Every finding on record at Community Care of Rutherford

Based on interview, record review, and facility document and policy review, the facility failed to immediately implement protective measures following an allegation of staff-to-resident physical abuse and complete a timely and thorough investigation for 1 (Residents #94) of 6 residents sampled for abuse. Findings included: A facility policy titled, Abuse Policy for [Facility Name], dated 06/02/2025, indicated, Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, nor visitors. 1. Any employee having direct or indirect knowledge of allegations of possible abuse, must report the event immediately. This facility will not retaliate against any resident, employee, or family member making good faith reports. The identity of the person reporting the allegation of abuse, [sic] will only be disclosed on a need to know basis. 2. When abuse is reported or observed, protect the resident first. Remove the resident from the source of suspected abusive behavior (intervene to keep them from harm). 3. Allegation [sic] of abuse must be immediately reported to Charge Nurse or Supervisor. Allegation can also be reported anonymously to [Name of a community based program to assist people in providing anonymous information about crimes] or our local Ombudsman. The policy also indicated, 6. Charge nurse is to conduct investigation immediately following the incidence to ensure resident will be protected from harm. 7. The results of all investigations will be completed within 5 days of the incident. Depending on the results of the investigation, all necessary corrective actions will be taken. The policy also indicated, D. Employee(s) suspected of potential harm to a resident or others will immediately be placed on administrative leave pending results of the investigation. An admission Record revealed the facility admitted Resident #94 on 12/20/2024. According to the admission Record, the resident had a medical history that included diagnoses of cognitive, social, or emotional deficit following other cerebrovascular disease, diabetes mellitus type 2, and acute kidney failure. A 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/24/2024, revealed Resident #94 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. A facility document titled Incident Reporting System [IRS], printed 03/03/2025, revealed an allegation of physical abuse involving a staff-to-resident interaction between Licensed Practical Nurse (LPN) #4 and Resident #94. The IRS record indicated facility staff became aware of the allegation on 12/24/2024, at approximately 6:36 PM, and reported the allegation on 12/24/2024 at 7:56 PM. The IRS record revealed Resident #94 alleged that staff used a silver lock to lock the resident's wheelchair and that LPN #4 pushed the resident's hand away when the resident attempted to grab the nurse during a transfer. Resident #94's Emergency Contact (EC) identified LPN #4 as the alleged perpetrator based on information provided by Resident #94. A graph, dated 01/24/2025, with resident names was included in the facility's investigation documents that indicated interviews were conducted with other residents regarding any abuse they may have witnessed. Four Head to Toe Skin Assessment[s], dated 01/24/2025, approximately 30 days after the alleged incident, were included in the facility's investigation. LPN #4's Timecard revealed she clocked in to work from 4:56 PM on 12/23/2024 until 7:44 AM the following morning. LPN #4's Timecard revealed she clocked in to work from 4:59 PM on 12/24/2024 until 6:08 AM the following morning. During an interview on 06/23/2026, at 1:12 PM, the Assistant Director of Nursing (ADON) stated that when an abuse allegation was reported, the facility's priorities were to ensure resident safety, obtain statements from involved staff, interview residents when appropriate, and complete skin assessments for residents with impaired cognition. The ADON stated that LPN #4 was identified as the alleged perpetrator in the incident involving Resident #94, and the facility's policy required any employee identified as an alleged perpetrator to be removed from duty pending completion of the investigation. During a telephone interview on 06/24/2026 at 9:02 AM, LPN #4 stated that on 12/24/2024 upon reporting to work, the Administrator informed her that Resident #94 had alleged that physical abuse occurred during the early morning hours of 12/24/2024. LPN #4 stated she provided a written statement, spoke with detectives and Adult Protective Services (APS), and completed her work shift while the investigation remained ongoing. During an interview on 06/23/2026 at 1:31 PM, the Director of Nursing (DON) stated that the facility's abuse investigation process was consistent with the process described by the Assistant Director of Nursing (ADON). The DON could not explain why resident interviews and skin assessments related to the allegation involving Resident #94 were not completed until 01/24/2025. The DON stated that the delay was significant because timely interviews and skin assessments were necessary to identify injuries, determine whether abuse occurred, and help prevent further incidents. The DON added that LPN #4 was present in the facility on 12/24/2024 and should have been suspended in accordance with facility policy pending completion of the investigation. During an interview on 06/24/2026 at 9:35 AM, the Administrator, who also served as the Abuse Coordinator, stated that when an abuse allegation was reported, especially allegations of physical abuse, the alleged perpetrator should be immediately removed from the facility and not allowed to remain in the building during the investigation. The Administrator stated the investigation should begin immediately and include identifying witnesses, obtaining written staff statements, interviewing residents with BIMS scores of 8 or higher, conducting skin assessments for residents with BIMS scores below 8, and providing abuse education to staff. The Administrator stated the investigation should conclude by day five. The Administrator stated the facility failed to complete key investigative tasks within its expected time. During a follow-up interview on 06/27/2026 at 2:17 PM, the DON stated that the expectation was for LPN #4 to have been removed from resident care pending completion of the investigation. The DON stated the investigation should have been comprehensive and should have immediately included resident skin assessments, resident interviews, and staff in-service education. During a follow-up interview on 06/27/2026 at 3:27 PM, the Administrator stated that the facility did not follow its policy by allowing LPN #4 to continue working during the investigation. The Administrator also stated resident interviews, skin assessments, and staff in-service education should have been initiated and completed within the required five-day timeframe.

Based on facility record review, interview, and facility document and policy review, the facility failed to protect a resident's right to be free from misappropriation of money and medications for 2 (Resident #6 and Resident #97) of 4 residents reviewed for misappropriation of property (Resident #6 and Resident #97)Findings included: A facility policy titled, Abuse Policy for [Facility Name], dated 06/02/2025, indicated, Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, nor visitors. Types: verbal, sexual, physical, mental, neglect, misappropriation of property, involuntary seclusion, injuries of unknown source. The attached document titled, Training on Abuse indicated, Misappropriation of patient property - the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a patient's belongings or money without the patients [sic] consent. 1. An admission Record revealed the facility admitted Resident #6 on 12/06/2024. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease and dementia in other diseases classified elsewhere (of unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety), and cognitive communication deficit. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/16/2026, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident cognitively intact. A facility document titled, Improvement Opportunity and Comment Form, signed by the Administrator (ADM) and dated 10/04/2025, revealed the resident discovered their wallet was missing from their lockbox after returning from a hospital stay. The missing contents included the resident's driver's license, Social Security card, approximately $30 to $40 in cash, and a diamond and mother of pearl ring. On 06/22/2026 at 1:39 PM, Resident #6 stated they went to the hospital for a few days and when they returned, they discovered the lockbox in their room had been broken into and their wallet and a ring were missing. On 06/25/2026 at 4:30 PM, the Administrator stated Resident #6 was sent to the hospital and when they returned, they reported they were unable to find their wallet and a ring. The Administrator interviewed the resident and assisted the resident in looking for the missing items. The resident had a lockbox in their room where they kept the items. The resident and the Administrator were unable to locate the items. The Administrator reported misappropriation to the State Agency and initiated an investigation. Interviews were conducted with the staff and residents. A resident in a neighboring room recalled hearing a strange sound on the night shift. The Administrator interviewed night shift staff and determined Resident #6 was assigned to Certified Nursing Assistant (CNA) #13's group. The Administrator interviewed CNA #13, and CNA #13 confessed to taking Resident #6's wallet, taking the money out of it, and hiding the wallet in the resident's room. The CNA told the Administrator where the wallet was hidden. The wallet was recovered with the resident's identification cards; however, no cash was in the wallet. The CNA denied taking the resident's ring. The Administrator called law enforcement and reported the theft, notified the resident and the ombudsman, and terminated CNA #13. The facility reimbursed the resident $50 for the money that was stolen from the wallet. The facility substantiated the investigation as misappropriation and reported to the State Agency within the regulatory timeframe. An Employee Counseling Statement revealed the facility terminated CNA #13 on 10/10/2025. On 06/27/2026 at 10:50 AM, the Director of Nursing (DON) stated the expectation was that staff would not borrow or take anything from a resident, theft would be reported immediately, and an investigation would be conducted. On 06/27/2026 at 10:17 AM, the Administrator stated the expectation was that staff would not steal from residents and they would follow their training on abuse, neglect, and misappropriation. 2. An admission Record revealed the facility admitted Resident #97 on 08/06/2024 and discharged the resident on 10/27/2025. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease and dementia in other diseases classified elsewhere (unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety), and other chronic pain. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/15/2025, revealed Resident #97 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. Resident #97's September 2025 Medication Administration Record (MAR) indicated the resident had a physician's order dated 08/07/2025 for oxycodone hydrochloride (HCl) oral tablet 10 milligrams (mg), to administer one tablet by mouth every four hours as needed for pain. An untitled facility document dated 09/01/2025 indicated Licensed Practical Nurse (LPN) #23 alerted the facility that the narcotic tracking sheet looked suspicious and that she was unable to locate Resident #97's oxycodone on the medication cart. On 06/27/2026 at 11:24 AM, LPN #23 stated the process for narcotic counts at the time of the incident involving Resident #97's oxycodone was that the outgoing nurse would conduct a narcotic count and the tell the incoming nurse what the count was. On the night of the incident, outgoing LPN #14 told incoming LPN #23 the narcotic count was 28. Resident #97 had been experiencing a decline and had an order for oxycodone. The resident requested their pain medication and LPN #14 was not able to find the resident's medication card. The nurse looked for the card and when it was not located, the nurse was able to access the medication in the Cubex and administer the requested medication to Resident #97. LPN #23 reviewed the narcotic count sheet and noticed the number 29 was scribbled out and the number 28 was written off to the side. LPN #23 notified the Administrator and wrote a statement. The pharmacist was contacted and they completed an audit of medications in the facility. The process was changed so that the incoming and outgoing nurses completed the narcotic count together. On 06/25/2026 at 3:51 PM, the Administrator stated on 09/01/2025, Resident #97 had requested an oxycodone for pain, and Licensed Practical Nurse (LPN) #23 was not able to locate the resident's medication card. The LPN searched the medication cart for the resident's medication card of oxycodone and did not locate the medication. LPN #23 reviewed the item tracking form for narcotics and discovered there was a discrepancy on the tracking form. The count on the form had been changed. The facility was able to access the medication in the Cubex and administer the oxycodone to the resident. An investigation was initiated. Staff were interviewed and it was determined the tracking form was changed on LPN #14's shift. LPN #14 was hired as agency staff and was not able to be reached for a statement. The Administrator notified the staffing agency of the discrepancy and asked the agency to have LPN #14 contact the Administrator. The Administrator checked LPN #14's license and found it had been surrendered on 04/29/2025 for medication diversion, and the LPN was not a licensed nurse at the time they were working in the facility. The facility called in a pharmacy to complete an audit of all medication carts. The Administrator provided copies of the facility's investigation and pharmacy medication audit. According to the documentation, the facility reported the incident to the state agency and local law enforcement timely.

Based on facility policy review, medical record review, and interview, the facility failed to ensure a resident was free of significant medication errors for 1 (Resident #3) of 7 sampled residents reviewed. The findings include: Review of the policy titled [Named Facility's] Incidents and Accidents Policy dated 1/17/24 (1/17/2024) revealed .It is the policy of this facility to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident .The following incidents/accidents require an incident/accident report but are not limited to .Medication or treatment errors .The nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders .The resident's family or representative will be notified .documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained . Review of the policy titled Consulting Physician/Practitioner Orders dated February 2023, revealed .The attending physician shall authenticate orders for the care and treatment of assigned residents. For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: a. Call the attending physician to verify the order. b. Document the verification order by entering the order and the time, date, and signature on the physician order sheet .c. Follow facility procedures for verbal or telephone orders including: noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses which included Dementia, psychotic disturbance, mood disturbance and anxiety, Major Depressive disorder, Heart Failure and Atrial Fibrillation (Afib). Review of Comprehensive Care Plan for Resident #3 with goals and interventions that included .12/01/2021 risk for alteration in neurological status r/t [related to] dementia .have A Fib .Give atrial fibrillation medication as ordered . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 revealed, a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of Order Recap Report dated 6/1/2023-3/31/2024 revealed a physician's order dated 5/17/2021 for Donepezil Tab 10mg (milligram) give one tablet by mouth at bedtime. The Donepezil order was discontinued on 2/22/2024. Review of the Order Recap Report dated 6/1/2023-3/31/2024 revealed a physician's order dated 5/17/2021 for Eliquis Tab 5mg give one tablet by mouth two times a day. The Eliquis 5mg order was discontinued on 10/30/2023. Review of the hospital Final Report dated 10/30/2023, revealed Resident #3 was directly admitted from the office of PCP (Primary Care Physician).Discharge Medications .apixaban (Eliquis 5mg oral tablet) 5 Milligram 1[one] tab(s) By mouth Twice daily for 30 Days .donepezil (donepezil 10mg oral tablet) 10 Milligram 1 tab (s) By mouth once daily, at bedtime . Review of the October 2023 Medication Administration Record (MAR) revealed physician orders for .11/22/2021 ELIQUIS TAB 5MG, Give 1 tablet by mouth two times a day related to .ATRIAL FIBRILLATION (D/C 10/30/2023) .10/31/2023 ELIQUIS TAB 5MG, Give 1 tablet by mouth two times a day related to UNSPECIFIED ATRIAL FIBRILLATION .for 30 Days . Review of the October 2023 MAR revealed a physician order for .11/22/2021 Donepezil Tab 10mg (milligram), Give 1[one] tablet orally at bedtime related to .DEMENTIA . Review of the November 2023 MAR revealed a physician's order for .10/31/2023 ELIQUIS TAB 5MG, give 1 tablet by mouth two times a day related to UNSPECIFIED ATRIAL FIBRILLATION for 30 days . The physician's order was automatically discontinued on 11/29/2023. Review of the PCP notes dated 12/22/2023, revealed resident was seen as a follow up. It had been confirmed that the resident does have a diagnosis of dementia and restarted donepezil. The resident had a history of A-fib and was on Eliquis 5mg tab as directed. Review of the January 2024 MAR revealed physician's orders for Donepezil Tab 10mg give 1 tablet orally at bedtime and Donepezil HCL Oral Tablet 5mg give 5mg by mouth one time a day for memory and cognition. There had been 31 days that both dosages were administered. Review of the January 2024 MAR revealed Eliquis 5mg was not restarted as ordered by the provider after hospital discharge. Review of the February 2024 MAR revealed a physician's order dated 11/22/2021 Donepezil Tab 10mg give 1 tablet orally at bedtime. The physician's order for Donepezil was discontinued on 2/22/2023. There was a physician's order for 2/20/2023 Donepezil HCL Oral Tablet give 5mg by mouth one time a day for memory and cognition. There had been 17 doses of Donepezil 10mg administered. Review of the February 2024 MAR revealed a physician's order dated 2/22/2024 to resume Eliquis Tab 5 give one tablet by mouth two times a day related to Atrial Fibrillation. There had been 43 doses of blood thinner missed during the month of February. Monitoring for blood thinner side effects had been discontinued on 2/17/2024 and 25 shifts of monitoring had not been documented on the MAR. Review of the March 2024 MAR revealed there had been no order for monitoring of blood thinner side effects. (There had been 36 shifts without monitoring order as of March 19 at 3:18 PM. During an interview on 3/18/2024 at 1:30 AM, Family Member (FM) #1 stated Resident #3 had been hospitalized and upon discharge, she had been given a prescription for blood thinner for Afib (Arterial Fibrillation) and the prescription was for 30 days therefore, it fell off the Medication Administration Record (MAR) at the end of November 2023. Since they were unable to contact the NP (Nurse Practitioner/MD (Medical Director), they decided to get an outside provider Family Nurse Practitioner (FNP). Resident #3 needed to be assessed for Dementia following COVID. FM #1 stated that the FNP wanted Resident #3 off Donepezil for dementia for 9 weeks prior to neurology appointment and this did not happen. FM #1 stated it had also been discovered that Resident #3, allegedly had been taking, 3 times the amount of medication prescribed for dementia. During an interview on 3/19/2024 at 1:10 PM, the Unit Manager (UM)/ RN #1 stated when it had been discovered that Resident #3's blood thinner had been discontinued, a request was sent to the NP for an order to resume the blood thinner. During an interview on 3/21/2024 at 1:30 PM, the Director of Nursing (DON) reviewed the order written by the Neurologist. When asked what she would do with the order that was written for Donepezil 5 MG knowing the resident was already on this medication at a different strength, the DON stated she would contact the outside provider to clarify whether the medication was meant to replace the order currently in place or whether the new dosage should be added to the dosage presently in place. During an interview on 3/21/2024 at 3:00 PM, the NP stated Resident #3's daughter chose to transfer physician services to an outside physician. When the NP was asked what the risks for a resident with Afib not being on an anticoagulant, the NP stated they have an increased risk for developing a blood clot and having a stroke. When residents under the care of the facility's physician services return from hospitalization , the resident has been seen by the NP or MD for stabilization visit/evaluation and medication review. At that visit, they monitor the length of medication care, and they may need prescriptions for them to be extended. During an additional interview on 3/21/2024 at 5:45 PM, the DON stated when a resident goes to an outside provider, they are sent with a copy of their current medication list. If they have new medications, then a prescription should be sent to the facility. The facility will then enter the order into the Electronic Medical Record and the MD will sign off on the medication. There was a prescription sent to the facility from the Neurologist dated 12/19/2023. This prescription was for Resident #3 and was for Donepezil 5MG daily. When the DON was asked how she would process this prescription, she stated she would clarify with the provider that wrote the prescription to see whether this medication should be added to her current dose or whether this prescription was meant to replace the current dosage. The DON agreed that the 5 MG dose was added to the 10mg dose already in place and should not have been. When the DON was asked if this was written up as a medication error, she stated No. She stated, when the resident returned from the provider there was no communication/visit summary sent to the facility from the physician.

Based on job description review, facility policy review, and interview, Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable wellbeing of the residents. The failure of Administration to ensure adequate supervision was provided and to ensure the care plan was updated, which placed 1 of 13 sampled Residents (Resident #2) reviewed for risk of wandering and/or elopement with a diagnosis of Dementia in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy on 11/15/2022 at 3:04 PM in the Administrator's Office. The facility was cited Immediate Jeopardy at F-835. The facility was cited at F-835 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 8/2/2022 to 11/15/2022. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 11/15/2022 at 7:18 PM. The corrective actions were validated onsite by the surveyors on 11/15/2022 at 7:30 PM. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: Review of Community Care of [NAME] County Nursing Home Administrator job description updated 2020, revealed, .This position has direct twenty-four (24) hour, seven (7) days a week, operational authority .Provides the leadership framework for planning, directing, coordinating and improving Services at Community Care of [NAME] County that are responsive to the needs of the patients .The administrator will ensure the development and implementation of policies and procedures for program operations .and will also assume direct responsibility for the planning and coordination of the Dietary, Housekeeping, Laundry, Maintenance, Business Office, Security, Nursing, and all other departments of Community Care of [NAME] County .Ensures development and implementation of organization-wide and unit specific age specific, safety, security . Review of [contracted agency] Administrator job description undated revealed, .Positions Supervised: Business Office Manager .Director of Maintenance & Housekeeping .Director of Nursing .Social Worker .The Administrator is responsible for administering, directing, facilitating, supporting and coordinating all activities of the community ensuring that quality care, financial and people objectives are in compliance with all local, state and federal laws and in accordance with United Church Homes, Inc. policy .Identifies and maintains accountability for security within assigned areas of responsibility .Ensures all care, treatment and services are provided with appropriate dementia care protocols . (Administrator is employed by contracted agency and contracted to serve as Administrator of Community Care of [NAME] County). Review of the facility's policy titled, Elopement and Wandering Residents, revised 5/1/2020, revealed, .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .Adequate supervision will be provided to help prevent accidents or elopements . The Administration failed to ensure care plans were developed for 1 of 13 sampled residents (Resident #2) reviewed for risk of wandering and/or elopement with a diagnosis of Dementia. Refer to F-656. The Administration failed to ensure adequate supervision for 1 of 13 sampled residents (Resident #2) reviewed for risk of wandering and/or elopement with a diagnosis of Dementia, which resulted in an elopement. Refer to F-689. During an interview on 11/15/2022 at 1:10 PM the Administrator stated he had been expecting the State Surveyors and was not surprised at receiving an IJ for the elopement incident of Resident #2. The surveyors verified the acceptable Immediate Action Removal Plan on 11/15/2022 at by: 1. The surveyors verified that after the elopement on 8/2/2022 Resident #2 received a WanderGuard and Elopement Plan of Care was put in place on 8/3/2022. 2. The surveyors verified a Wandering Elopement assessment dated [DATE] for Resident #2 was completed to show at risk to wander from or elope facility. 3. The surveyors verified the facility held an Elopement Assessment Changes Inservice on 8/3/2022. The facility implemented elopement assessments to be done on admission and again in 48 hours. The nurse would obtain an order for a WanderGuard for residents determined at risk for exiting the facility. Every ambulatory resident admitted will have WanderGuard placed X 7 days then re-evaluated. 4. The surveyors verified a facility elopement drill was performed on 8/12/2022. 5. On 11/15/2022 surveyors verified the facility educated staff on care planning and crafting of care plans. 6. Designee to report in facility weekly at-risk meeting regarding nursing notes and elopement risk assessments to ensure that all in need of a care update was completed. Weekly reporting to at-risk Interdisciplinary Team (IDT) meeting for 3 months and then monthly following for 3 months. The findings and progress will be reported in the quarterly Quality Assurance meeting. 7. On 11/15/2022, Executive Director of Managed Communities educated the Administrator on F835, and how it related to updating care plans in the community. The facility is required to submit a Plan of Correction for F-(Tag).

