**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility policy, the facility failed to ensure residents were free from verbal abuse for 1 of 9 sampled residents, Resident (R)1. On 08/28/2024, the Housekeeper cussed at and called R1 names after the resident was verbally aggressive towards the Housekeeper. The findings include: Review of the facility policy titled, Abuse, Neglect and Misappropriation of Property, last reviewed and revised 09/15/2023, revealed it was the organization's intention to prevent abuse and protect the health, welfare, and rights of each resident residing in the facility. Per review, instances of abuse, irrespective of any mental or physical condition, caused harm, pain, or mental anguish. Continued review revealed abuse included verbal abuse, which encompassed use of oral language with any threat, frightening, disparaging or derogatory language to residents or within their hearing distance, regardless of age, ability to comprehend, or disability. Review of the facility policy titled, Resident Rights, last reviewed 09/13/2024, revealed all residents had the right to be treated with respect and dignity, which was to be protected by the facility. Per review, all residents were to be treated in a manner and in an environment that promoted enhancement of quality of life. Review further revealed the facility was to make every effort to support each resident in exercising his/her right to assure the resident was always treated with respect, kindness, and dignity. Review of the facility's investigation for an incident on 08/28/2024, revealed the facility investigated a verbal altercation between the Housekeeper and R1 at 11:30 AM. Per review, the facility removed and suspended the Housekeeper. Review of the Housekeeper's written statement (located in the investigation documentation), dated 08/28/2024 at 4:35 PM, revealed it had been written by the Housekeeper's parent, as the Housekeeper had disabilities; however, was signed by the Housekeeper. Continued review of the Housekeeper's written statement revealed R1 called the Housekeeper a fat, ugly bitch over and over. Further review of the Housekeeper's written statement revealed the Housekeeper finally broke and told R1 to get out of her effing face and she too (R1) was a fat, ugly bitch. Further review of the facility's investigation revealed the facility determined the incident had been a situational, reactionary event without willful intent to harm and the staff member would not return to the premises. Continued review of the facility's investigation documentation, for the incident on 08/28/2024, revealed other staff members' statements. Review of Licensed Practical Nurse (LPN) 1's written statement revealed the nurse heard the Housekeeper yelling at R1 and she told the Housekeeper she could not speak to residents in that manner or that way in the resident area. Review of LPN 3's written statement revealed she heard yelling, which included get out of here you fat bitch and whore. Per review of LPN 3's written statement, LPN 1 asked the Housekeeper if it was her yelling, and the Housekeeper said yes. Further review of LPN 3's statement revealed she (LPN 3) took the Housekeeper's broom and dustpan and escorted the Housekeeper to the timeclock. Review of the clinical record for R1 revealed the facility admitted the resident on 06/21/2021, and re-admitted R1 on 09/30/2021, with diagnoses that included dementia, schizoaffective disorder and borderline personality disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R1 with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Review of the comprehensive care plan for R1 revealed the facility developed a behavioral problem area dated 07/01/2021 and edited 06/12/2024. Continued review of R1's behavior care plan revealed the resident's behaviors included being verbally abusive; difficult to redirect; known to yell/cuss at staff; and say racial slurs towards staff. Further review revealed the interventions included to provide a non-confrontational environment for care. In interview on 12/12/2024 at 2:42 PM, R1 stated a housekeeper yelled at her and cussed at her around a month ago. R1 further stated the Administrator fired the housekeeper. In interview on 12/12/2024 at 4:27 PM, the Housekeeper (involved in the incident on 08/24/2024) stated R1 called her a fat ugly bitch and she (the Housekeeper) went off and told R1 to look in the mirror. The Housekeeper stated she said what was noted in her written statement. She further stated the facility wanted her out of the building On 12/12/2024 at 5:37 PM, interview with LPN 1 revealed she had been involved in the situation with R1 and the Housekeeper. She stated she had been at the nurse's station and heard loud yelling and knew it was R1. LPN 1 said she went to where the resident was and intervened with R1. She reported she and another nurse told the Housekeeper she could not speak like that to R1 and asked the Housekeeper to leave the resident area. LPN 1 stated the Housekeeper said, that fucking bitch whore (R1) was not going to talk to her like that. The nurse said R1 called the Housekeeper a fucking bitch, and the housekeeper said no you're a fucking bitch. LPN 1 further stated she escorted the Housekeeper to the timeclock and watched the Housekeeper leave the building. She additionally stated she told R1 it (the incident) would be handled through proper channels. In interview on 12/18/2024 at 3:16 PM, the Housekeeping District Manager (DM) stated R1 made comments to the Housekeeper and when the Housekeeper attempted to walk away, R1 followed her. She stated the Housekeeper then screamed back at the resident. The Housekeeping DM reported the Housekeeper was walked out of the facility after she raised her voice to R1 and was terminated on the spot. She said she spoke with the Housekeeper and informed her R1 was still a patient and she (the Housekeeper) still needed to follow the facility's protocol. The Housekeeping DM further stated there were other things the Housekeeper could have done in that situation. In interview on 12/18/2024 at 12:51 PM, the Director of Nursing (DON) stated R1 started to cuss and yell at the Housekeeper while the Housekeeper was cleaning the resident's room. She said the Housekeeper tried to walk away; however, R1 followed the Housekeeper down the hall. The DON stated the Housekeeper began to talk back to R1, yelling and cussing, and was terminated for the verbal abuse. Interview on 12/18/2024 at 2:22 PM, the Administrator stated R1 did not need to be provoked in her behaviors. He reported LPN 1 heard the incident between R1 and the Housekeeper (on 08/24/2024) and got the Housekeeper immediately out of the building. The Administrator stated the LPN reported the incident to him and the housekeeper was immediately suspended and eventually terminated. He explained R1 had not wanted her room cleaned at the moment; however, the Housekeeper tried to go ahead and clean the room. The Administrator stated R1 followed the Housekeeper in the hall and called the Housekeeper a retard. He further stated the Housekeeper, who had a developmental disability, said R1's words back to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of staff training records, and review of the website utilized by the facility for training staff, the facility failed to provide staff training specific to a resident's mental illness diagnoses and behaviors for 1 of 9 sampled residents, Resident (R)1. R1's diagnoses included Borderline Personality Disorder and Schizoaffective Disorder, and the resident exhibited behaviors. However, the facility failed to provide training for staff directly related to R1's mental illness and diagnoses. The findings include: Review of the facility policy titled, Abuse, Neglect and Misappropriation of Property, last revised and reviewed on 09/15/2023, revealed it was the organization's intention to prevent the occurrence of abuse. Review of the policy revealed the facility included training to provide for the protection of the health, welfare, and rights of each resident residing in the facility. Continued review revealed training provided included understanding behavioral symptoms of residents that might increase the risk of abuse and how to respond. Review further revealed the resident behavioral symptoms included aggressive or catastrophic reactions of residents, outbursts or yelling out, and resistance to care. Review of the facility's investigation of an incident on 08/28/2024, revealed R1 became verbally aggressive toward the Housekeeper. Per review, R1 called the Housekeeper a fat, ugly bitch multiple times, which led to the Housekeeper repeating (the words) back to R1. Review further revealed the Housekeeper was removed and was not to return to the premises. Review of the facility's staff training overview for Behavioral Health for Older Adults revealed an overview of the training included the physical decline (of residents), loss of loved ones, and it discussed the most common behavioral disorders, levels of care, and community supports. Continued review revealed the goal of the course was to educate staff in post-acute care on behavioral health in older adults. Review further revealed the course overview did not define specific mental illness or any mental illness, such as R1's diagnoses. Review of the website www.reliasacademy.com training Behavioral Health for Older Adults, utilized by the facility, revealed the training included behavioral health disorders common in older adults. Per review, the behavioral health disorders in the training included Depression, Dementia, Alzheimer's Disease, Suicide, Anxiety, Substance Use Disorder, Bipolar Disorder, Eating Disorders, and Schizophrenia. However, further review revealed Borderline Personality Disorder and Schizoaffective Disorders were not identified as included in the training outline. Review of R1's clinical record revealed the facility admitted the resident on 06/21/2021 and re-admitted R1 on 09/30/2021, with diagnoses which included borderline personality disorder, dementia, and schizoaffective disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident had intact cognition. Review of R1's comprehensive care plan revealed the facility developed a problem area for behaviors for the resident dated 07/01/2021 and edited 12/09/2024. Review revealed the facility noted R1's behaviors as: being verbally abusive and physically aggressive; refusing care, medications, and psych services; being difficult to redirect; known to yell/cuss and say racial slurs towards staff; and hitting staff. Continued review revealed the facility listed other of R1's behaviors as: attempting to impede the care of others; being destructive to facility property and electronic devices; making unsubstantiated claims and allegations; displaying manipulative behaviors and paranoia; and demanding her care needs be first above other residents. In addition, the facility noted R1 had behaviors of rummaging through others' personal belongings; attempting to rummage through the food carts; and hoarding dishes, linens, food, snacks. Further review of the care plan revealed interventions that included: redirecting and providing education as needed on the benefits and risks of recommended care; two people (present) at all times during care; continuing to offer psychiatric support services; and discussing the behavior with resident if reasonable. Review further revealed other interventions to: intervene as needed to protect the rights and safety of others; divert the resident's attention; remove the resident from a situation as needed; encourage activity; allow the resident to express feelings and provide methods to cope; and re-approach later when she had less agitation. Review of R1's progress notes revealed R1 yelled at staff, cussed staff, and/or called staff names on the following dates: 08/05/2024, 08/07/2024, 08/22/2024, 08/25/2024, 08/28/2024, 09/07/2024, 09/19/2024, 09/23/2024, 10/11/2024, 10/12/2024, 10/13/2024, 10/18/2024, 10/19/2024, 10/22/2024, 11/03/2024, 11/11/2024, 11/19/2024, 11/29/2024, 11/30/2024, 12/02/2024, 12/03/2024, 12/07/2024, 12/08/2024, and 12/09/2024. In interview on 12/12/2024 at 2:42 PM, R1 stated she was calling the federal government and the governor to report staff at the facility. She stated an Adult Protective Services (APS) worker came to speak with her yesterday and the APS worker was going to call the supervisor of the State Survey Agency (SSA) to make her report. R1 spoke of how staff treated her in the facility, calling her names and cussing her. In interview on 12/13/2024 at 9:58 AM, the APS worker stated R1 had a lengthy history with the state. She reported she saw R1 on 12/11/2024, for allegations the resident made against Certified Nurse Aide (CNA) 1 and Licensed Practical Nurse (LPN) 2. In interview on 12/12/2024 at 5:37 PM, LPN 1 stated R1 had diagnoses that caused her to have mental health issues. She further stated R1 got the whole building in an uproar in general, and that was just who she was. In interview on 12/18/2024 at 10:36 AM, the Social Services Director (SSD) stated staff received education for dementia and mental illness when hired, and with yearly competencies (however, review of the facility's training revealed it did not specifically address R1's diagnoses of schizoaffective disorder and borderline personality disorder). The SSD reported staff used R1's care plan interventions when she had behaviors, although they did not prevent the resident's behavior of hitting staff. In interview on 12/18/2024 at 3:16 PM, the Housekeeping District Manager (DM) revealed the housekeepers completed the same trainings the facility staff completed, either in person or online. She stated the housekeepers completed their own training and any general education with the facility. The Housekeeping DM was unsure if