Nursing Home Survey Report Details for MEDICAL …nursinghomesabuseadvocate.com/wp-content/uploads/2016/12/MEDI… · MEDICAL MANAGEMENT HEALTH AND REHAB CENTER ... For information

DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED:6/6/2016FORM APPROVEDOMB NO. 0938-0391

STATEMENT OFDEFICIENCIESAND PLAN OFCORRECTION

(X1) PROVIDER / SUPPLIER/ CLIAIDENNTIFICATIONNUMBER

115692

(X2) MULTIPLE CONSTRUCTIONA. BUILDING ______B. WING _____

(X3) DATE SURVEYCOMPLETED

01/29/2016

NAME OF PROVIDER OF SUPPLIER

MEDICAL MANAGEMENT HEALTH AND REHAB CENTER

STREET ADDRESS, CITY, STATE, ZIP

1509 CEDAR AVEMACON, GA 31204

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORYOR LSC IDENTIFYING INFORMATION)

F 0224

Level of harm - Immediatejeopardy

Residents Affected - Few

Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on observation, clinical record review, facility policy and procedure review, and staff interview, the facility failed to ensure a cognitively impaired resident (#7) was free from neglect by not providing supervision necessary to ensure her safety, as well as to protect other residents in the facility from her potentially aggressive behaviors. The facility census was eighty-seven (87) residents, and the sample size was thirty (30) residents.There was documentation in the Nurse's Notes and Falling Star notes on 03/24/15 that the resident fell outside in the smoking area sustaining an abrasion to the left hip, with no documentation that staff were supervising her. In addition, the resident was involved in nine (9) resident-to-resident altercations from 04/12/15 to 01/21/16, resulting in injuries including a [MEDICAL CONDITION] and black eye for resident #7, and scratches for resident #23 and an unsampled resident.The noncompliance caused actual harm to R#2, who sustained a laceration to the chin on 11/29/2015, a fracture to the nose on 1/14/2016; resident S who sustained a [MEDICAL CONDITION] on 6/9/2015, a shoulder fracture on 11/10/2015, and; to R#7 who sustained a head injury on 3/14/2015, laceration to the head on 10/18/2015 and a fractured arm on 11/7/2015.On 01/26/16 at 2:01 p.m., the facility Administrator and Corporate Nurse Consultant were again notified that Immediate Jeopardy existed in CFR 483.25 Quality of Care (F 323 S/S: K), and that IJ was determined to exist as of 03/14/15, when resident #7 sustained a head injury after a fall with no documentation that the safety helmet was in place. The Immediate Jeopardy was also related to non-compliance with CFR 483.13 Resident Behaviors and Facility Practices (F 224 S/S: J), CFR 483.20 Resident Assessment (F 282 S/S: K), CFR 483.30 Nursing Services (F 353 S/S: K), and CFR 483.75 Administration (F 490 S/S: K), and CFR 483.75(o)(1) Qaa (F520 S/S:K).Immediate Jeopardy (IJ) was identified on 01/26/16, and the facility Administrator and Corporate Nurse Consultant were notified at 2:01 p.m. IJ was determined to exist as of 03/14/15 related to non-compliance at CFR 483.25 (F 323 S/S-K), and CFR 483.13 Resident Behavior/Facility Practices (F 224 S/S-J). The IJ also determined that the provider ' s non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The IJ was determined to be ongoing.Findings include:Review of resident #7's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of a History and Physical (H&P) from a geriatric behavioral health facility dated 10/13/14 noted the resident was referred to them after having combative behavior and violent outburst episodes.Continued review of this H&P revealed the resident had also been admitted to this psych facility on 08/02/10 for aggressive behavior, and had several admissions for the same behavior at that facility as well as other hospitals in Georgia. Review of an H&P from the geriatric behavioral health facility dated 08/18/15 revealed the resident was admitted there due to increased agitation and combative behavior, including physically striking and scratching other residents and staff, and was not able to be redirected.Further review of this H&P revealed that despite receiving a prn (as needed) drug, she was shrieking and screaming at the top of her lungs and was uncontrollable. Review of the Reason for hospitalization section of the form included that she was a potential danger to herself and others. Review of the History of Present Illness from this psych admission revealed that she was increasingly manic and highly delusional; had been throwing things such as chairs on other residents; extremely erratic and very dangerous.Review of resident #7's behavior care plan with a Problem Onset date of 01/13/16 revealed that she had socially inappropriate behavior as evidenced by yelling, cries out loud, screams, sexually inappropriate statements to staff, visitors, and residents, uses profanity, and altercations with residents at times. Review of the interventions for this care plan included to place her in an area where constant observation was possible; remove from public area when her behavior was disruptive or unacceptable.Review of resident #7's risk for injury care plan revealed interventions including to place the resident in a location where constant observation was possible and to not leave unattended; if resident wandering away from unit instruct staff to stay with her and persuade her back to designated area with them. Review of the risk for falls care plan revealed interventions to increase rounds to prevent risk of unwitnessed falls and injury, and to place resident in area where constant observation was possible.Review of Incident/Accident Reports, Falling Star notes, and Nurse's Notes revealed the following resident-to-resident incidents, or unwitnessed falls when out of her room:On 03/20/15 at 10:30 p.m.: The resident was noted with a skin tear to the left hip. On 03/23/15 at 9:15 a.m., the resident stated she fell while out in the smoking area.On 04/12/15 at 6:05 a.m.: The resident was noted in the dining room attempting to hit another resident, lost her balance and fell backward hitting the back of her head on the floor and causing lacerations to the back of her head.On 08/12/15 at 8:30 a.m.: Another resident reported that resident #7 fell in the lobby on Station 2. Resident noted to have abrasions to left side of face and forehead.On 08/14/15 at 9:40 a.m.: Resident combative, went into dining room and began hitting another resident, attacking staff and other residents on the C-hall, including resident #23. When resident #23 attempted to move out of the way he fell , no injuries noted.On 08/17/15 at 12:30 p.m.: Reported by another (unsampled) resident that resident #7 scratched his right lower arm for no reason. Resident #7 noted to be agitated. The (unsampled) resident was noted to have at least fifteen small to medium superficial scratches to his right lower arm.On 09/01/15 AT 5:00 p.m.: Per review of the Accident/Incident Monthly Tracking Log, there was a resident to resident altercation in the dining room involving resident #7. However, during interview with the interim Director of Nurses (DON) on 01/27/16 at 1:30 p.m., she could not find the Incident Report, and Medical Records staff could not locate Nurse's Notes for that date, so details of the incident are unknown.On 09/06/15 at 11:30 a.m.: Resident #7 was pushed to the floor in the dining room by another (unspecified) resident, who stated he pushed her when resident #7 hit him.On 09/07/15 at 12:00 p.m.: Resident #7 was agitated, went into the dining room during lunch, pinched another resident and threw the lunch tray across the table.On 10/18/15 at 10:40 a.m.: Writer called to the dining room by another nurse, resident noted attempting to get up from the floor (no documentation if the fall was witnessed). Sent to ER, three staples to back of head.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIERREPRESENTATIVE'S SIGNATURE

TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that othersafeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following thedate of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the datethese documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CMS-2567(02-99)Previous Versions Obsolete

Event ID: YL1O11 Facility ID: 115692 If continuation sheetPage 1 of 20





115692



01/29/2016







F 0224



(continued... from page 1)On 10/27/15 at 3:54 a.m.: Resident #7 was hit in the eye by another (unsampled) resident causing a bruise. The other resident was angry at resident #7 for something she said.On 11/13/15 at 1:00 p.m.: Resident fell off the commode when left unattended and sustained a skin tear to her left forearm and left eyelid.On 01/21/16 at 12:20 p.m.: Resident #7 pulled another resident's hair during breakfast and was removed from the dining room and redirected to hall, extremely agitated. Threw a cup of water at the writer at the nurse's station. At 11:45 a.m. the resident went into the dining room and hit another resident on the back of the head.During interview with Certified Nursing Assistant (CNA) EE on 01/21/16 at 10:45 a.m., she stated that it was not unusual for resident #7 to be agitated. During interview with CNA OO on 01/21/16 at 12:25 p.m., she stated that she had known resident #7 to hit other residents about three times, and that she will curse at them. During interview with Licensed Practical Nurse (LPN) KK on 01/21/16 at 12:30 p.m., she stated that resident #7 got agitated often and would hit other residents and they checked on her often, but that they could not isolate her.During interview with the Activity Director on 01/28/16 at 11:21 a.m., she stated that resident #7 had a very short attention span, and was disruptive and would yell, scream and curse at times. Upon further interview, she stated that the resident had hit her and other residents before.During interview with LPN CC on 01/28/16 at 12:22 p.m., she stated that resident #7 had to be sent to the geriatric behavioral health facility on 01/27/16, as she was threatening to kill staff and tried to kick a contractor working on the nurse call system off his ladder.During continuous observation on 01/21/16 beginning at 2:24 p.m., resident #7 was noted to curse, yell, and self-propel her wheelchair out of her room and down the C-hall. Further observation revealed that she passed three staff, none of whom tried to redirect her to her room.At 2:35 p.m., CNA WW was observed to redirect the resident back to her room after the resident reached the end of C-hall. During interview with CNA WW at this time, she stated that if resident #7 was agitated they tried to keep her in her room.At 2:37 p.m., resident #7 was observed to wheel herself out of her room and entered rooms C-9, B-2, B-6 while yelling and cursing, and was brought out of these rooms by staff. During further observation she was noted to wheel herself on the B- and C-halls, and then entered room C-3 at 2:48 p.m. at which time the resident in that room asked staff to remove her.During further observation the resident rolled herself into room C-7 at 2:52 p.m. During observation at 3:03 p.m., the resident was noted to wheel herself down the B-hall to the dining room, and a CNA passed her without attempting to redirect her.During observation at 3:07 p.m., the resident entered room B-7 where she stayed unsupervised for two minutes, before wheeling herself down to the Station 2 nurse's station. During further observation at 3:15 p.m., the resident wheeled herself to the dining room and stopped at the first table where two residents were sitting, and told them I hate you, and was crying out.During continued observation three staff were noted to walk past her as she was going down the B-hall, but they did not redirect her. After staff provided her a sandwich in the dining room at 3:22 p.m., the resident was observed to wheel herself into room B-12 at 3:40 p.m. at which time staff brought her to the Station 2 nurse's station.During observation at 3:45 p.m., the resident wheeled herself down the B-hall through the dining room and solarium, then down the A-hall and into A-5's bathroom, where she remained until 4:02 p.m., at which time a family member of a resident in room A-5 alerted staff.During interview with the interim DON on 01/22/16 at 1:13 p.m., she stated that they did not do one-on-one monitoring, and that staff and other residents would tell them where the resident was. During further interview, she stated that it was acceptable for resident #7 to wheel herself around the facility by herself as long as she was not agitated. During further interview, she stated that staff should try to redirect the resident close to the nurse's station or her room if she was agitated, as they did not want her to harm anyone else.Review of the facility's Abuse or Exploitation of Residents Policy and Procedure revealed that Neglect referred to failing to provide goods and services necessary to avoid physical harm. Review of the Resident to Resident Abuse section of the policy noted that the facility's goal was to provide a safe and loving environment to meet the needs of all that they served.

F 0250

Level of harm - Minimalharm or potential for actualharm


Provide medically-related social services to help each resident achieve the highest possible quality of life.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on observation, record review and staff interview, the facility failed to consistently provide social services related to ongoing psychiatric care per the Preadmission Screening and Resident Review (PASRR) recommendations for one (1) resident (#7). The sample size was thirty (30) residents.Findings include:Review of resident #7's clinical record revealed [DIAGNOSES REDACTED].During observations and interviews throughout the survey, resident #7 was noted with multiple behaviors, including the following:On 01/21/16 at 10:19 a.m.: Licensed Practical Nurse (LPN) CC stated that resident #7 threw a cup of water and swung at her that morning, and that she had been yelling and cursing before that.On 01/21/16 at 12:15 p.m.: The Social Services Director (SSD) stated resident #7 had just hit another resident in the dining room, and had hit her (the SSD) earlier in the day.On 01/21/16 at 2:24 p.m.: The resident was noted to curse and yell, and self-propel her wheelchair where she was observed to go up and down the hallways and into other resident rooms and the dining room, and the staff were not able to easily redirect her.On 01/22/16 at 10:32 a.m.: A staff member entered the conference room where the surveyors were located to obtain resident #7's chart and stated the resident was throwing furniture and out of control. During observations of the resident at this time she was noted to throw a styrofoam cup of water on the floor, propelled her wheelchair in the hall and another resident's room, and was crying out.On 01/28/16 at 12:22 p.m.: During interview with LPN CC, she stated that resident #7 had to be sent out to the psychiatric facility yesterday for continuing agitated behaviors, including threatening to kill staff, and had tried to kick a contractor working on the call light system off his ladder.Review of a History and Physical (H&P) from the geriatric behavioral health facility the resident was last sent to dated 08/19/15 noted that she had been physically striking and scratching other residents and staff and was unable to be redirected, and was a potential danger to herself and others with failure of outpatient treatment. Further review of the anticipated disposition section of the H&P noted that the resident would be returned to the nursing home and have recommended follow-up with mental health.Review of a PASRR Level II assessment dated [DATE] revealed that resident #7 met the PASRR population with [DIAGNOSES REDACTED].During interview with the SSD on 01/28/16 at 10:22 a.m., she stated that the nurses were responsible for asking the facility's psychiatric doctor to see a particular resident. Interview with the Administrator on 01/28/16 at 10:30 a.m. revealed that the facility did not have a behavior management policy and procedure. During interview with the SSD on 01/28/16 at 12:58 p.m., she stated that for the Level II PASRR residents, they would be set up to be seen by the facility's psychiatric doctor. Upon further interview she stated she had probably contacted the contracted psychiatric services group when the resident was first admitted and was told the resident did not meet the criteria for services, but she did not have documentation of this. Upon further interview, she stated that if the geriatric behavioral health facility recommendation at discharge back to the nursing home was for mental health follow-up, that they would contact the facility's psychiatrist for this, and did not know if this had been done.Review of the last Psychiatric Consultation seen in the active clinical record was dated 04/15/15, and noted outbursts of







115692



01/29/2016







F 0250



(continued... from page 2) tears, fear, and throwing self on floor, and a psychotropic med was recommended to be restarted. During interview with the SSD on 01/29/16 at 9:24 a.m. and record review, she provided the facility psychiatrist's Adult Progress Notes dated 05/27/15, 07/08/15, and 09/02/15, and stated the resident refused to be seen. Further review of these Progress Notes revealed that there was no documentation that the psychiatrist reviewed the resident's psychotropic medications nor made any recommendations to address her ongoing behaviors. Upon further interview, the SSD did not know why the psychiatrist was not asked to see the resident after September.Cross-refer to F 224.

F 0274



Review or revise the resident's care plan after any major change in a resident's physical or mental health.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on record review and staff interview, it was determined that the facility failed to conduct a comprehensive significant change Minimum Data Set (MDS) assessment on two residents (#7 and S) who had declines in their physical condition from a sample of thirty (30) residents.Findings include:1. Resident S was admitted on [DATE] with [DIAGNOSES REDACTED].Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was ambulatory with set-up assistance only from staff, was continent of bladder and bowel, required supervision only from staff for bathing and had no falls in the last six months prior to admission.Review of the Incident/Accident Report dated 6/9/15 at 10:10 a.m. revealed that the resident walked into his/her room with the rolling walker and closed the door. Staff heard a noise and found the resident on the floor beside her/his bed. Continued review revealed that she/he had tripped over his/her walker and sustained a left [MEDICAL CONDITION]. review of the resident's medical record revealed [REDACTED].Review of the Quarterly MDS assessment dated [DATE] revealed that the resident had significant declines after the fall with major injury and was non-ambulatory, was always incontinent of bladder and bowel and required extensive assistance from staff for bathing.Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 1/22/16 at 1:50 p.m., revealed that the resident was independent with ambulation and toileting when he/she was admitted to the facility. Continued interview revealed that the resident was bedbound and dependent on staff for bed mobility, transfer and toileting after the 6/9/15 fall with [MEDICAL CONDITION] and was now total care. Although staff had assessed the resident with significant declines in ambulation, bladder and bowel continence and bathing and having had a fall with major injury ([MEDICAL CONDITION]) on the 6/21/15 MDS assessment, staff failed to conduct a comprehensive significant change assessment to reflect the resident's physical decline.During an interview with the Corporate MDS Registered Nurse on 1/29/16 at 11:20 a.m., she confirmed that the resident had significant declines in ambulation, bladder and bowel continence, bathing and had a fall with major injury. Continued interview with her revealed that the 6/21/15 Quarterly MDS assessment should have been a comprehensive significant change assessment.2. Review of resident #7's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she needed limited assist by one staff for walking in room and corridor and for personal hygiene, and had no weight loss or pressure ulcers.Review of resident #7's Annual MDS dated [DATE] revealed that she had declines in the following areas:Walking in room and corridor and personal hygiene now required extensive assist by one staff; the resident had a significant weight loss that was not physician prescribed, and she had developed two Stage 2 pressure ulcers.During interview with the Corporate MDS Registered Nurse on 01/25/16 at 9:50 a.m., she stated that a Significant Change assessment should be done whenever there was a decline in two or more areas on the MDS. During further interview and record review, she stated that a Significant Change MDS should have been done for resident #7 instead of an Annual MDS on 01/11/16, as the resident had declines in two areas of Activities of Daily Living, a significant weight loss, and new pressure ulcers.Review of the facility's Persons at Risk (PAR) Weight Monitoring Program policy and procedure revealed that a new MDS will be done when the significant weight loss criteria was met.