Based on facility's policy review, medical record review, facility documentation review, observation, and interview, the facility failed to provide adequate supervision to prevent elopement for 1 of 13 sampled residents (Resident #2) reviewed for risk of wandering and/or elopement with a diagnosis of Dementia. The facility's failure to provide adequate supervision and implement interventions to prevent elopement for Resident #2 who eloped from the facility on 8/2/2022 on a hot summer day. This placed the resident in an Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident). The Administrator was notified of the Immediate Jeopardy on 11/15/2022 at 1:39 PM in the Administrator's Office. The facility was cited Immediate Jeopardy at F-689. The facility was cited at F-689 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 8/2/2022 to 11/15/2022. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 11/15/2022 at 7:18 PM. The corrective actions were validated onsite by the surveyors on 11/15/2022 at 7:30 PM. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. Review of the facility's policy titled, Accidents and Incidents-Investigating and Reporting, revised 3/7/2022, revealed, .All accidents or incidents involving residents, employees, visitors, vendors, etc. (similar items included), occurring on our premises must be investigated and reported to the Administrator .All incidents are to be reported timely and appropriate interventions implemented .The Nurse Supervisor and/or Charge Nurse shall: a. Examine all accident/incident victims .b. Notify the Medical Director or the victim's personal or Attending Physician, and inform the physician of the accident or incident .c. If necessary, transfer the injured person to the emergency room , medical treatment center, hospital . Review of the facility's policy titled, Elopement and Wandering Residents, revised 5/1/2020, revealed, .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff .TIPS FOR PREVENTION OF ELOPEMENTS .React to statements such as I want to go home. Observe for aimless wandering .Consider use of a personal alarm for the resident . Review of the facility's policy titled Comprehensive Care Plans, revised 5/1/2020, revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record . Review of the facility's policy titled Care Plan Revisions Upon Status Change, revised 5/1/2020, revealed, .The purpose of this procedure is to provide a consistent process for reviewing and revising for those residents experiencing a status change .The comprehensive care plan will be reviewed and revised as necessary, when a resident experiences a status change .Upon identification of a change in status the nurse will notify the MDS [Minimum Data Set] Coordinator, the physician .MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options .The care plan will be updated with the new or modified interventions .Care plans will be modified as needed .The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs . Review of medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included Polyarthritis, Unspecified, Hypertensive Heart Disease with Heart Failure, and Unspecified Dementia with Behavioral Disturbance. Resident #2 was discharged on [DATE]. Review of Brief Interview of Mental Status (BIMS) assessment dated [DATE], revealed, a score of 7 for Resident #2 indicating severe cognitive impairment. Review of the Comprehensive Care Plan for Resident #2 initiated 7/12/2022, revealed, a care plan with goals and interventions for .At risk for Cardiac Complications .I have an ADL self-care performance deficit .I am at risk for falls .I have potential for pain .The resident has impaired cognitive function or impaired thought processes . and a care plan created on 8/3/2022 .I am at risk for elopement positive Wandering/Elopement assessment . There was no documentation provided by the facility of a Care Plan for wandering or elopement prior to Resident #2's elopement on 8/2/2022. Review of a Social Services Progress Note dated, 7/13/2022 for Resident #2 revealed, .Resident is pleasantly confused . Review of History and Physical dated 7/15/2022 for Resident #2 revealed, .Past Medical History .Delirium, Dementia .Psychiatric: Forgetful Oriented to self, confused . Review of a Skilled Nursing Note dated, 7/16/2022 for Resident #2, revealed, .Patient is very confused. She doesn't know where she is .She thinks she is on vacation . Review of Admission MDS dated [DATE], revealed Resident #2 scored 13 on the BIMS Assessment indicating cognitively intact, limited assistance with bed mobility, transfer, dressing, toileting, and personal hygiene, supervision with walking and locomotion on unit, mobility devices of walker and wheelchair, and Non-Alzheimer's Dementia. The previous BIMS score for 7/12/2022 which was 7 indicating severe cognitive impairment and 7/17/2022 BIMS score of 13 (intact cognition) confirmed Resident #2's cognitive abilities varied at different times during her stay at the facility. Review of a Physical Therapy (PT) Progress Report dated 7/18/20/22, for Resident #2 revealed a functional skill assessment of .transfers .independent .Ambulation Walk 10 feet independent, Walk 50 feet with Two Turns .Reason for Skilled Services: Continued PT services are necessary in order to promote safety awareness, increase LE [lower extremity] ROM [range of motion] and strength, minimize falls, improve dynamic balance, facilitate independence with all functional mobility Review of a Social Services Note dated 7/19/2022 for Resident #2 revealed, .She is alert with some confusion noted . Review of a Social Services Noted dated 7/20/2022 for Resident #2 revealed, .Resident came out of her room with all her belongings on rollator [wheeled walker]. Social Worker [SW] asked Resident where she was going. Resident stated that she would like to go to front office to sign out and go home . Review of a Social Services Note dated 7/21/2022 for Resident #2 revealed, .Resident came out of her room with all of her belongings and with her purse on her shoulder ready to go home .She is pleasantly confused . Review of a Social Services Noted dated 7/27/2022 for Resident #2 revealed, .SW called [Family Member #1] about Resident d/c [discharge] plans. She is alert with confusion and requires redirection by Staff. She is able to use rollator. She is a fall risk . The Social Service notes from 7/13/2022 - 7/27/2022, confirmed Resident #2 was an elopement risk prior to 8/2/2022. Review of a Physical Therapy (PT) Treatment Encounter note dated 7/27/2022 for Resident #2 revealed, .Pt [patient] ambulated throughout F hall today for 3 laps, completing directional changes at supervision. Gait training completed for ~500 ' [500 feet] with pt presenting with no fatigue . Review of Medical Administration Record (MAR) note dated 7/27/2022 for Resident #2 revealed, .Patient exhibited confusion while lying in bed this afternoon .Patient stated she was here to play with friends and to make friends. Patient continued on to ask about when she could go home . Review of a Behavior Note dated 7/27/2022 for Resident #2 revealed, Patient is currently becoming increasingly anxious and confused .Patient believes she is supposed to go work at [named hospital] as a nurse and she says she is running late for work. Patient has purse, jacket, and car keys in hand currently. I reoriented patient, but this has been an ongoing pattern throughout the day . Review of a Nurses Note dated 7/27/2022 for Resident #2 revealed, AT BEDTIME RESIDENT REDIRECTED MULTIPLE TIMES FOR WANDERING, EXIT SEEKING, RESIDENT STATED THAT SHE WANTS TO GET HOME TO HER HUSBAND WHO IS HOME ALONE . Review of the MAR note dated 7/28/2022 for Resident #2 revealed, .Behavior Monitoring .resident wandering throughout unit, exit seeking . Review of Wandering Elopement assessment dated [DATE] for Resident #2 revealed .Wandering pattern .Purposeless wandering .Objects to living away from own home .Sensory dependent; searches for things/persons .At risk to wander or elope the facility .RESIDENT WANDERING ON UNIT, PURSE AND CAR KEYS WITH HER ON ROLLATOR, RESIDENT STATES NEED TO GET HOME TO HUSBAND WHO SHE SAYS IS HOME ALONE .Physical changes in the brain .Diagnosis of Dementia .Searching for home or people from past .Disorientation to time .Proceed to Care Plan as needed . Review of a PT Therapy Progress Report dated 7/29/2022 for Resident #2 revealed, .Functional Skill Assessment Bed Mobility .Independent .Transfers .Independent .Ambulation Walk 10 feet = Independent Walk 50 feet with Two Turns = Independent Walk 150 feet = Setup or clean-up assistance .Mobility Function Score (ranges from 0-12; 12 being the highest function) = 12 . Review of a PT Treatment Encounter note dated 7/29/2022 for Resident #2 revealed .Conversation with patient who stated she is ambulating ad lib [at pleasure] in the facility with the use of rollator. Patient amb [ambulate] 300ft [feet] in 6 min [minute] with rollator Review of a Skilled Nursing Note dated 8/1/2022 for Resident #2 revealed, .walks with walker. Wanders occasionally, dementia noted . Review of a Social Services Noted dated 8/2/2022 for Resident #2 revealed, .Resident is alert with confusion, requires curing and redirection daily by Staff . Review of a Nurses Note dated 8/2/2022 for Resident #2, revealed, .Notified at 6:28 PM that resident was found in front reception hallway/front lobby, turned around asking for help to the front door. Employee explained to her that she must have just come inside the front door and employee had previously seen resident about 6:20 PM outside walking .toward facility with walker clothes .employee assisted resident to hallway, to CNA [Certified Nursing Assistant] on the hallway and CNA assisted resident to her room .Prior to this incident .at approximately 6-6:10 pm Resident come out of her room with walker, purse, keys, and some clothing. Resident walking in the F hallway .Resident didn't have wanderguard [electronic bracelet used to protect residents from elopement] in place. Placed new Wanderguard transmitter on left ankle. Walk and Talk [a facility systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering] performed by staff and all residents accounted for. Increased visual checks, monitoring resident every 30 minutes. Notified daughter, Notified [Medical Director], Notified facility Director of Nursing [DON]. No injuries noted . Review of facility document Falls Committee Meeting Agenda dated 7/29/2022 revealed, an Interdisciplinary Meeting was held at 9:00 AM Resident #2 was reviewed with the following note .sundowns [the appearance of confusion, agitation, and other severely disruptive behavior markedly worsening at night in older patients with Dementia]: packs clothes enters other residents room @ [at] night - But stays on unit .Home/ALF [Assisted Living Facility] soon . Review of the facility's investigation of elopement dated 8/3/2022, which occurred on 8/2/2022 revealed, a Brief Interview of Mental Status (BIMS) Assessment score of 7 for Resident #2. Review of measurements requested from Community Care of [NAME] County Maintenance Director on 11/16/2022, revealed 0.5 miles or 2,640 feet distance from facility front door to creek using paved surfaces, 0.3 miles or 1,584 feet distance from far end of service drive area using paved surfaces to the creek, and 0.6 miles or 3,168 feet from facility back door to the creek using paved surfaces. Review of Time and Date website on 11/15/2022 revealed, weather in Murfreesboro, Tennessee for 8/2/2022 at 6:15 PM was a Temperature of 88 degrees Fahrenheit per website: https://www.timeanddate.com/weather/usa/murfreesboro/historic?month=8&year=2022. Observation of the train traveling on tracks across from facility entrance on 11/15/2022 at 9:30 AM, 11:10 AM, 11:50 AM, 4:30 PM, 5:15 PM, and on 11/16/2022 at 8:40 AM. During a phone interview on 11/15/2022 at 8:22 AM, Family Member #1 stated Resident #2 was admitted to the facility following a hospitalization for rehabilitation, and PT. Family Member #1 stated .the facility called me immediately after she tried to leave on 8/2/2022. I believe she became confused and followed someone out the door trying to go home During an interview at the entrance to F Hallway on 11/15/2022 at 10:00 AM, Medical Records Personnel #1 stated I was coming in late on 8/2/2022, walking toward F Hall and I looked out the window around 6:20 PM and saw a lady pushing a rollator walker down the driveway towards the front entrance with a purse and pile of clothing in a dry cleaner bag. I assumed she was a visitor bringing a resident some clothing, so I continued walking to the F Hall nurses desk. I finished my business there and walked around toward the front entrance reception area around 6:25 PM, and the same lady was now in the front reception hall. I asked her for her name and realized at that point it was [Resident #2]. [Resident #2] was confused and tired, so I got a wheelchair and assisted her back to F Hall and asked for help from the CNT [Certified Nursing Technician] on duty. During a phone interview on 11/15/2022 at 10:45 AM, LPN #1 stated that on 8/2/2022, Resident #2 had her clothes, purse, and keys walking with rollator up and down F Hall and was easily re-directed to return to her room. Around 6:00 PM to 6:10 PM Resident #2 was seen with rollator walker, purse, keys, and some clothing walking in F Hall toward the nurse's station. During an interview in the conference room on 11/15/2022 at 11:00 AM, Assistant Director of Nursing (ADON) confirmed that documented wandering/exiting behaviors exhibited by a resident should have been brought to the interdisciplinary team attention to review plan of care and initiate increased monitoring interventions as appropriate. During a phone interview on 11/15/2022 at 11:07 AM, CNT #1 confirmed her written statement that on 8/2/2022 Resident #2 was last seen on F Hall at 6:00 PM, was returned to F Hall at 6:25 PM, has a history of packing up all her belongings every night saying she wants to go home, and is easily redirected to go back to her room. During an interview on 11/15/2022 at 11:30 AM Maintenance Director and Assistant maintenance Director confirmed written statement dated 8/2/2022 that they were working in front of the facility completed their work at 6:00 PM, left the facility at 6:05 AM (confirmed by Time Clock Plus Records) and no residents were seen outside the facility. During an interview in the conference room on 11/15/2022 at 3:30 PM DON confirmed the expectation is when a resident has a history of/or identified as a wander/elopement risk, nursing should contact the physician to obtain an order for a WanderGuard which will initiate a care plan for wandering/elopement for the resident. During a phone interview on 11/15/2022 at 5:17 PM with RN #1 she confirmed she completed a Wandering/Elopement Assessment on Resident #2 on 7/28/2022 due to the resident was wondering the hall with her belongings on her rollator walking toward the doors asking if it was raining. RN #1 stated she did not remember any specific training on how to complete the Wandering/Elopement Assessment, the determination of At risk to wander or elope the facility but is not physically or mentally able was based on her nursing judgement that Resident #2 was easily re-directed to return to her room and Resident #2 was not cognitively able to follow commands needed to exit the facility. RN #1 further confirmed that she worked the 7 PM to 7 AM shift on 8/2/2022, received report of Resident #2's elopement, and a WanderGuard was placed on the resident. The surveyors verified the acceptable Immediate Action Removal Plan on 11/15/2022 at by: 1. The surveyors verified that Resident #2 received a WanderGuard and placed on Walk and Talk Residents list on 8/3/2022. Surveyors verified with medical record review frequent checks started every thirty minutes for the next 24 hours on Resident #2 on 8/2/2022. 2. The surveyors verified the facility educated staff on elopement risk management. 3. Surveyors verified with medical record review frequent checks started every thirty minutes for the next 24 hours on Resident #2 on 8/2/2022. 4. The surveyors verified the facility held an Elopement Assessment Changes Inservice on 8/3/2022. The facility implemented elopement assessments to be done on admission and again in 48 hours. The nurse would obtain an order for a WanderGuard for residents determined at risk for exiting the facility. Every ambulatory resident admitted will have WanderGuard placed X 7 days then re-evaluated. 5. If a resident is found to be an elopement risk, interventions will be addressed and communicated to all staff. If any resident has behaviors that are exit seek, behavior monitoring will be initiated and the behaviors documented. 6. All residents, new admissions, readmissions, and those residents who experience significant change will be assessed and considered for the least restrictive measures to ensure their safety and well-being and promote resident independence. The facility is required to submit a Plan of Correction for F-(Tag).

Based on facility policy review, medical record review, facility document review, observation, and interview, the facility failed to implement a care plan for risk of elopement for 1 of 13 sampled residents (Resident #2) reviewed for risk of wandering and/or elopement with a diagnosis of Dementia. The facility's failure to implement the care plan and interventions for Resident #2 placed the resident in Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The facility failed to implement an elopement care plan with interventions for Resident #2 which resulted in an elopement from the facility on 8/2/2022. The Administrator was notified of the Immediate Jeopardy on 11/15/2022 at 3:04 PM in the Administrator's Office. The facility was cited Immediate Jeopardy at F-656. The facility was cited at F-656 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was removed onsite and was effective from 8/2/2022 to 11/15/2022. An acceptable Immediate Action Removal Plan, which removed the immediacy of the jeopardy, was received on 11/15/2022 at 7:18 PM. The corrective actions were validated onsite by the surveyors on 11/15/2022 at 7:30 PM. The facility's noncompliance at F-656 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's policy titled, Elopement and Wandering Residents, revised 5/1/2020, revealed, .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff .TIPS FOR PREVENTION OF ELOPEMENTS .React to statements such as I want to go home. Observe for aimless wandering .Consider use of a personal alarm for the resident . Review of the facility's policy titled Comprehensive Care Plans, revised 5/1/2020, revealed, .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record . Review of the facility's policy titled Care Plan Revisions Upon Status Change, revised 5/1/2020, revealed, .The purpose of this procedure is to provide a consistent process for reviewing and revising for those residents experiencing a status change .The comprehensive care plan will be reviewed and revised as necessary, when a resident experiences a status change .Upon identification of a change in status the nurse will notify the MDS [Minimum Data Set] Coordinator, the physician .MDS Coordinator and the Interdisciplinary Team will discuss the resident condition and collaborate on intervention options .The care plan will be updated with the new or modified interventions .Care plans will be modified as needed .The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs . Review of medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia with Behavioral Disturbance. Review of Admission Minimum Data Set (MDS) dated [DATE], revealed Resident #2 scored 13 on the BIMS Assessment (indicating cognitively intact), limited assistance with bed mobility, transfer, dressing, toileting, and personal hygiene, supervision with walking and locomotion on unit, mobility devices of walker and wheelchair, and Non-Alzheimer's Dementia. Review of the Comprehensive Care Plan for Resident #2 initiated 7/12/2022, revealed, a care plan with goals and interventions for .At risk for Cardiac Complications .I have an ADL self-care performance deficit .I am at risk for falls .I have potential for pain .The resident has impaired cognitive function or impaired thought processes . and a care plan created on 8/3/2022 .I am at risk for elopement positive Wandering/Elopement assessment . There was no documentation provided by the facility of a Care Plan for wandering or elopement prior to Resident #2's elopement on 8/2/2022. Review of Resident #2's Social Services Notes revealed, .7/13/2022 .Resident is pleasantly confused .7/20/2022 .Resident came out of her room with all her belongings on rollator [wheeled walker]. SW [social worker] asked Resident where she was going. Resident stated that she would like to go to front office to sign out and go home .7/21/2022 .Resident came out of her room with all of her belongings and with her purse on her shoulder ready to go home .She is pleasantly confused . The SW notes from 7/13/2022 - 7/21/2022 confirmed Resident #2 was at risk for elopement. Review of a Behavior Note dated 7/27/2022 for Resident #2 revealed, Patient is currently becoming increasingly anxious and confused .Patient believes she is supposed to go work at [named hospital] as a nurse and she says she is running late for work. Patient has purse, jacket, and car keys in hand currently. I reoriented patient, but this has been an ongoing pattern throughout the day . Review of a Nurses Note dated 7/27/2022 for Resident #2 revealed, .AT BEDTIME RESIDENT REDIRECTED MULTIPLE TIMES FOR WANDERING, EXIT SEEKING, RESIDENT STATED THAT SHE WANTS TO GET HOME TO HER HUSBAND WHO IS HOME ALONE . Review of a Wandering Elopement assessment dated [DATE] for Resident #2 revealed .Wandering pattern .Objects to living away from own home .Wandering during disoriented period is common .At risk to wander or elope the facility .RESIDENT WANDERING ON UNIT, PURSE AND CAR KEYS WITH HER ON ROLLATOR, RESIDENT STATES NEED TO GET HOME TO HUSBAND WHO SHE SAYS IS HOME ALONE .Proceed to Care Plan as needed . Review of Facility's Reported Incident (FRI) #202282213039 dated 8/2/2022 confirmed Resident #2 eloped from the facility to an unsafe environment. During an interview in the conference room on 11/15/2022 at 11:00 AM, Assistant Director of Nursing (ADON) confirmed Resident #2's documented wandering/exiting behaviors exhibited should have been brought to the interdisciplinary teams attention to review plan of care and initiate increased monitoring interventions as appropriate. During an interview in the conference room on 11/15/2022 at 3:30 PM, the Director of Nursing (DON) confirmed the expectation was when a resident has a history of/or identified as a wander/elopement risk, nursing should contact the physician to obtain an order for a WanderGuard and initiate a care plan for wandering/elopement for the resident. The surveyors verified the acceptable Immediate Action Removal Plan on 11/15/2022 at by: 1. On 11/15/2022 surveyors revealed that Resident #2 who eloped from the facilty on 8/2/2022 did not have a care plan to reflect the risk for elopement. The nurse notes, social notes, and elopement risk assessment revealed prior to the elopement she was at high risk. 2. The surveyors verified that after the elopement on 8/2/2022 Resident #2 received a wanderguard and Elopement Plan of Care was put in place on 8/3/2022. 3. The facility will review nursing's notes and elopement risk assessments daily in morning meeting. Discuss the findings at daily Interdisciplinary Team (IDT) meetings to ensure that measures are put in place to ensure safety and the care plans are updated accordingly to reflect any changes in care. 4. The surveyors verified the facility educated all staff on care planning and crafting of care plans on 11/15/2022 and 11/16/2022. 5. The surveyor verified IDT Note on 8/3/2022 reviewed Resident #2's plan of care and interventions. 6. The surveyor verified Facility Elopement Books located at nurse's stations on each hall of facility were up to date with current of Walk and Talk Residents including pictures and WanderGuard battery expiration dates. 7. The surveyors verified the facility held an Elopement Assessment Changes Inservice on 8/3/2022. The facility implemented elopement assessments to be done on admission and again in 48 hours. The nurse would obtain an order for a WanderGuard for residents determined at risk for exiting the facility. Every ambulatory resident admitted will have WanderGuard placed X 7 days then re-evaluated. 8. The facility will report to the weekly at-risk meeting regarding nursing notes and elopement risk assessment to ensure that all in need of a care plan was completed. Weekly reporting to at-risk IDT meeting will continued for 3 months and then monthly for 3 months. Report findings and progress to quarterly Quality Assurance (QA). The facility is required to submit a Plan of Correction for F-(Tag).

Based on facility policy review, medical record review, and interview, the facility failed to prevent an accident which resulted in actual harm ([MEDICATION(S)] trauma to head with 3 staples needed for closure of a laceration) for 1 of 35 sampled residents (Resident #44). The findings include: Review of the facility's policy titled, Accidents and Incidents-Investigation and Reporting, revised 4/2006 revealed .All accidents or incidents involving residents .occurring on our premises must be investigated .the Nurse Supervisor .Charge Nurse shall .if necessary, transfer the injured person to the emergency room [ER] .hospital . Review of the facility's policy titled, Resident Accident/Incident Reporting, revised 3/7/2022, revealed .Purpose .All incidents are to be reported timely and appropriate interventions implemented .Resident incident reports are to be implemented at the time of the incident .investigation form to be completed immediately .incident reports will be reviewed by Interdisciplinary Team [IDT] within 24-72 hours .for additional interventions .or follow up needed . Review of the undated facility's policy titled, Falls Management Policy, revealed .It is a standard of practice to identify those residents that are at risk for falling and provide prompt intervention to decrease the number of occurrences .The facility understands that poor health and limited function makes the resident highly susceptible to falling .ensure interventions are on each report, and ensure that interventions are placed on the Care Plan . Review of the facility's policy titled, Fall Risk Assessment, dated 9/10/2022, revealed .it is the policy of this facility to provide an environment that is free from accidents .and provides .assistive devices to each resident to prevent avoidable accidents .An [At Risk for Falls] care plan will include interventions .consistent with a resident's needs, goals .in order to reduce the risk of an accident .Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary . Review of the medical record for Resident #44 revealed she was admitted to the facility on [DATE] with diagnoses which included Unspecified Dementia Without Behavioral Disturbance, Spinal Stenosis, Muscle Weakness, and Abnormalities of Gait and Mobility. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Continued review revealed Resident #44 required extensive assistance 1 person physical assistance for transfer, locomotion on unit, off unit and walking did not occur in the last 7 day period. Further review of the MDS revealed 2 falls with no injury and 2 falls with injury during the assessment reference dates. Review of the Care Plan for Resident #44 revealed a problem/assessment, .I am at risk falls related to impaired mobility .Anti-rollbacks to wheelchair . created on 3/4/2022. Review of the Progress Notes for Resident #44 revealed .3/4/2022 15:09 .Interdisciplinary Team [IDT] .Resident fall from chair on 3/3/2022, new skin tear .discussed in IDT meeting this AM .Anti-rollbacks to be applied to wheelchair . Continued review of the Progress Notes revealed .4/7/2022 13:50 IDT .fall from chair on 4/6/2022 discussed in IDT meeting this AM .Resident received head laceration to back of head, was sent to emergency room [ER] for eval/treatment [tx], returned with staples in place .therapy to evaluate seating .as resident often attempts to pull up on various objects . Review of the Disposition from the Emergency Department (ED) for Resident #44 revealed 4/6/2022 .The patient presents following fall .she has history of multiple falls .she complains of right shoulder pain .that worsened after the fall .head .2 centimeter [cm] scalp laceration .[MEDICATION(S)] trauma .due to fall .Procedure Laceration repair .4/6/2022 .Anesthesia .[MEDICATION(S)] .skin closure: #3 staples . Review of the Physical Therapy Treatment Encounter Note for Resident #44 dated 4/7/2022 revealed .Patient [Pt] had fall day prior .Pt was provided with dumped [slanted seat] manual wheelchair this date with nursing being made aware and with maintenance order being placed for anit-rollbacks to be installed .[manual] wheelchair was placed in room, with her to continue to use current chair until rollbacks can be added .Electronically signed .4/7/2022 02:48:33 PM . Review of The Equipment Lifecycle System (TELS) for Resident #44 (apartment-G4) revealed a work order created on 3/4/2022 with updated status on 4/1/2022 by Maintenance Director comment .this resident is in a high back reclinable wheelchair which prohibits me from installing anti rollback devices on it because the device is not designed to fit this type of chair . Further review of the TELS for Resident #44 revealed a work order created again on 4/8/2022 for Anti-rollbacks to wheelchair with updated status on 4/11/2022 by Maintenance Director comment .completed 4/11/2022 . Continued review of the TELS work order system confirmed an email dated 4/1/2022 was sent to the Administrator which confirmed comment .this resident is in a high back reclinable wheelchair which prohibits me from installing anti-rollback devices on it because the device is not designed to fit this type of chair . During an interview on 5/11/2022 at 3:43 PM, Maintenance Director confirmed he received a work order on 3/4/2022 to apply Anti-rollbacks to Resident #44's wheelchair and was unable to apply Anti-rollback to chair on 4/1/2022 and informed Administrator by email. Continued interview with the Maintenance Director confirmed Maintenance had numerous work orders to complete in TELS during that time frame. During an interview on 5/11/2022 at 3:39 PM, Rehab Director confirmed dump seat and anti-rollback to wheelchair were not completed until 4/11/2022. During an interview on 5/11/2022 at 3:46 PM, Administrator confirmed he did not inform the DON that Maintenance could not apply Anti-rollbacks to Resident #44's wheelchair. During an interview on 5/11/2022 at 4:20 PM, Director of Nursing (DON) confirmed Anti-rollbacks for wheelchair was on Care Plan on 3/4/2022 and also confirmed the intervention was not implemented until 4/7/2022 after the fall with injury on 4/6/2022.