facility staff completed training regarding a resident's mental illness. In interview on 12/18/2024 at 6:16 PM, CNA 4 stated she was very familiar with R1, although she did not usually provide care for the resident. She stated R1 called staff names, cussed at staff, and harassed certain staff. CNA 4 stated the facility provided training for working with residents with mental illnesses, such as mental disability or M.R. (mental retardation). In interview on 12/19/2024 at 10:24 AM, the MDS Nurse stated she did not know if any staff received training specific to R1's psychiatric diagnoses (of borderline personality disorder and schizoaffective disorder). She stated the facility had not had a Staff Development Coordinator (SDC) to provide staff education for about two months. The MDS Nurse said facility staff had different learning based on their various roles. She further stated she had not received training related to R1's mental illness diagnoses. In interview on 12/19/2024 at 12:51 PM, the Director of Nursing (DON) stated she was also the current SDC. She said staff had to walk on eggshells with R1 as they did not know how she would react to them. The DON said you could say good morning to R1 and she would cuss you out, or be as nice as can be. She reported each behavior was situational and the majority of R1's behaviors were from the same root cause, her personality disorder. The DON explained R1 targeted specific staff and called staff names and talked derogatively about them. She stated R1 has difficulty interacting appropriately with others and became defensive and angry. Per the DON in interview, the facility did not typically complete resident mental health training for staff as the facility was not a mental health facility. She said staff were trained in dementia and dementia type behaviors when hired and yearly. The DON reported however, staff were not trained on schizoaffective disorder or borderline personality disorder. She said the training the facility provided titled, Behavioral Health for Older Adults was dementia training. The DON stated training in schizoaffective disorder and borderline personality disorder was situational, as everybody's situation was different. She said the purpose of providing training for staff was to help them know how to handle situations or provide care or diversional activities for residents. The DON further stated housekeeping was a different company and she could not answer if they completed the same trainings the facility completed. In interview on 12/19/2024 at 2:22 PM, the Administrator stated R1 did things without being provoked. He said he was aware of R1's mental illness and it was uniquely directed toward staff and visitors and that was just who R1 was. The Administrator reported R1 responded to some staff better than others. He stated R1 hit a CNA and attempted to hit a nurse (on 12/09/2024), and the root cause of those two events had been R1's mental illness. Per the Administrator in interview, staff were trained on R1's mental illnesses in the Behavioral Health for Older Adults training. He stated that the facility's training was a general behavioral training for older adults and R1's diagnoses should be included in the training (however, schizoaffective disorder and borderline personality disorder were not included in the training outlined on the website). The Administrator said the purpose of the trainings was to educate staff on how to manage a resident's behaviors, whether it was mental illness or behavioral, to provide quality of life for residents and person centered care. He further stated the facility was the last stop for many of the residents and the facility wanted to make them as happy and comfortable as possible, and the trainings help in providing that kind of life for the residents.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy/procedure, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for one (Resident (R) 51) of 49 sampled residents. Staff entered R51's room, which was designated as a contact precaution room, without first donning proper Personal Protective Equipment (PPE). The findings include: Review of the facility's policy, titled Infection Control, with an effective date of 01/23/2024, revealed the intention of the policy was to help prevent and manage the transmission of diseases and infections. Added review of the policy revealed the objectives were to establish guidelines for implementing Isolation Precautions, including Standard and Transmission-Based Precautions. Review of the facility's signage for contact precautions (procedure to be used) revealed providers and staff must put on gloves and gown before room entry and discard the PPE before exiting the room. Review of R51's face sheet revealed the resident was admitted on [DATE] with diagnoses including candidiasis of the skin and nail. Review of R51's order set, dated 12/30/2023, revealed an order for contact precautions. Review of R51's Comprehensive Care Plan (CCP), dated 01/12/2024 with revision date of 04/09/2024, revealed the resident had a problem identified as being on ongoing contact isolation related to candidiasis auris, a species of fungus that grows as yeast. Review of interventions included staff were to use PPE as indicated. On 04/10/2024 at 8:15 AM, observation revealed signage for contact isolation on R51's door. Review of the contact isolation signage revealed it documented that staff were to don PPE, including gloves and a gown, prior to entering the room. An isolation cart containing PPE was available for use. Kentucky Medication Aide (KMA)1 failed to don the required PPE prior to entering R51's room, carrying medications in a medication cup. During interview at this time, KMA1 stated staff was told by nursing that if they were just walking in the room to hand pills, they did not need to gown up. In an additional interview with KMA1 on 04/11/2024 at 3:30 PM, she stated she has worked at facility since June of 2023 and her job tasks include passing medications to residents. KMA1 stated she had been given wrong instructions by nurses about not needing PPE when entering the room. KMA1 noted that she had training for contact isolation and knew better, and she should have donned PPE. During an interview with the Infection Preventionist (IP) on 04/11/2024 at 1:30 PM, she stated she is also the facility's Director of Nursing (DON). She stated she performs infection control trainings yearly and in-services as needed, adding the last training was in 12/2023. She added in the trainings she performs skill checkoffs with staff which included donning/doffing proper PPE for different isolation, adding re-education was given if needed. The IP/DON stated that random audits were performed on infection control procedures, but she did not keep evidence of the audits. During an interview with the Administrator on 04/12/2024 at 2:55 PM, he stated that staff had been educated on contact isolation, and education is an ongoing process in facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure it honored a decision of care made by a resident's legal representative or Power of Attorney (POA) for one (1) of thirty-seven (37) sampled residents (Resident #46). Review of previous admissions to the facility for Resident #46, revealed the facility had documented the resident's legal representative. Interview revealed the resident's significant other had provided the facility with a copy of Resident #46's POA documentation. Record review and interviews revealed, on 01/24/2020, the POA notified the facility of Resident #46's need to use a respiratory mask which assisted with the resident's respiratory efforts at night. The POA made multiple requests to allow the use of the mask for the resident's respiratory care needs. However, the facility failed to honor the POA's request and told the POA it was in contradiction of the Physician's admission Orders. The findings include: Review of the facility's policy titled, Advance Directive (AD) Procedure, revised 02/06/19, revealed the facility was to make an effort to obtain a written copy of the AD if it was notified, and it included provision of a POA for a resident. In addition, the facility was not to place conditions of the provision of care, on any individual whether or not the resident had completed an AD. Review of the facility's policy titled, Resident Rights, revised 08/16/18, revealed the facility ensured all residents were treated with respect and dignity. In addition, the policy revealed the facility's resident rights included making medical care decisions, which encompassed refusals. Review of the POA documentation for Resident #46, dated 05/09/17, revealed the resident had given his/her significant other the ability to make decisions when the resident did not have the capacity to make medical and financial decisions. Review of Resident #46's Discharge summary, dated [DATE], revealed a a pre-assessment document which noted the resident used a mask, for respiratory support at night, called a Bilevel Positive Airway Pressure (BiPAP) or Continuous Positive Airway Pressure (CPAP). Review of Resident #46 clinical record revealed the facility admitted the resident on 01/24/2020, with diagnoses which included Congestive Heart Failure, Dilated Cardiomyopathy, and Parkinson's disease. Review of the Facility Pre- Assessment admission Form for Resident #46, dated 01/23/2020, revealed a check mark for the answer of Yes for respiratory mask, use of a CPAP under the pulmonary section of the form. Review of the facility's Nursing admission Assessment, dated 01/24/2020 at 12:09 PM, revealed Resident #46's medical history included the use of a mask for respiratory support when asleep. Continued review revealed the information regarding the mask use had been obtained from a family member. Review of the facility's admission Minimum Data Set (MDS) Assessment, dated 01/31/2020, revealed the facility assessed the resident as impaired with decision making. Review of Licensed Practical Nurse (LPN) #1's Nursing Note, documented as a late entry on 01/27/2020 at 1:49 AM, revealed on 01/25/2020, staff had observed Resident #46's POA remove the resident's nasal oxygen from him/her, and place a respiratory mask on the resident. Continued review revealed staff attempted to remove the respiratory mask and replace it with the nasal oxygen, with the POA objecting to this being done. Further review revealed staff notified the Director of Nursing (DON) and received instructions to call the police if the POA continued to attempt to replace the nasal oxygen with the respiratory mask. In addition, staff also notified the Physician, who stated the representative had the right to remove it if they wanted to use the respiratory mask. Review of the Nurse's Note, dated 01/25/2020 at 01:15 PM, revealed documented LPN #1 entered the note on 01/46/2020 at 10:14 AM, and documented the POA notified staff the resident needed the mask and she wanted the resident to use the mask. Interview with Family Member #2, Resident #46's POA, on 03/01/2020 at 12:13 PM, revealed the resident needed the respiratory mask when sleeping as he/she stopped breathing at times. The POA stated Resident #46 had used the respiratory mask for over twenty (20) years. Per interview, the POA stated she had provided the facility paperwork for the POA documentation during the resident's previous admission to the facility. The POA stated she had made multiple requests of staff for Resident #46 to use the respiratory mask in order for the resident to be able to rest. Further interview revealed staff told her (the POA) multiple times the facility would call the police if she continued to attempt to apply the respiratory mask on Resident #46. An additional interview with Family Member #2/POA, on 03/03/20 at 2:56 PM, revealed when the facility did not allow Resident #46 to use the respiratory mask as the POA requested it had made her feel terrible. Per interview, the POA stated she had cared for Resident #46 for many years and the facility's refusal to listen to her and allow the resident to use the respiratory mask made her feel like garbage and ignorant. Continued interview revealed when the facility staff threatened to call the police if she continued to apply the respiratory mask on Resident #46, the staff's gruff and authoritative manner made her feel as though she had no choice in the care the resident received. The POA stated it felt as though Resident #46's care was controlled only by the facility. Further interview revealed the POA had a right to decide on the care Resident #46 received as the resident's POA. Interview with LPN #1, on 03/05/2020 at 9:34 AM, revealed the LPN knew if a resident was unable to make decisions regarding their care and they had a POA, the POA made the decisions regarding the resident's care. An additional interview with LPN #1, on 03/05/2020 at 3:30 PM, revealed Resident #46's POA made the choices or decisions regarding care for the resident now, as he/she was unable to make the decisions himself/herself. According to LPN #1, the rights of the resident to make decisions carried over to the POA when the resident could not make or verbalize his/her own decisions. She stated the POA wanted and requested the use of the respiratory mask for Resident #46. Continued interview revealed however, the resident required oxygen and the respiratory mask did not have oxygen. The LPN stated therefore, staff felt the POA had interfered with the doctor's order for oxygen. Further interview revealed, after being notified of the issue by staff, the doctor ordered the facility to obtain a respiratory mask with oxygen, and did not know why the resident did not have the unit at the bedside already. Interview with LPN #4, on 03/05/2020 at 10:21 AM, revealed the reason for a resident to have a POA was for the POA to represent the resident to