GOOD SAMARITAN SOCIETY -- LOVELAND VILLAGE

A health survey with Incident #37167 was completed on 10/21/24 to 10/22/24. No response necessary.

A survey for Incident #37974, #37977 and #38033 was conducted on 10/21/24 and 10/22/24. One deficiency was cited.

Based on record review and interviews, the facility failed to prevent two of six sample residents (#2 and #3) from sexual abuse by certified nurse aide (CNA) #1. Record review and interviews revealed Resident #2, cognitively impaired and physically dependent, was sexually abused by CNA #1 on 7/27/24. The CNA was suspended immediately and terminated on 8/13/24. Resident #3, cognitively intact but visually impaired, reported on 10/11/24, that she, too, was sexually abused by CNA #1 before his suspension. Findings include:Record reviews and interviews confirmed the facility corrected the deficient practice before the onsite investigation from 10/21/24 to 10/22/24. The deficiency was cited as past non-compliance with a correction date of 8/2/24. I. Situation of serious harmRecord review and interviews revealed Resident #2, cognitively impaired and physically dependent, was sexually abused by CNA #1 on 7/27/24. The CNA was suspended immediately and terminated on 8/13/24. Resident #3, cognitively intact but visually impaired, reported on 10/11/24, that she, too, was sexually abused by CNA #1 before his suspension. I. Facility policy The Abuse and Neglect policy and procedure, dated 7/22/24, was provided by the nursing home administrator (NHA) at approximately 12:00 p.m. on 10/21/24. It read in pertinent part, "The resident has the right to be free from abuse, misappropriation of resident's property and exploitation. Residents must not be subjected to abuse by anyone, including but not limited to, location, employees, other residents, consultants or volunteers, employees of other agencies serving the resident, family members, legal guardians or other individuals. If an employee receives an allegation of abuse, neglect, exploitation or misappropriation of resident property, the employee will take measures to protect the resident. The employee will then report the allegation to a supervisor." II. Sexual abuse of Resident #2 A. Resident status Resident #2, age over 65, was admitted to the facility on 8/2/19. According to the October 2024 computerized physician orders (CPO), pertinent diagnoses included Huntington's disease (a progressive brain disorder that causes uncontrolled movements, emotional problems, and loss of thinking ability), muscle weakness, encephalopathy (brain disease that alters brain function), anxiety and cognitive communication deficit (difficulty paying attention, remembering, responding, understanding, following direction). The 8/14/24 minimum data set assessment (MDS) revealed Resident #2 was severely cognitively impaired based on a staff assessment of her mental status. She was dependent on staff for bed mobility, transfers, dressing, toileting, personal hygiene, bathing, eating, and locomotion on and off the unit. A review of Resident #2's care plan, revised 9/26/23, revealed the resident had impaired cognitive function and thought process related to Huntington's disease, as evidenced by impaired memory and decisions, impaired executive functioning, impulsivity, poor safety awareness, delayed processing and responses, trouble concentrating, and inattention. Interventions included the resident understood consistent, simple, direct sentences. Staff were to ask yes/no questions to determine the resident's needs, to present one idea, question, or command at a time, to allow time for Resident #2 to process and respond, and to validate the resident's message by repeating it aloud. Resident #2 was observed on 10/22/24 at 9:30 a.m. in her room lying on the floor mat covered with a blanket. Her eyes were open. She was asked if she ate breakfast and if she was comfortable. She did not respond to the questions. B. Record review and interviews revealed Resident #2, cognitively impaired and physically dependent, was sexually abused by certified nurse aide (CNA) #1 on 7/27/24. 1. A nursing progress note in the resident's record, dated 7/27/24 at 6:14 p.m., documentedthat the police were notified of an incident concerning an elderly female resident. CNA#1 was found in a compromising position at Resident #2's bedside by CNA #2 when she entered the resident's room. CNA #2 immediately informed the onsite registered nurse (RN) of her observation. The RN called the on-call clinical nurse manager (CNM) who collaborated with the director of nursing (DON) and nursing home administrator (NHA) for directions to address the potential abuse. The onsite RN verified the resident's immediate safety and reported to the CNM that the resident was resting in bed. 2. The NHA provided an investigation report and a timeline of the 7/27/24 incident involving Resident #2 and CNA #1 at 12:00 p.m. on 10/21/24. a. Report The facility investigation report which included interviews with CNA #1, CNA #2, CNA #3, certified nurse aide with medication aide authority (CNA-Med) #1, and all residents CNA #1 cared for, read CNA #2 walked into Resident #2's room to find CNA #1 for report and witnessed Resident #2 lying in her bed fully clothed with a blanket up to her chest and her body turned to the left side. There was a food tray behind CNA #1, out of reach. CNA #1 was positioned with his right knee on the resident's bed and his left leg on the floor. CNA #1 was facing the resident at the level of her face. When CNA #2 walked in, CNA #1 jumped off the bed, startled, shifted his pants, and pulled his shirt down. CNA #2 immediately walked away to find a nurse. CNA #3 was also looking for CNA #1. She walked into the room as CNA #1 was walking out of the room carrying a tray of food. CNA #3 said CNA #1 was more talkative and friendly. b. Timeline On 7/27/24:-CNA #2 reported to RN #1 about what she witnessed with CNA #1 and Resident #2 at approximately 6:00 p.m. -RN #1 called the on-call clinical nurse manager (CNM) after getting CNA #2's report, to inform the CNM of a staff member reporting a possible abuse. -The CNM called the NHA and the director of nursing (DON) after the incident was reported to her on the phone. -The NHA, the DON, and the CNM spoke to CNA #1 on the phone together after the incident was reported, to get a description of the incident (see investigation interviews below).-CNA #1 was removed from the facility by security immediately and suspended from his job.-Resident #2 was assessed by RN #1 and licensed practical nurse (LPN) #1 at 6:18 p.m. There were no signs of injuries present. Resident #2 was interviewed by the CNM, RN #1, and LPN #1 (see investigation interviews below).-CNA #2, CNA #3, and CNA-Med) #1 were interviewed by the CNM, the DON, and the NHA by phone (see investigation interview below).-All other residents on CNA #1's assignment were interviewed by RN #1 and LPN #1 (see summary of recorded interviews below). On 7/29/24:-Ten residents on side one (1), where CNA #1 was working on 7/27/24, which included some residents on CNA #1's assignment and others in the hallways CNA #1 could have been helping out on, were interviewed by RN #1 and LPN #1. The 10 residents denied ever being abused by any staff members or having concerns about other residents being abused. -CNA #1 was brought into the facility and interviewed by the NHA, the DON, and the CNM (see investigation interviews below). On 7/30/24:-The facility began education on neglect and abuse to the nursing care staff, including all direct care staff (see action plan and facility follow-up below). c. Investigation interviews i. RN #1, LPN #1, and the CNM interview on 7/27/24 with Resident #2 Although, in an interview after the initial facility interview, Resident #2 responded no to all abuse questions, in her interview on the day of the incident, 7/27/24 (no exact time was recorded), the resident responded "uh-huh" (affirmative) when asked if she had been approached by CNA #1. She responded "uh-huh" (affirmative) when asked if CNA #1 had exposed his privates to her. She arched her back and emphatically said "yes" when asked if CNA #1 had put his penis on her face or in her mouth. ii. CNM, DON, and NHA interview on 7/27/24 with CNA #2, CNA #3, and CNA-Med #1 CNA #2 and CNA #3 interviews were as documented in the investigation report above. CNA #2 walked into Resident #2's room to find CNA #1 for report and witnessed Resident #2 lying in her bed fully clothed with a blanket up to her chest and her body turned to the left side. There was a food tray behind CNA #1, out of reach. CNA #1 was positioned with his right knee on the resident's bed and his left leg on the floor. CNA #1 was facing the resident at the level of her face. When CNA #2 walked in, CNA #1 jumped off the bed, startled, shifted his pants, and pulled his shirt down. CNA #3 reported she also was looking for CNA #1. She walked into the room as CNA #1 was walking out of the room carrying a tray of food. CNA #3 said CNA #1 was more talkative and friendly. CNA-Med #1 reported that she entered the room while CNA #1 was feeding Resident #2. CNA-Med #1 reported when she entered the room, CNA #1 got up and moved the chair he was sitting on. She did not witness any inappropriate behaviors. iii. The NHA, DON, and CNM interview together with CNA #1 on the phone on 7/27/24. CNA #1 said he was feeding Resident #2 in bed with her head elevated. CNA #1 stated he was sitting in a chair beside Resident #2 with the food tray to the side of him. CNA #1 stated that CNA-Med #1 came in to give Resident #2 medication. CNA #1 said he stood up to move the chair out of the way for CNA-Med #1 to get closer to Resident #2. After CNA-Med #1 left the room, CNA #1 decided to stand up and put his left knee on the bed because he had a sore on the bottom of his left foot and it was hurting because of the pressure on it while sitting in the chair. CNA #1 denied putting his groin in Resident #2's face. CNA #1 denied exposing himself or putting his penis in or around Resident #2's face or mouth. CNA #1 stated he was startled when CNA #2 entered the room behind him and as he stood up on both feet, he readjusted his pants at the waist so the bottom of the pants was not around his feet/shoes due to being long. But see CNA #2's interview for the investigation report above. CNA #2 reported she walked into Resident #2's room to find CNA #1 for report and witnessed Resident #2 lying in her bed fully clothed with a blanket up to her chest and her body turned to the left side. There was a food tray behind CNA #1, out of reach. CNA #1 was positioned with his right knee on the resident's bed and his left leg on the floor. CNA #1 was facing the resident at the level of her face. When CNA #2 walked in, CNA #1 jumped off the bed, startled, shifted his pants, and pulled his shirt down. 4. Action plan and facility follow-up to the incident of abuse on 7/27/24 a. CNA #1 See the facility timeline above. CNA #1 was suspended on 7/27/24 immediately after the incident was reported. An interview with the NHA at 4:00 p.m. on 10/22/24 (see below) revealed CNA #1 was terminated on 8/13/24 and reported to the appropriate governing agencies, and complaints were filed on his license. b. Facility staff A review of the facility investigation documents provided by the NHA at 12:00 p.m. on 10/21/24 revealed follow-up actions specific to training on abuse and neglect by the nurse educator (NE) and included interviews, assessments, education, and reporting. The training included for staff to take measures to protect the resident and then report the allegation to a supervisor, steps that had not been taken on 7/27/24, per the facility investigation report. The facility's investigation was completed on 8/2/24 and 75 percent (%) of the direct care staff training was completed by 8/2/24. The remaining staff training was completed by 8/15/24, as staff schedules allowed. C. Staff interviews1. CNA #4 was interviewed on 10/21/24 at 2:15 p.m. CNA #4 said shegot education on abuse and neglect when she started working there and the facility's NE held an education session about abuse and neglect at the end of July 2024 where CNA #4 learned about the different kinds of abuse and how to report it. She said if she saw a resident being abused, she would make sure the resident was safe and then report it to a nurse, the DON, or social services. She said there is always a nurse on-call to call if she could not find the nurse working. 2. RN #2 was interviewed on 10/21/24 at 2:50 p.m. RN #2 said she was educated about the types of abuse and who to report abuse to and how to report it at the end of July 2024. RN #2 said she would make sure the residents involved were safe before reporting the abuse. 3. The NHA and the DON were interviewed together on 10/22/24 at 4:00 p.m. -The NHA said there was no indication that CNA #1 would have engaged in sexually abusive behavior. She said the human resource (HR) department ran his background checks before his hiring on 4/30/24 and he completed all his abuse and neglect education before beginning orientation. -The NHA said they thought he was a "lazy" worker because he was frequently found in the restaurant part of the community and left work early. She said he always worked the 2:00 p.m to 10:00 p.m. shift and was always on the 500 hallway (on side 1). -The NHA said she instructed security to remove him from the building immediately following the incident on 7/27/24 and placed him on suspension. She said they ended up terminating him on 8/13/24. -The NHA said they conducted education for direct care staff, which included nurses and CNAs, on abuse and neglect beginning on 7/30/24. She said they got approximately 75% of the staff educated by 8/2/24, and the remaining staff were educated by 8/15/24, due to their schedules. 4. The CNM and the DON were interviewed together on 10/22/24 at 10:07 a.m. -The CNM said she was called by RN #1 on 7/27/24 around 6:00 p.m. and was asked to talk with CNA #2. She said CNA #2 said she was coming on to her shift and looking for CNA #1 to get a report. She walked into Resident #1's room without knocking and saw CNA #1's right leg on the resident's bed and he was leaning over the resident's face. She said Resident #2's face was turned toward the left side, facing CNA #1's groin area. She said she saw him jump up and adjust his pants, grabbing them from the front and he pulled down his shirt. She said the resident's food tray was across the room on top of stacked up mats and out of reach for him to be feeding the resident, and the head of the resident's bed was flat. CNA #2 walked away to find a nurse after witnessing this, as she said it made her feel uncomfortable. -The CNM said she interviewed CNA #3 on 7/27/24 around 6:00 p.m. and she said she walked into Resident #2's room after CNA #2 left. She said she was looking for CNA #1 to get a report. She said she walked into Resident #1's room and saw the room tray was across the room, not next to the bed. She noticed the head of the bed was flat. CNA #3 said CNA #1 was acting more friendly and talkative. -The CNM said she interviewed CNA #1 with the DON and the NHA on 7/29/24 in person. The CNM said CNA #1 demonstrated how he was positioned on the bed with his left knee on the bed. The CNM said CNA #1 showed her, the DON and the NHA the sore on his left foot and said it was the size of a pinprick. The CNM said she asked CNA #1 why he pulled his pants up from the front and not the back and she said CNA #1 did not have an answer. 5. The campus director (CD), the DON, and the NHA were interviewed together on 10/22/24 at 3:10 p.m. The CD said CNA #1 did not have to be exposed for abuse to occur. III. Sexual abuse of Resident #3 A. Resident status Resident #3, age over 65, was admitted to the facility on 1/13/24. According to the October 2024 CPO, pertinent diagnoses included type 2 diabetes, primary open-angle glaucoma, left eye severe stage (optic nerve damage resulting in vision loss), central retinal vein occlusion (eye condition affecting the retina and leading to vision loss), left eye with macular degeneration and need for assistance with personal care. The 7/17/24 MDS assessment revealed Resident #3 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required substantial/maximal assistance from staff for bed mobility, transfers, dressing, toileting, personal hygiene, bathing, eating, and locomotion on and off the unit. B. Record review and interviews revealed Resident #3, cognitively intact but visually impaired, reported on 10/2/24, that she, too, was sexually abused by CNA #1 before his suspension. 1. The NHA provided an investigation report and a timeline of the incident involving Resident #3 and CNA #1 at 12:00 p.m. on 10/21/24. 1. Report The facility investigation report read the NHA was informed on 10/4/24 by the local police and adult protective services that CNA #1 talked to the police (during an interview with the police on 10/3/24) about a second incident involving him before his suspension on 7/27/24. 2. Timeline On 10/4/24:-The local police department notified the NHA of CNA #1's statement (see above) and the facility determined that Resident #3 matched the description CNA #1 gave to the police. -The social services director (SSD) interviewed Resident #3 and the resident denied ever being abused at the facility. The SSD and social services assistant (SSA) #1 interviewed 50 total residents, all on the side of the unit where CNA #1 was assigned. -Facility-wide education was conducted on abuse and neglect. On 10/9/24:-The DON and SSA #1 interviewed Resident #3 and she denied ever being abused at the facility. -The HR department expanded the sample and interviewed all employees in the healthcare facility to ask if the staff had noticed any resident acting differently, if any dependent residents changed how they tolerated care, or if the behaviors of their coworkers ever made them feel uncomfortable. Staff denied this in the interviews. C. Interviews The NHA and DON were interviewed together on 10/21/24 at 4:00 p.m. The NHA said the police came back to the facility on 10/4/24 and told her CNA #1 had confessed to the police about sexual abuse with Resident #2. She said the police also told her CNA #1 made statements about other residents and gave identifying information. The NHA said because of this new information, they expanded their interview sample and initiated a facility-wide education on abuse and neglect on 10/4/24. The campus director (CD), the DON, and the NHA were interviewed together on 10/22/24 at 3:10 p.m. The CD said the police arrived at the building on 10/11/24 to interview Resident #3. The CD said the police told her staff were to stop conducting interviews with Resident #3. The CD reported she was told by the police that Resident #3, in an interview with the police on 10/11/24, said there was a male CNA who she did not like who worked at the facility. She said he put something in her hand. She said, "What did you put in my hands and I could tell it was his penis." She said she never told anyone, not even her family until then. The NHA said that the CNM documented this statement from Resident #3 in a trauma assessment in her medical record on 10/11/24. The NHA said the facility identified the incident, investigated, reported to all agencies, and put in place a plan of correction that included healthcare staff education that was completed by 8/2/24.

