR/>Fall Prevention Policy <BR/>o <BR/>Care Plan Policy: Updating the care plan with fall prevention/safety interventions.<BR/>o <BR/>Abuse and Neglect.<BR/>The following in-services were initiated by the Regional Compliance nurse, DON, and ADON on 2/16/24. Any staff member not present or in-service on 2/16/24 will not be allowed to assume their duties until in-serviced. All new hires will be in-service at orientation. All agency staff will in serviced before assuming their assignment. <BR/>All Staff: <BR/>Abuse and Neglect Policy<BR/>Notifying the charge nurse for any change in condition to include falls, pain or a change in mobility or transfer status. <BR/>All Direct Care Staff:<BR/>Abuse and Neglect Policy <BR/>Fall Prevention Policy <BR/>Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status. <BR/>How to identify a resident who is high risk for falls on the Kiosk or Care plan<BR/>Monitoring: <BR/>DON, Administrator, Designee will review all falls during the morning meeting to ensure appropriate interventions have been implemented. Monitoring will occur 5 days per week for a minimum of 6 weeks. <BR/>DON, Administrator, Designee will review all falls during the weekly Standard of Care Meeting to ensure appropriate interventions have been implemented. Monitoring will occur weekly for a minimum of 6 weeks. <BR/>Administrator or Designee will review the Event entry and ensure that care planned interventions are change with each fall during the weekly Standards of Care Meeting. Meeting will occur weekly, and monitoring will be in place for 6 weeks.<BR/>Regional Compliance Nurse and/or ADO will monitor, on a weekly basis, that monitoring tools are in place and up to date.<BR/>Monitoring of the facility's Plan of Removal through observations, interviews, and record reviews from 02/16/2023 at 2:40 pm through 02/16/2024 at 5:30 pm revealed: <BR/>Review of Resident #1's comprehensive care plan revealed new interventions added on 02/16/2024 to include: Continues PT/OT. Started OT in October for safety and strength. ST picked up for weight and cognition. PT started for strengthening endurance related to weakness to lower extremity. Date Initiated: 02/16/2024 PT o Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Date Initiated: 02/14/2024 Revision on: 02/15/2024 o Ensure that the resident is wearing appropriate nonskid footwear or nonskid socks when ambulating Date Initiated: 08/24/2021 Revision on: 02/15/2024 o Helmet ordered by Therapy for prevention of head trauma Date Initiated: 02/16/2024 Revision on: 02/16/2024 o Keep needed items, water, etc, in reach. 2/16/24 Staff to increase visual checks to promote safety and reduce risk of fall Date Initiated: 08/24/2021 Revision on: 02/16/2024 o Resident offered and refuses to use assistive device for safety. Date Initiated: 02/16/2024 o Staff x 1 to assist with transfers, staff to monitor while in room and when resident ambulating in hallway. Date Initiated: 02/14/2024 Revision on: 02/16/2024 o The resident needs a safe environment Date Initiated: 08/24/2021 Revision on: 02/16/2024.<BR/>Observation on 02/16/2024 at 2:40 pm, Resident #1 was lying in bed with family members in his room. Observed staff in line of sight of Resident #1.<BR/>Review of Resident #2's comprehensive care plan revealed new interventions added on 02/16/2024 to include: o Ensure a safe environment free of clutter and obstructions. Date Initiated: 02/16/2024 Revision on: 02/16/2024 o Staff to increase rounding on resident to promote safety Date Initiated: 02/16/2024.<BR/>Observation on 02/16/2024 at 2:43, Resident #2 was sitting on couch in the lobby with staff beside her. <BR/>Random record reviews revealed at least 6 of the 26 residents with falls in the last 30 days had their comprehensive care plans reviewed with new interventions added on 02/16/2024. <BR/>Observation on 02/16/2024 at 2:45 pm revealed CNA B accessing the POC Kiosk (computer system used by staff) and signing off on the high fall risk alert for Resident #1. Observed high fall risk alerts on 6 random residents. <BR/>Review of an email dated 02/16/2024, sent from the Medical Director to this surveyor, stated he was aware of the IJ, and he attended the QAPI meeting via phone. <BR/>Review of a QAPI document dated 02/16/2024 revealed d the IJ with signature page of all in attendance. <BR/>In-services: Reviewed in-service information and signature sheets for in-service given by RCN to Administrator, DON, and ADON on Fall Prevention Policy, Care Plan Policy: Updating the care plan with fall prevention/safety interventions, and Abuse and Neglect <BR/>During an interview on 02/16/2024 at 3:00 pm, the Administrator and DON confirmed understanding of in-services titled: Fall Prevention Policy, Care Plan Policy: Updating the care plan with fall prevention/safety interventions, and Abuse and Neglect. <BR/>During observation on 02/16/2024 at 3:10 pm, revealed the DON educating 3 nurses, 9 CNAs, and 1 human resources staff that work the 6:30 am-6:30 pm shift, on Abuse and Neglect Policy, Fall Prevention Policy, Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status, and how to identify a resident who is high risk for falls on the Kiosk or Care plan. Interview with 2 CNAs and 1 nurse verified understanding of in-service. <BR/>During observation on 02/16/2024 at 4:00 pm, revealed the DON educating 1 CNA and 1 medication aide that work the 2:00 pm- 10:100 pm shift, on Abuse and Neglect Policy, Fall Prevention Policy, Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status, and how to identify a resident who is high risk for falls on the Kiosk or Care plan.<BR/>During observation on 02/16/2024 at 4:00 pm, revealed the DON educating 1 nurse who works 6:30 pm- 6:30 am shift via phone, on Abuse and Neglect Policy, Fall Prevention Policy, Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status, and how to identify a resident who is high risk for falls on the Kiosk or Care plan. Interview with nurse verified understanding of in-service. <BR/>The Administer, RCN, ADO, and DON were informed the Immediate Jeopardy was removed on 02/16/2024 at 5:30 pm. The facility remained out of compliance at a severity level of harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (Resident #1) of three residents reviewed for infection control practices.<BR/>The facility failed to ensure CNA A performed proper hand hygiene and glove changes while providing incontinence care to Resident #1. <BR/>This failure could place residents at risk for the spread of infection. <BR/>Findings included:<BR/>Review of Resident #1's face sheet dated 01/10/25, revealed a 67- year- old female admitted to the facility on [DATE] with diagnoses including frequency of micturition (urinating), constipation, muscle weakness and Alzheimer's disease (neurological disorder).<BR/>Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1 required substantial/maximal assistance with most activities of daily living (ADLs). Resident #1 was always incontinent of bowel and bladder.<BR/>Observation of incontinence care for Resident #1 on 01/09/25 at 2:55p.m. revealed CNA A washed her hands prior to donning gloves. CNA A removed Resident #1's brief that was soiled with urine and placed it on the bed close to resident. She did not completely remove it. CNA A wiped the resident from front to back. She retrieved a clean brief and placed it on top of the soiled brief. She did not change gloves but continued to clean the resident. Her gloves were visibly soiled with urine. CNA A did not wash her hands, change gloves, or perform hand hygiene before placing the clean brief underneath the resident. CNA A changed her gloves, and retrieved the old, soiled brief and placed on a trash can. CNA A removed her gloves and picked up the trash. She washed her hands before leaving Resident #1's room.<BR/>In an interview on 01/09/24 at 3:06 p.m. with CNA A, she stated she should have changed her gloves before retrieving a clean brief and placing it underneath Resident #1. CNA A stated she has been in the facility for 2 years and received infection control training last month. She said cross contamination was going from clean to dirty. CNA A noted the resident could acquire an infection when she did not follow good infection control practices including changing gloves before retrieving the clean brief. CNA A stated she did not change her gloves because she was not thinking. <BR/>During interview on 01/10/25 at 5:11 p.m., the DON acknowledged being aware of some of the concerns raised about infection control practice. She stated ADON B was responsible for infection control in the facility. The ADON trained and monitored staffs with return demonstration periodically. The DON stated aides were expected to follow standard precaution including washing hands and changing gloves while providing care. She stated the corporate nurse also trained staff annually.<BR/>Review of the facility's infection control policy dated 04/27/22 reflected:<BR/>Purpose:<BR/>This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by<BR/>providing cleanliness and comfort to the resident, preventing infections and skin irritation, and<BR/>observing the resident's skin condition.<BR/>Important Points:<BR/>o Doffing and discarding of gloves are required if visibly soiled<BR/>o Always perform hand hygiene before and after glove use

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents/resident's representative had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he/ she preferred for 2 of 26 residents (Resident #50 and Resident #114) reviewed for antipsychotic consents.<BR/>1. The facility failed to ensure Resident #50's HHSC Form 3713 for Ziprasidone (also known as Geodon an antipsychotic medication used to treat bipolar 1 disorder and schizophrenia) was signed by Resident #50 or Resident 50'ss responsible party.<BR/>2. The facility failed to ensure Resident #114's HHSC Form 3713 for Seroquel (an antipsychotic medication used to treat mental health disorders, such as schizophrenia) was signed by Resident #114 or Resident #114's responsible party. <BR/>This failure could affect residents who received antipsychotics by placing them at risk of not being informed of their health status, to make informed decisions regarding their care.<BR/>Findings included: <BR/>Record review of Resident #50's electronic face sheet dated 12/04/2024 revealed a [AGE] year-old male admitted on [DATE] with the following diagnosis senile degeneration of (brain group of symptoms affecting memory, thinking and social abilities) schizoaffective disorder (mental health condition that includes hallucinations and delusions, depression and , mania), psychosis, and anxiety disorder. <BR/>Record review of Resident #50's MDS assessment dated [DATE] revealed Section C- Cognitive Patterns: Resident #50 had a BIMS of 10 (meaning moderate cognitive impairment); Section N-Medications: Resident #50 had received antipsychotic medications during the previous 7-day period. <BR/>Record review of Resident #50's physician order revealed: Ziprasidone HCL Oral Capsule 60 MG Give 1capsule by mouth two time a day related to schizoaffective disorder with a start date of 12/28/2023.<BR/>Record review of Resident #50's December Medical Administration Record dated December 2024 revealed Resident #50 received Ziprasidone on 12/01/2024, 12/02/2024, 12/03/2024 and 12/04/2024. <BR/>Record review of Resident #50's HHSC Form 3713 for Ziprasidone revealed no evidcnce of a signature by Resident #50 or their representative. <BR/>Record review of Resident #114's electronic face sheet dated 12/04/2024 revealed [AGE] year-old male admitted on [DATE] with the following diagnosis unspecified Dementia, and insomnia. <BR/>Record review of Resident #114's MDS assessment dated [DATE] revealed Section C- Cognitive Patterns: Resident #114 had a BIMS of 3 (meaning severe cognitive impairment); Section N-Medications: Resident #114 had received antipsychotic medications during the previous 7-day period. <BR/>Record review of Resident #114's physician orders revealed: Seroquel Oral Tablet 25 MG Give 0.5 tablet by mouth one time a day related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (f03.90) give half of tablet to equal 12.5m . Seroquel oral tablet 25 mg (quetiapine fumarate)<BR/>give 1 tablet by mouth one time a day related to unspecified, dementia, unspecified severity, without behavioral disturbance,<BR/>psychotic disturbance, mood disturbance, and anxiety (f03.90) with a start date of 11/14/2024.<BR/>Record review of Resident #114's December Medical Administration Record dated December 2024 revealed Resident #114 received Seroquel on 12/01/2024, 12/02/2024, 12/03/2024 and 12/04/2024. <BR/>Record review of Resident #114's HHSC Form 3713 for Seroquel revealed no evidence of a signature by Resident #114 or their representative.<BR/>During an interview on 12/04/24 at 5:02 PM, the DON stated her expectation was that the antipsychotic consent should have been signed by the resident or resident's representative prior to Resident # 50 and Resident #114 were given and antipsychotic medication. The DON stated she was responsible to monitor the completion of resident's HHSC Form 3713, and she monitored during their weekly team meetings. The DON stated the effect on residents could have been residents and their representatives were not made aware of what medication residents were on and the side effects of the medications. The DON stated what led to the failure was the lack oversight by staff and staff turnover. <BR/>Record review of facility policy titled Psychotropic Drugs dated 10/25/17 revealed A psychotropic consent from explains the risks and benefits of psychotropic medication. The resident or their representative must provide documented consent prior to administration of a newly offered psychotropic medication . Consent for antipsychotics must be in a written from. Phone o Seroquel r verbal consent is not allowed.<BR/>Review of LTCR Provider letter titled Consent for Antipsychotic and Neuroleptic Medications dated May 5, 2022, accessed on 08/30/2024 at https://www.hhs.texas.gov/sites/default/files/documents/pl2022-11.pdf, revealed The prescriber of the medication, the prescriber's designee, or the NF' s medical director must complete Section I of Form 3713. HHSC cannot specify who can be the designee for the prescriber. Prescribers should consult their own board, such as the Texas Medical Board, to determine who can act as their designee. A prescriber can delegate the completion of Form 3713, Section I, if the prescriber's license permits it . The resident or the resident's legally authorized representative must sign Section II of Form 3713 (Consent for Antipsychotic or Neuroleptic Medication Treatment). The rule requires consent in writing by the resident or by a person authorized by law to consent on behalf of the resident. Verbal consent does not meet the rule requirements. NF staff cannot sign on behalf of the resident. <BR/>Review of drugs.com accessed on 12/04/2024 at https://www.drugs.com, revealed Seroquel and Ziprasidone (Geodon) were Drug class: Atypical antipsychotics.<BR/>Review of [NAME]-Term Care Regulatory Provider Letter date issued 05/05/2022 revealed: Under 26 TAC &sect;554.1207, a resident receiving antipsychotic or neuroleptic medications must provide written consent. Written consent can also be given by a person authorized by law to consent on the resident ' s behalf. Consent for antipsychotic and neuroleptic medications must be documented on Texas Health and Human Services Commission (HHSC) Form 3713.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to refer residents for PASRR screening and evaluation, with a newly evident mental disorder or related condition for level II PASRR review, 1 of 3 residents (Resident #107) in that: <BR/>Resident #107 was not referred to the state-designated authority for PASRR re-evaluation upon evidence of past history significant for depression, anxiety, and PTSD when admitted to the facility on [DATE] with a negative PL1. <BR/>This failure placed residents at risk of not receiving adequate services or care related to mental illnesses.<BR/>Finding include:<BR/>Record review of Resident #107's Facesheet, dated 12/03/2024, revealed Resident #107 was a [AGE] year-old male, with an admission date into the facility on [DATE].<BR/>Record review of Resident #107's Diagnosis Report, dated 12/03/2024, revealed Resident #107's admission primary diagnosis was Bipolar disorder, unspecified, effective 09/12/2023. Other diagnoses included Generalized Anxiety Disorder, which was dated 12/12/2023, and Post-traumatic stress disorder and major depressive disorder, dated effective 12/13/2023.<BR/>Record review of Resident #107's Annual Minimum Data Set (MDS) assessment, dated 09/17/2024, indicated Resident #107 had a BIMS score of 15, which indicated intact cognitive response. Section I - Active Diagnoses revealed Resident #107 was coded a 13 which identified medically complex conditions. Active diagnoses identified were Anxiety disorder, depression, bipolar disorder, and post-traumatic stress disorder.<BR/>Record review of Resident #107's PL1, dated 09/11/2023, revealed the referring entity documented Resident #107 had no previous history of mental illness by answering C0100 Is there evidence or an indicator this is an individual that has a Mental Illness? as no.<BR/>Record review of Resident #107's progress note, dated 09/13/2023, completed by the PCP, revealed Resident #107 had a past history significant for depression, anxiety, and PTSD.<BR/>Record review of Resident #107's Care Plan, dated initiated on 09/15/2023, revealed Resident #107 had a focus of, The resident has a psychosocial well-being problem (actual or potential) related illness/disease process due to history of trauma from working as a police officer in a large City, has been homeless, had a family member commit suicide when at a young age and resident was age [AGE]. Resident has a diagnosis of bipolar. Review of Care Plan revealed Resident #107 had a focus of, The Resident has depression related to Bipolar maniac state.<BR/>Record review of Resident #107's Psychiatric Progress Note, dated 10/11/2023, revealed Resident #107 was seen for mania following PCP med adjustments. Formal diagnoses included Bipolar disorder, current episode manic without psychotic features, moderate and Generalized anxiety disorder, active. Psychiatric medications were adjusted.<BR/>Record review of Resident #107's Psychiatric Progress Note, dated 07/01/2024, revealed Resident #107 was seen due to symptoms of mania and his statement of, I think I need some help with my mood. Review revealed continued diagnoses of Bipolar disorder and Generalized anxiety disorder. Psychiatric medications were adjusted.<BR/>During an observation on 12/03/2024 at 1:35 p.m., Resident #107 sat in the designated smoking area of the facility and smoked a cigarette. Resident #107 look around the area with a frown on his face.<BR/>During an interview on 12/03/2024 at 1:39 p.m., Resident #107 said he was doing ok but he felt slightly nervous. Resident #107 said he had taken his medication, but he still felt anxious at times. Resident #107 said he saw the psychiatric doctor who came to the nursing facility and the psychiatric doctor adjusted his medication for anxiety.<BR/>During an interview on 12/04/2024 at 2:28 p.m., the MDS Coordinator said Resident #107 came into the facility with no psychological diagnoses when he was admitted on [DATE] and had self-diagnosed himself with depression. MDS Coordinator said Resident #107 had been formally diagnosed with Post-traumatic stress disorder after admission on [DATE]. MDS Coordinator said she completed the Form 1012 on 12/03/2024 and was waiting for the doctor's signature. MDS Coordinator said she had submitted the PL1 in the portal to request a new PASRR evaluation be completed on Resident #107 on 12/03/2024. MDS Coordinator said the facility had an internal audit recently and recognized the facility had an issue with Resident #107's record and submitted the PL1. MDS Coordinator said she was not familiar with the Form 1012 prior to 12/03/2024 and was not aware that the form was required to be submitted. The MDS Coordinator provided the policy, PASRR Nursing Facility Specialized Services Policy and Procedure, dated as revised 03/06/2024, and stated the policy was the only policy the facility had in the area of PASRR specialized services.<BR/>During an interview on 12/04/2024 at 3:30 p.m., the Area Director of Operations said the PASRR forms were monitored at a higher level than the facility. The Area Director of Operations said the corporate regional audit nurses inspected and audited, routinely, and provided feedback to the MDS Coordinators. The Area Director of Operations said the Form 1012 should have been completed and processed for Resident #107.<BR/>During an interview on 12/04/2024 at 3:40 p.m., the Administrator said the MDS Coordinators were monitored by the facility and corporate staff and audited routinely. The Administrator said the Coordinator who did not complete the Form 1012 as required for Resident #107 when a suspicion of mental illness was present was an error and the form should have been completed and processed.<BR/>Record review of the facility policy's, PASRR Nursing Facility Specialized Services Policy and Procedure, dated as revised 03/06/2024, revealed the policy did not address the process to take if a resident had a negative PL1 and the resident was diagnosed with a psychiatric diagnosis that could trigger a suspicion of eligibility for PASRR Mental Health services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 (Hall G medication cart and Hall E medication cart) of 6 medication carts reviewed for medication labeling and storage.<BR/>The facility failed to ensure that insulin stored on Hall G and Hall E's medication cart were properly labeled and not past the medications' expiration date. <BR/>These failures could place residents at risk of harm or decline in health due to lack of potency of medications/biologicals.<BR/>The findings included: <BR/>During an observation on [DATE] at 08:54 a.m., the G Hall medication cart located at the nurses station inspected for medication storage and labeling revealed: <BR/>1. <BR/>Two insulin lispro pen injectors not labeled with an open date.<BR/>2. <BR/>Two insulin glargine pen injectors not labeled with an open date.<BR/>During an observation on [DATE] at 09:08 a.m., the E Hall medication cart located on E Hall inspected for medication storage and labeling revealed:<BR/>1. <BR/>One insulin lispro pen injector not labeled with an open date. <BR/>During an interview on [DATE] at 09:08 a.m., LVN J stated she was not aware the insulin on G Hall medication cart did not have an open date labeled on pen injectors. She stated that the insulins are supposed to have an open date when first used. She did not give an explanation to why insulins were not labeled when opened. She stated she will take the unlabeled insulin pen injectors to DON to ask what needs to be done. <BR/>During an interview on [DATE] at 09:10 a.m., LVN K stated that he was unsure why insulin on E Hall medication cart did not have an open date labeled on pen injectors. He stated that insulins should be labeled with an open date when first used. He did not give an explanation to why insulins were not labeled when opened. <BR/>During an interview on [DATE] at 09:13 a.m., ADON L stated that insulin should be dated with an open date when it was first used. She did not know why insulins were found on medication carts with no open date. She stated that the effect on residents could be that medication would not be as effective. She stated that nurses have instructions from pharmacy on medication carts stating that insulin should be disposed of 28 days after open date.<BR/>During an interview on [DATE] at 02:39 p.m., the DON stated that insulin should be labeled with an open date when it was first used. She stated that the pharmacy and the ADONs were responsible for monitoring if medication was stored properly but ultimately the responsibility fell on her. She said that does not know the last date pharmacy was in facility to inspect carts and educate staff. She stated that if there is no open date on the insulin, facility could go by dispense date if it was less than 28 days in the past. She stated that the facility disposed of unlabeled insulin pen injectors brought to her earlier being the dispense date was over 28 days in the past and they had no way of knowing when opened. She stated that she expects the nurses to dispose of medications when they are expired. She stated that education and training led to the failure. She stated that medications' desired effect could decrease when used after 28 days of being opened or expired. <BR/>Record review on [DATE] of policy titled Recommended Mediation Storage last revised 07/2012 revealed Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that it is clear when the medication was opened. Below is a list of medications that require a date when opening and the recommended time frame the medication should be used. This is not an all-inclusive list and the manufacturer recommendations will supersede this list .INSULINS (Vials, Cartridge, Pens) .Humulin R, N, 70/30 and Mix Humalog and Humalog Mix .Insulin glarglne Lantus) .Refrigerate until initial use; Expires 28 days after initial use regardless of product storage (refrigerated or room temperature); Unopened, refrigerated insulin vials remain effective until the vial expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for 4 of 26 Residents (Residents #8, #9, #120, and #376) and one (1) of one (1) kitchen.<BR/>1. Residents #8, #9, #120, and #376 voiced concerns of cold food, flavor, and/or texture.<BR/>2. One (1) of the three (3) foods sampled on the meal tray was cold.<BR/>These failures could affect the residents by placing them at risk for malnutrition due to residents' decline in consumption in food, dissatisfaction of meals served, and residents to have unwanted weight loss.<BR/>Findings include:<BR/>Record review of Resident #120's Facesheet, dated 12/04/2024, revealed Resident #120 was a [AGE] year-old male, with an admission date into the facility of 09/12/2024. Diagnoses included Parkinson's disease (a progressive neurological condition that affects the brain and causes movement and non-movement issues) with dyskinesia (a range of movement disorders that involve involuntary muscle movements, such as tics, tremors, or spasms), with fluctuations (changes in the ability to move) and Depression (a serious mood disorder that can affect a person's thoughts, feelings, behavior, and sense of well-being). <BR/>Record review of Resident #120's admission MDS assessment, dated 09/16/2024, revealed Resident #120 had a BIMS score of 10 which indicated a moderate cognitive impairment.<BR/>During an interview on 12/02/24 at 2:45 p.m., Resident #120 said the food was the only thing that he would consider that needed to be worked on. Resident #120 said breakfast was usually cold, and the food overall was not very good. Resident #120 said the lunch served on the day of the on-site visit was actually pretty good for once, but it was cold when he ate it. <BR/>Record review of Resident #376's Facesheet, dated 12/03/2024, revealed Resident #376 was an [AGE] year-old male, with an admission date into the facility of 11/18/2024. Diagnoses included Type II Diabetes Mellitus without complications and Iron deficiency secondary to blood loss (chronic).<BR/>Record review of Resident #376's admission MDS, dated [DATE], revealed Resident #376's had a BIMS score of 15 which indicated an intact cognitive response.<BR/>During an interview on 12/03/24 at 12:27 p.m., Resident #376 said the food was inconsistent and he thought the kitchen should be overhauled. Resident #376 said the food was often cold. Resident #376 said he never received condiments and the food tasted terrible. Resident #376 said he attended the monthly council meeting and residents talked about cold food every meeting.<BR/>Record review of Resident #8's Facesheet, dated 12/04/2024, revealed Resident #9 was a [AGE] year-old female, with an admission date into the facility of 05/06/2004. Diagnoses included Other cerebrovascular disease (temporary blockage of an artery in the brain that causes stroke-like symptoms) and Gastro-esophageal reflux disease (a chronic condition that occurs when stomach contents leak into the esophagus). <BR/>Record review of Resident #8's Annual MDS, dated [DATE], revealed Resident #9 had a BIMS score of 15 which indicated an intact cognitive response.<BR/>During an interview on 12/03/2024 at 4:34 p.m., Resident #8 said the food being cold was brought up at every resident council meeting that was held on a monthly basis. Resident #8 said the was sent out of kitchen and by the time the aids passed the trays out, the food was not hot. <BR/>During an observation on 12/02/2024 at 12:25 p.m., a test tray was requested. At 12:40 p.m., preparation of the test tray began, and the tray was placed on the serving cart for Hall G. Plate was picked up with suction cup. Meat placed on plate with mashed potatoes and spinach. Observed a slice of cheese to be placed on top of meatloaf and tray place on the bottom slot of the cart for Hall G. Staff placed a roll, cake, tea, silver ware, and a cover on the tray. At 12:48 p.m., Hall G serving cart left the kitchen and was placed outside the kitchen into the hallway. At 12:55 p.m., the test tray left the area and CNA J took possession of the cart, which she took to Hall G.<BR/>During an interview on 12/02/2024 at 12:27 p.m., CNA J said the residents on Hall G often complained of tea being watered down and no condiments on the trays. CNA J said she observed no butter on the trays for the current meal.