ensure his/her care continued when he/she became unable to make decisions regarding their care. Per interview, a resident's POA's rights included the same rights of the resident with any decision regarding care, and this required staff to honor and respect the POA's decisions. LPN #4 stated the POA, as a resident's representative, knew the care needs of the resident, and wanted the best for the resident. She stated that decisions made affected a resident's outcome and the POA/family's emotional well being. Further interview revealed Resident #46's POA told her it was very upsetting to have been told the police would be called if she continued to place the respiratory mask on the resident. In addition, LPN #4 stated the POA told her after years of marriage to Resident #46, it upset her not to have a say in the resident's care. She further stated staff usually documented resident care issues when residents or families did not agree on the facility's care choices. Interview with the Director of Nursing (DON), on 03/05/2020 at 4:07 PM, revealed when a resident became unable to make a medical decision for care or for their care needs, then the POA made those decisions for the resident. She stated Resident #46's POA had interfered with Resident #46's medical orders when she removed the nasal oxygen, placed the respiratory mask on the resident. According to the DON, the POA continued to interfere with the nurses when they attempted to replace Resident #46's oxygen, which was why she had directed staff to call the police if the POA continued not to follow the doctor's orders. However, further interview revealed, the DON stated the POA's rights included making medical decisions for Resident #46 to ensure the resident's rights were upheld regarding making decisions or refusing care. Interview with the Administrator, on 03/05/2020 at 5:52 PM, revealed the facility's audits had not identified concerns or issues with the rights of the families and/or POAs to make decisions for care for residents unable to make those decisions. He stated the facility could not make its own orders for resident care as that was up to the doctor. Further interview reveled Resident #46 required oxygen, and the resident's oxygen levels dropped if oxygen was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, it was determined the facility failed to ensure to develop s resident-centered Comprehensive Care Plan (CCP) which accurately reflected care to meet the medical, physical and mental needs to prevent a fall for one (1) of thirty-seven (37) sampled residents (Resident #60). Resident #60 fell on [DATE] at 4:15 AM, which resulted in a fracture to the resident's right shoulder. The findings include: Review of the facility's policy titled, Comprehensive Care Plan, revised 07/19/18, revealed staff's assessments of the resident reflected the needs of the resident and presented the guide to complete an individualized care plan for residents. Review revealed the resident's care plan included the identified risks and problems which the facility developed the care plan. Review of the policy revealed the resident's interventions addressed the identified problems. Further review revealed the facility was to revise residents' care plans as necessary and to reflect changes in a resident's condition. The facility identified the risk of falls for Resident #60, on 07/08/19. Review of the facility's policy titled, Falls, revised 11/06/19, revealed the facility-assessed residents on admission, quarterly, and as needed for the risk of a fall. The goal included to minimize the risk of resident falls and related injuries. Continued review revealed the facility developed fall interventions for the individual resident to decrease the risks for the areas identified. The facility developed a fall's call plan, on 07/08/19, with the indication of Dementia as one of the factors for the resident's fall risk. Review of the facility's policy titled, Aspects of Care, undated, revealed the facility's clinical care services responsibilities included implementation of specific measures to prevent complications and maintain a resident's safety, which included falls. Review of Resident #60's clinical record revealed the facility admitted the resident, on 01/09/19, with diagnoses, which included Dementia, Muscle Weakness, and the History of falls. Review of Resident #60's admission Minimum Data Set (MDS) Assessment, dated 01/09/19, revealed the facility assessed the resident with a history of falls, as the resident had a fall which resulted in a fracture one month prior to admission. The resident used a walker or wheelchair for mobility and required transfers with an extensive two (2) person assist which included bed mobility, and toilet use. Further review revealed the facility assessed the resident's cognition with the Brief Interview for Mental Status (BIMS) assessment and scored the resident as a five (5) out of fifteen (15), which indicated the resident had severe cognitive impairment. However, the facility's initial care plan did not include falls or fall risk as a problem after completion of the MDS assessment, which included the documented history of a fall with fracture, cognition, and the extent of assistance for care needs. Continued review revealed, on 07/23/19, the facility completed a Quarterly MDS assessment and identified one (1) fall after admission. The resident continued to have severe cognitive impairment with an assessment score of zero (0). Further review revealed the resident's admission assessment included the resident's fall before admission, which resulted in a fracture. Record review revealed the facility initiated a fall's care plan on 07/08/19. The facility initiated the care plan for the resident six (6) months after admission, even though the facility assessed the resident to have severe cognitive impairment, extensive assist needs, and history of falls before admission. Review of Resident #60's fall's care plan revealed the facility initiated the care plan on 07/08/19. The fall interventions included to assist with ambulation, report fall to provider and family, when in wheelchair place in a common area, refer to therapy, and encourage activity participation to increase strength. Continued review of the fall care plan revealed to further prevent a fall, the interventions included to have the call light within reach, to rise in a slow manner, and rest before a transfer, to keep the area free of clutter, and glare free light. Further review revealed on 08/12/19, the facility added the interventions to use the call light to request help prior to transfer, to observe the resident's use of adaptive devices, teach the resident safety to reduce the fall risk and what to do if a fall occurred. However, the facility's assessments identified the resident with severe cognitive impairment, and extensive assist with all care needs, and he/she did not walk. The facility failed to ensure the interventions reflected the resident's cognitive impairment and functional ability. Review of Resident #60's Quarterly Fall Risk Assessment, dated 01/24/2020, revealed the facility identified risk factors as age (3 points), incontinence (2 points), unsteady gate (2 points), and an altered awareness of environment (1 point) as risk factors. Further review revealed a score of ten (10) which indicated a moderate risk for falls. However, record review revealed the resident's history included falls before admission (5 points) and the use of an antidepressant, which the side effect included sedation or increased confusion (3 points). The assessment form instructions included to choose all areas which applied to the resident's mobility, which included transfer assistance and unsteady gait (4 total points), an altered awareness of environment and lack of understanding of physical and cognitive limitations (5 total points). With these risk factors included, the resident's score would have been twenty-two (22). In addition, the assessment's written instruction noted if the resident's history included a fall, the assessment stopped at the high-risk level of evaluation. According to the instructions, the resident's score would indicate the resident to be in the high category for the risk of falls. Further review of Resident #60's Quarterly MDS Assessment, dated 01/23/2020, revealed the facility assessed the resident as an extensive two (2) person assist with transfers, bed mobility, and toileting. The resident required one (1) person extensive assist with toilet use and hygiene. The resident required incontinent care at all times. Furthermore, the resident required one (1) person assist for transfers because of balance issues; and, the resident did not walk and used a walker or wheelchair. The facility assessed the resident's cognition as four (4) out of fifteen (15), which determined the resident remained at the level of a severely cognitive impaired resident. Review of Resident #60's Progress Note, dated 02/04/2020 at 4:15 PM, revealed the resident fell at the end of the bed on his/her back and was found on the floor. Further review revealed staff heard a cry, while they were in another room. Resident #60's fall which resulted in fractures to two areas of his/her right shoulder. Continued record review revealed the hospital determined the resident was not a candidate for repair of the fracture due to the resident's age and frail condition. Observation of Resident #60 on 03/01/2020 at 10:39 AM, revealed the resident's call bell was on the resident's right side by his/her hip while in bed. Observation at 2:42 PM revealed the call bell was on the resident's right side on his/her lap. However, the resident's fracture to the right shoulder resulted in his/her arm immobilized in a sling and he/she was unable to access the call bell for assistance. Staff's placement of the call bell and the resident's cognitive ability, did not allow the resident to use the call light for assistance, as care planned. Interview with Family #1, on 03/04/2020 at 11:39 AM, revealed Resident #60 remained confused since he/she came to the facility. The family stated Resident #60 fell at home, which caused the resident's admission to the facility. Family Member #1 stated the resident had a fell in the facility after the admission to the facility. Continued interview with the family revealed Resident #60's roommate activated the call bell or called for assistance for the resident because he/she did not understand how to use the call bell. The family described the resident's overall needs as incontinent of bowel at all times, unsteady, and unable to walk. The family stated the resident used a wheelchair for locomotion after staff assisted him/her to stand and turn. During further interview, the family stated the resident complained of pain from the fall with every visit. The family stated the facility should have known the resident could fall because the resident fell frequently at home which required him/her to come and live at the facility. He further stated he/she wanted the resident to be safe and the main reason he/she kept the resident at the facility. Interview with CNA #10, on 03/03/20 at 2:40 PM, revealed staff were to review the aide care binder for interventions for resident care. However, the binder did not identify the resident's level of fall risk. She stated the use of a call bell to call for assistance was a normal intervention. However, she stated residents with memory issues did not remember to use the call bell or, not to get up without help because they were confused. Interview with CNA #8, on 03/05/2020 at 3:37 PM, revealed resident care plans provided the care and level of care needs for the aides and nurses. She stated that the residents required specific interventions for their level of care and ability. CNA #8 stated Resident #60 required full assist with all needs except to feed himself/herself, but he/she required supervisor with meals. She further stated when residents required care in all areas, she considered the resident a higher risk for a fall. Further interview revealed CNA #8 worked the day, the resident fell in the early am and broke his/her arm. She stated she and the nurse found the resident on the floor after hearing an unidentified cry on the unit. Interview with Licensed Practical Nurse (LPN) #3, on 03/05/2020 at 2:17 PM, revealed Resident #60's care included transfer and toileting assistance. She stated the resident had not had a fall in the facility before 02/04/2020. LPN #3 stated all residents required a care plan that included the needs of the resident's level of care. She stated Resident #60's care plan included to use the call bell for help and the cause of the resident's fall. LPN #3 stated the resident did not call or wait for help. However, LPN #3 stated the resident's diagnoses included Dementia and the resident may not know how to use the call bell. The LPN stated the resident's memory came and went depending on the day. She stated the care plan process was initiated at admission, which included the reason for the admission as well as the identified care areas. LPN #3 stated, Resident #60's care plan reflected appropriate interventions for the resident's fall risk before and after his/her fall. She stated the facility initiated the fall's care plan after a fall, although the resident's admission history included a fall. The LPN stated Resident #60's CCP did not include specific interventions for falls to meet the need of the resident, who has Dementia; and the facility assessed to have severe cognitive impairment; and, extensive assist with all care needs. Review of the clinical record revealed the facility did not initiate an individualized CCP to reflect the resident's needs. Interview with the Minimum Data Set (MDS) Coordinator, on 03/05/20202 at 3:53 PM, revealed the facility completed a CCP with review of all