Every finding on record at El Paso Health & Rehabilitation Center

Based on observation, interviews, and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and timeframes to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 3 residents (Resident #1, #2, and #3) reviewed for care plans.-The facility failed to ensure behaviors were addressed in Resident #1's Care Plan, refusal of bed baths, refusal of incontinent care, turning and repositioning, refusing to take prescribed medications as ordered, refusing to get out of bed according to physician's orders, pain to the left arm, and Moisture Associated Skin Damage. -The facility failed to ensure risk for falls related to running in the hallway was addressed in the care plan for Resident #2; Refusal to use splint to left arm for fractured left wrist was not addressed in the resident's care plan. - The facility failed to ensure behaviors were addressed in Resident #3's Care Plan when resident wheeled herself down the resident halls yelling for help and required frequent re-direction. The care plan did not address swearing, cussing, and hitting staff when personal care was provided. These failures could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.The findings included:1. Review of Resident #1's admission Record, dated 8/24/26, revealed original admission date 02/10/26 and re-admission date 04/13/2026.Review of Resident #1's History & Physical dated 2/22/25, revealed [AGE] year-old female with a history anxiety disorder (mental health condition characterized by intense, excessive, and persistent worry or fear about everyday situations), Major Depression (a serious mood disorder causing persistent sadness, hopelessness and loss of interest in activities, significantly affecting daily life, sleep, appetite and concentration), Morbid Obesity due to excessive calories (a serious, chronic medical condition defined as being 100 pounds or more over one's ideal body weight), and Post-Traumatic Stress Disorder (a mental condition that makes it hard to feel safe long after the danger is gone). Assessment and Plan: Encourage out of bed to chair, turning as per nursing protocol. Social Service for discharges services. Plan: Please begin dietary counseling for low salt diet and fluid limited diet to 1.5 - 2 Liters per day. Strict Intake and output). Unfortunately, patient cannot be medically optimized until functional status and weight has improved. The patient needs to undergo lifestyle changes. Weight: 484 pounds. Moisture Associated Skin Damage Moisture Associated Skin Damage (Skin becomes red, raw, and broken down because it stays wet for too long from sweat, urine, stool, or other body fluids). Review of Resident #1's Quarterly MDS dated [DATE] revealed, BIMS Score 15 (Cognitively Intact); Rejection of Care occurred 4 to 5 days, but less than daily. Frequently incontinent of bowel and bladder. Active Diagnoses: Moisture Associated Skin Damage, Reduced Mobility, Morbid Obesity. High-Risk Drug Classes: Hypoglycemic. Psychological Therapy. Review of Resident #1's Last Care Plan Review Completed on 7/02/26 revealed: -The resident is resistive to care. Interventions: Allow the resident to make decisions about treatment regime, to provide sense of control. Educate resident/family of the possible outcome(s) of not complying with treatment or care. If possible, negotiate a time for ADLs so that the resident participates in the decision-making process. Return at the agreed time. -The resident has a potential for pressure ulcer development. Interventions: Follow facility policies/protocols for the prevention/treatment of skin breakdown. Incontinent care after each episode and apply moisture barrier. The care plan did not address Resident #1 refused bed baths, refused to turn & reposition every two hours, refused to get out bed, refused brief changes and incontinent care, refused to take insulin as prescribed, refused to get out of bed and sit in a wheelchair. -The care plan did not address the resident had an order for low salt diet, 1800 calorie ADA diet and a fluid limited diet to 1.5 - 2 Liters per day. Strict Intake and Output. -The care plan did not address resident had Moisture Associated Skin Damage related to incontinence of bowel & bladder. -The care plan did not address resident had a swollen left arm and was complaining of pain to the left arm with movement. -The care plan did not address resident eats snacks throughout the day and keeps a lot of snacks in her room; resident orders fast food from restaurants to be delivered to her at the facility. -The care plan did not address resident's refusal to follow prescribed diet and fluid restriction. -The care plan did not address resident's refusal to get out of bed to go to the therapy gym for therapy. Review of Nurse's Progress Note dated 02/11/2026 for Resident #1 revealed, Resident refused morning shower, this nurse entered the room to confirm refusal. Resident stated she does not want to take a shower today and would prefer another time.Review of Registered Dietitian Consult Note dated 03/18/26 for Resident #1, written by Dietitian documented, she was asked to see Resident regarding Resident ordering food from outside and excessive weight gain of 66 lbs. in 30 days (13.3%). She is on Low Concentrated Sweets diet and No Salt on tray and eating 100 % of the food sent from the kitchen plus she is ordering food from outside. Had a discussion with her about how food affects glucose levels. Will continue to educate on better food choices. Review of Nurse's Progress Note dated 03/19/26 for Resident #1 revealed, Nurse notified Nurse Practitioner of resident refusal of insulin BID. New Order for Farxiga 10 mg by mouth daily for diabetes.Review of Nurse's Progress Note dated 06/09/26 at 6:03 a.m. for Resident #1 revealed, Resident refused brief change yesterday at 9:00 p.m. and 11:00 p.m. CNA attempted to change resident this morning at 5:30 a.m. Resident pretended to be asleep. This nurse entered room, resident's bed sheets soiled as resident was last changed yesterday at 3:00 p.m. Nurse educated resident to be changed when soiled to prevent any further skin damage. Resident agreed to brief change at this time.Review of Nurse's Progress Note dated 06/11/26 at 5:47 a.m. for Resident #1 revealed, Resident refused to be changed throughout the night. Resident voiced at this time she is too tired and barely went to sleep a little bit ago, wants to wait until later to be changed.Review of Nurse's Progress Note dated 03/27/26 [VT8.1]for Resident #1 revealed, Patient on fluid restrictions noticed not complying with orders; she has sodas at bedside and drinks with free access to her. Patient educated on importance of following with fluid restriction orders to prevent fluid overload.Review of Nurse's Progress Note dated 07/08/26 at 9:35 a.m. for Resident #1 revealed, Resident has been refusing Farxiga 10 mg for a couple of days. Nurse Practitioner notified. New orders for labs.Review of Nurse's Progress Note dated 07/09/26 at 10:15 a.m. for Resident #1 revealed, Resident refused Farxiga 10 mg morning dose. Resident stated, I don't need it. Educated about possible hyperglycemia. Review of Nurse's Progress Note dated 07/14/26 at 8:14 p.m. for Resident #1 revealed, Resident refused bed bath. Review of Weekly Skin Assessment Note dated 07/20/26, 07/27/26 and 08/10/26 completed by Treatment Nurse for Resident #1 revealed, Moisture Associated Skin Damage present: Yes. Chronic MASD noted to groin, inner thighs, buttocks and sacrum. Resident is functionally incontinent x2 and uses briefs to void. Barrier cream applied with every brief change. Resident has been refusing brief changes, high risk for MASD wound development due to refusing care. Resident morbidly obese with multiple skin folds and chronic MASD noted to areas. Resident makes no effort to turn or reposition while in bed and refuses to get out of bed to chair. Risk for pressure and moisture wound development due to continued non-compliance. Review of Nurse's Progress Note dated 07/21/26 at 10:06 p.m. for Resident #1 revealed, Resident refused brief change at this time when offered. Resident educated on needing brief changed to avoid MASD. Resident stated understanding and she did not need a change at this time. Review of Nurse's Progress Note dated 07/29/26 at 4:17 a.m. for Resident #1 revealed, Resident refused brief change this morning.Review of Nurse's Progress Note dated 07/29/26 at 4:59 p.m. for Resident #1 revealed, Resident complained about roommate and mentioned not being able to sleep prior night. Nurse discussed with resident about possibility of room change. Resident refused to be moved and verbalized she will stay where she is at the moment because she likes her window. ADONs notified and aware of resident's choice. Review of Nurse's Progress Note dated 08/01/26 at 5:18 a.m. for Resident #1 revealed, Resident refused brief change at this time voiced she is too tired. Review of Physician's Progress Note dated 08/03/26 for Resident #1 revealed, Moisture Associated Skin Damage present: Yes. Chronic MASD noted to groin, inner thighs, buttocks and sacrum. Resident is functionally incontinent x2 and uses briefs to void. Barrier cream applied with every brief change. Resident has been refusing brief changes, high risk for MASD wound development due to refusing care. Resident makes no effort to turn or reposition while in bed and refuses to get out of bed to chair. Risk for pressure and moisture wound development due to non-compliance. Review of Condition Change Evaluation dated 08/22/26 for Resident #1 revealed, resident had swelling, redness and increased heat to the left arm. Monitor extremity for any changes and educate resident on not massaging area. Portable doppler to left upper extremity. Review of Physician's Order Summary dated 08/24/26 for Resident #1 revealed, may apply barrier cream as needed every shift for other skin changes. Venous doppler to left upper arm diagnosis pain. Resident to be encouraged to get out of bed daily, placed into wheelchair, and offered activities outside of room every shift. Farxiga 10 mg give 1 tablet by mouth in the morning for Diabetes. Hydroxyzine HCL 25 mg give 1 tablet by mouth every 8 hours as needed for anxiety. Review of Medication Administration Record dated July 2026 for Resident #1 revealed, Farxiga was refused all month.Review of Medication Administration Record dated August 2026 for Resident #1 revealed, Farxiga was refused from August 1-24, 2026. During an observation and interview on 08/24/26 at 10:20 a.m. with Resident #1 revealed she was alert, oriented to person, place, time, and situation. The resident was lying in a Bariatric bed in a gown, oxygen cannula in place, receiving 4 L/min of oxygen. She said she never got out of bed because she was afraid to sit in a wheelchair, and movement caused pain in the arms and legs. She said the staff used a mechanical[VT9.1] lift for transfers. She said she was incontinent of bowel and bladder and used disposal briefs. She said she had been begging to get a catheter since she was admitted to the facility. She said she had a rash on her buttocks and private parts. She said, I do not want you to bring anyone to check the rash, because I do not want to be moved. I weigh 483 lbs. and movement causes discomfort. It was observed that resident had boxes of snacks in her room. She said that her mother would bring her boxes of snacks. She said she ordered food from outside because she got very hungry. She said she had been having pain in the left lower arm and was not able to bend it at the elbow joint because of the pain and swelling. During an interview on 08/24/26 at 2:25 p.m. with Administrator said the Social Worker and MDS nurses attended the daily morning meetings with all the department heads to review changes in condition and resident behavior to ensure these changes were addressed in the resident care plans.During an interview on 08/24/26 at 2:50 p.m. with the DON and ADONs E and F revealed the facility had a morning meeting with all department heads that included the Social Worker and the MDS Nurses to review changes in condition and resident behaviors. The DON said that they would follow up on physician notification and documentation in the resident's electronic record of changes in condition and/or reported resident behaviors. The DON said that the Social Worker and the MDS Nurses were aware of Resident #1's refusal of brief changes, showers, turning & repositioning, incontinent care, not following prescribed diet and fluid restriction, and refusal to take Farxiga as ordered. The DON said that the MDS nurses should address behaviors as soon as possible after the morning meeting to ensure that the residents had an updated comprehensive care plan that addressed behaviors to meet the needs of the residents. She said that the Social Worker was responsible for following up on those residents that were identified in the morning meeting as having behaviors to ensure she was addressing the behaviors and assist the residents in getting the necessary support and services. During an interview and record review on 08/24/26 at 3:05 p.m. with LVN MDS Nurse G revealed Resident #1 was alert, oriented to person, place, time, and situation. He said, Resident #1 was very particular about Activities of Daily Living. He said the resident was incontinent of bowel and bladder and had a rash on the buttock and perineal area due to refusal of incontinent care. He said that residents' behaviors and changes in condition are discussed in the morning meetings with all department heads. He said that he was aware of Resident #1's behaviors and refusal of care. MDS Nurse G said the last Care Plan Review was completed on 07/02/26 and he had not addressed in the Care Plan Resident #1 refused bed baths; refused to be turn & reposition every two hours; refused brief changes and incontinent care; refused to take insulin/Farxiga as prescribed; refused to get out of bed and sit in a wheelchair according to physician's orders; refused to follow prescribed diet order and fluid restriction. He said he had not care planned resident had Moisture Associated Skin Damage related to incontinence of bowel & bladder; had a swollen left arm and was complaining of pain to the left arm with movement; resident ate snacks throughout the day and kept a lot of snacks in her room; ordered fast food from restaurants to be delivered to her at the facility; had not addressed Resident #1 was receiving psychological services for Major Depression and Anxiety. During an interview on 08/24/26 at 3:19 p.m. with Director of Rehab Services I revealed Resident #1 was not currently on their caseload. She said Resident #1 had received Physical and Occupational therapy in her room in April 2026 and was not motivated at times. She said the resident was not willing to come to the gym for therapy, so all they could do for the resident was provide Range of Motion to the lower extremities and Bed Mobility. Based on Resident's refusal to come to the gym for therapy, they could not meet the treatment plan goals to continue therapy services. 2. Review of Resident #2's admission Record, dated 8/24/26, revealed original admission date 05/20/25.Review of Resident #2's History & Physical dated 5/20/26, revealed an [AGE] year-old male with a history Dementia (a general term for a group of brain disorders that cause a gradual decline in cognitive abilities such as memory, thinking, language, problem-solving, judgement, and orientation), he was transferred to the secure unit due to attempts to leave the facility. He was at high risk of injury due to dementia. History of falls. Past Medical History: Glaucoma (an eye disease that damages the optic nerve, often due to high fluid pressure inside the eye), Dizziness (feeling off-balance, lightheaded, or unsteady) and falls. Oriented to self. Review of Resident #2's Annual MDS dated [DATE] revealed clear speech, makes self-understood, understood others. BIMS Summary Score 04 (severely cognitively impaired); Active Diagnoses: Non-Alzheimer's Dementia (losing the thinking, memory, and social skills enough to mess up daily life), Difficulty walking, Lack of coordination; one fall with no injury.Review of Nurses' Note - Fall dated 08/16/26 at 4:30 p.m. for Resident #2 revealed, Unwitnessed Fall in resident's room. Cognition/Behavior at Time of Event: Cognitive Impairment, Paces. Pt. approached nurse and stated he had fallen in his room after feeling dizzy. Pt. complained of pain in his left wrist. Pain level on a scale of 1-10, 10 being the worst pain. Pain level at a 4 (Moderate Pain). X-ray to left wrist. Interventions initiated in response to this fall. Low Bed.Review of x-ray report dated 08/16/26 for Resident #2 revealed, Impression: The acute distal radial metaphyseal fracture (a fresh break in the main forearm bone on the thumb side, located right next to the wrist) visualized with anterior displacement. Review of Hospital emergency room report dated 08/16/26 for Resident #2 revealed, Pt. Seen today for Left Distal Radius Fracture(a broken wrist on the thumb side of the forearm). Closed Reduction of left wrist (fixed a broken or dislocated bone in the left wrist without cutting the skin open). The patient was placed in a splint. Need to see an orthopedic specialist in the next 5-7 days and possible casting and consideration of surgical intervention. He should use the sling as much as possible.Review of Resident #2's Care Plan [VT15.1]Review Provided by LVN MDS Nurse G revealed: -Splint/Brace to Left Wrist. Interventions: If ordered not to remove, do not remove the device. -Resident has impaired cognitive function/dementia or impaired thought processes. Interventions: Communication: The resident understands consistent, simple, directive sentences. Keep the resident's routine consistent and try to provide consistent care givers as much as possible to decrease confusion. -Resident has had an actual fall r/t poor communication/comprehension, unsteady gait. Interventions: PT consult for strength and mobility. Provide activities that promote exercise and strength building where possible. -Resident is high risk for falls r/t gait/balance problems, unaware of safety needs, wandering. Interventions: Anticipate and meet the resident's needs. Follow facility fall protocol. The Care Plan did not document:- Resident #2 was at risk for falls related to resident's tendency to jog or run in the Resident hallway in the secured unit; -Resident #2 had sustained a fall that resulted in closed comminuted impacted intra-articular fracture of the distal left radius.-Status Post Closed Reduction of the wrist (is a procedure to move the bones back into place after they are broken); The patient was placed in a splint. Need to see an orthopedic specialist in the next 5-7 days and possible casting and consideration of surgical intervention. The patient should not lift any weights or use the left arm. He should use the sling as much as possible. -Intervention initiated after this fall: Low Bed During an interview on 08/24/26 at 10:08 a.m. with LVN Charge Nurse J assigned to Resident #2 on the 6am-2pm shift in the secured unit revealed, resident was confused and oriented to person and place. He said the resident was independent with ADLs and only needed oversight supervision, ambulatory, and had impulsive behavior and ran down the hall in the secure unit. He said the resident was frequently reminded not to run to prevent falls. He said the resident had had a recent unwitnessed fall on 08/16/26 in his room. He said that the resident had removed the sling and did not want to use the sling according to physician's instructions. He said that the physician was notified and the resident had an appointment to see the orthopedic specialist tomorrow on 08/25/26. He said the resident was able to move his left hand with no complaints of pain. During an observation on 08/24/26 at 10:12 a.m. Resident #2 was asleep in his room in a low bed. The resident did not have the sling on the left arm. Room was free of clutter. During an interview on 08/24/26 at 10:13 a.m. with CNA K revealed Resident #2 was confused and was oriented only to person and place. She said that the resident had unsteady gait and ran down the halls while he was doing exercises with his arms. She said that the resident had recently sustained an unwitnessed fall and had sustained a fracture on the left wrist and refused to use the arm sling. She said the resident denied having pain in the left wrist with movement. She said the resident spent most of the time in his room or in the TV room. She said the resident was able to voice needs and enjoyed talking to other residents. During an observation on 08/24/26 at 10:16 a.m. the attending physician and LVN J entered Resident #2's room to examine the resident. The doctor asked the resident if he was having pain and the resident said. The doctor reminded the resident that he needed to use the sling to the left arm until he was seen by the bone specialist and reminded the resident that he had a scheduled appointment with the bone specialist tomorrow. The doctor examined the resident's left wrist, and he did not complain of pain with movement. The resident asked the physician if she was done because he was very sleepy. During an interview on 08/24/26 at 2:04 p.m. with Social Worker H revealed Resident #2 had been placed in the secured unit due to attempts to elope from the facility. She said that she did not know if the resident had a diagnosis of dementia and was not aware that the resident ran in the hallway and placed him at risk for falls. She said she was not aware that the resident was not using the sling to the left arm according to physician's orders. She said that she attended the morning meeting, and they discussed changes in condition and behaviors and did not recall hearing about this. During an interview and record review on 08/24/26 at 3:10 p.m. with LVN MDS Nurse G revealed Resident #2 was alert, and only oriented to person and place. He said that the resident was ambulatory. He said he had not interviewed the nurse or the CNAs when he had completed the MDS assessment on 05/31/26 so he was not aware that the resident ran instead of walking in the hallway, putting him at risk for falls and injury. He said that he did not remember if it had been reported during the morning meeting that the resident was not using the sling to the left arm according to physician's orders. He said that he attended the morning meetings to discuss changes in condition and behaviors. He said that after the morning meeting the MDS nurses were expected to address concerns, changes in condition and behaviors the same day after the morning meeting in the resident's care plans. 3. Review of Resident #3's admission Record, dated 8/24/26, revealed original admission date 07/02/25 and re-admission date 06/12/2026.Review of Resident #3's History & Physical dated 6/12/26, revealed [AGE] year-old male with a history of CVA (a stroke, causing blood flow to part of the brain gets cut off, starving brain cells of oxygen and causing them to die) and multifactorial encephalopathy (altered brain function caused by a combination of two or more distinct medical factors or systemic diseases). He was alert and oriented to person and place. Review of Resident #3's admission MDS revealed his BIMS Summary Score was 08 (Cognitively Moderately Impaired), Behavioral Symptoms - Physical behavioral symptoms directed at others hitting; Verbal behavioral symptoms directed at others threating others, screaming at others, cursing at others. Mobility Device - wheelchair. Active Diagnoses: CVA. High-Risk Drug Classes: Antipsychotic and Antidepressant. Review of Resident #3's Care Plan revealed:-07/24/26 Resident has a behavior problem r/t physical behavioral symptom, verbal behavior. Interventions: Intervene as necessary to protect the rights of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. The Care Plan did not addressed Resident #3 wheeled her wheelchair up and down resident halls, yelling out for help, and required re-direction. During an interview on 08/24/26 at 1:44 p.m. with RN B revealed Resident #3 had intermittent confusion, self-propelled her wheelchair for short distances, and would hit staff when care was provided. She said, Resident #3 is very strong and will attempt to strike the staff when they provide personal care. She will frequently refuse care. She said that Resident #3 would occasionally wheel herself to other resident halls and did not enter other residents' rooms. She said that Resident #3 had been moved from Hall A to Hall D because she was having issues with Resident #1. She said that it depends on Resident #3's mood and sometimes wants to be left alone and will not allow the staff to assist with personal care. RN B said Resident #3 has not had any issues with residents in the D Hall. During an observation on 08/24/26 at 1:47 a.m. Resident #3 was propelling her wheelchair down D Hall yelling out for help. It was observed that one of the CNAs came out of another resident's room and wheeled the resident to her room. During an interview on 08/24/26 at 1:53 p.m. with Social Worder H revealed Resident #3 was confused, oriented to person and place, would yell out for no reason, and would not allow the staff to touch her when they attempted to assist her with ADLs. She said the resident would swear at staff when care was provided. She said that Resident #3 wheeled herself up and down the resident halls and was not aware if she entered other resident rooms. During an interview and record review on 08/24/26 at 3:39 p.m. with LVN MDS Nurse M revealed Resident # 3 propelled her wheelchair up and down resident halls, yelling out for help and this was not addressed in the Care Plan. She said that she was not aware that Resident #3 would swear and cuss at the staff when personal care was provided. She said she attended the daily morning meeting where department heads discussed changes in condition and resident behaviors. She said it was reported during the morning meeting that Resident #3 would swear and yell when care was provided. She said the MDS nurses were expected to address changes in condition and behaviors as soon as possible after the morning meeting.During an interview on 08/24/26 at 3:53 p.m. with Med Aide N revealed that Resident #3 was confused, oriented to person and place, propelled her wheelchair with her hands and feet down the resident halls and occasionally entered other resident rooms. She said Resident #3 required close supervision and redirection because she yelled out for help and swear, cuss, and resist care.During an interview on 08/24/26 at 3:56 p.m. with RN O revealed that she was not aware if Resident #3 wheeled herself to Hall. She said that the resident would yell out for help, swear and cuss at the staff when care was provided.Review of the facility's policy and procedures on Comprehensive Person-Centered Care Plans revised March 2022, provided by the Administrator revealed: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including; services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; which professional services are responsible for each element of care; include the resident's stated goals upon admission and desired outcomes; reflects currently recognized standards of practice for problem areas and conditions. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem area(s), no just symptoms or triggers. Assessments of residents are ongoing, and care plans are revised as information about the residents and the resident's condition change. The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been re-admitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS assessment. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals are documented in the resident's clinical record in accordance with established policies.