<BR/>During an observation on 12/02/2024 at 1:10 p.m., the sample tray arrived at the conference room. At 1:11 p.m., the Dietary Manager took the temperature of the spinach, which was 117.5 degrees Fahrenheit, hamburger steak with cheese was 100.2 degrees Fahrenheit, and the mashed potatoes were 117.1 degrees Fahrenheit. The food was sampled by the Dietary Manager and surveyors. <BR/>During an interview on 12/02/2024 at 1:10 p.m., the Dietary Manager said the food was cold and could be warmer. The Dietary Manager said the meatloaf hamburger could be warmer and would taster better. The Dietary Supervisor said the food temperature did not meet her expectations. The Dietary Supervisor said the residents would not eat the food at the present temperature. <BR/>During record review of the facility's policy, Daily Food Temperature Control, dated 2012, revealed the facility would assure that food was served within acceptable ranges.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitization<BR/>The facility failed to ensure that kitchen staff obtained food temperatures prior to serving meals on 09/04/2023, 09/14/2023,09/15/2023, 09/19/2023, 09/20/2023, 09/24/2023, 09/27/2023, 09/28/2023, 09/29/2023, 09/30/2023, 10/01/2023, 10/02/2023, and 10/03/2023. <BR/>The facility failed to ensure plastic drinking cups were cleaned and sanitized properly. <BR/>These failures could place residents that eat out of the kitchen at risk for food borne illnesses.<BR/>Findings included: <BR/>During an observation on 10/03/2023 at 9:45 AM of the kitchen revealed blanks on temperature logs for the month of October 2023. <BR/>During an interview on 10/03/2023 at 9:45 AM the DM stated the cook was to write the temperatures of food when it was cooked on the temperature log. The DM stated if the cook did not write the temperature on log, then there was no way to prove that the temperatures were taken. <BR/>During an observation and interview on 10/03/2023 at 1:45 PM in the dining room revealed Resident # 1 sitting at a table with 2 other residents. Resident #1's pointed out cups at table that residents were served during lunch. One plastic cup had a cloudy film on the inside and one plastic cup had a brown film on the inside. Resident # 1 stated there had been a problem with cups not being clean. Resident # 1 stated look I can rub this brown stuff off the inside of the cup. Resident #1 stated the stained cup makes my milk look like root beer. Resident #1 stated she did not like drinking out of cups that are not clean. Resident #1 stated sometimes the food was not hot when they received food.<BR/>During an observation on 10/03/2023 at 2:00 PM of the kitchen revealed dietary staff pouring milk into plastic drinking cups. One of the plastic cups was observed to have a brown film on the inside of the cup, which made the white milk look like brown milk. Dietary staff put lids on cup and placed them into fridge. <BR/>During an interview on 10/03/2023 at 1:50 PM Resident # 2 stated she had received cups that did not appear to be clean. Resident # 2 stated it was gross to drink out of cups that looked dirty. Resident # 2 stated food was served cold at times and would have to ask them to heat food. <BR/>During an interview on 10/03/2023 at 3:15 PM the DM stated staff should not be serving residents drinks in cups that are stained. The DM stated staff should have thrown the cups away that appeared to be stained. The DM stated her expectation was that residents received cups that were not stained. The DM stated a lot of new staff and lack of training led to failure of residents receiving plastic cups that were stained. The DM stated the effect on the residents could have been a dignity issue or could have received cups that were not clean and have debris in cups. The DM stated her expectation was that staff take temperature of food when it was cooked and again before it was served; staff all need to record the temperatures on the temperature log. The DM stated there was no other way to ensure that the food was cooked to correct temperature without the logs. The DM stated there was a shift supervisor that was supposed to have checked to ensure the temperatures were taken and put on log. The DM stated new staff are trained when they are hired. The DM stated new staff were paired with shift supervisor to learn the recipes, taking temps, cleaning thermometer, and writing in log. The DM stated once the shift supervisor felt new staff were ready they would follow them and monitor them to ensure they were doing things correctly. The DM stated she monitored the logs by looking at the end of the month and when finds holes she would find the cook that was cooking that meal and will contact the supervisor to retrain that staff. The DM stated she had not reviewed the September 2023 temperature log before today and was not aware there were so many meals that were blank on the log. The DM stated she probably should have been looking more frequently. The DM stated what led to failure of temperature logs not being completed was the dietary staff get in a hurry and do not pay attention to the things they were supposed to have done. The DM stated the effect on residents could have caused residents to get sick. The DM stated she was not aware of residents getting sick from eating under cooked food. <BR/>During an interview on 10/03/2023 at 3:30 PM the IP stated there had not been any residents with gastrointestinal issues related to food. <BR/>During an interview on 10/03/2023 at 3:45 PM the ADMN stated his expectation was that cups should be cleaned properly and not have any stains on them when they were served to residents. The ADMN stated if residents were served drinks in cups that were not cleaned properly it could have caused them to become sick. The ADMN stated lack of oversight by the dietary supervisors, the DM and ADMN led to failure of residents having received cups with film on the inside of cup. The ADMN stated his expectation was that temperature of food should have been completed and recorded. The ADMN stated if temperatures were not recorded on the logs, then there was no way to prove temperatures were completed. The ADMN stated the dietary supervisors, and the DM should have been monitoring the temperature logs daily. The ADMN stated poor oversight led to the failure of food temperatures not being logged. The ADMN stated they did not have a policy in regard to clean and sanitary dishes. <BR/>Record review of facility temperature logs for the month of September 2023 and October 2023 revealed no evidence that temperatures were taken for the following meals:<BR/>09/04/2023 Dinner<BR/>09/14/2023 Breakfast, lunch, dinner<BR/>09/15/2023 Breakfast, lunch, dinner<BR/>09/19/2023 lunch, dinner<BR/>09/20/2023 Lunch<BR/>09/24/2023 Dinner<BR/>09/27/2023 Breakfast, lunch, dinner<BR/>09/28/2023 Dinner<BR/>09/29/2023 Lunch<BR/>09/30/2023 Breakfast, lunch, dinner<BR/>10/01/2023 Breakfast, lunch, dinner<BR/>10/02/2023 Breakfast<BR/>10/03/2023 Breakfast<BR/>Record review of facility policy titled Daily Food Temperature Control, dated with only year of 2012, revealed: We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #1, Resident #2, and Resident #3) of 10 residents reviewed for comprehensive person-centered care plans. <BR/>The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in areas such as impaired visual function, Seizure Disorder, and risk for falls for Resident #1.<BR/>The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in areas such as hypertension, Diabetes Mellitus, and risk for falls for Resident #2. <BR/>The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in areas such as Anticoagulant and Antiplatelet therapy, hypertension, and risk for falls for Resident #3.<BR/>This failure could place the residents at risk for decreased quality of life and not having their needs met.<BR/>Findings include:<BR/>Resident #1 <BR/>Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted to facility on 08/24/2021 with diagnoses to include: dementia, depression, schizophrenia, and repeated falls. <BR/>Review of Resident #1's Quarterly MDS assessment, dated 01/18/2024, revealed a BIMS score of 15 which indicated no impaired cognition. <BR/>Review of Resident #1's Comprehensive Care Plan initiated on 08/24/2021 revealed the lack of measurable objectives to be evaluated or quantified were in the order of the problems listed above: The Resident will maintain optimal quality of life within limitation imposed by visual function, The resident will remain free from injury related to seizure activity, The resident will be free of falls The resident will not sustain serious injury.<BR/>Resident #2<BR/>Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to facility on 09/28/2022 with diagnoses to include: dementia, depression, anxiety, and unsteadiness on feet. <BR/>Review of Resident #2's Quarterly MDS assessment, dated 11/03/2023, revealed no BIMS score. <BR/>Review of Resident #2's Comprehensive Care Plan initiated on 09/29/2022 revealed the lack of measurable objectives to be evaluated or quantified were in the order of the problems listed above: The resident will remain free of complication related to hypertension, The resident will be free from any s/sx of hyperglycemia, The resident will have no complications related to diabetes, The resident will be free from any s/sx of hypoglycemia, and The resident will not sustain serious injury.<BR/>Resident #3<BR/>Review of Resident #3's electronic face sheet revealed an [AGE] year-old male admitted to facility on 11/13/2023 with diagnoses to include: depression, kidney failure, and heart disease. <BR/>Review of Resident #3's Significant Change MDS assessment, dated 01/31/2024, revealed a BIMS score of 01 which indicated severely impaired cognition. <BR/>Review of Resident #3's Comprehensive Care Plan, initiated 11/14/2023, revealed the lack of measurable objectives to be evaluated or quantified were in the order of the problems listed above: The resident will be free from discomfort or adverse reactions related to anticoagulant and antiplatelet medication use, The resident will remain free of complication related to hypertension, The resident will be free of falls, and The resident will not sustain serious injury.<BR/>During an interview on 02/15/2024 at 10:40 am, the DON stated the facility had clinical meeting every morning to discuss day to day updates on all residents. She stated it was her responsibility to update the care plan with acute issues and new interventions. The DON stated the importance of measurable objectives in an accurate care plan were for residents to receive the care needed. The Comprehensive care plans were necessary for the staff to know the residents. The care plans that were not resident centered and lack of measurable objectives could be detrimental to the resident's health and well-being. The DON stated she expected care plans to address each resident's problems with measurable objectives and have a way to determine when the problem was resolved or needed to be re-evaluated. <BR/>During an interview on 02/15/2024 at 3:30 pm, the MDS Nurse stated she was not responsible for updating the care plan with acute or new issues. She stated she performed quarterly care plan conferences based on what was documented in the chart. She stated if the falls had been added to the care plan when they occurred and new interventions had been added then she would have discussed it in the care plan conferences. She stated it was not her responsibility to update the care plan.<BR/>Record review of the facility's policy, Comprehensive Care Planning, not dated, revealed; The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights that includes measurable objectives and timeframes to meet a residents needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, which were complete and accurately documented for 1 (Resident #1) of 4 residents reviewed for documentation.<BR/>RN B failed to accurately document the notification of Resident #1's resident representative when Resident #1 had a change in condition and was sent via ambulance to the hospital.<BR/>This failure could place residents at risk of inaccurate documentation in residents' records and decreased confidence in the facility staff.<BR/>Findings include:<BR/>Record review of Resident #1's Face Sheet, dated 07/29/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Unspecified Dementia (symptoms affecting memory, thinking, and social abilities), severe, without behavioral, psychotic, mood disturbances, or anxiety, Hypothyroidism (underactive thyroid), unspecified, Depression (mental state that can affect a person's thoughts, feelings, behavior, and sense of well-being), unspecified (term used when a patient's symptoms are primarily depressive but do not meet the full criteria for a specific depressive disorder), and Essential (primary) hypertension (high blood pressure that is multi-factorial and does not have one distinct cause). Resident #1 was discharged on 07/27/2024 to the local hospital. <BR/>Record review of Resident #1's admission MDS Assessment, dated 04/28/2024, in Section C- Cognitive Response Patterns, C0100 revealed Resident #1 was rarely/never understood and a BIMS score was not able to be determined. Section C0500 BIMS Summary Score was blank. Section C1000 - Cognitive Skills for Daily Decision Making - was coded as 3 - severely impaired - never/rarely made decisions.<BR/>Record review of Resident #1's Event Nurses' Note - Fall, dated 07/27/2024 at 12:31 (12:31 p.m.), revealed RN C documented RN C contacted Resident #1's POA and resident representative on 07/26/2024 at 22:30 (10:30 p.m.).<BR/>Record review of Resident #1's Progress Note, dated 07/26/2024 at 07:25 military time, (7:25 a.m.), revealed RN C documented Resident #1 was taken by EMS to the Emergency Room. The family, DON, and doctor were contacted. Documentation was recorded in military time.<BR/>Record review of Resident #1's Progress Note, dated 07/26/2024 at 19:00 military time, (7:00 p.m.), revealed RN C documented she called 911. EMS transported Resident #1 to the hospital. Provider, RP, and ADON notified. <BR/>Record review of Resident #1's Progress Note, 07/26/2024 at 22:23 military time, (10:23 p.m.), revealed RN C documented Resident #1 was taken by EMS to the emergency room. Family, DON, and doctor were contact. This entry was struck out with a line through the sentences. Strike Out Reason identified as Incomplete Documentation; Strike Out Date: 07/27/2024 03:00 military time, (3:00 a.m.).<BR/>During an interview a confidential person said Resident #1, who resided at the nursing facility, had a change in condition on 07/26/2024 at 7:05 p.m., which required Resident #1 to be transported to the local hospital via ambulance. The confidential person said Resident #1's POA/responsible party was not contacted by the facility or notified of the change of the condition or Resident #1 was discharged and transported to the emergency room. The confidential person said the facility nurse documented in Resident #1's permanent clinical record that the patient's family was contacted on 07/26/2024 after a change in condition occurred and Resident #1 was taken by EMS to the emergency room. The confidential person said he met with the facility administration staff on the morning of 7/27/2024 and the facility admitted the nurse falsified documentation when she recorded the resident representative was notified and was shown the clinical documentation and took a screen shot of the information. The confidential person said the facility reported the nurse who falsified the documentation was terminated but he felt this did not make up for what had happened. The confidential person said Resident #1 could have been conscious for several hours at the hospital and the family were not present to hold Resident #1's hand.<BR/>During an interview on 07/29/2024 at 12:29 p.m., Resident #1's POA said she was not contacted on 07/26/2024 by the facility that Resident #1 had a change in condition or had been transported to the hospital by the nursing facility immediately after the incident between 7:05 p.m. - 7:30 p.m. Resident #1's POA said she was not contacted by the facility at 10:30 p.m., by a facility nurse and said absolutely no one from the nursing home had contacted her since the incident had occurred.<BR/>Attempted interview on 07/29/2024 at 1:41 p.m., with RN C was unsuccessful. The phone went straight to voice mail and the message indicated the mailbox was full and the caller could not accept messages at that time.<BR/>During an interview on 07/29/2024 at 1:52 p.m., the DON said she was not aware Resident #1's POA was not contacted by the facility when Resident #1 had a change in condition on 07/26/2024 at 7:05 p.m., and was transported to the hospital via ambulance until 07/27/2024 at approximately 8:30 a.m. The DON said the Administrator informed her at that time. The DON said she called RN C on 07/27/2027 at approximately 9:00 a.m. and asked RN C to come into the facility to finish completing the documentation related to the incident. The DON said when RN C arrived, the DON asked her if she called Resident #1's POA/family member and RN C replied to her that she had become busy with another resident and by the time RN C finished, the time was 10 p.m. The DON said RN C admitted at this time she failed to contact Resident #1's POA. The DON said her expectation was for the nursing staff to document clear and precise records that were accurate. The DON said incorrect documentation could cause miscommunication with family and anxiety for the resident. The DON said Resident #1's family not being contacted was unacceptable to her. <BR/>During an interview on 07/29/2024 at 3:01 p.m., the Administrator said she was notified on 07/26/2024 at approximately 8:30 p.m., by CMA A when Resident #1 had a change in condition and was sent out by ambulance to the ER. The Administrator said she was contacted on 07/26/2024 at approximately 10:30 p.m. that the POA of Resident #1 was not notified by the facility and she spoke with the POA on 07/27/2025 by phone when Resident #1's POA arrived at the facility to retrieve Resident #1's personal items and demanded an explanation as to why she, the POA was not contacted immediately when Resident #1 was transported to the ER. The Administrator said RN C came into the facility on 7/27/2024 and admitted she had not contacted the POA or the family immediately or any time after Resident #1 was transported to the hospital via ambulance. The Administrator said at this time, the facility became aware the documentation in the clinical records was inaccurate. The Administrator said the documentation revealed RN C notified the ADON on 07/26/2024 at 7:00 p.m. and an interview with the ADON revealed she was not contacted. The Administrator said termination was appropriate action and felt the facility had taken the appropriate corrective actions. The Administrator said she would monitor documentation and what occurred on Friday (07/26/2024) was unacceptable.<BR/>Record review of the Facility: [Facility] Employee Disciplinary Report, dated 07/26/2024, revealed RN C would be discharged , with the following specific reasons for disciplinary action: [RN C] has failed to adhere to the Corporate Code of Conduct and Job Duties/Responsibilities. [RN C] on 07/26/2024 failed to adhere to her job duties/responsibilities. [RN C] failed to notify the responsible party about resident being transferred to emergency room. [RN C] is aware of her job duties/responsibilities as indicated by her signature on her employee handbook acknowledgement. [RN C] meets the criteria for immediate termination. [RN C] will be terminated effective immediately.<BR/>Record review of the facility's policy, Documentation, dated 05/2015, revealed the facility would maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. The facility would ensure that information was comprehensive and timely, and properly signed. It has legal requirements regarding accuracy and completeness, legibility, and timing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention, a significant change in the resident's physical, mental or psychosocial status, or a decision to transfer or discharge the resident from the facility for 1 (Resident #1) of 4 residents reviewed for notification of changes.<BR/>The facility failed to ensure Resident #1's POA/resident representative was immediately notified when the resident had a change in condition that required her to be transported via ambulance to the hospital.<BR/>The non-compliance was identified as PNC. The noncompliance began on 07/26/2027 and ended on 07/27/2027. The facility corrected the noncompliance before the survey began. <BR/>This failure placed residents at risk of not having the comfort and company of their families during traumatic times.<BR/>Findings include:<BR/>Record review of Resident #1's Face Sheet, dated 07/29/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included of Unspecified Dementia (symptoms affecting memory, thinking, and social abilities), severe, without behavioral, psychotic, mood disturbances, or anxiety, Hypothyroidism (underactive thyroid), unspecified, Depression (mental state that can affect a person's thoughts, feelings, behavior, and sense of well-being), unspecified (term used when a patient's symptoms are primarily depressive but do not meet the full criteria for a specific depressive disorder), and Essential (primary) hypertension (high blood pressure that is multi-factorial and does not have one distinct cause). Resident #1 was discharged on 07/27/2024 to the local hospital. <BR/>Record review of Resident #1's admission MDS Assessment, dated 04/28/2024, in Section C- Cognitive Response Patterns, C0100 revealed Resident #1 was rarely/never understood and a BIMS score was not able to be determined. Section C0500 BIMS Summary Score was blank. Section C1000 - Cognitive Skills for Daily Decision Making - was coded as 3 - severely impaired - never/rarely made decisions.<BR/>Record review of Resident #1's Event Nurses' Note - Fall, dated 07/27/2024 at 12:31 (12:31 p.m.), revealed RN C documented RN C contacted Resident #1's POA and resident representative on 07/26/2024 at 22:30 (10:30 p.m.).<BR/>During a confidential interview revealed that Resident #1, who resided at the nursing facility, had a change in condition on 07/26/2024 at 7:05 p.m., which required Resident #1 to be transported to the local hospital via ambulance. The confidential person said Resident #1's POA/responsible party was not contacted by the facility and notified of the change of the condition or that Resident #1 was discharged and transported to the emergency room. The confidential person said Resident #1 was care flighted from the local hospital to a hospital 30 miles away and the POA/responsible party not being contacted by the facility was unacceptable. The confidential person's voice crack and there was a sound of crying. The confidential person said he was told Resident #1 was in the hospital when he received a call from an employee who identified himself as a Chaplin on 07/26/2024 at approximately 10:30 p.m., from the hospital located 30 miles away. The confidential person said Resident #1's family lost at least three (3) hours that could have been spent holding Resident #1's hand and the family could have been there for Resident #1. <BR/>During an interview on 07/29/2024 at 12:29 p.m., Resident #1's POA said she was not contacted on 07/26/2024 at 7:30 p.m. or at 10:30 p.m., by the nursing facility that Resident #1 had a change in condition or had been transported to the hospital by EMS at 7:30 p.m. and Resident #1's POA said absolutely no one from the nursing home had contacted her since the incident had occurred. Resident #1's POA stated the first time she became aware Resident #1 was transported to the hospital was when she received a call on 07/26/2024 at 10:18 p.m., by an employee of a hospital approximately 30 miles from the facility who stated Resident #1 was at the ER and the hospital employee requested additional information for Resident #1 to be treated. Resident #1's POA said at the same time, her family member received a call from an employee from the same hospital and another family member was contacted and informed Resident #1 was care flighted from the local hospital. Resident #1's POA said she went up to the nursing home the morning of 07/27/2024 to pick up some of Resident #1's belongings and spoke with the Administrator by phone, but never received a call from an employee from the facility.<BR/>Attempted interview on 07/29/2024 at 1:41 p.m., with RN C was unsuccessful. The phone went straight to voice mail and the message indicated the mailbox was full and the caller could not accept messages at that time.<BR/>During an interview on 07/29/2024 at 1:52 p.m., the DON said she was not aware Resident #1's POA was not contacted by the facility when Resident #1 had a change in condition on 07/26/2024 at 7:05 p.m., and was transported to the hospital via ambulance until 07/27/2024 at approximately 8:30 a.m. The DON said the Administrator informed her at that time. The DON said she called RN C on 07/27/2027 at approximately 9:00 a.m. and asked RN C to come into the facility to finish completing the documentation related to the incident. The DON said when RN C arrived, the DON asked her if she called Resident #1's POA/family member and RN C replied to her that she had become busy with another resident and by the time RN C finished, the time was 10 p.m. The DON said RN C admitted at this time she failed to contact Resident #1's POA. The DON said her expectation when a resident left the building by EMS was for the nurse to contact the family, ensure the doctor was notified, and for the nurse to notify herself, as the DON. The DON said the actions of RN C did not meet her expectations. The DON said the POA/resident representative/family should be informed immediately of a change of in condition to be aware the resident was no longer in the facility, and the family could be there with the resident. The DON said notification was important for the resident to have family with them and to have an advocate in an emergency situation. The DON said all staff had been in-serviced on notification when a resident had a change-condition and to make sure all nursing staff understood that if an emergency occurred, the doctor was notified to obtain orders to transfer the resident out, the POA/resident representative, and DON were notified immediately. The DON said RN C was terminated and under the circumstances, and felt the disciplinary action was appropriate. The DON said the resident would need family present during an emergency situation for comfort.<BR/>During an interview on 07/29/2024 at 2:23 p.m., the ADON said her expectations when a resident had a change in condition and was transported out to the hospital was for the charge nurse to call the family, the doctor, the DON, and the administrator. The ADON said she typed out a short list that contained multiple situations and who was required to be contacted and posted the list at both of the nurses' stations for a reference. The ADON said she was contacted on 07/26/2024 at approximately 8:30 p.m., by the Administrator that Resident #1 had a change in condition and was transported to the ER by ambulance. The ADON said she was not contacted by RN C at any time.<BR/>During an interview on 07/29/2024 at 2:34 p.m., LVN E said if a resident was sent to the ER, she would contact the DON, Administrator, the doctor, and the family. LVN E said it was important to contact the residents' family so they would know about any changes in condition and families would not get a phone call from a hospital in the middle of night. LVN E said it was important for the resident, especially for residents who were confused, to have a familiar face to help with the transition in unfamiliar place. LVN E said the family could assist the resident to not be scared. LVN E said she was in-serviced on who to notify for emergency situations, falls, change in conditions, and abuse and neglect following the incident with Resident #1.<BR/>During an interview on 07/29/2024 at 2:45 p.m., LVN F said if a resident was sent to the ER, she would call the doctor to obtain orders for the resident to be sent to the ER, contact the family, call the DON, and Administrator to let them know a resident was transported and was discharged to the hospital. LVN F said the contact was done quickly and usually prior to the arrival of the ambulance. LVN F said she was recently in-serviced on this topic, reporting change of condition to physician, DON/ADON, and resident representative immediately, but this was standard procedure for a nurse, and she had done the steps for a long time. LVN F said she was in-serviced on abuse/neglect. LVN F said she was not on duty when Resident #1 was sent out to the ER on [DATE]. <BR/>During an interview on 07/29/2024 at 3:01 p.m., the Administrator said she was notified on 07/26/2024 at approximately 8:30 p.m., by CMA A Resident #1 had a change in condition and was sent out by ambulance to the ER. The Administrator said she was contacted on 07/26/2024 at approximately 10:30 p.m. that the POA of Resident #1 was not notified by the facility and she spoke with the POA on 07/27/2024 by phone when Resident #1's POA arrived at the facility to retrieve Resident #1's personal items and demanded an explanation as to why she, the POA was not contacted when Resident #1 was transported to the ER. The Administrator said RN C came into the facility on the morning of 7/27/2024 and admitted she had not contacted the POA or the family immediately or any time after Resident #1 was transported to the hospital via ambulance. The Administrator said termination was the appropriate action and felt the facility had taken the appropriate corrective actions. The Administrator said Resident #1's family needed to be notified of her change in condition and Resident #1 was transferred outside the facility. The Administrator said the negative effects were the family was unable to be with Resident #1 when she left the facility until they were able to get to the hospital over 2 &frac12; hours later. The Administrator said it was important for all residents to have their resident representative notified to protect their rights and comfort. The Administrator said her expectation was for the nurse to contact the doctor to receive orders, the responsible party, the DON, and the Administrator. The Administrator said she monitored contact of the resident representative when she was contacted of the incident as she would ask the nurse on the phone to ensure the family was notified. The Administrator said she would monitor documentation.