Mountain View Care Center

Based on clinical record review, staff interviews, facility documentation, and policies and procedures, the facility failed to complete a thorough investigation to rule out abuse regarding an injury of unknown origin for one resident (#118). The deficient practice could result in the injury of unknown origin not investigated and appropriate corrective actions not taken.

Findings include:

Resident #118 was admitted on June 7, 2023, with diagnoses of metabolic encephalopathy, muscle weakness, cognitive communication deficit, hypertension, epilepsy, syncope and collapse, adjustment disorder, anxiety disorder, depression, and adjustment insomnia.

The progress notes dated December 9, 2023 at 5:00 p.m., revealed the resident had bruising around her left eye; and that, the resident reported that her cousin did it.

The clinical record revealed no documentation that the bruise was assessed to include description on color or size.

There was no facility documentation found that family members recently visited the resident.

Review of a care plan dated June 8, 2023, revealed the resident was at risk for falls. Interventions included to avoid rearranging furniture, encourage resident to wear appropriate footwear when ambulating or wheeling in wheelchair; keep needed items, watch, in reach; maintain a clear pathway, free of obstacles; and physical therapy evaluation.

A care plan dated September 9, 2023, revealed the resident was at risk of wandering, was disoriented to place and had impaired safety awareness. Intervention included to document wandering behavior and attempted diversion interventions.

The skin evaluation dated December 14, 2023 (approximately 5 days after the bruise was identified) included that the resident "continues with bruised on eye".

A physician progress note dated December 14, 2023 revealed that the resident reported her cousin slapped her in the face; and that, staff reported that the resident kept on saying the same thing.

Review of the facility's investigative documentation revealed that resident #118 had bruising under her left eye; and that, her "cousin did it". Per the documentation, there was no documentation of any falls; the resident was independent with ambulation, had wandering behaviors, was capable of picking things up off the floor; and that, the injury was likely a result from her trying to pick something up from the floor and bumped her eye on a piece of furniture.

There was no evidence found that this incident was thoroughly investigated by the facility to include any interviews conducted.

During an interview conducted on January 18, 2024 at 11:00 a.m., the Administrator (staff #34) stated that they were unable to interview resident #118 due to her cognitive status. The administrator said that staff were not aware of any visitors; and that, there were no visitors identified on the visitor log as family members of the resident. The administrator said the facility visitor logs at that time were temperature check logs for Covid and were not actual visitor logs. The administrator further stated that the family was not contacted during the investigation to determine if anyone had visited the resident.

Review of the facility policy titled "Abuse: Prevention of and Prohibition Against" dated October 2022 revealed that the investigation would include interviews with person(s) reporting the incident, the resident(s) involved, any witnesses to the incident including the alleged perpetrator and staff member(s) on all shifts who may have information regarding the alleged incident.

Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that one resident (#57) was free from abuse from a visitor, five residents (#116, #59, #126, #112, and #134) were free from abuse from another resident and prevent an injury of unknown origin for one resident (#118). The deficient practice could result in residents being abused.

Findings include:

Regarding resident #116 and resident #117:

-Resident #116 was admitted to the facility on August 20, 2021, with diagnoses that included metabolic encephalopathy, necrotizing enterocolitis, anxiety, anemia, gastroesophageal reflux disease, hypertension, dementia with behavior disturbance, fracture of left ulna, fracture of left radius, moderate protein-calorie malnutrition, cellulitis left upper limb, and major depressive disorder.

A progress note dated October 23, 2022 at 10:56 AM, that stated staff witnessed another resident (#117) place his hands on the resident's (#116) neck. No injuries were noted and no signs of pain.

The care plan dated August 18, 2021 revealed the resident wandered aimlessly and was disoriented to place with impaired safety awareness with an intervention to document wandering behavior and attempted diversional interventions.

The Brief Interview for Mental Status (BIMS) score dated June 15, 2022 was "0" indicating resident had severe cognitive impairment.

The clinical record revealed that the resident was discharged to the hospital on December 21, 2022.