Based on observation, interview, and record review, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 3 residents reviewed for medically related social services. The facility failed to provide Resident #1 medically related social services when the resident was refusing personal care, prescribed medications, prescribed diet/fluid restriction, not following therapy treatment plan. No active discharge plan already occurring for the resident to return to the community. This failure could place residents at risk of decline in physical, mental, and psychosocial well-being dur to unmet care needs. Findings included: Review of Resident #1's admission Record, dated 8/24/26, revealed original admission date 02/10/26 and re-admission date 04/13/2026.Review of Resident #1's History & Physical dated 2/22/25, revealed [AGE] year-old female with a history of anxiety disorder (mental health condition characterized by intense, excessive, and persistent worry or fear about everyday situations), Major Depression (a serious mood disorder causing persistent sadness, hopelessness and loss of interest in activities, significantly affecting daily life, sleep, appetite and concentration), Morbid Obesity due to excessive calories (a serious, chronic medical condition defined as being 100 pounds or more over one's ideal body weight), and Post-Traumatic Stress Disorder (a mental condition that makes it hard to feel safe long after the danger is gone). Assessment and Plan: Encourage out of bed to chair, turning as per nursing protocol. Social Service for discharges services. Plan: Please begin dietary counseling for low salt diet and fluid limited diet to 1.5 - 2 Liters per day. Strict Intake and output. Unfortunately, patient cannot be medically optimized until functional status and weight has improved. The patient needs to undergo lifestyle changes. Weight: 484 pounds. Moisture Associated Skin Damage (Skin becomes red, raw, and broken down because it stays wet for too long from sweat, urine, stool, or other body fluids). Review of Resident #1's Social History dated 03/03/2026 completed by Social Worker revealed, Reasons and feelings about nursing home placement: Skilled Nursing. Future discharge planning: Home with daughter. Psychological: Behavioral Problems: NA. History of Mental Illness: NA. Mobility: Bed. Trauma Informed Care: Resident does not have a diagnosis of Post-Traumatic Stress Disorder. Review of Resident #1's Quarterly MDS dated [DATE] revealed, BIMS Score 15 (Cognitively Intact); Rejection of Care occurred 4 to 5 days, but less than daily. Frequently incontinent of bowel and bladder. Active Diagnoses: Reduced mobility, Moisture Associated Skin Damage. Morbid Obesity. High-Risk Drug Classes: Hypoglycemic. Night Terrors, Other Impulse Disorder; Reduced Mobility and Generalized Muscle Weakness; Asthma; Oxygen Therapy; Psychological Therapy. No active discharge plan already occurring for the resident to return to the community. Review of Resident #1's Last Care Plan Review Completed on 7/02/26 revealed: -The resident is resistive to care. Interventions: Allow the resident to make decisions about treatment regime, to provide sense of control. Educate resident/family of the possible outcome(s) of not complying with treatment or care. If possible, negotiate a time for ADLs so that the resident participates in the decision-making process. Review of Psychological Diagnostic assessment dated [DATE] for Resident #1 revealed, Reason for Referral: Depression (a medical illness that causes a deep, ongoing feeling of sadness, emptiness, and loss of interest in things you normally enjoy), and Anxiety (a normal feeling of worry, nervousness, or unease about something that might happen in the future). Assessment: oriented to person, place, time and situation. Patient reported long history of depression. Patient stated she struggles with self-esteem and does not like her current weight. Diagnoses: Major Depression, recurrent, mild. Adjustment disorder with anxiety (an intense, unhealthy emotional or behavioral reaction to a major life stressor that makes it hard to cope with daily life). Review of Registered Dietitian Consult Note dated 03/18/26 for Resident #1, written by Dietitian documented, she was asked to see Resident regarding Resident ordering food from outside and excessive weight gain of 66 lbs. in 30 days (13.3%). She is on Low Concentrated Sweets diet and No Salt on tray and eating 100 % of the food sent from the kitchen plus she is ordering food from outside. Had a discussion with her about how food affects glucose levels. Will continue to educate on better food choices. Review of Nurses Progress Note dated 03/19/26 for Resident #1 revealed, Nurse notified Nurse Practitioner of resident refusal of insulin BID. New Order for Farxiga 10 mg by mouth daily for diabetes.Review of Nurse's Progress Note dated 06/09/26 at 6:03 a.m. for Resident #1 revealed, Resident refused brief change yesterday at 9:00 p.m. and 11:00 p.m. CNA attempted to change resident this morning at 5:30 a.m. Resident pretended to be asleep. This nurse entered room, resident's bed sheets soiled as resident was last changed yesterday at 3:00 p.m. Nurse educated resident to be changed when soiled to prevent any further skin damage. Resident agreed to brief change at this time.Review of Nurse's Progress Note dated 06/11/26 at 5:47 a.m. for Resident #1 revealed, Resident refused to be changed throughout the night. Resident voiced at this time she is too tired and barely went to sleep a little bit ago, wants to wait until later to be changed.Review of Nurse's Progress Note dated 03/27/26 for Resident #1 revealed, Patient on fluid restrictions noticed not complying with orders; she has sodas at bedside and drinks with free access to her. Patient educated on importance of following with fluid restriction orders to prevent fluid overload.Review of Clinical Treatment Plan dated 07/16/26 for Resident #1 revealed, Diagnoses: Major depressive disorder, adjustment disorder with anxiety, post-traumatic stress disorder. Summary of Progress: Pt. has voiced frustration about not being able to lose weight. Staff have reported concerns about Pt. eating snacks and fast food that family brings her. Pt has not been wanting to get out of bed and sit in wheelchair. Pt. has expressed not wanting to leave her room and anxiety about getting into the wheelchair. Individual Psychotherapy 1 time per week. Referrals/Consultations: Consult with attending physician to review treatment plan and clinical recommendations. Involve activities director, social worker, nursing staff, ancillary staff, DON, and/or dietary staffing interventions. Review of Nurse's Progress Note dated 08/07/26 at 12:42 p.m. for Resident #1 revealed, nurse notified that resident's roommate started pushing resident's bedside table. Resident #1 had her son's medication on table, causing them to fall to the floor. Nurse and social worker spoke to resident, and she stated she was sorting her son's medications when her roommate came to her side of the room, pushed the bedside table and made her drop the medication. Nurse explained to resident she could not have medications in her room. The resident started crying and stated, That's the only thing I can do for my son. Nurse and social worker offer resident to be moved to another room. Resident refused to be moved. Resident educated about sorting son's medication in facility. Son's medications need to be administered at home not at facility. Review of Physician Progress Note dated 08/07/26 for Resident #1 revealed, Patient seen and re-evaluated as per facility and patient request. Patient refusing Farxiga to treat diabetes. Make appointment for consultation regarding weight gain. DM - Farxiga 10 mg po daily; Low salt no fried foods. 1800 ADA diet. Fluid limited diet to 1.5 - 2L per day. Psychological services to evaluate and treat. Nursing to manage bowel and bladder and interface with therapy. Turn patient frequently and as needed while in bed. Continue Speech therapy as indicated. Weekly weights. Social Services for discharge services.Review of Physician Order Summary dated 08/24/26 for Resident #1 revealed, may apply barrier cream as needed every shift for other skin changes. Venous doppler to left upper arm diagnosis pain. Resident to be encouraged to get out of bed daily, placed into wheelchair, and offered activities outside of room every shift. Farxiga 10 mg give 1 tablet by mouth in the morning for Diabetes. Hydroxyzine HCL 25 mg give 1 tablet by mouth every 8 hours as needed for anxiety. Review of Psychological Service Progress Note dated 08/12/26 for Resident #1 revealed, Pt. was alert, engaged and tearful at times during session. Pt. alleged that her roommate shoved a table that hit her arm and wouldn't let her sleep. Pt. stated that she was very upset and reported the incident with the staff. Pt. stated that her roommate also tugged at her son's shirt and frightened him. Therapist explored her options and how she can keep herself safe. Therapist informed administrator and nurse about alleged incident. Pt. expressed frustration about not being able to lose weight. Plan for Next Session: Encourage Pt. to advocate for her needs with staff and challenge negative thoughts. Review of Nurse Practitioner Progress Note dated 08/14/26 for Resident #1 revealed, Patient seen and evaluated today as per facility and patient request. Patient states she is having complaints about her roommate. She states this is causing her anxiety. She is requesting to speak with DON. I have advised DON that patient is having complaints she would need to address with resident. DON stated the social worker and administrator are aware and have been speaking to the resident. Make an appointment for consultation regarding weight gain. Low salt diet and no fried food. Psychological services to evaluate and treat.Review of Psychological Service Progress Note dated 08/20/26 for Resident #1 revealed, Pt. empowered that she is sad about having to be at the facility and wants to return home. Pt. stated that she does not understand why she keeps gaining weight. Patient voiced relief and stated that they moved her roommate out of her room. Patient stated that she was having difficulty sleeping and is glad that she was moved. Plan for next session: Encourage Pt. to increase positive self-talk and engage in self-soothing behaviors. During an observation and interview on 08/24/26 at 10:20 a.m. with Resident #1 revealed she was alert, oriented to person, place, time, and situation. She said she had been having problems with one of her roommates (Resident #3) and she was finally moved to another room when the resident had an incident and was screaming and hitting one of the CNAs in the bathroom. She said that after Resident #3 was moved to another hall. Resident #1 said, She still wheeled herself to my room and kept telling me that she wanted to help me. I am afraid of her because on one occasion she ripped off my oxygen cannula. Last week on Friday she slammed my bedside table on the side of my bed and hit my right arm and hit my stomach with bedside table. I had a bruise on my right forearm. She would become anxious when my family came to visit. One another occasion she pulled on my son's shirt. He is Autistic was very scared when she did that to him. He became so upset that he no longer wanted to come and visit me. She said she had reported all these concerns to the Social Worker and the DON. The Social Worker told her that all they could do was to move her to another room. The resident played a telephone video from her cell phone that she had recorded on the night that Resident #3 had pulled off her oxygen cannula. The recording revealed Resident #1 kept asking Resident #3 why she was at the side of the room and she was yelling out for help, she was coughing and kept saying she was short of breath. Resident #1 kept asking Resident #3 why she had removed her oxygen. Resident #3 kept telling Resident #1 to shut up. Resident #1 was tearful at times when talking to the state surveyor. Resident #1 was shaking and kept saying that when she heard Resident #3's voice in the hallway she started to hyperventilate and became very anxious. She said that Resident #3 would also cuss and swear at her and called her stupid and Fucking bitch for no apparent reason. She said she was getting therapy and was discharged because she had refused to go to the Gym for therapy. She said that she was afraid to sit in a wheelchair, because movement caused pain. She said that she had incontinence of urine and had been begging to get a catheter. She said she had a rash on her buttocks and private parts. She said, I do not want you to bring anyone to check the rash, because I do not want to be moved. I weigh 483 lbs. and movement causes discomfort. It was observed that resident had boxes of snacks in her room. She said that her mother would bring her snacks from home and at times she ordered food from outside because she got very hungry. She said that she was informed by the nurses that she needed to send all the snacks home. She said she had been having pain in the left lower arm and was not able to bend it at the elbow joint because of the pain and swelling. Resident was receiving oxygen at 4 L/min by nasal cannula. She said that the Administrator had scheduled a meeting to meet with her older son and the Administrator had not shown up for the meeting. The Resident said, The only reason that I came to this place was for therapy, so I could return home to help my children take care of my 10 grandchildren. I have lost the ability to stand and walk because the only therapy that I received was range of motion to my lower extremities while in bed for several sessions and was discharged from therapy due to my insurance not approving therapy services. The resident was tearful at times and kept saying that she needed to go back home to take care of her family.During an interview on 08/24/26 at 1:36 p.m. with LVN A Charge Nurse on the day shift assigned to Resident #1 revealed Resident #1 was alert, oriented to person, place, time and situation. She said that Resident #3 had been moved from A Hall to D Hall after an incident were Resident #3 had disconnected Resident #1's oxygen. LVN A said Resident #3 propels her wheelchair up and down the halls but never enters other residents' rooms. She said she had not seen Resident #3 enter Resident #1's room once during her shift. She said Resident #3 is always yelling out for help, cusses and swears for no apparent reason. She said she was not aware that resident hit when care was provided. She said Resident #3 was only oriented to person and place, never gets out of bed and eats snacks throughout the day. During an observation and interview on 08/24/26 at 1:42 p.m. revealed Resident #3 was sitting in a wheelchair by the entrance to her room. When the surveyor attempted to talk to the resident she said, Are you stupid or what? Leave me alone idiot. Resident #3 wheeled herself with her hands and feet in her wheelchair down the hall yelling out for help. During an interview on 08/24/26 at 1:44 p.m. with RN B revealed Resident #3 had intermittent confusion, self-propelled her wheelchair for short distances, and would hit staff when care was provided. She said, Resident #3 is very strong and will attempt to strike the staff when they provide personal care. She will frequently refuse care. She said that Resident #3 would occasionally wheel herself to other resident halls and did not enter other residents' rooms. She said that Resident #3 had been moved from Hall A to Hall D because she was having issues with Resident #1. She said that it depends on Resident #3's mood and sometimes wants to be left alone and will not allow the staff to assist with personal care. RN B said Resident #3 has not had any issues with residents in the D Hall. During an interview on 08/24/26 at 1:49 p.m. with CNA C and CNA D revealed Resident #3 was alert, oriented to person, place, time, and situation. The CNAs reported that Resident #3 had been moved to the D Hall after an incident during the night shift, when Resident #3 removed Resident #1's oxygen cannula. They said Resident #3 had Dementia and at times became anxious, restless, yelled out, cussed and swearing at staff when care was provided. They said Resident #3 propelled herself in her wheelchair up and down the resident halls and that they had not seen her enter other resident rooms. During an interview on 08/24/26 at 1:53 p.m. Social Worker H said Resident #1 was alert, oriented to person, place, time and situation. She said that she was not sure why Resident #3 had been moved to D Hall. She said, I guess that Resident #3 was moved on the weekend. She said that Resident #1 had alleged that Resident #3 had slammed her bedside table on the side of the bed and Resident #1's son's medication fell to the floor. She said all that Resident #1 wanted was to be in a room by herself, so her youngest son, who was autistic, could stay at night with her at the facility because they lived out of town and did not have someone to take him to the facility to visit her. She said that she did not know the name of town where Resident #1 lived. She said, The DON and I talked to [Resident #1] to let her know that her son could not stay at the facility at night. I do not remember if I documented this in the resident's clinical record. She said that she was not aware that Resident #1 had a recording on her cell phone on the night that Resident #3 had removed her oxygen and on the night that resident was yelling and hitting the CNA in the bathroom. She said that she was not aware that Resident #1 was saying that Resident #3 wheeled herself to D Hall to bait Resident #1. She said Resident #3 was confused, got mad for no reason and would yell and swear at times at other residents and staff. She said she could not remember if she had documented this in Resident #3's electronic record. She said, The DON and I offered to move [Resident #1] to another room after the incident with the oxygen. She said she had not documented this conversation in the resident's electronic record. She said that Nurses talk to the ADONs when they think that residents needed to be moved to another room. She said, That is why, I do not know who gave the approval to move [Resident #3] to another room. She was not aware of Resident #1 refusing to take the Farxiga as ordered for diabetes, refusal to follow prescribed diet and fluid restriction, showers, incontinent care, turning and repositioning in bed, sitting in a chair, or being discharged from therapy due to not wanting to go to the gym for therapy. She said, No one had reported this to me. She said that Resident #1 kept a lot of food in her room, refused to get out of bed and therapy services. She said that she did not know if Resident #1 had been sent for the ordered consultation for evaluation of excessive food intake and weight gain as ordered by the attending physician. The Social Worker said that with the change of ownership she no longer had access to her Social Service notes to see if she had addressed the behaviors for Resident #1. She said she could not remember if Resident #1 had voiced to her that she wanted to go live with her daughter after she completed rehabilitation services. During an interview on 08/24/26 at 2:25 p.m. with Administrator revealed that she was not aware that Resident #1 had reported Resident # 3 was going to A Hall and that it made her very scared and anxious that she could go into her room. The Administer said that Resident #1 had had another roommate after Resident # 3 was moved to D Hall. She said that the new roommate had complained on Friday about the room being cluttered with Resident #1's belongings, restroom not cleaned, and Resident #1's family using the toilet. She said the family members for Resident #1 visited daily and she was surprised that they were not in the facility today. She said Resident #1 had a son with special needs and the resident filled the pill boxes for her son and kept the medication containers in her room. She said that Resident #1 was informed that she could not keep any medications at the bedside. She said that she had scheduled a meeting to meet with Resident #1's oldest son at 10:30 a.m. and he arrived at 11:40 a.m. on that day. She said she had other scheduled meetings on that day and could not meet with the son because he had not come at the scheduled time. She said the Social Worker had let her know to call the son to schedule a Care Plan Conference. The Administrator said Resident #1 was her own responsible party. She said that the Social Worker was responsible for following up on resident behavior to ensure the staff had reported to the physician and/or Nurse Practitioner and if orders for referrals were ordered that the resident was receiving the necessary care and support and document this in the social service notes. During an interview on 08/24/26 at 2:50 p.m. with the DON and ADONs E and F, they said changes in condition and resident behaviors are discussed in the morning meetings with all department heads that include the Social Worker and the MDS nurses. It was reported that the Social Worker and MDS Nurses were aware of Resident #1's refusal of brief changes, showers, turning & repositioning, incontinent care, not following prescribed diet and fluid restriction, and refusal to take Farxiga as ordered. The DON said the Social Worker had explained to Resident #1 that her son could not spend the night in her room because she had a roommate. The DON said Resident #3 had been moved from the A Hall to D Hall after she had removed Resident #1's oxygen. The DON said that Resident #3 had a significant decline in condition and can only wheel herself for short distances. The DON said the Ombudsman representative had come to talk to Resident #1 about not having visitors over night and not allowed to keep resident's son's medication containers in her room. During an interview on 08/24/26 at 3:39 p.m. with LVN MDS Nurse M revealed Resident #3 was confused, propelled her wheelchair in the resident halls. She said that now the resident only propels her wheelchair for short distances in Hall D yelled for help and did not propel her wheelchair into other resident rooms and did not bait or bother Resident #1. Review of the Social Worker undated Job Description revealed: Job Summary - Identify social and emotional needs for residents. Provide medically related social services to attain or maintain the highest practical physical, mental, and psycho-social well being of each resident. Maintains the Rights of Residents as set forth by the Texas Department of Health Laws and regulations. Essential Functions: Assist residents transferring home or to another facility. Conduct social services assessments on each resident resulting in an individualized Care Plan. Prepare social service progress notes quarterly on each resident. Coordinate outpatient appointments, including transportation.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that:-The facility failed on 8/4/25 to thaw two bags of boneless pork loin properly.-The facility failed on 8/4/25 to seal a receptacle containing refried beans in refrigerator #1.-The facility failed on 8/4/25 to seal Ziplock bags containing jalapenos and onions in refrigerator #1.-The facility failed on 8/4/25 to label an object approximately 15 inches long, wrapped in brown butcher paper and sealed in plastic wrap that was found inside refrigerator #2. -The facility failed on 8/4/25 to seal a receptacle containing cooked beef in refrigerator #2 and it was not used by the labeled use by date.-The facility failed on 8/5/25 to prevent cross-contamination while preparing puree diets.These failures could place residents who eat foods prepared in the kitchen at risk of cross contamination and food-borne illnesses.The findings include:During observation and interview on 8/4/25 at 8:07 AM with [NAME] D in the kitchen, two packs of boneless pork loin were observed inside a gray, square plastic receptacle in the kitchen sink, under the faucet. The faucet was closed, and the water was not running. [NAME] D stated that if the pork was to be used the same day, it had to be thawed under cold running water. He said leaving pork meat to thaw at room temperature was not acceptable and the procedure of leaving the meat to thaw under running cold water should not be stopped until it was prepared for cooking. [NAME] D explained that this protocol was essential because thawing pork could be susceptible to bacterial growth and infection, which could expose residents to cross-contaminated food. [NAME] D stated that if residents were to eat cross-contaminated food, they could become sick and experience severe stomach illness, vomiting, or diarrhea from bacterial pathogens which could lead to more serious health hazards including hospitalization. Under U.S. FDA Food Code 2022 Chapter 3-501.13 Thawing. Except as specified in (D) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (B) Completely submerged under running water: (1) At a water temperature of 21oC (degrees Celsius) (70oF) (degrees Fahrenheit) or below, (2) With sufficient water velocity to agitate and float off loose particles in an overflow and (3) For a period of time that does not allow thawed portions of READY-TO-EAT FOOD to rise above 5oC (41oF). The facility failed to follow this procedure and was in violation of this code. During observation and interview on 8/4/25 at 8:24 AM, an observation and interview with [NAME] D in the kitchen revealed several findings:-Refrigerator #1: A square, clear receptacle containing refried beans with a clear lid was not labeled and was not properly closed. The lid was slightly slid from the corner of the receptacle, creating an opening of about one inch. -At 8:26 AM, two clear Ziploc bags inside the same refrigerator, one containing jalapenos and the other onions, were found open and not sealed. Under U.S. FDA Food Code 2022 Chapter 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings. The facility was in violation of this code. Refrigerator #2:-An object approximately 15 inches long, wrapped in brown butcher paper and sealed in plastic wrap, was found unlabeled and undated inside the refrigerator. [NAME] D stated it was probably leftover food from over the weekend. Under U.S. FDA Food Code 2022 Chapter 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. The facility was in violation of this code. Refrigerator #3:-A clear, square plastic receptacle with a green lid was labeled as Beef and had a prepared date of 7/17/25 with a use-by date of 7/23/25.Interview with [NAME] D: [NAME] D stated that all food items in the refrigerators needed to be properly closed, sealed, and labeled. He confirmed that Ziploc bags containing vegetables should have been closed to prevent cross-contamination. [NAME] D explained that using a cross-contaminated ingredient was potentially hazardous, and such items should have been disposed of immediately. [NAME] D reported that all cooks and the Director of Food and Nutrition were responsible for cleaning, organizing, and ensuring the contents of the refrigerators were properly sealed and labeled. He added that labels were used to provide use dates and identify contents that were not visible due to packaging. [NAME] D reported that this labeling system ensured food freshness, mitigated bacterial growth, and prevented cross-contamination. He confirmed that unlabeled food needed to be disposed of because cooks could not determine when it was received. [NAME] D also stated that if residents were to eat cross-contaminated food, they could become sick and experience symptoms like vomiting or diarrhea from bacterial pathogens, which could lead to serious illness and hospitalization. Under U.S. FDA Food Code 2022 Chapter 3-302.11 Packaged and Unpackaged Food - Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (4) Except as specified under Subparagraph 3-501.15(B)(2) and in (B) of this section, storing the food in packages, covered containers, or wrappings; The facility was in violation of this code.During an observation and interview on 8/5/2025 at 11:01 AM with [NAME] E, a demonstration of puree diets and mechanical chop diet were scheduled to be conducted with a surveyor present. During which time, [NAME] E placed 16 breaded chicken breasts and chicken stock into the blender. [NAME] E then proceeded to remove the lid to the blender with her bare hand and add more stock to improve consistency; it was observed [NAME] E placed the lid into the uncovered container where the cooked breaded chicken met the lid at 11:03 AM. She stated the blender lid was not allowed to be in the container with the cooked food due to concern for cross contamination. [NAME] E washed hands at the beginning of the puree demonstration, but failed to rewash her hands after cross contaminating the breaded chicken with the lid and her bare hand. [NAME] E reports gloves are not used as per facility's policy unless directly handling food with hands. Under U.S. FDA Food Code 2022 Chapter 3-301.11 paragraph B .FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment ., [NAME] E was not in compliance with the Food Code. [NAME] E had the equipment washed and sanitized by a dietary aide following the cross contamination, but failed to wash hands after touching the contaminated lid.In an interview conducted on 8/6/2025 at 01:32 PM, [NAME] E confirmed observations made on 8/5/2025 during puree demonstration where the blender lid was placed inside the container with the handle meeting cooked breaded chicken. [NAME] E reconfirmed this was cross contamination because the lid was handled by her bare hand with the potential outcome of feeding residents contaminated food. [NAME] E reported residents could become sick from their stomach if they were to eat contaminated food. [NAME] E was unable to elaborate on further outcomes or symptoms from sickness but agreed that some residents in the facility might have a compromised immune system, making them more susceptible to food borne illness. [NAME] E stated she was only required to use gloves when directly using her hands to prepare food and must practice hand hygiene before and after glove use. [NAME] E continued that it was the facility's policy that gloves do not have to be worn when using utensils as direct contact or serving food on the tray line.In an interview on 08/06/2025 at 1:32 PM with the Director of Food and Nutrition, he emphasized the critical importance of properly closing and sealing food items within the refrigerators to safeguard their composition and quality. He stated that if food was left unsealed or improperly closed, a range of contaminants including mold and bacteria, could compromise the food, potentially rendering it spoiled and requiring it to be discarded. The Director of Food and Nutrition also highlighted the risk of cross-contamination, where an item could contaminate other food inside the refrigerator. Regarding meat, he clarified the correct thawing procedure: it had to be completely thawed inside the refrigerator or, if necessary, thawed under running water in the sink. The purpose of this was to ensure even thawing and prevent the dangerous growth of bacteria. Thawing meat at room temperature was explicitly deemed unacceptable, as this could lead to bacterial growth and, if consumed, could result in residents suffering from diarrhea, vomiting, or dehydration. He explained that if a cook prepared pureed food without gloves, and utensils touched both the cook's hands and the food, this was considered a serious breach of protocol that could lead to residents becoming sick. The Director of Food and Nutrition concluded by stressing that the firm expectation for all staff was to wear gloves when preparing food and handling cooking utensils to prevent such incidents of cross-contamination which could result in resident's becoming ill. In an interview on 8/7/25 at 5:00 PM with the Administrator, she stated that staff were expected to follow the facility's Policies and Procedures for kitchen and safety practices to prevent cross-contamination and food born illness. The Administrator said staff not wearing gloves and using utensils that had touched their bare hands could lead to cross-contamination and bacterial growth if those utensils touched the food. She explained that containers in the refrigerator not being properly sealed or closed posed a similar risk for growing bacteria and contaminating other food inside the refrigerators. The Administrator stated that thawing meat at room temperature was also a significant concern and said the proper procedure was to leave the meat thawing underneath the faucet with cold water running so that meat thawed evenly and to prevent growth of bacteria. The Administrator stressed that all these actions could potentially lead to cross-contamination and the growth of bacteria, which in turn could make residents ill with stomach infections that could result in them experiencing vomiting, diarrhea or dehydration. Record review of the facility's policies and procedures labeled Dietary Service Policy and Procedure manual revised on 4/9/25 stated in part: Infection Control, Frozen items are thawed in refrigeration or under cold running water in a draining sink. Record review of the facility's policies and procedures labeled Dietary Department Glove Standard Protocol, not dated, stated in part: Glove use will be minimized in favor of serving utensils. This preference is based on the FDA's [NAME] Paper, Interventions to Prevent or Minimize Risks Associated with Bare-Hand Contact with Ready-to-Eat Foods . The Guidance to Surveyors for F371 also states The appropriate use of utensils such as gloves, tongs, deli paper and spatulas is essential in preventing food borne illness. Gloved hands are considered a food contact surface that can get contaminated or soiled. Failure to change gloves between tasks can contribute to cross-contamination. Proper hand washing techniques and glove use will be taught to all new hires to the dietary department during the orientation process. Their training will be verified with a hand washing and glove use proficiency audit . Gloves will not be worn on tray line. Instead, as much pre-assembly and/or prep work will be completed before meal service to minimize the potential for cross-contamination during service. If direct food contact is required to prepare a menu item, this preparation should be done prior to tray line while wearing a glove to perform this single task, and hands washed before and after glove use . Bare hand contact with tableware, glasses and eating utensils will also be minimized.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for one (Resident #9) of four resident reviewed for care plans.The facility failed to have a comprehensive person-centered care plan for Resident #9 to address the Resident's prescribed psychotropic medication, Mirtazapine 7.5 mg by mouth at bedtime.This failure could affect residents prescribed psychotropic medications by placing them at risk for not receiving care and services to meet their needs.Findings Include:Record review of Resident #9's face sheet dated 08/07/25 revealed an [AGE] year-old female with an admission date 06/09/21.Record review of Resident #9's health and physical dated 04/16/25 revealed resident's medical history, which were the following: Stroke (sudden interruption of continuous blood flow to the brain), Type 2 Diabetes (when the body cannot use insulin correctly and sugar builds up in the blood), Dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and Deep Vein Thrombosis (a blood clot in a vein located deep within your body, usually in your leg).Record review of Resident #9's Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status score of 0, indicating severe cognitive impairment. MDS revealed resident was taking an antidepressant.Record review of Resident #9's Order Summary Report dated 08/07/25 revealed resident was prescribed a psychotropic medication for appetite stimulation, Mirtazapine 7.5mg by mouth at bedtime, order start date 05/07/25.Record review of Resident #9's care plan dated 07/31/25 revealed her psychotropic medication, Mirtazapine, had not been cared planned. Interview on 08/07/25 at 3:29 PM with the Regional MDS Nurse revealed psychotropic medications were to be care planned. She stated psychotropics were to be added on the care plan so nursing staff could monitor residents for side effects relating to the psychotropic medications. She stated the risk to the resident was nursing staff being unable to identify the side effects and report as needed. The Regional MDS Nurse stated medications that were added to resident care was called an Acute Care Plan which was responsibility of the nursing staff.In an interview on 08/07/25 at 3:45 PM with the DON, she stated psychotropic medications were to be added to the residents' care plan. She stated care plans meant patient centered care, and it allows for staff to be aware of what medication side effects to monitor. She stated care plans also included non-pharmacological interventions that could benefit the residents. The DON stated, Acute Care Plans, and adding psychotropic medications to the care plan, were the responsibility of nursing staff and leadership. She stated the ADON's, and self (DON) were responsible for monitoring the care plans. She stated changes in resident care plans were discussed in daily morning rounding with the IDT team.During an interview on 08/07/25 at 4:14 PM with the ADON, she stated psychotropic medications were to be included in residents' care planned if prescribed. She stated care plans provided information about interventions and residents' specific health goals. The ADON stated nursing was responsible for reviewing care plans. She stated both ADON's and DON were responsible for monitoring residents' care plans on a quarterly basis. The ADON stated the risk of psychotropic medications not being in the care plan can affect the resident by not receiving the correct plan of care. She stated there was no reason psychotropic medication was not included in Resident #9's care plan. In an interview on 08/07/25 at 4:45 PM with the Administrator, she stated nursing was responsible for updated acute changes in the care plan and MDS nursing staff updated the Comprehensive Care Plan on a quarterly basis. She stated care plans reflected certain medications they were prescribed, and that information served as a guide on how to care for that resident. She stated risks of psychotropic medications not being included in residents' care plans would prevent staff on being aware of that resident's needs.Record Review of facility's policy and procedures, Nursing Policy & Procedure Manual, labeled Comprehensive Care Planning with no date, read in part: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. It also stated, Residents' goals set the expectations for the care and services he or she wishes to receive. Measurable objectives describe the steps toward achieving the resident's goals, and can be measured, quantified, and/or verified. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented.

Based on observation, interview, and record review, the facility failed to ensure biologicals were stored in locked compartments and accessed by authorized personnel for 1 (Resident #21) of 8 residents reviewed for medication storage, in that: Resident # 21 had two clear measuring cups at bedside, one with crushed medications and the second with a clear liquid, exposed and within reach of other residents. This failure could place residents at risk of access to medications not approved for administration by their physician. Findings included: Record Review of Resident # 21s' admission record dated 8/06/2025 revealed an [AGE] year-old female admitted to the facility on [DATE]. Record Review of Resident # 21's' history and physical dated 06/10/2025 revealed diagnoses of high blood pressure, other recurrent depressive disorder, constipation and rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood). Record Review of Resident # 21s' Quarterly MDS dated [DATE] revealed a BIMS score of 14, indicating intact cognitive function. Record Review of Resident # 21's care plan revealed nursing interventions to include giving medications as per doctor's orders and to monitor for side effects of medication. Record review of Resident # 21's medication administration record dated 08/06/2025 revealed Resident #21's morning medications as Bupropion HCL oral tablet 75mg, Jardiance oral tablet 10mg, Losartan Potassium oral tablet 25 mg, Miralax Oral 17gm/scoop, Carvediol oral tablet 12.5mg, Docusate Sodium oral tablet 100mg, Lactulose oral solution 10gm/15ml and Simethicone oral tablet 80 mg. In an observation and interview on 08/04/25 at 10:15 am in Residents #21 room revealed, the room door open, two clear plastic measuring cups, one with crushed medications mixed with pudding and another cup with an unknown clear liquid on Resident #21's bedside table. Resident #21 did not know what the medications were. She stated that the nurse had left them for her to take after breakfast as she had requested. Resident #21's roommate was present in room as well. In an interview on 08/07/25 at 1:40 PM with LVN A, she stated that nurses and medication aids were to dispose of medications when residents did not want to take them. She stated that they were to never leave medication unattended for residents to take by themselves. She stated that when administering medications, nurses or medication aides were to stay with residents until residents finished taking medications to ensure that medication was ingested. She stated that leaving medications unattended could pose a risk to residents because it could easily be gotten a hold of, and the wrong resident could ingest the medication. She stated that whoever was administering the medication was responsible for ensuring medications were not left unattended or properly disposed of. In an interview on 08/07/2025 at 3:30pm with DON, revealed that medications were not to be left at bedside unattended for any resident. She stated that leaving medication unattended could potentially expose the resident to misuse of the medication such as medication being taken by another resident. She stated that it was also an infection control issue because it was exposed to air. She stated that it was the responsibility of the nurses to ensure that medications were not left at the bedside. In an interview on 08/07/25 at 4:30 PM with the Administrator, she stated that medications were not supposed to be left unattended at bedside. She stated that if a resident did not want to take medication at the time of administration, they were to dispose medications. She stated that leaving the medications at bedside could potentially expose other residents to getting a hold of the medications and accidentally taking them. She stated that it was the responsibility of either the nurse or medication aide to ensure that medications were being taken as per doctor's orders. She stated that she could not recall the last training/In service that was given over leaving medications at bedside. Record Review of facility policies and procedures titled Medication Administration and General Guidelines, not dated, reads in part Medications are administered at the time they are prepared. Medications are not pre-poured. The procedure reads observe the resident take the medications.