<BR/>Record review of the Facility: [Facility] Employee Disciplinary Report, dated 07/26/2024, revealed RN C would be discharged , with the following specific reasons for disciplinary action: [RN C] has failed to adhere to the Corporate Code of Conduct and Job Duties/Responsibilities. [RN C] on 07/26/2024 failed to adhere to her job duties/responsibilities. [RN C] failed to notify the responsible party about resident being transferred to emergency room. [RN C] is aware of her job duties/responsibilities as indicated by her signature on her employee handbook acknowledgement. [RN C] meets the criteria for immediate termination. [RN C] will be terminated effective immediately.<BR/>Record review of in-service training, Topic: Incident Reporting: Notify RP, Physician, DON/ADON, Administrator, dated 07/27/2024, conducted by the Administrator, revealed nursing staff was in-serviced on the topic including LVN E, LVN F, CMA A and the ADON.<BR/>Record review of in-service training, Topic: Reporting Change of Condition to physician, DON/ADON, and RP immediately, dated 07/27/2024, conducted by the Administrator, revealed nursing staff were in-serviced on the topic including LVN E, LVN F, and the ADON.<BR/>Record review of in-service training, Topic: Reporting Change of Condition to charge nurse immediately, dated 07/27/2024, conducted by the Administrator, revealed nursing staff had been in-serviced on the topic including CMA A.<BR/>Record review of in-service training, Topic: Provide clear directives to nursing staff re: incidents, Follow-up to ensure proper notifications have been made and confirm time of notification, dated 07/27/2024, revealed the Administrator was in-serviced on 07/27/2024 by the Area Director of Operations.<BR/>Record review of the facility's policy, Transfer of Residents from the Facility, dated 2003, revealed the objectives of the policy were to assist in necessary resident transfers and to prevent trauma at the time of transfer. Emergency transfers of residents for medical reasons would be completed promptly and family notification would occur as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, which were complete and accurately documented for 1 (Resident #1) of 4 residents reviewed for documentation.<BR/>RN B failed to accurately document the notification of Resident #1's resident representative when Resident #1 had a change in condition and was sent via ambulance to the hospital.<BR/>This failure could place residents at risk of inaccurate documentation in residents' records and decreased confidence in the facility staff.<BR/>Findings include:<BR/>Record review of Resident #1's Face Sheet, dated 07/29/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Unspecified Dementia (symptoms affecting memory, thinking, and social abilities), severe, without behavioral, psychotic, mood disturbances, or anxiety, Hypothyroidism (underactive thyroid), unspecified, Depression (mental state that can affect a person's thoughts, feelings, behavior, and sense of well-being), unspecified (term used when a patient's symptoms are primarily depressive but do not meet the full criteria for a specific depressive disorder), and Essential (primary) hypertension (high blood pressure that is multi-factorial and does not have one distinct cause). Resident #1 was discharged on 07/27/2024 to the local hospital. <BR/>Record review of Resident #1's admission MDS Assessment, dated 04/28/2024, in Section C- Cognitive Response Patterns, C0100 revealed Resident #1 was rarely/never understood and a BIMS score was not able to be determined. Section C0500 BIMS Summary Score was blank. Section C1000 - Cognitive Skills for Daily Decision Making - was coded as 3 - severely impaired - never/rarely made decisions.<BR/>Record review of Resident #1's Event Nurses' Note - Fall, dated 07/27/2024 at 12:31 (12:31 p.m.), revealed RN C documented RN C contacted Resident #1's POA and resident representative on 07/26/2024 at 22:30 (10:30 p.m.).<BR/>Record review of Resident #1's Progress Note, dated 07/26/2024 at 07:25 military time, (7:25 a.m.), revealed RN C documented Resident #1 was taken by EMS to the Emergency Room. The family, DON, and doctor were contacted. Documentation was recorded in military time.<BR/>Record review of Resident #1's Progress Note, dated 07/26/2024 at 19:00 military time, (7:00 p.m.), revealed RN C documented she called 911. EMS transported Resident #1 to the hospital. Provider, RP, and ADON notified. <BR/>Record review of Resident #1's Progress Note, 07/26/2024 at 22:23 military time, (10:23 p.m.), revealed RN C documented Resident #1 was taken by EMS to the emergency room. Family, DON, and doctor were contact. This entry was struck out with a line through the sentences. Strike Out Reason identified as Incomplete Documentation; Strike Out Date: 07/27/2024 03:00 military time, (3:00 a.m.).<BR/>During an interview a confidential person said Resident #1, who resided at the nursing facility, had a change in condition on 07/26/2024 at 7:05 p.m., which required Resident #1 to be transported to the local hospital via ambulance. The confidential person said Resident #1's POA/responsible party was not contacted by the facility or notified of the change of the condition or Resident #1 was discharged and transported to the emergency room. The confidential person said the facility nurse documented in Resident #1's permanent clinical record that the patient's family was contacted on 07/26/2024 after a change in condition occurred and Resident #1 was taken by EMS to the emergency room. The confidential person said he met with the facility administration staff on the morning of 7/27/2024 and the facility admitted the nurse falsified documentation when she recorded the resident representative was notified and was shown the clinical documentation and took a screen shot of the information. The confidential person said the facility reported the nurse who falsified the documentation was terminated but he felt this did not make up for what had happened. The confidential person said Resident #1 could have been conscious for several hours at the hospital and the family were not present to hold Resident #1's hand.<BR/>During an interview on 07/29/2024 at 12:29 p.m., Resident #1's POA said she was not contacted on 07/26/2024 by the facility that Resident #1 had a change in condition or had been transported to the hospital by the nursing facility immediately after the incident between 7:05 p.m. - 7:30 p.m. Resident #1's POA said she was not contacted by the facility at 10:30 p.m., by a facility nurse and said absolutely no one from the nursing home had contacted her since the incident had occurred.<BR/>Attempted interview on 07/29/2024 at 1:41 p.m., with RN C was unsuccessful. The phone went straight to voice mail and the message indicated the mailbox was full and the caller could not accept messages at that time.<BR/>During an interview on 07/29/2024 at 1:52 p.m., the DON said she was not aware Resident #1's POA was not contacted by the facility when Resident #1 had a change in condition on 07/26/2024 at 7:05 p.m., and was transported to the hospital via ambulance until 07/27/2024 at approximately 8:30 a.m. The DON said the Administrator informed her at that time. The DON said she called RN C on 07/27/2027 at approximately 9:00 a.m. and asked RN C to come into the facility to finish completing the documentation related to the incident. The DON said when RN C arrived, the DON asked her if she called Resident #1's POA/family member and RN C replied to her that she had become busy with another resident and by the time RN C finished, the time was 10 p.m. The DON said RN C admitted at this time she failed to contact Resident #1's POA. The DON said her expectation was for the nursing staff to document clear and precise records that were accurate. The DON said incorrect documentation could cause miscommunication with family and anxiety for the resident. The DON said Resident #1's family not being contacted was unacceptable to her. <BR/>During an interview on 07/29/2024 at 3:01 p.m., the Administrator said she was notified on 07/26/2024 at approximately 8:30 p.m., by CMA A when Resident #1 had a change in condition and was sent out by ambulance to the ER. The Administrator said she was contacted on 07/26/2024 at approximately 10:30 p.m. that the POA of Resident #1 was not notified by the facility and she spoke with the POA on 07/27/2025 by phone when Resident #1's POA arrived at the facility to retrieve Resident #1's personal items and demanded an explanation as to why she, the POA was not contacted immediately when Resident #1 was transported to the ER. The Administrator said RN C came into the facility on 7/27/2024 and admitted she had not contacted the POA or the family immediately or any time after Resident #1 was transported to the hospital via ambulance. The Administrator said at this time, the facility became aware the documentation in the clinical records was inaccurate. The Administrator said the documentation revealed RN C notified the ADON on 07/26/2024 at 7:00 p.m. and an interview with the ADON revealed she was not contacted. The Administrator said termination was appropriate action and felt the facility had taken the appropriate corrective actions. The Administrator said she would monitor documentation and what occurred on Friday (07/26/2024) was unacceptable.<BR/>Record review of the Facility: [Facility] Employee Disciplinary Report, dated 07/26/2024, revealed RN C would be discharged , with the following specific reasons for disciplinary action: [RN C] has failed to adhere to the Corporate Code of Conduct and Job Duties/Responsibilities. [RN C] on 07/26/2024 failed to adhere to her job duties/responsibilities. [RN C] failed to notify the responsible party about resident being transferred to emergency room. [RN C] is aware of her job duties/responsibilities as indicated by her signature on her employee handbook acknowledgement. [RN C] meets the criteria for immediate termination. [RN C] will be terminated effective immediately.<BR/>Record review of the facility's policy, Documentation, dated 05/2015, revealed the facility would maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. The facility would ensure that information was comprehensive and timely, and properly signed. It has legal requirements regarding accuracy and completeness, legibility, and timing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 2 (Resident #1 and Resident #2) of 10 residents reviewed for multiple falls.<BR/>The facility failed to implement a system for identifying fall patterns and implementing interventions to prevent falls that lead to emergency room visits with serious injury on 12/17/2023 and 02/07/2024 for Resident #1 and 12/10/2023 and 01/04/2024 for Resident #2.<BR/>An IJ was identified on 02/16/2024. The IJ template was provided to the facility on [DATE] at 10:25 am. While the IJ was removed on 02/16/2024, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. <BR/>These failures could place the residents at risk for falls, serious injuries, hospitalizations, and death. <BR/>Findings include:<BR/>Resident #1<BR/>Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted to facility on 08/24/2021 with diagnoses to include: dementia, depression, schizophrenia, and repeated falls. <BR/>Review of Resident #1's Quarterly MDS assessment, dated 01/18/2024, revealed a BIMS score of 15 which indicated no impaired cognition. Section J Health Conditions: Falls revealed no falls since admission or prior assessment. <BR/>Review of Resident #1's Significant Change MDS assessment, dated 02/14/2024, revealed a BIMS score of 11 which indicated moderate impaired cognition. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. Further review revealed: 0 falls with no injury, 0 falls with injury, and 1 fall with major injury. <BR/>Review of Resident #1's Comprehensive Care Plan, initiated 08/24/2021, revealed: Focus: The resident is at risk for falls. Goal: The resident will be free from falls through the review date. The resident will not sustain serious injury through review date. Interventions: Anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed., ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, keep furniture in locked position, Keep needed items, water in reach. Staff to make frequent visual checks to promote safety and reduce risk of fall, Physical therapy evaluate and treat as ordered or as needed, the resident needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side fails as ordered, handrails on walls, personal items within reach. The resident needs activities that minimize the potential for falls while providing diversion and distraction. Further review of the Comprehensive Care Plan revealed no new interventions added or implemented since 08/24/2021.<BR/>Review of Resident #1's Fall Event Nurses' Note, dated 02/07/2024 at 4:48 PM, signed by LVN D, revealed: Resident #1 had an unwitnessed fall where he hit his head. Resident #1 was ambulating in hallway, and he fell in hallway face first. He bloodied his nose and received a bruise to the right side of his forehead. Doctor was notified and Resident #1 was sent to the emergency room for evaluation and treatment. <BR/>Review of Resident #1's hospital clinical record, dated 02/07/2024, revealed: Injuries: Subdural hematoma (blood around the brain), Hemorrhagic contusion right inferior temporal region (bleeding brain bruise), left periorbital hematoma (bruise around the eye), and left 7th, 9th, and 10th rib fractures. Resident #1 was discharged back to facility on 02/08/2024.<BR/>Review of Resident #1's Fall Event Nurses' Note, dated 12/17/2023 at 6:48 PM, signed by RN E, revealed: Resident #1 had an unwitnessed fall. Resident #1 fell and hit head on floor with laceration. Resident #1 was transferred to the emergency room.<BR/>Review of Resident #1's hospital clinical record, dated 12/17/2023, revealed: Injury: Laceration sustained to left parietal area (top rear of head) is clean, jagged, superficial, 2.6 by 7.5 centimeters. Wound care applied 5 stiches. Resident #1 was discharged back to facility on 12/17/2023.<BR/>Review of the facility's incident log from 11/16/2023-02/07/2024, revealed Resident #1 had falls on 12/17/2023 at 3:09 pm no injury, 12/17/2023 at 6:15 pm with injury, 01/25/2024 at 2:30 pm no injury, 01/29/2024 at 4:40 pm no injury, 01/30/2024 at 4:21 pm no injury, 02/01/2024 at 4:07 pm no injury, 02/06/2024 at 3:22 pm no injury, and 02/07/2024 at 4:46 pm with injury. <BR/>Review of Resident #1's Fall Risk Assessments dated 12/17/2023 revealed a score of 13 High Risk, 01/25/2024 score 18 High Risk, 01/29/2024 score 21 High Risk, 01/30/2024 score 21 High Risk, 02/01/2024 score 18 High Risk, 02/06/2024 score 20 High Risk, and 02/07/2024 score 23 High Risk.<BR/>Review of Resident #1's Care Plan Conference, dated 01/11/2024 at 9:44 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Family did not attend. Went over care plan, with no changes at this time. Continue current plan of care.<BR/>Observation on 02/14/2024 at 12:40 pm, revealed Resident #1 on the secure unit lying in bed no distress noted. Resident was alert but not oriented and not really communicating. Nurse and CNA were currently sitting at bedside.<BR/>Observation on 02/15/2024 at 9:30 am, revealed Resident #1 was lying in bed. The bed was in a low position. There was no siderail or handrails on the bed. Resident #1 had his eyes open and looked at the surveyor but did not speak. There were 3 CNAs in the resident's room.<BR/>Resident #2<BR/>Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to facility on 09/28/2022 with diagnoses to include: dementia, depression, anxiety, and unsteadiness on feet. <BR/>Review of Resident #2's Significant Change MDS assessment, dated 12/15/2023, revealed no BIMS score. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. 0 with no injury, 1 with injury, 1 with major injury. <BR/>Review of Resident #2's Quarterly MDS assessment, dated 11/03/2023, revealed no BIMS score. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. 0 with no injury, 1 with injury, 0 with major injury. <BR/>Review of Resident #2's Comprehensive Care Plan, initiated 09/29/2022, revealed: Focus: The resident is at risk for falls related to She has had actual falls since entering the facility due to poor gait and balance, dementia with poor safety awareness and judgment. Actual fall 12/10/23 Fall between bed and wall causing Right Rib Fracture and mild pneumothorax resulting in emergency room visit. Goal: The resident will not sustain serious injury through review date. Interventions: Anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, Ensure that the resident is wearing appropriate footwear when ambulating, Staff x 1 to assist with transfers, and the resident needs activities that minimize the potential for falls while providing diversion and distraction. Further review of the Comprehensive Care Plan revealed no new interventions added or implemented since 09/29/2022.<BR/>Review of Resident #2's Fall Event Nurses' Note, dated 12/10/2023 at 6:05 AM, signed by LVN G, revealed: Resident #2 had an unwitnessed fall. CNA reported that resident had fallen on the floor. This nurse went into residents' room and found her lying on the floor on her right side and screaming in pain and holding her right side at her rib cage. Having difficulty breathing at this time. Bedside toilet and table and walker all turned over on floor by her. Resident #2 was transferred to the emergency room.<BR/>Review of Resident #2's hospital discharge record, dated 12/10/2023, revealed: Diagnosis Fractured rib and head injury. Resident #2 was discharged back to the facility on [DATE].<BR/>Review of Resident #2's Fall Event Nurses' Note, dated 01/04/2024 at 9:50 PM, signed by LVN H, revealed: Resident #2 had an unwitnessed fall. CNA noticed blood on resident's shirt and observed blood in residents' hair and notified nurse. I assessed resident and observed laceration to right side of resident's head. Resident was guarding right shoulder as well. Resident #2 was transferred to the emergency room.<BR/>Review of Resident #2's hospital clinical record, dated 01/04/2024, revealed: Abrasion on the right scalp and shoulder pain. Resident #2 was discharged back to the facility on [DATE].<BR/>Review of the facility's incident log from 11/16/2023-02/07/2024, revealed Resident #2 had falls on 11/19/2023 at 11:00 pm with no injury, 12/10/2023 at 5:44 am with injury, 12/23/2023 at 10:00 am with no injury, and 01/04/2024 at 8:15 pm with injury.<BR/>Review of Resident #2's Fall Risk Assessments dated 11/19/2023 revealed score 16 High Risk, 12/10/2023 score 19 High Risk, 12/23/2023 score 15 High Risk, 01/04/2024 score 15 High Risk.<BR/>Review of Resident #2's Care Plan Conference, dated 12/26/2023 at 11:29 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Resident #2's [family member] did attend. Went over care plan, with no changes at this time. Continue current plan of care.<BR/>Observation on 02/15/2024 at 4:00 pm, revealed Resident #2 ambulating up and down the hall. Resident seemed unsteady on her feet. Resident was wandering in and out of other residents' rooms.<BR/>During an interview on 02/14/2024 at 12:45 pm, LVN A stated Resident #1 had a history of falling. She stated she had been sitting in his room since his return from the hospital as much as she could because she did not want him to fall again. She stated Resident had a history of wandering and was only oriented to his name. She stated she was trying to increase supervision. She stated she had not been instructed to sit or monitor Resident #1 by the facility. She stated she just was because she was concerned. She stated she had spoken to the DON and informed her that Resident #1 needed 1:1 supervision but she was told the facility did not have the staff for that. She stated there was always 2 CNAs on the secure unit. LVN A stated Resident #2 had a history of wandering and falls also. She stated Resident #2 walks the unit continuously and it was almost impossible to keep an eye on her all the time. She stated Resident #2 had no new fall interventions that she was aware of. <BR/>During an interview on 02/14/2024 at 12:50 pm, CNA B stated he was working with another resident the day Resident #1 fell and was injured. He stated his coworker was in a room and he was assisting the nurse with another resident when he heard a loud noise. He stated he turned around and Resident #1 was lying face down in his doorway covered in blood. He stated he had seen Resident #1 in his bed 15 minutes prior to the fall. He stated he always tried to watch Resident #1 closely and made sure to check on him every 15 minutes when possible. He stated he had asked for help and spoke to the DON and Administrator about not having adequate staff to meet Resident #1's needs. He stated Resident #2 was also a high fall risk. He stated Resident #2 continuously wandered and was very unsteady. CNA B stated he felt 2 CNAs was not enough to monitor the residents and to prevent falls. He stated he was not aware of any new fall prevention interventions put in place for Resident #1 or Resident #2. <BR/>During an interview on 02/14/2024 at 2:00 pm, the DON stated she did not know much about Resident #1. She stated she had 130 residents and could not keep up with all of them. She stated she was not aware of any clinical issues with Resident #1 prior to the fall. She stated she was not aware of how many falls he had had but she knew he had a history of falls. She stated when a fall occurred the staff assessed the resident, notified the physician and family member, then completed an incident report. She stated she was not always notified of all falls, only falls with major injury. She stated falls were reviewed every morning during morning meeting.<BR/>During an interview on 02/15/2024 at 9:35 am, CNA B stated he was told this morning by the DON to keep resident #1 in his line of site at all times. He stated they did not increase the staffing and he still had to do his normal work and watch resident. #1. He stated he had not received any in-service regarding increased supervision for Resident #1 or Resident #2.<BR/>During an interview on 02/15/2024 at 10:40 am, the DON stated the facility had clinical meeting every morning to discuss day to day updates on all residents. She stated if a resident fell it would be discussed in the clinical meeting and new interventions should be put into place. She stated it was her responsibility to update the care plan with acute issues and new interventions. The DON stated she did not have any documentation of what was discussed in the clinical meeting she just made herself a to-do list. She stated she had missed multiple clinical meetings lately due to having to work the floor. She stated she did not have a system where she tracked falls. She stated falls were discussed in QAPI meetings monthly. She stated the facility just stated how may falls they had each month. The DON stated she was unaware of any QAPI plan specifically for falls or any fall prevention programs in place. She stated the possibility of getting Resident #1 a helmet was brought up by the family on 02/07 prior to the fall. The DON stated since Residents #1's return from the hospital on [DATE], she placed the resident on increased supervision. She stated she verbally in-serviced the staff on the secure unit and instructed them to always keep Resident #1 in line of site. She stated she did not increase staffing and did not document, or care plan the new intervention. She stated she obtained an order to refer Resident #1 to a neurologist, but she was unsure where the facility was in the process of getting that done. The DON stated she was unable to perform her clinical duties because she was working the floor or constantly putting out fires and she had not had the time do her responsibilities. She stated she did not feel that any further interventions could have been put in place to prevent the falls but agreed that the facility did not attempt any new interventions.<BR/>Interview attempted on 02/15/2024 at 11:00 am with both Medical Directors via phone. Called office and left message with no returned phone call. <BR/>During an interview on 02/15/2024 at 11:45 pm, the Administrator stated he monitored the number of falls in QAPI meetings and looked for trends, but he just looked at overall fall numbers not resident specific. He stated more interventions should have been put into place for Resident #1 and Resident #2 and it was ultimately his responsibility to ensure this was done. The Administrator stated he was notified of all falls and ensured all documentation was done. He stated he only investigated falls with injury or unwitnessed or suspicious falls.<BR/>During an interview on 02/15/2024 at 1:00 pm, CNA C stated Resident #1 had always had multiple falls. She stated she was working the day he fell and the day he returned. CNA C stated she was not aware of any new interventions being put into place. She stated Resident #2 got up quickly and fell before staff even knew that he was out of bed. She stated she tried to watch him closely but most of the time there was only 2 CNAs on the unit, and it was hard to provide 1:1 supervision. CNA denied being in-serviced or told to increase monitoring or supervision when Resident #1 returned to the facility.<BR/>During an interview on 02/15/2024 at 3:30 pm, the MDS Nurse stated she was not responsible for updating the care plan with acute or new issues. She stated she performed quarterly care plan conferences based on what was documented in the chart. She stated if the falls had been added to the care plan when they occurred and new interventions had been added then she would have discussed it in the care plan conferences. She stated it was not her responsibility to update the care plan. She stated the failure occurred because the DON had not added new interventions when the falls occurred. <BR/>Review of facility policy titled, Preventive Strategies to Reduce Fall Risk, revised October 5, 2016, revealed in part: Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. Procedure: 1. After risk is assessed, individualized nursing care plans will be implemented to prevent falls. The resident and family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects .5. Incident Reporting: Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s).<BR/>This was determined to be an Immediate Jeopardy (IJ) on 02/16/2024. The Administrator, and Director of Nurses were notified on 02/16/2024 at 10:25 am that an Immediate Jeopardy was identified, and a Plan of Removal was requested at that time. <BR/>The Administrator was provided with the IJ template on 02/16/2024 at 10:25 am. <BR/>The following Plan of Removal was accepted on 02/16/2024 at 2:35 pm and included: <BR/>Problem: F689 Accidents/Hazards<BR/>Interventions:<BR/>Resident #1's care plan was reviewed for fall prevention interventions by the DON/Regional Compliance nurse on 2/16/24. <BR/>o <BR/>Helmet ordered for safety.<BR/>o <BR/>Refusal to use assistive devices.<BR/>o <BR/>PT/OT/ST<BR/>o <BR/>Offer diversions, activities, food, conversation, etc to reduce wandering.<BR/>o <BR/>Non-skid socks <BR/>o <BR/>Increased staff rounding<BR/>Resident #2's care plan was reviewed for fall prevention interventions by the DON/Regional Compliance nurse on 2/16/24. <BR/>o <BR/>Increase rounding to promote safety.<BR/>o <BR/>Ensure a safe environment free of clutter and obstructions.<BR/>All residents with falls in the last 30 days were reviewed by DON/Regional Compliance Nurse on 2/16/24 to ensure that appropriate fall interventions are listed on the care plan. There were 50 falls with 26 residents noted in the review.<BR/>A task on the POC Kiosk was added for all resident at high risk for easy identification by the DON, ADON, and Regional Compliance Nurse on 2/16/24.<BR/>The medical director was notified of the immediate jeopardy situation on 2/16/24 at 11:30pm by the Administrator. <BR/>Ad Hoc QAPI meeting will be held on 2/16/24 to discuss the IJ and review plan of removal.<BR/>In-services:<BR/>The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following in-services. <BR/>o <BR/>Fall Prevention Policy <BR/>o <BR/>Care Plan Policy: Updating the care plan with fall prevention/safety interventions.<BR/>o <BR/>Abuse and Neglect.<BR/>The following in-services were initiated by the Regional Compliance nurse, DON, and ADON on 2/16/24. Any staff member not present or in-service on 2/16/24 will not be allowed to assume their duties until in-serviced. All new hires will be in-service at orientation. All agency staff will in serviced before assuming their assignment. <BR/>All Staff: <BR/>Abuse and Neglect Policy<BR/>Notifying the charge nurse for any change in condition to include falls, pain or a change in mobility or transfer status. <BR/>All Direct Care Staff:<BR/>Abuse and Neglect Policy <BR/>Fall Prevention Policy <BR/>Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status. <BR/>How to identify a resident who is high risk for falls on the Kiosk or Care plan<BR/>Monitoring: <BR/>DON, Administrator, Designee will review all falls during the morning meeting to ensure appropriate interventions have been implemented. Monitoring will occur 5 days per week for a minimum of 6 weeks. <BR/>DON, Administrator, Designee will review all falls during the weekly Standard of Care Meeting to ensure appropriate interventions have been implemented. Monitoring will occur weekly for a minimum of 6 weeks. <BR/>Administrator or Designee will review the Event entry and ensure that care planned interventions are change with each fall during the weekly Standards of Care Meeting. Meeting will occur weekly, and monitoring will be in place for 6 weeks.