Based on facility policy review, medical record review, and interview the facility failed to implement a care plan intervention for a fall for 1 of 4 sampled residents (Resident #44), which resulted in actual harm ([MEDICATION(S)] trauma to head with 3 staples needed for closure of a laceration). The facility also failed to implement a care plan for 1 of 35 sampled residents (Resident #76) reviewed for care plans. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 9/20/2016, revealed, .Plans of Care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident related to clinical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .[named facility] staff will refer to the goals and interventions when evaluating the residents progress .the plan of care will be reviewed .as needed to enhance the resident's ability to meet his/her objectives . Review of the medical record for Resident #44 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Continued review revealed Resident #44 required extensive assistance 1 person physical assistance for transfer, locomotion on unit and off unit. Further review of the MDS revealed 2 falls with no injury and 2 falls with injury during the assessment reference dates. Review of the Care Plan for Resident #44 revealed an intervention created on 3/4/2022 for Anti-rollbacks (prevents wheelchair from rolling when resident stands) to wheelchair. Continued review revealed no additional interventions were placed on the care for 3/4/2022. Review of The Equipment Lifecycle System (TELS) for Resident #44 (apartment - G4) revealed a work order created on 3/4/2022 with updated status on 4/1/2022 by Maintenance Director commented .this resident is in a high back reclinable wheelchair which prohibits me from installing anti rollback devices on it because the device is not designed to fit this type of chair . Further review of the TELS for Resident #44 revealed an additional work order (for the Anti-Roll back devices) was submitted on 4/8/2022 with updated status on 4/11/2022 by Maintenance Director commented .completed 4/11/2022 .[referring to the placement of the Anti-rollback devices on another wheelchair]. Continued review of the TELS work order system confirmed an email dated 4/1/2022 was sent to the Administrator which confirmed comments .this resident is in a high back reclinable wheelchair which prohibits me from installing anti-rollback devices on it because the device is not designed to fit this type of chair . During an interview on 5/11/2022 at 3:43 PM, Maintenance Director confirmed he was unable to apply Anti-rollback to chair on 4/1/2022 and informed the Administrator by email. Continued interview with the Maintenance Director confirmed Maintenance had numerous work orders to complete in TELS during that time frame. During an interview on 5/11/2022 at 4:20 PM, Director of Nursing (DON) confirmed Anti-rollbacks for wheelchair was on Care Plan on 3/4/2022 and also confirmed the intervention was not implemented until 4/7/2022 after the fall on 4/6/2022. During an interview on 5/11/2022 at 3:46 PM, Administrator confirmed he did not inform the DON that Maintenance could not apply Anti-rollbacks to Resident #44's wheelchair. Review of the medical record revealed Resident #76 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #76 had poor short term and long term memory. Continued review of the MDS revealed Resident #76 required extensive assist with Activities of Daily Living (ADLs). Review of the active Order Summary Report for Resident #76 revealed 5/27/2021 .[MEDICATION(S)] [antiplatelet] tab 75 milligram [mg] give 1 tablet by mouth one time a day related to [CONDITION(S)] Disease .2/6/2022 .Levetiraceta Sol [Anticonvulsant] 100 mg/milliliters [ml] give 5 ml by mouth two times a day related to Unspecified Convulsions . Review of the current Care Plan revealed no care plan to address the use of [MEDICATION(S)] which puts Resident #76 at risk for bleeding or bruising and the use of an Anticonvulsant. During an interview on 5/10/2022 at 3:30 PM, MDS Coordinator confirmed the Care Plan did not address the use of an Antiplatelet and an Anticonvulsant medication.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure resident identifiable information was kept confidential for 2 of 32 sampled residents (Resident #3 and #34) reviewed. The facility also failed to maintain patient confidentiality related to 1 of 5 computer screens open with resident health information visualized with no staff attendance. The findings include: Review of facility policy titled, HIPAA (Health Information Portability and Accountability Act), dated 7/15/2020, revealed, .It is the policy of this facility to apply sanctions against employees who fail to comply with all policies and procedures regarding the protection of personal identifiable health information of our residents .This information from any source and in any form, including, but not limited to paper records, oral communications, audio/digital recordings, and electric display of information is strictly confidential . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation in Resident #3's room on 5/9/2022 at 10:25 AM and 2:32 PM, revealed the Nurse Aide Information Sheet containing Resident #3's identifiable patient information was on top of the bedside table at the foot of his bed in view of anyone who came in the room. Observation in Resident #34's room on 5/9/2022 at 10:25 AM, 11:20 AM, and 2:29 PM, revealed the Nurse Aide Information Sheet containing Resident #34's identifiable patient information was posted on the wall under the clock at the foot of her bed in view of anyone who came into the resident's room. Interview at the K Hall Nurses' station on 5/9/2022 at 2:42 PM, Certified Nurse Technician (CNT) #1 and Registered Nurse (RN) #1 both stated, Resident care plans are kept on the computer and a copy should be on the door inside the resident's closet. Observation and interview in Resident #3's room on 5/9/2022 at 2:44 PM, RN #1 confirmed the Nurse Aide Information Sheet for Resident #3 was laying on the bedside table at the foot of the resident's bed in view of anyone who entered his room. RN #1 stated, It [Nurse Aide Information Sheet] should not be out in the room, it should be in the closet out of sight due to HIPAA. During an interview in Resident #34's room on 5/9/2022 at 2:46 PM, RN #1 confirmed the resident's Nurse Aide Information Sheet was posted on the wall under the clock at the foot of the resident's bed. RN #1 stated, It should not be on the wall, it should be in the closet. During an interview on 5/9/2022 at 3:04 PM, the Director of Nursing (DON) confirmed Nurse Aide Information Sheets should be in the computer or posted inside the closet door in the patient rooms. Observation of the I Hall medication cart on 5/10/2022 at 4:20 PM, revealed a computer screen open and unattended containing resident identifiable information in view of visitors. During an interview on 5/10/2022 at 4:22 PM, Licensed Practical Nurse (LPN) #3 confirmed she had left the computer screen open with resident identifiable information in view while she wasn't at the medication cart. During an interview on 5/10/2022 at 4:30 PM, RN #2 (also known as the Unit Manager for I Hall) confirmed the computer screen was to be placed on the privacy screen when unattended.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure the food and drink was at the proper temperature during the noon meal on 5/9/2022. The findings include: Review of the facility's policy titled, Food Preparation and Service, dated 4/2018, revealed, .Food service employees will prepare and serve food in a manner that complies with safe handling food practices. The danger zone for food temperatures is between 41 F [degrees Fahrenheit] and 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Potentially hazardous foods include meat, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese .The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, potentially hazardous foods must be maintained at or below 40 F or at or above 136 F . Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with readmission on 3/2/2022, with diagnoses which included [CONDITION(S)], Chronic Diastolic [CONDITION(S)], and Morbid Severe Obesity. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with readmission on 6/16/2021, with diagnoses which included [CONDITION(S)] and [CONDITION(S)] Following Cerebral Infarction Affecting Left Non-Dominant Side, Major Depressive Disorder and Malignant Neoplasm of Colon. Review of the Quarterly MDS assessment 3/14/2022, revealed Resident #42 had a BIMS score of 15 which indicated no cognitive impairment. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with readmission on 12/13/2019 with diagnoses which included Type 2 Diabetes Mellitus with Diabetic [CONDITION(S)]/Chronic Kidney Disease and Morbid Obesity. Review of the Quarterly MDS assessment dated [DATE], revealed Resident #43 had a BIMS score of 15 which indicated no cognitive impairment. Observation and interview on the H hall on 5/9/2022 at 11:43 AM, during the noon meal, revealed the milk was 46 degrees Fahrenheit on test tray. The Dietary Manager confirmed the milk was 46 degrees and should be less than 40 degrees Fahrenheit. During an interview on 5/9/2022 at 10:06 AM, Resident #27 stated her food was always cold. During an interview on 5/9/2022 at 10:10 AM, Resident #43 stated her food was always cold, and food was being served on foam containers. During an interview on 5/9/2022 at 3:05 PM, Resident #42 stated her food was always served very cold.

Based on facility policy review, observation, and interview, the facility failed to serve food in a sanitary manner for residents being assisted with the lunch meal on 6/27/2022. The findings include: Review of the facility's policy titled, Food Safety Requirements, dated 4/12/2020, revealed, .Staff shall not touch food with bare hands . Observation in the H/I Dining room on 6/27/2022 at 12:03 PM, revealed Certified Nurse Assistant (CNA) #6 placed her bare left hand on the resident's sandwich and cut the sandwich with a knife with her right hand and then picked up a resident's sandwich from his meal tray with her bare right hand and began to hand the sandwich to the resident. During an interview on 6/27/2022 at 12:04 PM, CNA #6 confirmed she was holding the resident's sandwich in her right bare hand. During an interview on 6/27/2022 at 12:05 PM Registered Nurse #1 (who was sitting at the table with the resident and CNA #6), confirmed CNA #6 touched the resident's sandwich with her bare hands. She stated, We are not to touch residents' food with our bare hands.

Based on facility policy review, observation, and interview, the facility failed to serve food in a sanitary manner for residents being assisted with the lunch meal on 6/27/2022. The findings include: Review of the facility's policy titled, Food Safety Requirements, dated 4/12/2020, revealed, .Staff shall not touch food with bare hands . Observation in the H/I Dining room on 6/27/2022 at 12:03 PM, revealed Certified Nurse Assistant (CNA) #6 placed her bare left hand on the resident's sandwich and cut the sandwich with a knife with her right hand and then picked up a resident's sandwich from his meal tray with her bare right hand and began to hand the sandwich to the resident. During an interview on 6/27/2022 at 12:04 PM, CNA #6 confirmed she was holding the resident's sandwich in her right bare hand. During an interview on 6/27/2022 at 12:05 PM Registered Nurse #1 (who was sitting at the table with the resident and CNA #6), confirmed CNA #6 touched the resident's sandwich with her bare hands. She stated, We are not to touch residents' food with our bare hands.

Based on facility policy review, medical record review, observation, and interview the facility failed to provide ADL (activities of daily living) care for 1 of 35 sampled residents (Resident #24). The findings include: Review of the facility policy titled, Activities of Daily Living (ADLs) revised 5/1/2020 revealed .A resident who is unable to to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. Continued review revealed Resident #24 required extensive assistance of one staff member for personal hygiene. Review of the current Care Plan dated 12/8/2021, revealed, .I have an ADL self care performance deficit .Nutritional risk R/T (related to): [CONDITION(S)] .Interventions: Staff to provide set up and assist with daily oral care as needed . Observation in Resident #24's room on 5/9/2022 at 10:51 AM, revealed Resident #24 was seated in his wheelchair with the television on. A bedside table was in front of Resident #24 and he had 5 cups of various thickened liquids. Resident #24 had dried white debris on his mouth and face. Continued observation revealed Resident #24 was wearing a shirt and plaid pajama pants which had dried white debris stains. Observation in the J and K dayroom on 5/9/2022 at 2:58 PM, revealed Resident #24 seated in his wheelchair. Resident #24 had dried green debris covered on his mouth. Continued observation revealed Resident #24 was wearing both tennis shoes with one non-skid sock. The tennis shoes were dirty. During an interview on 5/9/2022 at 3:30 PM, Certified Nurse Technician (CNT) #1, stated when asked if Resident #24's mouth was clean, she confirmed, no it is not clean at the moment. CNT #1 confirmed Resident #24's shoes were dirty, and he was wearing only one non-skid sock. During an interview on 5/9/2022 at 3:38 PM Registered Nurse (RN) #1 confirmed Resident #24's mouth and shoes were dirty. RN #1 expected the residents to wear clean clothes, have clean teeth, brushed hair, and not to be in a gown. During an interview on 5/11/2022 at 11:31 AM, the Director of Nursing (DON) expected the staff to perform mouth care on the residents after a meal especially if their mouth is covered with food. The DON stated she expected staff to have residents wearing clean clothes and shoes.

Based on facility policy review, facility documentation review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored for 2 of 57 residents (Resident #10 and #51). The facility also failed to ensure medications and biologicals were stored and discarded properly in 2 of 5 medication carts. The findings include: Review of the facility's policy titled, Medication Storage, dated [DATE], revealed, .It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. During a medication pass, medications must be under the direct observations of the person administering medications or locked in the medication storage area/cart . Review of the facility's policy titled, Storage of Medication Requiring Refrigeration, dated [DATE], revealed, .It is the policy of this facility to assure proper and safe storage of medications requiring refrigeration and to prevent the potential alteration of medication by exposure to improper temperature controls. Date label of any multi-use vial when the vial is first accessed (needle punctured). the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial . Review of the undated facility's documentation titled, Extended Care Pharmacy Medication Expiration Dates, revealed, .Medication type: Insulin, Expiration Date: Must be dated when removed from refrigeration, Expectations: [MEDICATION(S)]-28 days, [MEDICATION(S)]-28 days. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Insulin [MEDICATION(S)] Solution 100 Unit/Ml [milliliter] Inject 10 unit subcutaneously every morning and at bedtime for diabetes . Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #51's Order Summary Report revealed, .[DATE] .Insulin Detemir Solution 100 Unit/Ml Inject 16 unit subcutaneously in the morning for diabetes . Observation and interview in Resident #28's room on [DATE] at 10:46 AM, revealed a cup with 8 unidentified pills and a bottle of prescription eye drops sitting on the over bed table, unattended. During interview, Licensed Practical Nurse (LPN) #1 and Unit Manager/Registered Nurse (RN) #2 confirmed the medications were unattended in the room on the table. Observation and interview in Resident #87's room on [DATE] at 2:54 PM, revealed two medicine cups containing cream and ointment were sitting on the dresser. During interview LPN #1 confirmed the medications were topical skin treatments and should not be sitting in the room unattended by the nurse. Observation and interview of the F & G Hall medication carts on [DATE] at 4:45 PM, in the presence of LPN #2 revealed one [MEDICATION(S)] [MEDICATION(S)] pen opened on [DATE] and two insulin [MEDICATION(S)] flex pens unopened and undated. During interview LPN #2 confirmed the [MEDICATION(S)] [MEDICATION(S)] pen on the cart was opened and expired and there were two insulin [MEDICATION(S)] flex pens unopened and undated on the medication cart. During continued interview she confirmed the unopened insulin was to be stored in the refrigerator until opened. During an interview on [DATE] at 10:45 AM, Registered Nurse (RN) #2 confirmed when insulin was brought in from the pharmacy, it was to be kept in the refrigerator until opened, then placed on the medication cart and discarded after 28 days.

Based on facility policy review, medical record review, and interviews, the facility failed to ensure 1 of 5 sampled residents (Resident #44) was monitored for the side effect of Tardive Dyskinesia (a condition affecting the nervous system, often caused by long-term use of some psychiatric drugs. Symptoms include repetitive muscle movements in the face, neck, arms and legs) related to the use of antipsychotic medication. The findings include: Review of the facility's policy dated 5/1/2020, with an addendum added on 5/11/2020, titled, Use of Antipsychotic Drugs, revealed, .It is the facility's policy that each resident's drug regimen is free from unnecessary drugs, including unnecessary antipsychotic drugs .AIMS [Abnormal Involuntary Movement Scale] Assessment done every 6 months to monitor for abnormal involuntary movements for residents taking Antipsychotic medications .AIMS are completed by Psyche or MDS [Minimum Data Set] Coordinator . Review of the medical record for Resident #44 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. Continued review revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed she received an antipsychotic 7 days out the the 7-day look back period. Review of the active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Records (MARs) for Resident #44 dated 4/1/2022 and 5/1/2022, revealed she was administered [MEDICATION(S)] 15 mg each morning. Review of the medical record for Residnt #44 revealed there was no AIMS assessment completed and the resident continued to receive antipyschotic medications. Review of the current Care Plan for Resident #44 revealed an assessment/problem, .The resident uses [CONDITION(S)] medications .Observe/document/report PRN [as needed] any adverse reactions of [CONDITION(S)] medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/11/2022 at 11:50 AM, the MDS Coordinator confirmed Resident #44 was scheduled to have an AIMS assessment completed in February 2022, and it was not done. During an interview on 5/11/2022 at 4:20 PM, the Director of Nursing confirmed Resident #44 should have had an AIMS assessment completed in February, and it was not done.

Based on medical record review, observation, and interview the facility failed to keep water in reach for 1 of 35 sampled residents (Resident #11) observed. The findings include: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated moderate cognitive impairment. Review of the current care plan dated 1/5/2022 revealed .Nutritional risk r/t [related to]: dx [diagnosis] dementia, history of GERD [Gastro-[CONDITION(S)] Reflux Disease], [CONDITION(S)] [Chronic Obstructive Pulmonary Disease], [CONDITION(S)], hx [history] breast CA [cancer], DM [diabetes mellitus], Constipation, dysphagia .Interventions: Offer fluids throughout the day . Observation in Resident #11's room on 5/9/2022 at 11:07 AM, revealed Resident #11 was in bed and her water pitcher and covered glass of water were on the bedside table out of reach of the resident. Observation and interview in Resident #11's room on 5/9/2022 at 11:12 AM, Resident #11 stated she felt she had something in her throat and reached for the water pitcher or glass of water and could not reach it. Observation in Resident #11's on 5/9/2022 at 11:19 AM, revealed Registered Nurse (RN) #1 moved the bedside table close to resident as she laid the lunch tray down. During an interview on 5/9/2022 at 11:22 AM, RN #1 confirmed Resident #11's water pitcher and glass of water were out of reach.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure 95 of 98 (3 of the 98 residents required enteral feedings) residents were treated in a dignified manner during the lunch meal on 5/9/2022. The findings include: Review of the facility's policy titled, Resident Rights, dated 2016, revealed, .The resident has a right to be treated with respect and dignity . Review of the medical record revealed Resident #15 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. Continued review revealed she had severely impaired vision and required extensive assistance for all Activities of Daily Living (ADLs), and total dependence for eating. Observation in Resident #15's room on 5/9/2022 at 11:35 AM, revealed she was sitting in a reclining chair beside her roommate's bed without a lunch tray. Her roommate was laying in bed eating her lunch. The privacy curtain was not pulled between the residents. Resident #15 stated, I'm hungry. When asked if she could smell the food she stated, Yes, and I am hungry. Observation and interview in Resident #15's room on 5/9/2022 at 12:08 PM, revealed the MDS coordinator delivered Resident #15's lunch tray, 30 minutes after her roommate's tray was delivered. Her roommate had finished her lunch tray. The MDS coordinator confirmed Resident #15 was an assisted diner and she delivered her tray at this time. She confirmed Resident #15's roommate had already received her tray and had already eaten. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE] revealed Resident #37 had short and long term memory problems. Continued review revealed Resident #37 required extensive assistance with one staff member during meals. Review of the undated paid feeding assistant list of residents revealed Resident #37 was assigned to the service to receive assistance. Observation in the J and K dayroom on 5/09/2022 at 11:45 AM and 11:46 AM revealed Certified Nurse Technician (CNT) #6 was standing and feeding Resident #37 her lunch meal. During an interview on 5/9/2022 at 11:48 AM, CNT #6 confirmed she was standing while feeding Resident #37's lunch. When surveyor asked how should you feed the resident, She stated, sit in front for her and correctly administer the food to her mouth. During an interview on 5/11/2022 at 11:31 AM, the Director Of Nursing (DON) stated, she expected staff to be seated while feeding residents their meals. Observation and interview in the kitchen on 5/9/2022 at 11:00 AM, revealed food was being served on foam dishware. During an interview, the Certified Dietary Manager (CDM) stated the food was being served on foam dishware because they were short staffed. She stated it should get better in 2 weeks. Observation in the J and K dayroom on 5/9/2022 during the lunch meal at 11:31 AM to 11:59 AM, revealed 4 residents were seated at a table. Continued observation revealed 3 of the 4 residents were served their meal at 11:31 AM. The fourth resident was served her meal at 11:59 AM, 28 minutes after the other residents were served. Further observation revealed the lunch meal was served to all residents in the dayroom on foam dishware. During an interview on 5/9/2022 at 11:49 AM, Licensed Practical Nurse (LPN) #5 confirmed there were 4 residents seated at the same table in the dayroom, and 3 residents were served their meal, and eating before the 4th resident was served. During an interview on 5/11/2022 at 10:30 AM, the DON stated the dining process was for the staff to pass out meal trays in the dining room to all the residents sitting at the same table at the same time and deliver the meal trays to the residents in the same room at the same time. Continued interview she stated she expected the staff to serve meals to the residents at the same time whether in the dayroom or in their rooms.

Based on facility policy review, medical record review, facility documentation, and interview, the facilty failed to update/revise the care plan for 1 of 35 sampled residents (Resident #63) reviewed. The findings include: Review of the facility policy titled, Care Plan Revision Upon Status Change revised 5/11/2022 revealed .The care plan will be updated with the new and modified interventions . Review of the medical record revealed Resident #63 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated no cognitive impairment. Continued review revealed Resident #63 had a fall prior to the assessment. Review of the fall investigations revealed Resident #63 had falls on 4/3/2021, 9/5/2021, and 2/14/2022. Review of the current care plan revealed no revised fall interventions for 4/3/2021, 9/5/2021, and 2/14/2022. During an interview on 5/11/2022 at 4:19 PM, the MDS Coordinator confirmed falls on 4/13/2021, 9/5/2021, and 2/14/2022 did not have revised fall interventions on the current care plan.