Based on observation, interview, and record review, the facility failed to ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming, personal and oral hygiene, for 1 Resident (#1) of 6 residents reviewed for activities of daily living. The facility failed to provide fingernail care for Resident #1 by not maintaining trim and clean fingernails. This failure could place residents at risk of not having their personal hygiene needs met and cause low self-esteem. The findings include: Record review of Resident #1's face sheet, dated 3/27/25, indicated the resident was admitted on [DATE] with diagnoses: hemiplegia (paralysis of one side of the body, either right or left) and hemiparesis (weakness of one side of the body, either right or left) following cerebral infarction (stroke) affecting left non-dominant side, dysarthria (difficulty in speech because of weakness of the speech muscles), unspecified dementia, and Alzheimer's disease (a brain disorder that affects memory, thinking, and behavior). Record review of Resident #1's Admission MDS dated [DATE] indicated a BIMS score of 2, indicating severe cognitive impairment. Per the MDS, Resident #1 required moderate assistance with personal hygiene meaning the helper did more than half the effort. Record review of Resident #1's Care Plan dated 03/15/25, revealed ADL Self-care performance deficit and interventions included nursing staff to Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. If diabetic, the nurse will provide toenail care. Observation on 3/26/25 at 11:24 AM of Resident #1 revealed she had nails approximately 1 inch off the nail bed for all fingers on both her hands. Her fingernails on both hand hands were observed with dirt under them and chipped nail polish. Resident #1 was not able to voice whether she liked her nails this length or not. During an interview on 3/26/25 at 1:32 PM with CNA A, she said that residents are offered nail trimming services during the resident's scheduled shower. She stated if the resident is diabetic, nurses were to trim fingernails. CNA A stated that fingernails of residents should be maintained short and clean. She stated long fingernails can cause an infection control risk. During an interview on 3/26/25 at 3:27 PM with LVN B, she said that nursing staff such as nursing assistants were to offer residents nail trimming during the resident's shower. She stated if the resident was diabetic only nurses were to file down fingernails. LVN B stated if a resident did not want nails groomed, the ADON, DON and family member were notified. She stated the risks for residents having long nails included residents could scratch themselves causing injury, or also an infection control issue as there are possible bacteria entrapped under the nail. In an interview on 03/26/25 at 4:00 PM with the ADON, she said that residents received grooming services with their fingernails on Sundays. She stated that if resident's nails are observed long, the service could be offered at any time. She stated the nurses were responsible for monitoring (checking during daily rounds) residents through their rounding during their shift and could offer to trim or cut the resident's nails. She stated the risks for residents having long and dirty nails included infection risk, as the resident could touch their face or scratch their skin. In an interview on 3/26/25 at 4:15 PM with the DON, she said that residents were offered nail grooming services from CNAs on the residents' scheduled shower days. She stated the nurses were to offer nail grooming service if the resident is diabetic. She stated the CNAs are responsible for monitoring, filing and cleaning the resident's nails, and the nurses could file and trim nails including diabetic residents. The DON stated If any resident declined care, they are to notify the charge nurse so that nurse could go in to assess and find the reason on why the resident does not want care at the time. She stated the resident had the right to have clean nails. The DON stated the risks of residents having ungroomed nails included an infection control concern to the resident. Record review of facility's policy and procedures titled Activities of Daily Living, revised 2007, read in part: The facility provides necessary care to all residents that are unable to carry out activities of daily living on their own.

Based on observations, interviews and record reviews the facility failed to ensure a resident who needs respiratory care is provided such care consistent with professional standards of practice for 2 of 10 residents (Residents #2, #3) who were reviewed for respiratory care in that: 1. The facility failed to ensure Resident #2's oxygen concentrator filter was clean. 2. The facility failed to ensure Resident #3's oxygen concentrator filter was clean. These deficiencies could affect the residents who received continuous oxygen and oxygen as needed and can result in a respiratory infection. Findings include: Resident #2 Record Review of Resident #2's face sheet dated 3/27/25 revealed a [AGE] year-old male that was admitted [DATE]. Resident #2 diagnoses included: Lymphedema (a condition of localized swelling caused by compromised lymphatic system), muscle weakness, obstructive sleep apnea, and peripheral vascular disease (a condition that narrows the vessels away from the heart and brain causing pain and discomfort in the limbs). Record Review of Resident #2's MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. The MDS revealed the resident required extensive assistance in bed mobility from 2 persons to physically assist. Record Review of Resident #2's Care Plan last revised 10/22/24 revealed that Resident #2 is at risk for ineffective gas exchange and used oxygen therapy routinely or as needed. The interventions included administering oxygen therapy per physician's orders. Observation on 3/26/25 at 10:13 AM at revealed Resident #2 sitting in bed with oxygen on through a nasal cannula (a medical device used to deliver supplemental oxygen to individuals with respiratory issues; it consists of a thin, flexible tube that wraps around the head, with two prongs that fit into the nostrils to provide oxygen directly) and an oxygen concentrator with dust particles on the filter. Resident #3 Record review of Resident #3's face sheet dated 3/29/25 revealed a [AGE] year-old male with an initial admitted [DATE], and re-admitted [DATE]. The face sheet revealed Resident #3's diagnoses included: cerebral infarction due to embolism (stroke due to a blockage in the blood vessel), metabolic syndrome (a cluster of conditions that increased the risk of heart disease, stroke, and type 2 diabetes), dysthymic disorder (persistent depressive disorder), cognitive communication disorder, hypertension (high blood pressure), and muscle weakness. Record review of Resident #3's MDS dated [DATE] revealed a BIMS score of 15 , indicating no cognitive impairment. The MDS revealed Resident #3 required a 2-person limited to extensive assistance with ADLs such as bed mobility. Record review of Resident #3's head and physical physician note dated 02/26/25 revealed Resident #3 is diagnosed with Acute Hypoxic respiratory failure and required oxygen supplementation, 4 liters, to achieve oxygen level of 92% or more. Observation on 3/26/25 at 10:20 AM revealed Resident #3 sitting at his bed with oxygen on through a nasal cannula and an oxygen concentrator with dust on the filter. In an interview on 3/26/25 at 3:29 PM with LVN , she stated that the resident's oxygen filters are cleaned every Sunday night. She stated that nursing staff, nurses, were responsible for monitoring, and maintaining oxygen filters. LVN stated the ADON and DON are also responsible for monitoring the cleanliness of the oxygen concentrator filters when they round. She stated the risks for oxygen concentrator filters not being clean included infection control issues since bacteria and dust collect. In an interview on 03/26/25 at 4:05 PM with the ADON, she said that oxygen concentrator filters were to be cleaned once a week. She stated that CNAs can clean them. She stated that if the filter was damaged or needed a replacement, Central Supply are to supply a new filter. The ADON stated the risks for oxygen air filters being dirty included infection risk and possible malfunction of the oxygen concentrator. During an interview on 3/26/25 at 4:19 PM with the DON, revealed she said that it is everybody's responsibility to monitor and clean the oxygen concentrator air filters. She stated Central Supply can also change them. She stated if staff are not able to clean or replace the filter, they should notify the nurse so it can be completed. The DON stated if the oxygen concentrator air filters were not cleaned, it can introduce foreign objects or bacteria to the resident's body. Record Review of the oxygen concentrator manufacturer manual , read in part: recommended cleaning interval for the air filter is every 7 days.

Based on observation, interview, and record review, the facility failed to ensure they had a full time DON for 1 of 1 facility reviewed for DON coverage. The facility failed to have a full-time DON since 12/05/24 . This failure could place residents at risk of a lack of nursing oversight and a higher level of care. Findings included: Record review of staff hours from 12/01/24 through 01/15/25 indicated there was no DON in the facility from 12/06/24 through 01/15/25. In an interview on 01/14/25 at 8:40 AM, with the Administrator, ADON C, and ADON D, the Administrator stated the facility currently did not have a DON. ADON C stated the facility did not have an acting or interim DON. ADON D stated the facility was looking for a DON. In an interview on 01/15/25 at 10:53 AM, with ADON C and ADON D, ADON C stated they did not have a full time DON but were actively seeking to hire a DON. ADON D stated the facility was about to hire a DON but the applicant at the last minute turned down the offer. ADON C stated the facility was using social media and other websites to actively try to recruit a DON. ADON C stated the risk of not having a DON would be that there might be some tasks that would be out of the scope of what some nurse can and cannot which why the facility needed a DON. ADON D stated the facility needed to have that oversight of a manager a DON to be looking at everything. In an interview on 01/15/25 at 11:13 AM, with the Administrator, she stated the purpose of having a DON was so the DON could provide guidance to the nursing department. The Administrator stated the facility did have a corporate nurse and a weekend supervisor who was an RN that could provide that guidance. The Administrator stated the facility was using social media, websites, and by word of mouth to try to hire a DON. In an interview on 01/15/25 at 12:22 PM, with HR, he stated the facility did not have a full time DON nor an interim DON. HR stated they had an applicant that they were going to hire for DON but in the minute the applicant turned down the offer . HR stated the facility was using social media and websites to try to hire a full DON. HR stated the purpose of a DON was to manage all the nursing department, regulate all the services for the residents, and making sure the residents had all the services they needed. HR stated the risk was that services being provided to residents might not have oversight to ensure they were being provided. HR stated the last DON's last day in the facility was on 12/02/24 and official last day was on 12/05/24, since then, the facility has not had a full DON. In an interview on 01/15/25 at 12:32 PM, with the Administrator, she stated the facility did not have a DON policy and followed state guidelines.

Based on observation, interview and record review, the facility failed to maintain housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for 1 of 6 resident rooms, observed for housekeeping and maintenance, in that: The facility failed to ensure CNA E used the facility work order system to input the lights in the restroom and room of Resident #5 would not turn on while Resident #5 wanted to use the restroom but was dark and could not see. These failures could lead to resident injury and a diminished quality of life. Findings include: Record review of Resident #5's face sheet dated 01/15/25, revealed, admission on 02/01/20, re-admission on 10/15/21, and re-admission again on 02/22/22 to the facility. Record review of Resident #5's facility history and physical dated 07/28/24, revealed, a [AGE] year-old female diagnosed with Anxiety, Cholecystitis (inflammation of the gallbladder), reduced mobility, history of falls, and GI bleeding (bleeding from any part of the digestive tract, from the mouth to the anus). Record review of Resident #5's annual MDS dated [DATE], revealed, little to no impairment of cognition BIMS score of 15 and to be able to recall or make daily decisions. ADLs revealed to be independent for toileting, shower/bath, dressing. Independent for walking 10 feet/50 feet. Record review of Resident #5's Care Plan dated 04/27/22, revealed the resident was incontinent of bowel/bladder related to history of UTI, confusion, and incontinence. Maintain unobstructed path to the bathroom. Resident #5 had impaired visual function and was at risk for falls, injury, and a decline in functional ability. Anticipate needs and meet them as able. Keep call light in reach when in room or bathroom. Involve in activities which do not require vision to participate such as music, parties, and exercise. Monitor and report eye problems, change in ability to perform ADLs, decline in mobility, sudden visual loss, tunnel vision, blurred vison, hazy vision. Resident #5 was able to see large print in a well illuminated room. ADLs was supervision with set-up for toileting due to impairment with balance coordination. Observation and interview on 01/15/25 at 8:44 AM, with Resident #5, she stated she was looking for staff due to her lights in her restroom and room not turning on. Resident #5 showed state agency her room and tried to turn on the light switch in the room. It was observed that the light in the room was not turning on. Resident #5 stated she had to go to the restroom, but could not cause the light in the restroom would not turn on and was afraid to go to the restroom without the lights turning on. State agency tried turning on the lights in the restroom and would not turn on. It was observed that the room was dark, and, in the restroom, it was dark and darker if the restroom door was closed. It was observed that nothing could be seen if the restroom door was closed. Resident #5 had stated she told a nursing staff about the issues a little over an hour ago and did not know what had happened. In an interview on 01/15/25 at 8:48 AM, with CNA E, she stated Resident #5 had told her about the lights not turning on in her room and restroom. CNA E stated she was looking for the floor charge nurse of the hall at the nurse's station and could not find her. CNA E stated since she was not able to find her, she went back to assist another resident with feeding as she was busy. CNA E stated she did not use the facility work order system to input the work order. CNA E stated she had been trained to use the facility work order system when facility needed to report facility stuff that needed fixing and tell the nurse. CNA E stated the risk of the lights not working for Resident #5 could have been a fall. Observation on 01/15/25 at 8:50 AM, revealed, visible facility work order system QR Scan postings in around the nurse's station of the facility. In an interview on 01/15/25 at 9:19 AM, with the Maintenance Director, he stated facility staff have been trained to use the facility work order system and what to do if they see, hear, or get reported facility stuff that were broken. The Maintenance Director stated there were QR Scan codes posted everywhere in the facility in which facility staff could place the work orders through there phones. The Maintenance Director stated not using the facility work order system could have a negative outcome of broken item(s) not getting fixed affecting the resident negatively depending on the situation. The Maintenance Director stated he was told of Resident #5's lights not turning on around 10 minutes ago which he observed that the lights were not turning on. The Maintenance Director stated Resident #5 told him she wanted them to turn on. The Maintenance Director stated an issue like the lights not turning on for Resident #5 was considered to be a 911 call (defined as notify the Maintenance Director immediately with clogged toilet, lights out, Exit lights out, etc.) and should have inputted into the facility work order system and told immediately. In an interview on 01/15/25 at 10:49 AM, with ADON C and ADON D, ADON C stated all facility staff were trained on how to place a work order. ADON D stated there were QR Scan code postings throughout the facility in which facility staff could use the facility work order system to place work orders which was sent to the maintenance department. ADON C stated if nursing staff were reporting a work order issue and cannot find the nurse, then they need to directly let the Maintenance Director know aside from using the facility work order system. ADON D stated the risk would depend on the situation. In an interview on 01/15/25 at 11:13 AM, with the Administrator, she stated facility staff were trained on the facility work order system on how to place work orders in. The Administrator stated the maintenance department should be reviewing the work orders daily. The Administrator stated the risk of not using the facility work order system could result in the broken item not being forgotten and would not be fixed. The Administrator stated the risk to the resident would depend on the situation.

Based on the observation, interview, and record review, the facility failed to ensure that the residents environment remains free of accidents hazards as possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #3) of 3 residents reviewed for accidents and supervision. The facility failed to ensure CNA A secured the brakes on a mechanical lift when lifting and lowering Resident #3 to bed. This failure could place residents at risk for falls or injury. The findings included: 1. Record review of Resident #3's face sheet dated 1/14/25 revealed a [AGE] year-old female was readmitted to the facility on [DATE]. Record review of Resident #3's history and physical dated 11/27/24 revealed diagnoses of diabetes (blood sugar is too high), hypertension (high blood pressure), pulmonary embolism (blood clot that blocks and stops blood flow to an artery in the lung), and an unstageable pressure ulcer of the heel. Record review of Resident #3's significant change in condition MDS assessment dated [DATE] revealed a BIMS score of 15, indicating her cognition was intact. The resident was dependent on staff for transfers. Record review of Resident #3's care plan dated 10/16/24 revealed a focus area of ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner and interventions that included assist x 2 (two people) with transfers, use mechanical lift. In an observation on 1/14/25 at 1:28 pm, CNA A and CNA B assisted with perineal care and performed a mechanical lift transfer for Resident #3. During the transfer, the brakes on the mechanical lift were not engaged, causing the lift to move slightly. The resident was moved over the bed, with CNA A maneuvering the mechanical lift and CNA B assisting. The brakes were also not secured when lowering the resident onto the bed. In an interview on 1/14/25 at 2:01 pm, CNA B stated that she had received training on how to properly hook the sling and secure brakes on mechanical lift. CNA B stated she received training twice a year. CNA B stated she did not see if CNA A had secured the brakes during the transfer. CNA B stated the brakes were required to be engaged when lifting and lowering the bed. CNA B stated risks included the potential for the mechanical lift to move during transfers, which could result in injury to the resident or staff. In an interview on 1/14/25 at 2:14 pm, CNA A stated she had received training on proper mechanical lift use, including how to hook the sling, ensure the sling is in good condition, and secure brakes during transfers. CNA A stated she forgot to secure the brakes during the lift and did not secure them when lowering the resident because the bed had been moved up. CNA A stated risks included potential injury to the resident or staff due to unsecured brakes. In an interview on 1/15/25 at 10:43 AM, with ADON C and ADON D, ADON C stated all nursing staff were trained on mechanical transfers and other transfers. ADON D stated they receive this training from the therapy department. ADON C stated when lifting a resident up from the bed or wheelchair the hoyer lift brakes have to be placed to lock. ADON D stated this was to secure and anchor the hoyer lift. ADON C stated the risk would be that the hoyer lift could move if it was not secure. Record review of the facility's Hydraulic Lift policy not dated read in part Goals: the resident will achieve safe transfer to bed or chair via mechanical lift device. The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair via the hydraulic lift. Procedure: prepare the lift by setting the adjustable base to its position. Lock or unlock the base wheels according to the lift manufacture's recommendations.

Based on observations, interviews, and record review the facility failed to ensure resident#1 was free from any physical or chemical restraints imposed for purposes of discipline or convenience for one (Resident #2) of five residents reviewed for freedom from physical restraints. The facility failed to ensure Residents #2 did not have pillows under his mattress which restricted his movement from getting off the bed and were not required to treat his medical symptoms. This failure could put residents at risk of unnecessary restriction of their movements. Findings included: Resident #2 Record review of Resident #2's Admission Record revealed he was a [AGE] year-old male who was admitted on [DATE] with diagnoses including paroxysmal atrial fibrillation (irregular heartbeat), atherosclerosis (with rest pain bilateral legs, type 2 diabetes, hyperlipidemia (high cholesterol), unspecified dementia without behavioral disturbance, hypertension, vascular disease, and shortness of breath. Record review of Resident #2's History and Physical dated 09/14/2024 did not have any documentation as the resident was just admitted into the facility on [DATE]. Record review of Resident #2's MDS dated [DATE] did not have anything documented as it was still pending completion due to him being a new admit. Record review of Resident #2's care plan, dated 09/14/2024, had no documentation regarding if the resident had any behavioral issues trying to get out of bed. The only focus that was set for the resident was the use of anxiety medication, with a goal that Resident #2 will be free from discomfort or adverse reactions related to anxiety therapy, with interventions of an increased risk of confusion, amnesia, loss of balance, and cognitive impairment that looks like dementia, fall, broken hips and legs, and monitor for safety. Record review of Resident #2's order recap report dated 09/14/2024 revealed a floor mat or other fall prevention device was ordered. In an observation on 09/20/2024 at 09:55 AM Resident #2 was lying in bed with about three pillows underneath his mattress. The pillows were placed on the left side under the resident's mattress causing the mattress to lean more towards the right side. Resident #2 could not verbalize complete sentences and mumbles words. In an interview on 09/21/2024 at 10:00 AM CNA A, stated the pillows were put that way so he did not roll off the bed. He was always falling and if the pillows were placed under the mattress, then the resident was unable to roll to the floor. She stated that was how they've done it for a while, and no one has told her differently. In an interview on 09/20/2024 at 11:13 AM RN A said that she just started here about 3 weeks ago and it was brought up to her attention by CNA A. RN A advised CNA A that it was not right and had her remove the pillows immediately. RN A educated CNA A and advised CNA A that there needed to be an order in place and there was not, so she needed to remove them, that it was a restraint. Resident #2 now does not have pillows under the mattress. RN A stated she always removed them if she sees that but believed CNA A has been doing it for a long time prior to her starting here. In an interview on 09/20/2024 at 11:23 am, the DON was shown the picture of Resident #2 and how the pillows where under his mattress. The DON has been employed with facility since July 15, 2024. Stated the pillows underneath the mattress was not considered appropriate and did not know that staff were doing that. She stated if she knew that, she would have had them immediately take it off and in-service the staff. It was usually the same aid during the day all week-long until nighttime the facility would have a different one. She stated everyone has been in-serviced and the weekend staff will be as well. On 09/21/2024 at 11:48 am an interview was conducted with ADON A and ADON B. ADON B has been employed with facility for 7 years and ADON B has been employed for [AGE] years with the facility. The same picture of Resident #2's pillows under the mattress were shown to both the ADON's. They both stated it was considered a restraint. They stated Resident #2 just arrived 2 weeks ago (more or less) and they stated they do educate their CNA's on ANE, Falls, and restraints. The last in-service was this past week, and they also have it on digital training system every year. ADON A can't recall if CNA A signed the in-service but did do the digital training system. She stated the resident had a consent form filed out by hospice and signed by family for bed rails, but they were taken off because he was not using them for repositioning. Staff knew it was a restraint free facility, and bed rails were only used for bed mobility. The resident wasn't using them, he was not able to move himself much, and the resident was not able to verbally communicate. The bed rails were removed last week, nursing staff removed them, called hospice, informed the family, did the assessment, and completed a consent while they were there. ADON B was not aware CNA A was placing the pillows like that. The CNAs usually work on their own, but the team nurses rotate so there was no same nurse on the same hallway all the time. There were 4 nurses on the floor right now, they should do rounds every 2 hours, at the beginning of the shift and on the off going shifts. ADON B couldn't say if they did it today since it was not seen. CNA A has been here about 3 years, they all know they were not supposed to do that. In an interview on 09/21/2024 at 12:05pm, CNA A, stated she's had multiple in-services on restraints and knows what a restraint was. She stated this was the first time that she has done this because she knew better. She stated that RN A was the one that told her this morning to do that. She knew that it was wrong but because her nurse told her to, she listened. She knew that she was to put the bed at a low position and have the floor mat on the floor only if they were a fall-risk or depending on the orders. Review of the facility policy Restraint revised February 1, 2007, states it is the policy of this facility to maintain an environment that prohibits the use of restraints for discipline of convenience. The facility is committed to nurturing the autonomy and independence of our residents by attempting to provide a restraint-free environment.

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Residents #1) of 7 residents reviewed for assistance with ADLs. -The facility failed to ensure Residents #1's fingernails were trimmed and cleaned. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk of infection, and decreased quality of life. Findings include: Review of Resident #1's Admission Record dated 09/13/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included cerebral palsy (congenital disorder of movement, muscle tone, or posture), depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), muscle weakness, lack of coordination, intellectual disability (deficits in theoretical thinking/learning), seizures (uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain), and paraplegia (paralysis that affects your legs, but not your arms). Review of Resident #1's quarterly MDS assessment dated [DATE], revealed a BIMS score of 12 indicating moderate cognitive impairment. Section GG - Functional Abilities and Goals section revealed Resident #1 requires substantial/maximal assistance (level of assistance where a helper provides more than half of the effort for a task) with toileting, showering, dressing, and personal hygiene. Review of Resident #1's care plan dated 09/13/2024, reads in part Resident #1 had potential/actual impairment to skin integrity related to fragile skin due to contractures. Part of the interventions included avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Another focus area includes Resident #1 had ADL self-care performance deficit and was at risk for not having needs met in timely manner. Part of the interventions included provide shower, shave, oral care, hair care, and nail care per schedule and when needed. During observation and interview on 09/16/2024 at 11:05 a.m., Resident #1 was lying in bed. Observed Resident #1 scratch right side of face and noted fingernails on right hand were long and dirty. Nails were approximately 2 cm long and jagged. There was brown/black discoloration noted under the nails. Resident #1 said he did not know the last time his nails were trimmed or filed. Resident #1 said he would like his nails trimmed because they were too long. During observation and interview on 09/16/2024 at 2:45 p.m., LVN I entered Resident #1's room and observed his nails. LVN I said the resident's nails were a little long, jagged, and dirty. LVN I said the CNAs take care of nail care for Resident #1 during showers or as needed. LVN I said she did not know when was the last time Resident #1 had his fingernails trimmed or filed. LVN I said there was a risk Resident #1 may scratch himself causing skin tear and possible infection from dirty nails. Resident #1 told LVN I that he wanted his nails cut. During an interview on 09/17/2024 at 9:54 a.m., LVN G said nail care was usually done on Sundays or as needed. LVN G said generally the CNAs will take care of nail care but if they are busy, they will let the nurses know and the nurses can trim and file the nails. LVN G said she worked from Friday through Sunday, and no one mentioned anything about Resident #1's nails being long or dirty. During an interview on 09/17/2024 at 1:20 p.m., the DON said the purpose of fingernail care was to avoid someone scratching themselves, skin issues, and infection control if there are dirty nails. The DON said the risks of a person dependent on ADLs having long and dirty fingernails was scratching and/or possible infection. The DON said nail care should be done on Sundays and could be done either by the aides or a nurse. During an interview on 09/17/2024 at 2:20 p.m., the Administrator said the purpose of fingernail care was to minimize the risk of scratching and skin tears. The Administrator said that nail care could have been performed by aides and nurses as needed. Record review of facility policy titled Nail Care dated 2003, reflected in part Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails . Goals: Nail care will be performed regularly and safely. The resident will be free from abnormal nail conditions.

Based on observation, interview and record review the facility failed to review and revise Resident Care Plans after each assessment for 1 (Resident #1) of 8 residents whose records were reviewed. -Resident #1's Care Plan was not updated to reflect discontinuation of padding the wall. These deficient practices could lead to errors in treatment and services provided based on incorrect information. Findings included: Resident #1: Review of Resident #1's Admission Record dated 09/13/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included cerebral palsy (congenital disorder of movement, muscle tone, or posture), depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), muscle weakness, lack of coordination, intellectual disability (deficits in theoretical thinking/learning), seizures (uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain), and paraplegia (paralysis that affects your legs, but not your arms). Review of Resident #1's quarterly MDS assessment dated [DATE], revealed a BIMS score of 12 indicating moderate cognitive impairment. Section E - Behavior revealed Resident #1 had not exhibited any physical, verbal or other behavioral symptoms. Review of Resident #1's care plan dated 09/13/2024, reads in part Resident #1 had history of behavior problem as evidenced by resident will hit the wall with his hand. Part of the interventions included Place padding on wall to cushion the resident's hand in case the behavior continues. During observation and interview on 09/16/2024 at 10:47 a.m., Resident #1 was observed lying in bed. One side of his bed was against the wall. The wall was noted without any padding. Resident #1 said he had moved to the room from another room last week but could not remember the date. Resident #1 said he did not need any padding for the wall as he did not hit the wall. Resident #1 said he did not know what instructions were written on his care plan regarding padding on the wall. During an interview on 09/17/2024 at 10:05 a.m., ADON C said Resident #1's care plan still shows that wall should be padded. ADON C said the intervention step was in place in 2021 as Resident #1 had exhibited behaviors and hit the wall. ADON C said the care plan intervention step was no longer applicable as Resident #1 had not exhibited the behavior anymore since 2021, and the intervention should have come off his care plan. ADON C said Resident #1's care plan should have been updated and she did not know why the intervention was not taken off the care plan. ADON C reviewed Resident #1's injury history and noted there had been no injuries resulting from Resident #1 hitting the wall from 01/01/2023 to 09/17/2024. ADON C said the care plan should have been updated by nursing or the MDS department. During an interview on 09/17/2024 at 1:03 p.m., the MDS Coordinator said the purpose of the care plan was to address what the resident needs. The MDS Coordinator said the care plan not being accurate or up to date could result in confusion. The MDS Coordinator said social services, nursing and MDS department were able to update the care plans. The MDS Coordinator said the care plan should be reviewed quarterly and whenever there was a change of condition to make sure information was accurate. The MDS Coordinator said Resident #1 did not have an order for a padded wall and that it was a precautionary part of the care plan. The MDS Coordinator said when it was determined that Resident #1 did not require the padding on the wall, it should have been removed from the care plan. The MDS Coordinator said nursing or social services could have removed the intervention step. The MDS Coordinator said it appeared that the intervention step carried over from 2021 and was overlooked for revision. During an interview on 09/17/2024 at 1:20 p.m., the DON said the purpose of a care plan was to individualize a plan of care to address resident needs, behaviors, psychosocial needs, and other things like falls and other risks. The DON said the risk of care plans not being revised timely was confusion or providing the wrong type of services. The DON said care plans should be revised immediately or at least the following day when a change in the plan was identified. The DON said nursing services and MDS should revise the care plan as needed. The DON said there was no oversight on revisions and would begin an audit immediately. During an interview on 09/17/2024 at 2:20 p.m., the Administrator said the purpose of a care plan was to let staff know how to take care of a resident. The Administrator said not revising a care plan timely could result in confusion in care of resident regarding if an intervention was still needed. The Administrator said nursing, MDS, and social services are responsible for updating and ensuring the care plan is accurate. Review of facility-provided Comprehensive Care Planning policy undated, reads in part Each resident will have a person-centered comprehensive care plan developed and implemented to meet his/her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented.