-Resident #117 was admitted to the facility on October 19, 2022, with diagnoses that included schizoaffective disorder, major depressive disorder, suicidal ideation's, diabetes mellitus, anxiety, insomnia, hyperlipidemia, and weakness.

The BIMS score dated October 7, 2022 was 13 indicating he was cognitively intact.

Review of a progress note dated October 23, 2022 at 10:56 AM, that stated the patient was witnessed physically putting his hands on another resident's (#116) neck. The two were immediately separated. The resident (#117) began making suicidal statements and throwing items at staff. The resident #117 was transported by emergency personnel to the emergency room.

Review of resident #117's care plan did not reveal any behaviors displayed by the resident.

The clinical record revealed the resident was discharged to the hospital on October 23, 2022.

The facility's investigative documentation revealed that staff #9 witnessed resident #117 get up during an activity and put his hands around resident #116's neck. The two residents were immediately separated. No injuries were noted. Resident #117 was sent out to the emergency room due to his behaviors.

During an interview conducted with a certified nursing assistant (CNA/staff #12) on January 19, 2024 at 2:28 p.m., the CNA stated that residents were not allowed to wander into other resident's rooms; and, if a resident wander into another room, she will redirect them to go somewhere else.

An interview was conducted on January 19, 2024 at 2:45 p.m., with a Registered Nurse (RN/staff #65) who stated that residents were not allowed to wander into other resident's rooms. The RN said that she will redirect the resident from wandering into other resident's room by talking to the resident, changing their direction, or by offering them a snack.

Regarding resident #57:

-Resident #57 was admitted to the facility on August 23, 2023, with diagnoses that included dementia, schizophrenia, dysphagia, hyperlipidemia, major depressive disorder, anxiety disorder, hypertension, and convulsions.

Review of resident #57's clinical records revealed the resident had wandered into another resident's (#47) room on October 1, 2023 at 1:52 PM. The other resident's visitor attempted to redirect the resident out of the room and accidentally scratched the resident's right shoulder/neck area. The visitor was educated to ask staff for assistance and was asked to leave the facility pending further investigation. No injury was noted other than a mark to the right shoulder.

The care plan dated August 25, 2023, revealed the resident was at risk for wandering and is disoriented to place with impaired safety awareness with an intervention to document wandering behavior and attempted diversional interventions.

The facility's investigative documentation revealed a summary that stated resident #57 had wandered into another resident's room and when the other resident's visitor attempted to redirect the resident, the visitor scratched resident #57's right shoulder.

Regarding injury of unknown source for resident #118

-Resident #118 was admitted to the facility on June 7, 2023, with diagnoses that included metabolic encephalopathy, muscle weakness, cognitive communication deficit, hypertension, epilepsy, syncope and collapse, adjustment disorder, anxiety disorder, depression, and adjustment insomnia. The resident discharged on June 29, 2023 and deceased on July 9, 2023.

The progress notes dated December 9, 2022 at 5:00 PM, revealed the resident had bruising around her left eye. The resident stated that her "cousin did it"; however, it was documented that no family members had recently visited the resident. No probably cause of the bruising was identified.

A care plan dated June 8, 2022, revealed the resident was at risk for falls. Interventions included: avoid rearranging furniture, encourage resident to wear appropriate footwear when ambulating or wheeling in wheelchair; keep needed items within reach; maintain a clear pathway, free of obstacles; and physical therapy evaluation.

A care plan dated September 9, 2022, revealed the resident was at risk for wandering and disoriented to place with impaired safety awareness with an intervention to document wandering behavior and attempted diversion interventions.

Review of the facility's investigative documentation revealed a summary that stated resident #118 had bruising under her left eye and that her "cousin did it". There was no documentation of any falls. The patient was independent with ambulation and wandering behaviors. She was capable of picking things up off the floor so the injury was likely a result from her trying to pick something up from the floor and bumped her eye on a piece of furniture.

During an interview conducted on January 18, 2024 at 11:00 AM, the Administrator (staff #34) stated that they were unable to interview resident #118 due to her cognitive status to obtain more information. The administrator said that staff were not aware of any visitors; and that, there were no visitors identified on the visitor log as family members of the resident. The administrator said that the facility visitor logs at that time were temperature check logs for Covid and were not actual visitor logs.