clinical information at admission, with interviews, and observations of the resident. She stated the initial CCP reflected the resident's history, admission, and current needs to complete care and maintain the resident's safety in the facility. She stated staff followed care plans to meet the resident's needs. She further stated any resident whose admission included a fall prior to admission required the start of a care plan for falls. The MDS Coordinator further stated the facility expected the care plans to reflect the resident's care needs. However, the resident's care plan did not reflect the initiation of a fall's care plan upon admission. Interview on 03/05/2020 at 1:12 PM and 3:02 PM, with Assistant Director of Nursing (ADON) #1, revealed the facility's process on admission included numerous areas of assessments to initiate the resident's CCP. She stated any known history of a resident's fall risk meant the facility initiated the fall's risk on the admission CCP. The ADON stated the residents' care plans reflected the needs of the residents and she expected staff to follow all interventions. In addition, she stated she did not complete audits of the residents' care plans to determine if the interventions were appropriate for the resident's needs. She stated if the resident's CCP did not meet the need of the resident, then the resident would not receive the care required and put the resident at risk. Interview on 03/05/2020 at 4:07 PM, with the Director of Nursing (DON), revealed the facility-implemented interventions, which the assessor individualized to the resident. She stated she expected staff to follow the initial care plan and report needs to change interventions to reflect the resident. The DON stated the facility initiated and continued an adequate plan of care for Resident #60's risk of falls, before the 02/04/2020 fall and after the fall. She stated the nurses or ADON's completed the fall risk assessments and she did not know why the resident's fall assessments before and after the resident's fall scored into the moderate fall risk. Further interview with the DON revealed the fall on 02/04/2020, had been the resident's first fall while in the facility. The DON stated she rounded on residents on the units to evaluate if the care plans reflected the resident's need; and Resident #60's care plan reflected his/her required needs. However, after review of the resident's record of previous falls, fall risk assessments, and cognition assessments, with the State Survey Agency, the DON stated the resident's cognition might play a factor. She stated education of the resident to use the call bell for staff assistance; to teach the resident safety, and what to do in case of a fall might not be appropriate. She stated the resident's cognition came and went so some days the interventions may not be appropriate In addition, she stated her expectations included staff to implement the interventions in place, and notify her if the interventions required revisions. She stated the facility's responsibility included to ensure the resident's care plan reflected interventions to support the resident's care needs and safety. However, Resident #60's initial care plan did not reflect a fall risk focus related to his/her severe cognition and the diagnosis of a fall, which the facility identified on the admission assessment on 01/09/19. In addition, the facility initiated a care plan focus for falls after the resident fell, on 07/08/2019, six (6) months after admission, which the interventions did not meet the individual cognitive level to prevent falls, as the facility assessed the resident to have poor short-term memory. Interview on 03/05/2020 at 5:52 PM with the Administrator, revealed the facility had self-identified issues with residents' care plans previously. He stated the identified issues included the lack of individualized interventions for residents' care plans. The Administrator stated the facility's responsibility included to ensure fall care plans and care plans in general met the need of the resident and were effective for the residents. He stated the IDT met to discuss new residents and the MDS Coordinator attended the meeting. Continued interview revealed the IDT team did not identify issues with Resident #60's care plan after the resident's fall. The Administrator stated Resident #60 was independent with most of his/her care needs, and transferred out of bed on 02/04/2020 without requested assistance from staff, as the staff previously educated and reminded the resident to do. However, record review revealed the facility assessed the resident to require the extensive assistance with care needs related to Dementia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to revise a resident's plan of care with interventions to prevent further falls for one (1) of thirty-seven (37) sampled residents (Resident #60). The findings include: Review of the facility's policy titled, Comprehensive Care Plan, revised 07/19/18, revealed the facility was to revise residents' care plans as necessary and to reflect changes in a resident's condition. Review of the facility's policy titled, Falls, revised 11/06/19, revealed the facility-completed residents' fall risk assessments quarterly and with a change of condition. The facility revised the care plan with necessary and appropriate interventions for the resident. Further review revealed the facility's Interdisciplinary Team (IDT) determined the root cause of a resident's fall and would initiate new interventions for the resident. Review of the facility's policy titled, Aspects of Care, undated, revealed the facility's clinical care services implemented specific interventions to maintain a resident's safety. Review of the John Hopkins Fall Risk Assessment tool, dated 2007, revealed the tool assisted facilities with the assessment of a resident's risk for a fall. The tool noted a resident would remain a high risk for falls when the history included a fall before or after facility admission. The facility used the assessment to review and revise the resident's care plan. Review of Resident #60's clinical record revealed the facility admitted the resident, on 01/09/19, with the diagnoses, of Dementia, Muscle Weakness, and the history of falls. Review of hospital discharge records revealed the resident's admission to the hospital included a fall at home on [DATE], which resulted in the fracture of the pubic bone. Review of Resident #60's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility noted under Section J, one (1) fall since admission to the facility. Review of Resident #60's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with the Brief Interview for Mental Status (BIMS) with a score of four (4) out of fifteen (15), which indicated the resident had severe cognitive impairment. Further review revealed the facility assessed Resident #60's functional status as an extensive one-person assist transfer due to unsteadiness and incontinent at all times. Review of the resident's care plan revealed the facility did not make revision changes to the fall care plan with new interventions to prevent falls. Review of the facility's Quarterly Fall Risk Assessment for Resident #60, dated 01/24/2020, revealed the facility assessed him/her as a moderate risk for falls with a score of ten (10). Review of Resident #60's assessment completed by the facility revealed risk factors that included age, incontinence, unsteady gait, altered awareness, and the need for assistance with ambulation. The clinical record indicated an admission with a fall and a fall in the facility, which would indicate a high risk for a fall. The resident's care plan did not include a revision for individualized interventions for the identified high fall risk. Review of Resident #60's fall care plan, initiated 07/08/19, revealed the facility initiated a care plan for falls. The fall interventions included to assist with ambulation, report fall to provider and family, when in wheelchair place in a common area, refer to therapy, and encourage activity participation to increase strength. Continued review of the fall care plan revealed to further prevent a fall, the facility included to have the call light within reach, to rise in a slow manner, and rest before a transfer, to keep the area free of clutter, and glare free light. Further review revealed on 08/12/19, the facility added the interventions to use the call light to request help prior to transfer, to observe the resident's use of adaptive devices, teach the resident safety to reduce fall risk and what to do if a fall occurred. However, the facility's assessments identified the resident with severe cognitive impairment, and extensive assist with all care needs, and he/she did not walk. The interventions, the facility care planned did not reflect the resident's cognitive impairment and functional ability for the resident's fall risk. Interview with Licensed Practical Nurse (LPN) #3, on 03/05/2020 at 2:17 PM, revealed Resident #60 fell on [DATE] when he/she attempted to go to the bathroom alone. She stated staff did not know the resident had gotten up out of bed until they found him/her on the floor with a broken shoulder. She stated the facility determined the resident did not request assistance as the reason for the fall. She stated the resident's diagnoses included Dementia, which caused memory issues. LPN #3 stated the resident's memory effected his/her ability to remember safety, or how to use the call bell. She stated the clinical team determined the revision to the care plan after review of the investigation. However, she stated the facility did not notify her of any revised interventions for the resident to prevent falls. She stated if the resident got up out of bed, unless someone was nearby or in the room, staff would not know the resident was trying to get up out of bed. She stated the care plan should reflect the needs of the resident. LPN #3 stated the facility did not revise the care plan to address the resident's new fall with appropriate intervention for the resident's cognition, the use of his/her right arm, which increased the resident's unsteady balance, or the transfer of the resident without staff's knowledge's with appropriate interventions to prevent a fall. Interview with Certified Nurse Aide (CNA) #8, on 03/05/2020 at 3:37 PM, revealed the resident had a fell on the floor on 02/04/2020 when he/she attempted to go to the bathroom without staff assistance. She stated the resident did not toilet or ambulate by himself/herself and this attempt to the bathroom was the first time the resident attempted. CNA #8 stated she did not know the resident got up out of bed until she heard a resident cry out. She stated the resident broke his/her arm when he/she fell. She stated Resident #60 required full assist with except to feed him/herself. CNA #8 stated the resident did not have fall prevention interventions on his/her care plan and, she did not receive report of revisions to the care plan to address the resident's fall. Interview with Family #1, on 03/04/2020 at 11:39 AM, revealed Resident #60 fell at home, which caused the resident's admission to the facility. The family member stated the resident also fell in the facility after the admission. Continued interview with Family Member #1 revealed Resident #60's roommate activated the call bell or called, and/or assisted the resident because of his/her confusion, and Dementia. Further interview revealed the resident did not understand how to use the call bell. The family member stated the resident did not walk and used a wheelchair for locomotion around the facility. Family Member #1 stated the resident was unable to stand and turn without help. The family member stated the facility should have known the resident could fall again because the resident fell at home and fell again in the facility. He further stated he/she wanted the resident to be safe at the facility. Family Member #1 further stated the facility requested permission to use an alarm for the bed, which he observed on the resident's bed. However, it was the last time he saw the use of the bed alarm and he did not know of any other way they decided to know if the resident got out of bed. Review of Resident #60's Fall Risk Assessment, dated 02/05/2020, revealed the facility assessed the fall risk level after the resident's fall with a fracture. The facility assessed the resident with the score of thirteen (13) which indicated the resident remained a moderate fall risk. The assessment instructions indicated the resident was a high fall risk and not a moderate risk of fall. However, the facility did not revise the care plan to reflect the known risks and place interventions to address the risks to prevent falls. The facility failed to follow its policy to revise the care plan. Continued review of Resident #60's fall care plan, initiated 07/08/19, revealed the care plan revision did not reflect the date of the resident's fall and the type of the injury. In addition, the facility assessed Resident #60 with severe cognitive impairment for short-term memory and the facility did not revise the care plan to address the resident's fall, or to address the level of severe cognition with interventions for the level of impairment to prevent further falls, as they should have per policy. Interview with the Assistant Director of Nursing (ADON) #1, on 03/05/2020 at 3:02 PM, revealed the facility's process was for the Director of Nursing (DON) to review residents' care plans, during the investigation, and make revisions necessary to prevent falls. She stated the clinical team recommended revisions to the care plan, with incidents and change of condition; and, with review of the investigation to determine the root cause of the fall. She stated care plan revisions included specific and individual interventions identified by the clinical team to prevent another fall for a resident. Interview on 03/05/2020 at 4:07 PM, with the Director of Nursing (DON), revealed staff revised residents' care plans after a fall with new interventions to prevent further falls. She stated the facility rounded every two hours for check and change Resident #60, as a revision to prevent further falls. She stated the facility determined the resident fell because he/she did not ask for assistance up out of bed to toilet. The DON stated Dementia caused memory issues and the resident's diagnoses included dementia. She stated the resident's care plan revision did not include appropriate interventions for a resident with dementia. The DON stated the facility's interventions for Resident 60, whose diagnoses included dementia, included retrain/education on safety, what to do when a fall occurred, to use the call bell, and to wait for staffs help. She stated those interventions for this resident were not appropriate. She stated the facility's responsibilities included to ensure the residents were safe in the facility, which included revisions to the care plan with interventions appropriate to the resident's condition and needs. Interview on 03/05/2020 at 5:52 PM with the Administrator, revealed the facility had self-identified issues with residents' care plans. He stated the facility-identified issues included that the residents' care plans needed to have individualized interventions and to ensure the care plan interventions reflected the specific needs and effective.