F 0278



Make sure each resident receives an accurate assessment by a qualified health professional.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on observation, record review, and staff interviews, the facility failed to ensure that accurate Minimum Data Set (MDS) assessments were completed for six (6) residents (#24, S, #25, #2, #27 and #7) of thirty (30) sampled residents.Findings include:1. Review of resident #27's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that they had no falls since the prior assessment. Further review of the MDS revealed a Discharge MDS on 10/06/15, and a Readmission MDS on 10/14/15. Review of the Incident/Accident Tracking Log and Reports revealed that the resident had falls in the facility on 11/05/15 (twice), and on 11/08/15. During interview with the interim Director of Nurses (DON) on 01/27/16 at 1:02 p.m., she verified resident #27 had a fall on 11/05/15.2. Review of resident #7's Annual MDS dated [DATE] revealed that she was assessed as having no falls since the last assessment with an Assessment Reference Date (ARD) of 09/07/15. Review of the Accident/Incident Monthly Tracking Log revealed that resident #7 had twelve falls between these two assessments. During interview with the Corporate MDS Registered Nurse on 01/25/16 at 9:50 a.m., she verified the January MDS was inaccurate related to falls, as the resident has had several falls including one with a fracture since the September MDS.Review of resident #7's Quarterly MDS dated [DATE] revealed that she was not assessed as having received an antianxiety during the seven day look-back period. Review of the resident's Medication Administration Record [REDACTED].3. Review of Resident Ss Quarterly MDS assessment dated [DATE] revealed that the resident was assessed as having no pressure sores. However, review of the resident's medical record revealed [REDACTED]. Continued review of the resident's medical record revealed [REDACTED]. On 1/20/16 at 10:31 a.m. during observation of pressure sore treatment, the resident had a 2.8 centimeter (cm.) by 4.7 cm. by 0.2 cm. Stage IV pressure sore on his/her left heel.Interview with Corporate MDS Registered Nurse on 1/29/16 at 11:20 a.m., revealed that the prior MDS coordinator had inaccurately assessed the resident as having no pressure sore on the 10/6/15 Quarterly MDS.4. Review of Resident #2's Quarterly MDS assessment dated [DATE] revealed that the resident was assessed as having no falls since the prior Quarterly MDS assessment dated [DATE]. However, review of the Incident/Accident Reports revealed that the resident had five (5) falls since 7/27/15 on 8/30/15 (1 fall), 9/21/15 (2 falls) and 9/24/15 (2 falls).During interview with the Director of Nursing (DON) on 1/22/16 at 1:30 p.m., she confirmed that the resident had falls between the assessments dated 7/27/15 and 10/26/15.5. Review of Resident #25's Quarterly MDS assessment dated [DATE] revealed that the resident was assessed as having no pressure sores. However, review of the resident's medical record revealed [REDACTED]. Continued review of the resident's medical record revealed [REDACTED].On 1/28/16 at 2:05 p.m. during observation of pressure sore treatment, the resident had a 0.8 cm. by 0.8 cm. by <0.2 cm. pressure sorewith soft black wound bed on his/her left heel.6. The physician order [REDACTED]. The resident ' s Brief Interview for Mental Status was not scored.Medical record review reveals the resident has a Stage 4 pressure ulcer to the sacral/coccyx area. Date of onset 11/1/20.A physician's order [REDACTED].A review of the Weekly Pressure Ulcer QI Log dated 11/1/2015 reveals resident 24 has a Stage IV sacral measure ulcer measuring 0.4X 0.3 X < .2 centimeters. A review of the annual MDS dated [DATE] lists dimensions of 4. X 3 x 2 cm.







115692



01/29/2016







F 0278



(continued... from page 3)An nurse ' s note entry on 12/9/ 2015 by the wound care nurse reveals Stage 4 sacral ulcer with pink/red tissue to wound bed measuring 0.8 x 0.8 x <0.2 centimeters.On 1/22/2016 at 2:30 p.m., the resident ' s wound care was observed. The wound was pink with some macerated tissue surrounding it. The treatment nurse cleaned the wound with normal saline, patted it dry, applied calcium [MEDICATION NAME] and a dry dressingAn interview was conducted with the corporate MDS registered nurse on 1/29/16 at 9:00 a.m. She reveals that she looks back for a week, and confirms the look back period would be from 12/13/2015 to 12/20/2015. She produced a weekly pressure ulcer QI log that reveals measurements of 0.4x0.3x<0.2. on 11/1/2015 and confirmed she had entered the data incorrectly

F 0280



Allow the resident the right to participate in the planning or revision of the resident's care plan.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on observation and record review, it was determined that the facility failed to revise the care plan to include interventions for staff to ensure that a resident was wearing non-skid socks at all times and were monitoring the resident's whereabouts per a specific monitoring schedule for one (1) resident (#2); failed to revise the care plan to include interventions to maintain the bed in the lowest position and ensure that the door to the resident's room remained open for one(1) resident (S); and failed to revise the care plan related to the use of bed and chair alarms for one (1) resident (#7). Nine (9) residents were reviewed for falls from a sample of thirty (30) residents.The facility did not revise the residents Falls care plans to decrease the likelihood of future falls. The facility's failure to update the Falls care plans resulted in Immediate Jeopardy (IJ) as evidenced by a chin laceration on 11/29/15 and a nose fracture on 1/14/16 for Resident #2; a [MEDICAL CONDITION] on 6/9/15 and a shoulder fracture on 11/10/15 for Resident S; and a [MEDICAL CONDITION] on 10/18/15 and an arm fracture on 11/07/15 for Resident #7.Immediate Jeopardy (IJ) was identified on 1/26/15 and the facility Administrator and Corporate Nurse Consultant were notified on 1/26/15 at 2:01 p.m. IJ was determined to exist as of 3/14/15 and remains ongoing. It was also determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The IJ was related to non-compliance with Resident Assessment (F280 S/S J) for Resident #2, Resident S, Resident #7.Cross reference to Quality of Care F323.The findings include:1. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED].Review of the Annual Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] revealed that the resident had a Brief Interview for Mental Health Status (BIMS) score of 0, indicating that the resident was severely cognitively impaired. Continued review revealed that the resident wandered daily and required supervision from staff for locomotion on and off the unit.Review of the resident's care plan dated 4/29/15 revealed that the resident was at risk for falls related to excessive walking, history of falls, use of multiple [MEDICAL CONDITION] medications and removal of call light with interventions to encourage the resident to lie down when exhaustion noted, administer medications as ordered and notify the physician of any abnormal side effects, psychiatric consult and visits as ordered, staff assistance with care needs as allowed, staff to approach resident and announce why you are addressing him/her to decrease combative behavior and for the physician to review the resident's medications.Continued review revealed that the resident was at risk for injury as evidenced by wandering throughout the facility, wandering in residents rooms and taking naps in other residents' beds with interventions for staff to redirect the resident and wander monitoring per facility protocol.Review of the facility's Wandering or Missing Resident Guideline revealed that the facility would provide supervision to promote a safe environment for residents at risk for injury due to wandering behavior. Continued review revealed that if a resident repeatedly wandered off the unit, the care plan would reflect a monitoring schedule to ensure the resident's safety.Continued review revealed that residents on a monitoring schedule would be monitored either hourly or every shift or as deemed necessary by the Patients at Risk (PAR) committee. Further review revealed that residents with an identified problem of wandering whose care plans did not meet the resident's needs would have a prompt review.review of the resident's medical record revealed [REDACTED]. Continued review revealed that the resident was hospitalized in 6/2015 for physically aggressive behaviors and his/her [MEDICAL CONDITION] medications were adjusted at that time.Review of the facility's Incident/Accident Reports revealed that the resident had ten (10) falls between 8/30/15 and 1/19/16. Review of the Incident/Accident Reports for 8/30/15, 9/21/15 at 9:00 a.m., 9/21/15 at 2:30 p.m., 10/30/15, 11/14/15, 11/29/15 and 1/19/16 revealed that the resident was out of his/her room while ambulating.Review of the Incident/Accident Report dated 11/29/15 at 8:20 p.m., revealed that the resident jumped up out of the bed and began walking very fast in the hallway with an unsteady gait. The resident fell facedown and sustained a two (2) inch laceration under his/her chin that required a visit to the Emergency Department and sutures.Review of the Falls Report Investigation dated 11/29/15 revealed that the resident was not wearing shoes or non-skid socks at the time of the fall. Review of the Falling Star Program Tracking Form dated 11/30/15 revealed that staff were supposed to ensure that the resident had on non-skid socks and/or appropriate shoes.Review of the facility's Incident/Accident Report dated 1/14/16 at 8:05 p.m., revealed that the resident was observed lying in his/her roommate's bed and staff documented that the resident had fallen in the room while ambulating. The resident was sent to the Emergency department and assessed with [REDACTED].Review of the Falls Report Investigation dated 1/14/16 revealed that the resident was wearing inappropriate footwear at the time of the fall. Review of the Falling Star Program Tracking Form dated 1/15/16 revealed that staff were supposed to ensure that the resident had on non-skid socks or shoes when out of bed.Review of the resident's care plan revealed new interventions for staff to place the resident on the Falling Stars Program, provide treatments as ordered, obtain Therapy screen/consult, redirect the resident after meals to his/her own room and assist the resident with putting on shoes when up. However, none of the new interventions were dated.Obseervation on 1/20/16 at 7:55 a.m., Resident #2 was sitting on the side of his/her bed eating breakfast. The resident was wearing regular socks at that time. On 1/21/16 at 7:20 a.m. and 12:30 p.m. and on 1/22/16 at 8:00 a.m., the resident was in the bed wearing regular socks.Interview with Licensed Practical Nurse (LPN) KK on 1/21/16 at 2:12 p.m. revealed that the resident wandered/paced all over the facility at will and that his/her gait was unsteady depending on how much sleep she/he had the previous night. Continued interview with KK revealed that she/he monitored the resident's room and hall for clutter and ensured that the resident's shoelaces were tied. Further interview revealed that staff attempted to redirect the resident to his/her room to lie down but, the resident would not stay there.Interview with Certified Nursing Assistant (CNA) LL on 1/21/16 at 2:25 p.m. revealed that staff monitored the resident for falls and that she/he encouraged the resident to sit and rest. Continued interview revealed that the resident would walk to other halls but, she/he did not follow the resident to the other halls. Further interview with LL revealed that she/he was unable to verbalize other interventions in place to prevent further falls for the resident.Interview with the Director of Nursing (DON) on 1/22/16 at 1:30 p.m. revealed that staff had not determined the root cause of the resident's falls since 8/30/15 and that the resident's falls had occurred on different shifts. Continued interview revealed that she expected licensed nursing staff to notify certified nursing staff to monitor a resident more frequently if that resident had received a medication that caused potential sedation/drowsiness.Further interview revealed that she did not expect staff to follow the resident to other parts of the facility to monitor because the resident did not pose harm to other residents.Interview with CNA II on 1/26/16 at 1:05 pm revealed that licensed nursing staff would tell her/him to watch the resident







115692



01/29/2016







F 0280



(continued... from page 4) after the nurse had administered his/her antianxiety medication.Continued interview revealed that the resident was supposed to be monitored every 15 minutes. Further interview revealed that she/he may be in another resident's room and Resident #2 will just get out of bed and start walking. Continued interview revealed that she/he would not be able to monitor the resident when providing care for another resident.Review of the facility's Falling Star Program Policy revealed that the purpose of the program was to identify a resident at risk for falls, to increase staff awareness of each resident's safety needs in order to protect the resident, to evaluate and determine reason (s) for falls and to implement measures to prevent falls.Further review revealed that the Falling Star Committee would be composed of the following team members: Director of Nursing (DON), Minimum Data Set/Care Plan Coordinator, Medical Records Coordinator, Restorative Nurse, Rehabilitation (Restorative) Aide, Maintenance Director and one Certified Nursing Assistant (CNA). The functions of the committee were to review incidents of falls and develop recommendations for the Care Plan Team, track the outcome of the plans of care in the prevention of future falls and to determine the educational needs of staff. Further review revealed that the MDS/Care Plan Coordinator was responsible for updating the Falling Stars list in the Activities of Daily Living (ADL) book and to ensure that the care plans of residents on the Falling Star program addressed falls and other related problems.Continued review revealed that Certified Nursing Staff and Licensed Nursing Staff were supposed to monitor the whereabouts and condition of all Falling Stars at regular intervals not to exceed two (2) hours.Although staff had identified Resident #2 as being at risk for injury due to wandering throughout the facility, staff failed to revise the resident's care plan to include an effective monitoring schedule to ensure the resident's safety.Although the Falling Stars committee had identified that the resident was not wearing appropriate footwear when he/she fell on [DATE] and 1/14/16 and sustained injuries at those times, there was no indication that staff had identified and revised the resident's care plan to include an intervention to address the resident's wandering at will and potential need to wear non-skid footwear at all times to prevent future falls.2. Resident S was admitted on [DATE] with [DIAGNOSES REDACTED].Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating that the resident was alert and oriented, was ambulatory with set-up assistance only from staff, was continent of bladder and bowel and independent with toileting, and was independent with transfer with set-up assistance only from staff.Review of the Quarterly MDS assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating that the resident was alert and oriented, was non-ambulatory, was always incontinent of bladder and bowel and required total assistance from one staff person for transfer and toileting.Review of the resident's care plan dated 2/16/15 revealed that the resident was at risk for falls related to medication usage, [MEDICAL CONDITION] in his/her left eye, hypertension, [MEDICAL CONDITION], dementia, [MEDICALCONDITION] and [MEDICAL CONDITION] disorder with interventions for staff to keep the room and common areas free of clutter, to keep the call light within reach, to encourage the resident to call for assistance, to provide therapy services to make functional gains in Activities of Daily Living (ADL) functioning and to provide adaptive equipment as needed.Review of the Incident/Accident Report dated 6/9/15 revealed that the resident had a fall in his/her room with the door closed. The resident sustained [REDACTED].Continued review of the Incident/Accident Report dated 11/10/15 revealed that the resident's bed was in the up position at the time of the fall. The resident sustained [REDACTED].Review of the resident's care plan revealed that staff revised the care plan to include new interventions for therapy to screen upon return from the hospital, to place the resident on the Falling Star Program and to apply a sling on the resident's right arm.Observation on 1/19/16 at 4:44 p.m., Resident S was lying in bed. Observation of the bed revealed that staff had failed to lower the bed to its lowest position. The top of the mattress was observed approximately 3 feet from the floor. On 1/20/16 at 8:15 a.m., the resident was in the bed but, the bed was not in its lowest position.Observation on 1/21/16 at 2:29 p.m., the resident was in his/ her wheelchair in his/her room reading with the door closed. Continued observation of the resident's closed door revealed that at 2:40 p.m., Certified Nursing Assistant (CNA) NN knocked on the resident's door and entered the resident's room. NN came out of the resident's room at 2:41 p.m. pulling the door almost closed behind him/her.Continued observation of the resident's door revealed that it remained closed until 4:00 p.m. Observation of the resident at that time revealed the resident in his/her wheelchair in the room. Resident S stated at that time that he/she preferred the door open but, his/ her roommate wanted it closed.On 1/25/16 at 4:30 p.m. and on 1/26/16 at 8:15 a.m. and 9:48 a.m., the resident was in the bed but, the bed was not in the lowest position. On 1/26/16 at 9:48 a.m., CNA DD used the crank at the end of the resident's bed to lower the bed to the lowest position. Interview with DD at that time revealed that she/he did not know why the bed had been raised but, that it should have been in its lowest position.Although staff had identified that the resident's fall on 6/9/15 was in his/her room with the door closed, staff failed to revise the resident's care plan after the 6/9/15 fall to include an intervention to keep the resident's door open for more effective monitoring.Although staff had identified that the resident's bed was in the up position when he/she fell on [DATE] while transferring from the wheelchair to the bed, staff failed to revise the resident's care plan after the 11/10/15 fall to include an intervention for staff to maintain the resident's bed in the lowest position to prevent further falls.

3. Review of a Falling Star Tracking Form dated 09/23/15 at 12:15 a.m. noted that resident #7 was witnessed throwing herself on the floor, with a plan to add a bed alarm so staff would know when the resident got out of bed.Review of a Falling Star Tracking Form dated 10/07/15 at 3:25 p.m. noted the resident was found on the floor by her wheelchair, with a plan to add alarm to the wheelchair. Review of the comprehensive risk for falls care plan with a Problem Onset of 10/03/14 noted an undated, handwritten intervention for adding a bed and chair alarm.Review of the risk for falls care plan with a Problem Onset date of 01/13/16 did not contain interventions for a bed or chair alarm.During observations in resident #7's room on 01/20/16 at 1:45 p.m.; 1/21/16 at 6:43 a.m., 9:18 a.m. and 11:15 a.m.; no bed alarm was seen. During interview with CNA EE on 01/21/16 at 11:22 a.m., she stated that resident #7 did not have a bed alarm, and that they kept her in a place where they could monitor her and keep her occupied.During observation of the resident in the wheelchair on 01/22/16 at 10:30 a.m., a chair alarm was noted on the back of the wheelchair, but it was not clipped to her clothing, and there was no seat belt. This was verified during interview with CNA JJ on 01/22/16 at 10:49 a.m., who stated the chair alarm was discontinued when the seat belt was applied.During observation on 01/25/16 at 9:18 a.m., a chair alarm was noted on the back of resident #7's wheelchair, but it was not clipped to her clothing.Review of Incident/Accident Reports noted falls from the wheelchair with no documentation of the presence of a chair alarm after this was added as an intervention:On 10/18/15 at 10:40 a.m. (sustained a laceration to the back of her head); and 11/02/15 at 7:30 a.m.Review of Incident/Accident Reports noted falls from the bed with no documentation of the presence of a bed alarm after this was added as an intervention: on 10/21/15 at 9:45 a.m.; on 11/07/15 at 10:50 p.m. (sustained an arm fracture); and on 11/27/15 at 12:00 a.m.During interview with the Corporate Minimum Data Set (MDS) Registered Nurse (RN) on 01/21/16 at 10:10 a.m., she stated that care plans were reviewed and updated with each Annual MDS assessment. During further interview, she stated that when this was done, the new falls care plan would not include all of the falls information from the previous falls care plan.

F 0281



Make sure services provided by the nursing facility meet professional standards of quality.Make sure services provided by the nursing facility meet professional standards of quality.