Based on clinical record review, staff interviews, facility documentation, and policies and procedures, the facility failed to complete a thorough investigation to rule out abuse regarding an injury of unknown origin for one resident (#118). The deficient practice could result in the injury of unknown origin not investigated and appropriate corrective actions not taken.

Findings include:

Resident #118 was admitted on June 7, 2023, with diagnoses of metabolic encephalopathy, muscle weakness, cognitive communication deficit, hypertension, epilepsy, syncope and collapse, adjustment disorder, anxiety disorder, depression, and adjustment insomnia.

The progress notes dated December 9, 2023 at 5:00 p.m., revealed the resident had bruising around her left eye; and that, the resident reported that her cousin did it.

The clinical record revealed no documentation that the bruise was assessed to include description on color or size.

There was no facility documentation found that family members recently visited the resident.

Review of a care plan dated June 8, 2023, revealed the resident was at risk for falls. Interventions included to avoid rearranging furniture, encourage resident to wear appropriate footwear when ambulating or wheeling in wheelchair; keep needed items, watch, in reach; maintain a clear pathway, free of obstacles; and physical therapy evaluation.

A care plan dated September 9, 2023, revealed the resident was at risk of wandering, was disoriented to place and had impaired safety awareness. Intervention included to document wandering behavior and attempted diversion interventions.

The skin evaluation dated December 14, 2023 (approximately 5 days after the bruise was identified) included that the resident "continues with bruised on eye".

A physician progress note dated December 14, 2023 revealed that the resident reported her cousin slapped her in the face; and that, staff reported that the resident kept on saying the same thing.

Review of the facility's investigative documentation revealed that resident #118 had bruising under her left eye; and that, her "cousin did it". Per the documentation, there was no documentation of any falls; the resident was independent with ambulation, had wandering behaviors, was capable of picking things up off the floor; and that, the injury was likely a result from her trying to pick something up from the floor and bumped her eye on a piece of furniture.

There was no evidence found that this incident was thoroughly investigated by the facility to include any interviews conducted.

During an interview conducted on January 18, 2024 at 11:00 a.m., the Administrator (staff #34) stated that they were unable to interview resident #118 due to her cognitive status. The administrator said that staff were not aware of any visitors; and that, there were no visitors identified on the visitor log as family members of the resident. The administrator said the facility visitor logs at that time were temperature check logs for Covid and were not actual visitor logs. The administrator further stated that the family was not contacted during the investigation to determine if anyone had visited the resident.

Review of the facility policy titled "Abuse: Prevention of and Prohibition Against" dated October 2022 revealed that the investigation would include interviews with person(s) reporting the incident, the resident(s) involved, any witnesses to the incident including the alleged perpetrator and staff member(s) on all shifts who may have information regarding the alleged incident.

-Resident #129 was admitted on December 10, 2023 with diagnoses of epilepsy, unspecified dementia, anxiety disorder, dysphagia, and fibromyalgia.

The elopement/wandering assessment dated December 10, 2023 included that the resident was a high risk for elopement/wandering.

The care plan dated December 11, 2023 revealed that the resident was an elopement risk and a wanderer related to disorientation to place and impaired safety awareness; and that, the facility entrances/exits are secured (alarmed), but resident is able to move freely throughout the building. The care plan did not identify any other interventions.

On December 13, 2023, the facility reported that on December 12, 2023 at approximately 1:30 p.m., staff were looking for the resident; and that, the resident was not in his room. According to the documentation, the resident was found outside the front of the building.

Per the facility's investigative report dated December 21, 2023, staff reported last seeing the resident at the nurses' station, visiting with staff at approximately 1:15 p.m. The investigative report only documented that the resident was found outside in front of the building; and that, the resident reported that he was looking for his wife.

An interview was conducted on January 16, 2023 at 2:30 p.m. with staff #57 who stated that when a resident was assessed as a high risk for elopement/wandering, the care plan interventions would be implemented as soon as possible but within 24 hours of the assessment.