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

A revisit survey was completed on 6/18/24 for all previous deficiencies cited on 5/7/24. The facility is in compliance with all regulations surveyed.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is one story, Type V (111), construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression system and is classified as Fully Sprinklered. The facility was constructed in 1971 and is licensed for 104 beds. This re-certification survey conducted on June 4, 2024 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) "Chapter 19, Existing Health Care Occupancies". The deficiencies cited were discussed with the Administrator and Maintenance Director during the exit conference conducted at the end of the on-site survey. The Administrator reported the daily census to be 98 residents on June 4, 2024.

Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain fire walls in accordance with NFPA 101, 8.3.1.2. This was evidenced by the following:1. There are penetrations through the fire-rated wall and ceiling in the Electrical room located in the 900 Hall. NFPA 101, 8.3.1.2 Fire barriers shall comply with one of the following:(1) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces.(2) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, and from the floor to the bottom of the interstitial space, provided that the construction assembly forming the bottom of the interstitial space has a fire resistance rating not less than that of the fire barrier. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator Maintenance Director at the exit conference.

Based on observation, it was determined that the facility failed to maintain wiring in accordance with NFPA 101 and NFPA 70. This was evidenced by the following:1. There is exposed wiring and an open junction box in the Mechanical Room located in the 900 Hall. NFPA 101 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 70, Section 110.12 Electrical equipment shall be installed in a neat and workmanlike manner. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator Maintenance Director at the exit conference.

Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by the following:1. No written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care rooms was conducted annually. NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Receptacle Testing in Patient Care Rooms. 6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection. 6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified. 6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed. 6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz). This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator Maintenance Director at the exit conference.

A recertification survey with Incident #CO36021 was completed on 5/1/24 to 5/7/24. Two deficiencies were cited.

An Emergency Preparedness survey was conducted from 5/1/24 to 5/7/24. No deficiencies were cited.