Based on facility policy review, facility investigation, medical record review, observation, and interview, the facility failed to ensure a safe environment and provide adequate supervision to prevent elopement for 1 (Resident #1) of 9 sampled residents reviewed with wandering behaviors, which resulted in Immediate Jeopardy. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to supervise a vulnerable resident who was assessed as a high elopement risk which resulted in Resident #1's elopement. The facility's failure placed Resident #1 in Immediate Jeopardy. The Administrator was notified of the Immediate Jeopardy on 8/5/2021 at 5:13 PM in the conference room. The facility was cited Immediate Jeopardy at F-689 at the scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was effective 8/1/2021 through 8/6/2021. An acceptable Removal Plan, which removed the immediacy of the Jeopardy, was received on 8/5/2021 at 6:00 PM. The corrective actions were validated onsite by the surveyor on 8/6/2021. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility must submit a Plan of Correction. The findings include: Review of the facility policy titled, Elopements and Wandering revised 7/19/2020 revealed .This facility ensures that residents who exhibit wandering behaviors and/or at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk .Elopement occurs when a resident leaves the premises or safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so .1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. 5. Procedure for Locating Missing Resident: a. Any staff member becoming aware of a missing resident will alert personnel using facility-approved protocol (e.g., internal alert WALK AND TALK) . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Dementia with Behavioral Disturbances, Mood Affective Disorder, Insomnia, and Wandering. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. Continued review revealed Resident #1 exhibited behavior of wandering from 1 to 3 days. Continued review revealed Resident #1 required a wandering/elopement alarm daily. Review of the Admission MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 13, indicating no cognitive impairment. Continued review revealed Resident #1 required a wandering/elopement alarm daily. Review of the Care Plan dated 7/20/2021 revealed Resident #1 was assessed for being at risk for elopement related to Dementia. Continued review of the Care plan interventions revealed .Staff to monitor and redirect exit seeking behaviors .Wander-guard device [body alarm to alert staff of close proximity to exits] checked weekly .Wander-guard to right ankle to alert staff of resident getting to the door to the outside with door auto-lock for resident safety . Continued review of the Care Plan intervention dated 8/1/2021 revealed .More frequent observation with every 15-minute checks . Review of the Elopement Risk Tool dated 7/19/2021 revealed Resident #1 had displayed exit-seeking- behaviors. Continued review revealed Resident #1 had a pattern of wandering through the facility and into other residents' rooms. Continued review revealed that Resident #1 was at risk for elopement. Review of the Elopement Risk Tool dated 8/1/2021 revealed that Resident #1 had left the facility without informing staff, and her behavior affected her safety and well-being. Review of the current Physician Orders dated 7/19/2021 revealed .Check wonderguard [wander guard] placement to right ankle every shift .weekly wanderguard [wander guard] check due this shift .Behaviors exhibited by resident this shift such as wandering and exit seeking . Review of the facility investigation dated 8/1/2021 revealed an alarm was sounding at one of the side exits or entrance. A visitor at the time had told staff Resident #1 had exited the door. Continued review revealed that Resident #1 was walking outside the facility .60 yards from the entrance . Resident #1 was found still on the grounds and told staff she wanted to go for a walk. Review of the Progress Notes dated 8/1/2021 revealed that the Activity Director asked Licensed Practical Nurse (LPN) #1 if Resident #1 was in bed. LPN #1 said Resident #1 was not in bed but was in the common area some minutes ago. Resident #1 was last seen approximately 11:15 AM to 11:20 AM. The Activity Director and LPN #1 left the unit to look for Resident #1. The visitors described Resident #1 and stated she had just walked through the lobby doors. The Activity Director and LPN #1 went outside to search for Resident #1. Other staff members notified the Activity Director they had noticed Resident #1 outside after hearing the alarm. Resident #1 was brought back into the facility while wearing the wander guard bracelet. Resident #1 apologized to LPN #1, stating she just wanted to go for a walk. Observation of the courtyard on 8/5/2021 at 10:18 AM revealed two doors to enter or exit the enclosure. Continued observation revealed the courtyard door furthest from the unit led to the Aviary lobby, which had an entrance or exit to the parking lot. Continued observation revealed visitors could enter through the Aviary lobby to participate in their scheduled visits with residents in the lobby or by going through the door to the courtyard for an outside visit. Observation in Resident #1's room on 8/5/2021 at 10:21 AM revealed she had a flat affect and was positioned in the fetal position while in bed with the blankets pulled very close to her body. Resident #1 was guarded and did not answer questions when spoken to by the surveyor. Observation and interview on 8/6/2021 at 11:54 AM revealed Resident #1 had eaten lunch and was observed conversing with staff. Resident #1 stated she did not know why she left the building but knew she wanted to get out of the facility. Continued interview revealed Resident #1 had walked to the end of the driveway and had started walking back to the facility. During an interview on 8/5/2021 at 10:08 AM and 3:15 PM, Certified Nurse Aide (CNA) #1 stated on 8/1/2021 she observed Resident #1 walking around the unit and asked her if she wanted to eat her lunch. Resident #1 said she did not want to eat. CNA #1 continued to pass lunch trays to the other residents. Further interview revealed that 20 to 25 minutes later, she was told Resident #1 was brought back from outside the facility. CNA #1 stated she did not hear an alarm go off and was not aware anyone had eloped. During an interview on 8/5/2021 at 12:03 PM, CNA #2 stated ton 8/1/2021 the staff had finished passing trays, and she went to the dining room to assist residents with their meals. CNA #2 said the last time she saw Resident #1, she was seated next to the dining room's double doors, and she was asked if she wanted her lunch, but she refused the offer. Continued review revealed LPN #1 was in the dining room assisting residents with their meals. CNA #2 had not noticed Resident #1 had walked out of the dining room. The Activity Director had walked into the dining room and asked if CNA #2 and LPN #1 had seen Resident #1. CNA #2 looked on the unit, and Resident #1 was not there. The Activity Director went back out to look for Resident #1. CNA #2 stated she did not hear the alarm when she left the building. During an interview on 8/5/2021 at 12:28 PM, LPN #1 stated at 11:00 AM or 11:15 AM on 8/1/2021, she was at the nurses' station charting. LPN #1 noticed Resident #1 walking on the unit and asked her if she wanted to eat and take her morning medications. Resident #1 then sat in the chair and stated, she might take a walk later or after a while. LPN #1 finished charting and went to the dining room to assist a resident with lunch. LPN #1 stated she saw Resident #1 walk past her and went outside with another resident. LPN #1 thought the courtyard was enclosed. LPN #1 said she heard the alarm go off, but it stopped quickly. Further interview revealed LPN #1 believed Resident #1 walked through the courtyard into the Aviary lobby and out the door. Visitation was going on in the Aviary lobby and the visitors saw Resident #1 leave through the door. Continued interview confirmed, can't say that there is always someone out there [courtyard] to watch the residents in the courtyard. Continued interview revealed the Activity Director had alerted LPN #1 that Resident #1 had left the building. LPN #1 and the Activity Director went to look for Resident #1. LPN #1 went out the Aviary lobby door. The Activity Director went the other way toward the H and I unit front door. While out in the parking lot LPN #1 and the Activity Director were alerted by staff that the resident was found. During an interview on 8/5/2021 at 1:25 PM with the Maintenance Director, revealed on 8/1/2021 he and the Central Supply Coordinator were driving toward the facility between 11:30 AM and 11:35 AM and saw someone walking on the rear-drive of the facility. The Maintenance Director turned around, and the Central Supply Coordinator recognized Resident #1. Resident #1 was located on the access road for deliveries located in the back of the facility. Continued interview revealed Resident #1 was approximately 60 yards from the building, walking toward the front of the main road. The Maintenance Director stopped his vehicle. The Central Supply Coordinator asked Resident #1 to ride with them back to the facility. Resident #1 refused to ride back. The Maintenance Director went to the facility and got help from the nurses and techs. The staff was able to persuade Resident #1 to ride in the truck back to the facility. One of the nurses rode with the Maintenance Director, the Central Supply Coordinator, and Resident #1 back to the facility. Resident #1 stated she just wanted to go for a walk. Continued interview revealed the Maintenance Director stated the facility was located on 22.5 acres of land. During an interview on 8/5/2021 at 2:43 PM, the Activity Director stated she had two family visits on 8/1/2021, one in the Aviary lobby and the other in J and K dining room. Both visits were scheduled at 11:00 AM and were 45 minutes long. Approximately 11:50 AM, the Activity Director went to the Aviary lobby and heard the alarm. The Activity Director asked the visitors what caused the alarm to sound. The visitors described Resident #1 and stated she had left the building through the door. The Activity Director went through the courtyard to alert LPN #1 who was assisting another resident with the lunch meal. The Activity Director told LPN #1 Resident #1 was out of the building, and they needed to find her. Continued interview confirmed I panicked. I probably should have told one of the staff members to do walk and talk in the whole building. Continued interview revealed that as soon as the Activity Director and LPN #1 went outside into the parking lot, a nurse was banging on the window, telling them Resident #1 was found and was heading back to the facility. Continued interview revealed that during visitation, the staff is not present. However, they come by often to check on the resident to inquire if they need toileting. The doors to the courtyard did not have alarms on them at the time of the elopement. During an interview on 8/5/2021 at 3:29 PM, the Director of Nursing (DON) confirmed staff did not call walk and talk on 8/1/2021 to make sure all residents were accounted for. Continued interview confirmed the DON expected the residents with wandering and exit-seeking behaviors to be monitored and for staff to check the resident's locations frequently. The DON revealed if the alarm to the Aviary lobby door sounded, it was heard at the G unit nurse station annunciator. The staff could locate which entry or exit alarm was sounding as well as the unit and section of the building. During an interview on 8/5/2021 at 4:18 PM, LPN #2 stated he worked on 8/1/2021 on the H and I unit and was alerted by the Maintenance Director. However, he did not know what time the alert happened. The Maintenance Director told LPN #2 Resident #1 was outside with the Central Supply Coordinator and they needed help bringing Resident #1 back to the facility. LPN #2 thinks he and possibly three CNAs ran to retrieve Resident #1. When they arrived, Resident #1 was at the end of the service road. The resident looked fine anybody would have thought she was someone just walking on the grounds until you started talking to her. Resident #1 had a book in her hands, and the weather was in the '80s with cloud coverage. LPN #2 assisted Resident #1 into the Maintenance Director's truck; rode to the front of the building; and met the F and G unit staff who escorted Resident #1 to her unit. During an interview on 8/6/2021 at 9:37 AM, the Central Supply Coordinator stated she and the Maintenance Director were driving to the facility around 11:30 AM or 11:45 AM on 8/1/2021 and saw a lady walking on the access road behind the building. The Central Supply Coordinator told the Maintenance Director to turn around, and she recognized the resident. The Central Supply Coordinator got out of the car and stayed with Resident #1. The Central Supply Coordinator stated Resident #1 looked fine to her and and was carrying two books. Resident #1 stated she wanted to walk. The Central Supply Coordinator and Resident #1 started to walk back, but then other staff members arrived. It was decided to have Resident #1 ride in the truck back to the front of the facility. During a telephone interview on 8/6/2021 at 12:27 PM, a visitor stated he visited a resident on 8/1/2021. A lady (Resident #1) came from the courtyard during the visitation; spoke with him; and walked toward the lobby door. The alarm sounded for 20 to 30 seconds, and the door opened to allow Resident #1 to exit. The Activity Director came around 40 to 50 seconds later, heard the alarm, and asked him what happened. The visitor told the Activity Director what happened, and she and another lady left the building. They then came back with Resident #1. They were pretty prompt. During an interview on 8/6/2021 at 1:25 PM, the Administrator stated he was not in the building on 8/1/2021 when the elopement took place. Continued interview revealed the Administrator thought Resident #1 was supervised. There was no documentation to instruct staff to conduct a one-on-one with the resident. Continued interview confirmed the staff did not perform the walk and talk procedure 100 % when the elopement was recognized. Continued interview confirmed all staff should know the policy to locate residents in the instance of an elopement. The Administrator stated, if a resident is going to get out, they are going to get out. It is unfortunate that it happened. Continued interview confirmed the Administrator felt Resident #1 was safe unless she physically encountered something that made her unsafe walking outside. Based on the documentation by the facility and interviews, it is difficult to tell how long the resident was outside. Resident #1 eloped on a Sunday when the weather was overcast with a temperature of 75 degrees at noon. On one side of the building there are train tracks which are in use daily. Further down the road to the facility is a creek which overflows when it rains. The surveyor verified the Removal Plan by: 1. The surveyor verified on 8/1/2021, the facility tested all secure care doors for proper function. All wander guard devices were tested . The surveyor reviewed the documentation, observed, and interviewed the Maintenance Director. 2. The surveyor verified on 8/1/2021, Resident #1 was placed on 15 minutes checks for 72 hours, 1 hour for 24 hours, and every 4 hours until review by the IDT (interdisciplinary team) on 8/10/2021. The surveyor reviewed the documentation and interviewed the DON. 3. The surveyor verified the Psychiatrist evaluated Resident #1 on 8/3/2021. The surveyor reviewed the consult. 4. The surveyor verified on 8/5/2021, the facility evaluated all the residents for elopement risks and to apply appropriate interventions if a chance was identified. The surveyor reviewed the documentation. 5. The surveyor verified on 8/5/2021, the facility provided education to all staff on procedures if a resident makes statements which describe eloping from the facility. The surveyor reviewed the documentation. Noncompliance of F-689 continues at a scope and severity of D for the monitoring of the effectiveness of corrective actions. The facility must submit a Plan of Correction.

Based on facility policy review, medical record review, observation and interview the facility failed to maintain 1 (F- Wing /COVID -19 Unit) of 4 outside hall exits in a safe and sanitary condition. The findings include: Review of the facility policy Disposal of Garbage and Refuse revised 7/15/2020 revealed .Refuse containers shall be emptied throughout the day .Storage areas, enclosures, and receptacles for refuse shall be maintained in good repair and cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents .Refuse containers shall be emptied at the end every shift, to avoid having it remain in areas . Review of the Job Description for Housekeeper, dated 6/30/2017 revealed .Trash pick-up .Empties and cleans ashtrays. Empties, cleans and relines wastebaskets and places bags in receptacle to be transported to dumpster. Checks rooms again and empties trash as needed while cleaning individual rooms . Observation on 9/22/2020 at 8:43 AM revealed a garbage bin overflowing with full garbage bags and three full garbage bags surrounding the garbage bin outside of the F-Wing exit. During an interview on 9/22/2020 at 12:26 PM with the Director of Nursing (DON), when shown a picture of the F-Wing exit, confirmed the garbage pile was from the F and G wings and it was housekeeping's job to pick up the garbage and take it to the dumpster every morning and throughout the day. During an interview on 9/22/2020 at 1:22 PM with the Houskeeping Manager confirmed our dumpster were maxed this morning and that is the reason we did not get a chance to dump them.

Based on facility policy review, medical record review, facility documentation review and interview, the facility failed to follow the care plan for Resident #1 related to transfers which caused harm that resulted in a Right Humerus Fracture for 1 resident (Resident # 1) of 6. The findings include: Facility policy review, Comprehensive Care Plan, dated (YEAR) revealed .the facility will develop and implement a care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .the care plan will include healthcare information necessary to properly care for a resident . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with readmission on 5/28/19 with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 00 indicating the resident was severely cognitively impaired. Continued review revealed the resident required total assist of staff with transfers. Medical record review of Resident #1's Care Plan dated 4/13/18 revealed .Transfer assistance of full body lift x 2 (two people assist) assist . Medical record review of Resident #1's Nurse Aid Information Sheet dated 4/29/19 revealed .full body lift x 2 assist for transfers . Medical record review of Resident #1's Resident Incident Report dated 5/18/19 revealed .CNA (Certified Nurse Assistant) (#3) called this nurse (Licensed Practical Nurse #2) (LPN) to the shower room .Resident laying on back on floor, CNA #3 has to assist resident to the floor because the resident was sliding out of the lift . Facility documentation review of the Injury Investigation form for Resident #1 dated 5/23/19 revealed .Fall was noted on 5/18/19 . resulting in a right humerus fracture. CNA was getting the resident in the shower chair via (by) stand up lift (mechanical equipement used to raise residents from sitting position to standing) .Resident is care planned for the full body lift with 2 people assist . Facility documentation review of the Inservice and Sign-in sheet Transfer and Lifts policy, dated 4/30/19 revealed CNA #3 had prior in-service training on proper use of lifts and transfer procedures. Facility documentation review of the Mechanical Full Body Lifts and Mechanical Stand Up Lifts General Procedure Guides inservice dated 5/2/19 revealed CNA #3 demonstrated competency in the use of both mechanical lifts. Review of Employee Disciplinary Action form dated 5/28/19 for CNA #3 revealed CNA #3 received a written warning for .failure to follow care plan resulting in accident/incident to patient, using incorrect lift . Interview with LPN #2 on 6/25/19 at 2:20 PM in the conference room when asked about the incident with Resident #1 she stated she (CNA #3) used the wrong lift; she was using a sit to stand lift by herself for which the resident was not care planned for, she was care planned for the Hoyer lift. Continued interview revealed LPN #2 re-educated CNA #3 on reviewing the resident's care guide on 5/18/19. Telephone Interview with CNA #3 on 6/25/19 at 2:52 PM confirmed she did not look at Resident #1's care guide prior to lifting the resident with the sit to stand lift resulting in the resident's fall, she stated I did not look at the care guide, I didn't even know where it was. Continued interview confirmed CNA #3 used a sit to stand lift by herself to transfer Resident #1 for the resident's bath on 5/18/19. Continued interview CNA #3 stated As I was putting (the resident) on the stand up lift, (the resident) was sliding out, I got behind (the resident) and kneeled (the resident) to the floor. Continued interview confirmed Resident #1 was care planned to use a hoyer lift for transfers. Continued interview confirmed CNA #3 was educated to the use of mechanical lifts when transferring residents and to review resident care guides prior to performing resident care. Interview with the Director of Nursing on 6/25/19 at 4:30 PM in the conference room confirmed CNA #3 did not use the correct lift when transferring Resident #1 on 5/18/19 resulting in the residents fall and fracture to the right humerus. Continued interview confirmed 2 people are required to transfer Resident #1 with the Hoyer lift. Continued interview confirmed CNAs were to look at the CNA care guide prior to providing care to the resident. Interview with the Staff Development Coordinator on 6/26/19 at 9:17 AM in the conference room confirmed CNA #3 was educated to refer to the CNA care guide prior to performing any resident care. Interview with the Administrator on 6/26/19 at 3:03 PM in the conference room when asked about the incident with Resident #1 which resulted in a [MEDICAL CONDITION] humerus she stated stated the appropriate interventions were in place and each staff member is to look at the resident's information sheet and double check the care guide to review what kind of lift to use on the resident for transfers.

Based on facility policy review, medical record review, facility documentation review and interview, the facility failed to prevent an injury during a transfer resulting in a Right Humerus Fracture causing Harm to 1 resident (Resident # 1) of 4. The findings include: Facility policy review, Patient/Resident Transfer and Handling Policy and Procedure Manual, undated, revealed .Purpose: Provide guidance and direction to promote injury free mobility/transfers for residents .This policy is intended to promote the safety/comfort of each resident .at this facility, two (2) persons should be in attendance when operating the lifts so that one person can operate the lift while the other persons attends and reassures the resident . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with readmission on 5/28/19 with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Quarterly Minimum (MDS) data set [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 00 indicating the resident was severely cognitively impaired. Continued review revealed the resident required total assist of staff with transfers. Medical record review of Resident #1's Care Plan dated 4/13/18 revealed .Transfer assistance of full body lift x 2 person assist . Medical record review of Resident #1's Nurse Aid Information Sheet dated 4/29/19 revealed .full body lift x 2 person assist for transfers . Medical record review of Resident #1's Resident Incident Report dated 5/18/19 revealed .CNA (certified nurse assistant) # 3 called (Licensed Practical Nurse #2) to the shower room. CNA #3 had to assist resident to the floor because the resident was sliding out of the lift. Medical record review of Resident #1's Progress Note dated 5/22/19 revealed .Patient has been having some increased discomfort in (Resident #1) right arm and it appears to be somewhat out of place and bent .It is tender to touch along the humerus .ordered x-ray of the shoulder and humerus . Medical record review of Resident #1's Radiology Report dated 5/22/19 revealed .there is a [MEDICATION NAME] fracture involving the right proximal humerus at the head/neck with mild displacement medially of the humeral shaft . Facility documentation review of the Injury Investigation form for Resident #1 dated 5/23/19 revealed .Fall was noted on 5/18/19 .CNA was getting the resident in the shower chair via (by) stand up lift .Resident is care planned for the full body lift with 2 person assist . Facility documentation review of the Inservice and Sign-in sheet Transfer and Lift policy dated 4/30/19 revealed CNA #3 had prior in-service training on proper use of lifts and transfer procedures. Facility documentation review of the Mechanical Full Body Lifts and Mechanical Stand Up Lifts General Procedure Guides inservice dated 5/2/19 revealed CNA #3 demonstrated competency in the use of both mechanical lifts. Review of Employee Disciplinary Action form dated 5/28/19 for CNA #3 revealed a written warning for .failure to follow care plan resulting in accident/incident to patient, using incorrect lift . Interview with LPN #2 on 6/25/19 at 2:20 PM in the conference room when asked about the incident with Resident #1 she stated she (CNA #3) used the wrong lift; she was using a sit to stand lift by herself for which the resident was not care planned forFurther interviewed revealed that the CNA #3 stated As I was putting (Resident #1) on the stand up lift, (the resident) was sliding out, I got behind (the resident) and kneeled (the resident) to the floor Telephone Interview with CNA #3 on 6/25/19 at 2:52 PM confirmed she did not look at Resident #1's care guide prior to lifting the resident with the sit to stand lift resulting in the residents fall and fracture to the right humerus. Interview with the Director of Nursing on 6/25/19 at 4:30 PM in the conference room confirmed CNA #3 did not use the correct lift when transferring Resident #1 on 5/18/19 resulting in the residents fall and fracture to the right humerus. Interview with the Staff Development Coordinator on 6/26/19 at 9:17 AM in the conference room confirmed CNA #3 was educated to refer to the CNA care guide prior to performing any resident care. Interview with the Administrator on 6/26/19 at 3:03 PM in the conference room when asked revealed concerning the incident with Resident #1 fall and fracture stated the appropriate interventions were in place and it is the responsibility of each staff member to look at the resident's information sheet and double check the care guide to review what kind of lift is used for resident transfers. CNA #3 did not use the right tranfer equipment and failed to get assitance resulting in fall and [MEDICAL CONDITION] humerus.

Based on a facility policy review, reference review of Lippincott Manual of Nursing Practice, for restraint guidelines, review of a job description, medical record review, observation and interview, the facility failed to ensure the Medical Director assisted the facility with identifying, evaluating and addressing clinical concerns; failed to coordinate the medical care and failed to provide clinical guidance and oversight regarding the implementation of resident care policies and procedures that reflect the current standards of practice for the residents residing in the facility. The facility failed to ensure the Medical Director assisted with addressing clinical concerns and provided guidance regarding care of the residents residing in the facility by failing to ensure there was an effective process that monitored and addressed the potential for adverse consequences related to physical restraint use; failed to ensure physical restraint consents were signed, dated and witnessed; failed to ensure physical restraint assessments and reassessments were completed for 12 (Residents # 160, 29, 56, 63, 73, 78, 94, 109, 111, 117, 142 and 158) of 13 residents; failed to ensure accuracy of care plans; failed to ensure care plans were revised with the current restraint information for 1 (Resident #160), thus resulting in an Immediate Jeopardy (IJ). An IJ is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment or death for the resident. The facility failed to ensure the Medical Director provided clinical guidance and oversight regarding infection control concerns, specifically a scabies infestation affecting 3 (Resident # 76, # 81 and # 158) of 7 residents reviewed for scabies. The findings included: 1. Review of the policy Medical Director Responsibilities revealed The facility retains a physician designated as Medical Director, to coordinate the medical care provided by attending physicians, and to assist with development and implementation of resident care policies.3. Medical Director will serve on the facility's QA (Quality Assurance) Committee quarterly and assist with the identification, evaluation and resolution of medical and clinical concerns that affect resident care, medical care, quality of life, or are related to the provision of services by physicians and other licensed health care practitioners. 2. Review of Lippincott Manual of Nursing Practice, 2014, Tenth Edition, Chapter 9 revealed (page) 191.These (restraint) guidelines must be met in any long-term care facility that participates in Medicare or Medicaid. However, these guidelines are useful for health care providers working with older adults in all settings. (a) The resident has the right to be free from any physical restraints imposed.for purposes of discipline or convenience and not required to treat the resident's medical condition. (b) Physical restraints are any manual method of physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the person cannot remove easily, which restricts freedom of movement or access to one's body (includes leg and arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, and geriatric chairs). (c) There must be a trial of less restrictive measures unless the physical restraint is necessary to provide life-saving treatment. (d) The resident of legal representative must consent to the use of restraints. (e) Residents who are restrained should be released, exercised, toileted, and checked for skin redness every 2 hours. (f) The need for restraints should be reevaluated periodically. (g) The specific facility will have to develop policies and procedures for the appropriate use of restraints and psychoactive drugs. (h) Primary health care providers will have to write appropriate orders for restraints. 3. Review of the facility's Restraints-Physical policy updated 2/4/14 revealed .Restraints will only be used in extreme circumstances and only with: 1. Documented behavior. 2. Consent from resident's representative 3. Physician and DON or designee. 4. All other non-restrictive alternatives have been tried and were unsuccessful (MD orders must be written).5. Physical restraint shall not be used to limit the resident's mobility for the convenience if the staff. Written policies and procedures governing the use of restraints specify which staff member may authorize the use of restraints and clearly delineate the following: (a) Orders indicate the specific reason, type and period of time for the use of restraints. Restraints must be used only as a last resort, and the medical record must indicate the events leading up to the necessity of the restraint. (b) Their use is temporary, and the resident will not be restrained for an indefinite amount of time.The attending physician must be notified of such use and the reason for the order. Consent for Restraint must be discussed with the responsible party.(e) Reorders are issued only after a review of the resident's condition by his or her physician.10. The need for restraints will be evaluated at least quarterly in the Falls Committee Meeting to determine their continued use of a restraint has been reevaluated and that reorder from the physician is so noted. 4. Interview on 7/22/15 at 1:45 PM with the Medical Director, by conference call revealed he participates in the QA process. When asked if the responsible party was notified upon the introduction of restraints, the Medical Director responded Every time a restraint is introduced, the responsible party should be notified. Continued interview revealed, when asked if he receives regular reports from the facility regarding the type and number of restraints used in the facility, the Medical Director responded No, I do not get regular reports about the use of restraints. Further interview revealed, when asked who determines what type of restraint was used, the Medical Director responded They call with a recommendation. I have one person, Licensed Practical Nurse (LPN) # 4), who contacts me about orders. I find it easier to have only one or two people handling that. When asked if he knew how many residents in the facility were restrained, the Medical Director responded No. When asked if he would be surprised to know that some residents had been utilizing the same type of restraint without any reassessments or an attempt at a reduction of restraints for the last 2 years, the Medical Director responded Yes, that would surprise me and should not happen. 5. During an interview on 7/24/15 at 1:29 PM in the J Hall Private Dining Room, the Medical Director was asked what his role in the QA process was and what issues were addressed in QA meetings. The Medical Director stated I attend the meetings and receive reports from individuals and provide input to what I think should be addressed. We talk about falls, wound care management, food temperatures, resident accounts. I'm not sure who determines what subjects are brought up or discussed. The Medical Director was asked if he had been notified about any issues regarding restraints. The Medical Director stated No, not a particular issue. Continued interview revealed, when asked to describe the process of addressing and identified concerns, the Medical Director stated We look at the policy first to see what we are committed to do in writing. If it is committed to paper, then that is what we are doing. The Medical Director was then provided a copy of the current physical restraint policy to read. The Medical Director stated We haven't been writing the orders like this states. When asked if there had been any concerns or issues brought up in QA meetings but not addressed, the Medical Director responded My concern is what's not being brought up. I wasn't aware of that issue, that there should be an assessment for restraints. Further interview of the Medical Director revealed The rash we've had had been a frustrating issue. Sent them (the residents involved) and had deep tissue scraping. An employee got treated, their doctor cleared them but the family didn't get treated. Refer to F221-K, F272-K, F280-J, F323-G, F441-D and F520-K.