In an interview with staff #34 conducted on January 18, 2024 at 11:00 a.m., staff #34 stated that resident #129 left the building without staff knowledge; and that, there was no documentation of any alarms going off. Staff #34 further stated that the resident exited the building through the front door which was not alarmed.

Review of the facility policy titled "Abuse: Prevention and Prohibition Against" dated October 2022, revealed that each resident had the right to be free from abuse including injuries of unknown origin. The policy included the facility will take action to protect and prevent abuse and neglect from occurring within the facility by; identifying, correcting and intervening in situations in which abuse is more likely to occur, to include validating that the facility has deployed the correct number of competent staff on each shift to meet the needs of the residents; and identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect such as: Verbally aggressive behavior, physically aggressive behavior, and wandering into other's rooms/space.

The policy further included that if an allegation of abuse is reported, discovered or suspected, the facility will protect all residents from physical and psychosocial harm during and after the investigation; including increase supervision of the alleged victim and residents. If the allegation of abuse involved another resident, the facility will separate the residents so that they do not interact with each other until circumstances of the reported incident can be determined and the facility would continue to assess, monitor and intervene as necessary to maximize resident health and safety.

Regarding resident #135 and #134:

-Resident #135 was admitted on July 9, 2021 with diagnoses including type 2 diabetes mellitus, chronic kidney disease, dementia, cognitive communication deficit, and schizophrenia.

The MDS assessment dated October 16, 2021 revealed a BIMS score of 00, indicating resident had severe cognitive impairment. Further review of the MDS revealed the resident had exhibited verbal behaviors directed at others on one to three days of the seven-day assessment period.

The comprehensive care plan revealed the resident received psychotropic medications for auditory hallucinations and angry outbursts. Intervention to provide a calm, quiet environment during episodes of yelling.

-Resident #134 was admitted on August 26, 2021 with diagnoses of dementia, anxiety, diabetes mellitus type 2, and aphasia.

Review of the MDS assessment revealed the resident had exhibited verbal behaviors directed at others on one to three days of the seven-day assessment period; and, had a BIMS score of 00 indicating severe cognitive impairment.

The comprehensive care plan included that the resident received an anti-anxiety medication for anxiety as evidenced by pacing. Intervention included to provide a calm, quiet environment when pacing.

The nursing progress note dated December 24, 2021 at 11:12 a.m. revealed resident #134 had been in a fight with resident #135 and received a scratch on the neck.

Review of the facility report dated December 30, 2021 revealed that the licensed practical nurse (LPN) had reported a resident to resident altercation involving residents #134 and #135; and that, resident #134 had a scratch on her arm and on her neck. Resident #135 was reported to have no visible injuries. The facility report concluded that a resident to resident altercation had occurred.

Review of the facility policy titled "Abuse: Prevention and Prohibition Against" dated October 2022, revealed that each resident had the right to be free from abuse including injuries of unknown origin. The policy included the facility will take action to protect and prevent abuse and neglect from occurring within the facility by; identifying, correcting and intervening in situations in which abuse is more likely to occur; and identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect such as: Verbally aggressive behavior, physically aggressive behavior, and wandering into other's rooms/space.

The policy further included that if an allegation of abuse is reported, discovered or suspected, the facility will protect all residents from physical and psychosocial harm during and after the investigation; including increase supervision of the alleged victim and residents. If the allegation of abuse involved another resident, the facility will separate the residents so that they do not interact with each other until circumstances of the reported incident can be determined and the facility would continue to assess, monitor and intervene as necessary to maximize resident health and safety.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure adequate supervision was provided to prevent resident from wandering into other resident's room for two residents (#57, #116); and, prevent one resident (#129) from elopement. The deficient practice could result avoidable harm to all residents due to lack of adequate supervision.

Findings include:

-Resident #57 was admitted on August 23, 2023, with diagnoses that included dementia, schizophrenia, major depressive disorder and anxiety disorder.

The progress notes dated September 29, 2023 revealed the resident was unable to communicate needs, was monitored for safety, ambulated independently on the hall and wandered in and out of rooms.

The progress notes dated October 1, 2023 at 1:52 p.m., revealed the resident had wandered into another resident's room; and that, the visitor of the other resident attempted to redirect the resident out of the room.