Based on record review and interviews, the facility failed to ensure one (#58) of six residents reviewed for accidents out of 39 sample residents remained free from accidents. Resident #58, who was known to be a fall risk and had care planned fall interventions in place, sustained a fall on 4/20/24 which resulted in a fracture of her left femur (upper leg). During the facility's investigation of the fall, it was discovered the floor alarm, which was care planned as an effective fall intervention for the resident, had been in the off position at the time of the resident's fall and did not sound, therefore staff had not been alerted to the resident's movements in her room. Staff was aware that in order to reset the alarm after it had been triggered, it was necessary to reset the alarm by switching it to the off position and returning it to the on position. However, staff failed to ensure the alarm was in the on position at the time of the resident's fall. Due to the facility's failure to ensure staff reset the alarm appropriately after it had been triggered, Resident #58 sustained a fall on 4/20/24 which resulted in a fracture of her left femur. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 5/1/24 to 5/7/24, resulting in the deficiency being cited as past noncompliance with a correction date of 5/4/24. I. Incident on 4/20/24The facility failed to ensure staff reset Resident #58's floor alarm, which had been implemented as an effective fall intervention for the resident, appropriately to the on position after the alarm triggered. Due to the facility's failure, Resident #58 sustained a fall on 4/20/24 which resulted in a fracture of the resident's left femur. Record review and interviews during the onsite investigation confirmed the deficient practice had been corrected and the facility was in substantial compliance at the time of the survey from 5/1/24 to 5/7/24. II. Facility plan of correctionA. Immediate action to correct the deficient practice for Resident #58The corrective action plan implemented by the facility in response to Resident #58's fall on 4/20/24 was provided by the director of nursing on 5/6/2024 at 10:00 a.m. On 4/20/24, the facility conducted an investigation of Resident #58's fall. The facility interviewed all staff on duty who were involved in care for the resident on the day of fall and a few days prior to the fall. Inspection of the floor alarm device determined the alarm device was in an off position at the time of the fall and therefore did not alert the staff about the resident's movement in the room. All interviewed staff reported that the alarm was functioning well and they heard the sound of it during their shift. Staff was aware that in order to reset the alarm after it was triggered, it was necessary to switch it to the off position and return it to an on position. It was unclear when the alarm was reset for the last time and why it was in the off position at the time of the fall. The last interaction with the resident was reported around 6:30 p.m., about 30 minutes prior to the fall, when a staff member assisted the resident with care. On 4/20/24 all direct care staff who were involved in Resident #58's care and had access to the alarm device were educated on how to reset it and to make sure it was turned on. The device was to be checked at the beginning of every shift and on an as needed basis. Staff were to ensure it was in the on position after the reset. A log was initiated to ensure every shift checked the alarm. On 4/24/24 the interdisciplinary team (IDT) met to review the fall for the Resident #58. Medications, care routines, non-pharmacological interventions and resident preferences were reviewed. The IDT recommended adding the following interventions and continuing to monitor: Bariatric bed for extended sleep surface, improve lighting in the room, and add an air mattress. B. Identification of other residentsThe facility completed an audit and identified other residents in the building who were at risk for falls. Thirteen identified residents were reviewed for appropriate fall interventions and care plans were updated to ensure the accuracy of the interventions. The audit review was completed by 5/3/24. C. Systemic changesNursing leadership re-educated the nursing staff in regards to reviewing the care plan and Kardex (tool utilized by staff to provide comprehensive care of the residents) as well as the importance of following and implementing interventions outlined in these documents in an effort to reduce the risk of falls for facility residents. The training of all staff was completed on 5/3/24. On 4/21/24 audits were initiated to verify fall prevention interventions outlined in the care plans for residents identified to be at risk of falls were in place accordingly via direct observations when rounding as well as via interviews with staff. D. MonitoringThe director of nursing (DON) was responsible for completing the audits weekly for the next four weeks, one a month for the next two months and quarterly for the next three quarters. A monthly Report Out, summarizing the findings of the audits, was to be completed and provided to the Quality Assurance Performance Improvement (QAPI) Committee. The QAPI Report Out was to be reviewed by the QAPI Committee for compliance and trends and to make additional recommendations as needed for continued improvement. The facility would be in substantial compliance by 5/4/24. Interviews and record review during the investigation revealed corrective actions to identify the resident and other residents who had the potential to be affected by the deficient practice, systematic changes to prevent its recurrence, and monitoring to ensure sustained corrections were in place. III. Facility policyThe Fall Prevention And Management- Rehab/Skilled, Therapy & Rehab (rehabilitation) policy, revised on 4/2/24, was provided by the nursing home administrator (NHA) on 5/7/24 at 2:10 p.m. It read in pertinent part, "The policy's purpose is to promote resident well-being by developing and implementing a fall prevention and management program, to identify risk factors and implement interventions before a fall occurs, to give prompt treatment after a fall occurs and to provide guidance for documentation. On admission or readmission, review the applicable documents ( discharge summary from transferring agency, transfer record, history and physical, lab values, nursing admit/readmit data collection) and any additional admit information documentation for fall risk factors."IV. Resident #58 A. Resident statusResident #58, age 81, was admitted on 8/25/20. According to the May 2024 computerized physician orders (CPO), diagnoses included muscle weakness, dementia with behaviors and history of falls. The 1/19/24 minimum data set (MDS) assessment revealed, resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 12 out of 15. Resident #58 did not have any physical limitations and she used a manual wheelchair. The resident required the assistance of one person for most activities of daily living (ADL). She had at least two falls since she was admitted with no major injury. B. Record reviewResident #58's fall care plan, initiated 8/25/2020 and revised 5/1/24, revealed the resident was at risk for falls and had had actual falls related to diagnosis of dementia, failure to thrive, poor safety awareness, weakness and poor balance. The resident was legally blind. Interventions included reminding the resident and encouraging her to use grab bars to prevent falls, using a padded floor alarm with the alarming device in the nurses station where the alarm alerted staff but did not sound in the resident's room to avoid scaring the resident (initiated 11/22/21), Adding anti-slip strips to the total length of the bedside area and by the sink to prevent slips leading to falls (initiated6/28/23), adding padding to the sink to prevent injury, adding a bedside commode (without the bucket insert), with handles, over the toilet to help guide the resident to know when she had reached the toilet to sit down safely, adding a grab bar in the room to allow safety when the resident was getting out of bed and returning to bed (initiated 7/12/23) and extending the sleep surface on the opposite side of the bed to allow the resident to move and sleep sideways and help prevent falls (initiated 4/24/24). According to the fall incident report, on 4/20/24 around 7:00 p.m., Resident #58 sustained a fall. Staff found the resident sitting on the floor in no acute distress, between her bed and the sink area, scooting backwards on her bottom towards the sink wall. Resident #58 stated she was just walking toward her door and fell. Resident #58 initially denied pain or injury. The physician was notified on 4/20/24 and x-rays were ordered due to increased discomfort in the resident's left leg. On 4/21/24 the results of the x-ray revealed Resident #58 had sustained a left femur fracture and the resident was transferred to the emergency room for further evaluation. According to the hospital discharge summary, dated 4/23/24, Resident #58 was admitted to the hospital on 4/21/24 after she had a mechanical fall at the long-term care facility. She was diagnosed with a left femur fracture. The resident's family chose not to pursue surgical repair of the femur fracture and the resident returned to the facility with a palliative care consultation on 4/23/24. V. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 5/6/24 at 1:15 p.m. LPN #1 said Resident #58 was currently bed bound after she had a fall in April 2024. She said the resident had a special floor alarm that alerted the staff at the nurses station about the resident's activity in the room. She said Resident #58 had the alarm for a long time and it was very effective at preventing falls. She said she had not worked on the day when Resident #58's fall occurred. LPN #1 said she was re-educated about alarm monitoring and its functioning a few weeks ago (April 2024). She said her responsibility was to check the alarm when she started her shift, every time it was reset and as needed to ensure the alarm was on. She said she usually checked it every time she was at the nurses station or at least every 20 minutes. Certified nurse aide (CNA) #1 was interviewed on 5/6/24 at 1:35 p.m. CNA #1 said Resident #58 required extensive assistance of two people with all cares. She said the resident was a risk for falls and her responsibility was to ensure the floor mattress that had an alarm was appropriately positioned, plugged in and turned on. She said the resident currently was not able to ambulate but she was still at risk of sliding off the bed. She said the floor alarm's sounding device was at the nurses station and she was familiar with its sound and knew how to reset it after it was triggered. She said the most recent education about the alarm was a few weeks ago (April 2024). The DON and the NHA were interviewed together on 5/7/24 at 11:00 a.m. The DON said Resident #58 was the only resident in the building who was using the type of alarm she had. He said it proved to be effective in preventing falls for the resident and the resident had been using it for a while. The DON said, on 4/20/24 when Resident #58 had the fall, the alarm was found to be in the off position. He said it was inconclusive at what point the alarm was switched off and the most probable cause was that the last person who reset the alarm did not switch it all the way to the on position. He said since the incident occurred, he had completed the investigation and re-educated staff on checking the alarm prior to the shift and on an as needed basis. The DON provided copies of the audits the facility had implemented on to ensure the alarm was being monitored to make sure it was in the on position. The NHA said she believed the facility had completed a thorough investigation and ensured that all residents at risk for falls had appropriate and effective fall interventions in place. She said the facility had taken appropriate actions following Resident #58's fall and ensured the safety of all residents.

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was not five percent (%) or greater. Specifically, the facility's medication error rate was 7.7% or two errors out of 26 opportunities for error. Findings include: I. Professional referencesAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.sevier, St. Louis Missouri, pp. 606-607, retrieved on 5/06/24, "Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, the right route, the right time, the right documentation and the right indication."According to the Food and Drug Administration (FDA) Metoprolol Succinate Extended-Release Tablets: 25 milligram (mg), 50 mg, 100 mg, and 200 mg, retrieved on 5/9/24 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2006/019962s032lbl.pdf, "Metoprolol Succinate extended-release tablets are scored and can be divided, however, the whole or half tablet should be swallowed whole and not chewed or crushed."II. Facility policy and procedureThe Medication Administration policy, dated 3/29/23, was provided by the director of nursing (DON) on 5/6/24 at 12:00 p.m. It read in pertinent part, "Nursing assessment is a function of the registered nurse. When the location uses medication aides, the delegating nurse is accountable for assessing a situation and making the final decision to delegate.""Follow the Six Rights: right medication, right dose, right resident, right route, right time, and right documentation."III. Resident #62A. Resident statusResident #62, age greater than 65, was admitted on 12/2/23. According to the May 2024 computerized physician orders (CPO), diagnoses included chronic kidney disease stage II (mild) and hypertension (high blood pressure). B. Record review According to the May 2024 CPO, Resident #62 was scheduled to receive the following medication:Nebivolol HCL (a medication used to treat high blood pressure) 2.5 milligrams (mg) one tablet by mouth one time a day for hypertension, and to hold the medication for a systolic blood pressure less than 100 millimeters of mercury (mmHg) or a heart rate less than 60 beats per minute (bpm), ordered 12/3/23. C. ObservationOn 5/6/24 at 9:30 a.m. the certified nurse aide with medication aide authority (CNA-Med) administered Nebivolol to Resident #62. The CNA-Med failed to check the resident's blood pressure or heart rate prior to administering the medication to the resident. D. Staff interviewThe CNA-Med was interviewed on 5/6/24 at 9:45 a.m. The CNA-Med said if vital signs were needed before giving a medication, either a heart icon was present under the medication order, or if you hovered over the order, medication parameters were listed within the further instructions section. The CNA-Med said Resident #62's order did not have a heart icon and when she hovered over the medication order, the blood pressure and heart rate parameters were not listed first under further instructions. The CNA-Med said she would take vital signs sometime that day (5/6/24). IV. Resident #49 A. Resident statusResident #49, age greater than 65, was admitted on 3/26/24. According to the May 2024 CPO, diagnoses included fracture of the left and right femur (thigh bone), hypertension (high blood pressure) and heart failure. B. Record review According to the May 2024 CPO, Resident #49 was scheduled to receive the following medication:Metoprolol Succinate (a medication used to treat high blood pressure) extended release (ER) oral tablet 25 mg, give half a tablet by mouth in the morning related to essential (primary) hypertension. Hold for systolic blood pressure (SBP) under 110 or heart rate under 65, ordered 3/27/24. C. Observation On 5/2/24 at 9:44 a.m., registered nurse (RN) #1 was administering medications to residents. She looked at orders for Resident #49. There was an order to check vital signs before administration of medication. She took a vital signs cart into the resident's room and measured the resident's heart rate and blood pressure. They were both within normal limits to administer the medication. She walked back to her medication cart and pulled out each medication scheduled to be administered.. RN #1 crushed all of the medications, including the metoprolol, and mixed them with applesauce. She walked into the resident's room and administered the medications.-However, according to the manufacturer's recommendations for metoprolol succinate extended release tablets, the medication should be swallowed whole and not chewed or crushed (see professional references above). V. Additional staff interviewsThe DON and unit manager (UM) #1 were interviewed together on 5/6/24 at 10:49 a.m. UM #1 said when original medication admission orders were entered, they were to be signed-off by two nurses. He said when vital signs or weights were needed prior to giving medications, the heart symbol should have shown up on the medication administration record (MAR) as a visual cue to check the resident's vital signs. UM #1 said since there was no heart icon on Resident #62's MAR for the Nebivolol, it meant whoever entered the medication order into the electronic medical record (EMR) missed that step of the entry process. The DON and UM #1 said physician's orders should always be followed. They said not all medications, even blood pressure medications, required vitals signs be checked prior to administration.-However, the physician's order for Resident #62's Nebivolol had specific systolic blood pressure and heart rate parameters for when the medication should not be administered. UM #1 said it was important to follow the physician's orders in order to maintain a safe regulatory system and monitor if the medication was working correctly. He said he would review residents' physician's orders to ensure the nurses were alerted when vital signs were required prior to medication administration. The DON said he would provide education to nurses to ensure the blood pressure and heart rate were checked prior to administering medications if it was requested in the physician's order. The DON said the facility provided education to staff on 5/2/24 regarding not crushing ER medications. UM #1 said extended release medications should never be crushed. He said this was because the medication was not processed in the body like it was intended if the medication was crushed. He said crushing the medication had the potential to give the medication a stronger effect on the resident causing the resident's blood pressure to get too low.