Based on review of Lippincott Manual of Nursing Practice, 2014, Tenth Edition regarding standard for restraints, facility policy review, review of the restraint manufacturer's Application Instructions, the medical record, the facility investigations, interview, and observation, the facility failed to ensure the use for a restraint was assessed, determine the least restrictive restraint, and periodically reassess the need for the restraints to ensure the resident's safety for 11 (Resident #160, 29, 56, 63, 73, 78, 94, 109, 111, 117, 142) of 13 residents reviewed with restraints. The failure of the facility to properly assess and re-assess the need for restraints, determine the least restrictive restraint, following the restraint manufacturer's application instructions and warnings placed Resident #160 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Administrator was informed of the Immediate Jeopardy on 7/21/15 at 2:40 PM in the conference room. The Immediate Jeopardy was effective 5/4/15 through 7/30/15. A Full Extended Survey was conducted on 7/21-29/15. An acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received on 7/29/15 at 9:00 AM, and the corrective actions were validated by the surveyors on 7/29/15. The findings included: Review of Lippincott Manual of Nursing Practice, 2014, Tenth Edition, Chapter 9 revealed (page) 191.These (restraint) guidelines must be met in any long-term care facility that participates in Medicare or Medicaid. However, these guidelines are useful for health care providers working with older adults in all settings. (a) The resident has the right to be free from any physical restraints imposed.for purposes of discipline or convenience and not required to treat the resident's medical condition. (b) Physical restraints are any manual method of physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the person cannot remove easily, which restricts freedom of movement or access to one's body (includes leg and arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, and geriatric chairs). (c) There must be a trial of less restrictive measures unless the physical restraint is necessary to provide life-saving treatment. (d) The resident or legal representative must consent to the use of restraints. (e) Residents who are restrained should be released, exercised, toileted, and checked for skin redness every 2 hours. (f) The need for restraints should be reevaluated periodically. (g) The specific facility will have to develop policies and procedures for the appropriate use of restraints. (h) Primary health care providers will have to write appropriate orders for restraints. Review of the facility policy, updated 2/4/14, Restraint-Physical revealed Restraints should only be used for the safety and well-being of the resident(s) and only after all alternatives have been tried unsuccessfully and results are documented. Further review revealed .Restraints will only be used in extreme circumstances and only with: 1) Documented behavior 2) Consent from resident's representative.All other non-restrictive alternatives have been tried and were unsuccessful.MD (Medical Doctor) orders MUST be written. Further review revealed .Orders indicate the specific reason, type and period of time for the use of restraints. Restraints must be used only as a last resort, and the medical record must indicate the events leading to the necessity of the restraint. Their use is temporary and the resident will not be restrained for an indefinite amount of time.The attending physician must be notified of such use and the reason for the order.The need for restraints will be re-evaluated at least quarterly in the Fall Committee Meeting to determine their continued use. Every effort will be made to eliminate their use.The least restrictive must always be utilized. Review of the manufacturer's .Application Instructions for the Posey Torso Support. and the .Posey Lap Belt/Padded Lap Belt. revealed .Before Applying Any Restraint: Make a complete assessment of the patient to ensure restraint use is appropriate. Medical record review revealed Resident #160 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had short and long term memory impairment, required extensive assistance of 1 person for bed mobility, toileting and hygiene; required extensive assistance of 2 persons for transfers, was frequently incontinent of bowel and bladder and had one fall without injury since admission. Medical record review of the ACKNOWLEDGEMENT OF RESTRAIN (restraint) POLICIES (a form that is provided to the resident and or family upon admission to the facility), signed by the responsible party on 3/30/15, revealed .If restraint use is deemed necessary the goal will be to use the least restrictive type of restraint for the shortest period of time possible.Every resident will be individually assessed regarding the need for appropriate safety measures and will be periodically reassessed. Medical record review of the Restraint Assessment dated 3/31/15 revealed Resident #160 was alert and oriented x (times) 2, had a fall in the past 12 months with a left [MEDICAL CONDITION], a check mark beside gait/balance problems, and .Behavioral Problems.Removes clothing frequently.Positioning Problems (was blank).Reason for Restraint (was blank). Further review documented the review date: .3/31/15 no restraints needed. Medical record review of the Physician Telephone Order dated 4/9/15 revealed .torso posey positioner in w/c (wheelchair), check for placement q (every) 30 min (minutes) and release/reposition q 2 hours x 10 min. Medical record review of the Informed Consent for Restraint Utilization, signed by the responsible party on 4/13/15, per nursing note review had verbal consent on 4/9/15, .Consenting to the use of restraints as described. revealed .Due to decreased safety awareness (with) unsteady gait, multiple attempts to get up unassisted.assessed and determined the torso posey positioner vest necessary to protect (Resident #160) from physical harm. Medical record review of the Restraint Assessment revealed no changes in the assessment from 3/31/15 for the 4/9/15 order for .torso posey positioner in w/c, check for placement q 30 min (minutes) and release/reposition q 2 hours x 10 min. Review of the facility's Fall Investigation for Charge Nurse form with the date of the fall on 5/4/15 at 7:15 PM revealed a w/c or geri-chair (a reclining chair with wheels that is not self-propelled) was involved, a chair alarm was functioning properly, and an ordered restraint was in place and applied correctly. Further review revealed .Did the resident remove the restraint?.Slid under restraint. Further review revealed .Description of incident: At approximately 715pm Resident was starting to slide down in w/c. This nurse pulled resident back up in w/c and went to get pads to put in.foam chair to transfer resident to.foam chair. On way back to the dayroom residents chair alarm started going off. Observed resident sliding down underneath posey positioner onto the edge of the w/c. Able to assist resident safely to floor.assisted to.foam chair. Further review revealed .Conclusion: Appropriate number of staff involved ? Yes.Equipment use appropriate? Yes.Proper technique used? Yes.Resident unattended inappropriately? No. Further review documented .Supervisor Report.New planned interventions: Staff training on correctly applying torso posey positioner. Medical record review of the Skilled Nursing Notes dated 5/8/15 revealed .Resident in Rock & Roll (Rock-n-Go, a rocking wheelchair) chair @ (at) 4PM. Observed resident roll self to side bar of wall and pull self out of chair. Resident placed in w/c (with) torso positioner. @ approximately 830 PM this nurse was walking past dayroom. Observed resident down in w/c, posey restraint around neck. Review of the facility's Fall Investigation for Charge Nurse form with the date of the fall on 5/8/15 at 8:30 PM revealed a w/c or geri-chair was involved, and an ordered restraint was in place and applied correctly, Further review documented .Did the resident remove the restraint? was blank.Was a chair alarm involved? No. Further revealed .Description of incident: Walked past dayroom observed resident down in w/c, posey torso restraint around neck.butt off of wheelchair. Undid restraint, lifted resident up in wheelchair x 2 assist.New Order 1) D/C (discontinue) soft torso positioner 2) soft posey belt in Rock & (and) Roll chair (with) pull alarm. Further review revealed the .Conclusion: Was appropriate number staff and equipment involved? Yes.Proper technique used? Yes.Resident left unattended inappropriately? No. Further review revealed .Supervisor Report.New planned intervention: posey belt in Rock-n-Go; cont (continue) pull alarm also. Further review of the Supervisor Report revealed in handwritten notes .were arms beneath torso positioner? Yes.Had she had belt before? Yes but in w/c then, now Rock-n-Go. Further review of the Supervisor Report revealed .Licensed Practical Nurse (LPN) #1: Resident was in w/c. Was in Rock-n-Go prior to dinner. She pulled herself up @ guardrail in Rock-n-Go. She was assisted to w/c (with) restraint. Review of the Employee Statement written by Registered Nurse (RN) #3 of the 5/8/15 incident revealed .The last time you saw resident before they fell ? Time 450 PM.Location: In front dayroom (dayroom/ diningroom) H + (and) I (Hall H and Hall I).Describe.what you observed/saw/heard: walking down hallway observed resident in dayroom (dayroom/dining room) dining room H + I in w/c had scooted self down so buttocks were off the seat of w/c. Torso posey positioner was still intact but was up around upper chest.With assist of two-release posey torso positioner and lifted back up into w/c-where she proceeded to.scoot downward in w/c. Medical record review of the Physician Telephone Orders revealed the following: .5/8/15.Trial period Rock in Go (with) pull alarm for restraint reduction. .5/9/15.1) DC torso positioner in w/c.2) Soft posey belt in Rock-&-Go chair (with) pull alarm, check placement Q 30 min release et (and) reposition q 2 hrs (hours) x 10 min. Review of the medical record revealed the facility failed to assess for the appropriateness of the soft waist belt in the Rock-n-Go restraint or alternatives per facility policy. Medical record review of the Restraint Assessment revealed no changes in the assessment from 3/31/15 for the 5/9/15 order for .Soft posey belt in Rock-&-Go chair (with) pull alarm, check placement Q 30 min release et (and) reposition q 2 hrs (hours) x 10 min. Medical record review of the Physician Telephone Orders dated 6/17/15 revealed .Trial period (with) w/c + alarming seat belt. Medical record review of the Restraint Assessment revealed no changes in the assessment from 3/31/15 for the 6/17/15 order for .Trial period (with) w/c + alarming seat belt. Review of the medical record revealed the facility failed to assess for the appropriateness of the alarming seat belt in w/c or alternatives per facility policy. Review of the facility's Fall Investigation for Charge Nurse form with the date of the fall on 6/20/15 at 8:10 PM revealed a w/c or geri-chair was involved, the restraint was not in place, a restraint was ordered, a chair alarm was involved.Did it (alarm) function properly? No.alarm did not sound Alarm not turned on. Further review revealed .Description of Incident: .resident on floor in dining room.transferred back to w/c.safety belt on and in place. Further review revealed the .Conclusion: Appropriate number of staff involved? Yes.Equipment use appropriate? No.Proper technique used? Yes. Further review revealed .Supervisor Report.New Planned Interventions: trial period w/c (with) alarming seat belt. Inservice /re-educ (reeducate) to (check) alarm as well as connection on any resident (with) alarming seatbelt. Further review of the Supervisor report revealed in hand writing .secured seatbelt but was unaware it was an alarming belt + did not make sure alarm was turned on. Further review revealed .Employee Statement of Incident.last time you saw resident before they fell ? 8:00 PM.Location: Dayroom.Does resident have some kind of personal alarm? Yes.Was it sounding? No.What do you think could prevent this incident/could prevent similar incidences in the future? Double check the alarm. The buckle was on but I didn't check the alarm box. Medical record review of the Physician Telephone Orders revealed the following: .7/9/15.1) D/C (discontinue) alarming seat belt.2) begin soft posey (belt) while in w/c. Apply 2 (hours), then release 10 min and reposition. .7/10/15.D/C soft posey (belt).Begin alarming seat belt (with) w/c. .7/10/15.DC alarming seat belt to w/c.Apply SWB (soft waist belt) while in w/c. Check for placement q (every) 2 hours + release x 10 min. .7/11/15.Start posey belt in Rock-n-Go chair.Check q 30 min + release q 2 hours + reposition x 10 min. Medical record review of the Restraint Assessment revealed the facility failed to reassess Resident #160 after the assessment dated [DATE] for the restraint ordered on [DATE] for the .SWB (soft waist belt) while in w/c. Check for placement q (every) 2 hours + release x 10 min., and on 7/11/15 for the ordered .posey belt in Rock-n-Go chair.Check q 30 min + release q 2 hours + reposition x 10 min. Review of the medical record revealed the facility failed to assess for the appropriateness of the restraints, soft waist belt in w/c on 7/9/15, alarming seat belt on 7/10/15, soft waist belt in w/c or Rock-n-Go chair on 7/10-11/15, or alternatives per facility policy. Review of the Nurses Notes dated 7/11/15 revealed .2 PM.Observed in w/c (with) posey waist belt-Resident sliding down in w/c (with) posey belt across her arms.Initiated Rock-n-Go w/c (with) posey soft waist belt. Medical record review of the Physician Telephone Order dated 7/15/15 revealed .D/C posey belt in Rock-n-Go. Res (Resident) to be in w/c (with) sensor pad + seatbelt. Check q 30 min + release q 2 (hours) x 10 min. Medical record review of the Restraint Assessment revealed no changes in the assessment from 3/31/15 for the 7/15/15 order for .Res (Resident) to be in w/c (with) sensor pad + seatbelt. Check q 30 min + release q 2 (hours) x 10 min. Review of the medical record revealed the facility failed to assess for the appropriateness of the w/c with seat belt or alternatives per facility policy. Observation of Resident #160 and/or staff interview revealed the following: 1. On 7/14/15 at 7:52 AM: Resident #160 was in the H hall and I hall dayroom/dining room in a reclined Rock-n-Go chair with a soft waist belt in place. 2. On 7/14/15 at 3:20 PM with LPN #1: Resident #160 was in the Rock-n-Go in the F hall and G hall dayroom/dining room with a soft waist in place. 3. On 7/15/15 at 7:37 AM: Resident #160 was in the H hall and I hall dayroom/dining room, with 15 other residents, in a reclined Rock-n-Go chair with a soft waist belt under her chin, both arms were under the soft waist belt with the right hand under her chin holding onto the top of belt, the resident had slid down in the chair, and no facility staff was present. The surveyor stayed with the resident. Observation at 7:39 AM revealed 2 nursing staff entering the H hall and I hall dayroom/dining room. Certified Nurse Aide (CNA) #3 did not see Resident #160 and left the dayroom/dining room. CNA #1 saw Resident #160 soft waist belt located under her chin, repositioned the belt to the waist area (without re-applying the straps) and left the dayroom. The surveyor stayed with the resident. Continued observation revealed Resident #160 took her right hand and pulled the soft waist belt up under her chin and both arms were under the belt. Continued observation at 7:42 AM revealed Registered Nurse (RN) #1 entering the H hall and I hall dayroom/dining room, went to Resident #160, knelt down behind the chair and touched the restraint belt straps. Interview with RN #1 when asked if the soft waist belt was fastened appropriately, RN #1 stated it should be tighter. Further interview with RN #1 when asked if it would be appropriate for staff to see the soft waist belt under the resident's chin, reposition the soft waist belt to the waist area without checking or re-applying the restraint straps and leaving the room with the resident unattended, the RN #1 stated, No, it could have serious consequences. Observation and interview revealed CNA #1 re-entering the H hall and I hall dayroom/dining room and demonstrated to RN #1 how CNA #1 had repositioned the soft waist belt and stated then .left the dayroom. the RN stated to CNA #1 That could result in serious consequences, even death. 4. On 7/15/15 at 8:53 AM in front of the H hall and I hall nurses station, revealed Resident #160 in a reclined Rock-n-Go chair with a soft waist belt in place. Continued observation revealed the resident had both arms under the belt, the belt was loose, and the belt was positioned across the breast. The surveyor stayed with the resident until a nurse arrived. Observation and interview with RN #1 on 7/15/15 at 8:54 AM through 8:58 AM in front of the H hall and I hall nurses station, revealed Resident #160 had removed several types of restraints and the current restraint (soft waist belt) was .not applied correctly, it was too loose. Continued interview confirmed the resident was capable of self-propelling in a wheelchair, and the Rock-n-Go chair was reclined to prevent the resident from propelling. When RN #1 was asked if the belt was applied correctly the RN stated the .soft posey belt was not applied correctly.belt was not appropriate for the resident. 5. On 7/15/15 at 1:55 PM and at 2:50 PM: The resident was in a reclined Rock-n-Go chair in the in H/I dayroom/dayroom with no staff present, no soft waist belt was on the resident. LPN #8 entered the H hall and I hall dayroom/dining room and stated the physician had changed the order to stop the soft waist belt and keep the Rock-n-Go. Medical record review of the undated Pre-Restraining Evaluation and interview, with MDS Coordinator #1 on 7/16/15 at 7:40 AM in the conference room, confirmed the evaluation was not dated, had been completed after the 7/15/15 observations, and failed to identify recommendations and alternatives to restraints. Interview with the Director of Nursing (DON) on 7/15/15 at 2:42: PM, in the Admissions Coordinator's office, confirmed, after the first incident on 5/4/15 at 7:15 PM, it was unsafe to leave the resident in a torso positioner. Further interview confirmed the torso positioner was still used on the 5/8/15 incident when the resident slid down the wheelchair again and the restraint was around the resident's neck. The DON confirmed the soft waist belt was not appropriate for Resident #160. The DON confirmed the facility's failure to assess for the appropriateness for any restraints and the failure to assess for the least restrictive restraint. The DON confirmed the facility had failed to keep Resident #160 monitored to ensure the resident's safety per facility policy. Interview with the MDS Coordinator #1 on 7/16/15 at 7:40 AM in the payroll office confirmed the facility failed to follow the policy to complete a restraint assessment to determine the need for the restraint and the appropriateness of the restraints used. Medical record review revealed Resident #29 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS dated [DATE] revealed Resident #29 to be severely cognitively impaired, and required extensive assistance of 1 for Activities of Daily Living (ADLs), and restraints in chair/out of bed were used daily. Medical record review of ACKNOWLEDGEMENT OF RESTRAIN (restraint) POLICIES (a form that is provided to the resident and or family upon admission to the facility) signed by Resident #29's legal representative on 4/11/14 revealed .if restraint use is deemed necessary the goal will be to use the least restrictive type of restraint for the shortest period of time possible.every resident will be individually assessed regarding the need for appropriate safety measures and will be periodically reassessed as their needs change throughout their stay. Medical record review of a Restraint assessment dated [DATE] revealed .4/15/14 Torso Posey belt.7/24/14 Posey Torso dc'd (discontinued). (Change) to Posey belt d/t pt removing. Continued review revealed the review dates between 8/12/14 and 6/10/15, the resident continued to use a soft waist restraint. Continued review revealed the facility failed to assess and/or reassess for a least restrictive restraint per the facility policy. Medical record review of the readmission Physician's Orders dated 6/10/15 revealed .OOB (out of bed) in w/c daily; dump seat (a seat tilted backward) in w/c.use soft Posey belt in w/c prn restlessness, agitation. Medical record review of an Informed Consent for Restraint Utilization dated 8/1/14 revealed .physician and an interdisciplinary team of medical professionals have assessed and determined that the use of a Posey belt is necessary. Observation on 7/21/15 at 7:20 AM revealed the resident lying in bed with eyes closed. Continued observation revealed a wheelchair positioned near Resident #29's bed with a soft waist restraint lying in the seat. Interview with the DON on 7/21/15 at 8:58 AM in the Admission Coordinators Office revealed, when questioned about the resident and use of the soft waist restraint, stated .she's doing good in the Broda (a high back, reclining geriatric chair).I haven't seen her in the w/c in a long time.we may need to reassess for its use. When asked if a complete restraint assessment or a reassessment for the least restrictive restraint had been completed in the past year, the DON stated .no.we've not done that. Interview with the DON on 7/21/15 at 10:04 in the conference room, when asked about restraint reassessment, the DON stated .I would expect them to be done quarterly and documented in the interdisciplinary notes. Medical record review revealed Resident #56 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed the resident was severely cognitively impaired. Continued review revealed documentation under the restraint section of a trunk restraint used less than daily, and a chair that prevented rising used less than daily. Further medical record review revealed a Restraint Assessment form dated 5-24-12, no restraints, on 6/24/13 documented, carafoam (Carefoam) ottoman (a padded foam chair used for fall prevention) (with) 3 pt (point) pelvic positioner prn (as needed, and on 12/11/14 documented, carefoam ottoman/lounger (with) 3 pt pelvic positioner release & reposition q (every) 2 (hours) x (times) 10 min (minutes) q 30 minutes. Further medical record review revealed Physicians Orders (recapitulation) for the month of 7/2015 documented .Padded side rails (4) up when in bed. Up OOB (out of bed) to carefoam lounger and put back to bed before 3 pm on shower days (M/W/F) (Monday, Wednesday, Friday) Carefoam lounger with 3 pt pelvic positioner. Release and reposition Q 2 hrs x 10 min. Check Q 30 min. Further medical review revealed a signed, but undated Informed Consent for Restraint Utilization form for a 3 point pelvic harness. Further medical record review revealed no documented evidence the facility had assessed/evaluated the resident for restraints prior to being placed in a restraint or having had reassessed/reevaluated the resident for the continued use of restraints. Observation on 7/20/15 at 3:45 PM in Resident #56's room, revealed the resident was lying in bed with four padded side rails in the raised position. Continued observation revealed a family member was present at the bedside. Continued observation revealed a foam recliner and ottoman in the room. Further observation on 7/24/15 at 10:56 AM in the resident's room revealed the resident seated in a foam lounger with feet resting on an ottoman and a 3 point restraint harness was in place. Interview with the DON on 7/21/15 at 10:30 AM in the conference room, confirmed the facility had failed to complete a restraint assessment and quarterly reassessment for the use of restraints. Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical Record Review of the Annual MDS dated [DATE] revealed Resident #63 was severely cognitively impaired. Continued review of the MDS revealed the resident had trouble concentrating, trouble sleeping and poor appetite, wandering occurred daily and restraints were used daily while the resident was up in a chair or out of bed. Medical record review of ACKNOWLEDGEMENT OF RESTRAIN (restraint) POLICIES (a form that is provided to the resident and or family upon admission to the facility) signed by Resident #63's legal representative on 1/31/14 revealed .if restraint use is deemed necessary the goal will be to use the least restrictive type of restraint for the shortest period of time possible.every resident will be individually assessed regarding the need for appropriate safety measures and will be periodically reassessed as their needs change throughout their stay. Medical record review of the Restraint assessment dated [DATE] revealed none of the twenty-six assessment questions were completed. Continued review revealed Review Dates of 5/2/14, 6/3/14, 7/5/14, 8/5/14, 10/1/14, 11/5/14, 12/5/14, 1/5/15, 2/3/15, 3/14/15 and 4/8/15 revealed a soft belt restraint was in use with no documentation on the assessment for the reason a restraint was required. Medical record review of the Non-Skilled Monthly assessment dated [DATE] revealed . Restraint: Soft Posey Belt . with no documentation of the reason the restraint was required. Medical record review of the Non-Skilled Monthly assessment dated [DATE] revealed . Restraint: Posey Belt . with no documentation of the reason the restraint was required. Medical record review of the Non-Skilled Monthly assessment dated [DATE] revealed . Restraint: Posey Belt . with no documentation of the reason the restraint was required. Observation on 7/13/15 at 3:42 PM of Resident #63 on the H hall and I hall nurses station revealed the resident was up in the wheelchair with a soft belt restraint in place. The resident was asking staff members to take the soft belt restraint off so she can get home. Interview on 7/21/15 at 10:10 AM with the DON in the Conference Room, in response to being asked about who makes the determination for use of restraints, revealed The nurse on the floor does. Sometimes the family requests one to be placed, like this one here (points to Resident # 63 chart). Her daughter insisted that her mother be in restraint and will not let us remove it. We have attempted a reduction with a Merry Walker, but the daughter just will not have it. When asked for the location of the restraint reassessment, the DON stated I would expect them to be done quarterly and in the Interdisciplinary Notes. Interview on 7/21/15 at 2:00 PM with the DON in the Admissions office revealed We did not reassess this resident's restraints because her daughter told us she wanted her mother in it. Interview on 7/21/15 at 2:10 PM with MDS Coordinator #2 and DON in the Admissions office, when asked about the Interdisciplinary Notes and Quarterly Assessments for Resident # 63, MDS Coordinator # 2 stated I only document on the Interdisciplinary Notes when there is a family meeting. When asked if 9/10/13 was the last family meeting, MDS Coordinator # 2 stated Yes. When asked where the quarterly restraint reassessment would be, the DON stated I don't know. Medical record review revealed Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Restraint Assessment dated 1/23/14 revealed the resident had a soft posey belt. Continued review revealed documentation in the comment section with a review date of 4/2/14, restraint reduction @ each meal of soft Posey belt.at table (with) staff present, and a review date of 7/5/15, soft Posey belt in w/c. Medical record review of Physician's Orders (recapitulation) from 3/2015 through 7/2015, revealed an order for [REDACTED]. Medical record review of Informed Consent for Restraint Utilization signed by the responsible party and dated 1/30/14 giving consent, revealed .Due to [MEDICAL CONDITION], (Advance) .determined that the use of Soft Posey Belt in W/C is necessary to protect resident from physical harm. Medical record review revealed no documentation of restraint assessment prior to restraint reduction, no assessments for or attempts at further restraint reduction, and no quarterly restraint reassessments having been completed, per facility policy. Observation on 7/21/15 at 7:53 AM in the I hall, revealed the resident seated in a wheelchair with a soft restraint belt around her abdomen, being transported in wheelchair by staff to her room. Observation on 7/21/15 at 8:38 AM in the H hall and I hall dayroom/dining room revealed staff assisted resident with meal and the resident was not wearing a restraint. Interview with the DON on 7/21/15 at 10:30 AM in the conference room, confirmed the facility had failed to assess the resident for the need of restraints, for the appropriateness of the restraint, for the need for continued use of restraints, and for further restraint reduction. Medical record review revealed Resident #78 was admitted to the facility on [DATE] and readmitted on [DATE] with Recurrent Episode of Manic, [MEDICAL CONDITION] Affect, [MEDICAL CONDITION], Anxiety, Depression, Lack of Coordination, Malaise and Fatigue, and Altered Mental Status. Medical record review of the Annual MDS dated [DATE] revealed the resident is severely cognitively impaired. Continued review revealed the resident had a restraint used daily when in chair or out of bed. Medical record review of a Restraint Assessment dated 7/19/13 revealed the resident had no restraints at that time. Continued review revealed documentation in the comment section with a review dat