The care plan dated August 25, 2023 revealed the resident was at risk for wandering, was disoriented to place and had impaired safety awareness. Intervention included to document wandering behavior and attempted diversional interventions.

Review of the facility's investigative documentation revealed that resident #57 had wandered into another resident's room; and that, the other resident's visitor attempted to redirect the resident.

There was no evidence found in the clinical record and facility documentation that adequate supervision was provided to prevent resident #57 from wandering to other resident's room.

-Resident #116 was admitted on August 20, 2021 with diagnoses of metabolic encephalopathy, necrotizing enterocolitis, anxiety, dementia with behavior disturbance and major depressive disorder.

The Brief Interview for Mental Status (BIMS) score dated June 15, 2022 was "0" indicating resident had severe cognitive impairment.

The care plan dated August 18, 2021 revealed the resident wandered aimlessly, was disoriented to place, and had impaired safety awareness. Intervention included to document wandering behavior and attempted diversional interventions.

A progress note dated July 22, 2022 included that the resident was alert and confused; and that, she was monitored for wandering and poor safety awareness.

There was no evidence found in the clinical record and facility documentation that adequate supervision was provided to prevent resident #57 from wandering to other resident's room.

A progress note dated July 23, 2022 at 11:09 a.m. revealed that the nurse heard a loud thud and found the resident lying on her back on the floor. Per the documentation, the resident was bleeding from her mouth and the back of her head; and, had a skin tear on her left arm. It also included that 911 was called and the resident was transported to the emergency room.

A progress note dated July 26, 2022 at 1:35 p.m. included that the fall committee interdisciplinary team determined that the resident had wandered into another resident's room and startled the other resident who was sleeping. The other resident raised his arm when he was startled and resulted in resident #116 losing her balance and falling.

Review of the facility's investigative documentation revealed that resident #116 had wandered into another resident's room.

During an interview conducted with a certified nursing assistant (CNA/staff #12) on January 19, 2024 at 2:28 p.m., the CNA stated that residents were not allowed to wander into other resident's rooms; and, if a resident wander into another room, she will redirect them to go somewhere else.

An interview was conducted on January 19, 2024 at 2:45 p.m., with a Registered Nurse (RN/staff #65) who stated that residents were not allowed to wander into other resident's rooms. The RN said that she will redirect the resident from wandering into other resident's room by talking to the resident, changing their direction, or by offering them a snack.

In an interview with the lead CNA (staff #100) conducted on January 19, 2024 at 2:55 p.m., the lead CNA stated that residents were not allowed to wander in other resident's rooms; and that, she will redirect the resident, ask them to come with her or go over where she is, or get them a drink/snack.

Based on clinical record review, staff interviews and facility policy, the facility failed to ensure adequate supervision was provided and fall prevention measures recommended by the provider were implemented for 1 of 3 sampled residents (#8). The deficient practice could result in resident having injury from a preventable fall.

Findings include:

Resident #8 was admitted on 7/26/2023 with diagnoses of malignant neoplasm of brain, cerebral edema, and anxiety disorder.

A fall risk evaluation dated 7/26/2023 included a score of 15, which indicated the resident was a high risk for fall. It also included that the resident had a history of falls and had 1-2 falls in the past 3 months.

The care plan dated 7/26/2023 revealed the resident was at risk for falls. Intervention included bed in lowest position.

A care plan initiated 7/27/2023 included that the resident was an elopement risk/wanderer related to being disoriented to place; and that, he had impaired safety awareness. Interventions included to assess for fall risk.

-Fall #1:

A fall risk evaluation dated 7/30/2023 included a score of 2 indicating the resident was low risk for fall. It also included that the resident had no history of falls in the past 3 months.

The nursing note dated 7/30/2023 revealed that the resident was found lying on his back with his head against the wall with the wheelchair next to the resident's left side. Per the documentation, the resident had previously been seen sitting in a wheelchair in the hallway and the resident refused to get out of his wheelchair. The documentation included that it was apparent that the resident attempted to get out of his wheelchair without locking the chair which resulted in the fall.