115692



01/29/2016







F 0281



(continued... from page 5)**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on record review and staff interview, the facility failed to develop an interim care plan for one (1) newly-admitted resident (#15). The sample size was thirty (30) residents.Findings include:Review of resident #15's closed clinical record revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].Review of Nurse's Notes revealed the following:On 12/10/15 at 6:00 p.m.: Sitting in bathroom on floor with feces all over bathroom and himself. Refuses to leave on adult icontient briefs. Tried to get out back door to smoke. Wandering into solarium with gown half off. Grabbed writer's wrist and twisted when attempted to redirect. Blood pressure 193/155. Sent to emergency room (ER).On 12/11/15 at 9:50 a.m.: Sitting on floor at bedside.On 12/11/15 at 7:00 p.m.: [MEDICATION NAME] given for agitation.On 12/12/15 at 7:25 a.m.: Found in bathroom, destroyed the commode, deep laceration to left forearm. Transported to ER at 8:00 a.m.On 12/13/15 at 7:45 a.m.: Suddenly became agitated and started ripping information off the wall and started crying and balling his fists, hitting the wall. Sent to ER at 10:10 a.m.On 12/15/15 at 7:00 p.m.: Returned from ER at 3:20 p.m. in four-point restraints. Transported to a behavioral health facility.Further review of the clinical record revealed that the Interim Plan of Care was blank. During interview with the Corporate Minimum Data Set (MDS) Registered Nurse on 01/28/16 at 10:53 a.m., she stated that the admitting nurse did an interim care plan after completing all of the assessments, such as fall risk and pressure ulcer risk assessments. Upon further interview, she verified that resident #15's interim care plan had never been completed.

F 0282


Residents Affected - Some

Provide care by qualified persons according to each resident's written plan of care.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on observation, record review, and staff interview, the facility failed to follow the care plans for seven (7) residents ( # 7, 13, S, 25, 26, 27, and T). of thirty (30) sampled residents.On 01/19/16 at 2:45 p.m., the interim Director of Nurses (DON) was notified that Immediate Jeopardy (IJ) existed, as the Administrator was not in the facility. IJ was determined to exist as of 01/19/16 at CFR 483.70 Physical Environment (F 463 Scope and Severity (S/S): K). this information was repeated with the Corporate Nurse Consultant on 01/19/16 at 2:55 p.m. It was determined that the noncompliance with one or more requirements of participation caused, is likely to cause, serious injury, harm, impairment or death to residents.The noncompliance caused actual harm to Resident #2, who sustained a laceration to the chin on 11/29/2015 and a fracture to the nose on 1/14/2016; to Resident S who sustained a [MEDICAL CONDITION] on 6/9/2015 and a shoulder fracture on 11/10/2015; to Resident T who sustained a lumbar compression fracture on 12/7/15; and to Resident #7 who sustained a head injury on 3/14/2015, laceration to the head on 10/18/2015 and a fractured arm on 11/7/2015. In addtion actual harm occurred to Resident #25 and Resident S who developed pressure sores in the facility due to failure to assess and apply pressure relief interventions.A Credible Allegation of Compliance related to CFR 483.70 Physical Environment (F 463 S/S: K) was received on 01/20/16 at 5:25 p.m., at which time the Immediate Jeopardy was removed. The facility remained out of compliance at a lower scope and severity of E, while they continued to do every fifteen minute checks of the affected rooms on Station 2 and continued to in-service staff on monitoring of these rooms.On 01/26/16 at 2:01 p.m., the facility Administrator and Corporate Nurse Consultant were again notified that Immediate Jeopardy existed in CFR 483.25 Quality of Care (F 323 S/S: K), and that IJ was determined to exist as of 03/14/15, when resident #7 sustained a head injury after a fall with no documentation that the safety helmet was in place. The Immediate Jeopardy was also related to non-compliance with CFR 483.13 Resident Behaviors and Facility Practices (F 224 S/S: J), CFR 483.20 Resident Assessment (F 282 S/S: K), CFR 483.30 Nursing Services (F 353 S/S: K), and CFR 483.75 Administration (F 490 S/S: K), and CFR 483.75(o)(1) Qaa (F520 S/S:K).1. Review of Resident T's care plan dated 3/7/15 and last reviewed 12/29/15 revealed that the resident was at risk for falls related to decreased mobility, [MEDICAL CONDITION] and use of psychiatric medications with an intervention for staff to have his/her call light within reach and to keep the bed in the lowest position at all times.On 1/22/16 at 3:32 p.m. and on 1/25/16 at 10:10 a.m., 12:15 p.m. and 5:20 p.m., Resident T was lying in his/her bed. The bed was not in its lowest position.On 1/25/16 at 5:30 p.m. the top of the mattress measured twenty-eight (28) inches from the floor.On 1/26/16 at 8:00 a.m., the resident was lying in the bed and the bed was not in its lowest position. Certified Nursing Assistant (CNA) LL confirmed at that time that the bed was not in its lowest position and used the crank at the end of the bed to lower the bed.On 1/26/16 at 8:05 a.m., the resident's call light was observed lying in his/her wheelchair out of reach of the the resident. Interview with Resident T at that time revealed that he/she could use the call light and that it was for emergencies.On 1/26/16 at 4:15 p.m., the resident was sitting in his/her wheelchair in the room. However, his/her call light was on the floor behind the wheelchair out of the resident's reach.On 1/27/16 at 1:15 p.m. and 3:30 p.m., the resident was in the bed and the bed was not in its lowest position.On 1/27/16 at 1:15 p.m., the resident demonstrated that he was able to use the call light to call for assistance.On 1/29/16 at 8:55 a.m., the resident's bed was assessed with [REDACTED].Cross reference to F323.2. Review of Resident #25's care plan dated 4/11/15 and reviewed 7/21/15 and 10/6/15 revealed that the resident was at risk for skin breakdown related to decreased mobility, history of pressure sores, diabetes, venous stasis disease, refusal to be turned and repositioned and incontinence of bowel and bladder. Interventions included certified nursing staff to observe the resident's skin during showers and activities of daily living (ADL) care for early signs of breakdown and to notify the charge nurse and for the charge nurse to conduct skin assessments per facility protocol.review of the resident's medical record revealed [REDACTED]. However, there was no indication that certified nursing staff had consistently assessed the resident's skin during showers or baths as care planned except for assessments on 7/16/15 and 7/17/15. Furthermore there was no indication that licensed nursing staff had assessed the resident's skin weekly per facility protocol as care planned.Interview with the LPN Treatment Nurse on 1/28/16 at 10:50 a.m. revealed that she was unable to locate any of the weekly skin assessments that licensed nursing staff were supposed to perform on the resident prior to the identification of the DTI on 7/26/15. Continued interview with the LPN Treatment Nurse revealed that she was responsible for ensuring that the CNAs and the nurses completed the skin assessments.Cross reference to F314.3. Review of Resident S's care plan dated 2/16/15 and reviewed 5/19/15 and 6/15/15 revealed that he/she had the potential for skin breakdown related to limited mobility with interventions for certified nursing staff to observe the resident's skin during showers/ADL care for early signs of skin breakdown and notify the charge nurse and for licensed nursing staff to perform skin assessments per facility protocol.review of the resident's medical record revealed [REDACTED]. However, there was no indication that certified nursing staff had consistently assessed the resident's skin during showers or baths as care planned prior to the identification of the DTI except on 7/7/15. Furthermore there was no indication that licensed nursing staff had assessed the resident's skin weekly per facility protocol as care planned.Interview with LPN Treatment Nurse on 1/22/16 at 11:25 a.m. revealed that she had reviewed the Licensed Nurse Skin Assessment Book and could not find any weekly skin assessments performed by licensed nursing staff prior to the identification of the DTI on the resident's heel on 7/14/15. Further interview revealed that she obtained the CNA Skin Assessment Checklist Forms and the Weekly Skin Assessment Forms completed by licensed nursing staff at the end of each week and kept the forms in a notebook in the copy room. Further interview revealed that she was responsible for ensuring that







115692



01/29/2016







F 0282



(continued... from page 6) the nurses were completing the weekly skin assessments.Cross reference F314.

4. Review of resident #27's comprehensive falls risk care plan included an intervention dated 03/30/15 to add a bed alarm, and an intervention dated 06/29/15 to add a safety seat belt to the wheelchair. During observation in resident #27's room on 01/25/16 at 9:24 a.m., no bed alarm was noted on her bed. This was verified during interview with Certified Nursing Assistant (CNA) EE at this time. During observation of resident #27 in her wheelchair on 01/25/16 at 9:28 a.m., no chair alarm or seat belt was observed. This was verified during interview with Restorative CNA OO at this time.5. Review of resident #7's comprehensive falls risk care plan with a Problem Onset date of 10/03/14 revealed the following interventions, and review of Incident/Accident Reports and Falling Star Forms revealed that the interventions were not being followed as follows:a. Apply safety helmet, and staff to assist resident with putting helmet on when resident isn't wearing helmet.-03/14/15: Resident was brought out of the dining room due to agitated behavior, and dropped to the floor and began banging her head on the floor causing a gash in the top of her head. Additional comments were to make sure resident has helmet on at all times.-08/13/15: Resident walking up B-hall, let go of railing and fell to floor receiving an abrasion to back of her head. Comment included to ensure wearing helmet.-10/21/15: Noted lying on floor bedside bed, complained of right ear pain. Additional comments included to keep helmet on at all times.b. Assist resident during smoke breaks.-Review of a Falling Star Program Tracking Form noted that on 03/23/15 at 9:15 a.m., the resident stated that she had a fall twice while outside in the smoking area and scraped her left hip. The Plan included for staff to assist her to and from the smoking area due to unsteady gait and non-compliance with wearing helmet.c. Ensure that resident has and wears properly-fitting non-skid soled shoes for ambulation.-07/10/15: Resident was witnessed walking in the hallway and she tirpped and fell and hit the right side of her head on the floor. Additional comments noted to ensure resident is wearing proper footwear.-07/20/15: Resident walking around in another resident's room and tripped over her foot, shoes not tied. Additional comments noted that shoe laces were put into resident's shoes.-08/13/15: Resident walking up B-hall, let go of railing and fell to floor receiving an abrasion to back of her head. Comment included to ensure proper fitting shoes.d. Analyze previous falls by resident to determine whether pattern/trend can be addressed.-During interview with the Corporate Registered Nurse Consultant on 01/25/16 at 1:32 p.m., she stated that the analysis for falls for resident #7 to analyze the number of falls per time of day and location was not done until the surveyor asked for it on 01/22/16, and that they otherwise only analyzed falls for all residents combined.Cross-refer to F 323.Review of resident #7's risk for skin breakdown care plan with a Problem Onset date of 01/13/16 noted interventions for a cushion to the chair, and nurses to perform weekly skin assessments.a. During observations of resident #7 in her wheelchair, no pressure-reduction pad was noted in the seat on 01/19/16 at 4:50 p.m.; 01/20/16 at 7:45 a.m.; 01/21/16 at 12:41 p.m. and 2:24 p.m.; 01/22/16 at 10:49 a.m.; and 01/25/16 at 9:18 a.m. This was verified during interview with CNA EE on 01/21/16 at 11:22 a.m.b. Review of Weekly Pressure Ulcer Records noted the resident developed two Stage II pressure ulcers on 11/18/15, one on each trochanter area over the bony prominences. Review of Skin Assessment Forms completed by licensed nurses revealed no skin breakdown on 10/02/15; 10/10/15; 10/22/15; and 10/29/15. Review of the next Skin Assessment Form done by a licensed nurse was dated 11/18/15, the day the pressure ulcers were identified. This was verified during interview with the Licensed Practical Nurse (LPN) Treatment Nurse on 01/20/16 at 12:46 p.m.Cross-refer to F 314.Review of resident #7's comprehensive falls risk care plan with a Problem Onset date of 01/13/16 included interventions to alert staff to resident's wandering behavior, and that if the resident was wandering away from the unit, instruct staff to stay with resident, converse and gently persuade resident to walk back to designated area with them.During continuous observations on 01/21/16 from 2:24 p.m. to 4:02 p.m., resident #7 was noted to exhibit agitated behaviors as evidenced by cursing, yelling, crying, and self- propelling her wheelchair on the B-hall and C-halls, including into seven resident rooms, and the dining room. At 3:45 p.m. the resident was observed to self-propel her wheelchair from the B-hall through the dining room and solarium, to the A-hall, without staff intervention. Upon further observation she rolled herself into room A-5, where she remained until 4:02 p.m. when a family member of a resident in that room alerted the staff.Cross-refer to F 224.Review of resident #7's comprehensive behaviors care plan dated 10/03/14 and 01/13/16 noted an intervention for a psych consult as needed.-Review of her Medication Administration Records revealed that besides her routine [MEDICAL CONDITION] meds, the resident received as-needed (prn) doses of an antianxiety drug seventeen times, and an antipsychotic drug twenty times in November; a prn antianxiety drug ten times and an antipsychotic drug sixteen times in December; and a prn antianxiety drug four times and antipsychotic drug eight times in January for agitation. Review of Nurse's Notes dated 01/27/16 at 8:15 a.m. noted the resident was extremely agitated including physical and verbal aggression,During interview with LPN CC on 01/28/16 at 12:22 p.m., she stated that resident #7 had to be sent to the senior behavioral heath hospital on [DATE] due to continuing agitated and aggressive behaviors. Review of the psychiatrist's progress notes revealed that the last time that there was documentation that she was asked to see the resident was on 09/02/15. This was verified during interview with the Social Services Director on 01/29/16 at 9:24 a.m.Cross-refer to F 250.

Findings included:6. Review of the Minimum Data Set (MDS) Quarterly Review dated 12/30/15 revealed Resident #26 to have a Brief Interview of Mental Status (BIMS) of nine (9) and active [DIAGNOSES REDACTED]., Anxiety, Depression, Manic Depressant, [MEDICAL CONDITIONS], Repeated Falls, and Altered Mental Status (AMS).Review of the MDS Annual assessment dated [DATE] revealed The Care Area Assessment Summary (CAAS) to include Activities of Daily Living (ADL) Functional/ Rehabilitation Potential, Falls, Behavioral Symptoms, Pressure Ulcer, and [MEDICAL CONDITION] Drug Use to be addressed in the Care-plan. Review of Section J: Falls since admit/reentry/prior assessment: any falls-yes, no injury-one, injury-one, major injury-none.Review of the Care-plan updated on 1/17/15 revealed:Problem: Resident #26 was at risk for falls related to having a history of a pacemaker, coronary anomaly, paranoid [MEDICAL CONDITION], mood disorder, neuropathic pain, anxiety, extrapyrimidal side effects (EPS), right [MEDICAL CONDITION] (BKA), [MEDICAL CONDITION] medication use and falls.Interventions included:Add anti-tippers to resident's wheelchair.Wheelchair for mobility.Assist with transfer and bed mobility.Administer medications as ordered.Therapy/restorative as indicated.Keep the call light in reach.Encourage resident to call for assistance.Keep area clean and free of clutter.Lock the wheelchair and assist resident out of bed when requested.Review of the Falling Star Program Tracking Form dated 1/16/16 at 6:45 pm revealed Resident #26 to have had a fall with injury and the plan was to apply a wheelchair alarm. On 1/18/16 at 9:30 am, documentation revealed the resident to have had







115692



01/29/2016







F 0282



(continued... from page 7) a fall without injury in the hallway; resident slid to the floor. The plan was to apply a safety belt.Review of the physician's orders [REDACTED].Current Pertinent medications: [REDACTED][MEDICATION NAME] 150 milligrams(mg) every twenty-one(21) days-[MEDICAL CONDITION] disorder[MEDICATION NAME] ER 1000 mg twice a day-[MEDICAL CONDITION][MEDICATION NAME] 20 mg twice a day-[MEDICAL CONDITION][MEDICATION NAME] 400 mg twice a day-[MEDICAL CONDITION][MEDICATION NAME] 40 mg daily-mood disorder[MEDICATION NAME] 80 mg at bedtime-[MEDICAL CONDITION][MEDICATION NAME] 1 mg as needed(PRN) at bedtime-[MEDICAL CONDITION]Further review of the physician's orders [REDACTED]. The physician's orders [REDACTED].Review of the physician's orders [REDACTED]. Clarification: skilled PT to see Resident #26 three (3) times per week for four (4) weeks for therapeutic exercises, neuromuscular pain, wheelchair training, and patient/caregiver education.On 12/28/15, MD orders reveal to send resident to ER for evaluation of AMS/Fall and oxygen at two (2) liters per minute via nasal cannula, check oxygen saturation each shift, and conduct neuro-checks.An observation on 1/25/16 at 3:45 p.m. revealed Resident #26 back to facility in his room. The resident was in bed in a hospital gown. The bed was not in the lowest position and no side rails were observed in the up position. The call light was out of reach. The resident showed no signs of acute distress and was resting with eyes closed.An observation on 1/26/16 at 8:45 a.m. revealed Resident #26 to be in the dining room in a wheelchair at a table. The blue/purple lift/draw sheet was under the resident . No safety belt or chair alarm observed.During an interview on 1/26/16 at 9:00 a.m., the certified nursing assistance (CNA) DD, transporting resident's in and out of the dining room, confirmed that the Resident #26 did not have a chair alarm in place and no safety belt was applied to the resident's chair. CNA DD notified the charge nurse and the resident was placed under close supervision.An observation on 1/27/15 in the dining room revealed Resident #26 was in his wheelchair at a table participating in an activity. The chair alarm was in place for safety precaution along with a safety belt.

7. A review of resident # 13 ' s medical record and Minimum Data Set (MDS) reveals [DIAGNOSES REDACTED]. The resident ' s Brief Interview for Mental Status (BIMS) score is 8. MDS reveals the resident has disorganized thinking and hallucinations, requires 1 person physical assist with transfers, walking in room, and locomotion on and off of the unit.The medical record reveals the resident had falls on 7/21/2015, 9/3/2015, 9/18/2015, 10/29/2015, and 12/7/2015.A review of the care plan initiated 6/3/2015 revealed an undated intervention for the resident to call for assistance, ensure the resident ambulates with nonskid socks, and ambulates with assistance.An observation of resident 13 on1/26/2016 at 12:1 0 p.m., reveals the resident lying in bed with regular socks on her feet. The resident states she goes to the bathroom by herself by holding on to objects. States she has had falls, but doesn ' t know why.On 1/26/2016 an interview was conducted with CNA HH at 2:20 p.m. HH reveals she assists the resident with her bath and dressing. She states the resident uses the socks in her drawer, but they are not non-skid socks. HH confirms that the resident ambulates to the bathroom without assistance.On 1/27/2016 at 8:30 a.m., resident # 13 was observed standing in the doorway of her room closing the door. The resident was observed to have on socks that did not have non-skid soles.On 1/28/2015 at 1:50 p.m., the resident was observed in bed and was wearing socks that did not have non-skid soles. An interview was conducted with LPN GGwho told surveyor that she did not know if the resident was supposed to have on non-skid socks or not.An observation completed on 1/29/2016 at 11:50 a.m. reveals the resident is lying in bed and wearing regular socks. The soles are not non-skid. The resident was agitated and requested the surveyor leave. No further observations were made.