Based on review of Lippincott Manual of Nursing Practice, 2014, Tenth Edition regarding standard for restraints, facility policy review, review of the restraint manufacturer's Application Instructions, the medical record, the facility investigations, interview, review of facility education forms, and observation, the facility failed to assess the need for the restraint; failed to determine the least restrictive restraint; failed to obtain consent for the restraint; failed to ensure the restraint was properly applied, and failed to monitor the resident in the restraint, to ensure the resident's safety for 12 (Resident #160, 29, 56, 63, 73, 78, 94, 109, 111, 117, 142, 158 ) of 13 residents reviewed with restraints. The failure of the facility to assess and reassess the need for restraints, determine the least restrictive restraint, follow the restraint manufacturer's application instructions and warnings, apply the restraint per the manufacturer's instructions, and monitor the resident while in the restraint placed Resident #160 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Administrator was informed of the Immediate Jeopardy on 7/21/15 at 2:40 PM in the conference room. The Immediate Jeopardy was effective 5/4/15 through 7/30/15. A Full Extended Survey was conducted on 7/21-29/15. An acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received on 7/29/15 at 9:00 AM, and the corrective actions were validated by the surveyors on 7/29/15. The findings included: Review of Lippincott Manual of Nursing Practice, 2014, Tenth Edition, Chapter 9 revealed (page) 191.These (restraint) guidelines must be met in any long-term care facility that participates in Medicare or Medicaid. However, these guidelines are useful for health care providers working with older adults in all settings. (a) The resident has the right to be free from any physical restraints imposed.for purposes of discipline or convenience and not required to treat the resident's medical condition. (b) Physical restraints are any manual method of physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the person cannot remove easily, which restricts freedom of movement or access to one's body (includes leg and arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, and geriatric chairs). (c) There must be a trial of less restrictive measures unless the physical restraint is necessary to provide life-saving treatment. (d) The resident or legal representative must consent to the use of restraints. (e) Residents who are restrained should be released, exercised, toileted, and checked for skin redness every 2 hours. (f) The need for restraints should be reevaluated periodically. (g) The specific facility will have to develop policies and procedures for the appropriate use of restraints. (h) Primary health care providers will have to write appropriate orders for restraints. Review of the facility policy, updated 2/4/14, Restraint-Physical revealed Restraints should only be used for the safety and well-being of the resident(s) and only after all alternatives have been tried unsuccessfully and results are documented. Further review revealed .Restraints will only be used in extreme circumstances and only with: 1) Documented behavior 2) Consent from resident's representative.All other non-restrictive alternatives have been tried and were unsuccessful.MD (Medical Doctor) orders MUST be written. Further review revealed .Orders indicate the specific reason, type and period of time for the use of restraints. Restraints must be used only as a last resort, and the medical record must indicate the events leading to the necessity of the restraint. Their use is temporary and the resident will not be restrained for an indefinite amount of time.The attending physician must be notified of such use and the reason for the order. Consent for Restraint must be discussed with the responsible party.The resident placed in a restraint will be observed at least every thirty (30) minutes by Nursing personnel and documented. Reorders are issued only after a review of the resident's condition by.physician. Further review revealed .The opportunity for motion and exercise is provided for a period of not less then ten (10) minutes during every two (2) hours in which checks will be documented.Restrained residents must be repositioned at least every two (2) hours on all shifts.The need for restraints will be re-evaluated at least quarterly in the Fall Committee Meeting to determine their continued use. Every effort will be made to eliminate their use.The least restrictive must always be utilized. Review of the manufacturer's .Application Instructions for the Posey Torso Support. revealed WARNING: ALWAYS Monitor patients per facility policy. Improper application or use of any restraint may result in serious injury or death. Further review revealed Contraindications:.STOP USE AT ONCE: if the patient has a tendency to slide forward or down in the device. Further review revealed WARNING: Straps must ALWAYS be snug.If a patient's body weight becomes suspended off the chair, chest compressions and suffocation could result. Restraints with a pelvic piece may be necessary to reduce sliding down.Monitor per facility policy to ensure that the patient cannot slide down, or fall off the chair seat and become suspended. Review of the manufacturer's .Application Instructions for the Posey Lap Belt/Padded Lap Belt. revealed WARNING: ALWAYS Monitor patients per facility policy. Improper application or use of any restraint may result in serious injury or death. Further review revealed .Application Instructions: Position the patient as far back in the seat as possible, with the buttocks against the back of the chair.Bring the ends of the connecting straps down at a 45-degree angle between the seat and the wheelchair sides.Adjust the tightness of the slide buckles.Check that the straps are secure and will not change position, loosen, or tighten if the patient pulls on them, or if the chair is adjusted.The belt must be snug but not interfere with breathing.To check for proper fit, slide an open hand (flat) between the belt and the patient. Further review revealed .WARNING: Heed these warnings to reduce the risk of serious injury or death: There is a risk of chest compression or suffocation, if the patient's body weight is suspended off the chair seat.Monitor per facility policy to ensure that the patient cannot slide down, or fall off he chair seat and become suspended.STOP AT ONCE: if the patient has a tendency to slide forward or down in the device. Medical record review revealed Resident #160 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had short and long term memory impairment, required extensive assistance of 1 person for bed mobility, toileting and hygiene; required extensive assistance of 2 persons for transfers, was frequently incontinent of bowel and bladder and had one fall without injury since admission. Medical record review of the ACKNOWLEDGEMENT OF RESTRAIN (restraint) POLICIES (a form that is provided to the resident and or family upon admission to the facility) signed by the responsible party on 3/30/15 revealed .If restraint use is deemed necessary the goal will be to use the least restrictive type of restraint for the shortest period of time possible.Every resident will be individually assessed regarding the need for appropriate safety measures and will be periodically reassessed. Medical record review of the Restraint Assessment dated 3/31/15 revealed Resident #160 was alert and oriented x (times) 2, had a fall in the past 12 months with a left [MEDICAL CONDITION], a check mark beside gait/balance problems, and the .Behavioral Problem was removes clothing frequently.Positioning Problems (was blank).Reason for Restraint (was blank). Further review revealed the review date: .3/31/15 no restraints needed. Medical record review of the Physician Telephone Order dated 4/9/15 revealed .torso Posey positioner in w/c (wheelchair), check for placement q (every) 30 min (minutes) and release/reposition q 2 hours x 10 min. Medical record review of the Informed Consent for Restraint Utilization, signed by the responsible party on 4/13/15, per nursing note review had verbal consent on 4/9/15, .Consenting to the use of restraints described. revealed .Due to decreased safety awareness (with) unsteady gait, multiple attempts to get up unassisted.assessed and determined the torso Posey positioner vest necessary to protect (Resident #160) from physical harm. Medical record review of the Restraint Assessment revealed the facility failed to reassess Resident #160 after the assessment dated [DATE] for the restraint ordered on [DATE] for a .torso Posey positioner in w/c. Review of the facility's Fall Investigation for Charge Nurse form with the date of the fall on 5/4/15 at 7:15 PM written by Licensed Practical Nurse (LPN) #1, revealed staff was present during the fall, a w/c or geri-chair was involved, a chair alarm was functioning properly, and an ordered restraint was in place and applied correctly. Further review revealed .Did the resident remove the restraint?.Slid under restraint. Further review revealed .Description of incident: At approximately 715pm Resident was starting to slide down in w/c. This nurse pulled resident back up in w/c and went to get pads to put in.foam chair to transfer resident to.foam chair. On way back to the dayroom residents chair alarm started going off. Observed resident sliding down underneath Posey positioner onto the edge of the w/c. Able to assist resident safely to floor.assisted to.foam chair. Further review revealed .Conclusion: Appropriate number of staff involved? Yes.Equipment use appropriate? Yes.Proper technique used? Yes.Resident unattended inappropriately? No. Further review revealed .Supervisor Report.New planned interventions: Staff training on correctly applying torso Posey positioner. Interview with LPN #1 on 7/14/15 at 3:17 PM in the conference room, after reading the Fall Investigation for Charge Nurse with the fall dated 5/4/15, confirmed LPN #1 was the nurse involved in the incident. When LPN #1 was asked to describe the event the LPN stated .the resident was in the dayroom and slid down the w/c and the Posey was under the resident's breasts.I positioned resident up in w/c and posey was at lap, and I left resident and I went to get a pad for foam chair. I came back and resident is sliding out of w/c again with posey at breast area. When the LPN was asked if staff was present in the room with the resident while the LPN got the pads for the foam chair the LPN stated .I left the resident unattended in the day room, no other staff was in the room. When asked if this nurse reapplied the torso positioner after pulling resident up in the w/c prior to leaving the resident unattended the LPN stated No. When LPN #1 was asked why the new intervention was to train staff on correctly applying the torso posey positioner the LPN stated . was to compliance me (LPN #1) on appropriate application. Further interview confirmed no other intervention other than the compliance. Review of the facility staff education Teachable Moment form dated 5/5/15 signed by LPN #1 revealed the LPN was instructed by the Director of Nursing on the .Related Procedure/Standard: Posey not applied correctly.Content of Instruction- employee didn't ensure resident's restraint applied properly. It was too loose + (and) resident was able to get her arm beneath it + move it upward. Ensure she is seated back in w/c before applying posey. Medical record review of the Skilled Nursing Notes dated 5/8/15 revealed .Resident in Rock & Roll (Rock-n-Go, a rocking wheelchair) chair @ (at) 4PM. Observed resident roll self to side bar of wall and pull self out of chair. Resident placed in w/c (with) torso positioner. @ approximately 830 PM this nurse was walking past dayroom. Observed resident down in w/c, posey restraint around neck. Review of the facility's Fall Investigation for Charge Nurse form with the date of the fall on 5/8/15 at 8:30 PM written by LPN #1, revealed a w/c or geri-chair was involved, and an ordered restraint was in place and applied correctly. Further review revealed .Did the resident remove the restraint? was blank.Was a chair alarm involved? No. Further review revealed .Description of incident: Walked past dayroom observed resident down in w/c, posey torso restraint around neck.butt off of wheelchair. Undid restraint, lifted resident up in wheelchair x 2 assist.New Order 1) D/C (discontinue) soft torso positioner 2) soft posey belt in Rock & (and) Roll chair (with) pull alarm. Further review revealed the .Conclusion: Was appropriate number staff and equipment involved? Yes.Proper technique used? Yes.Resident left unattended inappropriately? No. Further review revealed .Supervisor Report.New planned intervention: posey belt in Rock-n-Go; cont (continue) pull alarm also. Further review of the Supervisor Report revealed in handwritten notes .were arms beneath torso positioner? Yes.Had she had belt before? Yes but in w/c then, now Rock-n-Go. Further review of the Supervisor Report revealed .LPN #1: Resident was in w/c. Was in Rock-n-Go prior to dinner. She pulled herself up @ guardrail in Rock-n-Go. She was assisted to w/c (with) restraint. Review of the Employee Statement written by Registered Nurse (RN) #3 of the 5/8/15 incident revealed .The last time you saw resident before they fell ? Time 450 PM.Location: In front dayroom (dayroom/dining room) on H + I (H hall and I hall) pulling self up out of Rock-n-Go by using rails on wall.Alarm sounding? Yes. Further review of the Employee Statement revealed .Describe.what you observed/saw/heard: walking down hallway observed resident in dayroom H + I in w/c had scooted self down so buttocks were off the seat of w/c. Torso posey positioner was still intact but was up around upper chest.With assist of two-release posey torso positioner and lifted back up into w/c-where she proceeded to.scoot downward in w/c.Sensor pad intact.Obtained Rock-n-Go + SWB (soft waist belt) + pull alarm for sitting position. Interview with LPN #1 on 7/14/15 at 3:17 PM in the conference room, after reading the investigation dated 5/8/15 confirmed she had written the investigation report and confirmed the resident had slid down the w/c wearing a torso positioner and the restraint was around Resident #160's neck. Medical record review of the Physician Telephone Orders revealed the following: .5/8/15.Trial period Rock in Go (with) pull alarm for restraint reduction. .5/9/15.1) DC torso positioner in w/c.2) Soft posey belt in Rock-&-Go chair (with) pull alarm, check placement Q 30 min release et (and) reposition q 2 hrs (hours) x 10 min. Review of the medical record revealed the facility failed to obtain an Informed Consent for Restraint Utilization for the Rock-n-Go with a soft waist belt as indicated per facility policy. Further review revealed no assessment for the appropriateness of the restraint or alternatives per facility policy. Medical record review of the Physician Telephone Orders dated 6/17/15 revealed .Trial period (with) w/c + alarming seat belt. Medical record review of the Restraint Assessment revealed the facility failed to reassess Resident #160 after the assessment dated [DATE] for the restraint ordered on [DATE] for .Trial period (with) w/c + alarming seat belt. Further review revealed the facility included the .Rock-n-Go chair (with) soft posey belt (with) trial period with w/c + alarming seat belt. in the comment section of the assessment. Review of the facility's Fall Investigation for Charge Nurse form with the date of the fall on 6/20/15 at 8:10 PM revealed a w/c or geri-chair was involved, the restraint was not in place, a restraint was ordered, a chair alarm was involved.Did it (alarm) function properly? No.alarm did not sound Alarm not turned on. Further review documented .Description of Incident: .resident on floor in dining room.transferred back to w/c.safety belt on and in place. Further review revealed the .Conclusion: Appropriate number of staff involved? Yes.Equipment use appropriate? No.Proper technique used? Yes. Further review revealed .Supervisor Report.New Planned Interventions: trial period w/c (with) alarming seat belt. Inservice /re-educ (reeducate) to (check) alarm as well as connection on any resident (with) alarming seatbelt. Further review of the Supervisor report revealed in hand writing .secured seatbelt but was unaware it was an alarming belt + did not make sure alarm was turned on. Further review revealed .Employee Statement of Incident.last time you saw resident before they fell ? 8:00 PM.Location: Dayroom.Does resident have some kind of personal alarm? Yes.Was it sounding? No.What do you think could prevent this incident/could prevent similar incidences in the future? Double check the alarm. The buckle was on but I didn't check the alarm box. Medical record review of the Physician Telephone Orders revealed the following: .7/9/15.1) D/C (discontinue) alarming seat belt.2) begin soft posey (belt) while in w/c (wheelchair). Apply 2 (hours), then release 10 min and reposition. .7/10/15.D/C soft posey (belt).Begin alarming seat belt (with) w/c. .7/10/15.DC alarming seat belt to w/c.Apply SWB (soft waist belt) while in w/c. Check for placement q (every) 2 hours + release x 10 min. .7/11/15.Start posey belt in Rock-n-Go chair.Check q 30 min + release q 2 hours + reposition x 10 min. Medical record review of the Restraint Assessment revealed the facility failed to reassess Resident #160 after the assessment dated [DATE]. No assessment or reassessment was performed for the restraint ordered on [DATE] which states .SWB (soft waist belt) while in w/c. Check for placement q (every) 2 hours + release x 10 min., and on 7/11/15 for the ordered .posey belt in Rock-n-Go chair.Check q 30 min + release q 2 hours + reposition x 10 min. Review of the medical record revealed the facility failed to obtain the Informed Consent for Restraint Utilization for the soft waist belt while in w/c on 7/9/15; alarming seat belt (with) w/c and the soft waist belt in w/c on 7/10/15; and the soft waist belt in the Rock-n-Go on 7/11/15 per facility policy. Further review revealed no assessment for the appropriateness of the restraints or alternatives per facility policy. Review of the Nurses Notes dated 7/11/15 revealed .2 PM.Observed in w/c (with) posey waist belt-Resident sliding down in w/c (with) posey belt across her arms.Initiated Rock-n-Go w/c (with) posey soft waist belt. Medical record review of the Physician Telephone Order dated 7/15/15 revealed .D/C posey belt in Rock-n-Go. Res (Resident) to be in w/c (with) sensor pad + seatbelt. Check q 30 min + release q 2 (hours) x 10 min. Medical record review of the Restraint Assessment revealed the facility failed to reassess Resident #160 after the assessment dated [DATE] for the restraint ordered on [DATE] for .Res (Resident) to be in w/c (with) sensor pad + seatbelt. Check q 30 min + release q 2 (hours) x 10 min. Observation of Resident #160 and/or interview with staff revealed the following: 1. On 7/14/15 at 7:52 AM: Resident #160 was in the H hall and I hall dayroom/dining room in a reclined Rock-n-Go chair with a soft waist belt in place. 2. On 7/14/15 at 3:20 PM with LPN #1: Resident #160 was in the Rock-n-Go in the F hall and G hall dayroom/dining room with a soft waist belt in place. 3. On 7/15/15 at 7:37 AM: Resident #160 was in the H hall and I hall dayroom/dining room, with 15 other residents, in a reclined Rock-n-Go chair with a soft waist belt under her chin, both arms were under the soft waist belt with the right hand under her chin holding onto the top of belt, the resident had slid down in the chair, and no facility staff was present. The surveyor stayed with the resident. Observation at 7:39 AM revealed 2 nursing staff entering the H hall and I hall dayroom/dining room. Certified Nurse Aide (CNA) #3 did not see Resident #160 and left the dayroom. CNA #1 saw Resident #160 soft waist belt located under her chin and repositioned the belt to the waist area (without re-applying the straps) and left the dayroom. The surveyor stayed with the resident. Continued observation revealed Resident #160 took her right hand and pulled the soft waist belt up under her chin and both arms were under the belt. Continued observation at 7:42 AM revealed RN #1 entering the H hall and I hall dayroom/dining room, went to Resident #160, knelt down behind the chair and touched the restraint belt straps. Interview with RN #1 when asked if the soft waist belt was fastened appropriately, RN #1 stated it should be tighter. Further interview revealed when RN #1 was informed of the soft waist belt under the resident's chin, CNA #1 repositioning the soft waist belt to the waist area without checking or re-applying the restraint straps and left the room leaving the resident unattended and if that was appropriate, RN #1 stated No, it could have serious consequences. Observation and interview revealed CNA #1 re-entering the H hall and I hall dayroom/dining room and confirmed to RN #1 that CNA #1 had repositioned the soft waist belt and had then left the dayroom. The RN stated to CNA #1 That could result in serious consequences, even death. 4. On 7/15/15 at 8:53 AM in front of the H hall and I hall nurses station, revealed Resident #160 in a reclined Rock-n-Go chair with a soft waist belt in place. Continued observation revealed the resident had both arms under the belt, the belt was loose, and the belt was positioned across the breast. The surveyor stayed with the resident until a nurse arrived. Observation and interview with RN #1 on 7/15/15 at 8:54 AM through 8:58 AM in front of the H hall and I hall nurses station, revealed Resident #160 had removed several types of restraints and the current restraint (soft waist belt) was .not applied correctly, it was too loose. Continued interview confirmed the resident was capable of self-propelling in a wheelchair, and the Rock-n-Go chair was reclined to prevent the resident from propelling. When RN #1 was asked if the belt was applied correctly the RN stated the .soft posey belt was not applied correctly.belt was not appropriate for the resident. 5. On 7/15/15 at 1:55 PM and at 2:50 PM: The resident was in a reclined Rock-n-Go chair in the in H hall and I hall dayroom/dining room with no staff present, no soft waist belt was on the resident. LPN #8 entered the H hall and I hall dayroom/dining room and stated the physician had changed the order to stop the soft waist belt and keep the Rock-n-Go. Medical record review revealed no restraint assessment for the appropriateness of the restraint or alternative per facility policy. Medical record review revealed an undated Pre-Restraining Evaluation. Interview with MDS Coordinator #1 on 7/16/15 at 7:40 AM in the conference room confirmed the evaluation was not dated, had been completed after the 7/15/15 observations, and failed to identify recommendations and alternatives to restraints. Interview with the Director of Nursing (DON) on 7/15/15 at 2:42: PM, in the Admissions Coordinator's office, confirmed, after the first incident on 5/4/15 at 7:15 PM, it was unsafe to leave the resident in a torso positioner, no new intervention was put in place, and the facility failed to follow the manufacturer's instructions. Further interview confirmed the torso positioner was still used on the 5/8/15 incident when the resident slid down the wheelchair again and the restraint was around the resident's neck. Further interview confirmed the soft waist belt was not appropriate for Resident #160. The DON confirmed the facility's failure to assess for the appropriateness of the restraints, the failure to assess for the least restrictive restraint, and the failure to obtain consent for the restraints as the restraints changed. The DON confirmed the facility had failed to monitored Resident #160 to ensure the resident's safety per facility policy. Interview with MDS Coordinator #1 on 7/16/15 at 7:40 AM in the payroll office confirmed the facility failed to follow the policy to complete a restraint assessment to determine the need for the restraint and the appropriateness of the restraints used. Interview with the DON and Environmental Director, chairman of Falls Committee, on 7/20/15 at 9:00 AM and 10:45 AM in the conference room, confirmed LPN #1 failed to appropriately reapply the torso restraint after the first observation on 5/4/15 at 7:15 AM and left the resident unattended. Further interview confirmed LPN #1 had failed to accurately investigate when the LPN documented the proper technique was used and the resident was not left unattended. When the DON was asked about the two observations on 7/15/15, the DON stated an incident investigation would not have been completed since the resident had not been reported to be sliding out of the chair but would expect a nursing note. The DON confirmed neither event on 7/15/15 was documented in the nursing notes. The DON confirmed the facility failed to follow the manufacturer's instructions by discontinuing the torso positioner and the soft waist belt once the facility was aware the resident was sliding in the chairs. Interview with LPN #1 on 7/14/15 at 3:17 PM in the conference room confirmed leaving the resident unattended on 5/4/15, and came back to the room to find Resident #160 had slid down the wheelchair again with the soft waist restraint in the breast area. Medical record review revealed Resident #29 was admitted on [DATE], discharged on [DATE] for hospitalization and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS dated [DATE] revealed Resident #29 to be severely cognitively impaired, and required extensive assistance of 1 for Activities of Daily Living (ADLs), and restraints in chair/out of bed were used daily. Medical record review of ACKNOWLEDGEMENT OF RESTRAIN (restraint) POLICIES (a form that is provided to the resident and or family upon admission to the facility) signed by Resident #29's legal representative on 4/11/14 revealed .if restraint use is deemed necessary the goal will be to use the least restrictive type of restraint for the shortest period of time possible.every resident will be individually assessed regarding the need for appropriate safety measures and will be periodically reassessed as their needs change throughout their stay. Medical record review of a Restraint assessment dated [DATE] revealed .7/24/14 Posey Torso dc'd (discontinued). (Change) to Posey belt d/t (due to) pt removing. Continued review revealed the review dates between 8/12/14 and 6/10/15, the resident continued to use a soft waist restraint and the facility failed to reassess for a least restrictive restraint per the facility policy. Medical record review of the readmission Physician's Orders dated 6/10/15 revealed .OOB (out of bed) in w/c daily; dump seat (a seat tilted downward) in w/c.use soft Posey belt in w/c prn (as needed) restlessness, agitation. Medical record review of an Informed Consent for Restraint Utilization dated 8/1/14 revealed .physician and an interdisciplinary team of medical professionals have assessed and determined that the use of a Posey belt is necessary. Medical record review of a TAR (treatment administration record) dated June 2015 revealed .When restless transfer to WC (wheelchair) with soft Posey belt d/t (due to) increased risk for fall/unsteady gait. Check q 30 min. Observation on 7/21/15 at 7:20 AM revealed the resident lying in bed with eyes closed. Continued observation revealed a wheelchair positioned near Resident #29's bed with a soft waist restraint lying in the seat. Interview with the DON on 7/21/15 at 8:58 AM in the Admission Coordinators Office revealed, when questioned about the resident and use of the soft waist restraint stated, .she's doing good in the Broda (a high back, reclining geriatric chair).I haven't seen her in the w/c in a long time.we may need to reassess for its use. Continued interview, when asked if the resident had not been in the wheelchair with the soft waist restraint in the month of June, explain the staff initials on the TAR, the DON stated .it means they're aware of the order and monitoring of it . When asked if the staff initials could be interpreted as the restraint was in use, the DON stated .oh I see what you mean.yes it could. When asked if a complete restraint assessment or a reassessment for the least restrictive restraint had been completed in the past year, the DON stated .no.we've not done that. Interview with the DON on 7/21/15 at 10:04 in the conference room, when asked about restraint reassessment, the DON stated .I would expect them to be done quarterly and documented in the interdisciplinary notes. Medical record review revealed Resident #56 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly MDS dated [DATE] revealed the resident was severely cognitively impaired. Continued review revealed documentation under the restraint section, of a trunk restraint used less than daily, and a chair that prevented rising used less than daily. Medical record review revealed a Restraint Assessment form with a review date of 5/24/12 documented no restraints; 6/24/13 documented carafoam (padded foam chair with ottoman used for fall prevention) ottoman (with) 3 pt (point) pelvic positioner prn; and 12/11/14 documented .carefoam ottoman/lounger (with) 3 pt pelvic positioner release & (and) reposition q 2 (hours) x 10 min check q 30 minutes. Medical record review revealed Physicians Orders (recapitulation) for the months of 2/2015 through 7/2015, .Padded side rails (4) up when in bed. Up OOB (out of bed) to carefoam lounger and put back to bed before 3 pm on shower days (M/W/F) (Monday, Wednesday, Friday) Carefoam lounger with 3 pt pelvic positioner. Release and reposition Q 2 hrs x 10 min. Check Q 30 min. Medical record review revealed a signed, but undated, Informed Consent for Restraint Utilization form for a 3 point pelvic harness restraint with the reason for the restraint documented as .decreased safety awareness (secondary) dementia. Medical record review revealed no

Based on review of Administrator Job Description, and interview, the facility failed to be administered in a manner to ensure the residents were evaluated for the need of restraints; failed to determine the least restrictive restraint; failed to obtain consent for the restraint; failed to ensure the restraint was properly applied, and failed to monitor the resident in the restraint, to ensure the resident's safety for 12 (Resident #160, 29, 56, 63, 73, 78, 94, 109, 111, 117, 142, 158) of 13 residents reviewed with restraints. The failure of the facility to assess and reassess the need for restraints, determine the least restrictive restraint, follow the restraint manufacturer's application instructions and warnings, apply the restraint per the manufacturer's instructions, and monitor the resident while in the restraint placed Resident #160 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Administrator was informed of the Immediate Jeopardy on 7/21/15 at 2:40 PM in the conference room. The Immediate Jeopardy was effective 5/4/15 through 7/30/15. A Full Extended Survey was conducted on 7/21/15 to 7/29/15. The facility was cited Substandard Quality of Care at F221-K. An acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received on 7/29/15 at 9:00 AM, and the corrective actions were validated by the surveyors on 7/29/15. The findings included: Review of the undated Administrator job description revealed .General Purpose.to lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintain excellent care for the residents. Interview with the Administrator on 7/22/15 at 3:53 PM in the conference room, confirmed the facility was aware of the physical restraints stating .they flag on Quality Measures.it was brought up.maybe 2 months ago.10 to 12 people. Continued interview with the Administrator confirmed he was unaware the current residents in physical restraints had not been assessed for the need of restraints, had not been assessed for the least restrictive restraint, did not have completed consents for the restraint. Continued interview revealed staff had not applied restraints per the manufacturer's instructions, and had failed to monitor the use of the restraint. Continued interview revealed, when the QA (Quality Assurance Committee) met and restraints were reviewed on the Quality Measures, the Committee had started an evaluation, but changed the focus to dehydration due to the Medical Director's request. Refer to F221-K, F272-K, F280-J, F490-K, F501-K, and F520-K. The interventions put in place were evaluated by the survey team on 7/29/15, and verified the Allegation of Compliance by: 1. The facility re-assessed the 13 residents with restraints for appropriateness and for the least restrictive device. 2. Interviews with 20 nursing staff members selected from all units in the facility from the 7:00 AM-3:00 PM and 3:00 PM-11:00 PM shifts. These interviews included verbal explanation of who was responsible to assess and re-assess the need for a restraint, how to assess and reassess the resident need for restraint, how to order a restraint, how to monitor a resident while in a restraint, the requirements for documentation of residents utilizing restraints, how and who was to revise the care plan for changes in restraint orders, and how to apply the restraint. 3. Interview with the Administrator and Director of Nurses outlined the governing body's plan for on-going supervision and follow-up with the facility which would be conducted in response to the Immediate Jeopardy, by which means communication was to occur; how frequently over-site was provided; and for what duration follow-up would be performed on-site. Non-compliance continues at a E level for evaluation of the monitoring by the Quality Assurance Committee. The facility is required to submit a Plan of Correction.