<BR/>Regional Compliance Nurse and/or ADO will monitor, on a weekly basis, that monitoring tools are in place and up to date.<BR/>Monitoring of the facility's Plan of Removal through observations, interviews, and record reviews from 02/16/2023 at 2:40 pm through 02/16/2024 at 5:30 pm revealed: <BR/>Review of Resident #1's comprehensive care plan revealed new interventions added on 02/16/2024 to include: Continues PT/OT. Started OT in October for safety and strength. ST picked up for weight and cognition. PT started for strengthening endurance related to weakness to lower extremity. Date Initiated: 02/16/2024 PT o Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Date Initiated: 02/14/2024 Revision on: 02/15/2024 o Ensure that the resident is wearing appropriate nonskid footwear or nonskid socks when ambulating Date Initiated: 08/24/2021 Revision on: 02/15/2024 o Helmet ordered by Therapy for prevention of head trauma Date Initiated: 02/16/2024 Revision on: 02/16/2024 o Keep needed items, water, etc, in reach. 2/16/24 Staff to increase visual checks to promote safety and reduce risk of fall Date Initiated: 08/24/2021 Revision on: 02/16/2024 o Resident offered and refuses to use assistive device for safety. Date Initiated: 02/16/2024 o Staff x 1 to assist with transfers, staff to monitor while in room and when resident ambulating in hallway. Date Initiated: 02/14/2024 Revision on: 02/16/2024 o The resident needs a safe environment Date Initiated: 08/24/2021 Revision on: 02/16/2024.<BR/>Observation on 02/16/2024 at 2:40 pm, Resident #1 was lying in bed with family members in his room. Observed staff in line of sight of Resident #1.<BR/>Review of Resident #2's comprehensive care plan revealed new interventions added on 02/16/2024 to include: o Ensure a safe environment free of clutter and obstructions. Date Initiated: 02/16/2024 Revision on: 02/16/2024 o Staff to increase rounding on resident to promote safety Date Initiated: 02/16/2024.<BR/>Observation on 02/16/2024 at 2:43, Resident #2 was sitting on couch in the lobby with staff beside her. <BR/>Random record reviews revealed at least 6 of the 26 residents with falls in the last 30 days had their comprehensive care plans reviewed with new interventions added on 02/16/2024. <BR/>Observation on 02/16/2024 at 2:45 pm revealed CNA B accessing the POC Kiosk (computer system used by staff) and signing off on the high fall risk alert for Resident #1. Observed high fall risk alerts on 6 random residents. <BR/>Review of an email dated 02/16/2024, sent from the Medical Director to this surveyor, stated he was aware of the IJ, and he attended the QAPI meeting via phone. <BR/>Review of a QAPI document dated 02/16/2024 revealed d the IJ with signature page of all in attendance. <BR/>In-services: Reviewed in-service information and signature sheets for in-service given by RCN to Administrator, DON, and ADON on Fall Prevention Policy, Care Plan Policy: Updating the care plan with fall prevention/safety interventions, and Abuse and Neglect <BR/>During an interview on 02/16/2024 at 3:00 pm, the Administrator and DON confirmed understanding of in-services titled: Fall Prevention Policy, Care Plan Policy: Updating the care plan with fall prevention/safety interventions, and Abuse and Neglect. <BR/>During observation on 02/16/2024 at 3:10 pm, revealed the DON educating 3 nurses, 9 CNAs, and 1 human resources staff that work the 6:30 am-6:30 pm shift, on Abuse and Neglect Policy, Fall Prevention Policy, Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status, and how to identify a resident who is high risk for falls on the Kiosk or Care plan. Interview with 2 CNAs and 1 nurse verified understanding of in-service. <BR/>During observation on 02/16/2024 at 4:00 pm, revealed the DON educating 1 CNA and 1 medication aide that work the 2:00 pm- 10:100 pm shift, on Abuse and Neglect Policy, Fall Prevention Policy, Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status, and how to identify a resident who is high risk for falls on the Kiosk or Care plan.<BR/>During observation on 02/16/2024 at 4:00 pm, revealed the DON educating 1 nurse who works 6:30 pm- 6:30 am shift via phone, on Abuse and Neglect Policy, Fall Prevention Policy, Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status, and how to identify a resident who is high risk for falls on the Kiosk or Care plan. Interview with nurse verified understanding of in-service. <BR/>The Administer, RCN, ADO, and DON were informed the Immediate Jeopardy was removed on 02/16/2024 at 5:30 pm. The facility remained out of compliance at a severity level of harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #1 and Resident #3) of 10 Residents reviewed for accuracy of assessments. <BR/>- The facility failed to ensure the Quarterly MDS dated [DATE] reflected falls and Significant Change MDS dated [DATE] reflected accurate number of falls for Resident #1. <BR/>- The facility failed to ensure the Significant Change MDS dated [DATE] reflected accurate number of falls for Resident #3. <BR/>This failure could place residents at risk of inaccurate assessments and not receiving appropriate care according to their status. <BR/>Findings include:<BR/>Resident #1<BR/>Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted to facility on 08/24/2021 with diagnoses to include: dementia, depression, schizophrenia, and repeated falls. <BR/>Review of Resident #1's Quarterly MDS assessment, dated 01/18/2024, revealed a BIMS score of 15 which indicated no impaired cognition. Section J Health Conditions: Falls revealed no falls since admission or prior assessment which was 11/15/2023.<BR/>Review of Resident #1's Significant Change MDS assessment, dated 02/14/2024, revealed a BIMS score of 11 which indicated moderate impaired cognition. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. Further review revealed: 0 falls with no injury, 0 falls with injury, and 1 fall with major injury. <BR/>Review of Resident #1's Comprehensive Care Plan, initiated 08/24/2021, revealed: Focus: The resident is at risk for falls. Goal: The resident will be free from falls through the review date. The resident will not sustain serious injury through review date. Interventions: Anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed., ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, keep furniture in locked position, Keep needed items, water in reach. Staff to make frequent visual checks to promote safety and reduce risk of fall, Physical therapy evaluate and treat as ordered or as needed, the resident needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side fails as ordered, handrails on walls, personal items within reach. The resident needs activities that minimize the potential for falls while providing diversion and distraction.<BR/>Review of facility incident log from 11/16/2023-02/07/2024, revealed Resident #1 had falls on 12/17/2023 at 3:09 pm no injury, 12/17/2023 at 6:15 pm with injury, 01/25/2024 at 2:30 pm no injury, 01/29/2024 at 4:40 pm no injury, 01/30/2024 at 4:21 pm no injury, 02/01/2024 at 4:07 pm no injury, 02/06/2024 at 3:22 pm no injury, and 02/07/2024 at 4:46 pm with injury. <BR/>Resident #3's <BR/>Review of Resident #3's electronic face sheet revealed an [AGE] year-old male admitted to facility on 11/13/2023 with diagnoses to include: depression, kidney failure, and heart disease. <BR/>Review of Resident #3's Significant Change MDS assessment, dated 01/31/2024, revealed a BIMS score of 01 which indicated severely impaired cognition. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment which was 11/17/2023. Further review revealed: 0 falls with no injury, 0 falls with injury, and 1 fall with major injury. <BR/>Review of Resident #3's Comprehensive Care Plan, initiated 11/14/2023, revealed: Focus: The resident is risk for falls related to history of cerebral infarct with residual side effects of hemiparesis. Goal: The resident will be free of falls through the review date. The resident will not sustain serious injury through the review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Ensure that the resident is wearing appropriate footwear or nonskid socks when ambulating or mobilizing in wheelchair.<BR/>Review of facility incident log from 11/16/2023-02/07/2024, revealed Resident #3 had falls on 11/23/2023 at 3:20 pm no injury, 12/01/2024 at 5:00 am no injury, 12/27/2023 at 5:20 pm with injury, 01/04/2024 at 4:40 pm no injury, 01/09/2024 at 7:56 am, and 01/12/2024 at 11:31 am no injury, 01/18/2024 at 12:49 pm with injury.<BR/>During an interview on 02/15/2024 at 03:15 PM, the DON stated she was not responsible for the oversight of MDS transmission, completion, or accuracy. She stated it was the MDS nurse's responsibility to complete and submit the MDS. She stated the regional MDS nurse was the one who provided oversight and monitored the MDS nurse. <BR/>During an interview on 02/15/2024 at 3:30 pm, the MDS Nurse stated she performed MDS assessments based on what was documented in the chart. She stated if the falls had been added to the care plan for Resident #1 and Resident #3 when they occurred and new interventions had been added then she would have known to add it to the MDS assessment. She stated it was not her responsibility to update the care plan. She stated the failure occurred because the DON had not added new interventions when falls occurred. She stated the accuracy of MDS was important because it effected the facility's reimbursement for care, and it also effected the quality of care for the residents. She stated the regional MDS nurse was responsible for her oversight. <BR/>During an interview on 02/15/2024 at 3:40 PM, the RCN stated the facility did not have a policy for MDS. He stated the facility followed the RAI timetable.<BR/>Record review of the CMS RAI Version 3.0 Manual last revised October 2023 revealed: For a Quarterly, Significant Correction to Prior Quarterly, Discharge or PPS assessment, encoding must occur within 7 days after the MDS completion Date . Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. Care plans are not required to be transmitted. Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 +14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days) . Discharge Assessment Submit by Z0500B + 14.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #1, Resident #2, and Resident #3) of 10 residents reviewed for comprehensive person-centered care plans. <BR/>The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in areas such as impaired visual function, Seizure Disorder, and risk for falls for Resident #1.<BR/>The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in areas such as hypertension, Diabetes Mellitus, and risk for falls for Resident #2. <BR/>The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in areas such as Anticoagulant and Antiplatelet therapy, hypertension, and risk for falls for Resident #3.<BR/>This failure could place the residents at risk for decreased quality of life and not having their needs met.<BR/>Findings include:<BR/>Resident #1 <BR/>Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted to facility on 08/24/2021 with diagnoses to include: dementia, depression, schizophrenia, and repeated falls. <BR/>Review of Resident #1's Quarterly MDS assessment, dated 01/18/2024, revealed a BIMS score of 15 which indicated no impaired cognition. <BR/>Review of Resident #1's Comprehensive Care Plan initiated on 08/24/2021 revealed the lack of measurable objectives to be evaluated or quantified were in the order of the problems listed above: The Resident will maintain optimal quality of life within limitation imposed by visual function, The resident will remain free from injury related to seizure activity, The resident will be free of falls The resident will not sustain serious injury.<BR/>Resident #2<BR/>Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to facility on 09/28/2022 with diagnoses to include: dementia, depression, anxiety, and unsteadiness on feet. <BR/>Review of Resident #2's Quarterly MDS assessment, dated 11/03/2023, revealed no BIMS score. <BR/>Review of Resident #2's Comprehensive Care Plan initiated on 09/29/2022 revealed the lack of measurable objectives to be evaluated or quantified were in the order of the problems listed above: The resident will remain free of complication related to hypertension, The resident will be free from any s/sx of hyperglycemia, The resident will have no complications related to diabetes, The resident will be free from any s/sx of hypoglycemia, and The resident will not sustain serious injury.<BR/>Resident #3<BR/>Review of Resident #3's electronic face sheet revealed an [AGE] year-old male admitted to facility on 11/13/2023 with diagnoses to include: depression, kidney failure, and heart disease. <BR/>Review of Resident #3's Significant Change MDS assessment, dated 01/31/2024, revealed a BIMS score of 01 which indicated severely impaired cognition. <BR/>Review of Resident #3's Comprehensive Care Plan, initiated 11/14/2023, revealed the lack of measurable objectives to be evaluated or quantified were in the order of the problems listed above: The resident will be free from discomfort or adverse reactions related to anticoagulant and antiplatelet medication use, The resident will remain free of complication related to hypertension, The resident will be free of falls, and The resident will not sustain serious injury.<BR/>During an interview on 02/15/2024 at 10:40 am, the DON stated the facility had clinical meeting every morning to discuss day to day updates on all residents. She stated it was her responsibility to update the care plan with acute issues and new interventions. The DON stated the importance of measurable objectives in an accurate care plan were for residents to receive the care needed. The Comprehensive care plans were necessary for the staff to know the residents. The care plans that were not resident centered and lack of measurable objectives could be detrimental to the resident's health and well-being. The DON stated she expected care plans to address each resident's problems with measurable objectives and have a way to determine when the problem was resolved or needed to be re-evaluated. <BR/>During an interview on 02/15/2024 at 3:30 pm, the MDS Nurse stated she was not responsible for updating the care plan with acute or new issues. She stated she performed quarterly care plan conferences based on what was documented in the chart. She stated if the falls had been added to the care plan when they occurred and new interventions had been added then she would have discussed it in the care plan conferences. She stated it was not her responsibility to update the care plan.<BR/>Record review of the facility's policy, Comprehensive Care Planning, not dated, revealed; The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights that includes measurable objectives and timeframes to meet a residents needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, and record reviews, the facility failed to ensure the comprehensive care plan were prepared by an interdisciplinary team, that included but not limited to, a nurse aide or a registered nurse with responsibility for the resident for 3 (Resident #1, Resident #2, and Resident #3) of 10 residents reviewed for care plans.<BR/>The facility failed to invite and include the input of the nursing staff as members of the interdisciplinary team after the completion of the comprehensive assessment for Resident #1, Resident #2, and Resident #3.<BR/>This failure could place the residents at risk for decreased quality of life and not having their needs met.<BR/>Findings include:<BR/>Resident #1<BR/>Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted to facility on 08/24/2021 with diagnoses to include: dementia, depression, schizophrenia, and repeated falls. <BR/>Review of Resident #1's Quarterly MDS assessment, dated 01/18/2024, revealed a BIMS score of 15 which indicated no impaired cognition. Section J Health Conditions: Falls revealed no falls since admission or prior assessment. <BR/>Review of Resident #1's Significant Change MDS assessment, dated 02/14/2024, revealed a BIMS score of 11 which indicated moderate impaired cognition. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. Further review revealed: 0 falls with no injury, 0 falls with injury, and 1 fall with major injury. <BR/>Review of Resident #1's Comprehensive Care Plan, initiated 08/24/2021, revealed the care plan was not changed or updated during the quarterly care plan meeting on 01/11/2024. Further review of Comprehensive Care Plan revealed no new interventions added or implemented since 08/24/2022.<BR/>Review of Resident #1's Care Plan Conference, dated 01/11/2024 at 9:44 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Family did not attend. RN unable to attend. Nurse aide did not attend. The documentation revealed: Went over care plan, with no changes at this time. Continue current plan of care. Participants included LVN F and Social Worker. <BR/>Resident #2<BR/>Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to facility on 09/28/2022 with diagnoses to include: dementia, depression, anxiety, and unsteadiness on feet. <BR/>Review of Resident #2's Significant Change MDS assessment, dated 12/15/2023, revealed no BIMS score. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. 0 with no injury, 1 with injury, 1 with major injury. <BR/>Review of Resident #2's Quarterly MDS assessment, dated 11/03/2023, revealed no BIMS score. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. 0 with no injury, 1 with injury, 0 with major injury. <BR/>Review of Resident #2's Comprehensive Care Plan, initiated 09/29/2022, revealed the care plan was not changed or updated during the quarterly care plan meeting on 12/26/2023. Further review of Comprehensive Care Plan revealed no new interventions added or implemented since 09/29/2022.<BR/>Review of Resident #2's Care Plan Conference, dated 12/26/2023 at 11:29 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Resident #2's family did attend. RN unable to attend. Nurse aide did not attend. The documentation revealed: Went over care plan, with no changes at this time. Continue current plan of care. Participants included LVN F and Social Worker and Resident #2's family member.<BR/>Resident #3's <BR/>Review of Resident #3's electronic face sheet revealed an [AGE] year-old male admitted to facility on 11/13/2023 with diagnoses to include: depression, kidney failure, and heart disease. <BR/>Review of Resident #3's Significant Change MDS assessment, dated 01/31/2024, revealed a BIMS score of 01 which indicated severely impaired cognition. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment which was 11/17/2023. Further review revealed: 0 falls with no injury, 0 falls with injury, and 1 fall with major injury. <BR/>Review of Resident #3's Comprehensive Care Plan, initiated 11/14/2023, revealed the care plan was not changed or updated during the quarterly care plan meeting on 02/13/2024. Further review of Comprehensive Care Plan revealed no new interventions added or implemented since 11/14/2023.<BR/>Review of Resident #3's Care Plan Conference, dated 02/13/2024 at 11:12 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Resident #3's family did attend. RN unable to attend. Nurse aide did not attend. The documentation revealed: No changes made to plan of care. Continue current plan of care. Participants included LVN F and Social Worker and Resident #3's family member via phone.<BR/>During an interview on 02/15/2024 at 3:30 pm, the MDS Nurse stated she was not responsible for updating the care plan with acute or new issues. She stated she performed quarterly care plan conferences based on what was documented in the chart. She stated if the falls had been added to the care plan when they occurred and new interventions had been added then she would have discussed it in the care plan conferences. She stated it was not her responsibility to update the care plan. The MDS nurse stated nurse aides and registered nurses were not invited to the care plan conferences because it was just not feasible. She stated direct care staff did not have time to participate. She stated the social worker schedules the conferences and invites the attendees. The MDS nurse stated she was aware of the facilities policy that nurse aides and registered nurses were supposed to attend care conferences and she was aware the facility was cited for this in November. She stated there was a performance improvement plan in place but once again it just was not feasible. <BR/>During an interview on 02/15/2024 at 5:40 pm, LVN A said she had not attended or been invited to a care plan meeting. LVN A said the direct care staff should be able to attend the care plan meetings because they were the staff with key input to the residents' behaviors, monitoring and preventing behaviors and the CNAs knew what interventions worked and did not work. LVN A said the CNAs also knew the concerns and conditions of the residents they work with every day.<BR/>During an interview on 02/15/2024 at 5:50 pm, CNA B said he had never attended a care plan meeting or was asked for input for the care plan for Resident #1 or any other resident on the locked unit.<BR/>During an interview on 02/15/2024 at 6:00 pm, the Administrator stated he was unaware the facility had been cited in November for the same issue. He stated he was ultimately responsible for ensuring the previous plan of correction was being implemented. <BR/>Record review of the facility's policy, Comprehensive Care Planning, not dated, revealed the interdisciplinary team included but was not limited to - <BR/>- <BR/>The attending physician<BR/>- <BR/>A registered nurse with responsibility for the resident<BR/>- <BR/>A nurse aide with responsibility for the resident<BR/>- <BR/>A member of food and nutritional services staff<BR/>- <BR/>The resident and the resident's representative<BR/>- <BR/>Other appropriate staff or professionals determined by the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 2 (Resident #1 and Resident #2) of 10 residents reviewed for multiple falls.<BR/>The facility failed to implement a system for identifying fall patterns and implementing interventions to prevent falls that lead to emergency room visits with serious injury on 12/17/2023 and 02/07/2024 for Resident #1 and 12/10/2023 and 01/04/2024 for Resident #2.<BR/>An IJ was identified on 02/16/2024. The IJ template was provided to the facility on [DATE] at 10:25 am. While the IJ was removed on 02/16/2024, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. <BR/>These failures could place the residents at risk for falls, serious injuries, hospitalizations, and death. <BR/>Findings include:<BR/>Resident #1<BR/>Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted to facility on 08/24/2021 with diagnoses to include: dementia, depression, schizophrenia, and repeated falls. <BR/>Review of Resident #1's Quarterly MDS assessment, dated 01/18/2024, revealed a BIMS score of 15 which indicated no impaired cognition. Section J Health Conditions: Falls revealed no falls since admission or prior assessment. <BR/>Review of Resident #1's Significant Change MDS assessment, dated 02/14/2024, revealed a BIMS score of 11 which indicated moderate impaired cognition. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. Further review revealed: 0 falls with no injury, 0 falls with injury, and 1 fall with major injury. <BR/>Review of Resident #1's Comprehensive Care Plan, initiated 08/24/2021, revealed: Focus: The resident is at risk for falls. Goal: The resident will be free from falls through the review date. The resident will not sustain serious injury through review date. Interventions: Anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed., ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, keep furniture in locked position, Keep needed items, water in reach. Staff to make frequent visual checks to promote safety and reduce risk of fall, Physical therapy evaluate and treat as ordered or as needed, the resident needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side fails as ordered, handrails on walls, personal items within reach. The resident needs activities that minimize the potential for falls while providing diversion and distraction. Further review of the Comprehensive Care Plan revealed no new interventions added or implemented since 08/24/2021.<BR/>Review of Resident #1's Fall Event Nurses' Note, dated 02/07/2024 at 4:48 PM, signed by LVN D, revealed: Resident #1 had an unwitnessed fall where he hit his head. Resident #1 was ambulating in hallway, and he fell in hallway face first. He bloodied his nose and received a bruise to the right side of his forehead. Doctor was notified and Resident #1 was sent to the emergency room for evaluation and treatment. <BR/>Review of Resident #1's hospital clinical record, dated 02/07/2024, revealed: Injuries: Subdural hematoma (blood around the brain), Hemorrhagic contusion right inferior temporal region (bleeding brain bruise), left periorbital hematoma (bruise around the eye), and left 7th, 9th, and 10th rib fractures. Resident #1 was discharged back to facility on 02/08/2024.<BR/>Review of Resident #1's Fall Event Nurses' Note, dated 12/17/2023 at 6:48 PM, signed by RN E, revealed: Resident #1 had an unwitnessed fall. Resident #1 fell and hit head on floor with laceration. Resident #1 was transferred to the emergency room.<BR/>Review of Resident #1's hospital clinical record, dated 12/17/2023, revealed: Injury: Laceration sustained to left parietal area (top rear of head) is clean, jagged, superficial, 2.6 by 7.5 centimeters. Wound care applied 5 stiches. Resident #1 was discharged back to facility on 12/17/2023.<BR/>Review of the facility's incident log from 11/16/2023-02/07/2024, revealed Resident #1 had falls on 12/17/2023 at 3:09 pm no injury, 12/17/2023 at 6:15 pm with injury, 01/25/2024 at 2:30 pm no injury, 01/29/2024 at 4:40 pm no injury, 01/30/2024 at 4:21 pm no injury, 02/01/2024 at 4:07 pm no injury, 02/06/2024 at 3:22 pm no injury, and 02/07/2024 at 4:46 pm with injury. <BR/>Review of Resident #1's Fall Risk Assessments dated 12/17/2023 revealed a score of 13 High Risk, 01/25/2024 score 18 High Risk, 01/29/2024 score 21 High Risk, 01/30/2024 score 21 High Risk, 02/01/2024 score 18 High Risk, 02/06/2024 score 20 High Risk, and 02/07/2024 score 23 High Risk.<BR/>Review of Resident #1's Care Plan Conference, dated 01/11/2024 at 9:44 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Family did not attend. Went over care plan, with no changes at this time. Continue current plan of care.<BR/>Observation on 02/14/2024 at 12:40 pm, revealed Resident #1 on the secure unit lying in bed no distress noted. Resident was alert but not oriented and not really communicating. Nurse and CNA were currently sitting at bedside.<BR/>Observation on 02/15/2024 at 9:30 am, revealed Resident #1 was lying in bed. The bed was in a low position. There was no siderail or handrails on the bed. Resident #1 had his eyes open and looked at the surveyor but did not speak. There were 3 CNAs in the resident's room.<BR/>Resident #2<BR/>Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to facility on 09/28/2022 with diagnoses to include: dementia, depression, anxiety, and unsteadiness on feet. <BR/>Review of Resident #2's Significant Change MDS assessment, dated 12/15/2023, revealed no BIMS score. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. 0 with no injury, 1 with injury, 1 with major injury. <BR/>Review of Resident #2's Quarterly MDS assessment, dated 11/03/2023, revealed no BIMS score. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. 0 with no injury, 1 with injury, 0 with major injury. <BR/>Review of Resident #2's Comprehensive Care Plan, initiated 09/29/2022, revealed: Focus: The resident is at risk for falls related to She has had actual falls since entering the facility due to poor gait and balance, dementia with poor safety awareness and judgment. Actual fall 12/10/23 Fall between bed and wall causing Right Rib Fracture and mild pneumothorax resulting in emergency room visit. Goal: The resident will not sustain serious injury through review date. Interventions: Anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, Ensure that the resident is wearing appropriate footwear when ambulating, Staff x 1 to assist with transfers, and the resident needs activities that minimize the potential for falls while providing diversion and distraction. Further review of the Comprehensive Care Plan revealed no new interventions added or implemented since 09/29/2022.<BR/>Review of Resident #2's Fall Event Nurses' Note, dated 12/10/2023 at 6:05 AM, signed by LVN G, revealed: Resident #2 had an unwitnessed fall. CNA reported that resident had fallen on the floor. This nurse went into residents' room and found her lying on the floor on her right side and screaming in pain and holding her right side at her rib cage. Having difficulty breathing at this time. Bedside toilet and table and walker all turned over on floor by her. Resident #2 was transferred to the emergency room.<BR/>Review of Resident #2's hospital discharge record, dated 12/10/2023, revealed: Diagnosis Fractured rib and head injury. Resident #2 was discharged back to the facility on [DATE].<BR/>Review of Resident #2's Fall Event Nurses' Note, dated 01/04/2024 at 9:50 PM, signed by LVN H, revealed: Resident #2 had an unwitnessed fall. CNA noticed blood on resident's shirt and observed blood in residents' hair and notified nurse. I assessed resident and observed laceration to right side of resident's head. Resident was guarding right shoulder as well. Resident #2 was transferred to the emergency room.