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide adequate supervision, complete a thorough investigation to determine the root cause, and develop effective interventions to prevent further falls for one (1) of thirty-seven (37) sampled residents (Resident #60). Resident #60, who had a history of falls, sustained another fall on 02/04/2020 at 4:15 AM. When Resident #60 experienced the fall, the only nurse and aide assigned to his/her care were in another resident's room providing wound care. At the time of the fall, thirty-one (31) residents resided on Resident #60's unit, with the one (1) nurse and one (1) aide to provide resident care. Resident #60's fall resulted in transfer of the resident to the hospital emergency room (ER). The ER diagnosed the resident with a right shoulder fracture, with constant unrelieved pain. Additionally, the Director of Nursing's (DON's) fall investigation failed to include interviews with all staff present at the time of the fall to assist in determining the root cause of the fall. The DON also failed to ensure the revision of Resident #60's fall care plan to include necessary and appropriate interventions. In addition, the DON failed to document accurate information related to Resident #60's fall on the facility's investigation when finalized. The findings include: Review of the facility's policy titled, Falls, revised 11/06/2019, revealed the facility minimized the risk of falls, and fall related injuries with staff's assistance and supervision. Per policy review, the facility completed residents' fall risk assessment quarterly, with a change of condition, and included interventions appropriate to the resident. Further review revealed the facility's Interdisciplinary Team (IDT) was to determine the root cause of residents' falls as part of the investigation with initiation of new interventions for the resident. Review of the facility's policy titled, Accidents and Incidents Investigating Reporting, revised 11/06/2019, revealed the facility's investigation of incidents included documentation of the investigation performed. Review of the facility's policy titled, Pain Management, revised 11/06/2019, revealed the facility's commitment for residents' pain control included attaining and maintaining the highest reasonable level of pain control for the resident's well-being. Review of the facility's policy titled, Aspects of Care, undated, revealed clinical care services' responsibilities included implementation of specific measures to prevent complications and maintain a resident's safety. The policy review revealed the goal of clinical services was to maintain the resident's well-being and ensure quality of life. Review of the Facility Assessment document, dated 2020, revealed the facility accepted cognitively impaired residents, including residents with Dementia. Per review of the document, the facility assessed its staffing needs for its resident units to ensure staffing was sufficient. Further review revealed the Assessment document included the staffing for the facility's night shift, 7:00 PM to 7:00 AM, was to be two (2) nurses and two (2) aides. Review of the Facility Schedule document, dated 02/03/2020, revealed the facility scheduled for the 7:00 PM to 7:00 AM, night shift staff, after 12:00 AM on 02/04/2020, only one (1) aide and one (1) nurse providing care for the thirty-one (31) residents residing on Resident #60's unit. Review of Resident #60's clinical record revealed the facility admitted the resident, on 01/09/19, with the diagnoses of Dementia, a history of falls, and Muscle Weakness. Review of the facility's Quarterly Minimum Data Set (MDS) Assessment for Resident #60, dated 01/23/2020, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15), indicating he/she was severely cognitively impaired and not considered interviewable. Further review revealed the facility assessed Resident #60 as unsteady and to require extensive one (1) person assist. In addition, review of the MDS revealed the facility also assessed Resident #60 as always incontinent of bowel and bladder, and without pain. Review of the facility's Fall Risk Assessment document for Resident #60, dated 10/23/19, revealed the facility utilized the John Hopkins Fall Risk Assessment Tool for its assessment. The document revealed a score greater than thirteen (13) was indicative of being a high risk for falls. Continued review revealed the facility assessed Resident #60 to have a total score of twenty-one (21), making the resident a high risk for falls. Further review revealed the facility identified risk factors for Resident #60, which included a previous fall within six (6) months, incontinence, and use of a high-risk medication (anti-depressant). In addition, review revealed other risk factors, which placed Resident #60 at high risk for falls included 1.) If the resident required assistance; 2.) needed supervision with transfer and ambulation, 3.) if he/she had an unsteady gait, and 4.) if he/she had an altered awareness. Review of the John Hopkins Fall Risk Assessment tool, dated 2007, revealed the tool instructions for high-risk for falls category residents included: residents with a known history of falls before admission; during admission; or after a readmission. Further review revealed the total score of the assessment determined a resident's level of risk for falls. The score categories included six (6) to thirteen (13) as moderate risk, and higher than thirteen (13) denoted the resident was at high risk for falls. Review of the facility's Fall Risk Assessment for Resident #60, dated 01/24/2020, revealed the facility assessed the resident as a moderate risk for falls with a score of ten (10), even though he/she had a history falls. Further review revealed staff identified the risk factors for Resident #60 included: the resident's age, incontinence, unsteady gait, altered awareness, and need for assistance with ambulation. Review of the Nurse's Note, dated 02/04/2020 at 4:15 AM, revealed Licensed Practical Nurse (LPN) #3 documented Resident #60 was found lying on the floor, clutching his/her right shoulder, and telling staff his/her shoulder was broken. Per review, the LPN observed Resident #60's shoulder looked displaced, with a bump under the shoulder skin. Continued review revealed staff concluded Resident #60 had broken his/her right shoulder based on the observation. The Note stated Resident #60 cried out in pain while lying on the floor and continually guarded his/her shoulder with the left arm. Review of the Note revealed the LPN noted that she was unable to complete a bilateral upper extremity assessment on Resident #60 due to the resident's pain. Further review revealed the LPN had Emergency Medical Technicians (EMT's), who were present in the facility at that time, transport Resident #60 immediately to the hospital ER. In addition, review revealed the LPN notified the Physician prior to the EMT's transporting Resident #60 to obtain an order to do so immediately. Review of the Hospital admission ER records, dated 02/04/2020 at 6:00 AM, revealed the ER Physician had ordered an x-ray of Resident #60's right shoulder. Review revealed the x-ray was completed, and the results noted fractures located in Resident #60's right shoulder area. Continued review revealed Resident #60 was diagnosed with a fracture of the neck of the right humerus (long arm bone). Per review, at 11:11 AM, the Physician/Provider noted Resident #60 was to return to the facility after completion of the surgery. Further review revealed Resident #60 was to use a cradle sling at all times, and was to have the application of ice to his/her right shoulder. Continued review revealed the recommendation for Resident #60 to have Tramadol (narcotic pain medication) or Hydrocodone (narcotic pain medications) was ordered for his/her pain control. Review of the Nurse's Note, dated 02/04/2020 at 4:15 PM, revealed Resident #60 returned to the facility with a cradle sling in place to his/her right arm. Interview with LPN #3, on 03/05/2020 at 2:17 PM, revealed staff completed a full assessment after Resident #60 sustained the fall, with the exception of being able to assess the resident's left and right shoulder and arms due to the severe pain he/she was experiencing. She stated her observations during her assessment revealed Resident #60's right shoulder was clearly broken. Further interview revealed with observation of the resident's intense pain she had not attempted assessment of the resident's bilateral arms to check for Range of Motion (ROM), as she had not wanted to cause further harm or pain. Review of the facility's Event Report document, revealed staff had completed the event evaluation for Resident #60's fall sustained on 02/04/2020. Continued review of the document revealed the event evaluation was closed on paper on 02/07/2020, and completely closed out on 02/12/2020. Review of the Event Report evaluation notes revealed they included the information regarding the evaluation of Resident #60 in the hospital ER. Further review revealed the ER evaluation of Resident #60 was noted as no major injury for the resident and his/her pain associated with the event (fall) was noted as resolved. Observation, on 03/01/2020 at 10:39 AM, revealed Resident #60's shoulder sling was bunched up above his/her shoulder around the resident's mouth, and his/her call bell was lying at his/her right knee, inaccessible due the fractured right shoulder. Continued observation at 2:42 PM, revealed Resident #60's shoulder sling was loose and once again, bunched up around the resident's neck. In addition, Resident #60's call bell was still located on his/her right side and inaccessible to the resident. Further review of the Fall Risk Assessments for Resident #60 revealed the facility re-assessed the resident's fall risk, on 02/05/2020 at 5:23 PM, after the fall sustained on 02/04/2020. Further review revealed the facility continued assessing the resident as a moderate risk for falls, even though he/she had a history of falls, and had just experienced another fall, with injury. Review of the facility's Quarterly MDS Assessment for Resident #60, dated 02/11/2020, seven (7) days after his/her fall on 02/04/2020, revealed the facility assessed the resident to now require two (2) person assist with all transfers and toileting. Further review of the MDS revealed the facility assessed the resident to now have frequent pain, with a pain intensity score of eight (8) on a scale of zero (0) to ten (10), indicating severe pain. Review of Resident #60's Physician Orders (PO) revealed on 02/04/2020, the facility called the Physician to obtain pain medication orders for the resident's complaints of pain. Further review revealed Resident #60 returned to the facility from the ER with recommendations for Tramadol (a narcotic pain medication) every six (6) hours as needed (PRN). Per review, the Physician ordered Tramadol scheduled every six (6) hours for pain for Resident #60, as recommended. Review of Resident's 60's Medication Administration Record (MAR), dated 02/04/2020 through 03/03/2020, revealed, as he/she was non-verbal and unable to describe his/her pain, nursing staff used a non-verbal pain scale to assess the resident's pain level. Per review, nursing staff documented Resident #60's pain level ranged from moderate to severe. Continued review of the MAR revealed nursing staff referenced Resident #60's fractured right shoulder as the source of his/her moderate to severe pain. In addition, review revealed nursing staff had administered Resident #60's scheduled Tramadol every six (6) hours with no missed doses. Further review revealed prior to the fall on 02/04/2020, Resident #60's Physician's Orders included Tylenol (a non-narcotic pain medication) 250 milligrams (mgs), two (2) tablets as needed for pain every six (6) hours, which nursing staff had rarely administered for pain prior to 02/04/2020. However, further review of Resident #60's MAR revealed on 02/05/2020, staff obtained an order for the resident's breakthrough pain. Review of Physician's Orders revealed the Physician ordered Tylenol 250 milligram (mg), two (2) tablets every four (4) hours for breakthrough pain (a sudden increase in pain lasting a short time, which usually requires addition of further pain medication). Further