Based on facility policy review, reference review of Lippincott Manual of Nursing Practice, for restraint guidelines, medical record review, observation and interview, it was determined that the facility failed to ensure the Quality Assessment and Assurance Committee identified and put into place corrective action to ensure the facility restraint policy was followed, failed to ensure physician's orders were provided correctly, followed and monitored, failed to ensure staff was educated and knowledgeable in proper application and use of restraints, failed to ensure the resident care plans were updated to reflect the current use of restraints for 1 (Resident #160), failed to ensure the consent for restraints were obtained, restraint assessments/reassessments were completed to ensure the need for restraints, the appropriateness of the restraint, the least restrictive restraint, and restraint reduction for 12 ( Resident #160, 29, 56, 63, 73, 78, 94, 109, 111, 117, 142, 158) of 13 residents reviewed for restraints resulting in an Immediate Jeopardy to Resident #160; failed to ensure the safety and maintenance of equipment which resulted in Harm to Resident #10; failed to provide oversight of the infection control program which resulted in recurrent scabies infestation for 3 (Resident 81, 76, 158) of 7 residents reviewed for scabies. The failure of the facility to assess and reassess the need for restraints, determine the least restrictive restraint, follow the restraint manufacturer's application instructions and warnings, apply the restraint per the manufacturer's instructions, and monitor the resident while in the restraint placed Resident #160 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Administrator was informed of the Immediate Jeopardy on 7/21/15 at 2:40 PM in the conference room. The Immediate Jeopardy was effective 5/4/15 through 7/30/15. A Full Extended Survey was conducted on 7/21-29/15. An acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received on 7/29/15 at 9:00 AM, and the corrective actions were validated by the surveyors on 7/29/15. The findings included: Review of the facility's Restraints-Physical policy updated 2/4/14 revealed .Restraints will only be used in extreme circumstances and only with: 1. Documented behavior. 2. Consent from resident's representative 3. Physician and DON or designee. 4. All other non-restrictive alternatives have been tried and were unsuccessful (MD (Medical Doctor) orders must be written). 5. Physical restraint shall not be used to limit the resident's mobility for the convenience if the staff.Written policies and procedures governing the use of restraints specify which staff member may authorize the use of restraints and clearly delineate the following: (a) Orders indicate the specific reason, type and period of time for the use of restraints. Restraints must be used only as a last resort, and the medical record must indicate the events leading up to the necessity of the restraint. (b) Their use is temporary, and the resident will not be restrained for an indefinite amount of time.The attending physician must be notified of such use and the reason for the order. Consent for Restraint must be discussed with the responsible party.(e) Reorders are issued only after a review of the resident ' s condition by his or her physician.10. The need for restraints will be evaluated at least quarterly in the Falls Committee Meeting to determine their continued use of a restraint has been reevaluated and that reorder from the physician is so noted. Review of Lippincott Manual of Nursing Practice, 2014, Tenth Edition, Chapter 9 revealed (page) 191.These (restraint) guidelines must be met in any long-term care facility that participates in Medicare or Medicaid. However, these guidelines are useful for health care providers working with older adults in all settings. (a) The resident has the right to be free from any physical restraints imposed.for purposes of discipline or convenience and not required to treat the resident's medical condition. (b) Physical restraints are any manual method of physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the person cannot remove easily, which restricts freedom of movement or access to one's body (includes leg and arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, and geriatric chairs). (c) There must be a trial of less restrictive measures unless the physical restraint is necessary to provide life-saving treatment. (d) The resident of legal representative must consent to the use of restraints. (e) Residents who are restrained should be released, exercised, toileted, and checked for skin redness every 2 hours. (f) The need for restraints should be reevaluated periodically. (g) The specific facility will have to develop policies and procedures for the appropriate use of restraints. (h) Primary health care providers will have to write appropriate orders for restraints. Interview with the Administrator on 7/22/15 at 3:53 PM in the conference room revealed the Director of Nurses (DON) was the chair of the Quality Assessment and Assurance (QAA) committee. Continued interview stated he was an attendee of the QAA meetings which were held more often than quarterly. When asked if the scabies infestation had been addressed in the QAA meetings, he replied it had been. When asked if restraints had been discussed in the QAA meeting, he responded it had, but not at every meeting; we knew it triggered on the QM (Quality Measure) maybe 2 months ago.10-12 people, we had started an eval (evaluation).(Medical Director) felt UTI's (urinary tract infections) and dehydration needed to be looked at.that took priority. When asked if he was aware the facility had residents who'd had the same restraint for two years or more who had not been reassessed for continued restraint use and there had been no attempt at restraint reduction, he replied he was not aware. Interview with the DON on 5/24/15 at 12:51 PM in the private dining room on J Hall, confirmed she was the chair of the QAA committee. When asked what issues were routinely discussed in the QAA meeting, she responded, .UTI's, MDS (Minimum Data Set), pressure ulcers, infection control. When asked if the committee discussed triggers on the QMs, she responded, Yes, even (Medical Director) brought up hydration and we had a report that would pull up anyone who had not had at least 1000 cc (cubic centimeters). and the facility was now monitoring all residents hydration. When asked if restraints had been discussed in the committee, she replied, Yes, it was brought up on the last QAA meeting.how we compared nationally.I don't remember the last time residents with restraints was brought to the meetings.I had discussed with restorative nursing that we needed to have a meeting to discuss restraints.I actually had planned a meeting about 2 weeks before you came.something happened and we didn't have the meeting. When asked how long she had been aware of the restraints being a QAA issue, she replied, .(former Assistant Director of Nurses) was pretty good about things and keeping it up.it wasn't until she left that I realized there was a problem.she did not bring restraints to the meeting. The facility has failed to develop a QAA program and a Quality Assurance Performance Improvement (QAPI) to address the use of restraints. Refer to F221-K The facility has failed to develop a QAA program and a QAPI system to address Resident Assessment. Refer to F272-K The facility has failed to develop a QAA program and a QAPI system to address Care Plan Revision. Refer to F280-J The facility has failed to develop a QAA program and a QAPI system to address Accident Hazards. Refer to F323-G The facility has failed to develop a QAA program and a QAPI system to address Infection Control. Refer to F441-D The survey team identified systemic failures on the part of the Administration to ensure the residents were evaluated for the need of restraints; failed to determine the least restrictive restraint; failed to obtain consent for the restraint; failed to ensure the restraint was properly applied, and failed to monitor the resident in the restraint, to ensure the resident's safety for 12 (Resident #160, 29, 56, 63, 73, 78, 94, 109, 111, 117, 142, 158) of 13 residents reviewed with restraints. During survey the team identified concerns in the areas of F221, F272, F280, F323, F490, and F501. The facility has failed to develop a QAA program and a QAPI system to address Administration Refer to F221-K, F272-K, F280-J, F323-G, F441-E, F490-K, F501-K The survey team identified failures on the part of the facility to ensure the Medical Director assisted with addressing clinical concerns and provided guidance regarding care of the residents with restraints residing in the facility and regarding infection control concerns, specifically a scabies infestation. The facility has failed to develop a QAA program and a QAPI program to address the responsibilities of the Medical Director. Refer to F221-K, F272-K, F280-J, F441-E The interventions put in place were evaluated by the survey team on 7/29/15, and verified the Allegation of Compliance by: 1. The facility re-assessed the 13 residents with restraints for appropriateness and for the least restrictive device. 2. Interviews with 20 nursing staff members selected from all units in the facility from the 7:00 AM-3:00 PM and 3:00 PM-11:00 PM shifts. These interviews included verbal explanation of who was responsible to assess and re-assess the need for a restraint, how to assess and reassess the resident need for restraint, how to order a restraint, how to monitor a resident while in a restraint, the requirements for documentation of residents utilizing restraints, how and who was to revise the care plan for changes in restraint orders, and how to apply the restraint. 3. Interview with the Administrator and Director of Nurses outlined the governing body's plan for on-going supervision and follow-up with the facility which would be conducted in response to the Immediate Jeopardy, by which means communication was to occur; how frequently over-site was provided; and for what duration follow-up would be performed on-site. Non-compliance continues at a E level for evaluation of the monitoring by the Quality Assurance Committee. The facility is required to submit a Plan of Correction.

Based on facility policy and procedure review, review of the restraint manufacturer's Application Instructions, the medical record, the facility investigations, interview, and observation, the facility failed to revise the care plan to ensure the currently ordered restraint was addressed to ensure the resident's safety for 1 (Resident #160) of 13 residents reviewed with restraints. The failure of the facility to revise the care plan placed Resident #160 in Immediate Jeopardy (a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Administrator was informed of the Immediate Jeopardy on 7/21/15 at 2:40 PM in the conference room. The Immediate Jeopardy was effective 5/4/15 through 7/30/15. A Full Extended Survey was conducted on 7/21-29/15. An acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received on 7/29/15 at 9:00 AM, and the corrective actions were validated by the surveyors on 7/29/15. The findings included: Review of the facility policy, updated 2/4/14, Restraint-Physical revealed Restraints should only be used for the safety and well-being of the resident(s) and only after all alternatives have been tried unsuccessfully and results are documented. The nurse applying the restraint must update resident's care plan to indicate the continued use of a restraint has been reevaluated.The least restrictive must always be utilized. Review of the facility .Care Planning Procedure. revealed the .Purpose: To ensure the care plans are accurate and timely updated and reviewed by all disciplines. Further review revealed .Purpose: Care plans will be modified as needed on printed care plan by hand as indicated.Any handwritten changes will be dated and initialed. Review of the restraint manufacturer's Application Instructions revealed .Before Applying Any Restraint: A restraint must be used in accordance with the patient's individualized Care Plan. Medical record review revealed Resident #160 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #167 had short and long term memory impairment, required extensive assistance of 1 person for bed mobility, toileting and hygiene; required extensive assistance of 2 persons for transfers, was frequently incontinent of bowel and bladder and had one fall without injury since admission. Medical record review of the Physician Telephone Orders dated 6/17/15 revealed .Trial period (with) w/c (wheelchair) + (and) alarming seat belt. Medical record review of the Restraint Assessment dated 3/31/15 revealed Resident #160 information had not been revised since 3/31/15 and included the resident was alert and oriented x (times) 2, had a fall in the past 12 months with a left [MEDICAL CONDITION], a check mark beside gait/balance problems, and .Behavioral Problems.Removes clothing frequently.Positioning Problems (was blank).Reason for Restraint (was blank). Further review documented the review dates: .3/31/15 no restraints needed. Further review revealed no changes in the assessment from 3/31/15 for the 6/17/15 order for .Trial period (with) w/c + alarming seat belt. Review of the facility's Fall Investigation for Charge Nurse form with the date of the fall on 6/20/15 at 8:10 PM revealed a w/c or geri-chair were involved, the restraint was not in place, a restraint was ordered, a chair alarm was involved.Did it (alarm) function properly? No.alarm did not sound Alarm not turned on. Further review documented .Description of Incident: .resident on floor in dining room.transferred back to w/c.safety belt on and in place. Further review revealed the .Conclusion: Appropriate number of staff involved? Yes; Equipment use appropriate? NO; Proper technique used? Yes. Further review revealed .Supervisor Report.New Planned Interventions: trial period w/c (with) alarming seat belt. Inservice /re-educ (reeducate) to (check) alarm as well as connection on any resident (with) alarming seatbelt. Further review of the Supervisor report documented in hand writing .secured seatbelt but was unaware it was an alarming belt + did not make sure alarm was turned on. Further review revealed .Employee Statement of Incident.last time you saw resident before they fell ? 8:00 PM.Location: Dayroom.Does resident have some kind of personal alarm? Yes.Was it sounding? No.What do you think could prevent this incident/could prevent similar incidences in the future? Double check the alarm. The buckle was on but I didn't check the alarm box. Medical record review of the Physician Telephone Orders revealed the following: .7/9/15.1) D/C (discontinue) alarming seat belt.2) begin soft posey (belt) while in w/c. Apply 2 (hours), then release 10 min and reposition. .7/10/15.D/C soft posey (belt).Begin alarming seat belt (with) w/c. .7/10/15.DC alarming seat belt to w/c.Apply SWB (soft waist belt) while in w/c. Check for placement q (every) 2 hours + release x 10 min. .7/11/15.Start posey belt in Rock-n-Go chair (a rocking wheelchair).Check q 30 min + release q 2 hours + reposition x 10 min. Review of the Nurses Notes dated 7/11/15 revealed .2 PM.Observed in w/c (with) posey waist belt-Resident sliding down in w/c (with) posey belt across her arms.Initiated Rock-n-Go w/c (with) posey soft waist belt. Medical record review of the Physician Telephone Order dated 7/15/15 revealed .D/C posey belt in Rock-n-Go. Res (Resident) to be in w/c (with) sensor pad + seatbelt. Check q 30 min + release q 2 (hours) x 10 min. Medical record review of the Restraint Assessment revealed no changes in the assessment from 3/31/15 for the 7/15/15 order for .Res (Resident) to be in w/c (with) sensor pad + seatbelt. Check q 30 min + release q 2 (hours) x 10 min. Medical record review of the care plan dated 3/31/15, updated 4/6/15, 4/22/15, 7/6/15, and 7/8/15, revealed the problem of .at risk for falls r/t (related to) h/o (history of) falls, resulting in fx (fracture). Further review revealed the last entry was dated .5/17/15 trial period w/c (with) alarming seat belt, ck (check) q 30 min, release/reposition (x 10 min) q 2 hrs (hours). Further review revealed the facility failed to revise the care plan 7/9/15 to . D/C alarming seat belt.2) begin soft posey (belt) while in w/c. Apply 2 (hours), then release 10 min and reposition., on 7/10/15 to .D/C soft posey (belt).Begin alarming seat belt (with) w/c., on 7/10/15 to .DC alarming seat belt to w/c.Apply SWB (soft waist belt) while in w/c. Check for placement q 2 hours + release x 10 min. on 7/11/15 to .Start posey belt in Rock-n-Go chair.Check q 30 min + release q 2 hours + reposition x 10 min., on 7/15/15 .D/C posey belt in Rock-n-Go. Res (Resident) to be in w/c (with) sensor pad + seatbelt. Check q 30 min + release q 2 (hours) x 10 min. Observation of Resident #160 and/or interview revealed the following: 1. On 7/14/15 at 7:52 AM: Resident #160 was in the H hall and I hall dayroom/dining room in a reclined Rock-n-Go chair with a soft waist belt in place. 2. On 7/14/15 at 3:20 PM with LPN #1: Resident #160 was in the Rock-n-Go in the F hall and G hall dayroom/dining room with a soft waist belt in place. 3. On 7/15/15 at 7:37 AM: Resident #160 was in the H hall and I hall dayroom/dining room, with 15 other residents, in a reclined Rock-n-Go chair with a soft waist belt under her chin, both arms were under the soft waist belt with the right hand under her chin holding onto the top of belt, the resident had slid down in the chair, and no facility staff was present. The surveyor stayed with the resident. Observation at 7:39 AM revealed 2 nursing staff entering the H hall and I hall dayroom/dining room. Certified Nurse Aide (CNA) #3 did not see Resident #160 and left the dayroom. CNA #1 saw Resident #160 soft waist belt located under her chin, repositioned the belt to the waist area (without re-applying the straps) and left the dayroom. The surveyor stayed with the resident. Continued observation revealed Resident #160 took her right hand and pulled the soft waist belt up under her chin and both arms were under the belt. Continued observation at 7:42 AM revealed Registered Nurse (RN) #1 entering the H hall and I hall dayroom/dining room, went to Resident #160, knelt down behind the chair and touched the restraint belt straps. Interview with RN #1 when asked if the soft waist belt was fastened appropriately, RN #1 stated it should be tighter. Further interview with RN #1 when asked if it would be appropriate for staff to see the soft waist belt under the resident's chin, reposition the soft waist belt to the waist area without checking or re-applying the restraint straps and leaving the room with the resident unattended, the RN #1 stated, No, it could have serious consequences. Observation and interview revealed CNA #1 re-entering the H hall and I hall dayroom/dining room and demonstrated to RN #1 how CNA #1 had repositioned the soft waist belt and stated then .left the dayroom. the RN stated to CNA #1 That could result in serious consequences, even death. 4. On 7/15/15 at 8:53 AM in front of the H hall and I hall nurses station, revealed Resident #160 in a reclined Rock-n-Go chair with a soft waist belt in place. Continued observation revealed the resident had both arms under the belt, the belt was loose, and the belt was positioned across the breast. The surveyor stayed with the resident until a nurse arrived. Observation and interview with RN #1 on 7/15/15 at 8:54 AM through 8:58 AM in front of the H hall and I hall nurses station, revealed Resident #160 had removed several types of restraints and the current restraint (soft waist belt) was .not applied correctly, it was too loose. Continued interview confirmed the resident was capable of self-propelling in a wheelchair, and the Rock-n-Go chair was reclined to prevent the resident from propelling. When RN #1 was asked if the belt was applied correctly the RN stated the .soft posey belt was not applied correctly.belt was not appropriate for the resident. 5. On 7/15/15 at 1:55 PM and at 2:50 PM: The resident was in a reclined Rock-n-Go chair in the in H hall and I hall dayroom/dining room with no staff present, no soft waist belt was on the resident. LPN #8 entered the H hall and I hall dayroom/dining room and stated the physician had changed the order to stop the soft waist belt and keep the Rock-n-Go. Interview with the Director of Nursing (DON) on 7/15/15 at 2:42: PM, in the Admissions Coordinator's office, confirmed the facility failed to revise the care plan after 5/17/15 to reflect the restraint changes. The interventions put in place were evaluated by the survey team on 7/29/15, and verified the Allegation of Compliance by: 1. The facility re-assessed the 13 residents with restraints for appropriateness and for the least restrictive device. 2. Interviews with 20 nursing staff members selected from all units in the facility from the 7:00 AM-3:00 PM and 3:00 PM-11:00 PM shifts. These interviews included verbal explanation of who was responsible to assess and re-assess the need for a restraint, how to assess and reassess the resident need for restraint, how to order a restraint, how to monitor a resident while in a restraint, the requirements for documentation of residents utilizing restraints, how and who was to revise the care plan for changes in restraint orders, and how to apply the restraint. 3. Interview with the Administrator and Director of Nurses outlined the governing body's plan for on-going supervision and follow-up with the facility which would be conducted in response to the Immediate Jeopardy, by which means communication was to occur; how frequently over-site was provided; and for what duration follow-up would be performed on-site. Non-compliance continues at a D level for evaluation of the monitoring by the Quality Assurance Committee. The facility is required to submit a Plan of Correction.