<BR/>Review of Resident #2's hospital clinical record, dated 01/04/2024, revealed: Abrasion on the right scalp and shoulder pain. Resident #2 was discharged back to the facility on [DATE].<BR/>Review of the facility's incident log from 11/16/2023-02/07/2024, revealed Resident #2 had falls on 11/19/2023 at 11:00 pm with no injury, 12/10/2023 at 5:44 am with injury, 12/23/2023 at 10:00 am with no injury, and 01/04/2024 at 8:15 pm with injury.<BR/>Review of Resident #2's Fall Risk Assessments dated 11/19/2023 revealed score 16 High Risk, 12/10/2023 score 19 High Risk, 12/23/2023 score 15 High Risk, 01/04/2024 score 15 High Risk.<BR/>Review of Resident #2's Care Plan Conference, dated 12/26/2023 at 11:29 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Resident #2's [family member] did attend. Went over care plan, with no changes at this time. Continue current plan of care.<BR/>Observation on 02/15/2024 at 4:00 pm, revealed Resident #2 ambulating up and down the hall. Resident seemed unsteady on her feet. Resident was wandering in and out of other residents' rooms.<BR/>During an interview on 02/14/2024 at 12:45 pm, LVN A stated Resident #1 had a history of falling. She stated she had been sitting in his room since his return from the hospital as much as she could because she did not want him to fall again. She stated Resident had a history of wandering and was only oriented to his name. She stated she was trying to increase supervision. She stated she had not been instructed to sit or monitor Resident #1 by the facility. She stated she just was because she was concerned. She stated she had spoken to the DON and informed her that Resident #1 needed 1:1 supervision but she was told the facility did not have the staff for that. She stated there was always 2 CNAs on the secure unit. LVN A stated Resident #2 had a history of wandering and falls also. She stated Resident #2 walks the unit continuously and it was almost impossible to keep an eye on her all the time. She stated Resident #2 had no new fall interventions that she was aware of. <BR/>During an interview on 02/14/2024 at 12:50 pm, CNA B stated he was working with another resident the day Resident #1 fell and was injured. He stated his coworker was in a room and he was assisting the nurse with another resident when he heard a loud noise. He stated he turned around and Resident #1 was lying face down in his doorway covered in blood. He stated he had seen Resident #1 in his bed 15 minutes prior to the fall. He stated he always tried to watch Resident #1 closely and made sure to check on him every 15 minutes when possible. He stated he had asked for help and spoke to the DON and Administrator about not having adequate staff to meet Resident #1's needs. He stated Resident #2 was also a high fall risk. He stated Resident #2 continuously wandered and was very unsteady. CNA B stated he felt 2 CNAs was not enough to monitor the residents and to prevent falls. He stated he was not aware of any new fall prevention interventions put in place for Resident #1 or Resident #2. <BR/>During an interview on 02/14/2024 at 2:00 pm, the DON stated she did not know much about Resident #1. She stated she had 130 residents and could not keep up with all of them. She stated she was not aware of any clinical issues with Resident #1 prior to the fall. She stated she was not aware of how many falls he had had but she knew he had a history of falls. She stated when a fall occurred the staff assessed the resident, notified the physician and family member, then completed an incident report. She stated she was not always notified of all falls, only falls with major injury. She stated falls were reviewed every morning during morning meeting.<BR/>During an interview on 02/15/2024 at 9:35 am, CNA B stated he was told this morning by the DON to keep resident #1 in his line of site at all times. He stated they did not increase the staffing and he still had to do his normal work and watch resident. #1. He stated he had not received any in-service regarding increased supervision for Resident #1 or Resident #2.<BR/>During an interview on 02/15/2024 at 10:40 am, the DON stated the facility had clinical meeting every morning to discuss day to day updates on all residents. She stated if a resident fell it would be discussed in the clinical meeting and new interventions should be put into place. She stated it was her responsibility to update the care plan with acute issues and new interventions. The DON stated she did not have any documentation of what was discussed in the clinical meeting she just made herself a to-do list. She stated she had missed multiple clinical meetings lately due to having to work the floor. She stated she did not have a system where she tracked falls. She stated falls were discussed in QAPI meetings monthly. She stated the facility just stated how may falls they had each month. The DON stated she was unaware of any QAPI plan specifically for falls or any fall prevention programs in place. She stated the possibility of getting Resident #1 a helmet was brought up by the family on 02/07 prior to the fall. The DON stated since Residents #1's return from the hospital on [DATE], she placed the resident on increased supervision. She stated she verbally in-serviced the staff on the secure unit and instructed them to always keep Resident #1 in line of site. She stated she did not increase staffing and did not document, or care plan the new intervention. She stated she obtained an order to refer Resident #1 to a neurologist, but she was unsure where the facility was in the process of getting that done. The DON stated she was unable to perform her clinical duties because she was working the floor or constantly putting out fires and she had not had the time do her responsibilities. She stated she did not feel that any further interventions could have been put in place to prevent the falls but agreed that the facility did not attempt any new interventions.<BR/>Interview attempted on 02/15/2024 at 11:00 am with both Medical Directors via phone. Called office and left message with no returned phone call. <BR/>During an interview on 02/15/2024 at 11:45 pm, the Administrator stated he monitored the number of falls in QAPI meetings and looked for trends, but he just looked at overall fall numbers not resident specific. He stated more interventions should have been put into place for Resident #1 and Resident #2 and it was ultimately his responsibility to ensure this was done. The Administrator stated he was notified of all falls and ensured all documentation was done. He stated he only investigated falls with injury or unwitnessed or suspicious falls.<BR/>During an interview on 02/15/2024 at 1:00 pm, CNA C stated Resident #1 had always had multiple falls. She stated she was working the day he fell and the day he returned. CNA C stated she was not aware of any new interventions being put into place. She stated Resident #2 got up quickly and fell before staff even knew that he was out of bed. She stated she tried to watch him closely but most of the time there was only 2 CNAs on the unit, and it was hard to provide 1:1 supervision. CNA denied being in-serviced or told to increase monitoring or supervision when Resident #1 returned to the facility.<BR/>During an interview on 02/15/2024 at 3:30 pm, the MDS Nurse stated she was not responsible for updating the care plan with acute or new issues. She stated she performed quarterly care plan conferences based on what was documented in the chart. She stated if the falls had been added to the care plan when they occurred and new interventions had been added then she would have discussed it in the care plan conferences. She stated it was not her responsibility to update the care plan. She stated the failure occurred because the DON had not added new interventions when the falls occurred. <BR/>Review of facility policy titled, Preventive Strategies to Reduce Fall Risk, revised October 5, 2016, revealed in part: Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. Procedure: 1. After risk is assessed, individualized nursing care plans will be implemented to prevent falls. The resident and family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects .5. Incident Reporting: Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s).<BR/>This was determined to be an Immediate Jeopardy (IJ) on 02/16/2024. The Administrator, and Director of Nurses were notified on 02/16/2024 at 10:25 am that an Immediate Jeopardy was identified, and a Plan of Removal was requested at that time. <BR/>The Administrator was provided with the IJ template on 02/16/2024 at 10:25 am. <BR/>The following Plan of Removal was accepted on 02/16/2024 at 2:35 pm and included: <BR/>Problem: F689 Accidents/Hazards<BR/>Interventions:<BR/>Resident #1's care plan was reviewed for fall prevention interventions by the DON/Regional Compliance nurse on 2/16/24. <BR/>o <BR/>Helmet ordered for safety.<BR/>o <BR/>Refusal to use assistive devices.<BR/>o <BR/>PT/OT/ST<BR/>o <BR/>Offer diversions, activities, food, conversation, etc to reduce wandering.<BR/>o <BR/>Non-skid socks <BR/>o <BR/>Increased staff rounding<BR/>Resident #2's care plan was reviewed for fall prevention interventions by the DON/Regional Compliance nurse on 2/16/24. <BR/>o <BR/>Increase rounding to promote safety.<BR/>o <BR/>Ensure a safe environment free of clutter and obstructions.<BR/>All residents with falls in the last 30 days were reviewed by DON/Regional Compliance Nurse on 2/16/24 to ensure that appropriate fall interventions are listed on the care plan. There were 50 falls with 26 residents noted in the review.<BR/>A task on the POC Kiosk was added for all resident at high risk for easy identification by the DON, ADON, and Regional Compliance Nurse on 2/16/24.<BR/>The medical director was notified of the immediate jeopardy situation on 2/16/24 at 11:30pm by the Administrator. <BR/>Ad Hoc QAPI meeting will be held on 2/16/24 to discuss the IJ and review plan of removal.<BR/>In-services:<BR/>The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following in-services. <BR/>o <BR/>Fall Prevention Policy <BR/>o <BR/>Care Plan Policy: Updating the care plan with fall prevention/safety interventions.<BR/>o <BR/>Abuse and Neglect.<BR/>The following in-services were initiated by the Regional Compliance nurse, DON, and ADON on 2/16/24. Any staff member not present or in-service on 2/16/24 will not be allowed to assume their duties until in-serviced. All new hires will be in-service at orientation. All agency staff will in serviced before assuming their assignment. <BR/>All Staff: <BR/>Abuse and Neglect Policy<BR/>Notifying the charge nurse for any change in condition to include falls, pain or a change in mobility or transfer status. <BR/>All Direct Care Staff:<BR/>Abuse and Neglect Policy <BR/>Fall Prevention Policy <BR/>Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status. <BR/>How to identify a resident who is high risk for falls on the Kiosk or Care plan<BR/>Monitoring: <BR/>DON, Administrator, Designee will review all falls during the morning meeting to ensure appropriate interventions have been implemented. Monitoring will occur 5 days per week for a minimum of 6 weeks. <BR/>DON, Administrator, Designee will review all falls during the weekly Standard of Care Meeting to ensure appropriate interventions have been implemented. Monitoring will occur weekly for a minimum of 6 weeks. <BR/>Administrator or Designee will review the Event entry and ensure that care planned interventions are change with each fall during the weekly Standards of Care Meeting. Meeting will occur weekly, and monitoring will be in place for 6 weeks.<BR/>Regional Compliance Nurse and/or ADO will monitor, on a weekly basis, that monitoring tools are in place and up to date.<BR/>Monitoring of the facility's Plan of Removal through observations, interviews, and record reviews from 02/16/2023 at 2:40 pm through 02/16/2024 at 5:30 pm revealed: <BR/>Review of Resident #1's comprehensive care plan revealed new interventions added on 02/16/2024 to include: Continues PT/OT. Started OT in October for safety and strength. ST picked up for weight and cognition. PT started for strengthening endurance related to weakness to lower extremity. Date Initiated: 02/16/2024 PT o Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Date Initiated: 02/14/2024 Revision on: 02/15/2024 o Ensure that the resident is wearing appropriate nonskid footwear or nonskid socks when ambulating Date Initiated: 08/24/2021 Revision on: 02/15/2024 o Helmet ordered by Therapy for prevention of head trauma Date Initiated: 02/16/2024 Revision on: 02/16/2024 o Keep needed items, water, etc, in reach. 2/16/24 Staff to increase visual checks to promote safety and reduce risk of fall Date Initiated: 08/24/2021 Revision on: 02/16/2024 o Resident offered and refuses to use assistive device for safety. Date Initiated: 02/16/2024 o Staff x 1 to assist with transfers, staff to monitor while in room and when resident ambulating in hallway. Date Initiated: 02/14/2024 Revision on: 02/16/2024 o The resident needs a safe environment Date Initiated: 08/24/2021 Revision on: 02/16/2024.<BR/>Observation on 02/16/2024 at 2:40 pm, Resident #1 was lying in bed with family members in his room. Observed staff in line of sight of Resident #1.<BR/>Review of Resident #2's comprehensive care plan revealed new interventions added on 02/16/2024 to include: o Ensure a safe environment free of clutter and obstructions. Date Initiated: 02/16/2024 Revision on: 02/16/2024 o Staff to increase rounding on resident to promote safety Date Initiated: 02/16/2024.<BR/>Observation on 02/16/2024 at 2:43, Resident #2 was sitting on couch in the lobby with staff beside her. <BR/>Random record reviews revealed at least 6 of the 26 residents with falls in the last 30 days had their comprehensive care plans reviewed with new interventions added on 02/16/2024. <BR/>Observation on 02/16/2024 at 2:45 pm revealed CNA B accessing the POC Kiosk (computer system used by staff) and signing off on the high fall risk alert for Resident #1. Observed high fall risk alerts on 6 random residents. <BR/>Review of an email dated 02/16/2024, sent from the Medical Director to this surveyor, stated he was aware of the IJ, and he attended the QAPI meeting via phone. <BR/>Review of a QAPI document dated 02/16/2024 revealed d the IJ with signature page of all in attendance. <BR/>In-services: Reviewed in-service information and signature sheets for in-service given by RCN to Administrator, DON, and ADON on Fall Prevention Policy, Care Plan Policy: Updating the care plan with fall prevention/safety interventions, and Abuse and Neglect <BR/>During an interview on 02/16/2024 at 3:00 pm, the Administrator and DON confirmed understanding of in-services titled: Fall Prevention Policy, Care Plan Policy: Updating the care plan with fall prevention/safety interventions, and Abuse and Neglect. <BR/>During observation on 02/16/2024 at 3:10 pm, revealed the DON educating 3 nurses, 9 CNAs, and 1 human resources staff that work the 6:30 am-6:30 pm shift, on Abuse and Neglect Policy, Fall Prevention Policy, Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status, and how to identify a resident who is high risk for falls on the Kiosk or Care plan. Interview with 2 CNAs and 1 nurse verified understanding of in-service. <BR/>During observation on 02/16/2024 at 4:00 pm, revealed the DON educating 1 CNA and 1 medication aide that work the 2:00 pm- 10:100 pm shift, on Abuse and Neglect Policy, Fall Prevention Policy, Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status, and how to identify a resident who is high risk for falls on the Kiosk or Care plan.<BR/>During observation on 02/16/2024 at 4:00 pm, revealed the DON educating 1 nurse who works 6:30 pm- 6:30 am shift via phone, on Abuse and Neglect Policy, Fall Prevention Policy, Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status, and how to identify a resident who is high risk for falls on the Kiosk or Care plan. Interview with nurse verified understanding of in-service. <BR/>The Administer, RCN, ADO, and DON were informed the Immediate Jeopardy was removed on 02/16/2024 at 5:30 pm. The facility remained out of compliance at a severity level of harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and records review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to implement an appropriate action plan to address identified quality deficiencies for 1 of 1 facility.<BR/>The QAPI committee failed to implement the corrective actions outlined on the Plan of Correction dated 12/13/2023 for deficient practice F657.<BR/>This failure placed residents at risk for substandard quality of care due to the failure of the facility to take action on an identified problem affecting resident safety. <BR/>Findings include:<BR/>Review of a CMS 2567 dated 11/16/23 revealed that, based on observation, interviews, and record review, a deficient practice was cited at F657 (Care Plan Timing and Revision) during the 11/16/23 SSA recertification survey. Interviews and records revealed that the facility failed to invite and include the input of the nursing staff as members of the interdisciplinary team after the completion of the comprehensive assessment.<BR/>Review of the facility's 12/22/23 Plan of Correction which was submitted in response to the 02/15/23 SSA recertification survey revealed the facility's plan as The Administrator or designee will ensure required attendees for Comprehensive Care Plans are invited and attend per State and Federal regulations and Comprehensive Care Plan attendance sheets will be monitored for completion by the Administrator or designee and through QAPI for 3 months.<BR/>Review of Resident #1's Care Plan Conference, dated 01/11/2024 at 9:44 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Family did not attend. RN unable to attend. Nurse aide did not attend. The documentation revealed: Went over care plan, with no changes at this time. Continue current plan of care. Participants included LVN F and Social Worker. <BR/>Review of Resident #2's Care Plan Conference, dated 12/26/2023 at 11:29 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Resident #2's family did attend. RN unable to attend. Nurse aide did not attend. The documentation revealed: Went over care plan, with no changes at this time. Continue current plan of care. Participants included LVN F and Social Worker and Resident #2's family member.<BR/>Review of Resident #3's Care Plan Conference, dated 02/13/2024 at 11:12 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Resident #3's family did attend. RN unable to attend. Nurse aide did not attend. The documentation revealed: No changes made to plan of care. Continue current plan of care. Participants included LVN F and Social Worker and Resident #3's family member via phone.<BR/>During an interview on 02/15/2024 at 6:00 pm, the Administrator stated he was unaware the facility had been cited in November for the same issue. He stated he was ultimately responsible for ensuring the previous plan of correction was being implemented. <BR/>The Administrator confirmed he was not the Administrator during the recertification survey on 11/16/23 when SSA cited F657 as an area of concern. When asked about the facility's plan of correction, the Administrator did state he completed it, signed it, and submitted it. He stated he was ultimately responsible for ensuring the plan of correction was followed. The Administrator stated since he was new to the facility, he was playing catch up and had missed several things. He stated that he felt that the MDS nurse was following the plan of correction, but he had not followed up an monitored the care plan conference attendance. <BR/>Review of the facility's policy revised March 2020, titled, Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership, revealed, The Quality Assurance and Performance Improvement Program is overseen and implemented by the QAPI Committee, which reports its findings, actions and results to the Administrator and governing body. The responsibilities of the QAPI Committee are to: b. Identify, evaluate, monitor and improve facility systems and processes that support the delivery of care and services and g. Coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #1 and Resident #3) of 10 Residents reviewed for accuracy of assessments. <BR/>- The facility failed to ensure the Quarterly MDS dated [DATE] reflected falls and Significant Change MDS dated [DATE] reflected accurate number of falls for Resident #1. <BR/>- The facility failed to ensure the Significant Change MDS dated [DATE] reflected accurate number of falls for Resident #3. <BR/>This failure could place residents at risk of inaccurate assessments and not receiving appropriate care according to their status. <BR/>Findings include:<BR/>Resident #1<BR/>Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted to facility on 08/24/2021 with diagnoses to include: dementia, depression, schizophrenia, and repeated falls. <BR/>Review of Resident #1's Quarterly MDS assessment, dated 01/18/2024, revealed a BIMS score of 15 which indicated no impaired cognition. Section J Health Conditions: Falls revealed no falls since admission or prior assessment which was 11/15/2023.<BR/>Review of Resident #1's Significant Change MDS assessment, dated 02/14/2024, revealed a BIMS score of 11 which indicated moderate impaired cognition. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. Further review revealed: 0 falls with no injury, 0 falls with injury, and 1 fall with major injury. <BR/>Review of Resident #1's Comprehensive Care Plan, initiated 08/24/2021, revealed: Focus: The resident is at risk for falls. Goal: The resident will be free from falls through the review date. The resident will not sustain serious injury through review date. Interventions: Anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed., ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, keep furniture in locked position, Keep needed items, water in reach. Staff to make frequent visual checks to promote safety and reduce risk of fall, Physical therapy evaluate and treat as ordered or as needed, the resident needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side fails as ordered, handrails on walls, personal items within reach. The resident needs activities that minimize the potential for falls while providing diversion and distraction.<BR/>Review of facility incident log from 11/16/2023-02/07/2024, revealed Resident #1 had falls on 12/17/2023 at 3:09 pm no injury, 12/17/2023 at 6:15 pm with injury, 01/25/2024 at 2:30 pm no injury, 01/29/2024 at 4:40 pm no injury, 01/30/2024 at 4:21 pm no injury, 02/01/2024 at 4:07 pm no injury, 02/06/2024 at 3:22 pm no injury, and 02/07/2024 at 4:46 pm with injury. <BR/>Resident #3's <BR/>Review of Resident #3's electronic face sheet revealed an [AGE] year-old male admitted to facility on 11/13/2023 with diagnoses to include: depression, kidney failure, and heart disease. <BR/>Review of Resident #3's Significant Change MDS assessment, dated 01/31/2024, revealed a BIMS score of 01 which indicated severely impaired cognition. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment which was 11/17/2023. Further review revealed: 0 falls with no injury, 0 falls with injury, and 1 fall with major injury. <BR/>Review of Resident #3's Comprehensive Care Plan, initiated 11/14/2023, revealed: Focus: The resident is risk for falls related to history of cerebral infarct with residual side effects of hemiparesis. Goal: The resident will be free of falls through the review date. The resident will not sustain serious injury through the review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Ensure that the resident is wearing appropriate footwear or nonskid socks when ambulating or mobilizing in wheelchair.<BR/>Review of facility incident log from 11/16/2023-02/07/2024, revealed Resident #3 had falls on 11/23/2023 at 3:20 pm no injury, 12/01/2024 at 5:00 am no injury, 12/27/2023 at 5:20 pm with injury, 01/04/2024 at 4:40 pm no injury, 01/09/2024 at 7:56 am, and 01/12/2024 at 11:31 am no injury, 01/18/2024 at 12:49 pm with injury.<BR/>During an interview on 02/15/2024 at 03:15 PM, the DON stated she was not responsible for the oversight of MDS transmission, completion, or accuracy. She stated it was the MDS nurse's responsibility to complete and submit the MDS. She stated the regional MDS nurse was the one who provided oversight and monitored the MDS nurse. <BR/>During an interview on 02/15/2024 at 3:30 pm, the MDS Nurse stated she performed MDS assessments based on what was documented in the chart. She stated if the falls had been added to the care plan for Resident #1 and Resident #3 when they occurred and new interventions had been added then she would have known to add it to the MDS assessment. She stated it was not her responsibility to update the care plan. She stated the failure occurred because the DON had not added new interventions when falls occurred. She stated the accuracy of MDS was important because it effected the facility's reimbursement for care, and it also effected the quality of care for the residents. She stated the regional MDS nurse was responsible for her oversight. <BR/>During an interview on 02/15/2024 at 3:40 PM, the RCN stated the facility did not have a policy for MDS. He stated the facility followed the RAI timetable.<BR/>Record review of the CMS RAI Version 3.0 Manual last revised October 2023 revealed: For a Quarterly, Significant Correction to Prior Quarterly, Discharge or PPS assessment, encoding must occur within 7 days after the MDS completion Date . Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. Care plans are not required to be transmitted. Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 +14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days) . Discharge Assessment Submit by Z0500B + 14.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 (Hall G medication cart and Hall E medication cart) of 6 medication carts reviewed for medication labeling and storage.<BR/>The facility failed to ensure that insulin stored on Hall G and Hall E's medication cart were properly labeled and not past the medications' expiration date. <BR/>These failures could place residents at risk of harm or decline in health due to lack of potency of medications/biologicals.<BR/>The findings included: <BR/>During an observation on [DATE] at 08:54 a.m., the G Hall medication cart located at the nurses station inspected for medication storage and labeling revealed: <BR/>1. <BR/>Two insulin lispro pen injectors not labeled with an open date.<BR/>2. <BR/>Two insulin glargine pen injectors not labeled with an open date.<BR/>During an observation on [DATE] at 09:08 a.m., the E Hall medication cart located on E Hall inspected for medication storage and labeling revealed:<BR/>1. <BR/>One insulin lispro pen injector not labeled with an open date. <BR/>During an interview on [DATE] at 09:08 a.m., LVN J stated she was not aware the insulin on G Hall medication cart did not have an open date labeled on pen injectors. She stated that the insulins are supposed to have an open date when first used. She did not give an explanation to why insulins were not labeled when opened. She stated she will take the unlabeled insulin pen injectors to DON to ask what needs to be done. <BR/>During an interview on [DATE] at 09:10 a.m., LVN K stated that he was unsure why insulin on E Hall medication cart did not have an open date labeled on pen injectors. He stated that insulins should be labeled with an open date when first used. He did not give an explanation to why insulins were not labeled when opened. <BR/>During an interview on [DATE] at 09:13 a.m., ADON L stated that insulin should be dated with an open date when it was first used. She did not know why insulins were found on medication carts with no open date. She stated that the effect on residents could be that medication would not be as effective. She stated that nurses have instructions from pharmacy on medication carts stating that insulin should be disposed of 28 days after open date.<BR/>During an interview on [DATE] at 02:39 p.m., the DON stated that insulin should be labeled with an open date when it was first used. She stated that the pharmacy and the ADONs were responsible for monitoring if medication was stored properly but ultimately the responsibility fell on her. She said that does not know the last date pharmacy was in facility to inspect carts and educate staff. She stated that if there is no open date on the insulin, facility could go by dispense date if it was less than 28 days in the past. She stated that the facility disposed of unlabeled insulin pen injectors brought to her earlier being the dispense date was over 28 days in the past and they had no way of knowing when opened. She stated that she expects the nurses to dispose of medications when they are expired. She stated that education and training led to the failure. She stated that medications' desired effect could decrease when used after 28 days of being opened or expired. <BR/>Record review on [DATE] of policy titled Recommended Mediation Storage last revised 07/2012 revealed Medications that require an open date as directed by the manufacturer should be dated when opened in a manner that it is clear when the medication was opened. Below is a list of medications that require a date when opening and the recommended time frame the medication should be used. This is not an all-inclusive list and the manufacturer recommendations will supersede this list .INSULINS (Vials, Cartridge, Pens) .Humulin R, N, 70/30 and Mix Humalog and Humalog Mix .Insulin glarglne Lantus) .Refrigerate until initial use; Expires 28 days after initial use regardless of product storage (refrigerated or room temperature); Unopened, refrigerated insulin vials remain effective until the vial expiration date.