Based on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #3) of 4 residents reviewed for gastrostomy tube management quality of care. -The facility failed to ensure Residents #3 was provided with the correct feeding through gastrostomy tube (g-tube, feeding tube) as ordered per physician. This failure could place residents who received feedings by gastrostomy tube at risk for decline in health and weight loss. Findings included: Review of Resident #3's Admission Record dated 09/13/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3's diagnoses included cerebral infarction (lack of oxygen to the brain causing damage to brain tissue), unspecified protein-calorie malnutrition, dysphagia (swallowing difficulties), and gastrostomy status (a feeding tube that delivers nutrition to your stomach). Review of Resident #3's quarterly MDS assessment dated [DATE], revealed a BIMS score of 00 indicating severe cognitive impairment. Section GG - Functional Abilities and Goals revealed Resident #3 is dependent on staff for toileting, showering, dressing, and personal hygiene. Section K - Swallowing/Nutritional Status revealed Resident #3's nutritional approach was feeding tube. Review of Resident #3's Order Summary dated 09/17/2024, revealed enteral feed order in the morning start continuous enteral feeding. Start at 0600 and run until midnight. Hold feeding from 0000 (12:00 a.m.) to 0600 (6:00 a.m.). Review of Resident #3's care plan dated 09/17/2024, revealed Resident #3 required tube feeding related to dysphagia. Part of the interventions included resident was dependent with tube feeding and water flushes; see MD orders for current feeding orders. Observation on 09/16/2024 at 1:45p.m., revealed Resident #3 was lying in bed asleep with head of bed elevated. There was tubing with Jevity 1.2 (liquid nutritional supplement that can be used for tube feeding or oral consumption) connected to a feeding pump on a pole next to Resident #3's bed. Continuous feed pump was turned off. Observation and interview on 09/16/2024 at 2:46 p.m., revealed Resident #3 was lying in bed asleep with head of bed elevated. There was tubing with Jevity 1.2 connected to a feeding pump on a pole next to Resident #3's bed. Continuous feed pump was turned off. LVN I entered the room and noted the feed machine was off. LVN I said Resident #3 was on continuous enteral feeding during the day and did not know why the machine was turned off. LVN I said the CNAs had provided patient care to Resident #3 over an hour ago and may have turned off the machine. LVN I said no one told her the machine was turned off. LVN I began to assess the resident. LVN I said Resident #3 was not in any distress. LVN I said Resident #3 had not had any significant weight loss. LVN I said Resident #3's vitals were at baseline for the resident. Review of Resident #3's weight records revealed initial weight taken on 06/21/2024 was 130.0 lbs. The latest weight taken on 09/10/2024 was 129.6. During an interview on 09/17/2024 at 1:20 p.m., the DON said the purpose of enteral feeding was to give someone nutrients and calories that are required as they can no longer eat for themselves. The DON said the risk of failing to follow the orders and the feeding machine being turned off, if it were a recurring thing, would be a loss of weight, and malnutrition. The DON said an isolated incident would not necessarily have the same risk but needs to be addressed with staff to ensure it does not become a recurring issue. The DON said nursing staff are responsible to ensure that orders are being followed for residents. During an interview on 09/17/2024 at 2:20 p.m., the Administrator said the purpose of enteral feeding was to provide nutrition to the resident. The Administrator said failure to follow orders for continuous feeding could result in the resident not receiving the required nutrition and caloric intake. The Administrator said nursing staff are responsible for following orders and resident care plan. Record review of facility policy titled Enteral Nutrition dated 02/13/2007, reflected in part the facility will provide nutritionally complete enteral or parenteral feedings as ordered by the physician for the nourishment of residents who are unable to eat by mouth. The Nursing Services Department is responsible for all feeding equipment and the administration of tube feedings. Problems with the administration of the tube feeding are monitored and corrected by nursing.

Based on observation, interviews and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Residents #1) of 8 residents reviewed for call light placement. -The facility failed to ensure that Residents #1's call light was within his reach. This failure placed residents at risk of not being able to call for assistance when needed. Findings included: Review of Resident #1's Admission Record dated 09/13/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included cerebral palsy (congenital disorder of movement, muscle tone, or posture), depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), muscle weakness, lack of coordination, intellectual disability (deficits in theoretical thinking/learning), seizures (uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain), and paraplegia (paralysis that affects your legs, but not your arms). Review of Resident #1's quarterly MDS assessment dated [DATE], revealed a BIMS score of 12 indicating moderate cognitive impairment. Section GG - Functional Abilities and Goals section revealed Resident #1 requires substantial/maximal assistance with toileting, showering, dressing, personal hygiene, and dependent for transfers. Section J - Health Conditions indicates Resident #1 had not had any falls since admission/entry or reentry or the prior assessment. Review of Resident #1's care plan dated 09/13/2024, reads in part Resident #1 had a communication problem related to Intellectual Disabilities as evidenced by slurred and mumbled speech. Part of the interventions included Ensure/provide a safe environment: Call light in reach. Another focus area reads in part that Resident #1 was risk for falls related to gait/balance problems. Part of the interventions included Be sure the resident's call light is within reach and encourage the resident to use it. Another focus area reads in part that Resident #1 had impaired visual function and was at risk for falls, injury, and a decline in functional ability. Part of the interventions included Anticipate needs and meet them as able. Keep call light in reach when in room or bathroom. During an observation and interview on 09/13/2024 at 10:52 a.m., Resident #1 was lying in bed. Resident #1's call button was observed on top of a bed side dresser located next to a second unoccupied bed in the room, approximately four feet away from Resident #1. Resident #1 said he was not able to get up from bed on his own. Resident #1 said he was not able to reach the call button. Resident #1 said he did not know why his call button was out of reach. Resident #1 said he did not know how long the button was out of his reach. Resident #1 said he had not had any falls. During an observation and interview on 09/13/2024 at 11:00 a.m., LVN G entered Resident #1's room and said Resident #1 was able to use a call button when needing something. LVN G observed Resident #1's call button was out of his reach. LVN G said Resident #1's call button was out of reach, and he would not be able to get up to get his call button since he was not able to get up from bed on his own. LVN G said Resident #1 was a fall risk and had not had any recent falls that she was aware of. LVN G said she did not know how long Resident #1's call button had been out of reach. LVN G said Resident #1 had received patient care 15 to 20 minutes before and most likely the CNAs failed to return his button within reach of Resident #1. During an interview on 09/17/2024 at 1:20 p.m., the DON said the purpose of a call light was to alert nursing staff and CNAs that resident assistance was needed. The DON said Resident #1 was able to use a call button to call for assistance. The DON said Resident #1 had limited mobility. The DON said the risk of having the call button out of reach was a possible delay in emergency assistance for the resident, or resident's needs being met. The DON said it was the responsibility of all staff in the hall to ensure that the resident's call button always remains in reach when he was in bed. Surveyor requested a copy of the call light policy. During an interview on 09/17/2024 at 2:20 p.m., the Administrator said the purpose of a call light was for residents to ask for help and to get staff's attention. The Administrator said there was a risk that residents would not be able to call for help if the call button was not in reach of the resident. The Administrator said Resident #1 was able to use a call button and the button must be always within his reach. Surveyor requested a copy of the call light policy. Review of an undated facility provided Resident Rights policy, reads in part the resident had a right to receive the services and/or items included in the plan of care. On 09/17/2024 at 3:30 p.m., the requested copy of call light policy was not provided prior to exit.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 7 residents reviewed for care plans. -The facility failed to follow the comprehensive person-centered care plan for Resident #1's fall risk, by failing to have a fall mat in place next to bed while resident was lying down in bed. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services as indicated in their comprehensive person-centered plans developed to address their needs. Findings include: Review of Resident #1's Admission Record dated 09/13/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included cerebral palsy (congenital disorder of movement, muscle tone, or posture), depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), muscle weakness, lack of coordination, intellectual disability (deficits in theoretical thinking/learning), seizures (uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain), and paraplegia (paralysis that affects your legs, but not your arms). Review of Resident #1's quarterly MDS assessment dated [DATE], revealed a BIMS score of 12 indicating moderate cognitive impairment. Section GG - Functional Abilities and Goals section revealed Resident #1 was dependent for transfers. Section J - Health Conditions indicates Resident #1 had not had any falls since admission/entry or reentry or the prior assessment. Review of Resident #1's Order Summary Report dated 09/13/2024, revealed an order for a Fall mat while in bed two times a day for prevention of injury. Review of Resident #1's care plan dated 09/13/2024, reads in part, focus area with initiated date of 08/09/2024, Resident #1 had the potential for falls related to impaired mobility, such as cerebral palsy, paraplegia, seizures and intellectual disabilities. Part of the interventions included fall mat while in bed. During an observation and interview on 09/13/2024 at 10:52 a.m., Resident #1 was lying in bed. Fall mat noted leaning against a dresser located approximately six feet away from Resident #1's bed. Resident #1 said he did not know why the fall mat was away from the side of the bed. Resident #1 said he did not know who put the mat leaning up against the dresser. Resident #1 said he did not know how long the mat was leaning up against the dresser and not on the side of his bed. Resident #1 said he had not had any falls that he was aware of. During an observation and interview on 09/13/2024 at 11:00 a.m., LVN G entered Resident #1's room and said Resident #1 was a fall risk and should have a fall mat next to the bed when he was in bed. LVN G observed fall mat leaning up against the dresser approximately six feet away from Resident #1's bed. LVN G said it had been months since Resident #1 had a fall from her recollection. LVN G placed the fall mat next to Resident #1's bedside (other side of the bed was against the wall). LVN G said she did not know how long Resident #1's fall mat was not next to his bed. LVN G said Resident #1 had received patient care by CNAs about 15 to 20 minutes before and most likely the CNAs failed to return the fall mat next to Resident #1's bed. During an interview on 09/17/2024 at 1:20 p.m., the DON said the purpose of a care plan was to individualize a plan of care to address resident needs, behaviors, psychosocial needs, and other things like falls and other risks. The DON said the purpose of a fall mat was to reduce injuries. The DON said Resident #1 was a fall risk and failing to follow his plan regarding having a fall mat increased the risk of injury and/or severity of injury. The DON said it was all floor staff responsibility to follow the care plan and ensure interventions are implemented. During an interview on 09/17/2024 at 2:20 p.m., the Administrator said the purpose of a care plan was to let staff know how to take care of a resident. The Administrator said the purpose of a fall mat was to be used as a protective barrier to prevent injury. The Administrator said failure to follow the care plan for Resident #1, who was a fall risk, could place him at a higher risk of injury. The Administrator said staff on the floor have access to the resident care plans and are responsible for following the care plan. Review of facility-provided Comprehensive Care Planning policy undated, reads in part Each resident will have a person-centered comprehensive care plan developed and implemented to meet his/her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented.

Based on observation, interview and record review, the facility failed to maintain a safe, sanitary and comfortable environment for 2 (Resident #2 and Resident #5) of 4 residents and 1 (room [ROOM NUMBER]B) of 3 rooms reviewed for environment. The facility failed to ensure Resident #2's blue face of the feeding pump machine had white unknown substance. The top of the feeding pump machine was dirty with a brown-ish substance. Resident #5's feeding pump machine was greasy and dirty. The pole the feeding bag was hung from, and the feeding pump machine was hooked up too had brown-ish substances all around the pole and the black power cord. The Face of the feeding pump machine also on the left side had a reddish substance. The right side of the feeding pump machine had some black smeared substance. Underneath the feeding pump machine was a brown-ish substance. The facility failed to ensure the feeding pump machine in room [ROOM NUMBER]B was not covered with an unknown brown-ish substance. This deficient practice could place residents at risk for infection due to improper care practices. Findings Included: Resident #2 Record review of Resident #2's face sheet dated 08/05/24, revealed, admission on 06/07/24 to the facility. Resident #2 was a [AGE] year-old female diagnosed with gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), dysphagia (difficulty swallowing), and Oropharyngeal phase (consists of the structures in the back of the throat, including the base of the tongue, palatine tonsils, posterior pharyngeal wall and soft palate). Record review of Resident #2's admission MDS assessment dated [DATE], revealed, there was no BIMS was conducted to evaluate the cognitive status of resident #2. Resident #2 was diagnosed with Malnutrition and oropharyngeal. Resident #2 was marked for feeding tube. Record review of Resident #2's order recap dated 06/10/24, revealed, Enteral feeding order in the morning start continuous enteral feeding. Formula: Jevity (a 1.1 kcal/ml tube feed with fibre, for people with, or at risk of developing, disease-related malnutrition) 1.2, Rate: 55. Start at 06:00 AM and run until midnight. Record review of Resident #2's care plan dated 06/10/24, revealed she required tube feeding due to dysphagia. The resident was dependent with tube feeding and water flushes. An observation on 08/01/24 at 9:43 AM, revealed, there was a feeding pump machine that was connected to Resident #2 in her room. The blue face of the feeding pump machine had white unknown substance. The top of the feeding pump machine was dirty with a brown-ish substance. Resident #5 Record review of Resident #5's face sheet dated 08/05/24, revealed, admission on 07/03/23 and re-admission on 07/05/24 to the facility. Record review of Resident #5's facility history and physical dated 03/28/24, revealed, a [AGE] year-old male diagnosed with Gastrostomy status and gastro-esophageal reflux disease without esophagitis (a type of GERD that does not involve inflammation of the esophagus). Record review of Resident #5's quarterly MDS dated [DATE], revealed, there was no BIMS score taken to evaluate the cognitive status of resident #5. Resident #5 was diagnosed with malnutrition, gastrostomy, muscle wasting, and muscle weakness. Marked for feeding tube. During an observation on 08/05/24 at 10:19 AM, Resident #5 was in bed with a continuous feeding pump machine on. The face of the feeding pump machine was greasy and dirty. The pole the feeding bag was hung from, and the feeding pump machine was hooked up too had brown-ish substances all around the pole and the black power cord. The Face of the feeding pump machine also on the left side had a reddish substance. The right side of the feeding pump machine had some black smeared substance. Underneath the feeding pump machine was a brown-ish substance. room [ROOM NUMBER]B During an observation on 08/05/24 at 10:29 AM, it was observed the feeding pump machine on the side had brown-ish substance where the tubing was hooked up to the roller on the machine. Underneath the feeding pump machine there was brown-ish substance. During an observation and interview on 08/05/24 at 3:29 PM, the DON stated nursing staff were responsible for cleaning the feeding pump machine and the surrounding area. The DON stated the feeding pumps machines were to be cleaned when they got dirty and as needed. The DON observed Resident #2 and Resident #5's feeding pump machine and stated that they were dirty and had a brown substance. The DON stated she hoped the red mark/stain on Resident #5's feeding pump machine was juice and nothing else. The DON stated there was no log or monitoring tool to ensure that the feeding pump machines were being cleaned. The DON stated the risk of not cleaning the feeding pumps machine and surrounding area could be infection. During an interview on 08/05/24 at 4:09 PM, LVN C stated the nurses were responsible for cleaning the feeding pump machine and cords/pole if it got dirty with formula. LVN C stated the feeding pump machines should be cleaned daily. LVN C stated she did have residents that were on a feeding pump machine but when she came into work that day, she did not check the feeding pump machines to see if they were clean or dirty. LVN C stated the risk of not cleaning could be infection. Record review of the facility Feeding Pump Manual dated 03/2020, revealed, Section VII-Cleaning: cleaning should be performed as needed. It may also be desirable to define cleaning intervals based on knowledge of the environment in which the pump was used. Only trained in the cleaning of medical devices should perform cleaning .Cleaning Frequency - It was recommended that the pump be cleaned after each feeding set use for a minimum duration of 30 seconds, to prevent bacterial contamination of the pump. Record review of the facility Infection Control Plan: Overview policy dated 03/2023, revealed, Infection Control -The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection.

Based on observation, interview, and record review, the facility failed to provide foot care and treatment, or assist the resident in making appointments with a qualified person for 2 (Resident #3 and Resident #6) of 5 residents reviewed for quality of life. The facility failed to ensure Resident #3 and Resident #6's toenails were trimmed and cleaned, or podiatry appointments scheduled. This failure could place residents at risk of infection or mobility issues. Findings include: Resident #3 Record review of Resident #3's face sheet dated 08/05/24, revealed, admission on 06/07/24 to the facility. Record review of Resident #3's outside facility history and physical dated 05/31/24, revealed, an [AGE] year-old male diagnosed with muscle wasting, lack of coordination, Type 2 Diabetes Mellitus, and anxiety. Record review of Resident #3's quarterly MDS assessment dated [DATE], revealed severely impaired cognition to be able to recall and make daily decisions as evidence by a BIMS score of 4. ADLs for personal hygiene were substantial/maximal assistance (nursing staff do more than 50% of the help). Resident #3 was diagnosed with Diabetes Mellitus, Non-Alzheimer's Dementia, muscle weakness, muscle wasting, lack of coordination. Record review of Resident #3's care plan dated 08/18/22, revealed, he had impaired cognition and was at risk of further decline. Resident needs supervision/assistance with all decision making. Diabetes care plan dated 12/29/22, revealed, inspect feet during bathing and as needed for open areas, sores, pressure areas, blisters, edema, or redness and report it to the nurse. ADLs care planned dated 04/15/24, revealed, personal hygiene care: the resident requires extensive assistance by one staff assistance. Record review of Resident #3's order recap dated 11/07/23, revealed, Podiatrist consult. Resident #6 Record review of Resident #6's face sheet dated 08/05/24, revealed, admission on 10/19/21 and re-admission on 02/29/24 to the facility. Record review of Resident #6's facility history and physical dated 05/29/24, revealed, an [AGE] year-old female diagnosed with muscle wasting, muscle weakness, lack of coordination, pain in the joints, and Type 2 Diabetes Mellitus. Record review of Resident #6's annual MDS dated [DATE], revealed moderately impaired cognition to be able recall or make daily decisions as evidenced by a BIMS score of 9. ADLs for personal hygiene were supervision or touching assistance from staff. Resident #6 was diagnosed with Diabetes Mellitus, muscle weakness, muscle wasting, and lack of coordination. Record review of Resident #6's care plan dated 01/24/22, revealed she required x1 staff for personal hygiene. Diabetes care plan dated 01/24/22, revealed, weekly skin checks to monitor skin for redness, circulatory problems, infection, and breakdown. Notify physician of any new skin conditions. Record review of Resident #6's order recap dated 11/07/23 and end date of order 02/27/24 revealed she may have podiatry care for thick toenails PRN. There were no new orders present. During an interview on 08/05/24 at 11:00 AM with the Resident Council group meeting members revealed they were not receiving nail care. The Resident Council group meeting members stated they had not seen the podiatrist since the facility had changed ownership back in 02/23/24. The Resident Council group meeting members stated they thought they were supposed to see the podiatry every 30 days. The Resident Council group meeting members stated before the ownership change, they were given a consent form to fill out and then taken by the previous Transporter to the podiatrist. During an interview on 08/05/24 at 1:07 PM, Resident #1 stated he had his fingernails cut but not his toenails. Resident #1 stated it had been a long time since he had his toenails cut. During an observation and interview on 08/05/24 at 1:20 PM, Resident #6 stated it had been a long time since her nails have been cut. Resident #6 stated it had been more than 4 months since they were cut. Resident #6 stated the podiatrist would cut her toenails. During an interview on 08/05/24 at 1:25 PM, CNA I stated that nail care was done by the CNAs and only the fingernails. CNA I stated toenails were cut by the doctor. CNA I stated it had been more then 2-3 months since the doctor has come to cut resident toenails. CNA I stated that residents had complained to her that their feet hurt because they had not had their toenails cut. CNA I stated the resident was no longer at the facility. CNA I stated she told the nurse and was told that they were going to make an appointment to the doctor. CNA I stated that days later, the resident still complained about it. During an interview on 08/05/24 at 1:36 PM, CNA I stated toenails are done by a doctor who went to the facility. CNA I stated it had been a long time since the doctor had went to the facility. During an observation and interview on 08/05/24 at 1:38 PM, Resident #3 stated he could not remember the last time his toenails were cut. Resident #3 stated he did want his nails cut and had not refused to have them cut. During an interview 08/05/24 at 1:42 PM, LVN G stated residents' toenails were done by the podiatrist. During an observation and interview on 08/05/24 at 2:13 PM, with Resident #3 and LVN G. Resident #3 was in his room and LVN G took off Resident #3's right sock. Resident #3's toenails were yellow, jagged, thick, and broken. LVN G had asked Resident #3 if his toes hurt and Resident #3 shook his head up and down and stated, Si duele (English translation - Yes, it hurts). LVN G was touching Resident #3 toe and toenails and asking him where it hurt. Resident #3 did not answer. LVN G stated he could not recall the last time podiatry had gone to the facility. LVN G stated residents nor his staff had told him that residents were complaining because they want their nails cut. During an interview on 08/05/24 at 2:00 PM, with ADON A and ADON B. ADON A stated CNAs do not provide toenail care for diabetics. ADON A stated the nursing staff set up the residents' appointments to see the podiatrist. ADON A stated the last time podiatry had gone to the facility was back in February 2024. ADON B stated it was very rare that they would get referrals for residents to see podiatry. ADON B stated the CNAs and nurses need to be checking the residents' toenails to see that they don't have ingrown toenails or anything wrong. ADON B stated, before, the Transporter would schedule the appointments and take the residents to see the podiatrist. ADON B stated the risk of not providing nail care could be infection or ingrown. During an interview on 08/05/24 at 3:29 PM, the DON stated diabetic residents are to be seen by the Podiatrist. The DON stated Podiatry had come to the facility as she saw it on a group text from the facility. The DON stated after searching for the text message that she was wrong that Podiatry had not come to the facility. The DON stated an unknown resident (Could not remember the residents name) had asked her if she could cut her nails. The DON stated the ADONs (ADON A & ADON B) and herself had put out an in-service regarding fingernail and toenail care to the nursing staff about nail care for the residents. The DON stated she started working at the facility on 07/15/24 and did not know who was responsible for podiatry and residents seeing podiatry. The DON stated the negative outcome of not doing nail care for the residents could result in infection, and the resident(s) could scratch themselves or someone else. During an interview on 08/05/24 at 4:09 PM, LVN C stated the Podiatrist was going to start going to the facility to cut the residents toenails. LVN C stated there had been residents that complained about toenail care and the facility nurses had tried to set up appointments to go see the podiatrist. LVN C stated the previous Transporter was being given the referrals from the nurses and then she would make the appointment for the residents to go see podiatry but the transporter no longer works at the facility since last week (08/02/24). LVN C stated she made all the appointments for residents herself. LVN C stated she had not made any podiatry appointments lately. LVN C stated she had not checked the residents' toenails lately. LVN C stated the risk would be ingrown toenails and infection. Record review of the facility Nail Care manual dated 2003, revealed, Nail management was the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails .It includes cleansing, trimming, smoothing .Nail care especially trimming was performed by podiatrist in those with diabetes and peripheral vascular disease.

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 (Resident #3 and Resident #6) of 5 residents reviewed for quality of life. The facility failed to ensure Resident #3 and Resident #6's fingernails were trimmed and cleaned. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk of infection, and decreased quality of life. Findings include: Resident #3 Record review of Resident #3's face sheet dated 08/05/24, revealed, admission on 06/07/24 to the facility. Record review of Resident #3's outside facility history and physical dated 05/31/24, revealed, an [AGE] year-old male diagnosed with muscle wasting, lack of coordination, Type 2 Diabetes Mellitus, and anxiety. Record review of Resident #3's quarterly MDS assessment dated [DATE], revealed severely impaired cognition to be able to recall and make daily decisions as evidence by a BIMS score of 4. ADLs for personal hygiene were substantial/maximal assistance (nursing staff do more than 50% of the help). Resident #3 was diagnosed with Diabetes Mellitus, Non-Alzheimer's Dementia, muscle weakness, muscle wasting, lack of coordination. Record review of Resident #3's care plan dated 08/18/22, revealed, he had impaired cognition and was at risk of further decline. Resident needs supervision/assistance with all decision making. Diabetes care plan dated 12/29/22, revealed, inspect feet during bathing and as needed for open areas, sores, pressure areas, blisters, edema, or redness and report it to the nurse. ADLs care planned dated 04/15/24, revealed, personal hygiene care: the resident requires extensive assistance by one staff assistance. Resident #6 Record review of Resident #6's face sheet dated 08/05/24, revealed, admission on 10/19/21 and re-admission on 02/29/24 to the facility. Record review of Resident #6's facility history and physical dated 05/29/24, revealed, an [AGE] year-old female diagnosed with muscle wasting, muscle weakness, lack of coordination, pain in the joints, and Type 2 Diabetes Mellitus. Record review of Resident #6's annual MDS dated [DATE], revealed moderately impaired cognition to be able recall or make daily decisions as evidenced by a BIMS score of 9. ADLs for personal hygiene were supervision or touching assistance from staff. Resident #6 was diagnosed with Diabetes Mellitus, muscle weakness, muscle wasting, and lack of coordination. Record review of Resident #6's care plan dated 01/24/22, revealed she required x1 staff for personal hygiene. Diabetes care plan dated 01/24/22, revealed, weekly skin checks to monitor skin for redness, circulatory problems, infection, and breakdown. Notify physician of any new skin conditions. During an interview on 08/05/24 at 11:00 AM with the Resident Council group meeting members revealed they were not receiving nail care. During an observation and interview on 08/05/24 at 1:20 PM, Resident #6 stated it had been a long time since her nails have been cut. Resident #6 fingernails were long and dirty with a dark substance underneath the fingernails. Resident #6 stated it had been more than 4 months since they were cut. During an interview on 08/05/24 at 1:25 PM, CNA I stated that nail care was done by the CNAs and only the fingernails. CNA I stated they cut or trimmed resident nails on Sunday and as needed. During an interview on 08/05/24 at 1:36 PM, CNA J stated residents had not complained about nail care. CNA I stated CNAs cut and trimmed fingernails. During an observation and interview on 08/05/24 at 1:38 PM, Resident #3 stated he could not remember the last time his fingernails or toenails were cut. Resident #5 had long fingernails that were dirty and underneath had a dark black substance. Resident #3 stated he did want his nails cut and had not refused to have them cut. LVN J took Resident #3 into the dining room and began cutting Resident #3's fingernails and washed them in the sink. During an interview on 08/05/24 at 2:00 PM, with ADON A and ADON B. ADON A stated CNAs provided fingernail care such as filing. ADON B stated the nurse could file or cut the fingernails. ADON B stated the CNAs and nurses need to be checking the residents' fingernails to see that they don't have ingrown fingernails or anything wrong. ADON B stated the risk of not providing nail care could be infection or ingrown. During an interview on 08/05/24 at 3:29 PM, the DON stated nail care was done by the CNAs and nurses. The DON stated CNAs cleaned the fingernails, file them but cannot cut them. The DON stated nursing staff cut resident nails as well except if the resident was a diabetic. The DON stated an unknown resident (Could not remember the residents name) had asked her if she could cut her nails. The DON stated the ADONs (ADON A & ADON B) and herself had put out an in-service regarding fingernail care to the nursing staff about nail care for the residents. The DON stated she started working at the facility on 07/15/24 . The DON stated the negative outcome of not doing nail care for the residents could result in infection, and the resident(s) could scratch themselves or someone else. The DON stated there was no way for the CNAs to document that they had conducted nail care but would be adding a widget in the facility system to mark they had done it During an interview on 08/05/24 at 4:09 PM, LVN C stated she tried to cut the resident fingernails when they needed nail care. LVN C stated there had been residents that complained about fingernail care LVN C stated she had not checked the residents' fingernails lately. LVN C stated the risk would be ingrown fingernails/toenails and infection. Record review of the facility Nail Care manual dated 2003, revealed, Nail management was the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails .It includes cleansing, trimming, smoothing .Nail care especially trimming was performed by podiatrist in those with diabetes and peripheral vascular disease.

Based on interviews and record reviews, the facility failed to ensure that the assessment accurately reflected the resident's status for 1 (Resident #7) of 5 resident reviewed for accuracy of MDS assessment, in that: The facility failed to ensure Resident #7's quarterly MDS accurately reflected the residents' history of falls. This deficient practice could affect residents at the facility who had been assessed for risk of falls and could contribute to inadequate care. Findings included: Record review of Resident #7's face sheet dated 08/01/24, revealed, admission on 02/22/24 and re-admission on 07/31/24 to the facility. Record review of Resident #7's facility history and physical dated 05/29/24, revealed, an [AGE] year-old male diagnosed with Alzheimer's Disease, difficulty in walking, muscle wasting, muscle weakness, Dementia, lack of coordination, unspecified fall. Record review of Resident #7's quarterly MDS dated [DATE], revealed severely impaired cognition to be able to recall or make daily decision with a BIMS score of 6. Resident #7's ADLs were independence with sit to stand, transfers, and walking. Resident #7 was not marked for any mobility devices. Resident #7 was diagnosed with unspecified fall, difficult in walking, muscle wasting, muscle weakness (no muscle strength), lack of coordination, and Alzheimer's Dementia. Resident #7 was marked for fall history as having no falls since admission or re-entry to the facility. Record review of Resident #7's Care Plan dated 02/28/24, revealed he had the potential for falls related to impaired mobility and history of falls. Interventions: Fall Risk Screening upon admission and quarterly to identify risk factors. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Record review of Resident #7's Event Notes dated 06/23/24 and 06/25/24, revealed Resident #7 had a fall. On 06/23/24, Resident #7 fell on his rear and back hit the wall while trying to sit on a black round stool in the dining area. On 06/25/24, Resident #7 had an unwitnessed fall in his room and was found with his back against the closet door. During an interview on 08/01/24 at 11:17 AM, Family Member D stated Resident #7 had a history of falls. During an interview on 08/01/24 at 11:53 AM, Family Member E stated Resident #7 was having falls every week at the facility. During an interview on 08/05/24 at 10:37 AM, the Physician stated Resident #7 had a history of falls. The Physician stated Resident #7 had no safety awareness. The Physician stated Resident #7's fall history should put in the MDS to alert nursing staff that Resident #7 was a fall risk. The Physician stated the risk of not putting in the MDS would be not alerting nursing staff regarding resident's special care needs. During an interview on 08/05/24 at 11:35 AM, the MDS Coordinator stated the MDS department created the MDSs and were responsible for the MDSs. The MDS Coordinator stated Resident #7 had a history of falls. The MDS Coordinator stated the quarterly MDS dated [DATE], should have been marked indicating Resident #7 had a history of falls after admission or recently. The MDS Coordinator stated it would be important to have the MDS accurately marked because the information from the MDS was taken and put into the care plan and for interventions. The MDS Coordinator stated not marking the MDS accurately would have a negative outcome on the resident. During an interview on 08/05/24 at 3:29 PM, the DON stated Resident #7 had a history of falls. The DON stated the DON would oversee MDS. The DON stated she did not know the process of an MDS. Record review of the facility Resident Assessment Manual dated 2003, revealed, The facility will examine each resident and review the minimum date set expanded core elements specified in the RAI no less than once every three months and as appropriate. Results must be recorded to assure continued accuracy of the assessment. The results of the assessment are used to develop, review, and revise the resident's comprehensive care plan of care.