Another nursing note dated 7/30/2023 revealed that the resident had several areas of bruising, skin tear and a laceration; and that, the injuries were consistent with the fall. Further, the documentation included that the resident was monitored by the CNAs (certified nurse assistants) and the floor nurse.

A fall risk evaluation dated 7/31/2023 included a score of 9 indicating the resident was a medium risk for fall. It also included the resident had 1-2 falls in the past 3 months.

A Nurse Practitioner/Physician's Assistant (NP/PA) progress note dated 7/31/23 included that the resident was alert and oriented x3, had falls, will get up and would walk "ADLIB". Assessment included impaired mobility, weakness with recurrent falls. Per the documentation, a 1:1 sitter was recommended.

However, review of the clinical record revealed no evidence that the resident was provided with a 1:1 sitter.

-Fall #2:

The fall committee IDT (interdisciplinary team) note dated 7/31/2023 included that on 7/31/2023 at around 6:00 a.m., the resident was found on the floor in supine position with his head against the wall. Per the documentation, the resident was alert and oriented x1, had poor impulse control, har poor safety awareness and was alone at the time of the incident. It also included that fall appeared consistent with resident trying to get out of wheelchair by himself. The documentation also included that the resident had light purplish discoloration on the left arm, right hand and coccyx and a "small skin" was found on left eyebrow and right elbow; and that, four hours after the incident, resident's right hand got swollen. X-ray was ordered and had negative results. Further, the documentation included that neuro checks were started and interventions i.e., labs ordered were implemented.

-Fall #3

A nursing note dated 7/31/2023 included that the resident was ambulating without assistance and with an unsteady gait. Per the documentation, staff assisted the resident back to bed but resident would not sit still; and that, the resident was assisted to a wheelchair due to confusion and unsteady gait. The documentation included that resident continued to get up by himself; and that, "at 11:00" the nurse heard a loud noise coming from the dining room. Per the documentation, the resident was found lying on the floor on his right side with the wheelchair next to the resident. The documentation also included that the resident sustained a skin tear to the left forearm. Further, the documentation included that neuro checks were started and interventions i.e., psych consult was implemented

Another fall committee IDT note dated 7/31/2023 revealed that at around 11:00, the resident was found on the floor in supine position in the dining room. Per the documentation, the resident was alert and oriented x 1, had poor impulse control and poor safety awareness and was alone at the time of the incident. It also included that the resident was last seen in his wheelchair by staff. The documentation included that the fall appeared consistent with the resident trying to get out of the wheelchair by himself and fell. The documentation also included that the resident had bruises noted on his left arm, right hand and coccyx; and, had a small skin tear on his left eyebrow and right elbow.

Another nursing note dated 7/31/2023 included that the resident developed a hematoma on his back related to his previous two falls. The documentation included that there was a hard mass lump which was tender to touch and was red/blue in color found in the back area.

An Admission Minimum Data Set (MDS) assessment dated 8/2/23 included a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident had severe cognitive impairment. The assessment included the resident needed partial assistance from another person to complete some activities.

The weekly skilled review dated 8/2/2023 included that the resident had poor safety, poor balance, poor mobility and poor cognition. It also included that the resident had "impulsivity" and had a TUG (Timed Up and Go) test score of 22 indicating the resident was a high fall risk.

The physician admission progress note dated 8/2/2023 revealed the resident continued to experience falls and his new baseline may need to be considered as non-ambulatory for safety; but that, therapy would determine that. Assessments included impaired mobility, weakness with recurrent falls. Plan was for a 1:1 sitter.

A NP/PA progress noted dated 8/4/2023 included that the laboratory results and urinalysis were unremarkable. The documentation included that the provider continued to recommend a 1:1 sitter.

-Fall #4

The nursing note dated 8/5/2023 revealed that the resident fell from his wheelchair in the dining room and sustained a laceration to his right eyebrow and a skin tear to his left lateral elbow. Per the documentation the NP ordered for the resident to be sent out to the ER (emergency room) for possible sutures to the eyebrow.