F 0309



Provide necessary care and services to maintain the highest well being of each resident**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on record review and staff interview, it was determined that the facility failed to follow physician orders [REDACTED].#2) and to apply a splint and follow-up with the orthopedist for one resident (#7) from a sample of thirty (30) residents.Findings include:1. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED].Review of the medical record for resident #2 revealed that the resident had a physician's orders [REDACTED]. Continued review revealed that there was no indication that the resident was seen by the neurologist.Interview with the Assistant Director of Nursing (ADON) on 1/22/15 at 10:00 a.m. revealed that the resident was scheduled to see the neurologist on 10/16/15 at 9:15 a.m. but, the resident did not go to his/her appointment. Another appointment was made with the neurologist on 11/4/15 at 12:15 p.m. but, the resident did not go to that appointment either.Continued interview with the ADON revealed that she did not know why the resident missed both appointments with the neurologist. Interview with the ADON on 1/22/16 at 12 noon revealed that the facility had transport staff who scheduled residents appointments and were available to go with the residents to their appointments if needed. Continued interview with the ADON revealed that the charge nurse was responsible for ensuring that the resident went to his/her appointment and if there were any problems, staff were supposed to notify her.Interview with Certified Nursing Assistant (CNA) JJ who was responsible for appointment scheduling/transport on 1/25/16 at 10:00 a.m. revealed that she/he could not remember why the resident did not go to the first appointment with the neurologist on 10/16/15.Continued interview with JJ revealed that transportation did not arrive to the facility to pick up the resident for the rescheduled appointment on 11/4/15. Further interview revealed that she/he had called the neurologist to reschedule again but, was not able to obtain an appointment until February 2016.Continued interview with JJ revealed that she/he did notify the resident's nurse about the missed appointments but, was unable to say who. Further interview revealed that she/he had not notified the ADON about the missed appointments.

2. Review of a Nurse's Note dated 11/08/15 at 10:50 p.m. revealed resident #7 was found on the floor in her room, and complained of right wrist and hand pain, and was sent to the emergency room (ER). Review of an ER Patient Summary and Instructions report dated 11/08/15 noted the resident had a [DIAGNOSES REDACTED].Review of an orthopedic physician's Clinic Note dated 12/03/15 noted the resident was being seen post-fracture day twenty-five for a right oblique displaced midshaft ulna fracture, and was in a cock-up splint. The physician's Assessment/Plan was to continue the right forearm cock-up splint, and to follow-up in six weeks (which would be around 01/14/16) to x-ray the right forearm.During observations of resident #7 on 01/19/16 at 4:50 p.m., 01/20/16 at 7:45 a.m. and 5:45 p.m.; 01/21/16 at 8:40 a.m.; 01/22/16 at 10:30 a.m.; and 01/25/16 at 9:18 am., no splint or cast was seen on the resident's arm.During interview with the interim Director of Nurses (DON) on 01/27/16 at 1:30 p.m., she verified the last documentation in the Nurse's Notes that mentioned a splint was on 12/11/15, and that she could not find an order to discontinue the splint.During interview with the Assistant Director of Nurses (ADON) on 01/28/16 at 1:28 p.m., she verified that the orthopedic physician's plan on 12/03/15 was to continue the right arm splint, and she did not know why there was no documentation after 12/11/15 that the splint was being applied. During further interview, she stated she thought that the orthopedic doctor revisit would not be due for a few more weeks, and so had not been done.

F 0311



Make sure that residents receive treatment/services to not only continue, but improve the ability to care for themselves.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**







115692



01/29/2016







F 0311



(continued... from page 8)Based on record review and staff interview, it was determined that the facility failed to ensure that restorative services were provided for two residents (#2 and S) to maintain or improve their abilities as recommended by the Physical Therapist (PT) from a sample of thirty (30) residents.Findings include:1. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED].Review of the Annual Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] revealed that the resident had a Brief Interview for Mental Health Status (BIMS) score of 0, indicating that the resident was severely cognitively impaired. Continued review revealed that the resident wandered daily and required supervision from staff for locomotion on and off the unit.Review of the Physical Therapy Discharge Summary dated 8/7/15 revealed that the Physical Therapist treated the resident from 7/1/15 to 8/7/15 and recommended that the resident receive restorative services for ambulation and active range of motion (AROM) exercises to prevent decline after discharge from physical therapy.However, review of the Restorative Care Flow Record for 7/2015 revealed that the resident received restorative services for ambulation and dining six days a week until 7/22/15 when restorative services were discontinued.Review of the facility's Incident/Accident Reports revealed that the resident had ten (10) falls between 8/30/15 and 1/19/16, with two of the falls resulting in injury. Review of the Physical Therapy Discharge Summary dated 11/22/15 revealed that the Physical Therapist treated the resident from 9/24/15 to 11/22/15 and recommended restorative services to provide ambulation and AROM exercises for the resident six days a week after discharge from physical therapy. However, review of the 11/2015, 12/2015 and 1/2016 Restorative Nursing Flow Sheets revealed that restorative staff had provided the resident with AROM exercises and communication but, not ambulation.Although the Physical Therapist had recommended on 11/22/15 that the resident receive restorative services for ambulation, interview with Restorative Aide BB on 1/21/16 at 7:39 a.m. revealed that the resident received restorative nursing services for active range of motion exercises and communication only since 11/22/15.Further interview with BB revealed that restorative staff had not provided ambulation for the resident since 7/2015. Continued interview with BB revealed that he/she would occasionally walk with the resident if the resident wanted to go outside. Further interview with BB revealed that the resident's gait was unsteady sometimes and he/she was more ambulatory in the afternoon.Interview on 1/26/16 at 1:40 p.m. with Licensed Practical Nurse (LPN) MM who was responsible for restorative nursing services revealed that she/he would normally follow therapy's recommendation. Continued interview revealed that therapy completed a Restorative Nursing Inservice Form and checked the restorative services that therapy recommended the resident be provided. Further interview with MM revealed that she/he documented the recommended services on the Restorative Flow Record that the Restorative Aides followed.Although the Physical Therapist had recommended restorative services for ambulation on 8/7/15 and 11/22/15 for Resident #2, the facility failed to provide that service to the resident in order to maintain or improve the resident's ambulation.2. Resident S was admitted on [DATE] with [DIAGNOSES REDACTED].Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating that the resident was alert and oriented, was ambulatory with set-up assistance only from staff, was continent of bladder and bowel and independent with toileting, and was independent with transfer with set-up assistance only from staff.However, review of the Quarterly MDS assessment dated [DATE] revealed that the resident had a decline in his/her physical condition and was non-ambulatory, was always incontinent of bladder and bowel and required total assistance from one staff person for transfer and toileting.review of the resident's medical record revealed [REDACTED]. Continued review revealed that the resident had a fall that resulted in a left [MEDICAL CONDITION] on 6/9/15 and a fall that resulted in a right shoulder fracture on 11/10/15.Review of the Physical Therapy (PT) Discharge Summary dated 4/5/15 revealed that the resident received PT from 2/4/15 to 4/5/15 for bed mobility, transfers, ambulation and strengthening. Continued review revealed that the Physical Therapist recommended that the resident receive restorative services for ambulation and transfers to maintain his/ her current level of performance in order to prevent decline.However, review of the Restorative Nursing Flow Sheets provided by the facility revealed that restorative services were not provided for the resident after 4/5/15. Interview with Restorative Aide OO on 1/26/16 at 2:25 p.m., revealed that the resident was not provided restorative services until 11/2/15.Interview with the Certified Occupational Therapy Assistant (COTA) on 1/28/16 at 2:50 p.m., revealed that the Physical Therapist had recommended that the resident receive restorative services for ambulation and transfers after discharge from skilled therapy on 4/5/15 and that she/he did not know why the resident did not receive the services.Although the Physical Therapist had recommended restorative services for ambulation and transfers on 4/5/15 for Resident S, the facility failed to provide those services to the resident in order to maintain or improve the resident's ambulation and transfer ability.

F 0314

Level of harm - Actualharm


Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on observation, record review, review of the facility's Skin Care Guidelines and Skin Assessment Guidelines and staff interview, it was determined that the facility failed to ensure that pressure relieving measures to prevent pressure sores were initiated and implemented to prevent the development of pressure sores and promote the healing of pressure sores; failed to conduct weekly skin assessments in order to identify the development of pressure sores timely in order to initiate treatment promptly; and failed to ensure that dressings were monitored in order to promptly apply a clean dressing to an exposed pressure sore to prevent contamination for three (3) residents (#7, S and #25) of five (5) residents reviewed for pressure sores from a total sample of thirty (30) residents.This failure to identify the development of pressure sores timely resulted in harm for residents S and #25 who developed unstageable Deep Tissue Injuries (DTIs) prior to staff identification of the pressure sores.Findings include:1. Resident #25 was admitted on [DATE] with [DIAGNOSES REDACTED].Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Health Status (BIMS) score of 9 indicating that the resident was cognitive with confusion, was non-ambulatory, required total assistance from staff for bed mobility, transfer, eating, personal hygiene, bathing and toileting and was always incontinent of bowel and bladder.Review of the resident's care plan dated 4/11/15 and reviewed 7/21/15 and 10/6/15 revealed that the resident was at risk for skin breakdown related to decreased mobility, history of pressure sores, diabetes, venous stasis disease, refusal to be turned and repositioned and incontinence of bowel and bladder. Interventions included certified nursing staff to observe the resident's skin during showers and activities of daily living (ADL) care for early signs of breakdown and to notify the charge nurse and for the charge nurse to conduct skin assessments per facility protocol.Review of the facility's Skin Assessment Guidelines revealed that each resident was supposed to be provided a head to toe skin assessment during baths by their assigned Certified Nursing Assistant (CNA). The CNA completed the skin assessment on the CNA Skin Assessment Checklist form and gave the form to the charge nurse and/or treatment nurse.Review of the Skin Care Guidelines revealed that each resident would be assessed by the nurse for potential skin problems on admission, readmission and quarterly or if there was a change in the resident's condition. The charge nurse would conduct a head to toe skin assessment for low and moderate risk residents with each monthly nursing summary following the monthly schedule posted at each nurses station.The Care Plan Coordinator would update the resident's skin risk assessment with each quarterly Minimum Data Set (MDS) or change in condition. Any changes in score that caused a resident to become high risk, the MDS coordinator would notify the







115692



01/29/2016







F 0314



(continued... from page 9) Director of Nursing (DON).The DON and/or MDS coordinator was responsible for updating the High Risk Assessment book to be picked up by the nurses who were assigned to conduct weekly skin assessments. Resident's at high risk for skin breakdown would have weekly skin assessments performed by the charge nurse. The charge nurse was also responsible for ensuring that the residents were turned and repositioned every two hours and that proper pressure relieving devices were used.Review of the Pressure Ulcer Risk Assessment form reviewed on 1/6/15, 3/26/15, 5/26/15, 8/18/15 and 12/2/15 revealed that Resident #25 scored 14 to 15, indicating that the resident was at high risk for the development of pressure sores.Review of the Bath Schedule Book revealed that the resident was supposed to receive showers on the 7:00 a.m. to 3:00 p.m. shift every Tuesday, Thursday and Saturday. Review of the Weekly Skin Assessment Schedule Book revealed that licensed nursing staff were supposed to perform a head to toe skin assessment of the resident every Monday on the 11:00 p.m. to 7:00 a.m. shift.review of the resident's medical record revealed [REDACTED]. Although it was facility policy to perform a head to toe skin assessment on all residents readmitted to the facility, there was no indication that licensed or registered nursing staff had performed a head to toe skin assessment on the resident on 6/26/15 when he/she returned from the hospital.Review of the Nurses Note dated 7/21/15 revealed that the resident had a decline in condition, was total care for all activities of daily living (ADLs), was fed all meals and had poor intake, was having hallucinations, was incontinent and without skin breakdown at that time.Review of the Nurses Note dated 7/23/15 revealed that the resident's weight was down 7.2 pounds (#) from his/her previous weight of 177.7# on 7/16/15. Staff initiated Boost Glucose Control (a supplement) twice a day for thirty (30) days to prevent further weight loss.Further review of the medical record revealed that the Registered Dietician (RD) assessed the resident on 8/11/15 and recommended a Multivitamin with minerals every day, a House Shake (supplement) at bedtime for ninety (90) days and Boost Glucose Control for thirty (30) days to promote healing of the pressure sore and prevent further weight loss.On 1/28/16 at 11:52 a.m., the Licensed Practical Nurse (LPN) Treatment Nurse provided a Skin Assessment form and note dated 7/26/15 that revealed that the resident was identified with a 2 centimeter (cm.) by 2 cm. by <0.2 cm. dark maroon Deep Tissue Injury(DTI) on his/her left heel that was without drainage.The physician was notified at that time and treatment initiated. Continued review of the resident's medical record revealed [REDACTED].Review of the Weekly Pressure Ulcer QI Log dated 7/30/15 revealed that interventions to assist with healing of the DTI included heel protectors. However, review of the resident's medical record prior to the identification of the DTI on 7/26/15 revealed that there was no indication that staff had initiated any pressure relieving devices to prevent skin breakdown until after the resident developed the DTI on his/her left heel.Furthermore, there was no indication that certified nursing staff had assessed the resident's skin every bath/shower day as care planned or that licensed nursing staff had performed weekly skin assessments as per facility policy in order to identify potential breakdown promptly and initiate treatment timely.The LPN Treatment Nurse could only provide two CNA Skin Assessment Check List forms prior to the identification of the DTI on 7/26/15 that were dated 7/16/15 and 7/17/15 and were incomplete regarding the presence or absence of breakdown.Interview with the LPN Treatment Nurse on 1/28/16 at 10:50 a.m. revealed that she was unable to locate any of the weekly skin assessments that licensed nursing staff were supposed to perform on the resident prior to the identification of the DTI on 7/26/15. Continued interview with the LPN Treatment Nurse revealed that she was responsible for ensuring that the CNAs and the nurses completed the skin assessments.Interview with Certified Nursing Assistant (CNA) PP on 1/28/16 at 1:20 p.m. revealed that she/he assessed the resident's skin on shower days and also on other days when the resident received a bedbath. Continued interview revealed that PP documented on the CNA Skin Assessment Checklist form and would notify the nurse if she/he saw any redness or open areas.Interview with Licensed Practical Nurse (LPN) AA on 1/28/16 at 1:55 p.m. revealed that the nurses were supposed to perform weekly skin assessments but, were sometimes unable to perform as scheduled because staff were swamped.On 1/28/16 at 12 noon, the resident was lying in the bed with bilateral heel protectors on. On 1/28/16 at 2:05 p.m., the LPN Treatment Nurse provided treatment to the resident's left heel DTI as ordered by the physician. The DTI on the resident's left heel measured 0.8 cm. by 0.8 cm. by <0.2 cm. with soft black wound bed and no odor or drainage.Although the resident was assessed as being at high risk for the development of pressure ulcers on 1/6/15, 3/26/15 and 5/26/15, there was no indication that certified nursing staff consistently assessed the resident's skin on shower/bath days as care planned prior to the identification of the DTI on the resident's left heel on 7/26/15.There was no indication that licensed nursing staff assessed the resident's skin weekly as per facility policy prior to the identification of the DTI on the resident's left heel on 7/26/15.There was no indication that licensed nursing staff had performed a head to toe skin assessment of the resident on his/her 6/26/15 readmission from the hospital as per facility policy.Although staff had identified that the resident had a decline with poor intake and total care for activities of daily living (ADLs) on 7/21/15, there was no indication that staff had initiated heel booties as an effective pressure relieving measure to prevent the development of a pressure sore on the resident's heel until after the development of the DTI on 7/26/15.2. Resident S was admitted on [DATE] with [DIAGNOSES REDACTED].Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Health Status (BIMS) score of 15, indicating that he/she was alert and oriented. Continued review revealed that the resident was non-ambulatory, required extensive assistance from staff for bed mobility, transfer and bathing and was always incontinent of bowel and bladder. Further review revealed that the resident had a fall with major injury, had limitations on one side of his/her lower extremities and was at risk for the development of pressure sores.Review of the resident's care plan dated 2/16/15 revealed that he/she had the potential for skin breakdown related to limited mobility with interventions for certified nursing staff to observe the resident's skin during showers/ADL care for early signs of skin breakdown and notify the charge nurse and for licensed nursing staff to perform skin assessments per facility protocol.Review of the facility's Skin Assessment Guidelines revealed that each resident was supposed to be provided a head to toe skin assessment during baths by their assigned Certified Nursing Assistant (CNA). The CNA completed the skin assessment on the CNA Skin Assessment Checklist form and gave the form to the charge nurse and/or treatment nurse. Review of the Skin Care Guidelines revealed that each resident would be assessed by the nurse for potential skin problems on admission, readmission and quarterly or if there was a change in the resident's condition. The charge nurse would conduct a head to toe skin assessment for low and moderate risk residents with each monthly nursing summary following the monthly schedule posted at each nurses station. The Care Plan Coordinator would update the resident's skin risk assessment with each quarterly Minimum Data Set (MDS) or change in condition. Any changes in score that caused a resident to become high risk, the MDS coordinator would notify the Director of Nursing (DON).The DON and/or MDS coordinator was responsible for updating the High Risk Assessment book to be picked up by the nurses who were assigned to conduct weekly skin assessments.Resident's at high risk for skin breakdown would have weekly skin assessments performed by the charge nurse. The charge nurse was also responsible for ensuring that the residents were turned and repositioned every two hours and that proper pressure relieving devices were used.review of the resident's medical record revealed [REDACTED]. Review of the 6/15/15 and 6/18/15 nurses' notes revealed that the resident was readmitted with an immobilizer between his/her legs. Review of the Pressure Ulcer Risk Assessment form dated 6/24/15 revealed that the resident scored 13, indicating that she/he was at high risk for the development of pressure sores due to the resident being bedfast and presence of [MEDICAL CONDITION].Continued review of the resident's medical record revealed [REDACTED].Review of the Physical Therapy Discharge Summary for 6/15/15 to 6/26/15 revealed that the resident was ambulating five (5) feet with maximum assist when she/he was discharged to the hospital on [DATE].Further review of the resident's medical record revealed [REDACTED]. After readmission from the hospital on [DATE], the resident continued with skilled therapy.Review of the nurses notes after 7/1/15 revealed that the resident was occasionally turned and repositioned every two hours