review of the MAR revealed the Tylenol order documented as ordered. Further review of Resident #60's Comprehensive Care Plan revealed no documented evidence of the revision of the care plan after the resident's fall to implement additional interventions related to his/her care needs post fall. In addition, review revealed no documented evidence the care plan was revised to include Resident #60's use of Tramadol pain medications, the change in his/her Tylenol order, or for the use of the shoulder sling. Observation, on 03/02/2020 at 9:46 AM, revealed Resident #60 was in a wheelchair and was being transported back to his/her room after therapy by the Rehabilitation (Rehab) Manager. Continued observation revealed the Rehab Manager parked Resident #60 in his/her wheelchair at the room door entryway. Observation revealed the Rehab Manager educated staff on how to properly place Resident #60's sling on his/her right shoulder/arm area. Per observation, the Rehab Manager explained to Resident #60 he/she had completed therapy for strengthening, and told the resident someone would be in to put him/her to bed. Continued observation revealed Resident #60 told the Rehab Manager his/her arm hurt. Observation revealed the Rehab Manager informed Resident #60 he/she received scheduled pain medications, and the Rehab Manager left the resident's room. Further observation revealed Resident #60 was grimacing, holding his/her right shoulder/arm area, and attempting to shift himself/herself in the wheelchair. Observation further revealed nursing staff passed Resident #60, without addressing the resident or his/her observed grimaces of pain. In addition, observation revealed Resident #60 remained sitting up in the wheelchair, grimacing, for eleven (11) minutes after the Rehab Manager left him/her, until 9:58 AM, when CNA #10 wheeled the resident to the activity room. Additional observation, on 03/02/2020 at 2:45 PM, revealed Resident #60 lying on his/her bed, and not observed in the lowest height position. Observation further revealed Resident #60's call bell was clipped to the cord on the wall, out of reach and inaccessible to the resident. Interview with Licensed Practical Nurse (LPN) #1, on 03/02/2020 at 1:10 PM, revealed the Rehab Manager had not reported Resident #60's complaints of pain that morning to her. She stated Resident #60's pain relief regimen included scheduled pain medication administered every six (6) hours, at 6:00 AM, 12:00 PM, 6:00 PM, and 12:00 AM. Per interview however, Resident #60 did not have as needed (PRN) pain medications ordered for any breakthrough pain. She further stated she did not receive notification on 3/04/2020 after completion of therapy of complaints of pain by the resident. Therefore, she did not provide Resident #60 with non-medicated nursing interventions to alleviate his/her pain during the morning hours of her shift. Observation, on 03/03/2020 at 9:47 AM, revealed Resident #60 was lying on the bed with the call bell placed to the right side of the bed, near his/her fractured right shoulder and inaccessible to him/her. Continued observation at 3:30 PM, revealed Resident #60 remained in bed with the call bell off the bed, and again inaccessible to the resident. Interview with CNA #10, on 03/03/20 at 2:40 PM, revealed staff were to review the aide care binder for interventions to provide for fall risk residents. Further interview revealed interventions for fall risk residents included things like: making sure the resident's call light was within reach for his/her use at all times; making increased and frequent rounds; offering assistance as needed; and reminding the resident to call for assistance. Interview with Family #1, on 03/04/2020 at 11:39 AM, revealed Resident #60 was alert; however, always confused. The family member stated Resident #60 had fallen at home and while at the facility. Per interview, Resident #60's roommate called for assistance for the resident because he/she did not understand how to use the call bell. According to Family #1, when visiting they had observed Resident #60's arm sling loose and up around the resident's neck. The family member stated Resident #60 complained of pain at every visit, and always appeared to be pain while the family was there. Continued interview revealed Resident #60 was always incontinent of bowel and bladder; unsteady when standing; unable to walk; and used a wheelchair for locomotion. The family member stated when they visited Resident #60 staff never entered the room to check on the resident. Additionally, Family #1 stated it upset the family to have Resident #60 experiencing so much pain with the broken shoulder. Interview with CNA #8, on 03/05/2020 at 3:37 PM, revealed the scheduled staff for night shift after midnight, included only one (1) CNA and one (1) nurse for each of the facility's units. She stated Resident #60 required staff to check on him/her every two (2) hours due to being incontinent and not using the toilet. Continued interview revealed staff performed scheduled rounds every two (2) hours, which included documenting the care provided during rounds in the computer. CNA #8 stated Resident #60 required at least one (1) person assist for all of his/her care needs and transfers. Per interview, on 02/04/2020 LPN #3 needed assistance with another resident to complete wound care. The CNA stated when she assisted LPN #3 in another resident's room, Resident #60 sustained the fall. Interview revealed she had heard a resident yell for help while she was assisting LPN #3 in the other resident's room. Per CNA #8, when she left LPN #3, she found Resident #60 on the floor in his/her room, lying on his/her back, and crying out with complaints of arm pain. She stated Resident #60 was saying he/she had broken his/her arm. Further interview revealed the facility really didn't have any fall interventions in place for Resident #60 before the fall. CNA #8 further stated LPN #3 updated Resident #60's care plan immediately after the fall to have staff offer or take the resident to the toilet every two (2) hours during their rounds. In addition, she stated the facility's Nursing Administration had not interviewed her or asked her for a written statement regarding the circumstances of Resident #60's fall on 02/04/2020. Review of Resident #60's Point of Care (POC) CNA documentation, for 02/03/2020 at 11:07 PM, revealed CNA #5 had documented an episode of the resident being incontinent of bladder and bowel. Continued review revealed staff documented Resident #60 required total assistance with all care. Further review revealed no documented evidence of entries by CNA #5 or other staff after 11:07 PM on 02/03/2020, to the time the resident sustained the fall on 02/04/2020 at 4:15 AM, almost five (5) hours later. Interview, on 03/05/2020 at 2:17 PM with LPN #3, revealed CNA #8 worked with her on 02/04/2020, when Resident #60 experienced the fall at 4:15 AM. She stated the EMS (Emergency Medical System) transported Resident #60 to the ER approximately fifteen (15) minutes after the fall. Per the LPN, after midnight the facility only scheduled one (1) nurse and (1) one CNA to provide resident care on the units. LPN #3 stated staff were to put eyes on residents, by checking them every two (2) hours at night for incontinence, and reposition them as needed. LPN #3 stated put eyes, meant as staff walked the hall they looked into the rooms as they passed to observe the residents well-being. She stated the aides responsibilities included documenting on the residents after the every two (2) hour rounds were completed. Continued interview with LPN #3 on 03/05/2020, at 2:17 PM revealed she had required CNA #8's assistance with repositioning one (1) of the other residents on her unit in order to complete that resident's ordered treatment. Per LPN #3, on 02/04/2020, as CNA #8 was assisting her with repositioning the other resident in his/her room, they heard another resident yell for help. According to LPN #3, when CNA #8 left the room to see who needed help, the CNAfound Resident #60 lying on the floor by the bed in his/her room. LPN #3 stated CNA #8 observed Resident #60 holding onto his/her right shoulder. The LPN stated when she entered Resident #60's room, she found the resident in the same position as CNA #8 had found him/her. Per the LPN, Resident #60 was crying and stating his/her, shoulder was broken. Interview revealed upon assessment the resident's right shoulder appeared displaced under the skin. LPN #3 revealed she completed her assessment of Resident #60, SHOULD BE #60?? and notified emergency services. She stated Resident #60 slept throughout the night after staff placed him/her in bed and resident never attempted to self-transfer out of his/her bed since she worked at the facility. Per LPN #3, the Unit Manager (UM), and DON came to the unit later in the morning on 02/04/2020, and she reported the events of Resident #60's fall to them. According to the LPN, after providing that information, no one from the facility's administration staff had requested any further information or other documentation related to the resident's fall from her. During the interview with LPN #3, she stated Resident #60 stated, after the fall, that he/she had gotten up to attempt to go to the bathroom. She stated she initiated a new intervention for Resident #60, after the resident was transferred to the ER, for staff to perform every two (2) hour checks of Resident #60, and offer to toilet the resident if he/she was not wet. Per LPN #3, her reasoning for initiating the new intervention to offer to toilet Resident #60 if he/she was dry, was due to the resident telling staff he/she had been trying to go to the bathroom when the fall occurred. However, she stated the resident never previously requested to be toileted. The LPN stated the facility always scheduled minimal staff on night shift, and other facility staff called night shift the skeleton crew. Per LPN #3, approximately thirty (30) residents resided on the same unit as Resident #60, and she had to assist the one (1) aide, when she had time to do so, with performing the every two (2) hour rounds on her assigned residents. LPN #3 further revealed she also checked on the residents when she walked up and down the hallways of her unit during her shift. She stated staff kept residents' room lights off in their rooms at night, and used the hallway lights to observe the residents with their doors open. According to the LPN, the facility educated staff on fall prevention and the education included: staff checking on residents often; providing every two (2) hour check and change rounds; ensuring beds were in the lowest position; and to ensure residents' call bells were within reach at all times. She further stated the risk of injury and pain occurred anytime a resident sustained a fall, and it was staff's responsibility to ensure the safety of all residents. Review of the Fall Investigation document, dated 02/04/2020 at 4:15 AM, revealed the description of the event noted Resident #60 had attempted to self-transfer from his/her bed to the bathroom without assistance. Review revealed the interventions marked as in place at the time of the fall included the resident's call light being within reach and adequate light. Continued review revealed the contributing factors to the fall included muscle weakness for Resident #60. Further review revealed the root cause was determined to have been that Resident #60 needed assistance with transfers. In addition, the immediate interventions initiated by LPN #3 included staff to check on Resident #60 every two (2) to three (3) hours to check and change him/her if incontinent, and if dry to offer to toilet the resident. Interview with the Assistant Director of Nursing (ADON) #1, on 03/05/2020 at 1:12 PM, revealed the facility's policy for resident care and services included staff to check residents every two (2) hours, and toilet or change the resident's brief during the checks. She stated the facility expected the aides to chart every two (2) hours on residents who required care assistance. Continued interview at 3:02 PM revealed, the facility monitored fall risk residents by having staff perform room rounds every two (2) hours, and she monitored staff to ensure completion of resident care interventions through her daily walking rounds. According to the ADON, she also reviewed residents' care plans, which she carried with her during her walking rounds to assist with her monitoring of staff. Per interview, staff reported off to each other at shift change regarding residents who were a fall risk and/or used an alarm, and reported off to oncoming staff the last intervention initiated for the resident. The ADON stated Resident #60 required one (1) person assistance with all his/her care needs. She stated Resident #60's night routine usually included going to bed and staying in bed until the next morning when staff assisted him/her with getting up out of bed. She stated it was unusual that the resident had attempted to go to the bathroom on 02/04/2020. According to the ADON, per facility policy, any resident fall required an investigation be performed, and was to include interviewing all staff present at the time of the fall. Further interview revealed the completed fall investigation included review of the resident's chart for medications, Nursing Notes, and care documentation as part of the complete fall investigation. In addition, she stated the facility implemented immediate interventions for a resident after a fall, and additional interventions if needed after the IDT's review of the fall. She further stated her expectations were for nursing staff to complete all resident care and document the care as required. Interview with the Director of Nursing (DON), on 03/05/2020 at 4:07 PM, revealed the facility monitored a resident's risk for