A complaint survey, prompted by #CO34532 was conducted on 1/11/24. No deficiencies were cited.

A revisit to the 2/7/2023 was completed on 3/30/2023. The facility was in compliance with the regulations surveyed.

A revisit to the 2/7/2023 was completed on 3/30/2023. The facility was in compliance with the regulations surveyed.

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is one story, Type V (111), construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1971 and is license for 104 beds. This re-certification survey conducted on March 02, 2023 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) "Chapter 19, Existing Health Care Occupancies". The deficiencies cited were discussed with the Administrator and Maintenance Director during the exit conference conducted at the end on-site survey. The Administrator reported the daily census to be 85 residents on March 02,2023.

STANDARD is not met as evidenced by: During observation of the kitchen gas fired cooking equipment it did not meet the requirements of the 2012 Edition of NFPA 54 Fuel and Gas Code 9.6.1.2. This deficient practice could affect all residents, and staff should a fire occur due to failure to operate safely due to non-code compliant. This was evidence by the following. Gas fired cooking equipment with casters where not limited by a restraining device. The Maintenance Director acknowledge lack of a restraining on the gas fired cooking appliancesNFPA 54 -2012 Fuel and Gas Code 9.6.1.2 Restraints. Movement of appliance with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufactures installation instructions.

STANDARD is not met as evidenced by: Through record review and staff interview during the survey, the facility failed to inspect and test the fire alarm system per NFPA 72 and 2012 Life Safety Code 101. Failure to maintain and test the fire alarm system has the potential to harm all occupants, staff and visitor within the facility if the fire alarm system failed to operate if a fire was to occur. This was evidenced by the following:At the time of the survey, no documentation was available to indicate the Annual Testing of the fire alarm system had occurred in the past year. The Director of Maintenance acknowledge the lack of testing of the fire alarm system in the past year during the tour of the facility. 2012 Life Safety Code 101 section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

STANDARD is not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidence by the following.-pendent sprinkler shows signs of foreign materials around the working parts of the head. Condition found in the Kitchen and Laundry areas.-Fire Sprinkler Riser room 900, two gauges contained the manufacture date of 2017, gauges shall be calibrated or replaced every five years. The Director of Maintenance acknowledge the lack of maintenance of the automatic sprinkler system deficiency during record review of the facility. NFPA 101Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

A recertification survey with Incident #30603 was conducted 2/1/23-2/7/23. Two deficiencies were cited.

An Emergency Preparedness survey was conducted from 2/1/23 to 2/7/23. No deficiencies were cited.