115692



01/29/2016







F 0314



(continued... from page 10) but, there was no indication that any additional preventive measures were in place to prevent breakdown.Review of the Skilled Daily Nurses Note dated 7/14/15 at 12:30 p.m. revealed that the resident was observed with a new Deep Tissue Injury (DTI) on his/her left heel and that the treatment nurse was notified.Review of the Weekly Pressure Ulcer Record and the Nurses Note dated 7/14/15 revealed that the DTI measured 3 cm. by 3 cm. by <0.2 cm. with a dark red and maroon wound bed and small amount serosanguinous drainage. Continued review revealed that thetissue surrounding the wound bed was macerated and the heel was tender to the touch.Further review revealed that the resident's left lower leg was red and warm with 4+ [MEDICAL CONDITION] and the resident's right lower leg had 3+ [MEDICAL CONDITION]. The physician was notified and ordered Keflex 500 milligrams (mgs.) twice a day for ten (10) days for [MEDICAL CONDITION].The physician also ordered staff to clean the DTI on the resident's left heel with normal saline, to apply skin prep and dry dressing every day and as needed; if the pressure sore did not have any excessive drainage, licensed nursing staff could leave the DTI open to air.Continued review of the Weekly Pressure Ulcer Record dated 7/14/15 revealed that preventive measures included turning and repositioning the resident every two hours, administration of a multivitamin and a heel protector on the resident's left foot.Review of the resident's care plan revealed that new interventions for bilateral heel protectors and to off-load heels were added after the pressure sore was identified. Weekly assessments of the DTI were obtained to include staging, measurements and description of the pressure sore.Review of the Treatment Records revealed that treatments were done as ordered by the physician. Review of the Dietary Progress note dated 8/17/15 revealed that the Registered Dietician recommended Prostat 30 cubic centimeters (cms.)twice a day for decreased [MEDICATION NAME] level of 2 on 8/7/15 (normal range was between 3.5-5).Further review of the Weekly Pressure Ulcer Record dated 9/1/15 revealed that the DTI had increased in size to 4.6 cms. by 4.4 cms. by 1.0 cm. Further review of the resident's medical record revealed [REDACTED].On 1/19/16 at 4:44 p.m. and on 1/20/16 at 10:31 a.m., the resident was observed with a heel protector on his/her left heel and his/her left foot was elevated. On 1/20/16 at 10:51 a.m., Licensed Practical Nurse (LPN) Treatment Nurse removed the dressing dated 1/19/15 from the resident's left foot. The dressing had a moderate amount of serosanginous drainage without odor.The LPN Treatment Nurse provided treatment to the pressure sore on the resident's left heel as ordered by the physician. The pressure sore measured 2.8 cms. by 4.7 cms. by 0.2 cm. and appeared as a Stage IV pressure sore with pink granulation tissue in the wound bed. An assessment of the resident's right foot revealed no redness or breakdown.Review of the facility's Skin Assessment Guidelines revealed that each resident would receive a head to toe assessment by the charge nurse on duty at the time of admission, with any significant change, or upon return from a hospital stay. Continued review revealed that any resident at high risk of developing a pressure sore was provided a head to toe skin assessment weekly by the treatment nurse or RN/LPN.Further review revealed that each resident was provided a head to toe assessment during the delivery of a bath by their assigned Certified Nursing Assistant (CNA). Review of the facility's Skin Care Guidelines revealed that residents would be assessed on admission, readmission and quarterly for potential skin problems and more often if there was a change in condition. The Care Plan Coordinator would update the skin risk assessment with each quarterly MDS or change in condition.The MDS coordinator would notify the Director of Nursing (DON) of any changes in score that caused a resident to become high risk for pressure sore development. It would be their responsibility to update the high risk assessment book to be picked up by the nurses who were assigned to do weekly skin assessments.Interview with Certified Nursing Assistant (CNA) NN on 1/21/16 at 2:35 p.m. revealed that she/he assessed a resident's skin during care, baths and showers for any breakdown or redness and would notify her/his nurse if any change was observed. Continued interview with NN revealed that she/he provided incontinence care for the resident every two hours and ensured that the resident wore his/her heel booties.Interview with LPN Treatment Nurse on 1/22/16 at 11:25 a.m. revealed that she could not find the Readmission Assessment Form dated 7/1/15 when licensed nursing staff would have assessed the resident's skin on readmission from the hospital.Review of the CNA Skin Assessment Checklist forms provided by the LPN Treatment Nurse revealed that the earliest was dated 7/7/15 and had incomplete documentation regarding the presence or absence of any skin condition.Continued interview with LPN Treatment Nurse at that time revealed that she had reviewed the Licensed Nurse Skin Assessment Book and could not find any weekly skin assessments performed by licensed nursing staff prior to the identification of the DTI on the resident's heel on 7/14/15.Further interview revealed that she obtained the CNA Skin Assessment Checklist Forms and the Weekly Skin Assessment Forms completed by licensed nursing staff at the end of each week and kept the forms in a notebook in the copy room. Further interview revealed that she was responsible for ensuring that the nurses were completing the weekly skin assessments.Review of the Skin Assessment Book for Unit II on 1/27/16 at 1:29 p.m. revealed that the resident was supposed to have a weekly skin assessment on the 3:00 p.m. to 11:00 p.m. shift every Friday. Review of the Unit II Shower Sheet Book revealed that the resident received a bath every Monday, Wednesday and Friday on the 7:00 a.m. to 3:00 p.m. shift.Interview with LPN GG on 1/27/16 at 1:35 p.m., revealed that the CNAs completed their skin assessments on residents every bath and shower day and documented on the CNA Skin Assessment Checklist form. Further interview revealed that the nurses signed off on the form and would report to the Treatment Nurse of any changes in a resident's skin right away. Continued interview with GG revealed that if she/he observed breakdown during her/his weekly skin assessments, she/he would notify the physician for treatment orders, initiate treatment and notify the treatment nurse.Although the resident was assessed as being at high risk for the development of pressure ulcers on 6/24/15, there was no indication that certified nursing staff consistently assessed the resident's skin on shower/bath days as care planned prior to the identification of the DTI on the resident's left heel on 7/14/15. There was no indication that licensed nursing staff assessed the resident's skin weekly as per facility policy prior to the identification of the DTI on the resident's left heel on 7/14/15.There was no indication that licensed nursing staff had performed a head to toe skin assessment of the resident on his/her 7/1/15 readmission from the hospital as per facility policy. Although staff had identified that the resident was extensive care after his/her fall with left [MEDICAL CONDITION] on 6/9/15, there was no indication that staff had initiated heel booties as an effective pressure relieving measure to prevent the development of a pressure sore on the resident's heel until after the development of the DTI on 7/14/15.

3. Review of a Pressure Ulcer Risk Assessment for resident #7 dated 11/13/15 noted that the resident was assessed as high risk for developing pressure ulcers. Review of their severe risk for skin breakdown/pressure sores care plan revealed interventions for a cushion to the chair, and for nurses to perform weekly skin assessments. Review of the facility's Skin Care Guidelines Policy and Procedure noted that high risk residents are assigned to have weekly skin assessments by the RN/LPN (Registered Nurse/Licensed Practical Nurse) or treatment nurse. Continued review of the Policy and Procedure revealed that residents identified as high risk will have appropriate measures with necessary orders recorded and written by the treatment nurse, and the charge nurse will be responsible for proper use of positioning devices such as pillows or wedges. Review of Weekly Pressure Ulcer Records noted the resident developed two Stage II pressure ulcers on 11/18/15, one on each trochanter area over the bony prominences. Review of Skin Assessment Forms completed by licensed nurses revealed no skin breakdown on 10/02/15; 10/10/15; 10/22/15; and 10/29/15. Review of the next Skin Assessment Form provided was dated 11/18/15, and noted treatment to left and right trochanters.During interview with the LPN Treatment Nurse on 01/20/16 at 10:14 a.m., she stated that resident #7 developed pressure ulcers to both trochanters in the facility, that the dressing change order was for it to be done every three days, and that the last time she changed the dressing was on 01/17/16. During interview with the LPN Treatment Nurse on 01/20/16 at 1:59 p.m., she stated that skin assessments were done weekly by the staff nurse. During interview with the LPN Treatment Nurse on 01/21/16 at 12:46 p.m., she stated that the skin assessments she provided were all of the ones she had for October and November, and verified there were none done by a nurse for the two weeks prior to development of the pressure ulcers. During observation of wound care at this time, there were no dressings to either trochanter when the incontinent brief was removed. During interview with the LPN Treatment Nurse at this time, she stated the last time she observed the dressing to ensure it was intact was on 01/18/16.







115692



01/29/2016







F 0314



(continued... from page 11)During observations of resident #7 in her wheelchair, no pressure-reduction cushion was noted in the seat on 01/19/16 at 4:50 p.m.; 01/20/16 at 7:45 a.m. and 10:14 a.m.; 01/21/16 at 12:41 p.m. and 2:24 p.m.; 01/22/16 at 10:49 a.m.; and 01/25/16 at 9:18 a.m. During interview with Certified Nursing Assistant (CNA) EE on 01/21/16 at 11:22 a.m., she stated that she knew the resident's care needs because it was in a notebook at the nurse's station. Review of this notebook revealed a page which listed all residents who should have a cushion in the seat of their wheelchair, and resident #7 was not on this list. During further interview with CNA EE, she stated the resident had a seat cushion at one time, but did not have one now. During interview with CNA JJ on 01/22/16 at 10:49 a.m., she verified there was no cushion in the seat of resident #7's wheelchair.

F 0323



Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on observation, clinical record review, facility policy and procedure review, and resident and staff interview, the facility failed to provide supervision to prevent accidents; failed to do thorough investigations to determine the root cause of falls; failed to monitor and re-evaluate interventions put in place after a fall; and failed to assess for the appropriate use of a seat belt and side rails. This failure resulted in falls with injuries including fractures, lacerations, hematomas and abrasions for seven (7) of nine (9) residents reviewed for falls (residents #2, #7, #13, #26, #27, S, and T), on a total sample of thirty (30) residents. The facility's failure to have an effective falls program resulted in immediate jeopardy (IJ) as evidenced by a right arm fracture, head lacerations and abrasions; hip abrasions; and black eyes for resident #7; laceration and broken nose for resident #2; broken left hip and right shoulder for resident S; lumbar fracture for resident T; and hematoma to the head for resident #13.The noncompliance caused actual harm to Resident #2, who sustained a laceration to the chin on 11/29/2015 and a fracture to the nose on 1/14/2016; Resident S who sustained a fractured hip on 6/9/2015 and a shoulder fracture on 11/10/2015; to Resident T who sustained a lumbar compression fracture on 12/7/15; and to Resident #7 who sustained a head injury on 3/14/2015, laceration to the head on 10/18/2015 and a fractured arm on 11/7/2015.IJ was identified on 01/26/16, and the facility Administrator and Corporate Nurse Consultant were notified at 2:01 p.m. IJ was determined to exist as of 03/14/15. The IJ also determined that the provider's non-compliance with one or more requirements of participation has caused, is likely to cause, serious injury, harm, impairment or death to residents. The IJ was related to non-compliance with Quality of Care (F 323 S/S-K). The IJ was determined to be ongoing.Findings include:1. Review of Resident #7's clinical record revealed that she had [DIAGNOSES REDACTED].Review of her Annual Minimum Data Set ((MDS) dated [DATE] revealed that she had short- and long-term memory problems, and severely impaired cognitive skills for decision making. Further review of the MDS revealed that she needed extensive assist by one staff for walking in the room and hall; limited assist by one staff for locomotion on and off the unit; extensive assist by one person for toilet use and transfers; and that her balance during transitions and walking was not steady and only able to stabilize with human assistance.Review of the risk for falls care plan with an onset date of 01/13/16 revealed interventions that included to place the resident in an area where constant observation was possible; apply safety helmet at all times and replace when resident removed; assist resident during smoke breaks; analyze previous falls by resident to determine whether pattern/trend can be addressed. Further review of this care plan revealed no intervention listed for a seat belt or bed alarm.Review of a Fall Risk Evaluation dated 11/30/15 revealed that she had a total score of 26 (anything above a 10 was considered high risk). Review of Physician's Orders revealed that there was no order for a seat belt while in the wheelchair.During observation in the restorative dining room on 01/20/16 at 7:45 a.m., resident #7 was observed to have a clip-type seat belt on while in the wheelchair. This was verified during interview at this time with Licensed Practical Nurse (LPN) MM.During observation in the resident's room on 01/20/16 at 1:45 p.m.; 1/21/16 at 6:43 a.m., 9:18 a.m. and 11:15 a.m.; no bed alarm was seen.During interview with Certified Nursing Assistant (CNA) PP on 01/21/16 at 6:56 a.m., she stated she knew which residents were fall risks by looking at their Activity of Daily Living (ADL) sheet. During further interview, she stated that resident #7 was a fall risk, and could walk but she was unsteady. Review of the CNA's ADL sheet initiated 01/18/12 and last reviewed on 08/29/15 noted that it contained interventions for a bed and chair alarm, and that a helmet was to be on at all times.During interview with CNA EE on 01/21/16 at 10:45 a.m., she stated that she had seen resident #7 throw herself out of the wheelchair several months ago, and one time when she did this the wheelchair turned on top of her and the seat belt broke. During interview with CNA EE on 01/21/16 at 11:22 a.m., she stated that resident #7 did not have a bed alarm, and that they kept her in a place where they could monitor her and keep her occupied.During observation of the resident in the wheelchair on 01/22/16 at 10:30 a.m., a chair alarm was noted on the back of the wheelchair, but it was not clipped to her clothing, and there was no seat belt. This was verified during interview with CNA JJ on 01/22/16 at 10:49 a.m., who stated the chair alarm was discontinued when the seat belt was applied.During interview with Restorative CNA OO on 01/25/16 at 9:06 a.m., she stated that she and another Restorative CNA applied and checked the functionality of alarms every day but Sunday.Review of the Daily Safety Alarm Check for January noted that a bed alarm and chair alarm was functioning properly on 01/20/16 and 01/21/16 (noted observations above where no bed alarm was seen). During observation on 01/25/16 at 9:18 a.m., a chair alarm was noted on the back of resident #7's wheelchair, but it was not clipped to her clothing.Review of her Nurse's Notes, Incident/Accident (I/A) Reports, and Falling Star Program Tracking forms revealed that resident #7 sustained the following falls from March, 2015 to the present time. Noted in the parentheses are comments related to lack of investigation following the fall, or failure to have an intervention in place when the fall occurred:On 03/14/15 at 1:00 p.m.: The I/A Report noted the resident was brought out of the dining room due to agitated behavior, and while walking down the hall she dropped to the floor and began banging her head on the floor causing a gash in the the top of her head, and she was sent to the emergency room (ER). The Additional Comments section to prevent recurrence noted to make sure the resident had a helmet on at all times. (There was no documentation as to why the resident was in the dining room without a helmet on).On 03/23/15 at 9:15 a.m.: Resident #7 was found with an abrasion to her left hip, and the resident stated she fell twice while outside in the smoking area. Resident encouraged to be more aware of her surroundings. Staff to assist resident to and from the smoking area due to unsteady gait and non-compliance with wearing helmet. (There was no documentation that an investigation was done as to how the resident got outside unattended).On 04/12/15 at 6:05 a.m.: When attempting to hit another resident in the dining room, resident #7 lost her balance and fell backwards, causing a laceration to the back of her head. Plan to redirect resident when agitated, and give as needed (prn) medication for agitation. Sent to ER. (There was no documentation if the helmet was on).On 04/14/15 at 11:30 a.m.: Resident was sitting in chair in dining room, fell asleep and fell from chair onto floor. Plan to encourage and assist resident to her room to lie down once meal is complete or upon first sign of sleep.On 06/05/15 at 11:40 a.m.: Resident crying and stated she fell and hurt her back. Send to ER for evaluation. PT to screen and treat as indicated. (There was no indication that an investigation was done as to where or how the resident fell ).On 06/15/15 at 1:15 p.m.: Ambulating in dining room, fell to floor. Dining room staff to monitor more closely related to unsteady gait, poor safety awareness, medication regimen, behavior of throwing self to floor. Continue to encourage resident to wear safety helmet at all times. (There was no documentation as to why the resident was in the dining room without a helmet on).On 07/10/15 at 11:30 p.m.: Noted ambulating in hallway and she tripped and fell to floor hitting right side of head on floor causing a hematoma. Ensure resident is wearing proper footwear. Sent to ER. A witness statement was obtained from a CNA who wrote that she saw the resident walking up the hall and the next thing she fell . (There was no documentation as to why the