-Fall #5

The fall committee IDT note dated 8/7/2023 revealed that on 8/5/2023 at around 1:55 a.m., a CNA witnessed the resident stood up in his wheelchair and attempted to walk in the dining room; and that, the resident fell before the staff could intervene. Per the documentation, the resident sustained a laceration to the right eyebrow and a skin tear to his right elbow; and that, orders were received to send the resident to the ER due to resident potentially needing stitches to his laceration. Further the documentation included that the resident obtained stitches and a CT (computed-tomography) scan was don with no hemorrhage identified; and that, the resident was sent back to the facility within a few hours.

-Fall #6

A nursing note dated 8/6/2023 included that the resident was found on the floor, sitting upright with his back against the wall. Per the documentation, the resident was alert and oriented to self only, confused and was unable to answer any questions. The documentation also included that staff informed the family who requested for the resident to be sent to the E

Based on clinical record review, staff interviews and facility policy, the facility failed to ensure adequate supervision was provided and fall prevention measures recommended by the provider were implemented for 1 of 3 sampled residents (#8).

Findings include:

Resident #8 was admitted on 7/26/2023 with diagnoses of malignant neoplasm of brain, cerebral edema, and anxiety disorder.

A fall risk evaluation dated 7/26/2023 included a score of 15, which indicated the resident was a high risk for fall. It also included that the resident had a history of falls and had 1-2 falls in the past 3 months.

The care plan dated 7/26/2023 revealed the resident was at risk for falls. Intervention included bed in lowest position.

A care plan initiated 7/27/2023 included that the resident was an elopement risk/wanderer related to being disoriented to place; and that, he had impaired safety awareness. Interventions included to assess for fall risk.

-Fall #1:

A fall risk evaluation dated 7/30/2023 included a score of 2 indicating the resident was low risk for fall. It also included that the resident had no history of falls in the past 3 months.

The nursing note dated 7/30/2023 revealed that the resident was found lying on his back with his head against the wall with the wheelchair next to the resident's left side. Per the documentation, the resident had previously been seen sitting in a wheelchair in the hallway and the resident refused to get out of his wheelchair. The documentation included that it was apparent that the resident attempted to get out of his wheelchair without locking the chair which resulted in the fall.

Another nursing note dated 7/30/2023 revealed that the resident had several areas of bruising, skin tear and a laceration; and that, the injuries were consistent with the fall. Further, the documentation included that the resident was monitored by the CNAs (certified nurse assistants) and the floor nurse.

A fall risk evaluation dated 7/31/2023 included a score of 9 indicating the resident was a medium risk for fall. It also included the resident had 1-2 falls in the past 3 months.

A Nurse Practitioner/Physician's Assistant (NP/PA) progress note dated 7/31/23 included that the resident was alert and oriented x3, had falls, will get up and would walk "ADLIB". Assessment included impaired mobility, weakness with recurrent falls. Per the documentation, a 1:1 sitter was recommended.

However, review of the clinical record revealed no evidence that the resident was provided with a 1:1 sitter.

-Fall #2:

The fall committee IDT (interdisciplinary team) note dated 7/31/2023 included that on 7/31/2023 at around 6:00 a.m., the resident was found on the floor in supine position with his head against the wall. Per the documentation, the resident was alert and oriented x1, had poor impulse control, har poor safety awareness and was alone at the time of the incident. It also included that fall appeared consistent with resident trying to get out of wheelchair by himself. The documentation also included that the resident had light purplish discoloration on the left arm, right hand and coccyx and a "small skin" was found on left eyebrow and right elbow; and that, four hours after the incident, resident's right hand got swollen. X-ray was ordered and had negative results. Further, the documentation included that neuro checks were started and interventions i.e., labs ordered were implemented.