Based on record review, and interviews, the facility failed to provide supervision, assistance, services, and implement timely interventions to prevent falls with injuries for two (#66 and #47) of four residents reviewed for accidents/hazards out of 24 sample residents. Resident #66 had a history of falls upon admission, was cognitively intact, used a walker and wheelchair, and needed supervision with ambulation and transfers. Between 11/29/22 and 1/12/23, Resident #66 experienced eight falls: six unwitnessed and two witnessed. After the 12/20/22 fall, the resident sustained a fractured femur (thigh bone). After the femur fracture the resident became dependent for ambulation in a wheelchair. The facility failed to conduct an interdisciplinary team (IDT) review of Resident #66's repeated falls and implement effective interventions. Additionally, the facility failed to:-Implement effective fall interventions, conduct IDT review of falls and communicate with hospice provider for Resident #47; and, -Ensure the Resident #47's feet were secured during a transfer with a mechanical lift. Findings include:I. Facility policyThe Fall Prevention and Management policy, revised 3/30/22, was provided by the nursing home administrator (NHA) on 2/6/23 at 2:35 p.m. It read in pertinent part:"The purpose was to promote resident well-being by developing and implementing a fall prevention and management program, identify risk factors and implement interventions before a fall occurs, give prompt treatment after a fall occurs, and prevent further injury."A fall refers to unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force. "Upon admission the facility will review the applicable documents, discharge summary from the transferring agency, transfer record, history and physical, lab values, and any additional admit information documentation for fall risk factors. Complete the Falls Tools UDA (user defined assessment) for fall screening and identifying fall risk factors. Care plan the appropriate interventions, including personalizing all areas. Communicate fall risks and interventions to prevent a fall before it occurs per the 24 hour report, care plan, kardex, daily stand up meeting, and/or fall committee meetings. Communicate any identified environmental changes and /or referral needs (maintenance, dietary, therapy)."After a fall, the facility will:a. Assess the resident.b. Notify the physician and resident representative. c. Complete the Fall Scene Huddle worksheet.d. Document the physician's comments in the medical record.e. Complete the Falls Tool UDA.f. If appropriate, contact the physician for a referral to therapy.g. Communicate that a fall has occurred during shift change and daily stand-up meeting. h. Give completed fall scene huddle worksheet to the fall committee chair.i. Report to the state regulatory agency when appropriate.j. Continue to monitor condition and the effectiveness of the interventions.k. The investigation documentation is completed in the notes tab within the Risk Management module."II. Resident #66A. Resident statusResident #66, age 80, was admitted on 8/25/2020. According to the February 2023 computerized physician orders (CPO), the diagnoses included fracture of the right femur, unspecified dementia, anxiety disorder, severe protein-calorie malnutrition, depressive episode, muscle weakness, unsteadiness on feet, need for assistance with personal care, legal blindness, wedge compression fracture of T7-T8 (bones in the spine), difficulty in walking, and repeated falls. The 1/10/23 minimum data set (MDS) assessment revealed, the resident was cognitively intact with a brief mental status score (BIMS) of 14 out of 15. She required limited assistance with bed mobility, transfers, and walking in the room and corridor. She used a wheelchair and had a fracture related to a fall. She had falls prior to admission. B. Record reviewCare plansThe fall careplan, initiated 8/25/2020 and revised 1/12/23, revealed the resident was at risk for falls and had actual falls related to dementia, failure to thrive, poor safety awareness, weakness, poor balance, legally blind, and atrial flutter. The goal was for the resident to resume usual activities without further incident. The interventions included:-Monitor/document/ report pain and bruises-Initiated 2/20/22.-Provide activities that promote exercise and strength building where possible-Initiated 8/25/2020.-Contact physical therapy for strength and mobility as needed-Initiated 2/20/2022 and revised on 3/16/22.-Ensure the resident was wearing footwear when standing that has a gripping bottom and secure back such as slippers, shoes, or grip socks-Initiated 8/25/2020 and revised on 5/9/22.-Encourage the use of a wheelchair or walker when leaving the room-Initiated 8/25/2020 and revised on 5/9/22. -Frequent monitoring upon waking, before bed, before and after meals, and routinely through the night-Initiated 8/26/2020 and revised on 9/23/2020.-Monitor visual and auditory impairments-Initiated 8/25/2020.-Review as indicated for significant changes in cognition, safety, awareness, and decision making-Initiated 8/25/2020.-Review bowel and bladder continence status and establish and/or review toileting plan based on residents needs-Initiated 8/25/2020 and revised 3/16/22.-Ensure/provide a safe environment, monitor and remove tripping hazards - Initiated 9/23/2020 and revised 7/19/22.-Maintain a clear path in the corridor for ease of ambulation when the resident leaves the room-Initiated 9/23/2020 and revised 7/19/22.-Assist with maintaining a clear area around the bed to allow room to stand safely-Initiated 9/23/2020 and revised 7/19/22.-Purposeful proactive rounding every two hours for safety and assessing needs and comfort-Initiated 2/20/22 and revised on 1/10/23. The visible impairment care plan, initiated 9/14/2020 and revised 11/2/22, revealed the resident had impaired vision related to artificial left eye. She had prophylactic antibiotics for right eye health. The goal was for the resident to maintain optimal quality of life within limitations imposed by visual function left eye blindness. The interventions included:-Maintain room arrangement to promote independence.-Arrange consultation with an eye care practitioner as required.-Monitor/document/report change in ability to perform Activities of daily living (ADLS), decline in mobility, sudden visual loss, pupils dilated, gray or milky, complaint of halos around lights, double vision, tunnel vision, and blurred or hazy vision.-Tell resident where her items are being placed and be consistent with placement of personal items.-Approach the resident from her right side as she has a prosthetic left eye. According to the fall report, nursing progress notes and fall investigations dated 11/29/22 through 1/12/23, the resident had eight falls within three months. 1. According to the 11/29/22 risk management, at 5:30 p.m., the resident was walking down the hallway and did not see another resident in a wheelchair, causing her to lose her balance. She landed in the Indian style (crossed legs) sitting position. The nurse assessed her and walked her back to her room, where she sat on the bed. She was not injured and said she did not see the other resident and lost her balance. Predisposing factor was impaired vision. The fall was witnessed. The risk management note revealed the resident would continue working with restorative and encouraged to use her front wheeled walker when ambulating. A physician order was obtained for a PT evaluation. 2. According to the 12/9/22 risk management, at 12:35 p.m., the nurse found the resident in her room leaning with her back on her bed and her feet up against the closet and her behind up in the air. The nurse assessed the resident and assisted her to her bed. She was not injured and said she sat on the floor and was trying to get up. Predisposing factor was impaired vision. The fall was unwitnessed. The risk management note revealed the resident would continue working with restorative nursing. No new interventions were implemented since the resident was already working with restorative nursing from her previous fall (11/29/22). 3. According to the12/14/22 risk management, at 10:00 a.m., certified nurse aides witnessed the resident trip over her bedside table landing on her bottom. She was sitting on her bottom between the bed and the table. The nurse assessed the resident and assisted her to her bed. She was not injured and said she was going to the bathroom and tripped on the table. Predisposing factor was impaired vision. The risk management note revealed the resident would continue working with restorative. An electrocardiogram (EKG), labs, and urine sample was ordered related to dizziness and nausea. Staff were to ensure the room was free of clutter so the resident had a clear pathway to the bathroom and the room exit. No new interventions were implemented since the resident was already working with restorative and the room should have already been cleared of clutter from her previous two falls (11/29/22 and 12/9/22). 4. According to the 12/20/22 risk management, at 8:30 p.m., the resident was heard yelling out and was found sitting on her left buttocks with her legs to her right. She was holding onto the grab bars facing the toilet. She was wearing tennis shoes. The nurse assessed the resident as she was attempting to get up off the floor on her own. She refused to wait for the staff to use the lift to get her up. The resident was able to bear weight however she walked with a limp and complained of right outer thigh pain. She said, "Ow" with each movement. The resident said she tripped over her roommate who was at the sink and landed on the floor. She said she then scooted herself to the bathroom to try and stand up. A stat x-ray was ordered for the right hip pain. Predisposing factor was impaired vision and impaired memory. This was an unwitnessed fall. The resident was subsequently transferred to the emergency department for evaluation and treatment. She was found to have a right femur neck fracture which required surgical intervention. The risk management note revealed the resident had an increase of falls related to tripping over other residents. The resident appeared to be having difficulty adjusting to increasing impairment to good eye and loss of physical independence. The resident was hospitalized on 12/21/22 and readmitted to the facility on 12/27/22.5. According to the 1/5/23 risk management, at 3:30 p.m., the nurse was called to the resident's room by the floor certified nurse aide (CNA), and found the resident on the floor beside her bed wrapped up in her covers. The nurse assessed the resident and two CNAs used the hoyer lift to help her back into bed. She was not injured and said she was looking for her sock and slid off of the bed. Predisposing factor was impaired vision and gait imbalance. This was an unwitnessed fall. The risk management note revealed the resident was wearing socks. She was encouraged not to reach for items and to use the call light for assistance. The resident would continue working with restorative nursing for safe ambulation. 6. According to the 1/8/23 risk management, at 4:45 a.m., the nurse was walking down the hall, making rounds, and noticed the resident sitting on the floor in the doorway of her bathroom. She was not injured and said she rolled out of the bed and scooted to the bathroom. Predisposing factor was impaired vision and gait imbalance. This was an unwitnessed fall. The risk management note revealed the resident continues working with restorative nursing on safe ambulation. She will continue working with PT related to repeated falls. No new interventions were implemented since the resident was already working with restorative and PT from her previous five falls. 7. According to the 1/10/23 risk management, at 11:16 p.m., the resident was found in front of her dresser going through her clothes. She was not injured and said she put herself on the floor and was sorting her clothes. The nurse assessed her for any injuries. Predisposing factor was impaired vision and gait imbalance. This was an unwitnessed fall. The risk management note revealed the resident would continue working with PT related to repeated falls. The resident was reminded to use the call light and wait for assistance. No new interventions were implemented since the resident was already working with PT from her previous six falls (11/29/22 and 12/9/22), and the resident was reminded to use the call light from her previous two falls. 8. According to the 1/12/23 risk management, at 5:00 a.m., the resident's roommate went to the nurses station to report that Resident #66 was on the floor. The nurse found the resident on the toilet. She was not injured and said she was reaching for the grab bar and slid down onto the floor. Predisposing factor was impaired vision, impaired memory and gait imbalance. This was an unwitnessed fall. The risk management note revealed education was provided to the resident to use the call light and wait for assistance with transfers. No new interventions were implemented since the resident had already been educated to use her call light and wait for assistance from previous multiple falls. There were no IDT review notes for any of the above falls, the risk management notes were completed by the floor nurse. C. Staff interviewsCNA #1 was interviewed on 2/7/23 at 10:08 a.m. She said the Resident #66 could not see well and was very independent. She said the facility discontinued her air mattress because it was slippery. She said the staff put her shoes at her bedside so she can put them on before ambulating. She said she was sure there were other interventions in place, but she could not think of them at the time of the interview. Licensed practical nurse (LPN) #1 was interviewed on 2/7/23 at 10:11 a.m. She said the interventions for Resident #66's repeated falls were to keep the call light within reach, frequent checks, and working with therapy. She said the resident ambulated with a front wheel walker to the bathroom. She said she was not sure if the resident was supposed to ambulate independently or not. She looked in the resident's medical record which revealed the resident was a limited assist to and from the bathroom. The restorative nurse aide (RNA) was interviewed on 2/7/23 at 2:18 p.m. She said Resident #66 was discharged from PT on 2/3/23 and she had not started working with her, however she was on her list to start a restorative nursing program. She said Resident #66 was previously on a restorative program for ambulation but was ambulating independently and discontinued the program. She said the resident was one assist with cuing. She said there had not been a fall committee since COVID-19 began. She said she had not been involved with the fall committee. The director of nursing (DON) was interviewed on 2/7/23 at 2:33 p.m. He said himself and the NHA were new to the facility. He said they were aware there was no fall committee in place and planned on starting one. He said the NHA, himself, the two new unit managers, therapy, dietary, and the facility director had morning huddles in which they discussed resident changes, occurrences, and incidents. He said a resident with repeated falls was to have a fall committee in place to look at the root cause of the falls and put a plan in place for that individual resident. He said the unit managers were responsible for updating the care plans with recent falls and new interventions. He said a fall committee would help with follow up of interventions and would include the physician. The NHA was interviewed on 2/7/23 at 3:43 p.m. She said currently the fall