Based on interview, and record review, the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 of 5 (Resident #1) reviewed for quality of care. The facility failed to notify the physician and establish vital signs when [AGE] year-old female Resident #1, with a history of dementia, had multiple episodes of emesis. The facility failed to report to the NP or MD [DATE] when Resident #1 had a total of six episodes of emesis, beginning at approximately 10 a.m. The day shift CNA stated she informed the day RN after the second episode. The CNAs notified the facility nurses again at the change of shift, 2:20 pm, after 4 episodes. The facility failed to notify the NP until 5:00 pm-5:30 pm after the fifth episode and was not informed of Resident #1 being described as pale and shaking. NP stated if the nurses would have taken vitals for Resident #1 it would have established the baseline for her. The facility failed to assess or document vital signs until 6:40 p.m., when the Resident #1's vitals were BP ,d+[DATE], pulse 101, respiration 24 when the resident was looking pale, and cool to touch, and had purplish lips. The NP was not notified of additional episodes of emesis after the medication had been ordered and administered. The facility failed to contact the NP and instead contacted family for the decision to transport Resident #1 to the hospital. Resident #1 expired at the hospital. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of actual harm and a severity level of isolated because the facility failed to have a system in place to ensure residents are monitored and assessed for changes in condition and are immediately reported to the attending physician. This failure could affect residents by placing them at risk of delay medical treatment, hospitalization , decline in condition, and death. Findings included: Closed record Review revealed Resident #1's face sheet dated [DATE] listed initial admission on [DATE] and readmission on [DATE]. Record Review Resident #1's history and physical dated [DATE] revealed a [AGE] year-old female. Past medical history multiple sclerosis, neurogenic bladder with chronic urinary tract infections due to intermittent catheterization. Record Review Resident #1's quarterly MDS dated [DATE] revealed resident rarely made self-understood and rarely understands others; short-term, long term memory problems; Active Diagnoses-Renal Insufficiency, Renal Failure, or End-Stage Renal Disease, Neurogenic Bladder, Non-Alzheimer's Dementia, Multiple Sclerosis. Record Review Resident #1's Care Plan revised [DATE] revealed resident had neurogenic bladder and at times required catheterization. Monitor and report to Medical Doctor signs & symptoms of UTI. Record review of the Emergency Medical Services report dated [DATE] documented unit was dispatched at 6:36 PM and arrived at 6:47 PM. At resident 6:48 PM. Call Type: Sick Person. Urgency: Immediate. Patient Condition: Hypotension (low blood pressure). Primary Symptom-Hypovolemic (a condition that occurs you're your body loses fluid). Patient Care Narrative: Assessment Exam: Skin: Cyanotic (bluish color due to inadequately oxygenated blood), Mental Status: Unresponsive. Eyes: Non-reactive (A pupil which remains excessively dilated in the presence of light). Patient Care Narrative: According to staff patient was last seen 5 minutes prior to EMS arrival. Upon arrival patient agonal (related to or associated with the act of dying, gasping for air) with cyanotic (bluish or purplish discoloration) presumed patient had aspirated on vomit. EMS assisted ventilations and transferred patient to stretcher where manual Cardiopulmonary Resuscitation was initiated. EMS wheeled patient to rescue. Once in rescue auto pulse pads were placed and patient was showing Asystole (when your heart's electrical system fails, causing your heart to stop pumping). On the monitor, had copious amount of fluid coming from mouth. Patient was being suctioned and given CPR and ventilations throughout transport. Review of hospital emergency room record dated [DATE] 6:59 PM, revealed [AGE] year-old female brought to emergency department in cardiac arrest. Reportedly was at the nursing facility having aspiration. When EMS arrived around 6:49 PM, she was found to be with agonal respiration (when someone who is not getting enough oxygen is gasping for air) and vomiting. No pulse was noted, and CPR started at this time. Patient was intubated by EMS in field, difficulty with bagging, copious vomitus, abdominal distention. ETT (Endotracheal Tube - tube used to provide oxygen and inhaled gases to the lungs) was suspected to be in the stomach and was replaced in the emergency department. Patient continued to receive CPR in the emergency room . Ultrasound was used to identify cardiac activity, but there were no signs of life until Resident #1 was then pronounced dead at 7:10 PM. Record review of the office of medical examiner investigation dated [DATE] at 7:27 PM revealed the decedent was a [AGE] year-old white female who was viewed with episodes of emesis and hypotensive by staff while at the facility on [DATE]. 911 was phoned and Emergency Medical Services responded and transported the decent to the local hospital with cardiopulmonary resuscitation in progress. The decedent arrived to the Emergency Department on [DATE] at approximately 6:59 PM. CPR was continued; however, the decedent was viewed asystolic and was pronounced on [DATE] at 7:10 PM by physician. The following information was provided on [DATE] approximately 6:30 PM facility staff phoned Representative Party and advised Representative Party, that the decedent had emesis episodes x 6 and had sugar of 340. The facility advised decedent's physician who ordered an abdominal x-ray; however, they wanted to know if Representative Party wanted the decedent to be transported to the hospital. Representative Party advised the facility she did want the decedent to be transported to the hospital. Telephone interview on [DATE] at 11:00 AM with Resident #1's family member stated (RN I) called her on [DATE] at 6:30 PM to report Resident #1 had been vomiting all day and doctor had ordered an x-ray of the stomach and medication for nausea/vomiting. The family member stated, I told RN I to send Resident #1 to the hospital. When I called the nurse back, RN I reported that EMS had started CPR, when they got to the facility. The family member reported she had not been notified when Resident #1 started to vomit in the morning. The family member stated, If nurses had called to report to me when Resident #1 had the first emesis, I would have gone to check her and asked them to send her to the hospital. Interview on [DATE] at 1:04 PM with RN I revealed she worked [DATE] and was getting report from RN J at the change of shift at approximately 2:00 PM, when CNA K came to the nurse's station to report Resident #1 had vomited. RN I stated they continued with report and then proceeded to count narcotics. RN I stated she assessed Resident #1 at approximately 3:00 PM-3:30 PM on that day, Resident #1 was sitting in a wheelchair in the dining room, looked pale and complained of nausea. RN I stated that at approximately 5:00 PM MA L reported to her Resident #1 had vomited. RN I stated she checked the resident's physician's orders and there was not a standing order for to treat nausea/vomiting so she called the NP to report resident had vomited x 2 on her shift and was nauseated. NP gave orders for a KUB (KUB is an x-ray performed to assess the abdominal area for causes of abdominal pain, or to assess the organs and structures of the urinary and/or gastrointestinal system) and Promethazine IM (intramuscular) TID (three times a day) as needed for nausea/vomiting. RN I reported she administered Promethazine IM as ordered to Resident #1 at approximately 5:35 PM. RN I stated CNA K reported to her at approximately 6:40 PM, that Resident #1 had vomited after Promethazine was administered and did not look well. RN I stated she immediately went to the room to assess Resident #1. Resident #1 was lying in bed, blood pressure was low, she looked pale, was sweating and was having difficulty breathing. RN I stated at around 6:40PM-6:45PM she notified Resident #1's family member at which time family member requested resident be sent to ER. RN I stated she had not notified the NP, Resident #1 continued to vomit after the Promethazine was administered, because they had standing order to treat nausea/vomiting. RN I stated she had not notified the NP that Resident #1 was going to be sent out to the hospital emergency room for evaluation per family member's request. RN I stated, they had been trained to immediately notify attending physician and resident's responsible party of changes in condition, notify physician if resident's condition does not improve after PRN (as needed) medications has been administered and get a Physician's Order to send the resident to the hospital for evaluation per family's request. Telephone Interview on [DATE] at 2:42 PM RN J stated she worked on [DATE] and was assigned to Resident #1 during the morning shift, and resident did not have a change in condition during her shift. RN J denied CNA K had reported to her Resident #1 had vomited x 2 in the morning after breakfast. RN J stated, I was giving report to RN I at the change of shift at 2:00 PM, when CNA K came to the nurse's station to report Resident #1 had vomited. RN J stated she did not assess Resident #1 because her shift was over and continued to give report to RN I who was the on-coming nurse on the evening nurse and assigned to Resident #1. RN J stated that after report they proceeded to counted narcotics. RN J stated nurses have been trained to immediately assess and notify physician and/or nurse practitioner, responsible party when resident has a change in condition. Telephone interview on [DATE] at 1:47 PM with RN I stated she did not notify the physician of the 1st emesis Resident #1 had at 2:00 PM. RN I stated that at approximately 3:00 PM-3:30 PM MA L reported to her that Resident #1 had vomited in the dining room, and she went to assess resident and noted had vomited undigested food and did not notify the physician. RN I stated CNA K had reported to her, Resident #1 had another episode of vomiting in the dining room and she did not go assess the resident and did not notify physician. RN I stated nurses had been trained to immediately assess the resident and notify the attending physician and responsible party of the change in condition. RN, I stated Resident #1 vomited for the 4th time in her room and asked resident if she wanted to go to the hospital but resident stated No. RN I stated she had administered Promethazine for nausea and vomiting at approximately 5:35 PM and resident continued to vomit. RN I stated she had not notified the attending physician or NP that resident continued to vomit after the Promethazine was administered because they had a standing order for Promethazine to administered as needed for nausea/vomiting. Interview on [DATE] at 3:14 PM with CNA K reveled she had worked a double shift on [DATE] in the morning and evening shift and was assigned to Resident #1. CNA K stated, Resident #1 was not her usual self on that day and appeared to be having problems with eating. CNA K stated she went to resident's room after breakfast and noted Resident #1 vomited a large amount of undigested food that appeared to be egg/sausage. Resident #1 had vomitus on her left shoulder down to the leg. CNA K stated she left the room to go to answer the call light for another and forgot to report to RN J that Resident #1 had vomited. CNA K stated that approximately10 minutes later, she was walking by the Resident #1's room and noticed vomitus on the floor next by the side of the bed. CNA K stated she cleaned the emesis and saw RN J passing medications in the hallway and went to report to her that resident had vomited twice that morning. CNAK stated, RN J only looked at me and did not say anything. CNA K stated did not know if RN J had assessed the resident. CNA K reported that at approximately 1:45 PM Resident #1 yelling, so she went to the room to check the resident and noted that she had vomited for the 3rd. CNA K stated she did not immediately report to RN J that Resident #1 had vomited for the 3rd time during the morning shift because she was finishing her rounds. CNA K stated Resident #1 vomited for the 4th time while sitting in her wheelchair in the dining room at dinner time and had notified RN I. CNA K stated she did not know if RN I had assessed Resident #1. CNA K stated she was informed by resident's roommate family member at approximately 5:00 PM-5:30 PM that Resident #1 looked anxious and was shaking. CNA K stated she immediately reported this to RN I and did know if RN I went to go assess resident. CNA K stated MA L had reported to her that resident had vomited 2 times while in the dining and was being taken back to her room. CNA K stated she went to resident's room and Resident #1 did not look good, her breathing was different, fingertips were cold to touch, and lips looked slightly purplish. CNA K stated she informed RN I at around 5:30 PM. CNA K stated her and RN I went back to check on Resident #1 and tried taking Blood Pressure on right arm twice but could not get the reading and changed it to the left arm which was ,d+[DATE] and Pulse was 101. CNA K stated RN I gave Resident #1 a medication. CNA K stated at 6:30 PM Resident #1 was transferred to bed and was pale, with dark circles under her eyes. Interview on [DATE] at 3:36 PM with MA L revealed she noted Resident #1 had vomited in the dining room at around 5:00 PM and had not immediately reported this to the nurses because she went to get a cup of coffee for Resident #1. MA L stated 1 to 2 minutes later Resident #1 vomited again so she went to report this to the RN I. MA L stated at 6:30 PM she noticed Resident #1's call light room was ringing, went to the resident's room and noted RN I and LVN N were in the room and asked her to assist with changing the resident. MA L stated they had been trained to immediately report to the nurses when a resident had a change in condition. Interview on [DATE] at 4:19 PM with LVN N revealed she saw Resident #1 vomiting in the dining room during dinner time at approximately 5:00 PM, RN I was in the dining room and asked the CNAs to take Resident #1 to her room. LVN N stated at 6:00 PM-6:30 PM RN I had asked her to go with her to Resident #1's room to assist with changing the resident. LVN N stated RN I had checked resident's blood pressure and was ,d+[DATE], was pale, resident was trying to vomit but could not and was having trouble breathing. LVN N stated the CNAs needed to immediately report changes of condition and nurses immediately assess and notify the physicians of any changes of condition. LVN N stated if the doctor was not notified of a change of condition with a resident that would be a risk of not getting the necessary medical care. Telephone interview on [DATE] at 9:04 AM with the NP revealed nurses should immediately report a change in condition to physician and/or NP. NP confirmed RN I, had reported to her in the afternoon that Resident #1 had vomited multiple times and gave orders for a KUB and Promethazine as needed for nausea/vomiting. NP stated Nurses need to assess the resident after each emesis to determine if the resident is constipated, amount and color of emesis and they are expected to immediately notify the physician and/or NP each time that the resident had an emesis. NP stated, If the medication ordered for nausea/vomiting, has been administered and the resident continues to have emesis the nurses are expected to immediately notify the physician/NP. Interview on [DATE] at 4:43 PM with Roommate revealed that on [DATE] in the evening time she heard Resident #1 vomiting in the room but could not remember if it was before or after dinner time. Second interview on [DATE] at 9:29 AM with RN J revealed Resident #1 was had an emesis at the change of shift at 2:00 PM, and she had not assessed the resident. RN J stated they had been trained to assess the residents when they had a change in condition, even if it was the change of shift. RN J stated they were trained to check the resident, check the vital signs, and immediately notify the doctor. RN J stated CNAs had been trained to immediately report to the nurses when a resident had a change in condition. RN J stated CNA K came to the nurses' station to report Resident #1 had vomited at the change of shift, when she was giving report to RN I. Interview on [DATE] at 9:48 AM with Resident #1's roommates' family member revealed he arrived at the facility [DATE] at 5:30 PM and noticed Resident #1 was not in the cafeteria like she always was. Family Member #2 stated that upon return to the room at approximately 6:00 PM, Resident #1was not her usual self and appeared to be anxious and went to report this to CNA K. Family member #2 stated he told can K that Resident #1 was feeling sick and looked bad. Family member#2 stated Resident #1 was pale, eyes looked desperate, and upper body and hands were shaking. Family member #2 stated CNA K walked out of the room, and Family Member #2 followed CNA K and told CNA K Resident #1 needed help. Family member #2 stated he saw CNA K passed by the nurse's station and did not stop to talk to the nurses. Interview on [DATE] at 11:34 AM with the DON revealed CNAs had been trained to immediately report to the nurses when residents had a change in condition and the nurses had been trained to immediately report changes in condition to the physician/nurse practitioner and responsible party. The DON stated it was very important for the nurses to report to physician and/or NP when a resident vomited to ensure resident did not have any adverse effects like dehydration or other complications. The DON stated if Resident #1 was administered the prescribed medication for nausea and vomiting and continued to vomit, the nurse should have immediately notified the physician and/or NP to see if the physician and/or NP to see if they wanted to make a change to the treatment plan and/or give orders to send the resident to the hospital for evaluation of change in condition. Interview on [DATE] at 1:51 PM with the Administrator revealed CNAs had been trained and were expected to immediately report to the nurses when a resident has a change in condition. The Administrator stated the purpose of immediately reporting changes in condition to the nurses was for them to immediately assess the resident and call the physician and/or NP to ensure that the resident promptly received the needed medical care. The Administrator stated if the prescribed medication was not effective for a resident that had emesis, it was expected for the nurse to immediately notify NP or physician to see if they would make changes to the treatment plan. Second interview on [DATE] at 9:56 AM with the DON revealed they had conducted in-service training after the incident with Resident #1 on [DATE] for all nurses and CNAs on immediately reporting changes in condition to the nurses; nurses were trained to immediately assessing residents when they had a change in condition, check vital signs, document assessment findings in the resident's electronic clinical record and immediately notifying physician and/or NP of change in condition. Telephone call placed to attending Physician no answer, left a voice message to call surveyor back. Second telephone interview on [DATE] at 11:13 AM NP stated the evening nurse had called her on [DATE] to report Resident #1 had vomited and had not provide any other information to her on that day regarding the status of the resident. NP stated nurses were expected to assess Resident #1 after each vomiting episode, check vital signs as part of the assessment and immediately report to physician and/or NP. NP stated, If the nurses do not check vital signs when a resident has a change in condition, we do not have a baseline to determine if the residents' condition is getting worse and a need to change the treatment plan and/or send the resident to the hospital for evaluation. NP stated she was not notified that Resident #1 had 6 emesis throughout the day on [DATE]. Interview on [DATE] at 2:01 PM LVN V stated nurses were in-serviced on [DATE] on assessing residents when they had a change in condition, checking vital signs, documentation of assessment in residents' electronic clinical record, and immediate notification to physician and/or NP of changes in condition. Interview on [DATE] at 3:47 PM RN U stated since working for the facility she had not been in-serviced on anything as far as she recalls. Interview on [DATE] at 4:18 PM with LVN S stated she had not been in-serviced on anything since she started working at the facility on the 14th of [DATE]. LVN S stated she had not received any in-service training on what to do when a resident had a change in condition. Review of 24-Hour Report Worksheet dated [DATE] on the ,d+[DATE] shift documented Resident #1 Emesis x1; laying down, now. There was not time indicated on the 24-hour report of when the vomiting occurred. Review of 24-Hour Report Worksheet dated [DATE] on the ,d+[DATE] shift documented Resident #1 Emesis x4; NP notified. N.O. for KUB and Promethazine 12.5 mg TID PRN. Emesis x2 after New Orders, sent via Emergency Medical Services to hospital per family member's request. Coded on transfer to stretcher. Review of Weights & Vital Signs Summary report for Resident #1 revealed, pulse was last checked on [DATE], 81 beats per minute-Regular; Temperature was last checked on [DATE] and was 97.2 Fahrenheit; Blood Pressure was last checked on [DATE] and was ,d+[DATE]. Record review RN I had not completed an SBAR assessment for Resident #1 on [DATE] when she notified NP on [DATE] of Resident #1 having vomited x 3 on the ,d+[DATE] shift. Review of Order Recap Report dated [DATE] - [DATE] for Resident #1 documented in part: -Order Date: [DATE] for portable KUB due to resident being confined to nursing home. Diagnosis: Pain. -Order Date: [DATE] Promethazine HCL (Hydrochloride) inject 12.5 mg intramuscular every 8 hours as needed for nausea/vomiting. The Recap Order Report dated [DATE] - [DATE] for Resident #1 did not document an order to send the resident to the emergency room for evaluation of change in condition. Review of Medication Administration Record (MAR) date [DATE] - ,d+[DATE], printed on [DATE] for Resident #1 revealed an order for Promethazine HCL injection Solution inject 12.5 mg Intramuscular every 8 hours as needed for nausea/vomiting. Start Date: [DATE]. MAR did not document Promethazine was administered as ordered on [DATE] by RN I. Record review of facility's policy and procedure on Notification of Changes Reviewed/Revised [DATE] revealed: Policy: To provide guidance on when to communicate acute changes in status to MD, NP, and responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: -An emergency response situation that requires EMS involvement-A significant change in the physical, mental, or psychosocial status of the resident. -A decision to transfer or discharge the resident to another facility. Policy Explanation and Compliance Guidelines: -In the case of a resident who is incapable of making decision, the resident should still be notified. Notify the resident's physician. Decisions would be made by the legal representative or appropriate family members. -The facility documents resident assessment(s), interventions, precision and family notifications on SBAR, nurses progress notes or telephone order forms (physician/family notice) as appropriate The administrator, DON, and ADONs were informed on [DATE] at 10:44 AM that Immediate Jeopardy (IJ) had been identified and a copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested within the hour. On [DATE] at 9:20 AM Administrator was notified 3rd Plan of removal was accepted. The Plan of Removal revealed the facility took following actions: 1. The DON in the morning meeting reviews the 24- hour report to identify any resident with a change in condition. DON/Designee will review documentation/assess if indicated, to verify that any identified change had a physician notification and documentation. 2. The DON/Designee will review the Stop and Watch notebook daily to verify that any communication from nurse assistance to license nurse has been reviewed and with timely interventions as indicated. 3. The DON/Designee will complete: o A license nurse QAPI tool daily x 30 days verifying license nurses training and knowledge in regard to the education they received (Vital Signs Guidelines, Clinical Practice Guidelines Alert Charting, Notification of Change of Condition, and The Stop and Watch program (A program in which CNAs see a resident having a change of condition and fill out a yellow form submitting it and reporting the change of condition to the nurses)) o A Nurse Assistant QAPI tool daily x 30 days verifying nurse assistant training and knowledge in regard to the education they received (Notification of Change of Condition, and the Stop and Watch program) On [DATE] (unknown time) the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to notification of change in condition, and Quality of care and reviewed plan to sustain compliance. Interviews and record review to confirm implementation of the Plan of Removal were conducted as follows: Record review of facility Stop and Watch Early Warning Tool in-service dated [DATE]-[DATE] at 4:53 PM was signed and acknowledged competency by the CNAs. Record review of facility changes in condition in-service dated [DATE] at 4:53 PM was signed and acknowledged competency by the CNAs. Record review of facility notification changes in-service dated [DATE] at 1:00 PM was signed and acknowledged competency by the nurses. Record review of the facility alert charting dated [DATE] at 1:00 PM was signed and acknowledged competency by the nurses. Record review of the facility vital signs dated [DATE] at 1:00 PM was signed and acknowledged competency by the nurses. Record review of facility SBAR Communication UDS for changes of conditions in-service dated [DATE] at 9:00 AM was signed and acknowledged competency by the nurses. Record review of facility's stop and watch binder dated [DATE] at 10:03 AM revealed Stop and Watch Early Warning Tool. If you have identified a change while caring for or observing a resident, please circle the change and notify a nurse. Either give the nurse a copy of this tool or review it with her/him as soon as you can. Record review of facility e-mail dated [DATE] at 3:23 PM indicating the licensed nurses on all other shifts cannot work until they have had this education (SBAR) and signed the in-service sheet. Make sure nurse manager at the beginning of each shift and throughout the weekend to provide this training before they work. Interview on [DATE] at 2:01 PM with LVN V stated they were in-serviced on alert charting, vitals, and notification of changes. LVN V stated on alert charting which was charting everything that was reported by the CNAs regarding residents' changes of condition. LVN V stated vitals are to be taken when residents have changes of conditions. LVN V stated vitals establish a baseline for the resident. LVN V stated if a resident had a change of condition, they need to notify the physician or NP immediately regarding the change in the resident. LVN V stated anytime the CNAs see a change of condition they need to fill out a stop and watch yellow sheet and turn it in to the nurses so they can check on the resident. Interview on [DATE] at 4:13 PM with LVN R stated, recently this month ([DATE]) she had received in-services on changes of condition and assessing the residents. LVN R stated when preforming a head-to-toe assessment on a resident and something was found to let the physician know. LVN R stated she received an in-service on taking vitals and to communicate anything that was abnormal. LVN R stated it was important to take vitals when a resident had an incident because it could be a change of condition with the resident. LVN R stated she would then document it on the SBAR. Interview on [DATE] at 8:53 AM CNA K stated yesterday [DATE] was the first time she had got an in-service on stop and watch and changes of condition. CNA K stated if a resident had a change of condition, then they are to report it and write it down on a paper that was at the nurse's station and submit it to the nurses. CNA K stated any changes of condition that are not normal are considered changes to a resident and need to be reported immediately. Interview on [DATE] at 9:40 AM CNA W stated she received an in-service on changes of condition and vitals. CNA W stated she would report any changes a resident had that were not normal to the nurses. CNA W stated vitals are taken when a resident has a change in their condition that was different from what they normal act. Interview on [DATE] at 9:53 AM CNA X stated she had been in-serviced on changes of condition with a resident, reporting, and stop and watch. CNA X stated if the resident was having a change of condition that was not their normal self, then the CNAs were expected to go to the nurse's station where the Stop and Watch yellow sheet was at and fill one out. CNA X stated once filled it would be turned into the nurses reporting the change in the resident. Interview on [DATE] at 10:01 AM CNA Y stated she had received the in-services on changes of condition, reporting, and stop and watch. CNA Y stated anytime a resident shows a change in their condition the CNAs need to report it. CNA Y stated you go to the nurse's station and in the book called Stop and Watch fill out a yellow form. CNA Y stated once filled it was turned into the nurses so they may go assess the resident. Interview on [DATE] at 10:10 AM CNA D stated that the Stop and Watch binder was at the nurse's station. CNA D stated it was for when a resident had a change in condition. CNA D stated if they saw a resident different from their norm then they were to report by going to the stop and watch binder and pulling out a yellow sheet and filling it out. CNA D stated it would be turned into the nurses for follow up. Interview on [DATE] at 2:20 PM LVN AA stated she was in-serviced on alert charting, changes of condition, SBAR, and calling the physician. LVN AA stated anytime a resident has a change in condition it needed to be reported to the physician or if the CNAs see the change with a resident, they need to notify nursing. LVN AA stated the SBAR was where nurses document vitals, times, and anything vital with changes of condition with a resident. LVN AA stated it was a summary of what was going on with the resident. LVN AA stated everything needed to be charted regarding the residents change of condition and assessments. Second interview on [DATE] at 3:40 PM with LVN S stated she was