115692



01/29/2016







F 0323



(continued... from page 12) resident did not have proper footwear on despite an intervention for properly fitting non-skid shoes for ambulation).On 07/20/15 at 11:00 a.m.: Resident was ambulating in another resident's room and tripped over her foot, shoes not tied. Make sure resident is wearing proper footwear. Shoe laces put into resident's shoes. (There is an intervention to place the resident in an area where constant observation is possible. Also, there was no documentation as to why she did not have on proper footwear).On 08/12/15 at 8:30 a.m.: Resident #7 found in dining room with an abrasion to left side of forehead and face. A male resident reported that resident #7 fell in the Station 2 lobby and hit her head on the floor. Staff will try to encourage resident to go to room and relax if agitated or to reward resident with snack. Wear proper fitting shoes. Give prn med for agitation. (There was no documentation as to why encouraging the resident to go to her room if agitated was an intervention if the fall was unwitnessed. There was no documentation as to why proper footwear was not on).On 08/13/15 at 12:00 p.m.: Resident walking up B-hall, let go of railing and fell to floor receiving an abrasion to the back of her head. Give prn med for increased agitation. Ensure wearing helmet and proper fitting shoes. Sent to ER. There was no documentation as to why the helmet and proper footwear were not on).On 09/06/15 at 11:30 a.m.: Resident on floor in dining room said another resident pushed her down. Encouraged both residents to keep hands to themselves.On 09/12/15 at 2:35 p.m.: Resident found sitting on the floor in her room with a laceration to the back of her head, hat by her side. Sent to ER. Do every two hour room checks.(There was no documentation of investigation done to try and determine how she fell ).On 09/14/15 at 4:30 p.m.: Resident in room ambulating and fell to floor on buttocks. Helmet on. Therapy to work with resident on ambulation and balance. All staff to observe resident hourly until bedtime to prevent recurrence. (There is no care plan intervention for hourly monitoring. During interview with CNA EE on 01/21/16 at 11:22 a.m., she stated she made rounds every two hours).On 09/22/15 at 4:10 a.m.: Resident fell and hit the back of her head on the bed while trying to pull her pants up. No sock on left foot. Staff witnessed the fall. Staff will assist resident with clothes and dressing. Sent to ER. (The resident was assessed on the Quarterly MDS dated [DATE] to be extensive assist by one staff for dressing).On 09/23/15 at 12:15 a.m.: Seen by staff throwing herself to the floor in the hallway hitting her right forehead. Sent to ER. Two witness statements taken noted they observed the resident come out of her room and throw herself to the floor head first. Add bed alarm so staff will know when she gets out of bed.On 10/07/15 at 3:25 p.m.: Noted on floor on A-hall, witnessed falling while attempting to get out of the wheelchair. Discoloration right eye. Sent to ER. Add alarm to the wheelchair, and therapy to assess wheelchair.On 10/18/15 at 10:40 a.m.: Noted attempting to get up from the floor in the dining room. Small abrasion and laceration noted to head and right forearm. Sent to ER and returned with staples to back of head. (There was no documentation of any investigation done as to how the resident fell and/or if the fall was witnessed. There was no documentation if the helmet and alarm were intact. There was no intervention added to address the fall).On 10/21/15 at 9:45 a.m.: Noted lying on the floor beside her bed, unwitnessed. Bed in low position, keep helmet on at all times. Helmet intact. Bed down. (There is no documentation if the bed alarm was intact and/or alarming).On 11/02/15 at 7:30 a.m.: Noted lying on floor in her room behind the door, naked, wheelchair flipped over beside her. Extremely agitated. PRN given for agitation, increased visual checks. (There is no documentation as to what increased visual checks means, and for how long it is to be done. There is no documentation as to whether or not the chair alarm was intact and alarming).On 11/07/15 at 10:50 p.m.: Heard resident in room yelling, found on floor, helmet intact, complained of right wrist and hand pain. Sent to ER. diagnosed with [REDACTED]. Continue to monitor. (There is no documentation as to if the bed alarm was intact and alarming, and no investigation as to how the fall occurred).On 11/13/15 at 1:00 p.m.: Resident left unattended and fell asleep sitting on toilet, skin tears to left forearm and left eyelid. Scheduled toileting while awake, assist to restroom. Educate staff on resident safety and not leaving resident unattended on toilet. (Resident was assessed on the Quarterly MDS dated [DATE] as needing extensive assist by one staff for toilet use).On 11/27/15 at 12:00 p.m.: Resident got out of bed and fell on the floor. Alert staff to clean up spills to prevent falls and encourage resident to allow assistance with getting out of bed. Floor slippery, resident waste water. (There is no documentation if the bed alarm was intact and alarming). Review of the Daily Safety Alarm Check log noted that there was no notation if the bed alarm was functioning properly from 11/22/15-11/27/15.Review of an analysis of resident #7's falls from July 2015 to January 2016 provided by the Corporate Registered Nurse Consultant on 01/25/16 at 9:25 a.m. revealed that thirteen (13)of twenty-one (21) falls occurred on the day shift with nine occurring in the resident's room.During interview with the Corporate RN Consultant on 01/25/16 at 1:32 p.m., she stated this analysis of falls was not done until the surveyor asked if one was available on 01/22/16. Upon further interview, she stated that analysis of falls was done for all residents combined, but not done to analyze individual resident's falls.During interview with the Director of Nurses (DON) on 01/22/16 at 1:13 p.m., she stated that they did not do one-on-one monitoring of residents, but they did do hourly rounds. During further interview she stated that resident #7 moved around a lot, and staff and other residents will tell them where the resident was.During further interview with the DON regarding the individual falls for resident #7 as noted above, the DON responded as follows:03/14/15: I don't know if the helmet was on; she snatches it off.03/23/15: All smoke breaks are supervised, I don't know how the resident got outside.09/23/15: The bed alarm was implemented at some time, the restorative CNA was responsible for applying it and checking the batteries.10/21/15: I don't know if the bed alarm was on and sounding at the time of the fall; it's not on the investigation form.11/02/15: I don't know when the seat belt was applied; it should have been recommended by the Falling Star committee. If a seat belt is used a pre-restraining assessment is done first by the nurse, and the physician contacted for an order. I just found out on 01/21/16 that she had a seat belt. I don't know if the seat belt was on when the resident was found in her room with the wheelchair flipped over next to her.11/13/15: I don't know what the policy is, but a resident should not be left unattended in the bathroom.During further interview with the DON on 01/22/16 at 1:13 p.m., she stated she did not know why proper footwear was not on during the falls on 07/10/15, 07/20/15, 08/12/15 and 08/13/15, and assumed the fall was due to improper footwear. During further interview, she stated that she did not know if the cause of the fall on 08/13/15 was from letting go of the handrail or improperly fitting shoes, and that staff would have been asked to clarify this during the Falling Star meetings.2. Review of resident #27's clinical record revealed that she had [DIAGNOSES REDACTED].Review of the Quarterly MDS dated [DATE] noted they had severe cognitive impairment, and was assessed as being totally dependent on one staff for locomotion on and off the unit. Review of their Fall Risk Evaluation dated 11/08/15 noted that they were assessed as being high risk for falls.Review of the risk for cognitive loss related to dementia, bipolar, schizophrenia and depression, as evidenced by disorganized thinking, and rambling irrelevant conversation.Review of resident #27's comprehensive falls risk care plan revealed an intervention dated 03/30/15 to add a bed alarm, and an intervention dated 06/29/15 to add a safety seat belt to the wheelchair.During observation in resident #27's room on 01/25/16 at 9:24 a.m., no bed alarm was noted on her bed. This was verified during interview with Certified Nursing Assistant (CNA) EE at this time.During observation of resident #27 in her wheelchair on 01/25/16 at 9:28 a.m., no chair alarm or seat belt was observed. This was verified during interview with Restorative CNA OO at this time, who stated that the resident had a seat belt alarm at one time, but it was changed to a regular seat belt in the wheelchair per therapy recommendation.During further interview, CNA OO stated that on Saturday, 01/23/16, she had noted the seat belt was not firmly secured to the wheelchair, and put a Maintenance request in to fix it.During further interview, she verified that no other temporary intervention was put into place while the seat belt was waiting to be repaired. During interview with Restorative CNA OO on 01/25/16 at 9:37 a.m., she verified there was no alarm







115692



01/29/2016







F 0323



(continued... from page 13) on resident #27's bed, and there should have been one.Review of a Daily Safety Alarm Check form for January 2016 noted a non-functioning alarm dated 01/23/16 where one side of alarm needed to be screwed to the chair, and an intervention to report it to Maintenance as soon as possible.Further review of this Alarm Check Form revealed that a bed alarm was intact to the bed on 01/23/16 (note observation above where the alarm was not on the bed). Review of the CNA Care Plan Reference Sheet noted devices of bed alarm and seat belt alarm on at all times when the resident was out of bed.During observations of resident #27 in the wheelchair on 01/25/16 at 10:58 a.m. and 12:25 p.m.; 01/26/16 at 8:50 am. and 9:31 a.m., and 01/28/16 at 9:18 a.m., she was noted with a seat belt on. Review of her clinical record revealed that there was no assessment found for use of a seat belt, and no physician's order.During interview with the Director of Nurses on 01/26/16 at 9:26 a.m., she verified that there was no alarm on resident #27's wheelchair, stated she was unaware that there was such a thing as a seat belt alarm, and that she did not remember this as an intervention that was approved during a Falling Star meeting. Upon further interview the DON verified that no formal assessment had been done for the seat belt use.During observation and interview with the Certified Occupational Therapy Assistant (COTA) on 01/26/16 at 9:31 a.m., she demonstrated a seat belt that alarmed when opened, and verified that resident #27 did not have this type of seat belt. Upon further interview, she stated that resident #27 slid down in the chair when she pulled on the handrails in the hall, and the seat belt was to keep her from falling out of the wheelchair.Review of the care plan, Nurse's Notes and Incident/Accident Reports for resident #27's falls revealed the following:-03/16/15 at 4:30 p.m.: Found sitting on floor in front of wheelchair on A-hall. Resident condition before accident: confused and disoriented. Encourage resident not to attempt to get up without assistance. Return her to her unit after special events for monitoring.-03/30/15 at 5:30 p.m.: Fall in room. Add bed alarm.-05/29/15 at 4:30 p.m.: Fall in room, attempted to get up on own. Resident's condition before the accident: confused and disoriented. Remind resident to ask for assistance when getting out of bed. Honor wishes to not take a nap.-06/21/15 at 5:30 a.m.: Fall in resident room, heard resident calling out for help. Small abrasion to left knee. Height of bed was adjustable and down. Ensure bed in lowest position at all times. Staff to provide siderail bed mobility.-06/29/15 at 8:40 a.m.: Fall at Station 2 nurse's station. Scooted out of wheelchair. Multiple attempts had been made to throw herself to the floor. Initiate safety alarm belt as an enabler for positioning and to alert staff when attempts to throw self on floor.-08/15/15 at 3:10 p.m.: Found on floor in room after hearing a loud boom, resident said slid out of wheelchair. Resident condition before accident: confused and disoriented. Encourage to use call light for assistance with transfers. Therapy to evaluate for transfers.-09/02/15 at 2:00 p.m. Slid out of wheelchair on C-hall while self-propelling. Ensure safety belt and leg rests are properly working. Writer will discuss with other departments ways to assist resident and prevent falls.-09/08/15 at 2:30 a.m.: Fall in room on fall mat, dented mark on right forehead. Sent to ER. Encourage to ask for assistance with movement, place bedside table at foot of bed during sleep hours.-09/24/15 at 6:00 p.m.: Found leaned against wheelchair in upright position, resident stated she slid out of the wheelchair. Resident condition before accident: confused and disoriented. Encouraged resident to ask for assistance with movement. Add to Falling Star program.-11/05/15 at 1:30 p.m.: Fall in resident room, resident stated tried to get out of bed. Place safety mat at bedside.-11/05/15 at 9:00 p.m.: Slid out of chair onto floor on D-hall. Re-apply safety belt to a different wheelchair.-11/08/15 at 10:00 a.m.: Attempted to throw self out of the wheelchair several times, propelled self to room and found on floor. Physical Therapy referral for positioning.During interview with the DON on 01/27/16 at 1:02 p.m., she stated that she wrote the intervention to re-apply a safety belt to a different wheelchair after the fall on 11/06/15, as therapy had changed resident #27's wheelchair but had not applied a seat belt as per previous fall intervention.During interview with the DON on 01/27/16 at 2:10 p.m., she stated the investigation from the injury on 09/08/15 did not specify why the intervention was to place the bedside table at the foot of the bed, and that they needed to start putting information like this in the fall investigation.Review of the facility's Falling Star Program policy and procedure noted the program was intended to evaluate and determine reason(s) for falls and implement measures to prevent falls. The functions of the Falling Star committee included to review incidents of falls and develop recommendations for the care plan team; track the outcome of the plans of care in the prevention of future falls; and report findings of meetings to the QA committee.

3. Review of the Minimum Data Set(MDS) Quarterly Review dated 12/30/15 revealed Resident #26 to have a Brief Interview of Mental Status(BIMS) of nine(9) and active [DIAGNOSES REDACTED]., Anxiety, Depression, Manic Depressant, PsychoticDisorder, Schizophrenia, Repeated Falls, and Altered Mental Status(AMS).Review of the MDS Annual assessment dated [DATE] revealed The Care Area Assessment Summary (CAAS) to include Activities of Daily Living (ADL) Functional/ Rehabilitation Potential, Falls, Behavioral Symptoms, Pressure Ulcer, and Psychotropic Drug Use to be addressed in the Care-plan. Review of Section J: Falls since admit/reentry/prior assessment: any falls-yes, no injury-one, injury-one, major injury-none.The Care-plan updated on 1/17/15 revealed:Problem: Resident #26 was at risk for falls related to having a history of a pacemaker, coronary anomaly, paranoid schizophrenia, mood disorder, neuropathic pain, anxiety, extrapyramidal side effects (EPS), right below the knee amputation (BKA), psychotropic medication use and falls.Interventions included:Add anti-tippers to resident's wheelchair.Wheelchair for mobility.Assist with transfer and bed mobility.Administer medications as ordered.Therapy/restorative as indicated.Keep the call light in reach.Encourage resident to call for assistance.Keep area clean and free of clutter.Lock the wheelchair and assist resident out of bed when requested.Falls:On 12/28/15 at 12:45 p.m., resident was noted lying on the floor at bedside. Previous fall risk score: 14.On 1/6/16 at 6:50 am, resident attempted to self-transfer; no injuries. Previous Fall risk score: 16.On 1/6/16 at 7:10 p.m., resident was in hallway in wheelchair and fell on to the floor. Injury was a hematoma to the right side of his head.On 1/16/16 at 6:45 p.m., resident leaned forward and fell out of the wheelchair striking the right side of his face. Injury was a lacerations to the right side of his face.On 1/18/16 at 9:30 a.m., resident had fall without injury in the hallway when another resident pushed wheelchair.Interventions written in on the care-plan: falling star program, ER to evaluate and treat as indicated, neuro-checks as ordered, physical therapy(PT) screen/referral as needed, and again: send to emergency room for evaluation and treatment as indicated.The Falling Star Program Tracking Form dated 1/16/16 at 6:45 pm revealed Resident #26 to have had a fall with injury and the plan was to apply a wheelchair alarm. On 1/18/16 at 9:30 am, documentation revealed the resident to have had a fall without injury in the hallway; resident slid to the floor. The plan was to apply a safety belt.Fall Risk Assessments were completed for the following dates: 12/28/15, 1/6/16(2), 1/16/16, and 1/18/16 scoring 16 for the last three dates. Skin Assessment form dated 1/16/16 for fall revealed had R laceration/hematoma.Current Pertinent medications:Haldol 150 milligrams (mg) every twenty-one (21) days-schizoaffective disorder







115692



01/29/2016







F 0323



(continued... from page 14)Divalproex ER 1000 mg twice a day-psychosisLasix 20 mg twice a day-edemaSeroquel 400 mg twice a day-psychosisGeodon 40 mg daily-mood disorderGeodon 80 mg at bedtime-psychosisAtivan 1 mg as needed (PRN) at bedtime-insomniaFurther review of the physician's orders dated 1/16/16 revealed to send the resident to the emergency room (ER) for evaluation due to a fall with a head injury. The physician's orders dated 1/6/16 were to continue neuro-checks and physical therapy (PT) referral regarding a fall and to send to the ER for evaluation.Physician's orders for 1/7/16 were for PT to evaluate and treat as indicated. Clarification: skilled PT to see Resident #26 three(3) times per week for four(4) weeks for therapeutic exercises, neuromuscular pain, w/c training, and patient/ caregiver education.On 12/28/15, MD orders reveal to send resident to ER for evaluation of AMS/Fall and oxygen at two(2) liters per minute via nasal cannula, check oxygen saturation each shift, and conduct neuro-checks.An observation on 1/25/16 at 3:45 p.m. revealed Resident #26 back to facility in his room. The resident was in bed in a hospital gown. The bed was not in the lowest position and no side rails were observed in the up position. The call light was out of reach. The resident showed no signs of acute distress and was resting with eyes closed.An observation on 1/26/16 at 8:45 a.m. revealed resident to be in the dining room in a wheelchair at a table. The blue/purple lift/draw sheet was under the resident. No safety belt or chair alarm observed.During and interview on 1/26/16 at 9:00 a.m., the certified nursing assistance(CNA) DD, transporting resident's in and out of the dining room, confirmed that the Resident #26 did not have a chair alarm in place and no safety belt was applied to the resident's chair. The CNA notified the charge nurse and the resident was placed under close supervision.An observation on 1/27/15 in the dining room revealed Resident #26 was in his wheelchair at a table participating in an activity. The chair alarm was in place for safety precaution along with a safety belt.

4. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED].Review of the Annual Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] revealed that the resident had a Brief Interview for Mental Health Status (BIMS) score of 0, indicating that the resident was severely cognitively impaired. Continued review revealed that the resident wandered daily and required supervision from staff for locomotion on and off the unit. Further review of the Quarterly MDS dated [DATE] revealed that staff had erroneously coded the resident as having no falls since the last prior MDS assessment.Review of the resident's care plan dated 4/29/15 revealed that the resident was at risk for falls related to excessive walking, history of falls, use of multiple psychotropic medications and removal of call light with interventions to encourage the resident to lie down when exhaustion noted, administer medications as ordered and notify the physician of any abnormal side effects, psychiatric consult and visits as ordered, staff assistance with care needs as allowed, staff to approach resident and announce why you are addressing him/her to decrease combative behavior and for the physician to review the resident's medications.Continued review revealed that the resident was at risk for injury as evidenced by wandering throughout the facility, wandering in residents rooms and taking naps in other residents' beds with interventions for staff to redirect the resident and wander monitoring per facility protocol.Review of the facility's Wandering or Missing Resident Guideline revealed that the facility would provide supervision to promote a safe environment for residents at risk for injury due to wandering behavior. Continued review revealed that if a resident repeatedly wandered off the unit, the care plan would reflect a monitoring schedule to ensure the resident's safety.Continued review revealed that residents on a monitoring schedule would be monitored either hourly or every shift or deemed necessary by the Patients at Risk (PAR) committee. Further review revealed that residents with an identified problem of wandering whose care plans did not meet the resident's needs would have a prompt review.Review of the resident's current physician's orders revealed that the resident was administered Depakote Extended Release (ER) 500 milligrams (mgs.) every

F 0353



Have enough nurses to care for every resident in a way that maximizes the resident's well being.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on observation, clinical record review, and staff interview, the facility failed to ensure that there was sufficient staff to provide supervision to protect potentially all residents in the facility from aggressive behaviors of resident #7, as evidenced by nine (9) resident-to-resident altercations between 04/12/15 and 01/21/16. In addition, the facility failed to ensure sufficient staffing to prevent falls, and to monitor that interventions for falls prevention were implemented and re-evaluated for continued use for seven (7) residents (residents #2, #7, #13, #26, #27, S, and T), who sustained injuries including fractures, lacerations, hematomas and abrasions. In addition, the facility failed to ensure there was sufficient staff to monitor residents' skin weekly as per policy, and implement measures to help prevent the development of pressure ulcers for two high- risk residents (S and #25), who developed deep tissue injuries. The facility's failure to have sufficient staff resulted in Immediate Jeopardy (IJ). It was also determined that the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The sample size was thirty (30) residents.On 01/19/16 at 2:45 p.m., the interim Director of Nurses (DON) was notified that IJ existed, as the Administrator was not in the facility. IJ was determined to exist as of 01/19/16 in CFR 483.70 Physical Environment (F 463 Scope and Severity (S/S)-K). This information was repeated with the Corporate Registered Nurse Consultant on 01/19/16 at 2:55 p.m.On 01/26/16 at 2:01 p.m., the facility Administrator and Corporate Registered Nurse Consultant were again notified that IJ existed in CFR 483.25 Quality of Care (F 323 S/S-K), and that IJ was determined to exist as of 03/14/15, when resident #7 sustained a head injury after a fall with no documentation that the safety helmet was in place. The Immediate Jeopardy was also related to non-compliance with CFR 483.13 Resident Behaviors and Facility Practices (F 224 S/S-J), CFR 483.20 Resident Assessment (F 282 S/S-K), CFR 483.30 Nursing Services (F 353 S/S-K), and CFR 483.75 Administration (F 490 S/S-K, and F 520 S/S-K). In addition, Substandard Quality of Care (SQC) was determined to exist at 42.CFR 483.13 and 42.CFR 483.25.A Credible Allegation of Compliance related to CFR 483.70 Physical Environment (F 463 S/S-K) was received on 01/20/16 at 5:25 p.m., at which time the Immediate Jeopardy was removed. The facility remained out of compliance at a lower scope and severity of E, while they continued to do every fifteen minute checks of the affected rooms on Station 2 and continued to inservice staff on monitoring of those rooms.The Immediate Jeopardy related to CFR 483.25 Quality of Care (F 323 S/S-K), CFR 483.13 Resident Behaviors and Facility Practices (F 224 S/S-J), CFR 483.20 Resident Assessment (F 282 S/S-K), CFR 483.30 Nursing Services (F 353 S/S-K), and CFR 483.75 Administration (F 490 S/S-K, and F 520 S/S-K) was determined to be ongoing.Findings include:1. The facility failed to ensure that potentially all of the residents in the facility were free from neglect by not providing the staff supervision necessary to ensure the safety of the residents from the aggressive behaviors of resident #7. Review of Accident/Incident Monthly Tracking Logs, Incident Reports, and Nurse's Notes revealed that resident #7 was involved in nine resident-to-resident altercations between 04/12/15 and 01/21/16. Review of resident #7's care plan interventions included to place her where constant observation was possible and not leave unattended; check frequently on rounds; and to increase rounds to prevent risk of unwitnessed falls and injury. The lack of compliance to protect both resident #7 from unsafe behaviors, as well as the other residents from injury from resident #7's aggressive behaviors included a [MEDICAL CONDITION] for resident #7 when she fell attempting to hit another resident, and black eye resident #7 obtained when she was hit by another resident, as well as scratches for resident #23 and an unsampled resident.During interview with the DON on 01/22/16 at 1:13 p.m., she stated that they did not do one-on-one monitoring for residents, and that if resident #7 was moving about the facility that they relied on staff and other resident to tell them where she



MarisaD

Highlight





115692



01/29/2016







F 0353



(continued... from page 15) was.Cross-refer to F 224.2. The facility failed to ensure there was sufficient staff to provide supervision to prevent accidents, and to ensure that staff were knowledgeable at all times about the needs of the residents as evidenced by inconsistent implementation of care plan interventions for falls and re-evaluation of interventions to ensure they were appropriate and effective. Review of Accident/Incident Monthly Tracking Logs, Incident Reports, and Nurse's Notes revealed the following falls:Resident #2: There were a total of ten falls between 08/30/15 and 01/10/16. Injuries sustained included a nose abrasion, chin laceration, nose fracture.Resident #7: There were a total of twenty falls, plus two more falls related to either attempting to hit another resident or being pushed down by another resident, between 03/14/15 and 11/27/15. Injuries sustained included a fractured arm; [MEDICAL CONDITION]; abrasions; bruising and skin tears.Resident #13: There were a total of five falls between 07/21/15 and 12/07/15. Injuries included skin tears, abrasion, and laceration.Resident #26: There were five falls between 12/28/15 and 01/18/16 with injuries including [MEDICAL CONDITION] and hematoma.Resident #27: There were a total of twelve falls between 03/16/15 and 11/08/15, with a head injury.Resident S: There were a total of three falls between 05/27/15 and 11/10/15. Injuries sustained included abrasion, laceration, [MEDICAL CONDITION], and shoulder fracture.Resident T: There were a total of two falls between 06/29/15 and 12/07/15, one with a lumbar compression fracture.Cross-refer to F 323.3. The facility failed to ensure that there was enough staff to consistently complete weekly skin assessments done by nurses, as well as implement measures to prevent the development of pressure ulcers for two residents at high risk for skin breakdown (residents S and #25). Review of the clinical records for these residents revealed that resident S and #25 developed deep tissue injuries to the heel, and did not have any interventions in place to help prevent the pressure ulcers nor skin assessments done by a nurse prior to the development of the wounds. In addition, the facility failed to perform skin assessments by a nurse for two weeks prior to the development of two Stage II pressure ulcers for resident #7.Cross-refer to F 314.4. The facility failed to have sufficient staff to ensure the comprehensive care plans were revised for three of nine residents reviewed for falls (residents #2, #7, and S), to include falls prevention and monitoring interventions for these three residents with multiple falls with injury.Cross-refer to F 280.5. The facility failed to have sufficient staff to ensure the comprehensive care plan interventions were consistently followed including the following:Cross-refer to F 323:-A chair alarm and safety seat belt not intact for residents #26 and #27.-A bed alarm for residents #7 and #27 not intact.-The bed was not in lowest position and call light not in reach for resident T.-A safety helmet and to ensure proper footwear at all times for resident #7 not consistently followed.-Assist on smoke breaks for resident #7 documented as not done on one occasion.Cross-refer to F 314:-Weekly skin assessments not done by a nurse prior to the development of deep tissue injuries for residents #25 and S, and prior to the development of two Stage II pressure ulcers for resident #7.-Cushion in the seat of the wheelchair for resident #7 not intact.Cross-refer to F 224:-Instruct staff to stay with resident (#7) if she is wandering off the unit.Cross-refer to F 250:-Psych consult as needed for resident #7.During interview with the Assistant Director of Nurses (ADON) on 01/29/16 at 9:45 a.m., who scheduled the nursing staffing for the facility, she stated that she was not sure how to answer how they ensured that staffing was sufficient to meet the residents' needs. She stated that residents were assigned to a group, and then Certified Nursing Assistants (CNA) were assigned to a group to care for them. Upon further interview, she stated that she included herself and the Director of Nurses (DON) in the calculation of direct care nursing hours, but that they were administrative staff and did not do direct care.

F 0356

Level of harm - Potentialfor minimal harm


Post nurse staffing information/data on a daily basis.

Based on record review and staff interview, the facility failed to maintain eighteen (18) months of nurse staffing information. The current facility census was eighty-seven (87) residents, and the sample size was thirty (30) residents.Findings include:During interview with the Assistant Director of Nurses (ADON) on 01/29/16 at 1:26 p.m., she was asked to provide the archived copies of the facility's Nursing Daily Staffing records. Review of these records revealed that two months were provided.During interview with the ADON on 01/29/16 at 2:20 p.m., she stated that she was unaware that the Daily Staffing Information must be maintained for eighteen months.

F 0463



Make sure that a working call system is available in each resident's room or bathroom and bathing area.

2.)On 01/19/16 at 2:45 p.m., the interim Director of Nurses (DON) was notified that Immediate Jeopardy (IJ) existed, as the Administrator was not in the facility. IJ was determined to exist as of 01/19/16 in CFR 483.70 Physical Environment (F 463 Scope and Severity (S/S)-K).This information was repeated with the Corporate Nurse Consultant on 01/19/16 at 2:55 p.m. It was determined that the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents.The facility submitted a credible allegation o f compliance on 1/20/2016 5:25 p.m. alleging removal of the IJ. The facility remained out of compliance at a lower scope and severity of E while the call lights were repaired.Findings include:During the initial tour of the facility on 1/19/16 from 9:40 a.m. until 10:15 a.m., it was noted that there the nurse call signal light outside the rooms did not illuminate when the call button was pressed in rooms B-12 and B-6.During an interview with the Interim Director of Nursing on 1/19/2016 at 12:00 p.m., she stated that the call light system in Station One had been replaced in September of 2015 and she was unaware of any problems with resident call lights. During the continued interview she revealed that when call lights are being repaired residents are given bells to summon staff. During the interview, she stated that that maintenance staff check all call lights for function regularly if staff become aware of a non-functioning light, they notify maintenance staff by completing a repair requisition.During a tour of the B and C halls conducted with the Maintenance Director on 1/19/16 from 1:22 p.m. until 1:30 p.m., the surveyor and Maintainence Director tested the call lights by pressing the call bell and observing to see if the lights illuminated over the door There were no functioning lights observed above rooms B-6, B-12, C-5, C-6, C-8, C-3, and C-2.There was no call light cord in room C-4, and the cord was removed from the resident ' s drawer and inserted into the wall by the maintenance director. The common bath in C hall revealed that only one of two lights located in the shower area would cause the light above the door to illuminate. When the call bell was pulled in the common bath in C hall, the indicator light did not illuminate in the nurses' station panel.



MarisaD

Highlight





115692



01/29/2016







F 0463



(continued... from page 16)The call system panel at the nurse s station was tested during the tour. The indicator lights in the panel that would have alerted the staff that a resident needed assistance did not light for the following rooms: B-6, B-8, C-2, C-6, and C-8. There was no indicator light for the common bath in C hall and There was no audible alert in the system that would have notified staff that a resident needed assist. The panel was located over the nurses ' heads, and not immediately visible to staff sitting at the nurses ' station unless they looked up.An interview was conducted with CNA FF on 1/19/2016 at 1:40 p.m. FF revealed that he watches for resident call lights over their doors, and that most of them are working. If they do not work, maintenance repairs them.An interview was conducted with LPN CC on 1/19/2016 at 1:43 p.m. CC confirms that there is no audible alert on the nurses ' station call panel. She did not know how long the lights at nurses ' station call panel had not been working. She states that staff members are in the halls and monitor lights.An interview was conducted with LPN GG on 1/19/2016 at 1:45 p.m. She revealed that the residents do not use their call lights very often; most of them find the nurse if they need something. GG states Certified Nursing Assistants (CNAs) round on the residents.During interview with the facility's Maintenance Director XX on 01/19/16 at 12:35 p.m., he stated that the last time he checked all the call lights was about two weeks ago, and the only problems he had was with two call light triggers that had to be replaced in room B-7 and B-8. Upon further interview, he stated that the call light system on the B- and C- halls (Station 2) was obsolete, and they could not get parts to repair it unless it was something small like a bulb. Maintenance Director XX further stated that when he checked call lights, he activated both the bathroom and bed call lights in all of the rooms, and had an assistant that verified the light came on at the nurse's station and in the hall. During interview with Maintenance employee YY at this time, he stated that all call lights were checked monthly at the end of the month. Review of the Call Light System Rounds forms from 02/27/15 to 12/28/15 revealed that no concerns were documented for any of the forty-four rooms checked monthly.During observation on 01/19/16 at 2:10 p.m., call lights on the B-hall could not be visualized when sitting at the Station 2 nurse's station, and staff would have to lean over the desk to be able to visualize any call lights activated on the C-hall.During interview on 01/19/16 at 5:15 p.m. with a contractor called by the facility to check the call light system on Station 2, he stated that he found eight bad bulbs that he replaced in the console at the nurse's station. Upon further interview he stated that the nurse call system was very old.During observation and interview with Corporate Vice President VV on 01/19/16 at 5:20 p.m., he verified that the call light in the commode area of the C-hall Central Bath would only flicker once or twice at the nurse's station before going out when activated. During interview on 01/19/16 at 5:35 p.m., the Corporate Vice President VV stated that the nurse call system on Station 2 was not designed with an audible alarm. During interview with Maintenance Supervisor YY on 01/20/16 at 8:30 a.m., he verified that when the Central Bath light on the B-hall was activated, that it did not light up on the console at the nurse's station.During interview with Certified Nursing Assistant (CNA) PP on 01/21/16 at 6:56 a.m., she verified that she could not see call lights on in the hallway on one hall if she was on the other hall on Station 2. Upon further interview, she stated that she was aware of the call system not working at times for months, and would fill out a work order slip when something was not working. Review of Maintenance Repair Requisitions from November 2015 to the present time revealed none were seen related to non-functioning call lights.Review of the citations written during the last two standard surveys on 02/12/15 and 06/20/13 revealed that F 463 was written both times related to not all components of the call light system being functional, including on Station 2. During interview with the Administrator on 01/29/16 at 11:11 a.m., she stated that staff were supposed to fill out a work order if a call light was not working, and did not know how this process fell through. Upon further interview, she stated that the Quality Assurance and Assessment Committee had not recommended for the older call system on Station 2 be monitored more often than monthly, despite concerns with the call light system on the previous two surveys.

F 0469



Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Based on observation, record review, resident, family, and staff interviews, the facility failed to maintain an effective pest control program ensuring that the facility was free from ants, roaches, and rodents on two (2) of two (2) nursing units, the dining room and lobby. The facility census was eighty-seven (87) residents, and the sample size was thirty (30) residents.Findings include:During observations of the facility on 01/19/16 at 2:10 p.m., a brown insect that appeared to be a roach was noted crawling on a privacy curtain in room C-1. During observation in the main dining room on 01/19/16 at 5:49 p.m. revealed two small crawling insects, with the appearance of ants, crawling up a wall to the left of the ice machine. During observation on Station 1 on 01/19/16 at 5:54 p.m. revealed a small brown and black insect crawling up the wall above the thermostat next to the nurse's station. During observation on 01/25/16 at 9:05 a.m., a dead brown insect with the appearance of a roach was noted in the hall outside room C-8. During observation on 01/25/16 at 11:55 a.m., a live crawling brown insect approximately two inches long with the appearance of a roach was noted in the main lobby outside of the main dining room.During interview with a family member of an unsampled resident on 01/19/16 at 10:49 a.m., they stated that they had seen ants and roaches in the resident's room as recently as a few weeks ago, and there was a sticky trap by the resident's door. Upon further interview they stated that the resident told them he/she had seen a rat in the hall. During interview with resident R on 01/20/16 at 9:10 a.m., he/she stated that they saw small flying roaches in their room, and the last time he/she saw one was on their roommate's dresser the night before. During further interview, resident R added that they saw these insects in their room once or twice a week. Upon further interview, resident R stated that about a year ago there had been rats the size of his/her hand in their bathroom and one on the floor at the head of their bed, but they were caught with glue traps and he/she had not seen any since.Review of an exterminator's report dated 08/10/16 noted that all crawl space doors had holes around them, and that they were entry points for rodents. This Condition/Observation was reported by the exterminator on 08/10/15 with a Severity level of High, and that it was the Client's responsibility. This same Condition/Observation was noted on each of the ten subsequent exterminator reports through 01/13/16.Observations of the exterior perimeter of the facility with the Maintenance Director on 01/27/16 at 3:28 p.m. revealed that a screen for a ventilation opening in the foundation around room C-9 was off, leaving an unobstructed opening in the foundation. Additional observations revealed a crawl space door on the B-hall side of the building where the door did not fit the opening snugly, leaving gaps at the top and bottom of the door, and the door was being held in place by a log. During observation of another crawl space door under the Medical Records area of the building noted that the door was severely rotted, and had fallen away from the opening in the foundation, leaving a large unobstructed entrance into the crawlspace. These observations were verified during interview with the Maintenance Director.During an interview with Licensed Practical Nurse (LPN) AA on 01/28/16 at 8:35 a.m., she stated she didn't see roaches often, but she saw ants more than any other pest. During interview with Certified Nursing Assistant BB on 01/28/16 at 8:42 a.m. revealed that he occasionally saw ants and roaches in residents' nightstand drawers if they left unsealed food in them.During interview with resident Q on 01/28/16 at 9:15 a.m., he/she stated that roaches often came out of their closet, and that an exterminator would come out to spray if he/she told the staff, but that the roaches always came back. During observation in resident Q's room at this time revealed a barely-moving brown insect on the top of their nightstand, one on the floor in front of the nightstand, and one that crawled quickly under the resident's bed. During further observation, all three of these insects had the appearance of a roach.Review of the Pest Control notebook at Station 2 noted ants in C-4 and roaches in C-2 in January. Review of the Grievances noted that on 07/19/15 a family member complained of ants on a resident. Review of this unsampled resident's clinical record revealed no documentation of ant bites or hospital visit due to ant bites during this time.







115692



01/29/2016







F 0469



(continued... from page 17)Review of deficiencies cited during the facility's last standard survey on 02/12/15 revealed that F 469 was written for ants and roaches observed during the survey.