falls, which included any status changes occurring in the resident. She stated an appropriate intervention for residents with Dementia would include reminding the resident to use the call bell to request assistance. (However, per interview with Resident #60's family member, the resident could not use a call bell to request assistance.) Per interview, after Resident #60 sustained the fall, in order to prevent further falls, the nurse initiated an intervention to check and change Resident #60 every two (2) hours, and toilet him/her if needed at that time. The DON stated she initiated the fall investigation, and interviewed the nurse on duty as part of her investigation. She stated she had not asked the nurse about the events, which occurred prior to the resident's fall. According to the DON however, she was aware of where staff were located on the unit when Resident #60 sustained the fall on 02/04/2020. Continued interview revealed she had not interviewed the CNA working with LPN #3, at the time of Resident #60's fall. The DON stated she had not requested the LPN and CNA submit a written summary of the events occurring before Resident #60's fall on 02/04/2020. Continued interview with the DON, on 03/05/2020 at 4:07 PM, revealed the LPN and CNA had reported that Resident #60 told them he/she was attempting to go to the bathroom when the fall occurred. Per the DON, the LPN initiated an immediate intervention post fall for Resident #60 for every two (2) hours rounds to check for incontinence, and if the resident was found dry to assist him/her to the toilet. Continued interview revealed the facility's standard of care for residents with Dementia, included providing toileting assistance with the every two (2) hour rounds performed, and staff to document the care soon after completion of the rounds. She stated she had not reviewed CNA #8's documentation to see if it had been completed the night and early morning hours before Resident #60's fall. The DON stated the lack of documentation by the CNA prior to Resident #60's fall on 02/04/2020, meant the facility had nothing to show that the resident's care was provided as required. She stated staff should ensure Resident #60's call bell position included within reach of the resident's left hand. Per the DON however, the ability of a resident, with dementia, to know what a call bell was and how to use it depended on the resident's state of mind, and he/she might not have the ability to use the call bell. The DON stated she did not know the reason Resident #60's fall risk evaluations had determined the resident to be a moderate fall risk before and after the fall on 02/04/2020. Further interview revealed she also was not aware of why the fall risk evaluation completed on 10/23/2019, had determined Resident #60 to be a high fall risk at that time. During the interview, on 03/05/2020 at 4:07 PM, with the DON, the State Surveyor reviewed the facility's Fall Investigation Event Report, dated 02/04/2020, with the DON, who had completed it. The DON acknowledged she had documented and completed the facility's Fall Investigation Event Report. She also acknowledged she had noted on the Fall Investigation Event Report document, there was adequate lighting at the time of Resident #60's fall, and she had additionally noted the resident's call light was within reach at the time of the fall. Continued interview with the DON revealed she was unaware of what light illuminated Resident #60's room the night the resident fell (02/04/2020). She stated the lighting might have come from the light in the resident's bathroom. According to the DON, the Fall Investigation Event Report had the following items not checked for the resident: impaired safety awareness; assist with transfers; and reminders for the resident to call for assistance. She stated she should have checked the areas as they applied to Resident #60's care needs. Continued interview with the DON revealed she had closed the Fall Investigation Event Report, and completed all the documentation on 02/07/2020. The DON stated in her conclusion, documented on the Fall Investigation Event Report, she noted Resident #60 had received: an evaluation in the ER; he/she had no major injury; and his/her pain was resolved. She stated she had also documented the fall prevention program as not initiated on the Fall Investigation Event Report. Per the DON, she had documented incorrect information on the facility's Fall Investigation Event Report, which she realized she now needed to go back and correct to ensure the accurate information was included. The DON further stated the IDT met after a resident's fall to review the events of the fall, and determine whether the immediate intervention initiated after the fall was adequate or not. She stated the facility's DON's and IDT's responsibilities included to complete a thorough investigation of a resident's fall, and determine the reason the fall had occurred. Additionally, she stated the facility's administrative staff had not reviewed the completed fall investigation regarding Resident #60's fall on 02/04/2020. Interview with the DON, on 03/05/2020 at 4:07 PM, revealed the facility's staffing for night shift included one (1) aide and one (1) nurse for each unit after 11:00 PM and remarked that the staffing level was a skeleton crew. The DON stated that th

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to provide necessary equipment to assist with respiratory function while the resident slept for one (1) of thirty-seven (37) sampled residents (Resident #46). The resident's representative notified the facility at admission, on 01/24/2020, of Resident #46's need for a respiratory support machine called a BiPAP (Bi-Level Positive Airway Pressure) and mask for a known chronic medical condition upon admission. On, 01/26/2020, after staff notified the resident's physician over the concern of the family's removal of oxygen and placement of the mask brought from home, the provider verbalized to order a BiPAP unit with the ability to provide Oxygen. However, the facility never ordered the machine for the resident. The findings include: Review of the Power of Attorney (POA) document for Resident #46, dated 05/09/2017, revealed Resident #46 had given his/her significant other (spouse) the ability to make medical decisions for him/her when he/she was unable to have the decisional capacity to make those decisions. Review of the contract agency's Respiratory Service Agreement, dated 08/05/2016, revealed the agency provided respiratory equipment and services for the facility, including BiPAP and CPAP (Continuous Positive Airway Pressure) units for resident use. Review of the Facility Assessment, dated 2020, revealed the facility's provision of care requirement for residents included providing CPAP and BiPAP machines as needed, ensuring sufficient staff to meet the care requirement, and to have the respiratory equipment available from the contracted company. Review of Resident #46's clinical record revealed the facility admitted the resident on 01/24/2020 with diagnoses, which included Congestive Heart Failure (CHF), Dilated Cardiomyopathy, and Parkinson's disease. Further review revealed Resident #46 was previously admitted to the facility on [DATE]. Review of Resident #46's Transition Care/Discharge summary, dated [DATE] revealed the pre-assessment data noted the resident's treatments included using a BiPAP/CPAP with oxygen. Review of Resident #46's Pre-Assessment, dated 01/23/2020, revealed BiPAP marked Yes under the pulmonary section. Review of the Nursing admission Assessment, dated 01/24/2020 at 12:09 PM, revealed Resident #46's medical history included difficulty sleeping, shortness of breath when flat in bed, and shortness of breath when he/she woke up. Further review revealed Resident #46 used a BiPAP when asleep. Review of the facility's admission Minimum Data Set (MDS) Assessment for Resident #46 dated 01/31/2020, revealed the facility assessed the resident as moderately impaired with decision making and required supervision. The assessment revealed Resident #46 experienced shortness of breath with exertion, at rest, and when lying flat. Further review revealed under Section O: Special Treatments, Procedures, and Programs, the facility did not include Resident #46 required a non-invasive mechanical ventilator or BiPAP. Review of the late entry Nurse's Note dated 01/27/2020 at 1:27 AM, revealed Licensed Practical Nurse (LPN) #5 entered a late entry Nurse's Note. The entry included that she had notified the doctor on 01/25/2020 that the resident's family member removed the resident's oxygen nasal cannula, and replaced it with his/her BiPAP mask, which the family brought from home for use. The Note stated the doctor had given a verbal order to obtain a new Continuous Positive Airway Pressure (CPAP) which accommodated oxygen hookup. Continued review revealed LPN #5 reported to the doctor the POA's continued attempts to remove Resident #46's nasal cannula oxygen. Review revealed LPN #5 informed the doctor the removal of the oxygen resulted in decreased oxygen saturation levels for the resident. The nurse noted she requested to send Resident #46 to hospital emergency room (ER) if the family continued removing the resident's oxygen nasal cannula, and placed the BiPAP on him/her. Further review revealed the doctor declined the nurse's request and informed her, The wife has a right to remove it if she wants. Review of the facility's North Station 24 Hour Report document, dated 01/25/2020, revealed the remark and change of condition section contained no documented evidence of placement of the BiPAP on Resident #46 by the POA. Further review of the Report revealed no documented evidence to include concerns of use of oxygen versus BiPAP use. Review of a Nurse's Note, dated 01/25/2020 at 1:15 PM, revealed LPN #1 documented she had written the Note on 01/46/2020 at 10:14 AM. Review revealed LPN #1 documented on 01/25/2020, she entered Resident #46's room to find the resident had a BiPAP in use, and not his/her ordered oxygen in place. Continued review revealed the LPN removed the BiPAP from Resident #46, and replaced it with the nasal cannula oxygen. Per review, the LPN provided education for the family regarding the reason for the oxygen. Further review revealed LPN #1 documented Resident #46's POA stated that after forty (40) years of marriage, he/she knew the resident's needs, and informed staff he/she needed the BiPAP for sleeping. Review of the Nurse's Note, dated 01/26/2020 at 8:28 PM, revealed the nurse's shift assessment determined the resident's alert status as lethargic. The POA requested use of BiPAP for the lethargic condition. The nurse notified the doctor of the change of condition with the POA's request to use the BiPAP. The nurse noted the doctor was okay with the request to use the BiPAP. Review of the North Station 24 Hour Report, dated 01/26/2020, revealed no documented evidence staff included Resident #46's change of condition, nor of the doctor's approval of the use of the BiPAP for the resident. Further review revealed no medical order for the use of the BiPAP dated 01/26/2020. Review of the Nurse's Note, dated 01/31/2020 at 1:15 PM, revealed the Director of Nursing (DON) documented an Inter-Departmental Team (IDT) review of Resident #46's admission information. Review revealed the IDT's documentation included an observation of Resident #46, and noted the resident's decline from his/her previous admission to the facility. In addition, review revealed the documentation noted Resident #46's POA was involved with the resident's care. Observations, on 03/01/2020 through 03/05/2020, revealed the contract agency's respiratory equipment in Resident #46's room, which included observation of a suction machine and an oxygen concentrator. Interview with Family #2, Resident #46's POA, on 03/01/2020 at 12:13 PM, revealed the resident had used a BiPAP machine for over twenty (20) years. Per the POA, she had notified the facility's staff on the resident's admission to the facility of his/her use of the BiPAP. The POA stated Resident #46 used the BiPAP during his/her previous admission to the facility. According to the POA, the hospitalists at the hospital instructed him/her (the POA) to bring the BiPAP machine to the facility for the resident's use after admission. Continued interview revealed the POA had spoken to staff on multiple occasions, after the resident's current admission, of the resident's need to use the BiPAP for sleep and rest. The POA further stated staff had repeatedly informed her the facility would call the police if she continued with her attempts to apply the BiPAP on the resident, and remove the resident's nasal cannula oxygen. Further interview revealed therefore, the POA had taken Resident #46's BiPAP machine home. Interview with the facility's Central Supply Clerk (CSC), on 03/05/2020 at 8:41 AM, revealed the facility provided BiPAP or CPAP respiratory equipment for residents as needed. She stated she ordered the units through the company the facility contracted. Per interview, staff notified her verbally if a resident had an order for a BiPAP or CPAP, and the Admissions Manager (AM) emailed her if the resident required the equipment before admission to the facility. The CSC stated however, she had not received, either verbally or by email, Resident #46's need for a BiPAP or CPAP respiratory unit, which had the capability for use of oxygen with the unit for the resident's use. Interview with LPN #1, on 03/05/2020 at 9:34 AM, revealed she provided care for Resident #46 routinely, and on 01/25/2020. She stated the POA had visited and removed the resident's oxygen nasal cannula and attempted to place a BiPAP on him/her. She stated the POA explained that Resident #46 required the use of the BiPAP unit. LPN #1 stated Resident #46 had arrived