Based on record review and interview, the facility failed to immediately consult with resident physician and notify the resident representative when there was a significant change in the resident's physical or mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 5 (Resident #1) reviewed for notification of changes of condition. The facility failed to notify the physician and establish vital signs when [AGE] year-old female Resident #1, with a history of dementia, had multiple episodes of emesis. The facility failed to report to the NP or MD [DATE] when Resident #1 had a total of six episodes of emesis, beginning at approximately 10 a.m. The day shift CNA stated she informed the day RN after the second episode. The CNAs notified the facility nurses again at the change of shift, 2:20 pm, after 4 episodes. The facility failed to notify the NP or MD until 5:00 pm-5:30 pm after the fifth episode and was not informed of Resident #1 being described as pale and shaking. NP stated if the nurses would have taken vitals for Resident #1 it would have established the baseline for her. The facility failed to assess or document vital signs until 6:40 p.m., when the Resident #1's vitals were BP ,d+[DATE], pulse 101, respiration 24 when the resident was looking pale, and cool to touch, and had purplish lips. The NP or MD was not notified of additional episodes of emesis after the medication had been ordered and administered. The facility failed to contact the NP or MD and instead contacted family for the decision to transport Resident #1 to the hospital. Resident #1 expired at the hospital. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of actual harm and a severity level of isolated because the facility failed to have a system in place to ensure residents are monitored and assessed for changes in condition and are immediately reported to the attending physician. This failure could affect residents by placing them at risk of delay medical treatment, hospitalization , decline in condition, and death. Findings included: Closed record Review revealed Resident #1's face sheet dated [DATE] listed initial admission on [DATE] and readmission on [DATE]. Record Review Resident #1's history and physical dated [DATE] revealed a [AGE] year-old female. Past medical history multiple sclerosis, neurogenic bladder with chronic urinary tract infections due to intermittent catheterization. Record Review Resident #1's quarterly MDS dated [DATE] revealed resident rarely made self-understood and rarely understands others; short-term, long term memory problems; Active Diagnoses-Renal Insufficiency, Renal Failure, or End-Stage Renal Disease, Neurogenic Bladder, Non-Alzheimer's Dementia, Multiple Sclerosis. Record Review Resident #1's Care Plan revised [DATE] revealed resident had neurogenic bladder and at times required catheterization. Monitor and report to Medical Doctor signs & symptoms of UTI. Record review of the Emergency Medical Services report dated [DATE] documented unit was dispatched at 6:36 PM and arrived at 6:47 PM. At resident 6:48 PM. Call Type: Sick Person. Urgency: Immediate. Patient Condition: Hypotension (low blood pressure). Primary Symptom-Hypovolemic (a condition that occurs you're your body loses fluid). Patient Care Narrative: Assessment Exam: Skin: Cyanotic (bluish color due to inadequately oxygenated blood), Mental Status: Unresponsive. Eyes: Non-reactive (A pupil which remains excessively dilated in the presence of light). Patient Care Narrative: According to staff patient was last seen 5 minutes prior to EMS arrival. Upon arrival patient agonal (related to or associated with the act of dying, gasping for air) with cyanotic (bluish or purplish discoloration) presumed patient had aspirated on vomit. EMS assisted ventilations and transferred patient to stretcher where manual Cardiopulmonary Resuscitation was initiated. EMS wheeled patient to rescue. Once in rescue auto pulse pads were placed and patient was showing Asystole (when your heart's electrical system fails, causing your heart to stop pumping). On the monitor, had copious amount of fluid coming from mouth. Patient was being suctioned and given CPR and ventilations throughout transport. Review of hospital emergency room record dated [DATE] 6:59 PM, revealed [AGE] year-old female brought to emergency department in cardiac arrest. Reportedly was at the nursing facility having aspiration. When EMS arrived around 6:49 PM, she was found to be with agonal respiration (when someone who is not getting enough oxygen is gasping for air) and vomiting. No pulse was noted, and CPR started at this time. Patient was intubated by EMS in field, difficulty with bagging, copious vomitus, abdominal distention. ETT (Endotracheal Tube - tube used to provide oxygen and inhaled gases to the lungs) was suspected to be in the stomach and was replaced in the emergency department. Patient continued to receive CPR in the emergency room . Ultrasound was used to identify cardiac activity, but there were no signs of life until Resident #1 was then pronounced dead at 7:10 PM. Record review of the office of medical examiner investigation dated [DATE] at 7:27 PM revealed the decedent was a [AGE] year-old white female who was viewed with episodes of emesis and hypotensive by staff while at the facility on [DATE]. 911 was phoned and Emergency Medical Services responded and transported the decent to the local hospital with cardiopulmonary resuscitation in progress. The decedent arrived to the Emergency Department on [DATE] at approximately 6:59 PM. CPR was continued; however, the decedent was viewed asystolic and was pronounced on [DATE] at 7:10 PM by physician. The following information was provided on [DATE] approximately 6:30 PM facility staff phoned Representative Party and advised Representative Party, that the decedent had emesis episodes x 6 and had sugar of 340. The facility advised decedent's physician who ordered an abdominal x-ray; however, they wanted to know if Representative Party wanted the decedent to be transported to the hospital. Representative Party advised the facility she did want the decedent to be transported to the hospital. Telephone interview on [DATE] at 11:00 AM with Resident #1's family member stated (RN I) called her on [DATE] at 6:30 PM to report Resident #1 had been vomiting all day and doctor had ordered an x-ray of the stomach and medication for nausea/vomiting. The family member stated, I told RN I to send Resident #1 to the hospital. When I called the nurse back, RN I reported that EMS had started CPR, when they got to the facility. The family member reported she had not been notified when Resident #1 started to vomit in the morning. The family member stated, If nurses had called to report to me when Resident #1 had the first emesis, I would have gone to check her and asked them to send her to the hospital. Interview on [DATE] at 1:04 PM with RN I revealed she worked [DATE] and was getting report from RN J at the change of shift at approximately 2:00 PM, when CNA K came to the nurse's station to report Resident #1 had vomited. RN I stated they continued with report and then proceeded to count narcotics. RN I stated she assessed Resident #1 at approximately 3:00 PM-3:30 PM on that day, Resident #1 was sitting in a wheelchair in the dining room, looked pale and complained of nausea. RN I stated that at approximately 5:00 PM MA L reported to her Resident #1 had vomited. RN I stated she checked the resident's physician's orders and there was not a standing order for to treat nausea/vomiting so she called the NP to report resident had vomited x 2 on her shift and was nauseated. NP gave orders for a KUB (KUB is an x-ray performed to assess the abdominal area for causes of abdominal pain, or to assess the organs and structures of the urinary and/or gastrointestinal system) and Promethazine IM (intramuscular) TID (three times a day) as needed for nausea/vomiting. RN I reported she administered Promethazine IM as ordered to Resident #1 at approximately 5:35 PM. RN I stated CNA K reported to her at approximately 6:40 PM, that Resident #1 had vomited after Promethazine was administered and did not look well. RN I stated she immediately went to the room to assess Resident #1. Resident #1 was lying in bed, blood pressure was low, she looked pale, was sweating and was having difficulty breathing. RN I stated at around 6:40PM-6:45PM she notified Resident #1's family member at which time family member requested resident be sent to ER. RN I stated she had not notified the NP, Resident #1 continued to vomit after the Promethazine was administered, because they had standing order to treat nausea/vomiting. RN I stated she had not notified the NP that Resident #1 was going to be sent out to the hospital emergency room for evaluation per family member's request. RN I stated, they had been trained to immediately notify attending physician and resident's responsible party of changes in condition, notify physician if resident's condition does not improve after PRN (as needed) medications has been administered and get a Physician's Order to send the resident to the hospital for evaluation per family's request. Telephone Interview on [DATE] at 2:42 PM RN J stated she worked on [DATE] and was assigned to Resident #1 during the morning shift, and resident did not have a change in condition during her shift. RN J denied CNA K had reported to her Resident #1 had vomited x 2 in the morning after breakfast. RN J stated, I was giving report to RN I at the change of shift at 2:00 PM, when CNA K came to the nurse's station to report Resident #1 had vomited. RN J stated she did not assess Resident #1 because her shift was over and continued to give report to RN I who was the on-coming nurse on the evening nurse and assigned to Resident #1. RN J stated that after report they proceeded to counted narcotics. RN J stated nurses have been trained to immediately assess and notify physician and/or nurse practitioner, responsible party when resident has a change in condition. Telephone interview on [DATE] at 1:47 PM with RN I stated she did not notify the physician of the 1st emesis Resident #1 had at 2:00 PM. RN I stated that at approximately 3:00 PM-3:30 PM MA L reported to her that Resident #1 had vomited in the dining room, and she went to assess resident and noted had vomited undigested food and did not notify the physician. RN I stated CNA K had reported to her, Resident #1 had another episode of vomiting in the dining room and she did not go assess the resident and did not notify physician. RN I stated nurses had been trained to immediately assess the resident and notify the attending physician and responsible party of the change in condition. RN, I stated Resident #1 vomited for the 4th time in her room and asked resident if she wanted to go to the hospital but resident stated No. RN I stated she had administered Promethazine for nausea and vomiting at approximately 5:35 PM and resident continued to vomit. RN I stated she had not notified the attending physician or NP that resident continued to vomit after the Promethazine was administered because they had a standing order for Promethazine to administered as needed for nausea/vomiting. Interview on [DATE] at 3:14 PM with CNA K reveled she had worked a double shift on [DATE] in the morning and evening shift and was assigned to Resident #1. CNA K stated, Resident #1 was not her usual self on that day and appeared to be having problems with eating. CNA K stated she went to resident's room after breakfast and noted Resident #1 vomited a large amount of undigested food that appeared to be egg/sausage. Resident #1 had vomitus on her left shoulder down to the leg. CNA K stated she left the room to go to answer the call light for another and forgot to report to RN J that Resident #1 had vomited. CNA K stated that approximately10 minutes later, she was walking by the Resident #1's room and noticed vomitus on the floor next by the side of the bed. CNA K stated she cleaned the emesis and saw RN J passing medications in the hallway and went to report to her that resident had vomited twice that morning. CNAK stated, RN J only looked at me and did not say anything. CNA K stated did not know if RN J had assessed the resident. CNA K reported that at approximately 1:45 PM Resident #1 yelling, so she went to the room to check the resident and noted that she had vomited for the 3rd. CNA K stated she did not immediately report to RN J that Resident #1 had vomited for the 3rd time during the morning shift because she was finishing her rounds. CNA K stated Resident #1 vomited for the 4th time while sitting in her wheelchair in the dining room at dinner time and had notified RN I. CNA K stated she did not know if RN I had assessed Resident #1. CNA K stated she was informed by resident's roommate family member at approximately 5:00 PM-5:30 PM that Resident #1 looked anxious and was shaking. CNA K stated she immediately reported this to RN I and did know if RN I went to go assess resident. CNA K stated MA L had reported to her that resident had vomited 2 times while in the dining and was being taken back to her room. CNA K stated she went to resident's room and Resident #1 did not look good, her breathing was different, fingertips were cold to touch, and lips looked slightly purplish. CNA K stated she informed RN I at around 5:30 PM. CNA K stated her and RN I went back to check on Resident #1 and tried taking Blood Pressure on right arm twice but could not get the reading and changed it to the left arm which was ,d+[DATE] and Pulse was 101. CNA K stated RN I gave Resident #1 a medication. CNA K stated at 6:30 PM Resident #1 was transferred to bed and was pale, with dark circles under her eyes. Interview on [DATE] at 3:36 PM with MA L revealed she noted Resident #1 had vomited in the dining room at around 5:00 PM and had not immediately reported this to the nurses because she went to get a cup of coffee for Resident #1. MA L stated 1 to 2 minutes later Resident #1 vomited again so she went to report this to the RN I. MA L stated at 6:30 PM she noticed Resident #1's call light room was ringing, went to the resident's room and noted RN I and LVN N were in the room and asked her to assist with changing the resident. MA L stated they had been trained to immediately report to the nurses when a resident had a change in condition. Interview on [DATE] at 4:19 PM with LVN N revealed she saw Resident #1 vomiting in the dining room during dinner time at approximately 5:00 PM, RN I was in the dining room and asked the CNAs to take Resident #1 to her room. LVN N stated at 6:00 PM-6:30 PM RN I had asked her to go with her to Resident #1's room to assist with changing the resident. LVN N stated RN I had checked resident's blood pressure and was ,d+[DATE], was pale, resident was trying to vomit but could not and was having trouble breathing. LVN N stated the CNAs needed to immediately report changes of condition and nurses immediately assess and notify the physicians of any changes of condition. LVN N stated if the doctor was not notified of a change of condition with a resident that would be a risk of not getting the necessary medical care. Telephone interview on [DATE] at 9:04 AM with the NP revealed nurses should immediately report a change in condition to physician and/or NP. NP confirmed RN I, had reported to her in the afternoon that Resident #1 had vomited multiple times and gave orders for a KUB and Promethazine as needed for nausea/vomiting. NP stated Nurses need to assess the resident after each emesis to determine if the resident is constipated, amount and color of emesis and they are expected to immediately notify the physician and/or NP each time that the resident had an emesis. NP stated, If the medication ordered for nausea/vomiting, has been administered and the resident continues to have emesis the nurses are expected to immediately notify the physician/NP. Interview on [DATE] at 4:43 PM with Roommate revealed that on [DATE] in the evening time she heard Resident #1 vomiting in the room but could not remember if it was before or after dinner time. Second interview on [DATE] at 9:29 AM with RN J revealed Resident #1 was had an emesis at the change of shift at 2:00 PM, and she had not assessed the resident. RN J stated they had been trained to assess the residents when they had a change in condition, even if it was the change of shift. RN J stated they were trained to check the resident, check the vital signs, and immediately notify the doctor. RN J stated CNAs had been trained to immediately report to the nurses when a resident had a change in condition. RN J stated CNA K came to the nurses' station to report Resident #1 had vomited at the change of shift, when she was giving report to RN I. Interview on [DATE] at 9:48 AM with Resident #1's roommates' family member revealed he arrived at the facility [DATE] at 5:30 PM and noticed Resident #1 was not in the cafeteria like she always was. Family Member #2 stated that upon return to the room at approximately 6:00 PM, Resident #1was not her usual self and appeared to be anxious and went to report this to CNA K. Family member #2 stated he told can K that Resident #1 was feeling sick and looked bad. Family member#2 stated Resident #1 was pale, eyes looked desperate, and upper body and hands were shaking. Family member #2 stated CNA K walked out of the room, and Family Member #2 followed CNA K and told CNA K Resident #1 needed help. Family member #2 stated he saw CNA K passed by the nurse's station and did not stop to talk to the nurses. Interview on [DATE] at 11:34 AM with the DON revealed CNAs had been trained to immediately report to the nurses when residents had a change in condition and the nurses had been trained to immediately report changes in condition to the physician/nurse practitioner and responsible party. The DON stated it was very important for the nurses to report to physician and/or NP when a resident vomited to ensure resident did not have any adverse effects like dehydration or other complications. The DON stated if Resident #1 was administered the prescribed medication for nausea and vomiting and continued to vomit, the nurse should have immediately notified the physician and/or NP to see if the physician and/or NP to see if they wanted to make a change to the treatment plan and/or give orders to send the resident to the hospital for evaluation of change in condition. Interview on [DATE] at 1:51 PM with the Administrator revealed CNAs had been trained and were expected to immediately report to the nurses when a resident has a change in condition. The Administrator stated the purpose of immediately reporting changes in condition to the nurses was for them to immediately assess the resident and call the physician and/or NP to ensure that the resident promptly received the needed medical care. The Administrator stated if the prescribed medication was not effective for a resident that had emesis, it was expected for the nurse to immediately notify NP or physician to see if they would make changes to the treatment plan. Second interview on [DATE] at 9:56 AM with the DON revealed they had conducted in-service training after the incident with Resident #1 on [DATE] for all nurses and CNAs on immediately reporting changes in condition to the nurses; nurses were trained to immediately assessing residents when they had a change in condition, check vital signs, document assessment findings in the resident's electronic clinical record and immediately notifying physician and/or NP of change in condition. Telephone call placed to attending Physician no answer, left a voice message to call surveyor back. Second telephone interview on [DATE] at 11:13 AM NP stated the evening nurse had called her on [DATE] to report Resident #1 had vomited and had not provide any other information to her on that day regarding the status of the resident. NP stated nurses were expected to assess Resident #1 after each vomiting episode, check vital signs as part of the assessment and immediately report to physician and/or NP. NP stated, If the nurses do not check vital signs when a resident has a change in condition, we do not have a baseline to determine if the residents' condition is getting worse and a need to change the treatment plan and/or send the resident to the hospital for evaluation. NP stated she was not notified that Resident #1 had 6 emesis throughout the day on [DATE]. Interview on [DATE] at 2:01 PM LVN V stated nurses were in-serviced on [DATE] on assessing residents when they had a change in condition, checking vital signs, documentation of assessment in residents' electronic clinical record, and immediate notification to physician and/or NP of changes in condition. Interview on [DATE] at 3:47 PM RN U stated since working for the facility she had not been in-serviced on anything as far as she recalls. Interview on [DATE] at 4:18 PM with LVN S stated she had not been in-serviced on anything since she started working at the facility on the 14th of [DATE]. LVN S stated she had not received any in-service training on what to do when a resident had a change in condition. Review of 24-Hour Report Worksheet dated [DATE] on the ,d+[DATE] shift documented Resident #1 Emesis x1; laying down, now. There was not time indicated on the 24-hour report of when the vomiting occurred. Review of 24-Hour Report Worksheet dated [DATE] on the ,d+[DATE] shift documented Resident #1 Emesis x4; NP notified. N.O. for KUB and Promethazine 12.5 mg TID PRN. Emesis x2 after New Orders, sent via Emergency Medical Services to hospital per family member's request. Coded on transfer to stretcher. Review of Weights & Vital Signs Summary report for Resident #1 revealed, pulse was last checked on [DATE], 81 beats per minute-Regular; Temperature was last checked on [DATE] and was 97.2 Fahrenheit; Blood Pressure was last checked on [DATE] and was ,d+[DATE]. Record review RN I had not completed an SBAR assessment for Resident #1 on [DATE] when she notified NP on [DATE] of Resident #1 having vomited x 3 on the ,d+[DATE] shift. Review of Order Recap Report dated [DATE] - [DATE] for Resident #1 documented in part: -Order Date: [DATE] for portable KUB due to resident being confined to nursing home. Diagnosis: Pain. -Order Date: [DATE] Promethazine HCL (Hydrochloride) inject 12.5 mg intramuscular every 8 hours as needed for nausea/vomiting. The Recap Order Report dated [DATE] - [DATE] for Resident #1 did not document an order to send the resident to the emergency room for evaluation of change in condition. Review of Medication Administration Record (MAR) date [DATE] - ,d+[DATE], printed on [DATE] for Resident #1 revealed an order for Promethazine HCL injection Solution inject 12.5 mg Intramuscular every 8 hours as needed for nausea/vomiting. Start Date: [DATE]. MAR did not document Promethazine was administered as ordered on [DATE] by RN I. Record review of facility's policy and procedure on Notification of Changes Reviewed/Revised [DATE] revealed: Policy: To provide guidance on when to communicate acute changes in status to MD, NP, and responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: -An emergency response situation that requires EMS involvement-A significant change in the physical, mental, or psychosocial status of the resident. -A decision to transfer or discharge the resident to another facility. Policy Explanation and Compliance Guidelines: -In the case of a resident who is incapable of making decision, the resident should still be notified. Notify the resident's physician. Decisions would be made by the legal representative or appropriate family members. -The facility documents resident assessment(s), interventions, precision and family notifications on SBAR, nurses progress notes or telephone order forms (physician/family notice) as appropriate The administrator, DON, and ADONs were informed on [DATE] at 10:44 AM that Immediate Jeopardy (IJ) had been identified and a copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested within the hour. On [DATE] at 9:20 AM Administrator was notified 3rd Plan of removal was accepted. The Plan of Removal revealed the facility took following actions: 1. The DON in the morning meeting reviews the 24- hour report to identify any resident with a change in condition. DON/Designee will review documentation/assess if indicated, to verify that any identified change had a physician notification and documentation. 2. The DON/Designee will review the Stop and Watch notebook daily to verify that any communication from nurse assistance to license nurse has been reviewed and with timely interventions as indicated. 3. The DON/Designee will complete: o A license nurse QAPI tool daily x 30 days verifying license nurses training and knowledge in regard to the education they received (Vital Signs Guidelines, Clinical Practice Guidelines Alert Charting, Notification of Change of Condition, and The Stop and Watch program (A program in which CNAs see a resident having a change of condition and fill out a yellow form submitting it and reporting the change of condition to the nurses)) o A Nurse Assistant QAPI tool daily x 30 days verifying nurse assistant training and knowledge in regard to the education they received (Notification of Change of Condition, and the Stop and Watch program) On [DATE] (unknown time) the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to notification of change in condition, and Quality of care and reviewed plan to sustain compliance. Interviews and record review to confirm implementation of the Plan of Removal were conducted as follows: Record review of facility Stop and Watch Early Warning Tool in-service dated [DATE]-[DATE] at 4:53 PM was signed and acknowledged competency by the CNAs. Record review of facility changes in condition in-service dated [DATE] at 4:53 PM was signed and acknowledged competency by the CNAs. Record review of facility notification changes in-service dated [DATE] at 1:00 PM was signed and acknowledged competency by the nurses. Record review of the facility alert charting dated [DATE] at 1:00 PM was signed and acknowledged competency by the nurses. Record review of the facility vital signs dated [DATE] at 1:00 PM was signed and acknowledged competency by the nurses. Record review of facility SBAR Communication UDS for changes of conditions in-service dated [DATE] at 9:00 AM was signed and acknowledged competency by the nurses. Record review of facility's stop and watch binder dated [DATE] at 10:03 AM revealed Stop and Watch Early Warning Tool. If you have identified a change while caring for or observing a resident, please circle the change and notify a nurse. Either give the nurse a copy of this tool or review it with her/him as soon as you can. Record review of facility e-mail dated [DATE] at 3:23 PM indicating the licensed nurses on all other shifts cannot work until they have had this education (SBAR) and signed the in-service sheet. Make sure nurse manager at the beginning of each shift and throughout the weekend to provide this training before they work. Interview on [DATE] at 2:01 PM with LVN V stated they were in-serviced on alert charting, vitals, and notification of changes. LVN V stated on alert charting which was charting everything that was reported by the CNAs regarding residents' changes of condition. LVN V stated vitals are to be taken when residents have changes of conditions. LVN V stated vitals establish a baseline for the resident. LVN V stated if a resident had a change of condition, they need to notify the physician or NP immediately regarding the change in the resident. LVN V stated anytime the CNAs see a change of condition they need to fill out a stop and watch yellow sheet and turn it in to the nurses so they can check on the resident. Interview on [DATE] at 4:13 PM with LVN R stated, recently this month ([DATE]) she had received in-services on changes of condition and assessing the residents. LVN R stated when preforming a head-to-toe assessment on a resident and something was found to let the physician know. LVN R stated she received an in-service on taking vitals and to communicate anything that was abnormal. LVN R stated it was important to take vitals when a resident had an incident because it could be a change of condition with the resident. LVN R stated she would then document it on the SBAR. Interview on [DATE] at 8:53 AM CNA K stated yesterday [DATE] was the first time she had got an in-service on stop and watch and changes of condition. CNA K stated if a resident had a change of condition, then they are to report it and write it down on a paper that was at the nurse's station and submit it to the nurses. CNA K stated any changes of condition that are not normal are considered changes to a resident and need to be reported immediately. Interview on [DATE] at 9:40 AM CNA W stated she received an in-service on changes of condition and vitals. CNA W stated she would report any changes a resident had that were not normal to the nurses. CNA W stated vitals are taken when a resident has a change in their condition that was different from what they normal act. Interview on [DATE] at 9:53 AM CNA X stated she had been in-serviced on changes of condition with a resident, reporting, and stop and watch. CNA X stated if the resident was having a change of condition that was not their normal self, then the CNAs were expected to go to the nurse's station where the Stop and Watch yellow sheet was at and fill one out. CNA X stated once filled it would be turned into the nurses reporting the change in the resident. Interview on [DATE] at 10:01 AM CNA Y stated she had received the in-services on changes of condition, reporting, and stop and watch. CNA Y stated anytime a resident shows a change in their condition the CNAs need to report it. CNA Y stated you go to the nurse's station and in the book called Stop and Watch fill out a yellow form. CNA Y stated once filled it was turned into the nurses so they may go assess the resident. Interview on [DATE] at 10:10 AM CNA D stated that the Stop and Watch binder was at the nurse's station. CNA D stated it was for when a resident had a change in condition. CNA D stated if they saw a resident different from their norm then they were to report by going to the stop and watch binder and pulling out a yellow sheet and filling it out. CNA D stated it would be turned into the nurses for follow up. Interview on [DATE] at 2:20 PM LVN AA stated she was in-serviced on alert charting, changes of condition, SBAR, and calling the physician. LVN AA stated anytime a resident has a change in condition it needed to be reported to the physician or if the CNAs see the change with a resident, they need to notify nursing. LVN AA stated the SBAR was where nurses document vitals, times, and anything vital with changes of condition with a resident. LVN AA stated it was a summary of what was going on with the resident. LVN AA stated everythi [TRUNCATED]

Based on interview and record review, the facility failed to develop and implement written policies and procedures to identify events and prohibit mistreatment, neglect and abuse of residents, for one (Resident #2) of 8 residents reviewed for abuse and neglect. The facility failed to identify, report, and investigate Resident #2's allegation of a certified nurse aide( CNA) hitting her, to the State survey and certification agency (DADS) and failed to have evidence of a thorough investigation of the resident's allegation. These failures could affect the 39 residents, who were residing on Hall B by placing them at risk for abuse, neglect, mistreatment, and decreased quality of life. Findings included: Review of Abuse Prohibition Policy and Procedure revised July 2012, stated, in part the following: III. Prevention of Abuse: A. The facility will provide residents, families, staff, volunteers, staff of other agencies serving the residents, and consultants; information of how and to whom they may report concerns, incidents and grievances without fear of retribution. VII. Reporting and Response to Alleged Incidents: A. Incidents of alleged abuse, neglect or misappropriation of resident property must be reported to the appropriate local, state and federal agencies. B. All alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source, and misappropriation of resident property shall be reported immediately (not to exceed 2 hours after discovery) to the Administrator or the DON. C. If neither is in the facility when such incidents occur or are discovered after hours, the report will be given to the Charge Nurse or Supervisor in charge. D. The Charge Nurse or Supervisor must immediately contact the Administrator or the DON of the incident. Review of Admissions Record documented resident #2 was an [AGE] year old female admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Nurses Notes dated 5/1/13 at 8:55 PM by Licensed Vocational Nurse (LVN) B which documented in part: Resident #2 stated " that CNA A hit her " . Review of Incident and Accident Reports on 5/23/13 revealed report dated 5/4/13 timed 7:30 AM, documented CNA C noticed a bruise on Resident #2 ' s left leg. The facility was unable to provide an Incident and Accident Report for Resident #2 ' s accusation of physical abuse on 5/1/13. In an interview on 5/23/13 at 4:05 PM LVN B said he had written the Nurses Note dated 5/1/13 regarding Resident #2. LVN B stated he questioned Resident #2 because CNA A had told him she was combative. When LVN B questioned Resident #2 she said " I don ' t like that lady. That CNA (CNA A) hit her. " LVN B stated " Assistant Director of Nursing (ADON) D and former Nursing Home Administrator (NHA) were here at the nurse ' s station, I told them and they took care of it " . In an interview on 5/24/13 at 9:45AM with Resident #2 stated everything at the facility is ok. Resident #2 stated no staff member has ever harmed her in any way. Resident stated the only person she was upset with was her son because he placed her in the nursing home. In an interview on 5/24/13 at 8:45 AM with the Administrator G, he stated ADON D was not an employee with the facility on 5/1/2013; the day LVN B said he gave report to ADON D regarding the allegation. The Administrator G contacted the former Administrator who made a statement expressing he did not receive any allegations of abuse with Resident #2. Interview on 5/23/13 at 4:15 PM ADON E said his first day of employment was 4/26/13 and no one has ever reported abuse to him. ADON E stated he is in charge of Halls A & D and reviews the documentation in his skilled resident charts. Interview with Director of Nurses (DON) H on 5/23/13 at 4:30 PM said all abuse, neglect, bruises, and anything else is to be reported to the DON and Administrator. All abuse and neglect is called into the state and investigated. DON H said she was not aware of the allegations made by Resident #2 until that day. Interview on 5/23/13 at 4:20 PM ADON F said her first day of employment was 3/8/13. Two incidents, both resident to resident have been reported to her but she has never been told a resident accused CNA A of hitting her. ADON F said she is in charge of Halls B & C. She does not review Nursing Notes. The universe of 39 residents who resided on Hall B was obtained from the daily census dated 5/23/13 provided by the Administrator G.