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to ensure equipment was safe for resident use for 1 (Resident #10); failed to ensure residents were correctly placed in mechanical lifts for 2 (Resident #84, 26); failed to ensure belts were secured on a merry walker for 1 (Resident #18) of 4 residents reviewed for accidents with medical equipment; and failed to supervise a resident in a restraint to ensure safety which resulted in an injury for 1 (Resident #158) of 13 residents reviewed for restraints. This failure resulted in actual HARM to Resident #10 who sustained a fall from a mechanical lift and suffered a head laceration. The findings included: Review of the facility policy entitled Patient/Resident Transfer and Handling, undated, revealed .the Prolift may be used for total care or non-weight bearing residents and it allows the resident to have a sitting position during transfer. All mechanical lift users are responsible to: 1. Inspect devices prior to use to insure equipment is in good repair and working order. 2. Insure slings are laundered when indicated. 3. Report maintenance and repair issue to DON when indicated. 4. Follow the guide lines exactly for using mechanical lifts. Continued review of the facility policy addendum dated 2/1/13, revealed .Two or more people are required for the total dependent lift such as the Pro One lift. Further review of the facility policy addendum dated 4/13/15, revealed .It is the policy of. (named facility) to inspect the integrity of all lift pads prior to uses. Any frayed edges or stitching coming undone is to be reported immediately to supervisor and the pad is not to be used. Continued review of the facility policy revealed the statement .DO NOT LEAVE RESIDENT UNATTENDED. Medical record review revealed Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident was severely impaired cognitively; was total dependence of two people for transfer, dressing, grooming, and bathing; required extensive assistance for eating; and was always incontinent of bowel and bladder. Medical record review of nursing notes dated 4/12/15, at 8:30 AM, revealed .Summoned to room. Observed resident lying on floor between bed and bars of Pro 1 lift (mechanical lift). Resident was dressed in gown and was lying on left side with head lying on lt (left) bar of lift and feet were elevated above floor D/T (due to) contractures of (lower) extremities causing body to be in semi-fetal position which is resident's normal positioning. Blood was noted to back of head - Resident was saying Oh, my head. On assessment laceration noted to (upper) center back of head. An abrasion was noted on posterior (L) (left) leg extending from ankle to knee approx. 2-3 wide. Pressure applied to laceration. Resident was left on left side with staff in attendance until emergency service arrived. 2 CNAs (Certified Nursing Aides) were using Pro 1 lift when strap on rt (right) side of lift (front side when facing handle) broke causing resident to fall. Emergency service notified and resident was transported to.(named hospital). Review of the admission History and Physical from the hospital dated 4/12/15, revealed.patient was in lift and the strap broke and the patient fell hitting the back of the head on the floor. There was bleeding of note from the scalp wound. The patient received 2 sutures to the posterior aspect of the scalp. A CT (computerized technology) of the head revealed scalp hematoma of overlying the left posterior superior calvarium. Review of the facility investigation of a statement from CNA #1 dated 4/12/15, revealed .Had resident connected to Pro 1 lift. (named CNA) and I were in the process of transferring when pulling Pro 1 lift away from bed the lift pad strap broke (front strap on right side when facing handle of Pro 1) and resident fell out. Her head hit leg of Pro 1 and because her body twisted as going down she ended up hitting against siderail of bed with her lower left leg. Nurse came in and we left her in the position she was in (on her side) until EMTs (Emergency Medical Technicians) got here. Continued review of the statement from CNA #1, in response to the question of what could prevent similar incidents in the future, revealed .It would help if laundry would inspect straps after washing prior to putting out for use. The washing of slings is causing straps to thin out. Continued review of the facility investigation of a statement from CNA #4 dated 4/11/15, revealed .(named CNA #1) and I was transferring (named Resident #10) from bed to chair. While in mid air the lift pad strap broken and fell to floor. Her head hit leg of lift. Her leg hit side rail. Further review of the facility investigation revealed an unsigned note dated 4/12/15, with a 1 marked over the 2, revealed .I examined all lift slings I could find including in laundry. All appeared ok. Except for stand-up lift sling had some strings that are starting to come loose - the strap is reinforced however this needs to be stitched up. It is ok to use for now. Also on the stand up lift sling on F & G (F hall and G hall) has a small worn area on one of the green colored hoop of strap. We had difficulty getting H & I (H hall and I hall) pro 1 lift to lock (wheels). (named maintenance) looked at it. It is the design of the brake. This needs to be looked at. It will lock if you can get the brake to go all way down when pushed on. Also Pro 1 lift on J & K one front wheel has no tread on it. Interview with the DON on 7/15/15, at 2:00 PM, in the Case Management office, revealed Resident #10's CNA had dressed her and placed the sling of the Pro 1 lift under her. Continued interview revealed 2 other CNAs went in to get the resident up in the chair. Further interview revealed the CNAs had cleared the bed with the sling and were moving the legs of the lift out from under the bed. Continued interview revealed at that point the strap on the lift broke and the resident fell on the floor. Further interview revealed one strap was frayed but it was hidden by another piece of the sling. Continued interview revealed Restorative had removed the slings that appeared worn and frayed but left others in use that appeared to be intact, and confirmed the frayed strap was overlooked. Medical record review revealed Resident #84 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE], revealed the resident was cognitively intact scoring 15/15 on the Brief Interview for Mental Status; required extensive assistance with transfers, dressing, bathing, and grooming; was continent of bowel and bladder; and utilized a wheelchair for mobility. Review of a facility fall investigation dated 3/2/15, at 10:30 PM, revealed .Tech reported standing lift battery went dead. Resident standing on lift over bed. Tech (Certified Nursing Aide) went to get new battery and help from another tech. Tech put battery in lift went down by self. Resident lost footing. Resident stated he was not touching the floor at any time. Resident stated tech did nothing wrong. Techs x (times)1 used lift to helped resident on lift so resident not come out of lift. Tech helped resident get footing and tech x 2 helped resident get back up in bed. Continued review of the facility investigation revealed an undated, unsigned note which stated the resident .came into Falls Meeting for interview. Resident states lift stopped working while he was up in air. Battery stopped working before resident was up high enough to sit on the bed. CNA hit the button (manual) on the left and it lowered resident almost to floor - had him suspended off floor. His feet were still on platform. He states no part of his body touched the floor. States lift was beeping when she first started helping him. Further review of the facility investigation of a note written by CNA #5 dated 3/2/15, revealed .I had him in the stand-up lift and I was putting him to bed. When I start the lift batteries to stop work on me and went got another that when lift when all the way down and I ask (CNA #6) and the when (named resident #84) lose his footing. Continued review of the facility investigation of an unsigned note dated 3/2/15, revealed .(CNA #6) came to me at 11 PM and told me to ask (CNA #5) about named Resident #84. I went to investigate immediately. Talk with (CNA #5) about not telling me and reporting anything even when resident did not get hurt or not. Further review of the facility investigation of a note from CNA #6 dated 3/2/15, when asked to describe what he observed/saw/heard, revealed .Residents was sitting on his ass. Continued review of the facility investigation of a note by the Director of Nursing (DON) dated 3/4/15, at 3:00 PM, revealed .via (CNA #5) states she was transferring him from w/c (wheel chair) to the bed. Had moved the lift over the bed. When going down his foot slipped. His bottom went off the edge of the mattress and then down. Resident strapped in lift - says his bottom didn't hit the floor - it landed on the legs of lift (to the platform). Thighs were on the legs of Lift(where it opens and closes). States she went to get assist. Says pt (patient) was safe. Saw (CNA #6) and got another battery. Says she didn't think to get the nurse since he was still on lift and didn't think it was a fall. Interview with the DON on 7/15/15, at 2:00 PM, in the Case Management office, revealed Resident #84 was in the lift being transferred when the battery went dead. Further interview revealed the lift has an emergency button to lower the sling to the bed which the CNA should have used. Continued interview confirmed the CNA should not have left the resident alone in the lift while she went in search of a battery. Medical record review revealed Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review the Quarterly MDS dated [DATE], revealed the resident was severely impaired cognitively; required extensive assistance with transfers; was total dependence for dressing, eating, grooming, and bathing; was always incontinent of bowel and bladder; and used a wheelchair for mobility. Review of the facility investigation of a statement by the Licensed Practical Nurse (LPN) #13 dated 5/20/15 revealed .Resident was observed still in her merri walker (a standing walker with a seat) sitting on the floor with her hands on the bar and black strap on the floor. Resident on her buttocks. The clip to the black strap that connects to the seat was not buckled. Resident was assisted by staff into her wheelchair and clip alarm attached. Continued review of the facility investigation of the supervisor's report dated 5/21/15, revealed the resident was seen ½ hour earlier with strap in place. Further review revealed a concern if the buckle was completely snapped on the safety strap when the resident was placed in the merri walker and the CNA's comment was .pulled it, it was secure but didn't actually look at buckle. Medical record review revealed Resident #26 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the 30 day MDS dated [DATE], revealed the resident was severely impaired cognitively; was total dependence for transfers, eating, grooming, and bathing; was always incontinent of bowel and bladder; and used a wheelchair (w/c) for mobility. Review of the facility investigation dated 5/3/15 revealed .observed resident attached to Vera-lift (mechanical lift) but feet off the lift. Lowered the resident to floor and then manually transferred to bed with 3 person assist. Checked res (resident) for any injuries with none noted. Continued review of the facility investigation of a note written by CNA #7 revealed .I was getting resident ready for bed. I hooked up to vera lift and secured her in and her feet slipped so I called for other CNAs to help me lift her up. She needs to be either on a pro 1 lift or two people should be there to assist her on vera lift. Further review of the facility investigation of a note written by CNA #8 revealed .I am in a resident's room and here my name being yelled. I go to see who it is. I got to resident's room and I see resident on vera lift with the Tech holding her up off the floor and the resident is slowly going to the floor. It took 3 techs and 2 nurses to get her off lift to the floor and then in the bed. Need a Pro 1 lift or 2 people with vera and her bed needs the brakes fixed. Continued review of the facility investigation of a note written by CNA #9 revealed .around 8 PM I was getting things together to clean up an resident and put him to bed when CNA #8 came around looking for me. She told me they needed me in (room of Resident #26). I went in with her. Three other CNAs was already in there. (named Resident #26) was hooked up the vera lift, looked like she had slid down when I came in she was on the lift, with the sling around her, she was kind of on her knees. Her legs were bent under her. We unhooked her, moved her legs out in front of her, put a gait belt around her. CNA #8 and another CNA was on her sides of her holding the gait belt and I had a hold of her legs, we lifted her up and put her on the bed. CNA #7 and CNA #8 started to change her and I went to change my resident. Review of the facility policy Falls Management dated 1/22/10, revealed .It is a standard of practice to identify those residents that are at risk for falling and provide prompt intervention to decrease the number of occurrences.Interventions.update care plan to reflect.resident specific interventions (alarms, devices, restraints).Fall Committee QA (Auality Assurance) Audit will be conducted.to ensure timely update of interventions. Medical record review revealed Resident #158 was admitted to the facility on [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. Review of the manufacturer's .Application Instructions for the Posey Lap Belt/Padded Lap Belt. revealed WARNING: ALWAYS Monitor patients per facility policy. Improper application or use of any restraint may result in serious injury or death. Further review revealed .Application Instructions: Position the patient as far back in the seat as possible, with the buttocks against the back of the chair.Bring the ends of the connecting straps down at a 45-degree angle between the seat and the wheelchair sides.Adjust the tightness of the slide buckles.Check that the straps are secure and will not change position, loosen, or tighten if the patient pulls on them, or if the chair is adjusted.The belt must be snug but not interfere with breathing.To check for proper fit, slide an open hand (flat) between the belt and the patient. Further review revealed .WARNING: Heed these warnings to reduce the risk of serious injury or death: There is a risk of chest compression or suffocation, if the patient's body weight is suspended off the chair seat.Monitor per facility policy to ensure that the patient cannot slide down, or fall off he chair seat and become suspended.STOP AT ONCE: if the patient has a tendency to slide forward or down in the device. Medical record review of a Care Plan onset date 2/25/15 revealed .I'm at risk for falls. Medical record review of a Restraint Assessment dated 2/25/15 revealed .Review dates.2/26/15 no restraints at time. Medical record review of a Physician's Telephone Order dated 3/27/15, revealed .due to recent fall.sensor pad in bed.pull alarm in wheel chair (w/c). Medical record review of a Fall Risk Evaluation dated 4/3/15 revealed a history of falls, confined to chair, and at risk for falls. Medical record review of a Skilled Nursing Notes dated 4/6/15 at 7:20 AM revealed .res (resident) found on floor in front of bed. Medical record review of a Physician's Telephone Order dated 4/7/15 revealed .use soft posey belt (restraint) while up in w/c d/t (due to) increase fall risk (res (resident) has had multiple attempts to get up out of w/c). Medical record review of a Care Plan updated 4/7/15 revealed .soft posey belt while up in chair.care foam lounger (a padded foam chair with ottoman for fall prevention) for sleep and place near nurses' station. Medical record review of a Restraint Assessment review date 4/7/15 revealed .soft posey belt in w/c.alert confused.res unable to comprehend instr (instructions).Falls within past 12 months: multiple. last fall 4/6/15.R (right) side paralysis.agitated at times.multiple attempts to get up out of w/c increase fall risk. Medical record review of a Skilled Nursing Notes dated 4/8/15 at 11:50 AM revealed .Res up in w/c, soft posey belt on.continues to have multiple attempts of getting up OOB (out of bed) and w/c.shows s/s (signs and symptoms) of depression.loss of independence. Medical record review of a Skilled Nursing Notes dated 4/8/15 at 9:00 PM revealed .Resident observed in room in w/c, resident sliding out of w/c with softy posey up to chest.w/c locked.helped resident to bed. Medical record review of an Incident/Change Screen Form dated 4/8/15 revealed .Res slid partway out of w/c.posey on around chest.res is restless and frequently tries to get up out of.w/c.recommendation.keep in common areas when up in w/c. Review of facility documentation dated 4/8/15 revealed New planned interventions .resident to be in common area, not left unattended in his room. Medical record review of a 5 day MDS dated [DATE] revealed Resident #158 was severely impaired for daily decision making, required extensive assistance of 2 for Activities of Daily Living (ADL's), frequently incontinent, and physical restraints used daily in chair. Medical record review of a Fall Risk Evaluation dated 4/9/15 revealed .resident seen sliding down out of w/c with soft posey belt at chest. Review of facility documentation Falls/Incident Committee dated 4/9/15, revealed .in wheelchair slid out.posey up to chest. Medical record review of a Skilled Nursing Notes dated 4/10/15 revealed .restless pulling on clothes, diaper, posey, while in the w/c.slipped down in chair pulled posey up slipped under it.hips off w/c seat.we sat him in floor so we could get R arm out of posey.so he could be undone from w/c. Medical record review of a Physician's Telephone Order dated 4/10/15 revealed .Care Foam Lounger while asleep in front of NS (Nurses Station) d/t multiple falls. Medical record review of an Incident/Change Screen Form dated 4/10/15 revealed .slid down in w/c and slid posey over his head lowered to floor.in common area. Review of facility documentation Falls/Incident Committee dated 4/10/15 revealed .sitting by nursing station (with) posey on sliding down in wheelchair under posey. Interview with LPN #1 on 7/15/15 at 4:15 PM at the F hall and G hall nurses station, revealed on 4/10/15 at 8:30 PM the resident was sitting at the nurses station, started pulling at the soft waist belt, pulled the belt over his head, and was slipping out of the wheelchair. Continued interview confirmed the soft waist belt was loose and the resident had been able to get the soft waist belt over his head. Review of facility documentation dated 4/10/15 revealed .Care Foam lounger at HS (hours of sleep) for sleep. Review of facility documentation dated 5/11/15 revealed .Pull alarm in Care Foam Lounger. Medical record review of a Physician's Telephone Order dated 5/11/15 revealed .Pull alarm in Care Foam Lounger. Medical record review of a Physician's Telephone Order dated 6/23/15 revealed .Must sleep in bed while on contact isolation. Medical record review of a Skilled Nursing Notes dated 6/28/15 at 11:05 AM, revealed .observed on floor in front of bathroom door.res yelled out as this nurse was walking by.resident assisted back into w/c.restraint secured.abrasion to left wrist.contact isolation confined to room (placed on isolation 6/23/15). Review of facility documentation dated 6/28/15 revealed .Does not like being in room. Medical record review of an Incident/Change Screen Form dated 6/28/15 at 11:05 AM, revealed .Resident has order for posey belt in w/c.resident was in his w/c reported by nursing that he managed to get restraint belt over his head. Review of facility documentation dated 6/29/15 revealed .Hourly checks while on isolation. Medical record review of a Skilled Nursing Note dated 7/1/15 at 9:50 AM, revealed falls x 2 in 3 days.currently on Q (every) 1 hour staff checks to aide in preventing falls. Review of facility documentation Falls/Incident Committee dated 7/1/15 revealed .got up from bed. Medical record review of a Skilled Nursing Notes dated 7/1/15 at 1:45 AM, revealed .alarm went off.standing on blue pad.went to floor. Medical record review of facility documentation dated 7/1/15 revealed .no new intervention.continue 1 hour checks until isolation over. Medical record review of a Skilled Nursing Notes dated 7/9/15 at 10:05 PM, revealed .resident bed alarm going off.heard resident fall.resident lying on floor.gash (cut) to forehead.R elbow skin tear R knuckle skin tear R back side abrasion L (left) forearm abrasion.c/o (complained) pain to head and back.send to ER (emergency room ). Medical record review of a Physician's Telephone Order dated 7/9/15 revealed send to ER to Tx (treat) and eval (evaluation). Medical record review of a Skilled Nursing Notes dated 7/10/15, revealed .returned at 3:20 AM.durabond (skin glue) to R forehead laceration. Observation and interview on 7/14/15 at 4:16 PM at the F hall and G hall dayroom/dining room, revealed Resident #158 sitting in a wheelchair. A soft waist belt was in place with the left strap over the arm of the w/c and attached to the kick spur of the w/c. Continued observation and interview with LPN #10 confirmed the soft waist restraint had not been applied correctly. Further observation and interview with Certified Nurse Aide (CNA) #6 and #11 on 7/14/15 at 4:17 PM at the F hall and G hall dayroom/dining room, confirmed the soft waist belt had not been applied correctly and CNA #6 reapplied the restraint. CNA #6 confirmed the soft waist restraint had been applied by CNA #11, who had been employed at the facility for 5 to 6 days. Interview with LPN #10 on 7/15/15 at 4:08 PM at the F hall and G hall nurses station, revealed on 4/8/15 the resident slid down in the chair, the restraint at the chest area (pointing to the breast) and staff witnessed the resident attempting to get the soft waist belt loose/off. The resident often slid down in the W/C, staff placed the resident back in the w/c with the restraint in place after the incident, and the soft waist belt was used daily for Resident #158. Interview with the DON on 7/15/15 at 9:24 AM through 10:08 AM in the Case Manager's Office, revealed on 4/8/15 at 8:15 PM Resident #158 was observed in his room by staff sliding out of the wheelchair, the soft belt was positioned at the resident's chest, the intervention was not to leave the resident unattended in his room and the resident was placed back in the restraint. Continued interview confirmed the resident was reviewed on 4/9/15 in a Falls Committee, no changes were made related to the resident's restraint, and no education had been provided to the staff. Continued interview revealed the resident had a second incident on 4/10/15 at 8:30 PM in the w/c, with the soft belt in place, at the F hall and G hall nurses station. The staff witnessed the resident loosen the soft waist belt and the resident slipped under the restraint. Further interview confirmed the resident was reviewed in the Falls Committee Meeting on 4/13/15, no changes were made to the restraint and no education related to the restraint had been provided to the staff. Continued interview revealed the resident had a third incident on 6/28/15 at 11:05 AM. The resident was left in the room unattended in the w/c with the soft waist belt in place, the resident exited the wheelchair, the soft belt still attached to the w/c, stood up and fell , the resident had been placed back in the w/c, the soft belt was reapplied and the resident was left in his room unattended. Continued interview confirmed the resident had been reviewed in Falls Committee on 6/29/15 no changes were made to the restraint and no education related to the restraint had been provided to the staff. Continued interview revealed on 7/1/15 at 1:45 AM the resident had been put to bed in his room, the resident exited the bed and fell . Continued interview confirmed the resident had not been placed in the Care Foam Lounger in the common area for sleep due to 10 days of isolation and no new interventions were put in place. Further interview revealed on 7/9/15 at 10:05 PM the resident had been put to bed in his room, the resident exited the bed and fell . Further interview confirmed the resident had not been placed in the Care Foam Lounger in the common area for sleep, the CNA failed to follow the Care Plan and the resident had been transported to the ER for treatment of [REDACTED]. Interview with LPN #2, the Staff Development Education Nurse, on 7/15/15 at 10:12 AM, in the Case Manager Office, revealed the LPN #2 did not provide any formal in-service on restraints at time of hire. Continued interview revealed new hire CNA's were given a skills checklist to be completed during orientation on floor with staff that included restraints. Continued interview revealed the CNA's were given an annual skills checklist and the licensed nurses on the floor checked the CNA's. Interview with the DON on 7/15/15 at 10:15 AM in the Case Manager's Office, confirmed the resident had 3 incidents with a restraint. Continued interview confirmed no additional education had been given to the staff related to restraint application/use, and the restraint continued to be used for the resident. Further interview confirmed on 7/9/15 the facility failed to follow an intervention for a fall; the resident sustained [REDACTED].

Based on medical record review, review of facility investigations, observation, review of facility policy, review of manufacturer's recommendations, and interview, the facility failed to apply a pull alarm to a recliner chair and to prevent a resident from exiting the building resulting in two separate falls for one resident (#1) and secure a safety strap on a merrywalker for one resident (#3) of fourteen residents reviewed. The facility's failure to ensure a pull alarm was in place and to intervene immediately to prevent Resident #1 from exiting the building resulted in two seperate falls and lacerations with one laceration requiring sutures (Harm). The findings included: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Nurse Aide's Information Sheet dated May 8, 2013, revealed "...Pull String is in recliner...(whatever seating)..." Medical record review of the Care Plan dated May 23, 2013, revealed "At risk for falls...Resident has multiple seating options (i.e. (for example) WC (wheelchair) GC (Geri chair) recliner, straight back chair, etc) pull alarm should be attached in whatever seating in at the time...Pull alarm to be used if resident in...recliner..." Medical record review of a Fall Risk Evaluation dated June 19, 2013, revealed the resident was a high risk for falls. Medical record review of the Physician's Recapitulation Orders dated July 2013 revealed "...Pull alarm in Geri-chair, recliner...Pull alarm to be used with whatever seating resident is using at the time..." Medical record review of a Nurse's Note dated July 5, 2013, revealed "...lying on the floor on left side and blood coming from the L (left) side of...head...N.O. (new order) send to ER (emergency room )..." Medical record review of an emergency room Summary dated July 5, 2013, revealed "...Chief Complaint: Fall...Follow-up Instructions: Sutures out in 10-12 days...Laceration..." Review of a facility investigation dated July 5, 2013, at 11:10 p.m., revealed "...What was the resident's cognition?...confused...heard a thump from dayroom...saw...lying on the floor on...L side with blood coming from laceration L side of his forehead...Laceration size 4 cm (centimeter) x (times) 1 cm x 1.5 cm deep..." Review of an Employee Statement of Incident dated July 5, 2013, revealed "...Res (resident) has order for pull alarm in recliner alarm was not on..." Medical record review of a Physical and/or Occupational Therapy Screen Form dated July 8, 2013, revealed "...Any recommended changes...Nsg (nursing) to reeducate staff on using pull alarm in recliner per CP (care plan)..." Medical record review of Interdisciplinary Progress Notes dated July 16, 2013, revealed "...continues to be up in WC daily and propels...in hallway...requires close monitoring for safety...try to get up unassisted...has pull alarm in recliner which is used when tired or trying to get out of bed...had a fall 7/5/13 which resulted in laceration to lt (left) brow which required sutures at ED (emergency department)..." Observation on January 22, 2014, at 11:00 a.m., and January 23, 2014, at 9:00 a.m., revealed the resident in the resident's room in a Merry walker. Observation on January 23, 2014 at 11:00a.m., revealed the resident in the hallway in the Merry walker with strap in place and propelling self and wanderguard noted on right ankle. Interview with Certified Nursing Assistant (CNA #4) on January 23, 2014, at 3:25 p.m., by telephone revealed the CNA placed the resident in a recliner in the JK dayroom on July 5, 2013. Continued interview revealed the CNA was unaware the resident required a pull alarm in the recliner. Interview with the Director of Nursing (DON) on January 23, 2014, at 3:45 p.m., in the conference room confirmed the facility had failed to apply the alarm (fall prevention intervention) to the recliner. The resident fell out of the recliner, sustained a laceration to the left side of the face, required an ER visit, and received sutures (Harm) to the left side of the face. Medical record review of a Minimum Data Set (MDS) dated [DATE], revealed the resident had severe impairment for daily decision making, wandering behaviors 1-3 days per week, required limited assistance for locomotion, and required extensive assistance for transfers. Medical record review of a Care Plan dated November 21, 2012, revealed "...Problem...wanderer...ankle bracelet...direct resident away from exits...walk and talk member..." Medical record review of a Nurse Aide's Information Sheet dated December 13, 2012, revealed "...Behavior...Wanderer..." Medical record review of the Physician's Recapitulation Order's dated January 2013 revealed "...Wanderguard Ankle Bracelet..." Review of facility policy, Elopement, dated March 16, 2012, revealed "...A wanderer is a mobile resident/patient who is cognitively impaired and exhibits potential for leaving the facility unassisted. This person does not realize the potential dangers of the outside environment ...will have wanderguard transmitters to limit their access to the exits...Walk & Talk Club...list of residents identified by the Care Plan Team as Wanders...list is posted at each nurse's station...it is the responsibility of all employees to know which residents are members..." Review of a facility investigation dated January 15, 2013, at 5:20 p.m., revealed "...saw...resident...going through dining room door and then from dining room to outside porch in front of dining room...did not go to resident but instead went down the J Wing Hall to get help...resident...was sitting at the end of the porch and was bleeding above L eye...noted two lacerations above L eye a small hematoma also...very cold and raining outside and not a safe place for...resident...new orders to send to ER..." Medical record review of the ER Aftercare Instructions dated January 15, 2013, revealed "...Wound to left eye brow cleaned and dermabond (skin adhesive to close skin injuries) and steristrips (adhesive strips to close wounds)..." Interview with Floor Care Technician #1 on January 23, 2014, at 3:16 p.m., in the Conference Room revealed the Floor Care Technician had been in-serviced on Elopement and was aware the resident was a wanderer. Continued interview revealed the Floor Technician witnessed the resident exit the Dining Room to the outside, failed to assist the resident back in the facility, and left the resident to get assistance. Further interview revealed the Floor Care Technician stated "I guess I panicked...it was about a minute until I found help." Interview with CNA #4 on January 23, 2014, at 3:01 p.m., by telephone revealed the CNA heard an alarm but could not find it. Continued interview revealed the CNA started down the hall, met the Floor Care Technician on J Wing Hall, and was informed the resident had exited the dining room doors and went outside. Further interview revealed the CNA immediately went outside and found the resident sitting on the steps, head bleeding. Interview revealed the CNA assisted the resident inside to the Charge Nurse. Continued interview revealed the resident was approximately forty feet from the doors sitting on the dining room porch. Interview with Licensed Practical Nurse (LPN) #1 on January 23, 2014, at 3:30 p.m., in the Conference Room revealed the resident had a wanderguard bracelet in place and a wheelchair alarm. Continued interview revealed the resident had a laceration to the left forehead and a hematoma. Interview with the Environmental Services Director on January 23, 2014, at 2:10 p.m., in the Conference Room revealed the staff were in-serviced on the Elopement Policy on hire and periodically. Continued interview revealed the Floor Care Technician had been in-serviced on elopement. Interview with the Director of Nursing (DON) on January 23, 2014, at 3:45 p.m., revealed resident #1 was identified as a wanderer and an elopement risk on admission and a wanderguard bracelet was placed on the resident's ankle to alert the staff of exit seeking behaviors. Continued interview revealed the resident exited the building on January 15, 2013, and sustained injuries. The resident required an ER visit for the injuries and received dermabond and steristrips to the facial area. Further interview confirmed the facility had failed to prevent the resident identified as a wanderer and exit seeker from exiting the building. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Care Plan dated July 7, 2013, revealed "...Merry walker (wheeled chair) for ambulation...walk independently in Merry walker, assist me as needed and observe me for safety...at risk for falls..." Medical record review of a Falls Risk Evaluation dated July 7, 2013, revealed the resident was a high risk for falls. Medical record review of the Physician's Recapitulation Orders dated July 2013 revealed "...May use Merry walker as needed for ambulation..." Medical record review of a MDS dated [DATE], revealed the resident was severely impaired for daily decision making, wandered 1-3 days per week, required supervision for transfers, walking in room, locomotion on and off unit, unsteady balance, and restraints in chair used daily. Medical record review of a Merry walker In-service (no date) revealed "...ensure...(resident)...is secure in Merry walker with the strap and bar in place..." Review of a facility investigation dated August 7, 2013, revealed "...resident inside Merry walker but on the floor lying on L hip...strap that connects to crossbar on Merry walker not strapped...no injuries found at this time...resident placed back in Merry walker strap double checked to be sure it strapped correctly...New planned intervention: educate staff on strap..." Review of manufacturer's recommendations revealed "...Secure the black safety strap between the legs and latch safely on the gate..." Observation on January 23, 2014, at 1:00 p.m., in the J Wing hall revealed the resident in the Merry walker with the bar and strap secured. Interview with the Director of Nursing (DON) on January 23, 2014, at 3:20 p.m., in the Conference Room confirmed the facility had failed to secure the safety strap of the Merry walker resulting in the resident in a fall. C/O #

Based on medical record review, facility document review, and staff interview, the facility failed to ensure, on two occasions, to provide the required assistance and use the appropriate equipment for one resident (#21) of twenty-five records reviewed. The failure of the staff not providing the necessary assistance and using the appropriate equipment resulted in a fractured right hip to resident #21. The findings included: Medical record review revealed resident #21 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the resident's care plan initiated September, 2009, revealed the resident was at high risk for falls. Continued review revealed the care plan was updated December 17, 2009, with the intervention "...assist (resident) 1-2 (one to two persons) using gait belt..." Continued review of the care plan revealed the intervention was updated March 17, 2010, to "...2 people with gait belt..." Medical record review of the Minimum Data Set, dated dated dated [DATE], revealed the resident was totally dependent with two plus person physical assistance for transfers; extensive assistance with two plus persons physical assistance for bed mobility; and extensive assistance with one person physical assistance for toilet use, personal hygiene and bathing. Medical record review of the nursing note dated February 6, 2010, revealed "...was called in resident's room...was informed resident slid down w/c (wheelchair) while transferring from toilet to w/c...Tech helped...slide to floor and went for help." Two staff members "helped...to get to...electric w/c with gait belt...informed resident had skin tear on right lower leg...denies pain." Review of a facility investigation revealed on February 6, 2010, at 3:25 p.m., the resident had fallen. Further review revealed "1-2 person assist needed to transfer and/or ambulate...resident slid off w/c (wheelchair) while transferring from the toilet to w/c (electric)...Found a skin tear on right lower leg near ankle...Resident helped up by 2 staff and gait belt." Further review revealed "careplan transfers with 1-2 assist and gait belt...not follow plan of care and using gait belt". Review of the hand written statement of the Certified Nurse Aide (Technician) involved in the February 6, 2010, incident, revealed the resident "was in the bathroom with light on for help. I went in and helped...sit on the toilet. When finished, I helped...get up. When...was going to sit on...chair...sat at the edge started sliding on the floor. I could not pull...back up on the chair by myself so I told...to let go of the bar...was holding because it was a struggle. So...sled (sic) down in a sitting position in front of...chair. I called for help..." Medical record review of the nursing note dated April 1, 2010, at 7:10 p.m., revealed "CNT (Certified Nurse Technician) trying to assist res (resident) to commode when...legs gave out. CNT stated that 'res right leg was curled under...body'...4 (four) CNT worked together to help res off floor to bed using lift...c/o (complaining of) unbearable pain to right hip and right leg...sent to ER (emergency room )." Review of a facility investigation revealed the resident fell on [DATE], at 7:10 p.m., complaining of pain in right hip and right leg. Further review revealed "1 - 2 person assistance needed to transfer and/or ambulate...equipment used appropriately?...No, no gait belt." Further review reveled the "CNT trying to assist res (resident) to commode when...legs gave out. CNT stated that 'right leg was curled under...body.'...4 (four) CNT worked together to help res off floor to bed using lift. C/o (complaining of) unbearable pain to right hip and right leg...sent to ER." Further review revealed "CNT did not transfer per plan of care. Walked off job after incident. Resident should have been transferred with 2 (two) people." Medical record review of the nursing note dated April 2, 2010, at 12 a.m., revealed "ER phoned to find out...status. Received report that...has been admitted ...for right hip fracture." Interview with the Director of Nursing, on May 12, 2010, at 1:16 p.m., in the conference room, revealed the CNT involved in the February 6, 2010, incident, and the CNT involved on April 1, 2010, incident, were interviewed and both were aware the resident required two person assist with a gait belt for transfers. Further interview revealed the CNT involved in the April 1, 2010, incident, had been suspended for one day on March 26, 2010, for "not following plan of care for transfer. Care issues discussed..." The facility's failure to ensure the staff was providing two person assistance with a gait belt for transfers resulted in a fractured right hip for resident #21. C/O #