at the facility with doctor's orders for the use of oxygen; however, there was no order for use of a BiPAP. Per LPN #1, she was aware staff had obtained an order for the use of the BiPAP after contacting the doctor regarding the POA's attempts to use the BiPAP for the resident. However, according to the LPN, she was unaware of why a BiPAP unit was not at the bedside, nor did she follow-up on the location of Resident #46's BiPAP unit. She stated the reason a resident used a BiPAP unit was to keep them from having periods of not breathing while they were asleep. Further interview revealed if a resident did not have their BiPAP and stopped breathing the result could be death. In addition, she stated the responsibility of the assigned nurse who received the order included to ensure the facility acquired the BiPAP or CPAP unit for the resident. Interview with LPN 4, on 03/05/2020 at 10:21 AM, revealed the facility had previously admitted Resident #46 for provision of care, and during that admission, he/she had used the BiPAP unit for sleeping. She stated the nurse who took the telephone order from the Physician was responsible for the order and needed to complete the input of the order immediately, which ensured the availability of the respiratory unit. Per LPN #4, the facility's responsibility included to ensure the resident received the BiPAP unit for his/her use. Further interview revealed residents' who did not receive his/her BiPAP could experience impaired sleep, which could lead to a negative change in the resident's condition. Interview with Registered Nurse (RN) #5, on 03/05/2020 at 3:30 PM, revealed she assisted LPN #1 on 01/25/2020, when the POA had removed Resident #46's oxygen nasal cannula. She stated she called the doctor regarding staff's concern of the POA's removal of the oxygen to place the BiPAP mask on Resident #46. Per RN #5, the Physician ordered Resident #46 a new BiPAP unit; however, she could not remember if she completed the order or notified the CSC for the new BiPAP unit. She stated the facility assigned her to the South Hall on 01/25/2020 and the North Hall included Resident #46's assigned room. Further interview with RN #5 revealed the staff member who received the order included the responsibility to enter the order into the facility's electronic system followed with entry of a nurses' note. Staff's responsibility included to place new orders onto the facility's 24 Hour Report form to notify the DON of the new order. In addition, she stated the facility expected staff to complete the process of verbal orders when received. RN #5 stated the facility failed to order the medical equipment because completion of the verbal order process did not occur. RN #5 further revealed long-term negative effects, such as, heart failure, could occur if a resident required the BiPAP. However, she stated the North Unit assigned LPN #1 for the resident and did feel responsible to follow through with the order. Interview with the Assistant Director of Nursing (ADON), on 03/05/2020 at 3:02 PM revealed her expectations of staff included to place Physician's Orders into the facility's computer program. She stated the process included entering the verbal order into the computer; place the order on the facility's 24 Hour Report form, and document the order in the Nurse's Note. She stated she had no knowledge of the doctor's order for Resident #46's respiratory unit to include the ability to have oxygen administered via the unit. She stated the BiPAP machine would allow Resident #46 to rest properly and therefore, not be tired. The ADON stated the facility had not completed the Physician's Order for Resident #46's BiPAP unit as the resident did not have the unit to use. In addition, she stated she expected all nurses to follow through to ensure the resident received the ordered medical device. Interview with the Director of Nursing (DON), on 03/05/2020 at 4:07 PM, revealed the facility's CSC ordered all equipment for residents; however, the ADON, DON, and Administrator were able to order as well. She stated she expected nursing staff to follow through to completion when they received a Physician's Order. She stated this included ensuring documentation of orders was in the facility's computer system, notification of the order(s) on the facility's Daily Report Sheet. She stated the best practice for clinical staff included entry of the Physician's Order into the computer system first with a Nurse's Note of the conversation with the doctor and order. In addition, she stated the facility's responsibility included to ensure Resident #46 received the respiratory equipment ordered by the Physician. Interview with the Administrator, on 03/05/2020 at 5:52 PM, revealed facility staff did not previously identify a family with a request of the use of respiratory equipment for apnea or, of an order to obtain equipment to meet the need of oxygen with the use of BiPAP for a resident. He stated facility staff identified the resident without his/her ordered respiratory equipment when the Surveyor (State Survey Agency) interviewed staff in the facility. He stated the facility failed to follow the Physician's Order to obtain the respiratory unit for the requested use of the BiPAP with oxygen for the resident.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide sufficient nursing staff in order to implement supervision to ensure resident's safety for one (1) of thirty-seven (37) sampled residents (Resident #60). Resident #60 sustained a fall, on 02/04/2020 at 4:15 AM, when the facility-scheduled staff included one (1) nurse and one (1) aide for the North Unit Hall with a census of thirty-one (31) residents, who required care and supervision. The findings include: The facility did not provide a Staff or Staffing Policy upon request. Review of the facility's policy, Safety and Supervision of Resident, reviewed 05/31/18, revealed the facility ensured the safety and well-being of the resident with routine checks on residents. Routine checks involved staff to physical enter the resident's room to determine the residents' needs. The policy identified needs included the change of condition, sleep status, toileting assistance, and possible concerns identified by the resident. The facility addressed resident safety needs on an individualized basis. Furthermore, the implementation of resident interventions, which reduced the risk of an accident, included assigned responsibility to carry out the interventions. In order to monitor the facility's effectiveness for safety, the facility completed a through evaluation of the facility's interventions. Review of the facility's policy, Falls, revised 11/06/19, revealed the facility provided residents with assistance and supervision to reduce the possibility of a resident fall. All falls, which occurred in the facility, required monthly review from the Quality Assurance Performance Improvement (QAPI) Committee, which reviewed and determined the course of action required for the identified trend. Review of the facility's policy titled, Aspects of Care, undated, revealed the facility's clinical care services' responsibilities included implementation of care to prevent complications and maintain residents' safety. The Director of Nursing's (DON) responsibility included to ensure residents received the implementation of their identified care on a twenty-four (24) hour basis. Review of the facility's policy titled, Dementia Care, reviewed 07/11/18, revealed care for residents with cognitive impairment included to maintain a safe environment. Review of the Facility Assessment document, dated 2020, revealed the facility assessed the staffing requirements for each resident on each unit to ensure the facility provided sufficient staff for the assessed need(s) of all residents. The facility assessed that adequate staff for the shift hours of 7:00 PM to 7:00 AM, was two (2) nurses and two (2) aides. Review of the Facility Schedule, dated 02/03/2020, revealed for the 7:00 PM to 7:00 AM shift, after 12:00 AM on 02/04/2020, the staffing only included one (1) aide and one (1) nurse. The census for the North Unit Hall included thirty-one (31) residents. Resident #60 resided on the North Unit Hall. Review of Resident #60's clinical record revealed the facility admitted the resident, on 01/09/19, with diagnoses, which included Dementia, Muscle Weakness, and History of falls. Review of the facility's Quarterly Minimum Data Set (MDS) Assessment for Resident #60, dated 01/23/2020, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15), indicating the resident was severely cognitively impaired. Further review revealed the facility assessed Resident #60 to be unsteady and required extensive one (1) person assist. In addition, review of the MDS revealed the facility also assessed Resident #60 as always incontinent of bowel and bladder. Review of Resident #60's history revealed the resident had a fall, at home, on 01/05/19 and sustained a fracture of the sacrum and pubis. Further review of Resident #60's clinical record revealed the facility care planned the resident for the risk of falls. Further review revealed the facility identified fall risk factors that included the resident's age, incontinence, unsteady gate, altered awareness, and need for assistance. The fall interventions, initiated on 07/08/19, included to assist with ambulation, report falls to provider and family, when in wheelchair place in a common area, refer to therapy, and encourage activity participation to increase strength. Continued review of the fall care plan revealed to further prevent a fall, the facility included to have the call light within reach, to rise in a slow manner, and rest before a transfer, to keep the area free of clutter, and glare free light. Interview with Certified Nursing Assistant (CNA) #8, on 03/05/2020 at 3:37 PM, revealed the facility scheduled one (1) aide and one (1) nurse after midnight for each unit of the facility. The CNA stated she took care of thirty (30) residents with one nurse after midnight. She stated the facility has scheduled this level of staff since her employment with the facility. Further interview revealed on the night of Resident #60's fall, the nurse required assistance for another resident's dressing change; therefore, she and the nurse provided care in the other resident's room. The CNA stated while in the room with the nurse, they both heard a resident's cry for help, she left the room, and discovered Resident #60 on the floor. She stated the resident cried out and stated that his/her arm was broken. The CNA stated when the facility scheduled two (2) staff for the unit, the Director of Nursing (DON) expected the nurse to work with the aide to meet the needs of all residents, which included up to thirty-three (33) residents. Interview with Licensed Practical Nurse (LPN) #3, on 03/05/2020 at 2:17 PM, revealed she worked with one CNA on 02/04/2020 after midnight, when Resident #60 experienced the fall at 4:15 AM. The LPN stated, the facility's routine schedule included one (1) nurse, and (1) one CNA to provide resident care on the unit after midnight. LPN #3 stated on the night of the fall, a resident on the unit required her and the aide to complete a wound dressing change, and they both were in the room with the door closed. Continued interview revealed the facility expected the aide and nurse to work together to meet the needs of the residents. However, when care required two (2) staff to be in a room it left the residents alone on the floor. LPN #3 stated staff supervised and checked on the residents when they passed the doors and looked into the rooms. The LPN further stated the lights used for observation of residents included the hallway light, not the resident's room lighting. She stated Resident #60 fell onto the floor while she and the aide provided care behind a closed door. The LPN stated staff's responsibilities included to ensure to keep residents safe. Interview with the Director of Nursing (DON), on 03/05/2020 at 4:07 PM, revealed staffing after 11:00 PM included one (1) aide and one (1) nurse for each unit and remarked the staffing level was a skeleton crew. The DON stated the nurse's and aide's responsibilities after 11:00 PM included all care needs of up to thirty-three (33) residents on the unit. The DON stated residents who required more than one staff to assist with care would have to wait until the second staff became available. During continued interview with the DON, she stated the facility expected the nurses to assist the aides after 11:00 PM. The DON stated the nurses helped the aides when the nurses' time allowed. She further stated, she did not interview staff scheduled 11:00 PM on 02/03/2020 to 7:00 AM on 02/04/2020, and she was unaware of the specifics of the fall. The DON stated she was not aware the staff was in another resident's room behind closed doors when the fall occurred. She stated the facility's responsibilities included to provide the residents' care needs at all times. Interview with the Administrator, on 03/05/2020 at 5:52 PM, revealed the facility's routine included to staff night shift per unit with one (1) nurse and one (1) aide for each unit. He stated the facility expected staff to work together to maintain a safe environment and to meet the care needs of residents. He stated the level of care of Resident #60 as independent. He stated the resident ambulated without calling staff for assistance and the facility concluded this as the reason for the resident's fall with injury. However, the facility assessed Resident #60 to be unsteady and required extensive one (1) person assist and he/she was always incontinent of bowel and bladder. He further stated he had not been aware of the unavailability of the scheduled staff because of another resident's need for both staff to be in a room for treatment.