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitization<BR/>The facility failed to ensure that kitchen staff obtained food temperatures prior to serving meals on 09/04/2023, 09/14/2023,09/15/2023, 09/19/2023, 09/20/2023, 09/24/2023, 09/27/2023, 09/28/2023, 09/29/2023, 09/30/2023, 10/01/2023, 10/02/2023, and 10/03/2023. <BR/>The facility failed to ensure plastic drinking cups were cleaned and sanitized properly. <BR/>These failures could place residents that eat out of the kitchen at risk for food borne illnesses.<BR/>Findings included: <BR/>During an observation on 10/03/2023 at 9:45 AM of the kitchen revealed blanks on temperature logs for the month of October 2023. <BR/>During an interview on 10/03/2023 at 9:45 AM the DM stated the cook was to write the temperatures of food when it was cooked on the temperature log. The DM stated if the cook did not write the temperature on log, then there was no way to prove that the temperatures were taken. <BR/>During an observation and interview on 10/03/2023 at 1:45 PM in the dining room revealed Resident # 1 sitting at a table with 2 other residents. Resident #1's pointed out cups at table that residents were served during lunch. One plastic cup had a cloudy film on the inside and one plastic cup had a brown film on the inside. Resident # 1 stated there had been a problem with cups not being clean. Resident # 1 stated look I can rub this brown stuff off the inside of the cup. Resident #1 stated the stained cup makes my milk look like root beer. Resident #1 stated she did not like drinking out of cups that are not clean. Resident #1 stated sometimes the food was not hot when they received food.<BR/>During an observation on 10/03/2023 at 2:00 PM of the kitchen revealed dietary staff pouring milk into plastic drinking cups. One of the plastic cups was observed to have a brown film on the inside of the cup, which made the white milk look like brown milk. Dietary staff put lids on cup and placed them into fridge. <BR/>During an interview on 10/03/2023 at 1:50 PM Resident # 2 stated she had received cups that did not appear to be clean. Resident # 2 stated it was gross to drink out of cups that looked dirty. Resident # 2 stated food was served cold at times and would have to ask them to heat food. <BR/>During an interview on 10/03/2023 at 3:15 PM the DM stated staff should not be serving residents drinks in cups that are stained. The DM stated staff should have thrown the cups away that appeared to be stained. The DM stated her expectation was that residents received cups that were not stained. The DM stated a lot of new staff and lack of training led to failure of residents receiving plastic cups that were stained. The DM stated the effect on the residents could have been a dignity issue or could have received cups that were not clean and have debris in cups. The DM stated her expectation was that staff take temperature of food when it was cooked and again before it was served; staff all need to record the temperatures on the temperature log. The DM stated there was no other way to ensure that the food was cooked to correct temperature without the logs. The DM stated there was a shift supervisor that was supposed to have checked to ensure the temperatures were taken and put on log. The DM stated new staff are trained when they are hired. The DM stated new staff were paired with shift supervisor to learn the recipes, taking temps, cleaning thermometer, and writing in log. The DM stated once the shift supervisor felt new staff were ready they would follow them and monitor them to ensure they were doing things correctly. The DM stated she monitored the logs by looking at the end of the month and when finds holes she would find the cook that was cooking that meal and will contact the supervisor to retrain that staff. The DM stated she had not reviewed the September 2023 temperature log before today and was not aware there were so many meals that were blank on the log. The DM stated she probably should have been looking more frequently. The DM stated what led to failure of temperature logs not being completed was the dietary staff get in a hurry and do not pay attention to the things they were supposed to have done. The DM stated the effect on residents could have caused residents to get sick. The DM stated she was not aware of residents getting sick from eating under cooked food. <BR/>During an interview on 10/03/2023 at 3:30 PM the IP stated there had not been any residents with gastrointestinal issues related to food. <BR/>During an interview on 10/03/2023 at 3:45 PM the ADMN stated his expectation was that cups should be cleaned properly and not have any stains on them when they were served to residents. The ADMN stated if residents were served drinks in cups that were not cleaned properly it could have caused them to become sick. The ADMN stated lack of oversight by the dietary supervisors, the DM and ADMN led to failure of residents having received cups with film on the inside of cup. The ADMN stated his expectation was that temperature of food should have been completed and recorded. The ADMN stated if temperatures were not recorded on the logs, then there was no way to prove temperatures were completed. The ADMN stated the dietary supervisors, and the DM should have been monitoring the temperature logs daily. The ADMN stated poor oversight led to the failure of food temperatures not being logged. The ADMN stated they did not have a policy in regard to clean and sanitary dishes. <BR/>Record review of facility temperature logs for the month of September 2023 and October 2023 revealed no evidence that temperatures were taken for the following meals:<BR/>09/04/2023 Dinner<BR/>09/14/2023 Breakfast, lunch, dinner<BR/>09/15/2023 Breakfast, lunch, dinner<BR/>09/19/2023 lunch, dinner<BR/>09/20/2023 Lunch<BR/>09/24/2023 Dinner<BR/>09/27/2023 Breakfast, lunch, dinner<BR/>09/28/2023 Dinner<BR/>09/29/2023 Lunch<BR/>09/30/2023 Breakfast, lunch, dinner<BR/>10/01/2023 Breakfast, lunch, dinner<BR/>10/02/2023 Breakfast<BR/>10/03/2023 Breakfast<BR/>Record review of facility policy titled Daily Food Temperature Control, dated with only year of 2012, revealed: We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, and record reviews, the facility failed to ensure the comprehensive care plan were prepared by an interdisciplinary team, that included but not limited to, a nurse aide or a registered nurse with responsibility for the resident for 3 (Resident #1, Resident #2, and Resident #3) of 10 residents reviewed for care plans.<BR/>The facility failed to invite and include the input of the nursing staff as members of the interdisciplinary team after the completion of the comprehensive assessment for Resident #1, Resident #2, and Resident #3.<BR/>This failure could place the residents at risk for decreased quality of life and not having their needs met.<BR/>Findings include:<BR/>Resident #1<BR/>Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted to facility on 08/24/2021 with diagnoses to include: dementia, depression, schizophrenia, and repeated falls. <BR/>Review of Resident #1's Quarterly MDS assessment, dated 01/18/2024, revealed a BIMS score of 15 which indicated no impaired cognition. Section J Health Conditions: Falls revealed no falls since admission or prior assessment. <BR/>Review of Resident #1's Significant Change MDS assessment, dated 02/14/2024, revealed a BIMS score of 11 which indicated moderate impaired cognition. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. Further review revealed: 0 falls with no injury, 0 falls with injury, and 1 fall with major injury. <BR/>Review of Resident #1's Comprehensive Care Plan, initiated 08/24/2021, revealed the care plan was not changed or updated during the quarterly care plan meeting on 01/11/2024. Further review of Comprehensive Care Plan revealed no new interventions added or implemented since 08/24/2022.<BR/>Review of Resident #1's Care Plan Conference, dated 01/11/2024 at 9:44 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Family did not attend. RN unable to attend. Nurse aide did not attend. The documentation revealed: Went over care plan, with no changes at this time. Continue current plan of care. Participants included LVN F and Social Worker. <BR/>Resident #2<BR/>Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to facility on 09/28/2022 with diagnoses to include: dementia, depression, anxiety, and unsteadiness on feet. <BR/>Review of Resident #2's Significant Change MDS assessment, dated 12/15/2023, revealed no BIMS score. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. 0 with no injury, 1 with injury, 1 with major injury. <BR/>Review of Resident #2's Quarterly MDS assessment, dated 11/03/2023, revealed no BIMS score. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. 0 with no injury, 1 with injury, 0 with major injury. <BR/>Review of Resident #2's Comprehensive Care Plan, initiated 09/29/2022, revealed the care plan was not changed or updated during the quarterly care plan meeting on 12/26/2023. Further review of Comprehensive Care Plan revealed no new interventions added or implemented since 09/29/2022.<BR/>Review of Resident #2's Care Plan Conference, dated 12/26/2023 at 11:29 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Resident #2's family did attend. RN unable to attend. Nurse aide did not attend. The documentation revealed: Went over care plan, with no changes at this time. Continue current plan of care. Participants included LVN F and Social Worker and Resident #2's family member.<BR/>Resident #3's <BR/>Review of Resident #3's electronic face sheet revealed an [AGE] year-old male admitted to facility on 11/13/2023 with diagnoses to include: depression, kidney failure, and heart disease. <BR/>Review of Resident #3's Significant Change MDS assessment, dated 01/31/2024, revealed a BIMS score of 01 which indicated severely impaired cognition. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment which was 11/17/2023. Further review revealed: 0 falls with no injury, 0 falls with injury, and 1 fall with major injury. <BR/>Review of Resident #3's Comprehensive Care Plan, initiated 11/14/2023, revealed the care plan was not changed or updated during the quarterly care plan meeting on 02/13/2024. Further review of Comprehensive Care Plan revealed no new interventions added or implemented since 11/14/2023.<BR/>Review of Resident #3's Care Plan Conference, dated 02/13/2024 at 11:12 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Resident #3's family did attend. RN unable to attend. Nurse aide did not attend. The documentation revealed: No changes made to plan of care. Continue current plan of care. Participants included LVN F and Social Worker and Resident #3's family member via phone.<BR/>During an interview on 02/15/2024 at 3:30 pm, the MDS Nurse stated she was not responsible for updating the care plan with acute or new issues. She stated she performed quarterly care plan conferences based on what was documented in the chart. She stated if the falls had been added to the care plan when they occurred and new interventions had been added then she would have discussed it in the care plan conferences. She stated it was not her responsibility to update the care plan. The MDS nurse stated nurse aides and registered nurses were not invited to the care plan conferences because it was just not feasible. She stated direct care staff did not have time to participate. She stated the social worker schedules the conferences and invites the attendees. The MDS nurse stated she was aware of the facilities policy that nurse aides and registered nurses were supposed to attend care conferences and she was aware the facility was cited for this in November. She stated there was a performance improvement plan in place but once again it just was not feasible. <BR/>During an interview on 02/15/2024 at 5:40 pm, LVN A said she had not attended or been invited to a care plan meeting. LVN A said the direct care staff should be able to attend the care plan meetings because they were the staff with key input to the residents' behaviors, monitoring and preventing behaviors and the CNAs knew what interventions worked and did not work. LVN A said the CNAs also knew the concerns and conditions of the residents they work with every day.<BR/>During an interview on 02/15/2024 at 5:50 pm, CNA B said he had never attended a care plan meeting or was asked for input for the care plan for Resident #1 or any other resident on the locked unit.<BR/>During an interview on 02/15/2024 at 6:00 pm, the Administrator stated he was unaware the facility had been cited in November for the same issue. He stated he was ultimately responsible for ensuring the previous plan of correction was being implemented. <BR/>Record review of the facility's policy, Comprehensive Care Planning, not dated, revealed the interdisciplinary team included but was not limited to - <BR/>- <BR/>The attending physician<BR/>- <BR/>A registered nurse with responsibility for the resident<BR/>- <BR/>A nurse aide with responsibility for the resident<BR/>- <BR/>A member of food and nutritional services staff<BR/>- <BR/>The resident and the resident's representative<BR/>- <BR/>Other appropriate staff or professionals determined by the resident.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitization<BR/>The facility failed to ensure that kitchen staff obtained food temperatures prior to serving meals on 09/04/2023, 09/14/2023,09/15/2023, 09/19/2023, 09/20/2023, 09/24/2023, 09/27/2023, 09/28/2023, 09/29/2023, 09/30/2023, 10/01/2023, 10/02/2023, and 10/03/2023. <BR/>The facility failed to ensure plastic drinking cups were cleaned and sanitized properly. <BR/>These failures could place residents that eat out of the kitchen at risk for food borne illnesses.<BR/>Findings included: <BR/>During an observation on 10/03/2023 at 9:45 AM of the kitchen revealed blanks on temperature logs for the month of October 2023. <BR/>During an interview on 10/03/2023 at 9:45 AM the DM stated the cook was to write the temperatures of food when it was cooked on the temperature log. The DM stated if the cook did not write the temperature on log, then there was no way to prove that the temperatures were taken. <BR/>During an observation and interview on 10/03/2023 at 1:45 PM in the dining room revealed Resident # 1 sitting at a table with 2 other residents. Resident #1's pointed out cups at table that residents were served during lunch. One plastic cup had a cloudy film on the inside and one plastic cup had a brown film on the inside. Resident # 1 stated there had been a problem with cups not being clean. Resident # 1 stated look I can rub this brown stuff off the inside of the cup. Resident #1 stated the stained cup makes my milk look like root beer. Resident #1 stated she did not like drinking out of cups that are not clean. Resident #1 stated sometimes the food was not hot when they received food.<BR/>During an observation on 10/03/2023 at 2:00 PM of the kitchen revealed dietary staff pouring milk into plastic drinking cups. One of the plastic cups was observed to have a brown film on the inside of the cup, which made the white milk look like brown milk. Dietary staff put lids on cup and placed them into fridge. <BR/>During an interview on 10/03/2023 at 1:50 PM Resident # 2 stated she had received cups that did not appear to be clean. Resident # 2 stated it was gross to drink out of cups that looked dirty. Resident # 2 stated food was served cold at times and would have to ask them to heat food. <BR/>During an interview on 10/03/2023 at 3:15 PM the DM stated staff should not be serving residents drinks in cups that are stained. The DM stated staff should have thrown the cups away that appeared to be stained. The DM stated her expectation was that residents received cups that were not stained. The DM stated a lot of new staff and lack of training led to failure of residents receiving plastic cups that were stained. The DM stated the effect on the residents could have been a dignity issue or could have received cups that were not clean and have debris in cups. The DM stated her expectation was that staff take temperature of food when it was cooked and again before it was served; staff all need to record the temperatures on the temperature log. The DM stated there was no other way to ensure that the food was cooked to correct temperature without the logs. The DM stated there was a shift supervisor that was supposed to have checked to ensure the temperatures were taken and put on log. The DM stated new staff are trained when they are hired. The DM stated new staff were paired with shift supervisor to learn the recipes, taking temps, cleaning thermometer, and writing in log. The DM stated once the shift supervisor felt new staff were ready they would follow them and monitor them to ensure they were doing things correctly. The DM stated she monitored the logs by looking at the end of the month and when finds holes she would find the cook that was cooking that meal and will contact the supervisor to retrain that staff. The DM stated she had not reviewed the September 2023 temperature log before today and was not aware there were so many meals that were blank on the log. The DM stated she probably should have been looking more frequently. The DM stated what led to failure of temperature logs not being completed was the dietary staff get in a hurry and do not pay attention to the things they were supposed to have done. The DM stated the effect on residents could have caused residents to get sick. The DM stated she was not aware of residents getting sick from eating under cooked food. <BR/>During an interview on 10/03/2023 at 3:30 PM the IP stated there had not been any residents with gastrointestinal issues related to food. <BR/>During an interview on 10/03/2023 at 3:45 PM the ADMN stated his expectation was that cups should be cleaned properly and not have any stains on them when they were served to residents. The ADMN stated if residents were served drinks in cups that were not cleaned properly it could have caused them to become sick. The ADMN stated lack of oversight by the dietary supervisors, the DM and ADMN led to failure of residents having received cups with film on the inside of cup. The ADMN stated his expectation was that temperature of food should have been completed and recorded. The ADMN stated if temperatures were not recorded on the logs, then there was no way to prove temperatures were completed. The ADMN stated the dietary supervisors, and the DM should have been monitoring the temperature logs daily. The ADMN stated poor oversight led to the failure of food temperatures not being logged. The ADMN stated they did not have a policy in regard to clean and sanitary dishes. <BR/>Record review of facility temperature logs for the month of September 2023 and October 2023 revealed no evidence that temperatures were taken for the following meals:<BR/>09/04/2023 Dinner<BR/>09/14/2023 Breakfast, lunch, dinner<BR/>09/15/2023 Breakfast, lunch, dinner<BR/>09/19/2023 lunch, dinner<BR/>09/20/2023 Lunch<BR/>09/24/2023 Dinner<BR/>09/27/2023 Breakfast, lunch, dinner<BR/>09/28/2023 Dinner<BR/>09/29/2023 Lunch<BR/>09/30/2023 Breakfast, lunch, dinner<BR/>10/01/2023 Breakfast, lunch, dinner<BR/>10/02/2023 Breakfast<BR/>10/03/2023 Breakfast<BR/>Record review of facility policy titled Daily Food Temperature Control, dated with only year of 2012, revealed: We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 6 residents (Resident #1) reviewed for misappropriation of property. <BR/>The facility staff failed to prevent the misappropriation of Resident #1's bottled water by staff. <BR/>This failure could place residents at risk of staff taking their property. <BR/>Findings include:<BR/>Record review of Resident #1's electronic file revealed a [AGE] year-old male whose admission date was 4/05/2021 and discharge date was 6/1/2023. Resident #1 had diagnoses which included nontraumatic intracerebral hemorrhage (subtype of stroke), other seizures, hyperlipidemia (elevated level of lipids), hypothyroidism (thyroid gland doesn't make enough thyroid hormones), other recurrent depressive disorders, hypertension (elevated blood pressure), dysphagia (difficulty swallowing, diabetes mellitus due to underlying condition with diabetic neuropathy (diabetes that causes nerve pain), insomnia (difficulty sleeping), anxiety disorder, gastro-esophageal reflux disease without esophagitis (acid that flows back into tube connecting your mouth and stomach, unspecified dementia, and retention of urine. <BR/>Record review of a video from a Ring Camera, dated 5/29/23 at 1:59 pm revealed CNA-A stood at Resident #1's tray table filling her (CNA-A's) water cup with a one-gallon jug of water that belonged to Resident #1. CNA A placed the gallon jug back on the tray table, placed the lid back on her cup, took a drink from the cup and walked out of Resident #1's room with her (CNA-A's) cup. <BR/>Interview on 6/3/23 at 11:30 AM with the family member revealed they had video evidence that CNA-A took water for herself from Resident #1's bottled water. The family member reported she provided the bottled water for Resident #1. <BR/>Interview on 6/9/23 at 3:11 PM, CNA-B stated Resident #1's family member offered food and snacks to staff regularly when she brought them in for Resident #1. CNA-B also revealed there was a facility policy against it, so she had never done it. <BR/>Interview on 6/9/23 at 5:20 PM with the HR Coordinator revealed staff were not allowed to accept snacks or water from the residents or their family. The HR Coordinator further revealed this policy was located in the Personnel Handbook or the orientation checklist that was gone over at hire. <BR/>Interview on 6/9/23 at 6:34 PM with the DON, revealed CNA-A took the water, and she was retrained on not to accept gifts from family no matter how long they say you could help yourself. The DON also revealed the resident's family member always offered the staff snacks and water and now she was barred from the building, she decided to take it back. that the DON stated staff learned a valuable lesson on why they should not accept it to begin with.<BR/>Record review of the Personnel Handbook 2019, revision dated 9/20/2019, pages 13-14, revealed Gratuities and gifts should not be accepted by individual facility personnel. Gratuities may be considered when they are: extended to the facility as a whole, shared by all employees and/or residents, or benefit the facilities environment. <BR/>Record review of CNA-A employee file revealed: the employee disciplinary report, dated 5/30/23, revealed CNA-A was suspended pending investigation. Statement from CNA-A, dated 5/29/23, revealed Resident #1's family member called CNA-A cursing at me for getting his dad water when she previously said I was very welcome to take some snacks and drinks because she trusts me with the care, I give her dad. The document further revealed CNA-A completed training on Freedom from abuse, neglect and mistreatment of belongings, signed and dated 7/12/13. <BR/>Record review of CNA-A's employee file of Orientation checklist which included resident rights: Resident's personal belongings and property rights, signed and dated 7/12/13. <BR/>Record review of the Grievance Form dated 5/30/23, from complainant revealed staff took bottles of water. The facility started an investigation and found CNA-A took the water from the bottle because she was offered by Resident #1's family. The facility retrained CNA-A. <BR/>Record review of the facility's, undated, Nursing Facility Resident Rights policy revealed residents have the right to keep and use property, and have it secured from theft or loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document the appropriate reason for discharge in the resident's medical record for one of 6 resident's (Resident #1) reviewed. <BR/>This failure could place the resident's at risk of being discharge without accurate reason for discharge and inaccurate information communicated to provider or furture health care institution's. <BR/>Finding's include:<BR/>Record review of Resident #1's electronic file revealed a [AGE] year-old male with an admission date of 4/05/2021 and a discharge date of 6/1/2023. Resident #1 had diagnoses which included nontraumatic intracerebral hemorrhage (subtype of stroke), other seizures, hyperlipidemia (elevated level of lipids), hypothyroidism (thyroid gland doesn't make enough thyroid hormones), other recurrent depressive disorders, hypertension (elevated blood pressure), dysphagia (difficulty swallowing, diabetes mellitus due to underlying condition with diabetic neuropathy (diabetes that causes nerve pain), insomnia (difficulty sleeping), anxiety disorder, gastro-esophageal reflux disease without esophagitis (acid that flows back into tube connecting your mouth and stomach, unspecified dementia, and retention of urine. <BR/>Record review of the Facility Initiated Discharge Protocol, dated 5/31/23, signed by the Regional Compliance Nurse stated Resident #1's discharge date was 5/31/23 and the Discharge Notice was provided on 5/31/23 to the resident, Resident Representative and Ombudsman on 5/31/23. This notice revealed on page 2, The Resident's responsible party is not permitted in the facility due to threats to the facility and residents' staff within the facility. <BR/>Record Review of the Discharge Notification, dated 5/31/23, revealed a discharge date of 5/31/23 and the reason for discharge was: The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident .The health of individuals in the facility would otherwise be endangered. The explanation of items checked revealed The resident's responsible party, poses a threat to the safety and well-being of all residents in the facility. The responsible party stated, with local authorities present, that she would burn the facility to the ground with everyone inside it. Prior to this statement, the responsible party was noted to be acting belligerent in the facility around other residents being verbally aggressive and cursing in the main dining room during dinner service. <BR/>Record review of Resident #1's electronic health record showed no evidence of a specific reason for discharge. Also, revealed resident was safely discharged to to another nursing facility. <BR/>Interview on 6/9/23 at 6:22 PM with the DON revealed the discharge of Resident #1 was due to not being able to meet the needs of the resident because the responsible party could not be in the facility. The DON did not know why the discharge paperwork stated they discharged Resident #1 because of behavioral concerns for resident. The DON stated the resident wasn't the issue; it was the representative. We have always had issues with her but never with him. I just don't know how we could hold care plan meetings when she won't attend the zoom ones and can only meet outside with the resident.<BR/>Interview on 6/9/23 at 6:34 PM with the Administrator In-Training revealed the box which stated the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident should not have been checked, it should have been that the facility could not meet the resident's needs. The Administrator in Training stated the residents needs could not be met because the facility could not have the responsible person in the facility due to her behavior towards staff and threats and they tried to hold telehealth meetings, but she did not show and with the health and safety of the residents, they couldn't have her back in the building which made it too difficult to meet the resident's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the notice of transfer or discharge was made by the facility at least 30 days before the resident was transferred or discharged for one of 6 residents (Resident #1) reviewed for transfers and discharges. <BR/>The facility failed to notify the resident representative of the transfer or discharge with at least 30 days' notice in a language and manner they understood for Resident #1.<BR/>This failure could place residents at risk of being discharged without proper notice, without accurate reason for discharge and could also result in residents not having time to utilize the appeal process. <BR/>Findings include:<BR/>Record review of Resident #1's electronic file revealed a [AGE] year-old male with an admission date of 4/05/2021 and a discharge date of 6/1/2023. Resident #1 had diagnoses which included nontraumatic intracerebral hemorrhage (subtype of stroke), other seizures, hyperlipidemia (elevated level of lipids), hypothyroidism (thyroid gland doesn't make enough thyroid hormones), other recurrent depressive disorders, hypertension (elevated blood pressure), dysphagia (difficulty swallowing, diabetes mellitus due to underlying condition with diabetic neuropathy (diabetes that causes nerve pain), insomnia (difficulty sleeping), anxiety disorder, gastro-esophageal reflux disease without esophagitis (acid that flows back into tube connecting your mouth and stomach, unspecified dementia, and retention of urine. <BR/>Record review of the Facility Initiated Discharge Protocol, dated 5/31/23, signed by the Regional Compliance Nurse stated Resident #1's discharge date was 5/31/23 and the Discharge Notice was provided on 5/31/23 to the resident, Resident Representative and Ombudsman on 5/31/23. This notice revealed on page 2, The Resident's responsible party is not permitted in the facility due to threats to the facility and residents' staff within the facility. <BR/>Record Review of the Discharge Notification, dated 5/31/23, revealed a discharge date of 5/31/23 and the reason for discharge was: The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident .The health of individuals in the facility would otherwise be endangered. The explanation of items checked revealed The resident's responsible party, poses a threat to the safety and well-being of all residents in the facility. The responsible party stated, with local authorities present, that she would burn the facility to the ground with everyone inside it. Prior to this statement, the responsible party was noted to be acting belligerent in the facility around other residents being verbally aggressive and cursing in the main dining room during dinner service. <BR/>Record review of Resident #1's electronic health record showed no evidence of a specific reason for discharge. Also, revealed resident was safely discharged to to another nursing facility. <BR/>Interview on 6/9/23 at 6:22 PM with the DON revealed the discharge of Resident #1 was due to not being able to meet the needs of the resident because the responsible party could not be in the facility. The DON did not know why the discharge paperwork stated they discharged Resident #1 because of behavioral concerns for resident. The DON stated the resident wasn't the issue; it was the representative. We have always had issues with her but never with him. I just don't know how we could hold care plan meetings when she won't attend the zoom ones and can only meet outside with the resident.