Based on observation, interview and record review the facility failed to implement policies that prohibit the neglect for 1(resident #1) of 30 residents reviewed for accidents/change in condition. On 2/19/13 between 4 PM and 5 PM, 2 Certified Nurse Aides (CNAs K and M) saw swelling and bruising on resident #1's left thigh and reported this finding to the licensed nurse (who denied being informed). On the 10 PM - 6 AM shift, 2 more CNAs noticed the bruising and swelling of resident #1 ' s left thigh and reported it to the licensed nurse (who also denied being informed). The following day (2/20/13) at 9:30 AM, CNA K reported the bruising and swelling to Licensed Vocational Nurse (LVN) H who notified the Nurse Practitioner of the bruising and swelling on resident #1 ' s left thigh. A STAT (immediate) x-ray was ordered. On 2/20/13 at 4:32 PM, LVN F received the x-rays results, failed to read the entire 2 pages that were faxed to the facility, failed to see there was a [MEDICAL CONDITION] femur and failed to notify the physician of the x-ray results. LVN F reported to the oncoming nurse, LVN G, the x-ray was negative. LVN G reported to LVN H at 6:00 AM on 2/21/13 that the x-ray was negative. When LVN H read the entire x-ray results at 10:30 AM on 2/21/13, she saw the report of resident #1 ' s fractured left femur and notified the Nurse Practitioner who ordered resident #1 transferred to the hospital. This was 41 hours after the initial finding on 2/19/13 of the swelling and bruising on resident #1 ' s left thigh. This deficient practice resulted in an immediate jeopardy identified on 3/21/13. While the immediate jeopardy was removed on 3/25/13, the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. This failure could place 22 residents who are totally dependent on staff for care at risk of not receiving timely and appropriate medical intervention. The findings included: Review of medical records documented resident #1 was a [AGE] year old man admitted on [DATE] and re-admitted on [DATE]. Re-admit Progress Notes dated 5/08/12 documented [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] documented resident #1 had no speech, was rarely/never understood, rarely/never understands, cognitive skills for daily decision making were severely impaired, continually present inattention and psychomotor [MEDICAL CONDITION], had physical impairments of both his upper and lower extremities that interfered with daily function and extensive assistance of 1-2 persons for ADLs (Activities of Daily Living). Review of resident #1's Comprehensive Plan of Care revised on 2/26/13 documented the resident has an ADL self care performance deficit r/t (related to) limited ROM (range of motion) due to [MEDICAL CONDITION]. The resident is totally dependent on staff for toileting, bath, dressing and grooming, enteral feedings and oral care. Resident #1 has impaired communication evidenced by reduced ability to be understood by others, reduced ability to understand others, impaired daily decision making ability and [MEDICAL CONDITION]. Review of Incident/Accident Report dated 2/20/13 documented at 9:00 AM, resident #1 had bruising and swelling of inner and outer left thigh and knee and grimacing with movement. NP W and Responsible Party (RP) were notified. Additional comments said to continue with skin checks on weekly basis as well as staff education. Recommendations/New Interventions: x-ray to left leg. Communicate between shifts. Review of Physician's Telephone Orders dated 2/20/13 at 9:20 AM documented order for STAT x-ray to left leg. Review of a late entry in the Nurse's Notes for 2/20/13 the nurse called the mobile x-ray provider at 12:00 PM to follow-up for the STAT x-ray ordered at 9:15 AM. Review of e-mail to Nursing Facility Administrator from the Account Manager of the mobile x-ray provider dated 2/26/13 documented "results were called to LVN F at 1747." (Central Daylight Time) (4:47 PM, Mountain Daylight Time) Record review of Radiology Report from mobile x-ray provider dated 2/20/13 and timed for 5:24 PM Central Time (4:24 PM Mountain Time) provided the following findings: Left Femur, single lateral view only (side view) Conclusion: 1. Acute moderately displaced fracture of proximal shaft of femur. 2. Chronic deformity of the left femoral head with possible avascular necrosis. 3. Moderate degree of [MEDICAL CONDITION]. Left Tibia and Fibula, single view (lower leg bones) Conclusion: 1. No definite radiographic evidence of acute fracture or dislocation. 2. Moderate [MEDICAL CONDITION] demonstrated. In review of 24 Hour Report/Change of Condition Reports dated 2/19/13 through 2/21/13 the following was documented: a. 2/19/13 - nothing concerning any bruising or swelling on resident #1 b. 2/20/13 - remarks (evening) - received results c. 2/21/13 - remarks (night) (begins the day's 24 hour report) - x-ray results (-) (negative) d. 2/21/13 - Deaths/Discharges - resident #1 to hospital Left fractured femur Review of Physician's Telephone Order dated 2/21/13 at 10:35 AM, documented an order to Transfer (resident #1) to a local hospital; ortho to evaluate and transfer for fracture proximal shaft of femur. In an observation on 3/18/13 at 1:47 PM, resident #1 was lying in bed with the head of bed elevated. He had wedge cushions on both sides of the bed. There was a landing mat standing against the wall next to the right side of the bed. There was another landing mat on the floor on the left side of the bed. Resident #1 was a small, frail man with contractures of both arms and both legs from. (Resident #1 suffered from Infantile [MEDICAL CONDITION], a brain disorder that affects a person's muscle tone and motor skills sometimes caused, among other reasons, by problems during labor and the delivery of a baby). His hips and knees were contracted in flexed positions while his arms were extended with his hands flexed. Resident #1 was able to move his upper body from side to side in a wiggling motion. He was lying with his head against the pad on the wall. Resident #1 was alert and unable to speak but he could make noises. He also was able to smile and cry. Resident #1 received nourishment through a gastrostomy tube (a tube placed through the skin into the stomach for feeding and medications). In an interview on 3/21/13 at 8:09 AM, LVN H said CNA K had worked day shift (6 am - 2 PM) on 2/20/13 and asked the LVN if she had seen resident #1's leg. LVN H went to resident #1's room and said his whole thigh and knee were bruised and swollen all around the left thigh. LVN H said resident #1 usually did not cry with movement, but he did that morning. LVN H said she called the attending physician and Nurse Practitioner W ordered a STAT (to be done immediately) x-ray of resident #1's left leg. The mobile x-ray provider came towards the end of the day shift and the report had not been received before LVN H left for the day. When LVN H came the next morning (2/21/13), she saw in the 24 Hour Report Book that resident #1's x-ray was negative and said that was hard to believe because of how much it was swollen. LVN H said when she reached resident #1's room during med pass, he appeared to be in pain and she administered his scheduled pain medication. LVN H said resident #1's leg was still very bruised but the swelling seemed to have gone down a little. When she returned to the nurse's station at the end of the med pass, she saw the x-ray results for resident #1 on the desk. There were 2 pages. The first page were results for the left thigh and it showed a [MEDICAL CONDITION] femur. The 2nd page was the results for the x-rays of the lower leg bones which were negative for fractures. In a telephone interview on 3/21/13 at 8:26 AM, LVN F said LVN H had found a bruise on resident #1's knee and a CNA had told LVN F about it on 2/19/13. LVN F said this was not true. That afternoon after her evening shift had started ( 2 PM - 10 PM), LVN F said the mobile x-ray provider faxed results of x-rays for resident #1. LVN F said the mobile x-ray provider called her and only asked if she had received the fax and when she said she had, they ended the call. The provider did not verbally give her the x-ray results. She read the x-ray results as negative for fractures and passed this information on to LVN G who said she was unaware of the bruise of resident #1's left leg. LVN F said no CNA notified her of resident #1 having a bruised and swollen left leg and if they had, she would have assessed the resident and called the doctor. A couple of nights before 2/20/12, LVN F said resident #1 was uncomfortable and grimacing - not himself, but she "did not notice anything unusual." In an interview on 3/21/13 at 3:17 PM, CNA K said that on 2/19/13 between 4 PM and 5 PM, she and CNA M pulled resident #1 up in bed and CNA M saw a bruise on resident #1's left leg. It was on the front of his thigh and was swollen also. CNA K said she told LVN Q who told her to tell her nurse. CNA K said she told LVN F to go see it and she said OK. CNA K, towards the end of the shift, said she reminded LVN F to see resident #1 and she answered she already had. When CNA K came in on the day shift (2/20/13) she said she told LVN H about the bruising and swelling on resident #1's left leg. CNA K said when anything out of the ordinary for a resident is seen, a Stop and Watch form is filled out. CNA K said she always tells the nurse and said she forgot to fill out the form and LVN F did not remind her to do so. CNA K said she did not do rounds with the nurse when she left as she left early and did not report off to the oncoming CNA either. In an interview on 3/21/13 at 4:00 PM, CNA M said she was on orientation the evening of 2/19/13. During the 2 PM - 10 PM shift she assisted CNA K to provide incontinent care for resident #1. When the covers were removed CNA M said she pointed out resident #1's red left leg to CNA K and asked what they were supposed to do. She said CNA K said they were supposed to fill out a paper and tell the nurse. After they had completed the incontinent care, CNA M said she went back to the hallway where she was orienting and did not know if CNA K told the nurse. In a telephone interview on 3/21/13 at 4:09 PM, LVN G said she was not aware of any bruising on resident #1 until the next day at the beginning of her shift (10 PM - 6 AM) on 2/20/13. LVN G said when LVN F gave her report, the LVN told her of the bruise on resident #1's leg and told her the x-ray of resident #1's leg was negative for a fracture. LVN G said LVN F showed her a 1 page x-ray report. LVN G said x-ray reports are placed in the 24 Hour Report book and only 1 page was in the 24 Hour Report book. LVN G said the night before (2/19/13) she did not look at resident #1's leg. She just used the draw sheet to reposition him in bed, but said he did seem a little "breathless." LVN G said when she learned of the bruised thigh on resident #1 she went to talk with the CNA (CNA J) and asked the CNA if she knew about the bruise. LVN G said CNA J told her she did not report the bruise because it had been there since the weekend. LVN G said the CNAs are supposed to fill out a Stop and Watch form for the nurse to initial and follow-up on what was reported and document on an SBAR form (used to gather information prior to calling the physician). When an x-ray is ordered STAT (to be done immediately) the results are called to the physician for any result - negative or positive. LVN G said LVN F told her she had called the doctor but does not remember who LVN F said she called. This information is also put onto the 24 hour report. In an interview on 3/21/13 at 7:56 PM, LVN Q said she worked Monday through Friday on the 2 PM - 10 PM shift and did work the evening of 2/19/13. LVN Q said she does not remember anybody telling her about a bruise on resident #1, but that the CNAs are always telling her things about residents because she speaks Spanish and most of the CNAs speak Spanish. LVN Q said she tells the CNAs to go and tell their nurse and when she sees them heading for the other nurses, she just continues on with her work and doesn't think about what she might have been told. If a CNA tells her about one of her residents, she will act on that. In an interview on 3/21/13 at 8:12 PM, CNA L said she was on orientation the night of 2/19/13 and was working with CNA J. CNA L said CNA J noticed resident #1 was "fussier" than usual; usually he was very calm. CNA L said there was a bruise on resident #1's leg and LVN G went into resident #1's room after that while she and CNA J continued with their work. CNA L said she has since been trained to use a Stop and Watch form when she sees anything different about a resident. CNA L said CNA J did not talk about a Stop and Watch form that night. In an interview on 3/21/13 at 10:23 PM, with the use of a translator, CNA J said she did not see the bruise, but she reported to LVN G on 2/19/13 that resident #1 was acting different than usual and was crying. Resident #1 also was usually still, but that night he was "very unstill" - moving his upper body in the bed. CNA J said LVN G went into resident #1's room after notifying her that resident #1 was acting different. CNA J said when she sees something unusual in a resident she is supposed to fill out a Stop and Watch form to give to the nurse. CNA J said she did not fill out a Stop and Watch form that night and she did not know why she didn't. In a telephone interview on 3/22/13 at 9:22 AM, NP W said LVN H notified her in the morning (2/20/13) that resident #1 had a red and swollen left hip and that the hip did not look right. NP W said LVN H notified her of the x-ray result of a [MEDICAL CONDITION] either the day the x-ray was ordered or the next morning. NP W did not remember speaking to anyone else about the x-ray result. Review of the policy Diagnostic Testing revised August 2012, stated in the part the following: Policy; It is the policy of this facility that residents receive diagnostic testing as ordered by their physician(s) and results of the testing are communicated to that physician so that prompt appropriate action can be taken if indicated for the resident's care. Procedure; When test results are received the physician will be notified of any abnormal findings on the day the results are received by the facility. Notification may be by phone, fax, or in person. The physician will be notified immediately when test results classified as critical are received. Documentation; Physician notification of results may be documented either in the N/N (nurse's notes) or on the test result document. Review of Abuse Prohibition Policy and Procedure last revised July 2012, stated, in part the following: III. Prevention of Abuse: A. The facility will provide residents, families, staff, volunteers, staff of other agencies serving the residents, and consultants; information of how and to whom they may report concerns, incidents and grievances without fear of retribution. C. A committee selected and chaired by the Administrator or designated representative will function under the Quality Assurance and Assessment committee and meet as needed to identify, correct and intervene in situations in which abuse, neglect or misappropriation of resident property is more likely to occur. This includes an analysis of the assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents' rooms, resident with self-injurious behaviors, residents with communication disorders, those that require heavy nursing care and/or are totally dependent on staff. VII. Reporting and Response to Alleged Incidents: A. Incidents of alleged abuse, neglect or misappropriation of resident property must be reported to the appropriate local, state and federal agencies. B. All alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source, and misappropriation of resident property shall be reported immediately (not to exceed 2 hours after discovery) to the Administrator or the DON. C. If neither is in the facility when such incidents occur or are discovered after hours, the report will be given to the Charge Nurse or Supervisor in charge. D. The Charge Nurse or Supervisor must immediately contact the Administrator or the DON of the incident. Attachment A: Neglect - A deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to the resident. An immediate jeopardy was identified on 3/21/13 and the Nursing Facility Administrator, Interim Director of Nurses, Director of Nurses, Regional Director of Operations and Regional Nurse Consultant were informed at 1:54 PM on 3/21/13. The Plan of Action was accepted at 3:45 PM on 3/25/13. PLAN OF ACTION: Plan of Removal: Immediate Jeopardy based on Failure to notify Abuse Coordinator of Injury of unknown origin; failure to document assessment; failure to notify physician of x-ray results; failure to communicate shift to shift regarding the x-ray results. On February 20.2013 Charge Nurse H and LVN V assessed resident #1 head to toe and noted bruising around left knee. Charge nurse notified Nurse Practitioner who ordered x-rays of upper and lower leg. Charge nurse completed incident report and assessed resident for pain. Scheduled narcotic pain medications were administered as scheduled. On February 21, 2013, Charge Nurse H reported to Director of Nurses that x-ray results showed an acute moderately placed fracture of proximal shaft of femur, chronic deformity of the left femoral head with possible avascular necrosis and moderate degree of [MEDICAL CONDITION]. Charge notified nurse practitioner of results and orders were obtained to send resident out to hospital for treatment and evaluation. Director of Nurses reported fracture to Administrator and State reportable was filed. Facility immediately initiated investigation on same day. On February 21, 2013, ADON (Assistant Director of Nurses) and Administrator in-serviced facility staff on notifying Abuse Coordinator, Director of Nurses and Charge Nurses regarding injuries of unknown origin. Staff were educated that if Administrator and DON are not available to report incident to the Regional Vice President, (915) [PHONE NUMBER], Regional Nurse Consultant, (817) [PHONE NUMBER] or Compliance Hotline 24/7: [PHONE NUMBER]. In-service also included that facility staff should immediately report any injuries to the Charge Nurses and to use the Stop and Watch Tool to document any changes in the residents' condition that was observed. Report if the resident seems different than usual, report if the resident talks or communicates less than usual, report if the resident participated less than usual in activities, report if resident ate less than usual and it was not because they didn't like the food, report if the resident drank less than usual, report of the resident looks like they are losing weight, report if resident is agitated or nervous more than usual, report if the resident is tired, weak, confused or drowsy, report if the resident has a change in skin color, bruising, scrapes or in condition, and to report if the resident needs help with walking, transferring, toileting more than usual. Facility staff in-serviced on identifying skin issues on the Skin Identification Tool, on notifying the Charge Nurse of the skin issues and having the Charge Nurse to sign the Stop and Watch Tool, on making a copy of the Stop and Watch Tool and placing the copy in the box on the DON's door, and on giving the original Stop and Watch Tool to the Charge Nurse. Facility Staff were immediately in-serviced on Abuse Prohibition Policy and reporting injuries of unknown origin such as bruises and scrapes to the Abuse Coordinator and Director of Nurses. Facility staff were also in-serviced that the Administrator is the Abuse Coordinator on February 21, 2013. Charge Nurses were in-serviced on February 21, 2013 on reporting injuries of unknown origin including bruising, scrapes to the Abuse Coordinator and Director of Nurses. Charge Nurses were in-serviced on February 22, 2013 on responding to resident concerns communicated by facility staff, assessing the resident in a timely manner with documentation in the chart and documentation of any follow through. Charge Nurses were in-serviced in February 28, 2013 on notifying the physician, responsible party and Abuse Coordinator (Administrator), DON if abuse is suspected or injury seems out of the ordinary. If deep tissue injury/fracture is suspected, obtain orders and schedule necessary x-rays as well as obtaining treatment orders if necessary. Charge Nurses were in-serviced on February 26, 2013 on the importance of documentation in the medical record as a means of communication between physician and other professional contributing to the resident's care. Entries are to be made in a sequential manner. Charting reflects care provided during the shift. On February 22, 24 & 28, 2013 Director of Nurses, ADON & Weekend Supervisor in-serviced Charge Nurses that upon receipt of x-ray report for a resident the nurse must review the report completely. If more than one view of an x-ray was ordered, then more than likely the report will consist of an assessment and a conclusion of each view by the radiologist. Charge Nurses must review the report and ensure follow-up is done promptly as needed. If the resident sustains a fracture, Charge Nurse must notify physician, responsible party, Director of Nursing, ADON on call and the Administrator and ensure documentation is completed. Once the lab or x-ray has been noted and follow-up done, a copy of the lab or x-ray must be made and placed in the 24-Hour report book for review by oncoming nurse and ADONs. On February 26, 2013 Director of Nurses in-serviced Charge Nurses on Pain Management including the use of Pain Management Data Collection Tool and documenting any assessments of pain along with interventions. Charge Nurses were in-serviced on February 26, 2013 on notifying the Director of Nurses for falls and changes of condition. DON and/or designee conduct a daily start-up meeting Monday-Friday. DON and/or designee began documenting the start up review on the daily start up tool on March 22, 2013. The Director of Nurses, Assistant Director of Nurses, Case Mix Managers (CMM), Treatment Nurses and anyone else deemed necessary attend the Daily Start Up meeting. The Daily Start Up meeting provides nursing administration a systematic procedure for monitoring compliance in care and service areas. The meeting is approximately 30 minutes in length but the process is ongoing throughout the day. It is a look back of events since the last tour of duty which includes a review of resident conditions, documentation and many other nursing procedures that have the potential to impact resident care. The following documentation is brought to the meeting: 24 hour report Pink copies of all orders received since last meeting Incident reports Charts for any new admission, re-admissions and discharged residents Stop and Watch Tool During the meeting any changes of condition identified on the 24 hour report, incident reports and all new orders are communicated to the nursing management team. The CMMs note all changes and review the individual resident care plans for any needed update or modification, this process in ongoing. DON and/or designee during Stand Down began reviewing daily start up audit tool to ensure appropriate follow-up was completed on March 22, 2013. DON and/or designee reported to the QA/QI Committee the progress of reportable incidents, notification of physician, documentation of assessments, and shift to shift communication on March 6, 2013 and will continue to report monthly for 3 months. Facility administrator and/or designee has assigned each department head resident rooms. Each one of these department heads is the Quality of Life Specialist for these assigned rooms. Quality of Life (QoL) monitors round each morning prior to the Stand-Up meeting, this is ongoing, QoL members interview and complete a Quality of Life round form to present at daily stand up and/or stand down meetings. Quality of Life Specialist report to the attendees the results of their rounds. Any areas of concern are addressed at the meeting and plans are made to correct if not already corrected during the rounds. QoL Program is an ongoing process. Administrator maintains a notebook for these Quality of Life Rounds. Results of these rounds will be reported to the QA QI Committee X3 months. Administrator conducts daily walking rounds X5 as part of his daily duties to ensure resident and staff needs are met. On February 21.22 & 24 management staff In-serviced staff on Stop and Watch program to include that staff should provide a copy of any Stop and Watch tool that is completed to the Director of Nurses. Director of Nurses and/or designee monitor that Stop and Watch tool being utilized by interviewing random staff X5 per week X3 months by using a questionnaire that quizzes the use of the Stop and Watch tool. The Director of Nursing and/or designee will immediately in-service staff that fail to understand how to utilize the Stop and Watch tool. Director of Nursing will report findings to the QA/QI committee for tracking and trending. Administrator and/or designee continue to monitor (resident #1) condition to ensure resident needs are being met. Through observations, interviews, and record reviews the surveyors determined that the interventions documented in the facility's action plan were implemented and the immediate jeopardy was removed effective 3/25/13 at 3:45 PM. The facility remained out of compliance at a scope and severity of pattern at actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. The universe of 22 residents who are dependent on staff for all care was obtained from the CMS 672 dated 3/18/13.

Based on observation, interview and record review the facility failed to immediately consult with the resident's physician for an injury that had the potential for requiring physician intervention for 1 (resident #1) of 30 residents reviewed for accidents/change of condition. On 2/19/13 between 4 PM and 5 PM, 2 Certified Nurse Aides (CNAs K and M) saw swelling and bruising on resident #1's left thigh and reported this finding to the licensed nurse (who denied being informed). On the 10 PM - 6 AM shift, 2 more CNAs noticed the bruising and swelling of resident #1 ' s left thigh and reported it to the licensed nurse (who also denied being informed). The following day (2/20/13) at 9:30 AM, CNA K reported the bruising and swelling to Licensed Vocational Nurse (LVN) H who notified the Nurse Practitioner of the bruising and swelling on resident #1 ' s left thigh. A STAT (immediate) x-ray was ordered. On 2/20/13 at 4:32 PM, LVN F received the x-rays results, failed to read the entire 2 pages that were faxed to the facility, failed to see there was a [MEDICAL CONDITION] femur and failed to notify the physician of the x-ray results. LVN F reported to the oncoming nurse, LVN G, the x-ray was negative. LVN G reported to LVN H at 6:00 AM on 2/21/13 that the x-ray was negative. When LVN H read the entire x-ray results at 10:30 AM on 2/21/13, she saw the report of resident #1 ' s fractured left femur and notified the Nurse Practitioner who ordered resident #1 transferred to the hospital. This was 41 hours after the initial finding on 2/19/13 of the swelling and bruising on resident #1 ' s left thigh. This deficient practice resulted in an immediate jeopardy identified on 3/21/13. While the immediate jeopardy was removed on 3/25/13, the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. This failure placed 22 residents who required total care at risk for not receiving appropriate and timely medical services. The findings included: Review of medical records documented resident #1 was a [AGE] year old man admitted on [DATE] and re-admitted on [DATE]. Re-admit Progress Notes dated 5/08/12 documented [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] documented resident #1 had no speech, was rarely/never understood, rarely/never understands, cognitive skills for daily decision making were severely impaired, continually present inattention and psychomotor [MEDICAL CONDITION], had physical impairments of both his upper and lower extremities that interfered with daily function and extensive assistance of 1-2 persons for ADLs (Activities of Daily Living). Review of resident #1's Comprehensive Plan of Care revised on 2/26/13 documented the resident has an ADL self care performance deficit r/t (related to) limited ROM (range of motion) due to [MEDICAL CONDITION]. The resident is totally dependent on staff for toileting, bath, dressing and grooming, enteral feedings and oral care. Resident #1 has impaired communication evidenced by reduced ability to be understood by others, reduced ability to understand others, impaired daily decision making ability and [MEDICAL CONDITION]. Review of Incident/Accident Report dated 2/20/13 documented at 9:00 AM, resident #1 had bruising and swelling of inner and outer left thigh and knee and grimacing with movement. NP W and Responsible Party (RP) were notified. Additional comments said to continue with skin checks on weekly basis as well as staff education. Recommendations/New Interventions: x-ray to left leg. Communicate between shifts. Review of Physician's Telephone Orders dated 2/20/13 at 9:20 AM documented order for STAT x-ray to left leg. Review of a late entry in the Nurse's Notes for 2/20/13 the nurse called the mobile x-ray provider at 12:00 PM to follow-up for the STAT x-ray ordered at 9:15 AM. Review of e-mail to Nursing Facility Administrator from the Account Manager of the mobile x-ray provider dated 2/26/13 documented "results were called to LVN F at 1747." (Central Daylight Time) (4:47 PM, Mountain Daylight Time) Record review of Radiology Report from mobile x-ray provider dated 2/20/13 and timed for 5:24 PM Central Time (4:24 PM Mountain Time) provided the following findings: Left Femur, single lateral view only (side view) Conclusion: 1. Acute moderately displaced fracture of proximal shaft of femur. 2. Chronic deformity of the left femoral head with possible avascular necrosis. 3. Moderate degree of [MEDICAL CONDITION]. Left Tibia and Fibula, single view (lower leg bones) Conclusion: 1. No definite radiographic evidence of acute fracture or dislocation. 2. Moderate [MEDICAL CONDITION] demonstrated. Review of Physician's Telephone Order dated 2/21/13 at 10:35 AM, documented an order to Transfer (resident #1) to a local hospital; ortho to evaluate and transfer for fracture proximal shaft of femur. In review of Nurse's Notes and Triage Nursing Assessments covering the dates of 2/19/13 through 2/21/13 there was no documentation resident #1's attending physician or surrogate was notified of the resident's fractured femur until 10:35 AM on 2/21/13. This was approximately 20 hours after the STAT x-ray was taken and 18 hours after the results for the STAT x-ray were faxed to the facility. In review of 24 Hour Report/Change of Condition Reports dated 2/19/13 through 2/21/13 the following was documented: a. 2/19/13 - nothing concerning any bruising or swelling on resident #1 b. 2/20/13 - remarks (evening) - received results c. 2/21/13 - remarks (night) (begins the day's 24 hour report) - x-ray results (-) (negative) d. 2/21/13 - Deaths/Discharges - resident #1 to hospital Left fractured femur In an observation on 3/18/13 at 1:47 PM, resident #1 was lying in bed with the head of bed elevated. He had wedge cushions on both sides of the bed. There was a landing mat standing against the wall next to the right side of the bed. There was another landing mat on the floor on the left side of the bed. Resident #1 was a small, frail man with contractures of both arms and both legs from. (Resident #1 suffered from Infantile [MEDICAL CONDITION], a brain disorder that affects a person's muscle tone and motor skills sometimes caused, among other reasons, by problems during labor and the delivery of a baby). His hips and knees were contracted in flexed positions while his arms were extended with his hands flexed. Resident #1 was able to move his upper body from side to side in a wiggling motion. He was lying with his head against the pad on the wall. Resident #1 was alert and unable to speak but he could make noises. He also was able to smile and cry. Resident #1 received nourishment through a gastrostomy tube (a tube placed through the skin into the stomach for feeding and medications). In an interview on 3/21/13 at 8:09 AM, LVN H said CNA K had worked day shift (6 am - 2 PM) on 2/20/13 and asked the LVN if she had seen resident #1's leg. LVN H went to resident #1's room and said his whole thigh and knee were bruised and swollen all around the left thigh. LVN H said resident #1 usually did not cry with movement, but he did that morning. LVN H said she called the attending physician and NP W ordered a STAT (to be done immediately) x-ray of resident #1's left leg. The mobile x-ray provider came towards the end of the day shift and the report had not been received before LVN H left for the day. When LVN H came the next morning (2/21/13), she saw in the 24 Hour Report Book that resident #1's x-ray was negative and said that was hard to believe because of how much it was swollen. LVN H said when she reached resident #1's room during med pass, he appeared to be in pain and she administered his scheduled pain medication. LVN H said resident #1's leg was still very bruised but the swelling seemed to have gone down a little. When she returned to the nurse's station at the end of the med pass, she saw the x-ray results for resident #1 on the desk. There were 2 pages. The first page were results for the left thigh and it showed a [MEDICAL CONDITION] femur. The 2nd page was the results for the x-rays of the lower leg bones which were negative for fractures. In a telephone interview on 3/21/13 at 4:09 PM, LVN G said she was not aware of any bruising on resident #1 until the next day at the beginning of her shift (10 PM - 6 AM) on 2/20/13. LVN G said when LVN F gave her report on 2/20/13, the LVN told her of the bruise on resident #1's leg and told her the x-ray of resident #1's leg was negative for a fracture. LVN G said LVN F showed her a 1 page x-ray report. LVN G said x-ray reports are placed in the 24 Hour Report book and only 1 page was in the 24 Hour Report book. When an x-ray is ordered STAT (to be done immediately) the results are called to the physician for any result - negative or positive. LVN G said LVN F told her she had called the doctor but does not remember who LVN F said she called. This information is also put onto the 24 hour report. In a telephone interview on 3/21/13 at 8:26 AM, LVN F said LVN H had found a bruise on resident #1's knee and that a CNA had told LVN F about it on 2/19/13. LVN F said this was not true. That afternoon (2/20/13) after her evening shift had started ( 2 PM - 10 PM), LVN F said the mobile x-ray provider faxed results of x-rays for resident #1. LVN F said the mobile x-ray provider called her and only asked if she had received the fax and when she said she had, they ended the call. The provider did not verbally give her the x-ray results. She read the x-ray results as negative for fractures and passed this information on to LVN G who said she was unaware of the bruise on resident #1's left leg. In a telephone interview on 3/22/13 at 9:22 AM, NP W said LVN H notified her in the morning (2/20/13) that resident #1 had a red and swollen left hip and that the hip did not look right. NP W said LVN H notified her of the x-ray result of a [MEDICAL CONDITION] either the day the x-ray was ordered or the next morning. NP W did not remember speaking to anyone else about the x-ray result. Review of the policy Condition Change of the Resident (Observing, Recording and Reporting), undated, stated the purpose was to observe, record and report any condition change to the attending physician so proper treatment will be implemented. Review of the policy Diagnostic Testing revised August 2012, stated in the part the following: Policy; It is the policy of this facility that residents receive diagnostic testing as ordered by their physician(s) and results of the testing are communicated to that physician so that prompt appropriate action can be taken if indicated for the resident's care. Procedure; When test results are received the physician will be notified of any abnormal findings on the day the results are received by the facility. Notification may be by phone, fax, or in person. The physician will be notified immediately when test results classified as critical are received. Documentation; Physician notification of results ay be documented either in the N/N or on the test result document. An immediate jeopardy was identified on 3/21/13 and the Nursing Facility Administrator, Interim Director of Nurses, Director of Nurses, Regional Director of Operations and Regional Nurse Consultant were informed at 1:54 PM on 3/21/13. The Plan of Action was accepted at 3:45 PM on 3/25/13. PLAN OF ACTION: Plan of Removal: Immediate Jeopardy based on Failure to notify Abuse Coordinator of Injury of unknown origin; failure to document assessment; failure to notify physician of x-ray results; failure to communicate shift to shift regarding the x-ray results. On February 20.2013 Charge Nurse H and LVN V assessed resident #1 head to toe and noted bruising around left knee. Charge nurse notified Nurse Practitioner who ordered x-rays of upper and lower leg. Charge nurse completed incident report and assessed resident for pain. Scheduled narcotic pain medications were administered as scheduled. On February 21, 2013, Charge Nurse H reported to Director of Nurses that x-ray results showed an acute moderately placed fracture of proximal shaft of femur, chronic deformity of the left femoral head with possible avascular necrosis and moderate degree of [MEDICAL CONDITION]. Charge notified nurse practitioner of results and orders were obtained to send resident out to hospital for treatment and evaluation. Director of Nurses reported fracture to Administrator and State reportable was filed. Facility immediately initiated investigation on same day. On February 21, 2013, ADON (Assistant Director of Nurses) and Administrator in-serviced facility staff on notifying Abuse Coordinator, Director of Nurses and Charge Nurses regarding injuries of unknown origin. Staff were educated that if Administrator and DON are not available to report incident to the Regional Vice President, (915) [PHONE NUMBER], Regional Nurse Consultant, (817) [PHONE NUMBER] or Compliance Hotline 24/7: [PHONE NUMBER]. In-service also included that facility staff should immediately report any injuries to the Charge Nurses and to use the Stop and Watch Tool to document any changes in the residents' condition that was observed. Report if the resident seems different than usual, report if the resident talks or communicates less than usual, report if the resident participated less than usual in activities, report if resident ate less than usual and it was not because they didn't like the food, report if the resident drank less than usual, report of the resident like they are losing weight, report if resident is agitated or nervous more than usual, report if the resident is tired, weak, confused or drowsy, report if the resident has a change in skin color, bruising, scrapes or in condition, and to report if the resident needs help with walking, transferring, toileting more than usual. Facility staff in-serviced on identifying skin issues on the Skin Identification Tool, on notifying the Charge Nurse of the skin issues and having the Charge Nurse to sign the Stop and Watch Tool, on making a copy of the Stop and Watch Tool and placing the copy in the box on the DON's door, and on giving the original Stop and Watch Tool to the Charge Nurse. Facility Staff were immediately in-serviced on Abuse Prohibition Policy and reporting injuries of unknown origin such as bruises and scrapes to the Abuse Coordinator and Director of Nurses. Facility staff were also in-serviced that the Administrator is the Abuse Coordinator on February 21, 2013. Charge Nurses were in-serviced on February 21/2013 on reporting injuries on unknown origin including bruising, scrapes to the Abuse Coordinator and Director of Nurses. Charge Nurses were in-serviced on February 22, 2013 on responding to resident concerns communicated by facility staff, assessing the resident in a timely manner with documentation in the chart and documentation of any follow through. Charge Nurses were in-serviced in February 28,2013 on notifying the physician, responsible party and Abuse Coordinator (Administrator), DON if abuse is suspected or injury seems out of the ordinary. If deep tissue injury/fracture is suspected, obtain orders and schedule necessary x-rays as well as obtaining treatment orders if necessary. Charge Nurses were in-serviced on February 26, 2013 on the importance of documentation in the medical record as a means of communication between physician and other professional contributing to the resident's care. Entries are to be made in a sequential manner. Charting reflects care provided during the shift. On February 22, 24 & 28, 2013 Director of Nurses, ADN & Weekend Supervisor in=serviced Charge Nurses that upon receipt of x-ray report for a resident the nurse must review the report completely. If more than one view of an x-ray was ordered, then more than likely the report will consist of an assessment and a conclusion of each view by the radiologist. Charge Nurses must review the report and ensure follow-up is done promptly as needed. If the resident sustains a fracture, Charge Nurse must notify physician, responsible party, Director of Nursing, ADON on call and the Administrator and ensure documentation is completed. Once the lab or x-ray has been noted and follow-up done, a copy of the lab or x-ray must be made and placed in the 24-Hour report book for review by oncoming nurse and ADONs. On February 26, 2013 Director of Nurses in-serviced Charge Nurses on Pain Management including the use of Pain Management Data Collection Tool and documenting any assessments of pain along with interventions. Charge Nurses were in-serviced on February 26, 2013 on notifying the Director of Nurses for falls and changes of condition. DON and/or designee conduct a daily start-up meeting Monday-Friday. DON and/or designee began documenting the start up review on the daily start up tool on March 22, 2013. The Director of Nurses, Assistant Director of Nurses, Case Mix Managers, Treatment Nurses and anyone else deemed necessary attend the Daily Start Up meeting. The Daily Start Up meeting provides nursing administration a systematic procedure for monitoring compliance in care and service areas. The meeting is approximately 30 minutes in length but the process is ongoing throughout the day. It is a look back of events since the last tour of duty which includes a review of resident conditions, documentation and many other nursing procedures that have the potential to impact resident care. The following documentation is brought to the meeting: 24 hour report Pink copies of all orders received since last meeting Incident reports Charts for any new admission, re-admissions and discharged residents Stop and Watch Tool During the meeting any changes of condition identified on the 24 hour report, incident reports and all new orders are communicated to the nursing management team. The CMMs note all changes and review the individual resident care plans for any needed update or modification, this process in ongoing. DON and/or designee during Stand Down began reviewing daily start up audit tool to ensure appropriate follow-up was completed on March 22, 2013. DON and/or designee reported to the QA/QI Committee the progress of reportable incidents, notification of physician, documentation of assessments, and shift to shift communication on March 6, 2013 and will continue to report monthly for 3 months. Facility administrator and/or designee has assigned each department head resident rooms. Each one of these department heads is the Quality of Life Specialist for these assigned rooms. Quality of Life (AOL) monitors round each morning prior to the Stand-Up meeting, this is ongoing, QoL members interview and complete a Quality of Life round form to present at daily stand up and/or stand down meetings. Quality of Life Specialist report to the attendees the results of their rounds. Any areas of concern are addressed at the meeting and plans are made to correct if not already corrected during the rounds. QoL Program is an ongoing process. Administrator maintains a notebook for these Quality of Life Rounds. Results of these rounds will be reported to the QA QI Committee X3 months. Administrator conducts daily walking rounds X5 as part of his daily duties to ensure resident and staff needs are met. On February 21, 22 & 24 management staff In-serviced staff on Stop and Watch program to include that staff should provide a copy of any Stop and Watch tool that is completed to the Director of Nurses. Director of Nurses and/or designee monitor that Stop and Watch tool being utilized by interviewing random staff X5 per week X3 months by using a questionnaire that quizzes the use of the Stop and Watch tool. The Director of Nursing and/or designee will immediately in-service staff that fail to understand how to utilize the Stop and Watch tool. Director of Nursing will report findings to the QA/QI committee for tracking and trending. Administrator and/or designee continue to monitor (resident #1) condition to ensure resident needs are being met. Through observations, interviews, and record reviews the surveyors determined that the interventions documented in the facility's action plan were implemented and the immediate jeopardy was removed effective 3/25/13 at PM. The facility remained out of compliance at a scope and severity of pattern at actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. The universe of 22 residents who are totally dependent of staff for daily care was obtained from the CMS 672 dated 3/18/13.