F 0490



Be administered in an acceptable way that maintains the well-being of each resident .**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on observation, record review, and staff interview, the facility failed to be administered in a manner to ensure there was an effective falls program that determined the root cause of falls, failed to monitor the implementation and effectiveness of interventions to keep residents safe from falls, and failed to ensure the facility's falls policy was fully implemented. In addition, the facility failed to ensure that there was supervision to protect the residents in the facility from resident #7's aggressive behaviors. In addition, the facility failed to ensure there was sufficient staff to provide supervision to prevent falls, neglect, and pressure ulcers. In addition, the facility failed to effectively monitor the functionality of the nurse call system on one (1) of two (2) nursing units (Station 2). It was also determined that the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents.On 01/19/16 at 2:45 p.m., the interim Director of Nurses (DON) was notified that Immediate Jeopardy (IJ) existed, as the Administrator was not in the facility. IJ was determined to exist as of 01/19/16 in CFR 483.70 Physical Environment (F 463 Scope and Severity (S/S)-K). This information was repeated with the Corporate Registered Nurse Consultant on 01/19/16 at 2:55 p.m.On 01/26/16 at 2:01 p.m., the facility Administrator and Corporate Registered Nurse Consultant were again notified that IJ existed in CFR 483.25 Quality of Care (F 323 S/S-K), and that IJ was determined to exist as of 03/14/15, when resident #7 sustained a head injury after a fall with no documentation that the safety helmet was in place. The Immediate Jeopardy was also related to non-compliance with CFR 483.13 Resident Behaviors and Facility Practices (F 224 S/S-J), CFR 483.20 Resident Assessment (F 282 S/S-K), CFR 483.30 Nursing Services (F 353 S/S-K), and CFR 483.75 Administration (F 490 S/S-K, and F 520 S/S-K). In addition, Substandard Quality of Care (SQC) was determined to exist at 42.CFR 483.13 and 42.CFR 483.25.A Credible Allegation of Compliance related to CFR 483.70 Physical Environment (F 463 S/S-K) was received on 01/20/16 at 5:25 p.m., at which time the Immediate Jeopardy was removed. The facility remained out of compliance at a lower scope and severity of E, while they continued to do every fifteen minute checks of the affected rooms on Station 2 and continued to inservice staff on monitoring of those rooms.The Immediate Jeopardy related to CFR 483.25 Quality of Care (F 323 S/S-K), CFR 483.13 Resident Behaviors and Facility Practices (F 224 S/S-J), CFR 483.20 Resident Assessment (F 282 S/S-K), CFR 483.30 Nursing Services (F 353 S/S-K), and CFR 483.75 Administration (F 490 S/S-K, and F 520 S/S-K) was determined to be ongoing.The noncompliance caused actual harm to Resident #2, who sustained a laceration to the chin on 11/29/201 and a fracture to the nose on 1/14/2016; Resident S who sustained a [MEDICAL CONDITION] on 6/9/2015 and a shoulder fracture on 11/10/2015; Resident T who sustained a lumbar compression fracture on 12/7/15; and to Resident #7 who sustained a head injury on 3/14/2015, laceration to the head on 10/18/2015 and a fractured arm on 11/7/2015.Findings include:1. During review of Accident/Incident Monthly Tracking Logs and Nurse's Notes, it was noted that resident #7 was involved in nine resident-to-resident altercations between 04/12/15 and 01/21/16. During interview with the interim DON on 01/22/16 at 1:13 p.m., she stated that they did not do one-on-one monitoring of residents, and that staff and other residents would tell them where resident #7 was located. Review of Preadmission Screening and Resident Review (PASRR) and a geriatric behavioral health facility discharge information revealed recommendations for psychiatric assessment and care and follow-up with mental health. During interview with the Administrator on 01/28/16 at 10:30 a.m., she stated that the facility did not have a behavior management policy and procedure. During interview with the Social Services Director on 01/29/16 at 9:24 a.m., she verified that resident #7 had not been seen by a psychiatrist since September.Cross-refer to F 224.2. During review of the Accident/Incident Monthly Tracking Log, Nurse's Notes, Falling Star Program Tracking Forms, and Incident/Accident Reports, it was noted that resident #7 had twenty-two falls between 03/14/15 and 11/27/15. During interview with the interim DON on 01/22/16 at 1:13 p.m. and 01/27/16 at 10:15 a.m., she verified that there was not enough information available in the accident investigations for many of resident #7's falls to be able to effectively determine the cause of the fall and/or if interventions were in place at the time of the falls. During interview with the Corporate Registered Nurse Consultant on 01/25/16 at 1:32 p.m., and with the Administrator on 01/29/16 at 11:11 a.m., they stated that falls were analyzed for all residents combined, but they did not analyze individual resident's falls that would help in determining a root cause.Review of facility documents revealed that Resident #2 had ten falls between 08/30/15 and 01/19/16. During interview with the interim DON on 01/22/16 at 1:30 p.m. revealed that staff had not determined the root cause of Resident #2's ten falls since 8/30/15 and that the resident's falls had occurred on different shifts. Continued interview revealed that she expected licensed nursing staff to notify certified nursing staff to monitor a resident more frequently if that resident had received a medication that caused potential sedation/drowsiness. Further interview revealed that she did not expect staff to follow the resident to other parts of the facility to monitor because the resident did not pose harm to other residents.Although review of Physical Therapist (PT) recommendations for restorative services for ambulation and transfers to prevent a decline after resident S was discharged from skilled PT on 04/05/15, the facility staff failed to provide those restorative services which may have possibly prevented the subsequent fall with [MEDICAL CONDITION] on 06/09/15. Further review of clinical records and observations during the survey revealed that interventions to prevent future falls for resident S, such as leaving the room door open for more effective monitoring and ensuring the resident's bed was maintained in a low position were not consistently done, as well as not updating the care plan to reflect these interventions.Interview with the interim DON and Assistant Director of Nursing (ADON) on 01/22/16 at 1:50 p.m., revealed that resident S was independent with ambulation and toileting when he/she was admitted to the facility, but was now bedbound and dependent on staff for bed mobility, transfer and toileting after the 06/09/15 fall with [MEDICAL CONDITION]. Continued interview revealed that staff were not inserviced after the 06/09/15 fall regarding any special interventions to prevent future falls. Continued interview with the interim DON and ADON revealed that the 11/11/15 fall with shoulder fracture was due to the resident transferring him/herself. Further interview revealed that staff had not determined the root cause of the resident's falls.Review of resident T's clinical record revealed they had a fall over the siderail on 12/07/15 that resulted in a lumbar compression fracture, with documentation that the bed was not in its lowest position at the time. However, staff failed to address the resident's fall over the siderail in order to effectively evaluate the continued use of the siderails as a potential hazard for the resident. During observations during the survey, it was noted the staff failed to consistently keep the resident's bed in its lowest position and failed to keep the call light within the resident's reach as care planned.During observation and interview with the interim DON on 01/29/16 at 8:55 a.m., she verified that resident T's bed was not in its lowest position, and that she was not aware that the siderails were a potential hazard for the resident.Cross-refer to F 323.3. The facility failed to ensure that there was sufficient staff to ensure that resident #7 and the other residents in the facility were free from neglect to prevent altercations from resident #7's behaviors. In addition, the facility failed to provide sufficient staff to provide supervision to prevent accidents for seven residents (#2, #7, #13, #26, # 27, S, and T) and to monitor for the implementation and effectiveness of fall prevention interventions. In addition, the facility failed to ensure that there was sufficient staff to consistently monitor resident's skin weekly and implement preventive skin breakdown measures for two residents (S and #25) who developed unstageable pressure ulcers. When the ADON was asked on 01/29/16 at 9:45 a.m. how she ensured that staffing was sufficient to meet the residents' needs, she stated that she was not sure how to answer that question, and that residents were assigned to a group and a Certified Nursing Assistant (CNA) assigned to take care of residents in a group.Cross-refer to F 353.4. The facility failed to ensure that the nurse call system on Station 2 with a known history of malfunctioning was not

FORM CMS-2567(02-99) Event ID: YL1O11 Facility ID: 115692 If continuation sheet

Previous Versions Obsolete Page 18 of 20





115692



01/29/2016







F 0490



(continued... from page 18) monitored more frequently in order to detect when the components of the system were not all fully functional, so that they could be repaired in a timely manner. During interview with the Administrator on 01/29/16 at 11:11 a.m., she stated that the Quality Assessment committee had not recommended the older nurse call system on Station 2 be monitored more often than monthly, as most of the concerns cited with the call light system on the previous survey were on Station 1.Cross-refer to F 463.

F 0514



Keep accurate, complete and organized clinical records on each resident that meet professional standards

Based on record review and staff interview, the facility failed to ensure that all residents' care plans were readily accessible, and failed to ensure that information related to a resident-to-resident altercation was available for one (1) resident (#7). The census was eighty-seven (87), and the sample size was thirty (30) residents.Findings include:1. Review of resident #7's active clinical record revealed that it contained no care plan. During interview with Licensed Practical Nurse (LPN) CC on 01/21/16 at 8:52 a.m., she stated that all residents' care plans were kept in the Minimum Data Set (MDS) office, and that this office was kept locked after the MDS staff left and on the weekends.During interview with the Corporate MDS Registered Nurse (RN) on 01/21/16 at 8:59 a.m., she stated that when she started working at the facility in October of 2015, that the previous MDS Coordinator had kept the care plans in her office. During further interview, she stated that she had continued to keep care plans in the MDS office because she was reviewing them all for accuracy. Continued interview revealed that the MDS RN was generally in her office weekdays until 5:00 p.m., and that the care plans were locked up in the MDS office after she left including the weekends, and that nobody would be able to get to them. The MDS RN further stated that it was Corporate procedure to have care plans kept at the nurse's stations.2. Review of the Accident/Incident Monthly Tracking Log revealed that there was a resident-to-resident altercation in the dining room on 09/01/15 at 5:00 p.m. involving resident #7. However, during interview with the interim Director of Nurses (DON) on 01/27/16 at 1:30 p.m., she could not find the Incident Report, and the Medical Records staff could not locate a Nurse's Notes for that date, so details of the incident were unknown.DONE

F 0520



Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**Based on record review and staff interview, the facility failed to maintain a Quality Assessment and Assurance (QAA) committee that identified, developed, and implemented corrective action plans for residents that sustained multiple falls. The QAA committee also failed to identify that their established policies for accidents were not being fully operationalized, and therefore failed to implement effective corrective actions to address the problems. In addition, the QAA committee failed to ensure that concerns with non- functioning call lights identified at the facility's last two (2) standard surveys on 02/12/15 and 06/20/14, and with pests cited during the last standard survey on 02/12/15 continued to be effectively monitored to prevent recurrence. The facility census was eighty-seven (87) residents, and the sample size was thirty (30) residents.On 01/19/16 at 2:45 p.m., the interim Director of Nurses (DON) was notified that Immediate Jeopardy (IJ) existed, as the Administrator was not in the facility. IJ was determined to exist as of 01/19/16 in CFR 483.70 Physical Environment (F 463 Scope and Severity (S/S)-K). This information was repeated with the Corporate Nurse Consultant on 01/19/16 at 2:55 p.m. It was determined that the provider's non-compliance with one or more requirements of participation has caused, or was likely to cause, serious injury, harm, impairment or death to residents.The noncompliance caused actual harm to R#2, who sustained a laceration to the chin on 11/29/2015, a fracture to the nose on 1/14/2016; resident S who sustained a [MEDICAL CONDITION] on 6/9/2015, a shoulder fracture on 11/10/2015, and; to R#7 who sustained a head injury on 3/14/2015, laceration to the head on 10/18/2015 and a fractured arm on 11/7/2015.On 01/26/16 at 2:01 p.m., the facility Administrator and Corporate Nurse Consultant were again notified that Immediate Jeopardy existed in CFR 483.25 Quality of Care (F 323 S/S-K), and that IJ was determined to exist as of 03/14/15, when resident #7 sustained a head injury after a fall with documentation that the safety helmet was not in place. The Immediate Jeopardy was also related to non-compliance with CFR 483.13 Resident Behaviors and Facility Practices (F 224 S/S-J), CFR 483.20 Resident Assessment (F 282 S/S-K), CFR 483.30 Nursing Services (F 353 S/S-K), and CFR 483.75 Administration (F 490 S/S-K, and F 520 S/S-K). In addition, Substandard Quality of Care (SQC) was determined to exist at 42.CFR 483.13 and 42.CFR 483.25.A Credible Allegation of Compliance related to CFR 483.70 Physical Environment (F 463 S/S-K) was received on 01/20/16 at 5:25 p.m., at which time the Immediate Jeopardy was removed. The facility remained out of compliance at a lower scope and severity of E, while they continued to do every fifteen minute checks of the affected rooms on Station 2 and continued to inservice staff on monitoring of these rooms.The Immediate Jeopardy related to CFR 483.25 Quality of Care (F 323 S/S-K), CFR 483.13 Resident Behaviors and Facility Practices (F 224 S/S-J), CFR 483.20 Resident Assessment (F 282 S/S-K), CFR 483.30 Nursing Services (F 353 S/S-K), and CFR 483.75 Administration (F 490 S/S-K, and F 520 S/S-K) was determined to be ongoing.Findings include:1. Review of the citation text for tag F 463 written during the facility's standard survey on 02/12/15 noted that not all of the components of the call light system were fully functional, including rooms B-8-2, C-3, C-4, and C-8. Review of the citation text for tag F 463 written during the facility's standard survey on 06/20/13 revealed that not all of the components of the nurse call system were fully functional, including four rooms on the B-hall and two rooms on the C-hall. During observations for functionality of all call lights on Station 2 on 01/19/16 at 1:22 p.m., it was noted that there were a total of eight resident rooms and two of two common baths that did not have fully functioning call lights, including rooms B-8, C-3, C-4, and C-8 which were specifically cited on 02/12/15. During interview with the Administrator/QAA Coordinator on 01/29/16 at 11:11 a.m., she stated that call lights had been removed from QAA because most of the call light concerns cited during the standard survey were located on Station 1, and they got a new nurse call system for that unit. During further interview she stated that staff were supposed to fill out a work order if a call light was not working, and did not know how this process fell through. Upon further interview, she stated that the QAA committee had not recommended that the older call light system on Station 2 be monitored by maintenance more frequently.Cross-refer to F 463.2. Review of the citation text for tag F 469 written during the facility's standard survey on 02/12/15 noted observations of ants and roaches in the solarium, A-hall, and D-hall. During multiple observations of the facility on 01/19/16 at 2:10 p.m., 5:49 p.m. and 5:54 p.m.; 01/25/16 at 9:05 a.m. and 11:55 a.m., insects with the appearance of ants and roaches were observed on the B- and C-halls, dining room, Station 1 nurse's station, and lobby. During a family interview with an unsampled resident on 01/19/16 at 10:49 a.m., they stated they had seen ants and roaches in the resident's room recently. During interview with resident R on 01/20/16 at 9:20 a.m., they stated they saw roaches in their room once or twice a week. During interview with the Administrator/QAA Coordinator on 01/29/16 at 11:11 a.m., she stated that pests were no longer in QAA, because their plan was for the pest control company to come out twice a month and as needed, and to implement a Pest Control book at the nurse's station.Cross-refer to F 469.3. During interview with the Administrator/QAA Coordinator on 01/29/16 at 11:11 a.m., she stated that falls were discussed in the Safety Committee meetings, but was not presented in the QAA meetings. Upon further interview, she stated that the Assistant Director of Nurses (ADON) collected falls data such as location and time of day and presented it at the Safety Committee meeting to see if there was a pattern of falls, and that the data was an overall look at all resident falls but







115692



01/29/2016







F 0520



(continued... from page 19) was not broken down to individual resident's falls. During further interview, she stated that individual resident falls were discussed in the Falling Star meetings, and there was nothing they felt that should have been taken to QAA as the fall stats were different every month.During interview with the facility's Medical Director on 01/26/16 at 11:35 a.m., he stated that he could not think of anything else other than a restraint to prevent resident #7 from falling, and that there were a lot of falls at all nursing homes. During further interview, the Medical Director stated that he occasionally attended the QAA meetings, but didn't attend more than he attended. Upon further interview, he stated that if he could not attend a QAA meeting, he reviewed the minutes and signed the attendance sheet. During interview with the Director of Nurses (DON) on 01/29/16 at 1:00 p.m., she stated that the Medical Director may arrive late to a QAA meeting or leave early, but that he was at every meeting and was given any information he may have missed. Review of the monthly QA Meeting sign-in sheets from February 2015 to December 2015 (no sheet provided for May 2015) revealed that the Medical Director signed as having attended each meeting.Review of the facility's Quality Improvement Principles policy and procedure revealed the following:We as a company will ensure that our processes or systems identify areas to improve the outcomes that will benefit all our staff and residents. The root cause of problems are not always easy to identify, but there are tools and exercises that teams can use, like cause and effect diagrams, brainstorming and flow charting, that can help our teams uncover the next step in order to truly address problems. Monthly QA/PI (Quality Assessment/Performance Improvement) meetings will be held to ensure the processes are on target and that our monthly triggers have been implemented and met. The QA committee will focus on identifying quality issues; address quality issues through development and implementation of corrective action plans; promote a culture of teamwork and empowerment processes; and identify pertinent issues and develop realistic action plans that result in improved outcomes and overall customer satisfaction. Process Improvement involves fact finding through data collection and root cause analysis to identify and measure the problem and its source. Once the source of the problem is identified, improvement comes through generating salutations (sic) that address the root cause of the problem.Despite the facility QAA policy which noted that root cause analysis would be done to identify problems, the QAA committee failed to determine that there was a concern with falls for seven (7) residents between March 2015 and January 2016, including one (1) resident (#7) who sustained twenty-one (21) falls during this time. Injuries for these seven (7) residents included fractures, lacerations, abrasions, hematomas and bruising.Cross-refer to F 323.



Documents

Nursing Home Survey Report Details for MEDICAL …nursinghomesabuseadvocate.com/wp-content/uploads/2016/12/MEDI… · MEDICAL MANAGEMENT HEALTH AND REHAB CENTER ... For information