-Fall #3

A nursing note dated 7/31/2023 included that the resident was ambulating without assistance and with an unsteady gait. Per the documentation, staff assisted the resident back to bed but resident would not sit still; and that, the resident was assisted to a wheelchair due to confusion and unsteady gait. The documentation included that resident continued to get up by himself; and that, "at 11:00" the nurse heard a loud noise coming from the dining room. Per the documentation, the resident was found lying on the floor on his right side with the wheelchair next to the resident. The documentation also included that the resident sustained a skin tear to the left forearm. Further, the documentation included that neuro checks were started and interventions i.e., psych consult was implemented

Another fall committee IDT note dated 7/31/2023 revealed that at around 11:00, the resident was found on the floor in supine position in the dining room. Per the documentation, the resident was alert and oriented x 1, had poor impulse control and poor safety awareness and was alone at the time of the incident. It also included that the resident was last seen in his wheelchair by staff. The documentation included that the fall appeared consistent with the resident trying to get out of the wheelchair by himself and fell. The documentation also included that the resident had bruises noted on his left arm, right hand and coccyx; and, had a small skin tear on his left eyebrow and right elbow.

Another nursing note dated 7/31/2023 included that the resident developed a hematoma on his back related to his previous two falls. The documentation included that there was a hard mass lump which was tender to touch and was red/blue in color found in the back area.

An Admission Minimum Data Set (MDS) assessment dated 8/2/23 included a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident had severe cognitive impairment. The assessment included the resident needed partial assistance from another person to complete some activities.

The weekly skilled review dated 8/2/2023 included that the resident had poor safety, poor balance, poor mobility and poor cognition. It also included that the resident had "impulsivity" and had a TUG (Timed Up and Go) test score of 22 indicating the resident was a high fall risk.

The physician admission progress note dated 8/2/2023 revealed the resident continued to experience falls and his new baseline may need to be considered as non-ambulatory for safety; but that, therapy would determine that. Assessments included impaired mobility, weakness with recurrent falls. Plan was for a 1:1 sitter.

A NP/PA progress noted dated 8/4/2023 included that the laboratory results and urinalysis were unremarkable. The documentation included that the provider continued to recommend a 1:1 sitter.

-Fall #4

The nursing note dated 8/5/2023 revealed that the resident fell from his wheelchair in the dining room and sustained a laceration to his right eyebrow and a skin tear to his left lateral elbow. Per the documentation the NP ordered for the resident to be sent out to the ER (emergency room) for possible sutures to the eyebrow.

-Fall #5

The fall committee IDT note dated 8/7/2023 revealed that on 8/5/2023 at around 1:55 a.m., a CNA witnessed the resident stood up in his wheelchair and attempted to walk in the dining room; and that, the resident fell before the staff could intervene. Per the documentation, the resident sustained a laceration to the right eyebrow and a skin tear to his right elbow; and that, orders were received to send the resident to the ER due to resident potentially needing stitches to his laceration. Further the documentation included that the resident obtained stitches and a CT (computed-tomography) scan was don with no hemorrhage identified; and that, the resident was sent back to the facility within a few hours.

-Fall #6

A nursing note dated 8/6/2023 included that the resident was found on the floor, sitting upright with his back against the wall. Per the documentation, the resident was alert and oriented to self only, confused and was unable to answer any questions. The documentation also included that staff informed the family who requested for the resident to be sent to the ED (emergency department); 911 was called and at 6:15 p.m., the resident was transferred

Based on observation while on tour the facility failed allowed a rated door to the kitchen to be held open. Failing to keep self-closing or automatic closing doors closed will allow smoke and heat, during a fire, to spread throughout the facility, which could cause harm to the patients.

NFPA 101 Life Safety Code, 2012, Chapter 19 Existing, Section 19.3.6.3.10 Doors shall not be held open by devices other than those that release when the door is pushed or pulled.

Findings include:

Observations made while on tour on June 13, 2023, revealed the rated door between the kitchen and a corridor was being held open with a clean plate rack.

During the exit conference on June 13, 2023, the above findings were again acknowledged by the management team.

Based on observation, the facility failed to ensure the use of extension cords in resident rooms and appliances being plugged into a power strip. A power strip plugged into a power strip could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area.

Findings include:

Observations made while on tour on June 13, 2023, revealed the following;

1) a refrigerator was seen plugged into a power strip in the Director of Nursing Office
2) an extension cord was observed in resident room 302, which had a cellular telephone charger plugged into it

During the exit conference conducted on June 13, 2023 the above findings were again acknowledged by the management team.