<BR/>Interview on 6/9/23 at 6:34 PM with the Administrator In-Training revealed the box which stated the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident should not have been checked, it should have been that the facility could not meet the resident's needs. The Administrator in Training stated the residents needs could not be met because the facility could not have the responsible person in the facility due to her behavior towards staff and threats and they tried to hold telehealth meetings, but she did not show and with the health and safety of the residents, they couldn't have her back in the building which made it too difficult to meet the resident's needs. <BR/>Record review of the nursing facility's Resident's Rights, dated November 2021, page 3 revealed residents had the right to not be discharged from the facility, except in accordance with nursing facility regulations. Receive a 30-day written notice sent to you, your legally authorized representative or a family member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 2 (Resident #1 and Resident #2) of 10 residents reviewed for multiple falls.<BR/>The facility failed to implement a system for identifying fall patterns and implementing interventions to prevent falls that lead to emergency room visits with serious injury on 12/17/2023 and 02/07/2024 for Resident #1 and 12/10/2023 and 01/04/2024 for Resident #2.<BR/>An IJ was identified on 02/16/2024. The IJ template was provided to the facility on [DATE] at 10:25 am. While the IJ was removed on 02/16/2024, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. <BR/>These failures could place the residents at risk for falls, serious injuries, hospitalizations, and death. <BR/>Findings include:<BR/>Resident #1<BR/>Review of Resident #1's electronic face sheet revealed a [AGE] year-old male admitted to facility on 08/24/2021 with diagnoses to include: dementia, depression, schizophrenia, and repeated falls. <BR/>Review of Resident #1's Quarterly MDS assessment, dated 01/18/2024, revealed a BIMS score of 15 which indicated no impaired cognition. Section J Health Conditions: Falls revealed no falls since admission or prior assessment. <BR/>Review of Resident #1's Significant Change MDS assessment, dated 02/14/2024, revealed a BIMS score of 11 which indicated moderate impaired cognition. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. Further review revealed: 0 falls with no injury, 0 falls with injury, and 1 fall with major injury. <BR/>Review of Resident #1's Comprehensive Care Plan, initiated 08/24/2021, revealed: Focus: The resident is at risk for falls. Goal: The resident will be free from falls through the review date. The resident will not sustain serious injury through review date. Interventions: Anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed., ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair, keep furniture in locked position, Keep needed items, water in reach. Staff to make frequent visual checks to promote safety and reduce risk of fall, Physical therapy evaluate and treat as ordered or as needed, the resident needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Side fails as ordered, handrails on walls, personal items within reach. The resident needs activities that minimize the potential for falls while providing diversion and distraction. Further review of the Comprehensive Care Plan revealed no new interventions added or implemented since 08/24/2021.<BR/>Review of Resident #1's Fall Event Nurses' Note, dated 02/07/2024 at 4:48 PM, signed by LVN D, revealed: Resident #1 had an unwitnessed fall where he hit his head. Resident #1 was ambulating in hallway, and he fell in hallway face first. He bloodied his nose and received a bruise to the right side of his forehead. Doctor was notified and Resident #1 was sent to the emergency room for evaluation and treatment. <BR/>Review of Resident #1's hospital clinical record, dated 02/07/2024, revealed: Injuries: Subdural hematoma (blood around the brain), Hemorrhagic contusion right inferior temporal region (bleeding brain bruise), left periorbital hematoma (bruise around the eye), and left 7th, 9th, and 10th rib fractures. Resident #1 was discharged back to facility on 02/08/2024.<BR/>Review of Resident #1's Fall Event Nurses' Note, dated 12/17/2023 at 6:48 PM, signed by RN E, revealed: Resident #1 had an unwitnessed fall. Resident #1 fell and hit head on floor with laceration. Resident #1 was transferred to the emergency room.<BR/>Review of Resident #1's hospital clinical record, dated 12/17/2023, revealed: Injury: Laceration sustained to left parietal area (top rear of head) is clean, jagged, superficial, 2.6 by 7.5 centimeters. Wound care applied 5 stiches. Resident #1 was discharged back to facility on 12/17/2023.<BR/>Review of the facility's incident log from 11/16/2023-02/07/2024, revealed Resident #1 had falls on 12/17/2023 at 3:09 pm no injury, 12/17/2023 at 6:15 pm with injury, 01/25/2024 at 2:30 pm no injury, 01/29/2024 at 4:40 pm no injury, 01/30/2024 at 4:21 pm no injury, 02/01/2024 at 4:07 pm no injury, 02/06/2024 at 3:22 pm no injury, and 02/07/2024 at 4:46 pm with injury. <BR/>Review of Resident #1's Fall Risk Assessments dated 12/17/2023 revealed a score of 13 High Risk, 01/25/2024 score 18 High Risk, 01/29/2024 score 21 High Risk, 01/30/2024 score 21 High Risk, 02/01/2024 score 18 High Risk, 02/06/2024 score 20 High Risk, and 02/07/2024 score 23 High Risk.<BR/>Review of Resident #1's Care Plan Conference, dated 01/11/2024 at 9:44 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Family did not attend. Went over care plan, with no changes at this time. Continue current plan of care.<BR/>Observation on 02/14/2024 at 12:40 pm, revealed Resident #1 on the secure unit lying in bed no distress noted. Resident was alert but not oriented and not really communicating. Nurse and CNA were currently sitting at bedside.<BR/>Observation on 02/15/2024 at 9:30 am, revealed Resident #1 was lying in bed. The bed was in a low position. There was no siderail or handrails on the bed. Resident #1 had his eyes open and looked at the surveyor but did not speak. There were 3 CNAs in the resident's room.<BR/>Resident #2<BR/>Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to facility on 09/28/2022 with diagnoses to include: dementia, depression, anxiety, and unsteadiness on feet. <BR/>Review of Resident #2's Significant Change MDS assessment, dated 12/15/2023, revealed no BIMS score. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. 0 with no injury, 1 with injury, 1 with major injury. <BR/>Review of Resident #2's Quarterly MDS assessment, dated 11/03/2023, revealed no BIMS score. Section J Health Conditions: Falls revealed yes falls since admission or prior assessment. 0 with no injury, 1 with injury, 0 with major injury. <BR/>Review of Resident #2's Comprehensive Care Plan, initiated 09/29/2022, revealed: Focus: The resident is at risk for falls related to She has had actual falls since entering the facility due to poor gait and balance, dementia with poor safety awareness and judgment. Actual fall 12/10/23 Fall between bed and wall causing Right Rib Fracture and mild pneumothorax resulting in emergency room visit. Goal: The resident will not sustain serious injury through review date. Interventions: Anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, Ensure that the resident is wearing appropriate footwear when ambulating, Staff x 1 to assist with transfers, and the resident needs activities that minimize the potential for falls while providing diversion and distraction. Further review of the Comprehensive Care Plan revealed no new interventions added or implemented since 09/29/2022.<BR/>Review of Resident #2's Fall Event Nurses' Note, dated 12/10/2023 at 6:05 AM, signed by LVN G, revealed: Resident #2 had an unwitnessed fall. CNA reported that resident had fallen on the floor. This nurse went into residents' room and found her lying on the floor on her right side and screaming in pain and holding her right side at her rib cage. Having difficulty breathing at this time. Bedside toilet and table and walker all turned over on floor by her. Resident #2 was transferred to the emergency room.<BR/>Review of Resident #2's hospital discharge record, dated 12/10/2023, revealed: Diagnosis Fractured rib and head injury. Resident #2 was discharged back to the facility on [DATE].<BR/>Review of Resident #2's Fall Event Nurses' Note, dated 01/04/2024 at 9:50 PM, signed by LVN H, revealed: Resident #2 had an unwitnessed fall. CNA noticed blood on resident's shirt and observed blood in residents' hair and notified nurse. I assessed resident and observed laceration to right side of resident's head. Resident was guarding right shoulder as well. Resident #2 was transferred to the emergency room.<BR/>Review of Resident #2's hospital clinical record, dated 01/04/2024, revealed: Abrasion on the right scalp and shoulder pain. Resident #2 was discharged back to the facility on [DATE].<BR/>Review of the facility's incident log from 11/16/2023-02/07/2024, revealed Resident #2 had falls on 11/19/2023 at 11:00 pm with no injury, 12/10/2023 at 5:44 am with injury, 12/23/2023 at 10:00 am with no injury, and 01/04/2024 at 8:15 pm with injury.<BR/>Review of Resident #2's Fall Risk Assessments dated 11/19/2023 revealed score 16 High Risk, 12/10/2023 score 19 High Risk, 12/23/2023 score 15 High Risk, 01/04/2024 score 15 High Risk.<BR/>Review of Resident #2's Care Plan Conference, dated 12/26/2023 at 11:29 am signed by LVN F, revealed: Resident did not attend due to inability to understand care plan discussion. Resident #2's [family member] did attend. Went over care plan, with no changes at this time. Continue current plan of care.<BR/>Observation on 02/15/2024 at 4:00 pm, revealed Resident #2 ambulating up and down the hall. Resident seemed unsteady on her feet. Resident was wandering in and out of other residents' rooms.<BR/>During an interview on 02/14/2024 at 12:45 pm, LVN A stated Resident #1 had a history of falling. She stated she had been sitting in his room since his return from the hospital as much as she could because she did not want him to fall again. She stated Resident had a history of wandering and was only oriented to his name. She stated she was trying to increase supervision. She stated she had not been instructed to sit or monitor Resident #1 by the facility. She stated she just was because she was concerned. She stated she had spoken to the DON and informed her that Resident #1 needed 1:1 supervision but she was told the facility did not have the staff for that. She stated there was always 2 CNAs on the secure unit. LVN A stated Resident #2 had a history of wandering and falls also. She stated Resident #2 walks the unit continuously and it was almost impossible to keep an eye on her all the time. She stated Resident #2 had no new fall interventions that she was aware of. <BR/>During an interview on 02/14/2024 at 12:50 pm, CNA B stated he was working with another resident the day Resident #1 fell and was injured. He stated his coworker was in a room and he was assisting the nurse with another resident when he heard a loud noise. He stated he turned around and Resident #1 was lying face down in his doorway covered in blood. He stated he had seen Resident #1 in his bed 15 minutes prior to the fall. He stated he always tried to watch Resident #1 closely and made sure to check on him every 15 minutes when possible. He stated he had asked for help and spoke to the DON and Administrator about not having adequate staff to meet Resident #1's needs. He stated Resident #2 was also a high fall risk. He stated Resident #2 continuously wandered and was very unsteady. CNA B stated he felt 2 CNAs was not enough to monitor the residents and to prevent falls. He stated he was not aware of any new fall prevention interventions put in place for Resident #1 or Resident #2. <BR/>During an interview on 02/14/2024 at 2:00 pm, the DON stated she did not know much about Resident #1. She stated she had 130 residents and could not keep up with all of them. She stated she was not aware of any clinical issues with Resident #1 prior to the fall. She stated she was not aware of how many falls he had had but she knew he had a history of falls. She stated when a fall occurred the staff assessed the resident, notified the physician and family member, then completed an incident report. She stated she was not always notified of all falls, only falls with major injury. She stated falls were reviewed every morning during morning meeting.<BR/>During an interview on 02/15/2024 at 9:35 am, CNA B stated he was told this morning by the DON to keep resident #1 in his line of site at all times. He stated they did not increase the staffing and he still had to do his normal work and watch resident. #1. He stated he had not received any in-service regarding increased supervision for Resident #1 or Resident #2.<BR/>During an interview on 02/15/2024 at 10:40 am, the DON stated the facility had clinical meeting every morning to discuss day to day updates on all residents. She stated if a resident fell it would be discussed in the clinical meeting and new interventions should be put into place. She stated it was her responsibility to update the care plan with acute issues and new interventions. The DON stated she did not have any documentation of what was discussed in the clinical meeting she just made herself a to-do list. She stated she had missed multiple clinical meetings lately due to having to work the floor. She stated she did not have a system where she tracked falls. She stated falls were discussed in QAPI meetings monthly. She stated the facility just stated how may falls they had each month. The DON stated she was unaware of any QAPI plan specifically for falls or any fall prevention programs in place. She stated the possibility of getting Resident #1 a helmet was brought up by the family on 02/07 prior to the fall. The DON stated since Residents #1's return from the hospital on [DATE], she placed the resident on increased supervision. She stated she verbally in-serviced the staff on the secure unit and instructed them to always keep Resident #1 in line of site. She stated she did not increase staffing and did not document, or care plan the new intervention. She stated she obtained an order to refer Resident #1 to a neurologist, but she was unsure where the facility was in the process of getting that done. The DON stated she was unable to perform her clinical duties because she was working the floor or constantly putting out fires and she had not had the time do her responsibilities. She stated she did not feel that any further interventions could have been put in place to prevent the falls but agreed that the facility did not attempt any new interventions.<BR/>Interview attempted on 02/15/2024 at 11:00 am with both Medical Directors via phone. Called office and left message with no returned phone call. <BR/>During an interview on 02/15/2024 at 11:45 pm, the Administrator stated he monitored the number of falls in QAPI meetings and looked for trends, but he just looked at overall fall numbers not resident specific. He stated more interventions should have been put into place for Resident #1 and Resident #2 and it was ultimately his responsibility to ensure this was done. The Administrator stated he was notified of all falls and ensured all documentation was done. He stated he only investigated falls with injury or unwitnessed or suspicious falls.<BR/>During an interview on 02/15/2024 at 1:00 pm, CNA C stated Resident #1 had always had multiple falls. She stated she was working the day he fell and the day he returned. CNA C stated she was not aware of any new interventions being put into place. She stated Resident #2 got up quickly and fell before staff even knew that he was out of bed. She stated she tried to watch him closely but most of the time there was only 2 CNAs on the unit, and it was hard to provide 1:1 supervision. CNA denied being in-serviced or told to increase monitoring or supervision when Resident #1 returned to the facility.<BR/>During an interview on 02/15/2024 at 3:30 pm, the MDS Nurse stated she was not responsible for updating the care plan with acute or new issues. She stated she performed quarterly care plan conferences based on what was documented in the chart. She stated if the falls had been added to the care plan when they occurred and new interventions had been added then she would have discussed it in the care plan conferences. She stated it was not her responsibility to update the care plan. She stated the failure occurred because the DON had not added new interventions when the falls occurred. <BR/>Review of facility policy titled, Preventive Strategies to Reduce Fall Risk, revised October 5, 2016, revealed in part: Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by eliminating or managing contributing factors while maintaining or improving the resident's mobility. Procedure: 1. After risk is assessed, individualized nursing care plans will be implemented to prevent falls. The resident and family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects .5. Incident Reporting: Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s).<BR/>This was determined to be an Immediate Jeopardy (IJ) on 02/16/2024. The Administrator, and Director of Nurses were notified on 02/16/2024 at 10:25 am that an Immediate Jeopardy was identified, and a Plan of Removal was requested at that time. <BR/>The Administrator was provided with the IJ template on 02/16/2024 at 10:25 am. <BR/>The following Plan of Removal was accepted on 02/16/2024 at 2:35 pm and included: <BR/>Problem: F689 Accidents/Hazards<BR/>Interventions:<BR/>Resident #1's care plan was reviewed for fall prevention interventions by the DON/Regional Compliance nurse on 2/16/24. <BR/>o <BR/>Helmet ordered for safety.<BR/>o <BR/>Refusal to use assistive devices.<BR/>o <BR/>PT/OT/ST<BR/>o <BR/>Offer diversions, activities, food, conversation, etc to reduce wandering.<BR/>o <BR/>Non-skid socks <BR/>o <BR/>Increased staff rounding<BR/>Resident #2's care plan was reviewed for fall prevention interventions by the DON/Regional Compliance nurse on 2/16/24. <BR/>o <BR/>Increase rounding to promote safety.<BR/>o <BR/>Ensure a safe environment free of clutter and obstructions.<BR/>All residents with falls in the last 30 days were reviewed by DON/Regional Compliance Nurse on 2/16/24 to ensure that appropriate fall interventions are listed on the care plan. There were 50 falls with 26 residents noted in the review.<BR/>A task on the POC Kiosk was added for all resident at high risk for easy identification by the DON, ADON, and Regional Compliance Nurse on 2/16/24.<BR/>The medical director was notified of the immediate jeopardy situation on 2/16/24 at 11:30pm by the Administrator. <BR/>Ad Hoc QAPI meeting will be held on 2/16/24 to discuss the IJ and review plan of removal.<BR/>In-services:<BR/>The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following in-services. <BR/>o <BR/>Fall Prevention Policy <BR/>o <BR/>Care Plan Policy: Updating the care plan with fall prevention/safety interventions.<BR/>o <BR/>Abuse and Neglect.<BR/>The following in-services were initiated by the Regional Compliance nurse, DON, and ADON on 2/16/24. Any staff member not present or in-service on 2/16/24 will not be allowed to assume their duties until in-serviced. All new hires will be in-service at orientation. All agency staff will in serviced before assuming their assignment. <BR/>All Staff: <BR/>Abuse and Neglect Policy<BR/>Notifying the charge nurse for any change in condition to include falls, pain or a change in mobility or transfer status. <BR/>All Direct Care Staff:<BR/>Abuse and Neglect Policy <BR/>Fall Prevention Policy <BR/>Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status. <BR/>How to identify a resident who is high risk for falls on the Kiosk or Care plan<BR/>Monitoring: <BR/>DON, Administrator, Designee will review all falls during the morning meeting to ensure appropriate interventions have been implemented. Monitoring will occur 5 days per week for a minimum of 6 weeks. <BR/>DON, Administrator, Designee will review all falls during the weekly Standard of Care Meeting to ensure appropriate interventions have been implemented. Monitoring will occur weekly for a minimum of 6 weeks. <BR/>Administrator or Designee will review the Event entry and ensure that care planned interventions are change with each fall during the weekly Standards of Care Meeting. Meeting will occur weekly, and monitoring will be in place for 6 weeks.<BR/>Regional Compliance Nurse and/or ADO will monitor, on a weekly basis, that monitoring tools are in place and up to date.<BR/>Monitoring of the facility's Plan of Removal through observations, interviews, and record reviews from 02/16/2023 at 2:40 pm through 02/16/2024 at 5:30 pm revealed: <BR/>Review of Resident #1's comprehensive care plan revealed new interventions added on 02/16/2024 to include: Continues PT/OT. Started OT in October for safety and strength. ST picked up for weight and cognition. PT started for strengthening endurance related to weakness to lower extremity. Date Initiated: 02/16/2024 PT o Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Date Initiated: 02/14/2024 Revision on: 02/15/2024 o Ensure that the resident is wearing appropriate nonskid footwear or nonskid socks when ambulating Date Initiated: 08/24/2021 Revision on: 02/15/2024 o Helmet ordered by Therapy for prevention of head trauma Date Initiated: 02/16/2024 Revision on: 02/16/2024 o Keep needed items, water, etc, in reach. 2/16/24 Staff to increase visual checks to promote safety and reduce risk of fall Date Initiated: 08/24/2021 Revision on: 02/16/2024 o Resident offered and refuses to use assistive device for safety. Date Initiated: 02/16/2024 o Staff x 1 to assist with transfers, staff to monitor while in room and when resident ambulating in hallway. Date Initiated: 02/14/2024 Revision on: 02/16/2024 o The resident needs a safe environment Date Initiated: 08/24/2021 Revision on: 02/16/2024.<BR/>Observation on 02/16/2024 at 2:40 pm, Resident #1 was lying in bed with family members in his room. Observed staff in line of sight of Resident #1.<BR/>Review of Resident #2's comprehensive care plan revealed new interventions added on 02/16/2024 to include: o Ensure a safe environment free of clutter and obstructions. Date Initiated: 02/16/2024 Revision on: 02/16/2024 o Staff to increase rounding on resident to promote safety Date Initiated: 02/16/2024.<BR/>Observation on 02/16/2024 at 2:43, Resident #2 was sitting on couch in the lobby with staff beside her. <BR/>Random record reviews revealed at least 6 of the 26 residents with falls in the last 30 days had their comprehensive care plans reviewed with new interventions added on 02/16/2024. <BR/>Observation on 02/16/2024 at 2:45 pm revealed CNA B accessing the POC Kiosk (computer system used by staff) and signing off on the high fall risk alert for Resident #1. Observed high fall risk alerts on 6 random residents. <BR/>Review of an email dated 02/16/2024, sent from the Medical Director to this surveyor, stated he was aware of the IJ, and he attended the QAPI meeting via phone. <BR/>Review of a QAPI document dated 02/16/2024 revealed d the IJ with signature page of all in attendance. <BR/>In-services: Reviewed in-service information and signature sheets for in-service given by RCN to Administrator, DON, and ADON on Fall Prevention Policy, Care Plan Policy: Updating the care plan with fall prevention/safety interventions, and Abuse and Neglect <BR/>During an interview on 02/16/2024 at 3:00 pm, the Administrator and DON confirmed understanding of in-services titled: Fall Prevention Policy, Care Plan Policy: Updating the care plan with fall prevention/safety interventions, and Abuse and Neglect. <BR/>During observation on 02/16/2024 at 3:10 pm, revealed the DON educating 3 nurses, 9 CNAs, and 1 human resources staff that work the 6:30 am-6:30 pm shift, on Abuse and Neglect Policy, Fall Prevention Policy, Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status, and how to identify a resident who is high risk for falls on the Kiosk or Care plan. Interview with 2 CNAs and 1 nurse verified understanding of in-service. <BR/>During observation on 02/16/2024 at 4:00 pm, revealed the DON educating 1 CNA and 1 medication aide that work the 2:00 pm- 10:100 pm shift, on Abuse and Neglect Policy, Fall Prevention Policy, Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status, and how to identify a resident who is high risk for falls on the Kiosk or Care plan.<BR/>During observation on 02/16/2024 at 4:00 pm, revealed the DON educating 1 nurse who works 6:30 pm- 6:30 am shift via phone, on Abuse and Neglect Policy, Fall Prevention Policy, Notification of a change in condition policy include falls, pain, or a change in mobility or transfer status, and how to identify a resident who is high risk for falls on the Kiosk or Care plan. Interview with nurse verified understanding of in-service. <BR/>The Administer, RCN, ADO, and DON were informed the Immediate Jeopardy was removed on 02/16/2024 at 5:30 pm. The facility remained out of compliance at a severity level of harm and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat residents with respect, dignity, and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (Resident #1) reviewed for dignity. <BR/>The facility failed to ensure staff treated Resident #1 with dignity while providing personal care. <BR/>This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation. <BR/>The findings included:<BR/>Review of Resident # 1's face sheet dated 02/28/2023 revealed, [AGE] year-old female admitted on [DATE], with the following diagnosis chronic kidney disease, dementia, abnormal findings in urine and hypertension (high blood pressure). <BR/>Review of Resident # 1's MDS assessment dated [DATE] revealed, Section C- Cognitive Behavior revealed a BIMS score of 99 (resident not able to complete the interview); Section G- Functional Status revealed Resident #1 required extensive assistance( resident involved in activity, staff provide weight bearing support) and two+ person physical assist for toilet use; Section H- Bladder and Bowel revealed Resident # 1 occasionally incontinent; Section M-Skin Conditions revealed Resident #1 was at risk of developing pressure ulcers/injuries. <BR/>Review of Resident #1's care plan dated 01/06/2023 revealed; Focus: The resident has a potential for pressure ulcer development; Goal: The resident will have intact skin, free of redness, blisters or discoloration by/through review date; Interventions/Tasks: Incontinent care after each episode and apply moisture barrier. <BR/>During observation on 02/28/2023 at 12:22 PM revealed Resident #1 asked NA A to assist her to the toilet. NA A responded to Resident #1 by saying go ahead and pee pee in your diaper and that NA A would change her later when she put her to bed. <BR/>During an interview on 02/28/2023 at 12: 50 PM, Resident #1 stated it made her feel terrible when NA A told her to pee pee in her diaper, and she felt like she could not ask her for help. <BR/>During an interview on 02/28/2023 at 1:25 PM, NA A stated Resident #1 was [AGE] years old and did not understand the word brief that is why she used diaper. NA A stated she was going to find someone to help her transfer Resident #1. NA A stated she should have told Resident #1 that she was going to find someone to help her instead of telling Resident #1 to go pee pee in her diaper . <BR/>During an interview on 2/28/2023 at 4:00 PM, the ADMIN stated her expectation was that if residents asked staff to assist them to toilet, that staff would have assisted resident to be put on toilet or tell the resident that they were going to get help and would be right back. The ADMIN stated staff should have never told a resident to go pee pee in her diaper. The ADMIN stated the word diaper should have never been used, the appropriate term was brief. The ADMIN stated the effect on resident could have been resident felt belittled, embarrassed and/or not want to ask for help. The ADMIN stated the physical effect on resident could have been skin breakdown or UTI from sitting in a soiled brief. The ADMIN stated what led to failure was staff's poor judgement, and lack of training. <BR/>Review of facility policy titled, Resident Rights dated 11/28/16 revealed: The Resident has a right to be treated with respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards of practice for 6 (Resident #25, Resident #30, Resident #105, Resident #107, Resident #263, and Resident #264) of 22 residents reviewed for respiratory care.<BR/>The facility failed to:<BR/>1. Provide a method for storing for Resident's #30, #105, #107, #263 and #264 oxygen tubing when not in use.