committee was the morning clinical stand up. She said the DON and herself were currently working on updating care plans and reviewing interventions. She said the facility recently hired two new unit managers who would be responsible for fall management investigations and care plan updates as well as the minimum data set coordinator (MDSC). She said the facility completed a fall audit in December 2022 and identified documentation missing from the neurological assessment. She said she had put together a plan to bring back the fall committee to identify residents with repeated and high fall risks and trends. She said the facility had areas that needed improvement such as neurological assessments, use of the fall huddle worksheet, interventions, and updating/revision of the care plans. She acknowledged the facility triggered high for falls. She said she would put a performance improvement plan (PIP) in place for falls. III. Resident #47A. Professional referenceReference for safe use of the sit to stand the resident must be able to stand on his feet to ensure proper placement of the sit to stand seat halves. https://safetyucsf.edu/sites/g/files/tkssra256/f/Arjo%20Sara%20Stedy%20Instructions%20for%20Use.pdf accessed 2/6/23 read in pertinent part, "the sit to stand lift is intended to transfer a resident to and from a chair, a wheelchair, a bed and a toilet. Instructions for safe use of a sit to stand are -Position resident near the sit to stand; -Ask the resident to stand up; -Pivot the two seat halves on the sit to stand upward; -Ask the resident to sit down back down on the chair while holding the sit to stand crossbar. "B. Resident statusResident #47, age 88, was admitted on 11/22/22. According to the February 2023 computerized physician orders (CPO) diagnoses included Parkinson's disease, Alzheimer's disease, depression, syncope (loss of consciousness) and collapse, urinary incontinence, and malaise (general discomfort). On 11/30/22 he was admitted to hospice care at the facility. The 11/28/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) of four out 15. The resident required extensive assistance from two or more persons for bed mobility, transfers, toileting, and extensive assistance of one person for dressing and personal hygiene. The MDS assessment documented the resident had a fall history upon admission; with at least one fall in the previous month, and additional falls in the previous two to six months. On 11/22/22 the resident scored a 20 of 20, high risk, on the facility fall risk assessment. C. ObservationsOn 1/1/23 at 10:30 the resident was observed sitting in the facility common area recliner and was assisted to a wheelchair by facility staff of one person using a sit-stand transfer device so that he could use the toilet in his room. The resident was able to use his arms to grasp the sit-to stand and he did not place his feet on the floor during the transfer (see professional reference). The resident's room contained an electric bed and personal items. There was a call light cord clipped to the bed linens. The cord length was too short to allow the resident to use it from the floor. D. Resident representative interviewThe resident's spouse was interviewed on 2/6/23 at 11:55 a.m. She stated her husband was admitted to the facility because he had several falls at home and she was unable to care for him alone. She was aware her husband had fallen since he was admitted to the facility but did not recall how many times. She was aware the resident had once crawled from his room to the common area and had sustained a skin abrasion on his foot. She said "they will never know what happened with that." The resident's spouse said she thought the resident had multiple falls because his legs were weak. She did not recall facility staff speaking to her about a plan of care for occupational therapy or physical therapy, although she recalled one meeting after admission before the falls occurred. She also stated she liked to take the resident home sometimes and wished someone would help her understand how to use atransport style wheelchair so that she could do that more often. The resident's spouse was unsure if the resident would be able to consistently use his call bell light because he likely would not remember because of his anxiety. E. Record reviewA review of the resident's medical record revealed he had sustained 12 falls from 11/24/22 to 2/7/23. A hospice care plan was provided by the DON on 2/7/23 and identified the care area of mobility/safety/falls. The goals identified for the falls care area were for the resident to maintain a level of mobility and decreased risk of falls. Interventions for the achievement included: -Assess resident need for supportive devices;-Assess for impaired physical limitations;-Train resident/caregiver on reporting falls/safety issues to hospice;-Train resident/caregiver on safe use of equipment;-Wheelchair for transfers;-Train patient/caregiver on methods to reduce falls to use a gait belt, minimum to moderate assist of 2 people present was preferred;-Train patient/caregiver on mechanical lift;-Assess risk vs benefits for bed rails;-Hospital bed with bed rails elected by patient and primary caregiver;-Train the patient/caregiver to move and function safely within the patient's limitations;-Use an electric recliner modified 1-2 persons with supervision and use a toileting schedule;-Encourage appropriate use of durable medical equipment;-Use a sit to stand aid used in the facility with 1-2 persons;-Remove hazards and reduce injury;-Keep bed in low position/fall pad next to bed while in bed. A review of the February 2023 CPO indicated the facility failed to obtain physician orders for those fall prevention interventions recommended by the hospice provider, durable medical equipment, fall risk assessments, to notify the physician with resident changes in conditions, to complete frequent safety checks, and document transfer status. On 11/25/22 the facility and hospice physician initiated an order for an occupational therapy evaluation. Fall #1The nurse progress note dated 11/24/22 at 7:15 p.m. documented the resident had an unwitnessed fall and was found on the floor in front of his recliner. The nurse completed a post-fall assessment and determined the resident was not injured. The nurse documented the director of nursing (DON) nursing home administrator (NHA), wife, and nurse practitioner were notified of the resident's fall. -The documentation failed to include documentation of how those notified responded and did not indicate the hospice provider was notified of the fall. Fall #2The nurse progress note dated 11/27/22 at 2:30 p.m. documented the certified nurse aide (CNA) heard the resident's wheelchair bump into a heater. The resident was found by the CNA sitting on the floor between his wheelchair and bed. -The nurse did not document that a post-fall assessment was completed. The nurse note failed to reveal notification to the family, physician, hospice provider, DON, or NHA. Fall #3A nurse progress note dated 11/29/22 at 5:30 p.m. documented the resident had an unwitnessed fall and was found on the floor in front of his wheelchair. The nurse completed a post-fall assessment and determined the resident was not injured. The nurse documented the resident's call light was in his reach and frequent safety checks were in place. -There was no documentation that indicated the resident had the ability to understand and use a call light system. Results of the results of the safety checks were not found in the record. The note revealed the DON, NHA, wife, and nurse practitioner were notified of the fall. The documentation failed to include how those notified responded or any if any recommendations were made. The documentation failed to reveal the hospice provider was notified. The facility's residents care plan was updated on 11/30/22 and initiated a focus for fall prevention. The facility care plan added the following and interventions:-Monitor/document/report as needed x 72 hours (after a fall) to health care provider for signs and symptoms, pain, bruises, changes in mental status, new onset, confusion, sleepiness, inability to maintain posture, agitation; -Ensure the resident wears appropriate non-slip footwear when mobilizing in wheelchair;-Monitor resident for significant changes in gait, mobility, positioning devices, standing/sitting balance and lower extremity joint function. Fall #4A nurse progress note dated 12/5/22 at 11:38 a.m. documented the resident was found on the floor, on his back. The nurse completed a post-fall assessment and determined the resident was not injured. The nurse documented responsible parties notified; the DON, NHA, wife, and physician. -The documentation failed to include responses or recommendations from those notified. There was no documentation the hospice provider was notified of the resident's fall. On 12/8/22 the facility updated the resident's care plan with the following intervention: -Cognitive: encourage participation and plan diversional activities that are of resident interest. There was no documentation of assessment or interdisciplinary team review for consideration of effectiveness or failure of previous interventions and why and how the resident's cognition contributed to his falls prevention. Fall #5A nurse progress note dated 12/9/22 at 6:49 p.m. documented a fall that was reported by another resident who noticed the resident was on the floor by his recliner. The nurse completed a post-fall assessment and determined the resident was not injured. After the fall the nurse placed a fall mat next to the resident's bed and put the resident's bed in the lowest position. The nurse documented the DON, NHA, wife, and after-hours provider were notified about the fall. -The documentation failed to include responses or recommendations from those notified. After the two new interventions were initiated, the facility did not update the residents care plan and did not document that communication with the hospice provider occurred. The hospice nurse completed a nurse visit on 12/22/22. It documented on the Missouri Alliance for Home Care (MAHC) 10-Fall Risk Assessment the resident had a score of 10 with a score of four or more was considered a risk for falling. -The hospice nurse did not include documentation of an awareness of the resident's falls. Falls #6 and #7The nurse progress note dated 12/20/22 at 4:16 a.m. documented the resident had two falls during the shift. The nurse note revealed the resident was found on the floor next to his bed on the fall mat. -The documentation failed to include a post-fall nursing assessment for each fall and did not document whether or not injuries were present. The nurse determined the resident required anti-anxiety medication. The documentation did not reveal if notifications to family, facility staff, physician,or the hospice provider we completed. Fall #8A nurse progress note dated 1/2/23 at 4:15 p.m. documented the resident was found on the floor in his room between the recliner and bed. The nurse documented the resident said he was getting up and out of his recliner. The nurse documented the resident's vital signs and neurological assessment was all normal and did not indicate whether or not any injuries occurred. -The nurse documented all notifications were made, but did not include who was notified of the fall, or whether or not those notified had responses or recommendations. There was no note the hospice provider was notified of the resident's fall. On 1/4/23 the facility edited the resident's care plan and listed some of the dates the resident had falls: 11/24/22, 11/17/22, 11/29/22, 12/5/22, 12/9/22, 1/2/23. The care plan edits failed to include changes to the fall prevention interventions and there was no documentation the facility or hospice provider interdisciplinary teams had reviewed the residents fall status. Fall #9, #10 and #11The nurse progress note dated 1/17/23 at 6:48 a.m. was a nurse summary note for three separatefalls during the shift. The nurse documented the resident was found out of bed on the fall mat next to his bed after each fall. -The nurses documentation failed to include a post-fall nursing assessment after each fall and did not document whether or not the resident was injured. The documentation did not reveal if notifications to family, facility staff, physician,or the hospice provider we completed. On 1/19/23 the facility physician discontinued the order for occupational therapy evaluation and treatment. On 2/7/23 the facility produced a copy of a handwritten sticky note which indicated the resident had refused the occupational therapy evaluation. There was no documentation why the resident refused or if therapy benefits were reviewed with the resident and family. Fall #12The facility physician documented on 1/25/23 the resident was found on the floor on a previous day. The physician documented the resident had crawled out of his room, across a common area to where he was found by the facility staff. The physician documented as a result of crawling on the floor, the resident sustained an abrasion to his right foot which required wound care evaluations and physician orders for treatment. The facility physician documented the resident had a problem with falls and all interventions were in place. The nurse progress notes dated 1/21/23 documented the resident had a new wound on his right foot. The nurse progress note failed to document if the family or hospice physician was notified of the resident's change in condition. F. Staff interviewsRegistered nurse (RN) #1 was interviewed on 2/6/23 at 11:30 a.m She stated the staff keep a close eye on the resident to prevent falls. She said the resident sits in a recliner in the common area and his wife visits him to help calm his anxiety. She stated the resident has impulsive behaviors and did not use his call light for staff assistance when he was in his room. The RN was unable to locate a hospice care or communication binder. She stated at times communication with the hospice nurse occurred when the hospice nurse visited the resident. The RN was unable to identify when the hospice nurse visited the resident and could not locate documentation that revealed the hospice had been notified of the resident's falls. The RN stated she was unaware how the hospice and facility reviewed and collaborated with the resident's care and believed it was up to the hospice company to complete nurse assessments and communicate with the providers regarding resident status. She was unaware of fall prevention interventions recommended by the hospice provider. The restorative nurse aide (RNA) was interviewed on 2/7/22 at 2:15 p.m. She stated she was unaware the resident had fallen numerous times. She stated she could evaluate the resident and spouse's request for assistance with wheelchair use and training. The director of nursing (DON) was interviewed on 2/7/22 at 2:33 p.m. The DON stated when a resident had a fall the nurse was to complete an assessment form and a facility incident report form. He stated he was unaware of the numerous falls the resident had and that the facility staff had not been communicating with the hospice provider. The DON provided several printed hospice nurse visit notes but was unable to locate documentation the facility had communicated the resident's problem with falls with the hospice provider. The DON stated the facility did not currently have an interdisciplinary team that reviewed resident falls or a fall prevention team. The DON stated the facility was aware improvement was necessary and planned to start a quality improvement project for falls prevention in February 2023.