<BR/>2. Change Resident's #25 oxygen delivery tubing on a weekly basis. <BR/>3. Label Resident's #30, #105, #107 and #264 oxygen tubing with the date the tubing was attached to the oxygen concentrator and the date the bottle was attached to the oxygen concentrator. <BR/>4. Place signage outside Resident's #105, #263, and #264 door indicating oxygen was in use. <BR/>5. Obtain an order for oxygen administration for Resident #105.<BR/>These deficient practices could place residents who receive supplemental oxygen at risk for respiratory infection, injury, or insufficient oxygenation resulting in a decline in health.<BR/>Findings included:<BR/>Resident #263's electronic face sheet revealed a [AGE] year-old female admitted [DATE]. Medical diagnoses included chronic respiratory failure and pulmonary hypertension. A Brief Interview of Mental Status (BIMS) score on 09/29/22 was 4 out of 15 indicating severe cognitive impairment. <BR/>Resident #263's electronic physician orders dated 09/27/22 related to oxygen therapy revealed may use oxygen at 2-4 l/m via nasal cannula, Change respiratory tubing, mask, bottled water, clean filter q7d, and check O2 sat q shift and PRN. <BR/>Observation on 10/04/22 at 10:25 AM, Resident #263 was wearing supplemental oxygen via concentrator delivered by nasal cannula set at 2 Lpm. A bag for storing the oxygen tubing when not in use was not available. No signage indicating oxygen was in use was posted outside of Resident #263's door. <BR/>Resident #105's electronic face sheet revealed a [AGE] year-old male admitted [DATE]. Medical diagnoses included an irregular heart rhythm and a stroke. His BIMS score on 09/30/22 was 6 out of 15 indicating severe cognitive impairment. <BR/>Resident #105's electronic physician orders accessed 10/05/22 revealed no order for oxygen therapy.<BR/>Observation on 10/04/22 10:28 AM, Resident #105 was wearing supplemental oxygen via concentrator delivered by nasal cannula set at 2 Lpm. The oxygen tubing and humidifier bottle were not labeled with a date. A bag for storing the oxygen tubing when not in use was not available. No signage indicating oxygen was in use was posted outside of Resident #105's door. <BR/>Resident #264's electronic face sheet revealed a [AGE] year-old female admitted [DATE]. Medical diagnoses included congestive heart failure and respiratory failure. Her BIMS score on 09/30/22 was 9 out of 15 indicating moderate cognitive impairment. <BR/>Resident #264's electronic physician orders dated 10/04/22 related to oxygen therapy revealed May use oxygen at 2 l/m via nasal canula.<BR/>Observation on 10/04/22 at 10:31 AM, Resident #264 was wearing supplemental oxygen via concentrator delivered by nasal cannula set at 2 Lpm. The oxygen tubing and humidifier bottle were not labeled with a date. A bag for storing the oxygen tubing when not in use was not available. There was no signage outside Resident #264's door indicating oxygen was in use.<BR/>Resident #30's electronic face sheet revealed a [AGE] year-old female admitted [DATE]. Medical diagnoses included chronic obstructive pulmonary disease and obstructive sleep apnea. Her BIMS score on 09/15/22 was 15 out of 15 indicating no cognitive impairment. <BR/>Resident #30's electronic physician orders dated 10/04/22 related to oxygen therapy revealed may use CPAP at night. <BR/>Observation and interview on 10/05/22 at 10:22 AM, Resident #30 was lying in bed wearing a continuous positive airway pressure (CPAP) nasal cannula for supplemental oxygen via concentrator. Resident stated she liked to wear it when she lays down, it helped her breath better. The CPAP cannula was attached to an oxygen concentrator via oxygen tubing. The oxygen tubing was not labeled with a date. A bag for storing the oxygen tubing or the CPAP cannula when not in use was not available. <BR/>Resident #107's electronic face sheet revealed an [AGE] year-old female admitted [DATE]. Medical diagnoses included respiratory failure and heart failure. Her BIMS score on 09/21/22 was 8 out of 15 indicating moderate cognitive impairment. <BR/>Resident #107's electronic physician orders dated 09/20/22 related to oxygen therapy revealed may use oxygen at 2 l/m via NC, and change respiratory tubing, mask, bottled water, clean filter q7d .<BR/>Observation on 10/05/22 at 02:30 PM, Resident #107 was lying in bed on left side, eyes closed, breathing was even and not labored. The oxygen tubing attached to the oxygen concentrator was dated 7/19. The tubing went from the oxygen concentrator to the far side of the bed. The end of the tubing was not on the resident or visible. A bag for storing the oxygen tubing when not in use was not available. <BR/>Resident #25's electronic face sheet revealed a [AGE] year-old male admitted [DATE]. Medical diagnoses included heart failure and shortness of breath. His BIMS score on 07/22/22 was 9 out of 15 indicating moderate cognitive impairment. <BR/>Resident #25's electronic physician orders dated 09/17/20 related to oxygen therapy revealed O2 at 2 L NC PRN and Change O2 tubing q Sunday. <BR/>Record review of Resident #25's Treatment Administration Record (TAR) accessed 10/05/22 revealed the physician order to change oxygen tubing every Sunday was not documented for 10/02/22.<BR/>During an interview on 10/04/22 at 11:47 AM. LVN D stated night shift was responsible for changing oxygen tubing, storage bag, and humidifier bottle on Sundays. She stated all items should be dated.<BR/>During an interview on 10/05/22 at 08:46 AM, LVN A stated he had worked at this facility for 2 weeks and did not know what the policy was for changing and labeling oxygen tubing. <BR/>During an interview on 10/06/22 at 06:41 AM, LVN B was a night nurse at the south nurse's station. LVN B stated the night nurses were responsible for changing oxygen tubing, the water bottle and tubing storage bag. She stated everything should be labeled with at least a date, some nurses will initial also. LVN B stated record of changing O2 tubing for all residents on oxygen therapy was entered into the electronic records system in the TAR section.<BR/>During an interview on 10/06/22 at 06:43 AM, LVN C was a night nurse at the north nurse's station. LVN C stated the night nurses changed the oxygen tubing once a week, usually on the weekend. The old tubing, water bottle and storage bag all go in the trash and all new equipment is labeled with the date. LVN C stated that was per policy. She stated the consequences of not changing the oxygen delivery equipment would be risk for infection.<BR/>During an interview and record review on 10/06/22 at 11:33 AM, the DON stated entering orders into the electronic system could be missed because agency nurses or new nurses were not familiar with the process. The DON stated the consequences may be the oxygen tubing would get yucky and they need to have clean tubing. The DON stated the oxygen tubing should be stored in a bag when not being used. She stated she was responsible for following up on orders. The DON explained that herself, the ADON, and the nurses are responsible for entering orders. Orders are received via verbal or written form. The nurse that receives the order is responsible for entering it into the system. The DON stated when a problem was identified she did an in-service and initiated a Performance Improvement Plan (PIP). The DON was made aware of the missing oxygen order for Resident #105. She verified by checking Resident #105's physician orders and the care plan and stated the order was not in the system. The DON explained the oxygen tubing dated 7/19 was due to the resident not using oxygen on a regular basis but tubing was attached so it was available if the resident should need it. The DON stated she prefers tubing not be labeled with a date especially for residents with a PRN oxygen order. The DON explained the staff could track tubing changes by checking the TAR in the electronic records system.<BR/>Facility policy title Oxygen Administration revised 02/13/07 revealed The amount of oxygen by percent of concentration or L/min, and the method of administration, is ordered by the physician. In the Procedure section, Item #10 revealed Change device and tubing when needed. Oxygenation administration disposable equipment should be changed weekly and PRN and Item #11 revealed Place NO SMOKING signs in the area where oxygen is administered and stored.

Based on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitization<BR/>The facility failed to ensure that kitchen staff obtained food temperatures prior to serving meals on 09/04/2023, 09/14/2023,09/15/2023, 09/19/2023, 09/20/2023, 09/24/2023, 09/27/2023, 09/28/2023, 09/29/2023, 09/30/2023, 10/01/2023, 10/02/2023, and 10/03/2023. <BR/>The facility failed to ensure plastic drinking cups were cleaned and sanitized properly. <BR/>These failures could place residents that eat out of the kitchen at risk for food borne illnesses.<BR/>Findings included: <BR/>During an observation on 10/03/2023 at 9:45 AM of the kitchen revealed blanks on temperature logs for the month of October 2023. <BR/>During an interview on 10/03/2023 at 9:45 AM the DM stated the cook was to write the temperatures of food when it was cooked on the temperature log. The DM stated if the cook did not write the temperature on log, then there was no way to prove that the temperatures were taken. <BR/>During an observation and interview on 10/03/2023 at 1:45 PM in the dining room revealed Resident # 1 sitting at a table with 2 other residents. Resident #1's pointed out cups at table that residents were served during lunch. One plastic cup had a cloudy film on the inside and one plastic cup had a brown film on the inside. Resident # 1 stated there had been a problem with cups not being clean. Resident # 1 stated look I can rub this brown stuff off the inside of the cup. Resident #1 stated the stained cup makes my milk look like root beer. Resident #1 stated she did not like drinking out of cups that are not clean. Resident #1 stated sometimes the food was not hot when they received food.<BR/>During an observation on 10/03/2023 at 2:00 PM of the kitchen revealed dietary staff pouring milk into plastic drinking cups. One of the plastic cups was observed to have a brown film on the inside of the cup, which made the white milk look like brown milk. Dietary staff put lids on cup and placed them into fridge. <BR/>During an interview on 10/03/2023 at 1:50 PM Resident # 2 stated she had received cups that did not appear to be clean. Resident # 2 stated it was gross to drink out of cups that looked dirty. Resident # 2 stated food was served cold at times and would have to ask them to heat food. <BR/>During an interview on 10/03/2023 at 3:15 PM the DM stated staff should not be serving residents drinks in cups that are stained. The DM stated staff should have thrown the cups away that appeared to be stained. The DM stated her expectation was that residents received cups that were not stained. The DM stated a lot of new staff and lack of training led to failure of residents receiving plastic cups that were stained. The DM stated the effect on the residents could have been a dignity issue or could have received cups that were not clean and have debris in cups. The DM stated her expectation was that staff take temperature of food when it was cooked and again before it was served; staff all need to record the temperatures on the temperature log. The DM stated there was no other way to ensure that the food was cooked to correct temperature without the logs. The DM stated there was a shift supervisor that was supposed to have checked to ensure the temperatures were taken and put on log. The DM stated new staff are trained when they are hired. The DM stated new staff were paired with shift supervisor to learn the recipes, taking temps, cleaning thermometer, and writing in log. The DM stated once the shift supervisor felt new staff were ready they would follow them and monitor them to ensure they were doing things correctly. The DM stated she monitored the logs by looking at the end of the month and when finds holes she would find the cook that was cooking that meal and will contact the supervisor to retrain that staff. The DM stated she had not reviewed the September 2023 temperature log before today and was not aware there were so many meals that were blank on the log. The DM stated she probably should have been looking more frequently. The DM stated what led to failure of temperature logs not being completed was the dietary staff get in a hurry and do not pay attention to the things they were supposed to have done. The DM stated the effect on residents could have caused residents to get sick. The DM stated she was not aware of residents getting sick from eating under cooked food. <BR/>During an interview on 10/03/2023 at 3:30 PM the IP stated there had not been any residents with gastrointestinal issues related to food. <BR/>During an interview on 10/03/2023 at 3:45 PM the ADMN stated his expectation was that cups should be cleaned properly and not have any stains on them when they were served to residents. The ADMN stated if residents were served drinks in cups that were not cleaned properly it could have caused them to become sick. The ADMN stated lack of oversight by the dietary supervisors, the DM and ADMN led to failure of residents having received cups with film on the inside of cup. The ADMN stated his expectation was that temperature of food should have been completed and recorded. The ADMN stated if temperatures were not recorded on the logs, then there was no way to prove temperatures were completed. The ADMN stated the dietary supervisors, and the DM should have been monitoring the temperature logs daily. The ADMN stated poor oversight led to the failure of food temperatures not being logged. The ADMN stated they did not have a policy in regard to clean and sanitary dishes. <BR/>Record review of facility temperature logs for the month of September 2023 and October 2023 revealed no evidence that temperatures were taken for the following meals:<BR/>09/04/2023 Dinner<BR/>09/14/2023 Breakfast, lunch, dinner<BR/>09/15/2023 Breakfast, lunch, dinner<BR/>09/19/2023 lunch, dinner<BR/>09/20/2023 Lunch<BR/>09/24/2023 Dinner<BR/>09/27/2023 Breakfast, lunch, dinner<BR/>09/28/2023 Dinner<BR/>09/29/2023 Lunch<BR/>09/30/2023 Breakfast, lunch, dinner<BR/>10/01/2023 Breakfast, lunch, dinner<BR/>10/02/2023 Breakfast<BR/>10/03/2023 Breakfast<BR/>Record review of facility policy titled Daily Food Temperature Control, dated with only year of 2012, revealed: We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, and staff, reviewed for 3 of 11 rooms (#2, #5, #6) reviewed for safe environment.<BR/>The facility failed to have residents' rooms without damage to RM [ROOM NUMBER], RM [ROOM NUMBER], and RM [ROOM NUMBER] on Hall A. <BR/>These failures could place residents and staff at risk of unsafe, and unsanitary environment.<BR/>Findings include:<BR/>During observation on 10/05/2022 between 9:25 and 9:40 AM revealed: <BR/>RM 2 revealed a cable box located on north wall adjacent to closet had coax cable protruding from exposed hole in the wall that was not properly boxed or plated for coax cable, which left the drywall and interior wall exposed. <BR/>RM 5 revealed a 7-inch diameter hole in the north wall behind the door, interior wall and sheetrock were exposed. RM [ROOM NUMBER]'s private bathroom revealed a toilet with the tank lid missing, which allowed access to the tank water.<BR/>RM 6 revealed a cable box located on south wall adjacent to closet had coax cable protruding from exposed hole in the wall that was not properly boxed or plated for coax cable, which left the drywall and interior wall exposed.<BR/>During interview on 10/05/2022 at 9:30 AM with Resident # 101 stated the hole in wall did not look good and that it bothered her, and she did not like having the lid on the toilet tank missing. <BR/>During an observation and interview on 10/06/2022 at 9:30 AM the ADMN stated she was not aware of the damage on the walls in RM [ROOM NUMBER], RM [ROOM NUMBER], or RM [ROOM NUMBER]. The ADMN, stated the holes were not supposed to be there and did not promote a home like environment. The ADMN stated that toilet tank should have a lid to cover the tank. <BR/>During interview on 10/06/2022 at 11:30 AM the ADMN stated there were signs throughout building with QR (Quick Response) codes where staff or visitors can report concerns about things that need to be addressed throughout building, then concerns were sent to maintenance care electronic system. The ADMN stated the Maintenance Director monitors electronic system to ensure issues are resolved. The ADMN stated she reviewed electronic maintenance system and did not find work orders for damages in RM [ROOM NUMBER], RM [ROOM NUMBER], or RM6. The ADMN stated effect on residents could be potentially harm themselves. The ADMN stated the Maintenance supervisor was responsible to monitor the electronic maintenance care and supposed to make rounds of the building. The ADMN stated staff were assigned hallways to check at least weekly and complete a form if they observed damage or issues in the building. The ADMN stated what led to failure of damages not being repaired was staff had not communicated with the ADMN.<BR/>During an interview on 10/06/2022 at 11:50 AM the Maintenance Director stated he was able to track work order requests in their electronic system. The Maintenance Director stated the toilet in RM [ROOM NUMBER] was a work in progress. The Maintenance Director stated the tank got cracked in process of resetting the toilet last week. The Maintenance Director stated he did not receive work orders for the damage on walls in RM [ROOM NUMBER], RM5 or RM [ROOM NUMBER]. The Maintenance Director stated the damage and missing toilet lid could have been a safety issue for residents. The Maintenance Director was not sure what led to failure of the damages not being repaired. <BR/>During interview on 10/06/22 at 12:00 PM the Housekeeping Supervisor stated she had completed an electronic work order request the previous week for the toilet needing to be fixed. The Housekeeping Supervisor stated she had not noticed the damage in RM [ROOM NUMBER], RM [ROOM NUMBER] or RM [ROOM NUMBER]. <BR/>Record review of facility report titled, Task List Report dated 10/06/2022 revealed no evidence of work request for RM [ROOM NUMBER], RM [ROOM NUMBER], or RM [ROOM NUMBER]. <BR/>Record review of Facility admission Packet not dated revealed: Residents' Rights . You have the right to: Live in safe, decent and clean conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for one (Resident #1) of three residents reviewed for infection control practices.<BR/>The facility failed to ensure CNA A performed proper hand hygiene and glove changes while providing incontinence care to Resident #1. <BR/>This failure could place residents at risk for the spread of infection. <BR/>Findings included:<BR/>Review of Resident #1's face sheet dated 01/10/25, revealed a 67- year- old female admitted to the facility on [DATE] with diagnoses including frequency of micturition (urinating), constipation, muscle weakness and Alzheimer's disease (neurological disorder).<BR/>Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1 required substantial/maximal assistance with most activities of daily living (ADLs). Resident #1 was always incontinent of bowel and bladder.<BR/>Observation of incontinence care for Resident #1 on 01/09/25 at 2:55p.m. revealed CNA A washed her hands prior to donning gloves. CNA A removed Resident #1's brief that was soiled with urine and placed it on the bed close to resident. She did not completely remove it. CNA A wiped the resident from front to back. She retrieved a clean brief and placed it on top of the soiled brief. She did not change gloves but continued to clean the resident. Her gloves were visibly soiled with urine. CNA A did not wash her hands, change gloves, or perform hand hygiene before placing the clean brief underneath the resident. CNA A changed her gloves, and retrieved the old, soiled brief and placed on a trash can. CNA A removed her gloves and picked up the trash. She washed her hands before leaving Resident #1's room.<BR/>In an interview on 01/09/24 at 3:06 p.m. with CNA A, she stated she should have changed her gloves before retrieving a clean brief and placing it underneath Resident #1. CNA A stated she has been in the facility for 2 years and received infection control training last month. She said cross contamination was going from clean to dirty. CNA A noted the resident could acquire an infection when she did not follow good infection control practices including changing gloves before retrieving the clean brief. CNA A stated she did not change her gloves because she was not thinking. <BR/>During interview on 01/10/25 at 5:11 p.m., the DON acknowledged being aware of some of the concerns raised about infection control practice. She stated ADON B was responsible for infection control in the facility. The ADON trained and monitored staffs with return demonstration periodically. The DON stated aides were expected to follow standard precaution including washing hands and changing gloves while providing care. She stated the corporate nurse also trained staff annually.<BR/>Review of the facility's infection control policy dated 04/27/22 reflected:<BR/>Purpose:<BR/>This procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by<BR/>providing cleanliness and comfort to the resident, preventing infections and skin irritation, and<BR/>observing the resident's skin condition.<BR/>Important Points:<BR/>o Doffing and discarding of gloves are required if visibly soiled<BR/>o Always perform hand hygiene before and after glove use

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary activities of daily living (ADL) services to 1 (Resident #2) of 4 residents reviewed for activity of daily living (ADL) services to dependent residents. <BR/>The facility failed to ensure NA A assisted Resident #2 when eating lunch, by leaving Resident #2 alone while eating. <BR/>This failure could place residents who were dependent on staff for ADLs at risk of not receiving proper care and services and a decreased quality of life.<BR/>The Findings included:<BR/>Review of Resident # 2's face sheet dated 02/28/2023 revealed, an [AGE] year-old female admitted on [DATE] with the following diagnoses Alzheimer's disease, muscle weakness, anxiety, and dementia. <BR/>Review of Resident #2's MDS assessment dated [DATE] revealed, Section C- Cognitive Patterns revealed a BIMS score of 0 (meaning severe cognitive impairment); Section G- Functional Status revealed Resident #2 required extensive assistance and one-person physical assist while eating. <BR/>Review of Resident #2's care plan dated 11/17/2022 revealed; Focus- The resident has an ADL self-Care Performance Deficit, Treatment/Tasks - Eating: requires staff x 1<BR/>During observation on 02/28/2023 between 1:00 PM and 1:15 PM, NA A was sitting beside Resident #2 assisting her with her lunch. NA A gave Resident #2 a roll and left Resident #2 sitting beside table with her plate of food sitting next to her. NA A returned to table 10 minutes later and began assisting resident eating. <BR/>During an interview on 02/28/2023 at 1:25 PM, NA A stated when assisting a resident eating you should not leave them during the meal. NA A stated leaving resident alone could have caused a choking hazard. NA A stated she left resident because she needed to help finish passing out meal trays on the hall. <BR/>During an Interview on 2/28/2023 at 4:00 PM, the ADMIN stated her expectation of staff while assisting residents eating, staff should not leave resident until resident had completed eating the meal. The ADMIN stated that NA A should have not left resident in the middle of resident eating lunch. The ADMIN stated the effect on resident could have been the resident had been neglected if they are not able to feed themselves and food sitting next to them. The ADMIN stated the food would have been cold after sitting there for 10 minutes. The ADMIN stated she was not sure what led to failure not sure or why staff would have left resident. <BR/>Review of facility policy titled, Feeding, Assistive/Complete dated February 14, 2007 revealed Constant supervision will be provided throughout the meal for complete feeders. Close supervision will be provided throughout the meal for assistive feeders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically transmitted to the CMS System for 1 (Resident #84) of 3 residents records reviewed for closed records. <BR/>The facility did not ensure the discharge MDS assessment was completed and electronically transmitted as required for Resident #84. <BR/>This failure could place residents at risk of facility not providing complete and specific information for payment and quality of measure purposes. <BR/>Finding included:<BR/>Review of Resident #84's electronic face sheet, accessed 11/15/2023, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosis to include: broken left leg, anxiety, and kidney disease. Further review of electronic face sheet revealed resident discharged home on [DATE]. <BR/>Review of Resident #84's Discharge MDS dated [DATE], revealed assessment was not completed and had not been submitted. <BR/>During an interview on 11/15/23 at 02:18 PM, the DON stated she was not responsible for the oversight of MDS transmission, completion, or accuracy. She stated it was the MDS nurse responsibility to complete and submit the MDS. She stated the regional MDS nurse was the one who provided oversight and monitored the MDS nurse. <BR/>During an interview on 11/15/23 at 02:28 PM, the MDS nurse stated she oversaw MDS for skilled residents and short stay residents. She stated MDS must be completed within 5 days and submitted within 14 days. She stated the same rules applied for discharged residents. She stated the accuracy and timely transmission of MDS was important because it effected the facilities reimbursement for care, and it also effected the quality of care for the residents. She stated she was aware of the discharge MDS not being submitted yet. She stated she had not had time to complete it yet. She stated she had multiple things to complete, and it was not on the top of her priority list. She stated the regional MDS nurse was responsible for her oversight. <BR/>During an interview on 11/15/2023 at 3:30 PM, the ACN stated the facility did not have a policy for transmitting MDS's. He stated the facility followed the RAI timetable.<BR/>Record review of the CMS RAI Version 3.0 Manual last revised October 2023 revealed: For a Quarterly, Significant Correction to Prior Quarterly, Discharge or PPS assessment, encoding must occur within 7 days after the MDS completion Date . Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. Care plans are not required to be transmitted. Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 +14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days) . Discharge Assessment Submit by Z0500B + 14.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 (Resident #3 and Resident #7) of 6 residents reviewed who required working call lights for quality of care. <BR/>The facility failed to ensure the call light in Resident #3 and Resident #7's room was in good working order. The string to activate call light was long enough to be within reach of residents in room. <BR/>This failure could place residents at risk of not being able to alert staff to their room. <BR/>Findings include:<BR/>Record review of MDS dated [DATE] reflected . Resident #3 Female [AGE] years old, admitted on [DATE]. BIMS of 0, severe cognitive impairment. Medical Diagnosis of Alzheimer's (neurodegenerative disease). Resident's Care Plan dated 5/2/24 states the resident has a communication problem r/t impaired cognitive status, ensure/provide a safe environment: Call light in reach. <BR/>Record review of MDS dated [DATE] reflected . Resident #7, Female [AGE] years old, admitted to facility on 4/8/23. BIMS of 3 cognitive impaired. Resident #7 has a medical diagnosis of Dementia (neurodegenerative disease with decline in cognitive abilities)<BR/>Care Plan dated 7/3/24 states The resident is risk for falls r/t cognition impaired, poor safety awareness, unsteady.<BR/>balance. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.<BR/>Observation on 7/23/24 at 10:20am revealed that the call light system in Resident #7's room was not within reach. The system was a string system that when pulled turns the call light on, much like a light switch in a room. Observation revealed that the string connected to the switch on the wall was 8 inches long, not long enough for residents sitting, or lying in bed to be able to reach the string to activate the call light if needed. <BR/>Observation on 7/23/24 at 10:20am revealed Resident #3 was observed sitting in her wheelchair ambulating down the hall, Resident #3 was non interview able. <BR/>Interview on 7/23/24 at 10:30am resident #7, was sitting on her bed, call light was not within reach, resident #7 stated she did not know there was a call light system in her room and had never used it. <BR/>Interview on 7/23/24 at 10:25am CNA A stated she has worked at the facility for 3 months and had not noticed that the call light string was cut and non-usable. CNA A stated staff performed rounds constantly and call lights were not used much in the secure unit. <BR/>Interview on 7/23/24 at 10:40am Administrator stated she was unaware of the string being cut. Observed Administrator herself repaired call light in room A008 by adding two new strings long enough to be within reach of residents when needed. Administrator stated that having a call light system in each room that was functional was necessary for each residents' safety and well-being. <BR/>Review of the Facility Call Light System Check Policy (no date) states, Step 2. Check wall station in each patient room. Repair as necessary.