Based on record review, observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, for two of three medication storage rooms. Specifically, the facility failed to discard expired medications. Findings include:I. Facility policyThe Medication Storage, dated January 2021, was requested and received on 2/6/23. The policy stated in pertinent part:-Medications and biologicals are stored properly, in containers that meet requirements. The pharmacy dispenses medications that meet labeling requirements which may include medication carts, medication rooms, or other suitable containers;-Outdated medications and containers are immediately removed from stock, disposed of according to medication disposal procedures;-Medication storage conditions are monitored on a regular basis as a random quality assurance check. II. Observations and interviewsA. Medication room #1On 2/6/23 at 10:25 a.m., the Heritage Square medication room and medication cart were observed with registered nurse (RN) #1. RN #1 verified the medication cart had a bottle of open multi-dose floor stock guaifenesin cough syrup and the label indicated the medication expired in June 2022. The RN stated staff involved in administering medications was responsible for verifying expiration dates and removing expired items from supply. RN #1 stated using expired medications could expose the resident to a risk for infection and/or receiving ineffective medications. She immediately removed the bottle of medication for proper disposal. A review of February 2023 computerized physician orders for residents on the Heritage Square hallway revealed four of 16 residents had an active order for liquid guaifenesin cough medication. One of the residents was administered a dose of guaifenesin on 2/2/23. RN #1 stated when the medication was prepared, the nurse selected the medication from the medication cart. There was one bottle on the medication cart. B. Medication room #2 On 2/6/23 at 10:55 a.m., the Mountain Lodge medication room and medication cart was observed with licensed practical nurse (LPN) #2. LPN #2 verified the emergency medications kit had expired in January 2023. There was a sticky note on the outside of the kit that read a new kit was ordered from the pharmacy on 1/29/23. The LPN stated she did not know who was responsible to follow-up and ensure a replacement medication kit was received. On 2/7/23 at 10:25 a.m., RN #2 verified the expired emergency medication kit had not been removed from stock and replacement emergency medications had not been received. LPN #2 verified the medication room supply cabinet contained blue top vacutainers, BD - 81 each had expired on 1/31/23 and had not been removed from supply. LPN #2 stated the blue top vacutainers were used by nurses when immediate laboratory orders were received from the physician. She stated using expired blood collection tubes could contribute to inaccurate lab results. A blue top collection tube used for blood coagulation testing and other plasma or whole blood determination laboratory testing. The blue top collection tube contained a measured amount of citrate, a reversible anticoagulate, which preserved the blood until processed in the laboratory. III. InterviewsThe infection preventionist was interviewed on 2/6/23 at 11:00 a.m. He stated expired items should be removed from supply and the removal of expired items was assigned to the night shift nurses. He said that staff were not comfortable with disposing of glass items and were unsure when items could be thrown in the trash or if specific disposal containers were required. He stated the emergency medication kits were prepared and sealed at the pharmacy. When a used or expired medication kit was used, the pharmacy would replace the kit on a one-to-one exchange basis and expired items should be removed from stock. The director of nursing (DON) was interviewed on 2/6/23 at 11:15 a.m. He stated he was unaware of the expired items in the medication rooms. He said it was the responsibility of the night shift nursing staff to identify and remove expired medications from the medication rooms and carts. The DON was unsure if the pharmacy tracked and replaced the kits automatically or if the facility was required to order a new kit with each expiration. The DON stated he would contact the pharmacy on 2/6/23 and request a replacement for the expired emergency medication kit.

A licensure survey was completed on 2/1/23 to 2/7/23. One deficiency was cited.

Based on observation, record review and interviews, the facility failed to provide supervision, assistance, services, and implement timely interventions to prevent falls with injuries for two (#66 and #47) of four residents reviewed for accidents/hazards out of 24 sample residents. Resident #66 had a history of falls upon admission, was cognitively intact, used a walker and wheelchair, and needed supervision with ambulation and transfers. Between 11/29/22 and 1/12/23, Resident #66 experienced eight falls: six unwitnessed and two witnessed. After the 12/20/22 fall, the resident sustained a fractured femur (thigh bone). After the femur fracture the resident became dependent for ambulation in a wheelchair. The facility failed to conduct an interdisciplinary team (IDT) review of Resident #66's repeated falls and implement effective interventions. Additionally, the facility failed to:-Implement effective fall interventions, conduct IDT review of falls and communicate with hospice provider for Resident #47; and, -Ensure the Resident #47's feet were secured during a transfer with a mechanical lift. Findings include:I. Facility policyThe Fall Prevention and Management policy, revised 3/30/22, was provided by the nursing home administrator (NHA) on 2/6/23 at 2:35 p.m. It read in pertinent part:"The purpose was to promote resident well-being by developing and implementing a fall prevention and management program, identify risk factors and implement interventions before a fall occurs, give prompt treatment after a fall occurs, and prevent further injury."A fall refers to unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force. "Upon admission the facility will review the applicable documents, discharge summary from the transferring agency, transfer record, history and physical, lab values, and any additional admit information documentation for fall risk factors. Complete the Falls Tools UDA (user defined assessment) for fall screening and identifying fall risk factors. Care plan the appropriate interventions, including personalizing all areas. Communicate fall risks and interventions to prevent a fall before it occurs per the 24 hour report, care plan, kardex, daily stand up meeting, and/or fall committee meetings. Communicate any identified environmental changes and /or referral needs (maintenance, dietary, therapy)."After a fall, the facility will:a. Assess the resident.b. Notify the physician and resident representative. c. Complete the Fall Scene Huddle worksheet.d. Document the physician's comments in the medical record.e. Complete the Falls Tool UDA.f. If appropriate, contact the physician for a referral to therapy.g. Communicate that a fall has occurred during shift change and daily stand-up meeting. h. Give completed fall scene huddle worksheet to the fall committee chair.i. Report to the state regulatory agency when appropriate.j. Continue to monitor condition and the effectiveness of the interventions.k. The investigation documentation is completed in the notes tab within the Risk Management module."II. Resident #66A. Resident statusResident #66, age 80, was admitted on 8/25/2020. According to the February 2023 computerized physician orders (CPO), the diagnoses included fracture of the right femur, unspecified dementia, anxiety disorder, severe protein-calorie malnutrition, depressive episode, muscle weakness, unsteadiness on feet, need for assistance with personal care, legal blindness, wedge compression fracture of T7-T8 (bones in the spine), difficulty in walking, and repeated falls. The 1/10/23 facility assessment revealed, the resident was cognitively intact with a brief mental status score (BIMS) of 14 out of 15. She required limited assistance with bed mobility, transfers, and walking in the room and corridor. She used a wheelchair and had a fracture related to a fall. She had falls prior to admission. B. Record reviewCare plansThe fall care plan, initiated 8/25/2020 and revised 1/12/23, revealed the resident was at risk for falls and had actual falls related to dementia, failure to thrive, poor safety awareness, weakness, poor balance, legally blind, and atrial flutter. The goal was for the resident to resume usual activities without further incident. The interventions included:-Monitor/document/ report pain and bruises-Initiated 2/20/22.-Provide activities that promote exercise and strength building where possible-Initiated 8/25/2020.-Contact physical therapy for strength and mobility as needed-Initiated 2/20/2022 and revised on 3/16/22.-Ensure the resident was wearing footwear when standing that has a gripping bottom and secure back such as slippers, shoes, or grip socks-Initiated 8/25/2020 and revised on 5/9/22.-Encourage the use of a wheelchair or walker when leaving the room-Initiated 8/25/2020 and revised on 5/9/22. -Frequent monitoring upon waking, before bed, before and after meals, and routinely through the night-Initiated 8/26/2020 and revised on 9/23/2020.-Monitor visual and auditory impairments-Initiated 8/25/2020.-Review as indicated for significant changes in cognition, safety, awareness, and decision making-Initiated 8/25/2020.-Review bowel and bladder continence status and establish and/or review toileting plan based on residents needs-Initiated 8/25/2020 and revised 3/16/22.-Ensure/provide a safe environment, monitor and remove tripping hazards - Initiated 9/23/2020 and revised 7/19/22.-Maintain a clear path in the corridor for ease of ambulation when the resident leaves the room-Initiated 9/23/2020 and revised 7/19/22.-Assist with maintaining a clear area around the bed to allow room to stand safely-Initiated 9/23/2020 and revised 7/19/22.-Purposeful proactive rounding every two hours for safety and assessing needs and comfort-Initiated 2/20/22 and revised on 1/10/23. The visible impairment care plan, initiated 9/14/2020 and revised 11/2/22, revealed the resident had impaired vision related to artificial left eye. She had prophylactic antibiotics for right eye health. The goal was for the resident to maintain optimal quality of life within limitations imposed by visual function left eye blindness. The interventions included:-Maintain room arrangement to promote independence.-Arrange consultation with an eye care practitioner as required.-Monitor/document/report change in ability to perform Activities of daily living (ADLS), decline in mobility, sudden visual loss, pupils dilated, gray or milky, complaint of halos around lights, double vision, tunnel vision, and blurred or hazy vision.-Tell resident where her items are being placed and be consistent with placement of personal items.-Approach the resident from her right side as she has a prosthetic left eye. According to the fall report, nursing progress notes and fall investigations dated 11/29/22 through 1/12/23, the resident had eight falls within three months. 1. According to the 11/29/22 risk management, at 5:30 p.m., the resident was walking down the hallway and did not see another resident in a wheelchair, causing her to lose her balance. She landed in the Indian style (crossed legs) sitting position. The nurse assessed her and walked her back to her room, where she sat on the bed. She was not injured and said she did not see the other resident and lost her balance. Predisposing factor was impaired vision. The fall was witnessed. The risk management note revealed the resident would continue working with restorative and encouraged to use her front wheeled walker when ambulating. A physician order was obtained for a PT evaluation. 2. According to the 12/9/22 risk management, at 12:35 p.m., the nurse found the resident in her room leaning with her back on her bed and her feet up against the closet and her behind up in the air. The nurse assessed the resident and assisted her to her bed. She was not injured and said she sat on the floor and was trying to get up. Predisposing factor was impaired vision. The fall was unwitnessed. The risk management note revealed the resident would continue working with restorative nursing. No new interventions were implemented since the resident was already working with restorative nursing from her previous fall (11/29/22). 3. According to the12/14/22 risk management, at 10:00 a.m., certified nurse aides witnessed the resident trip over her bedside table landing on her bottom. She was sitting on her bottom between the bed and the table. The nurse assessed the resident and assisted her to her bed. She was not injured and said she was going to the bathroom and tripped on the table. Predisposing factor was impaired vision. The risk management note revealed the resident would continue working with restorative. An electrocardiogram (EKG), labs, and urine sample was ordered related to dizziness and nausea. Staff were to ensure the room was free of clutter so the resident had a clear pathway to the bathroom and the room exit. No new interventions were implemented since the resident was already working with restorative and the room should have already been cleared of clutter from her previous two falls (11/29/22 and 12/9/22). 4. According to the 12/20/22 risk management, at 8:30 p.m., the resident was heard yelling out and was found sitting on her left buttocks with her legs to her right. She was holding onto the grab bars facing the toilet. She was wearing tennis shoes. The nurse assessed the resident as she was attempting to get up off the floor on her own. She refused to wait for the staff to use the lift to get her up. The resident was able to bear weight however she walked with a limp and complained of right outer thigh pain. She said, "Ow" with each movement. The resident said she tripped over her roommate who was at the sink and landed on the floor. She said she then scooted herself to the bathroom to try and stand up. A stat x-ray was ordered for the right hip pain. Predisposing factor was impaired vision and impaired memory. This was an unwitnessed fall. The resident was subsequently transferred to the emergency department for evaluation and treatment. She was found to have a right femur neck fracture which required surgical intervention. The risk management note revealed the resident had an increase of falls related to tripping over other residents. The resident appeared to be having difficulty adjusting to increasing impairment to good eye and loss of physical independence. The resident was hospitalized on 12/21/22 and readmitted to the facility on 12/27/22.5. According to the 1/5/23 risk management, at 3:30 p.m., the nurse was called to the resident's room by the floor certified nurse aide (CNA), and found the resident on the floor beside her bed wrapped up in her covers. The nurse assessed the resident and two CNAs used the hoyer lift to help her back into bed. She was not injured and said she was looking for her sock and slid off of the bed. Predisposing factor was impaired vision and gait imbalance. This was an unwitnessed fall. The risk management note revealed the resident was wearing socks. She was encouraged not to reach for items and to use the call light for assistance. The resident would continue working with restorative nursing for safe ambulation. 6. According to the 1/8/23 risk management, at 4:45 a.m., the nurse was walking down the hall, making rounds, and noticed the resident sitting on the floor in the doorway of her bathroom. She was not injured and said she rolled out of the bed and scooted to the bathroom. Predisposing factor was impaired vision and gait imbalance. This was an unwitnessed fall. The risk management note revealed the resident continues working with restorative nursing on safe ambulation. She will continue working with PT related to repeated falls. No new interventions were implemented since the resident was already working with restorative and PT from her previous five falls. 7. According to the 1/10/23 risk management, at 11:16 p.m., the resident was found in front of her dresser going through her clothes. She was not injured and said she put herself on the floor and was sorting her clothes. The nurse assessed her for any injuries. Predisposing factor was impaired vision and gait imbalance. This was an unwitnessed fall. The risk management note revealed the resident would continue working with PT related to repeated falls. The resident was reminded to use the call light and wait for assistance. No new interventions were implemented since the resident was already working with PT from her previous six falls (11/29/22 and 12/9/22), and the resident was reminded to use the call light from her previous two falls. 8. According to the 1/12/23 risk management, at 5:00 a.m., the resident's roommate went to the nurses station to report that Resident #66 was on the floor. The nurse found the resident on the toilet. She was not injured and said she was reaching for the grab bar and slid down onto the floor. Predisposing factor was impaired vision, impaired memory and gait imbalance. This was an unwitnessed fall. The risk management note revealed education was provided to the resident to use the call light and wait for assistance with transfers. No new interventions were implemented since the resident had already been educated to use her call light and wait for assistance from previous multiple falls. There were no IDT review notes for any of the above falls, the risk management notes were completed by the floor nurse. C. Staff interviewsCNA #1 was interviewed on 2/7/23 at 10:08 a.m. She said the Resident #66 could not see well and was very independent. She said the facility discontinued her air mattress because it was slippery. She said the staff put her shoes at her bedside so she can put them on before ambulating. She said she was sure there were other interventions in place, but she could not think of them at the time of the interview. Licensed practical nurse (LPN) #1 was interviewed on 2/7/23 at 10:11 a.m. She said the interventions for Resident #66's repeated falls were to keep the call light within reach, frequent checks, and working with therapy. She said the resident ambulated with a front wheel walker to the bathroom. She said she was not sure if the resident was supposed to ambulate independently or not. She looked in the resident's medical record which revealed the resident was a limited assist to and from the bathroom. The restorative nurse aide (RNA) was interviewed on 2/7/23 at 2:18 p.m. She said Resident #66 was discharged from PT on 2/3/23 and she had not started working with her, however she was on her list to start a restorative nursing program. She said Resident #66 was previously on a restorative program for ambulation but was ambulating independently and discontinued the program. She said the resident was one assist with cuing. She said there had not been a fall committee since COVID-19 began. She said she had not been involved with the fall committee. The director of nursing (DON) was interviewed on 2/7/23 at 2:33 p.m. He said himself and the NHA were new to the facility. He said they were aware there was no fall committee in place and planned on starting one. He said the NHA, himself, the two new unit managers, therapy, dietary, and the facility director had morning huddles in which they discussed resident changes, occurrences, and incidents. He said a resident with repeated falls was to have a fall committee in place to look at the root cause of the falls and put a plan in place for that individual resident. He said the unit managers were responsible for updating the care plans with recent falls and new interventions. He said a fall committee would help with follow up of interventions and would include the physician. The NHA was interviewed on 2/7/23 at 3:43 p.m. She said currently the fall committee was the morning clinical stand up. She said the DON and herself were currently working on updating care plans and reviewing interventions. She said the facility recently hired two new unit managers who would be responsible for fall management investigations and care plan updates as well as the facility coordinator (FC). She said the facility completed a fall audit in December 2022 and identified documentation missing from the neurological assessment. She said she had put together a plan to bring back the fall committee to identify residents with repeated and high fall risks and trends. She said the facility had areas that needed improvement such as neurological assessments, use of the fall huddle worksheet, interventions, and updating/revision of the care plans. She acknowledged the facility triggered high for falls. She said she would put a performance improvement plan (PIP) in place for falls. III. Resident #47A. Professional referenceReference for safe use of the sit to stand the resident must be able to stand on his feet to ensure proper placement of the sit to stand seat halves. https://safetyucsf.edu/sites/g/files/tkssra256/f/Arjo%20Sara%20Stedy%20Instructions%20for%20Use.pdf accessed 2/6/23 read in pertinent part, "the sit to stand lift is intended to transfer a resident to and from a chair, a wheelchair, a bed and a toilet. Instructions for safe use of a sit to stand are -Position resident near the sit to stand; -Ask the resident to stand up; -Pivot the two seat halves on the sit to stand upward; -Ask the resident to sit down back down on the chair while holding the sit to stand crossbar. "B. Resident statusResident #47, age 88, was admitted on 11/22/22. According to the February 2023 computerized physician orders (CPO) diagnoses included Parkinson's disease, Alzheimer's disease, depression, syncope (loss of consciousness) and collapse, urinary incontinence, and malaise (general discomfort). On 11/30/22 he was admitted to hospice care at the facility. The 11/28/22 facility assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) of four out 15. The resident required extensive assistance from two or more persons for bed mobility, transfers, toileting, and extensive assistance of one person for dressing and personal hygiene. The facility assessment documented the resident had a fall history upon admission; with at least one fall in the previous month, and additional falls in the previous two to six months. On 11/22/22 the resident scored a 20 of 20, high risk, on the facility fall risk assessment. C. ObservationsOn 1/1/23 at 10:30 the resident was observed sitting in the facility common area recliner and was assisted to a wheelchair by facility staff of one person using a sit-stand transfer device so that he could use the toilet in his room. The resident was able to use his arms to grasp the sit-to stand and he did not place his feet on the floor during the transfer (see professional reference). The resident's room contained an electric bed and personal items. There was a call light cord clipped to the bed linens. The cord length was too short to allow the resident to use it from the floor. D. Resident representative interviewThe resident's spouse was interviewed on 2/6/23 at 11:55 a.m. She stated her husband was admitted to the facility because he had several falls at home and she was unable to care for him alone. She was aware her husband had fallen since he was admitted to the facility but did not recall how many times. She was aware the resident had once crawled from his room to the common area and had sustained a skin abrasion on his foot. She said "they will never know what happened with that." The resident's spouse said she thought the resident had multiple falls because his legs were weak. She did not recall facility staff speaking to her about a plan of care for occupational therapy or physical therapy, although she recalled one meeting after admission before the falls occurred. She also stated she liked to take the resident home sometimes and wished someone would help her understand how to use a transport style wheelchair so that she could do that more often. The resident's spouse was unsure if the resident would be able to consistently use his call bell light because he likely would not remember because of his anxiety. E. Record reviewA review of the resident's medical record revealed he had sustained 12 falls from 11/24/22 to 2/7/23. A hospice care plan was provided by the DON on 2/7/23 and identified the care area of mobility/safety/falls. The goals identified for the falls care area were for the resident to maintain a level of mobility and decreased risk of falls. Interventions for the achievement included: -Assess resident need for supportive devices;-Assess for impaired physical limitations;-Train resident/caregiver on reporting falls/safety issues to hospice;-Train resident/caregiver on safe use of equipment;-Wheelchair for transfers;-Train patient/caregiver on methods to reduce falls to use a gait belt, minimum to moderate assist of 2 people present was preferred;-Train patient/caregiver on mechanical lift;-Assess risk vs benefits for bed rails;-Hospital bed with bed rails elected by patient and primary caregiver;-Train the patient/caregiver to move and function safely within the patient's limitations;-Use an electric recliner modified 1-2 persons with supervision and use a toileting schedule;-Encourage appropriate use of durable medical equipment;-Use a sit to stand aid used in the facility with 1-2 persons;-Remove hazards and reduce injury;-Keep bed in low position/fall pad next to bed while in bed. A review of the February 2023 CPO indicated the facility failed to obtain physician orders for those fall prevention interventions recommended by the hospice provider, durable medical equipment, fall risk assessments, to notify the physician with resident changes in conditions, to complete frequent safety checks, and document transfer status. On 11/25/22 the facility and hospice physician initiated an order for an occupational therapy evaluation. Fall #1The nurse progress note dated 11/24/22 at 7:15 p.m. documented the resident had an unwitnessed fall and was found on the floor in front of his recliner. The nurse completed a post-fall assessment and determined the resident was not injured. The nurse documented the director of nursing (DON) nursing home administrator (NHA), wife, and nurse practitioner were notified of the resident's fall. -The documentation failed to include documentation of how those notified responded and did not indicate the hospice provider was notified of the fall. Fall #2The nurse progress note dated 11/27/22 at 2:30 p.m. documented the certified nurse aide (CNA) heard the resident's wheelchair bump into a heater. The resident was found by the CNA sitting on the floor between his wheelchair and bed. -The nurse did not document that a post-fall assessment was completed. The nurse note failed to reveal notification to the family, physician, hospice provider, DON, or NHA. Fall #3A nurse progress note dated 11/29/22 at 5:30 p.m. documented the resident had an unwitnessed fall and was found on the floor in front of his wheelchair. The nurse completed a post-fall assessment and determined the resident was not injured. The nurse documented the resident's call light was in his reach and frequent safety checks were in place. -There was no documentation that indicated the resident had the ability to understand and use a call light system. Results of the results of the safety checks were not found in the record. The note revealed the DON, NHA, wife, and nurse practitioner were notified of the fall. The documentation failed to include how those notified responded or any if any recommendations were made. The documentation failed to reveal the hospice provider was notified. The facility's residents care plan was updated on 11/30/22 and initiated a focus for fall prevention. The facility care plan added the following and interventions:-Monitor/document/report as needed x 72 hours (after a fall) to healthcare provider for signs and symptoms, pain, bruises, changes in mental status, new onset, confusion, sleepiness, inability to maintain posture, agitation; -Ensure the resident wears appropriate non-slip footwear when mobilizing in wheelchair;-Monitor resident for significant changes in gait, mobility, positioning devices, standing/sitting balance and lower extremity joint function. Fall #4A nurse progress note dated 12/5/22 at 11:38 a.m. documented the resident was found on the floor, on his back. The nurse completed a post-fall assessment and determined the resident was not injured. The nurse documented responsible parties notified; the DON, NHA, wife, and physician. -The documentation failed to include responses or recommendations from those notified. There was no documentation the hospice provider was notified of the resident's fall. On 12/8/22 the facility updated the resident's care plan with the following intervention: -Cognitive: encourage participation and plan diversional activities that are of resident interest. There was no documentation of assessment or interdisciplinary team review for consideration of effectiveness or failure of previous interventions and why and how the resident's cognition contributed to his falls prevention. Fall #5A nurse progress note dated 12/9/22 at 6:49 p.m. documented a fall that was reported by another resident who noticed the resident was on the floor by his recliner. The nurse completed a post-fall assessment and determined the resident was not injured. After the fall the nurse placed a fall mat next to the resident's bed and put the resident's bed in the lowest position. The nurse documented the DON, NHA, wife, and after-hours provider were notified about the fall. -The documentation failed to include responses or recommendations from those notified. After the two new interventions were initiated, the facility did not update the residents care plan and did not document that communication with the hospice provider occurred. The hospice nurse completed a nurse visit on 12/22/22. It documented on the Missouri Alliance for Home Care (MAHC) 10-Fall Risk Assessment the resident had a score of 10 with a score of four or more was considered a risk for falling. -The hospice nurse did not include documentation of an awareness of the resident's falls. Falls #6 and #7The nurse progress note dated 12/20/22 at 4:16 a.m. documented the resident had two falls during the shift. The nurse note revealed the resident was found on the floor next to his bed on the fall mat. -The documentation failed to include a post-fall nursing assessment for each fall and did not document whether or not injuries were present. The nurse determined the resident required anti-anxiety medication. The documentation did not reveal if notifications to family, facility staff, physician,or the hospice provider we completed. Fall #8A nurse progress note dated 1/2/23 at 4:15 p.m. documented the resident was found on the floor in his room between the recliner and bed. The nurse documented the resident said he was getting up and out of his recliner. The nurse documented the resident's vital signs and neurological assessment was all normal and did not indicate whether or not any injuries occurred. -The nurse documented all notifications were made, but did not include who was notified of the fall, or whether or not those notified had responses or recommendations. There was no note the hospice provider was notified of the resident's fall. On 1/4/23 the facility edited the resident's care plan and listed some of the dates the resident had falls: 11/24/22, 11/17/22, 11/29/22, 12/5/22, 12/9/22, 1/2/23. The care plan edits failed to include changes to the fall prevention interventions and there was no documentation the facility or hospice provider interdisciplinary teams had reviewed the residents fall status. Fall #9, #10 and #11The nurse progress note dated 1/17/23 at 6:48 a.m. was a nurse summary note for three separate falls during the shift. The nurse documented the resident was found out of bed on the fall mat next to his bed after each fall. -The nurses documentation failed to include a post-fall nursing assessment after each fall and did not document whether or not the resident was injured. The documentation did not reveal if notifications to family, facility staff, physician,or the hospice provider we completed. On 1/19/23 the facility physician discontinued the order for occupational therapy evaluation and treatment. On 2/7/23 the facility produced a copy of a handwritten sticky note which indicated the resident had refused the occupational therapy evaluation. There was no documentation why the resident refused or if therapy benefits were reviewed with the resident and family. Fall #12The facility physician documented on 1/25/23 the resident was found on the floor on a previous day. The physician documented the resident had crawled out of his room, across a common area to where he was found by the facility staff. The physician documented as a result of crawling on the floor, the resident sustained an abrasion to his right foot which required wound care evaluations and physician orders for treatment. The facility physician documented the resident had a problem with falls and all interventions were in place. The nurse progress notes dated 1/21/23 documented the resident had a new wound on his right foot. The nurse progress note failed to document if the family or hospice physician was notified of the resident's change in condition. F. Staff interviewsRegistered nurse (RN) #1 was interviewed on 2/6/23 at 11:30 a.m She stated the staff keep a close eye on the resident to prevent falls. She said the resident sits in a recliner in the common area and his wife visits him to help calm his anxiety. She stated the resident has impulsive behaviors and did not use his call light for staff assistance when he was in his room. The RN was unable to locate a hospice care or communication binder. She stated at times communication with the hospice nurse occurred when the hospice nurse visited the resident. The RN was unable to identify when the hospice nurse visited the resident and could not locate documentation that revealed the hospice had been notified of the resident's falls. The RN stated she was unaware how the hospice and facility reviewed and collaborated with the resident's care and believed it was up to the hospice company to complete nurse assessments and communicate with the providers regarding resident status. She was unaware of fall prevention interventions recommended by the hospice provider. The restorative nurse aide (RNA) was interviewed on 2/7/22 at 2:15 p.m. She stated she was unaware the resident had fallen numerous times. She stated she could evaluate the resident and spouse's request for assistance with wheelchair use and training. The director of nursing (DON) was interviewed on 2/7/22 at 2:33 p.m. The DON stated when a resident had a fall the nurse was to complete an assessment form and a facility incident report form. He stated he was unaware of the numerous falls the resident had and that the facility staff had not been communicating with the hospice provider. The DON provided several printed hospice nurse visit notes but was unable to locate documentation the facility had communicated the resident's problem with falls with the hospice provider. The DON stated the facility did not currently have an interdisciplinary team that reviewed resident falls or a fall prevention team. The DON stated the facility was aware improvement was necessary and planned to start a quality improvement project for falls prevention in February 2023.