Based on observation, interview and record review the facility failed to develop and implement its written policies and procedures that prohibit neglect for 1 (resident #1) of 30 residents reviewed for accidents/change of condition. On 2/19/13 between 4 PM and 5 PM, 2 Certified Nurse Aides (CNAs K and M) saw swelling and bruising on resident #1's left thigh and reported this finding to the licensed nurse (who denied being informed). On the 10 PM - 6 AM shift, 2 more CNAs noticed the bruising and swelling of resident #1 ' s left thigh and reported it to the licensed nurse (who also denied being informed). The following day (2/20/13) at 9:30 AM, CNA K reported the bruising and swelling to Licensed Vocational Nurse (LVN) H who notified the Nurse Practitioner of the bruising and swelling on resident #1's left thigh. A STAT (immediate) x-ray was ordered. On 2/20/13 at 4:32 PM, LVN F received the x-rays results, failed to read the entire 2 pages that were faxed to the facility, failed to see there was a [MEDICAL CONDITION] femur and failed to notify the physician of the x-ray results. LVN F reported to the oncoming nurse, LVN G, the x-ray was negative. LVN G reported to LVN H at 6:00 AM on 2/21/13 that the x-ray was negative. When LVN H read the entire x-ray results at 10:30 AM on 2/21/13, she saw the report of resident #1's fractured left femur and notified the Nurse Practitioner who ordered resident #1 transferred to the hospital. This was 41 hours after the initial finding on 2/19/13 of the swelling and bruising on resident #1's left thigh. This deficient practice resulted in an immediate jeopardy identified on 3/21/13. While the immediate jeopardy was removed on 3/25/13, the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. This failure could place 22 residents who totally depend on the staff for care at risk for neglect due to not following policies on reporting observations in a timely manner. The findings included: Review of Abuse Prohibition Policy and Procedure revised July 2012, stated, in part the following: III. Prevention of Abuse: A. The facility will provide residents, families, staff, volunteers, staff of other agencies serving the residents, and consultants; information of how and to whom they may report concerns, incidents and grievances without fear of retribution. C. A committee selected and chaired by the Administrator or designated representative will function under the Quality Assurance and Assessment committee and meet as needed to identify, correct and intervene in situations in which abuse, neglect or misappropriation of resident property is more likely to occur. This includes an analysis of the assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents' rooms, resident with self-injurious behaviors, residents with communication disorders, those that require heavy nursing care and/or are totally dependent on staff. VII. Reporting and Response to Alleged Incidents: A. Incidents of alleged abuse, neglect or misappropriation of resident property must be reported to the appropriate local, state and federal agencies. B. All alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source, and misappropriation of resident property shall be reported immediately (not to exceed 2 hours after discovery) to the Administrator or the DON. C. If neither is in the facility when such incidents occur or are discovered after hours, the report will be given to the Charge Nurse or Supervisor in charge. D. The Charge Nurse or Supervisor must immediately contact the Administrator or the DON of the incident. Attachment A: Neglect - A deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to the resident. Review of medical records documented resident #1 was a [AGE] year old man admitted on [DATE] and re-admitted on [DATE]. Re-admit Progress Notes dated 5/08/12 documented [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] documented resident #1 had no speech, was rarely/never understood, rarely/never understands, cognitive skills for daily decision making were severely impaired, continually present inattention and psychomotor [MEDICAL CONDITION], had physical impairments of both his upper and lower extremities that interfered with daily function and extensive assistance of 1-2 persons for ADLs (Activities of Daily Living). Review of resident #1's Comprehensive Plan of Care revised on 2/26/13 documented the resident has an ADL self care performance deficit r/t (related to) limited ROM (range of motion) due to [MEDICAL CONDITION]. The resident is totally dependent on staff for toileting, bath, dressing and grooming, enteral feedings and oral care. Resident #1 has impaired communication evidenced by reduced ability to be understood by others, reduced ability to understand others, impaired daily decision making ability and [MEDICAL CONDITION]. Review of Incident/Accident Report dated 2/20/13 documented at 9:00 AM, resident #1 had bruising and swelling of inner and outer left thigh and knee and grimacing with movement. Nurse Practitioner W and Responsible Party (RP) were notified. Additional comments said to continue with skin checks on weekly basis as well as staff education. Recommendations/New Interventions: x-ray to clef leg. Communicate between shifts. Review of Physician's Telephone Orders dated 2/20/13 at 9:20 AM documented order for STAT x-ray to left leg. Review of a late entry in the Nurse's Notes for 2/20/13 the nurse called the mobile x-ray provider at 12:00 PM to follow-up for the STAT x-ray ordered at 9:15 AM. Record review of Radiology Report from mobile x-ray provider dated 2/20/13 and timed for 5:24 PM Central Time (4:24 PM Mountain Time) provided the following findings: Left Femur, single lateral view only (side view) Conclusion: 1. Acute moderately displaced fracture of proximal shaft of femur. 2. Chronic deformity of the left femoral head with possible avascular necrosis. 3. Moderate degree of [MEDICAL CONDITION]. Left Tibia and Fibula, single view (lower leg bones) Conclusion: 1. No definite radiographic evidence of acute fracture or dislocation. 2. Moderate [MEDICAL CONDITION] demonstrated. Review of Physician's Telephone Order dated 2/21/13 at 10:35 AM, documented an order to Transfer (resident #1) to a local hospital; ortho to evaluate and transfer for fracture proximal shaft of femur. In an observation on 3/18/13 at 1:47 PM, resident #1 was lying in bed with the head of bed elevated. He had wedge cushions on both sides of the bed. There was a landing mat standing against the wall next to the right side of the bed. There was another landing mat on the floor on the left side of the bed. Resident #1 was a small, frail man with contractures of both arms and both legs from. (Resident #1 suffered from Infantile [MEDICAL CONDITION], a brain disorder that affects a person's muscle tone and motor skills sometimes caused, among other reasons, by problems during labor and the delivery of a baby). His hips and knees were contracted in flexed positions while his arms were extended with his hands flexed. Resident #1 was able to move his upper body from side to side in a wiggling motion. He was lying with his head against the pad on the wall. Resident #1 was alert and unable to speak but he could make noises. He also was able to smile and cry. Resident #1 received nourishment through a gastrostomy tube (a tube placed through the skin into the stomach for feeding and medications). In an interview on 3/21/13 at 3:17 PM, CNA K said on 2/19/13 between 4 PM and 5 PM, she and CNA M pulled resident #1 up in bed and CNA M saw a bruise on resident #1's left leg. It was on the front of his thigh and was swollen also. CNA K said she told LVN Q who told her to tell her nurse. CNA K said she told LVN F to go see it and she said OK. CNA K, towards the end of the shift, said she reminded LVN F to see resident #1 and she answered she already had. When CNA K came in on the day shift (2/20/13) she said she told LVN H about the bruising and swelling on resident #1's left leg. CNA K said when anything out of the ordinary for a resident is seen, a Stop and Watch form is filled out. CNA K said she always tells the nurse and said she forgot to fill out the form and LVN F did not remind her to do so. CNA K said she did not do rounds with the nurse when she left as she left early and did not report off to the oncoming CNA either. In an interview on 3/21/13 at 4:00 PM, CNA M said she was on orientation the evening of 2/19/13. During the 2 PM - 10 PM shift she assisted CNA K to provide incontinent care for resident #1. When the covers were removed CNA M said she pointed out resident #1's red left leg to CNA K and asked what they were supposed to do. She said CNA K said they were supposed to fill out a paper and tell the nurse. After they had completed the incontinent care, CNA M said she went back to the hallway where she was orienting and did not know if CNA K told the nurse. In an interview on 3/21/13 at 8:12 PM, CNA L said she was on orientation the night of 2/19/13 and was working with CNA J. CNA L said CNA J noticed resident #1 was "fussier" than usual; usually he was very calm. CNA L said there was a bruise on resident #1's leg and LVN G went into resident #1's room after that while she and CNA J continued with their work. CNA L said she has since been trained to use a Stop and Watch form when she sees anything different about a resident. CNA L said CNA J did not talk about a Stop and Watch form that night. In an interview on 3/21/13 at 10:23 PM, with the use of a translator, CNA J said she did not see the bruise, but she reported to LVN G on 2/19/13 that resident #1 was acting different than usual and was crying. Resident #1 also was usually still, but that night he was "very unstill" - moving his upper body in the bed. CNA J said LVN G went into resident #1's room after notifying her that resident #1 was acting different. CNA J said when she sees something unusual in a resident she is supposed to fill out a Stop and Watch form to give to the nurse. CNA J said she did not fill out a Stop and Watch form that night and she did not know why she didn't. In an interview on 3/21/13 at 7:56 PM, LVN Q said she worked Monday through Friday on the 2 PM - 10 PM shift and did work the evening of 2/19/13. LVN Q said she does not remember anybody telling her about a bruise on resident #1, but that the CNAs are always telling her things about residents because she speaks Spanish and most of the CNAs speak Spanish. LVN Q said she tells the CNAs to go and tell their nurse and when she sees them heading for the other nurses, she just continues on with her work and doesn't think about what she might have been told. If a CNA tells her about one of her residents, she will act on that. In a telephone interview on 3/21/13 at 8:26 AM, LVN F said LVN H had found a bruise on resident #1's knee and a CNA had told LVN F about it on 2/19/13. LVN F said this was not true. That afternoon after her evening shift had started ( 2 PM - 10 PM), LVN F said the mobile x-ray provider faxed results of x-rays for resident #1. LVN F said the mobile x-ray provider called her and only asked if she had received the fax and when she said she had, they ended the call. The provider did not verbally give her the x-ray results. She read the x-ray results as negative for fractures and passed this information on to LVN G who said she was unaware of the bruise of resident #1's left leg. LVN F said no CNA notified her of resident #1 having a bruised and swollen left leg and if they had, she would have assessed the resident and called the doctor. A couple of nights before 2/20/12, LVN H said resident #1 was uncomfortable and grimacing - not himself, but she did not notice anything unusual. In an interview on 3/22/13 at 8:40 AM, Interim Director of Nurses (IDON) A said the facility did not have a written policy for use of the Interact II Early Warning Tool - "Stop and Watch", but provided the training materials dated 3/12/12. Review of the training materials titled "Reducing Avoidable Acute Care Transfers and Bounce Backs" dated 3/12/12 contained, in part, the following: -Goal; Staff and practitioners must recognize an acute change of condition (ACOC) and identify its nature, severity and cause(s). Interact II (Interventions to Reduce Acute Care Transfers); Early warning tools assist staff and family members to recognize and report resident changes before a condition becomes acute. -Early Warning & Skin ID Tool; We have combined these two tools to make it easier to provide the nurses with the first warning signs of something not being right with their assigned residents. In order for this tool to be utilized effectively, permanent nursing assignments and shift report WITH the CNAs is mandatory. -Communication Tools; Early Warning Tool "Stop and Watch" Pocket Card and Report. Uses: Certified Nursing Assistants; Regular evaluation of and recognition of changes in residents under their care, Reporting changes to licensed nurses. -Early Warning Tool "Stop and Watch" stated the following in part: If you have identified an important change while caring for a resident today, please circle the change and discuss it with the charge nurse before the end of your shift. Name of Resident. The form continues with the acronym "Stop and Watch" Some of the pertinent acronyms are Seems different than usual, Talks or communicates less than usual, Change in skin color or condition A human body form, front and back, is provided for the CNA to mark an "X" in the area where they have identified a skin site. The form has a space to provide the name of the staff member, who the problem was reported to and the date and time of the report. It is available in English and Spanish. -Change in Condition: When to report tot he MD/NP/PA Immediate Notification: Any symptom, sign or apparent discomfort that is: 1. Sudden in onset 2. A marked change (i.e. more severe) in relation to usual symptoms and signs 3. Unrelieved by measures already prescribed -Laboratory Tests/Diagnostic Procedures (Report Why the Test or Procedure was Done) X-ray, Report Immediately new or suspected finding (e.g., fracture, pneumonia, [MEDICAL CONDITION]) An immediate jeopardy was identified on 3/21/13 and the Nursing Facility Administrator, Interim Director of Nurses, Director of Nurses, Regional Director of Operations and Regional Nurse Consultant were informed at 1:54 PM on 3/21/13. The Plan of Action was accepted at 3:45 PM on 3/25/13. PLAN OF ACTION: Plan of Removal: Immediate Jeopardy based on Failure to notify Abuse Coordinator of Injury of unknown origin; failure to document assessment; failure to notify physician of x-ray results; failure to communicate shift to shift regarding the x-ray results. On February 20.2013 Charge Nurse H and LVN V assessed resident #1 head to toe and noted bruising around left knee. Charge nurse notified Nurse Practitioner who ordered x-rays of upper and lower leg. Charge nurse completed incident report and assessed resident for pain. Scheduled narcotic pain medications were administered as scheduled. On February 21, 2013, Charge Nurse H reported to Director of Nurses that x-ray results showed an acute moderately placed fracture of proximal shaft of femur, chronic deformity of the left femoral head with possible avascular necrosis and moderate degree of [MEDICAL CONDITION]. Charge notified nurse practitioner of results and orders were obtained to send resident out to hospital for treatment and evaluation. Director of Nurses reported fracture to Administrator and State reportable was filed. Facility immediately initiated investigation on same day. On February 21, 2013, ADON (Assistant Director of Nurses) and Administrator in-serviced facility staff on notifying Abuse Coordinator, Director of Nurses and Charge Nurses regarding injuries of unknown origin. Staff were educated that if Administrator and DON are not available to report incident to the Regional Vice President, (915) [PHONE NUMBER], Regional Nurse Consultant, (817) [PHONE NUMBER] or Compliance Hotline 24/7: [PHONE NUMBER]. In-service also included that facility staff should immediately report any injuries to the Charge Nurses and to use the Stop and Watch Tool to document any changes in the residents' condition that was observed. Report if the resident seems different than usual, report if the resident talks or communicates less than usual, report if the resident participated less than usual in activities, report if resident ate less than usual and it was not because they didn't like the food, report if the resident drank less than usual, report of the resident looks like they are losing weight, report if resident is agitated or nervous more than usual, report if the resident is tired, weak, confused or drowsy, report if the resident has a change in skin color, bruising, scrapes or in condition, and to report if the resident needs help with walking, transferring, toileting more than usual. Facility staff in-serviced on identifying skin issues on the Skin Identification Tool, on notifying the Charge Nurse of the skin issues and having the Charge Nurse to sign the Stop and Watch Tool, on making a copy of the Stop and Watch Tool and placing the copy in the box on the DON's door, and on giving the original Stop and Watch Tool to the Charge Nurse. Facility Staff were immediately in-serviced on Abuse Prohibition Policy and reporting injuries of unknown origin such as bruises and scrapes to the Abuse Coordinator and Director of Nurses. Facility staff were also in-serviced that the Administrator is the Abuse Coordinator on February 21, 2013. Charge Nurses were in-serviced on February 21, 2013 on reporting injuries of unknown origin including bruising, scrapes to the Abuse Coordinator and Director of Nurses. Charge Nurses were in-serviced on February 22, 2013 on responding to resident concerns communicated by facility staff, assessing the resident in a timely manner with documentation in the chart and documentation of any follow through. Charge Nurses were in-serviced in February 28, 2013 on notifying the physician, responsible party and Abuse Coordinator (Administrator), DON if abuse is suspected or injury seems out of the ordinary. If deep tissue injury/fracture is suspected, obtain orders and schedule necessary x-rays as well as obtaining treatment orders if necessary. Charge Nurses were in-serviced on February 26, 2013 on the importance of documentation in the medical record as a means of communication between physician and other professional contributing to the resident's care. Entries are to be made in a sequential manner. Charting reflects care provided during the shift. On February 22, 24 & 28, 2013 Director of Nurses, ADON & Weekend Supervisor in-serviced Charge Nurses that upon receipt of x-ray report for a resident the nurse must review the report completely. If more than one view of an x-ray was ordered, then more than likely the report will consist of an assessment and a conclusion of each view by the radiologist. Charge Nurses must review the report and ensure follow-up is done promptly as needed. If the resident sustains a fracture, Charge Nurse must notify physician, responsible party, Director of Nursing, ADON on call and the Administrator and ensure documentation is completed. Once the lab or x-ray has been noted and follow-up done, a copy of the lab or x-ray must be made and placed in the 24-Hour report book for review by oncoming nurse and ADONs. On February 26, 2013 Director of Nurses in-serviced Charge Nurses on Pain Management including the use of Pain Management Data Collection Tool and documenting any assessments of pain along with interventions. Charge Nurses were in-serviced on February 26, 2013 on notifying the Director of Nurses for falls and changes of condition. DON and/or designee conduct a daily start-up meeting Monday-Friday. DON and/or designee began documenting the start up review on the daily start up tool on March 22, 2013. The Director of Nurses, Assistant Director of Nurses, Case Mix Managers (CMM), Treatment Nurses and anyone else deemed necessary attend the Daily Start Up meeting. The Daily Start Up meeting provides nursing administration a systematic procedure for monitoring compliance in care and service areas. The meeting is approximately 30 minutes in length but the process is ongoing throughout the day. It is a look back of events since the last tour of duty which includes a review of resident conditions, documentation and many other nursing procedures that have the potential to impact resident care. The following documentation is brought to the meeting: 24 hour report Pink copies of all orders received since last meeting Incident reports Charts for any new admission, re-admissions and discharged residents Stop and Watch Tool During the meeting any changes of condition identified on the 24 hour report, incident reports and all new orders are communicated to the nursing management team. The CMMs note all changes and review the individual resident care plans for any needed update or modification, this process in ongoing. DON and/or designee during Stand Down began reviewing daily start up audit tool to ensure appropriate follow-up was completed on March 22, 2013. DON and/or designee reported to the QA/QI Committee the progress of reportable incidents, notification of physician, documentation of assessments, and shift to shift communication on March 6, 2013 and will continue to report monthly for 3 months. Facility administrator and/or designee has assigned each department head resident rooms. Each one of these department heads is the Quality of Life Specialist for these assigned rooms. Quality of Life (QoL) monitors round each morning prior to the Stand-Up meeting, this is ongoing, QoL members interview and complete a Quality of Life round form to present at daily stand up and/or stand down meetings. Quality of Life Specialist report to the attendees the results of their rounds. Any areas of concern are addressed at the meeting and plans are made to correct if not already corrected during the rounds. QoL Program is an ongoing process. Administrator maintains a notebook for these Quality of Life Rounds. Results of these rounds will be reported to the QA QI Committee X3 months. Administrator conducts daily walking rounds X5 as part of his daily duties to ensure resident and staff needs are met. On February 21.22 & 24 management staff In-serviced staff on Stop and Watch program to include that staff should provide a copy of any Stop and Watch tool that is completed to the Director of Nurses. Director of Nurses and/or designee monitor that Stop and Watch tool being utilized by interviewing random staff X5 per week X3 months by using a questionnaire that quizzes the use of the Stop and Watch tool. The Director of Nursing and/or designee will immediately in-service staff that fail to understand how to utilize the Stop and Watch tool. Director of Nursing will report findings to the QA/QI committee for tracking and trending. Administrator and/or designee continue to monitor (resident #1) condition to ensure resident needs are being met. Through observations, interviews, and record reviews the surveyors determined that the interventions documented in the facility's action plan were implemented and the immediate jeopardy was removed effective 3/25/13 at 3:45 PM. The facility remained out of compliance at a scope and severity of pattern at actual harm that was not immediate jeopardy. The noncompliance continued based on the facility's need to monitor its corrective action for effectiveness, and to ensure all staff received all scheduled training. The universe of 22 residents who are totally dependent on staff for care was obtained from the CMS 672 dated 3/18/13.

Based on observations, interview and record review the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable, mental, and psychosocial well-being of each resident. A. The Administrator and the Director of Nurses (DON) failed to monitor that self releasable Velcro alarm belts were applied per manufacturers recommendations even after the incident with Resident #1 who was found on 9/26/11 unresponsive with the belt around his throat, choking him. There were 9 residents during the investigation who had loose self releasable Velcro alarm belts. B. The Administrator and the DON failed to implement the policy and procedure on Fall Management by not: 1. Identifying residents at risk for falls, implementing preventive measures and completing Physical Restraint Elimination assessments for 4 (#1, #4, #6, #10) of 11 residents with self releasable Velcro alarm belts. 2. Evaluating and providing a safe environment for residents at risk for falls. These failures resulted in an immediate jeopardy that was identified 10/18/11 at 12:40 PM. While the immediate jeopardy was removed on 10/20/11, the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. This failure could place 29 residents identified to have restraints/assistive devices at risk of not receiving the necessary assessment to ensure that each resident attains and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. The findings include: RESIDENT #1: Record review of the facility's Admission Record for resident #1 documented an initial admission date of [DATE] and a re-admission date of [DATE]. A self releasable Velcro alarm belt is attached to the wheelchair and secured around the individual's waist and adjusted to the desired length. The belt is secured together in the front with Velcro and when the resident releases the belt the alarm will activate to alert staff. Record review of the facility's Incident/Accident Report dated 9/26/11 at 4:25 PM, for resident #1 documented in part: Resident was found slid off of wheelchair with the self releasable Velcro alarm belt around throat, choking him. Hematoma around neck, unresponsive. Additional comments: Staff inserviced as to safety belt placement. Wheelchair cushion positioning. Not to be left in room while up in wheelchair with seat belt. The resident was sent to the hospital and returned later to the facility. In an interview on 10/20/11 at 11:10 AM, Licensed Vocational Nurse (LVN) #I reported that resident #1 would "scoot down " in the wheelchair and he would also attempt to transfer without assistance. In an interview on 10/20/11 at 4:15 PM, CNA #U reported that Resident #1 had a tendency to slide down the wheelchair as she had to reposition him a few times. Observation on 10/13/11 at 8:30 AM revealed Resident #1 lying in low bed, said hi and stated his name, verbalized he was feeling well. Observation on 10/19/11 at 10:55 AM, revealed Resident #1 lying in a low bed in his room. His wheelchair was nest to his bed with a pressure pad alarm and pommel cushion. In an interview on 10/13/11 at 10:00 AM, ADON #C reported that resident #1 had a history of [REDACTED].#1 used to have Velcro belt when the resident sat in the wheelchair. ADON #C stated, "Resident #1 had a history of [REDACTED]. I didn't find this out until after the incident. Now resident #1 has a pressure pad alarm on his wheelchair." ADON #C reported that the self releasable Velcro alarm belt was the least restrictive measure attempted. Record review of the Restraint/Device Log provided on 10/13/11 at 11:35 AM by the Director of Nurses (DON) listed 29 residents who were currently at the facility and had orders for a restraint/assistive device. The log documented 22 residents were using Self Release Belts/Velcro Belts/ Harness Belt, Lap Buddies, G/C (Geri-chair) with lap tray, Lap Tray, and Geri-chair. In an interview on 10/18/11 at 12:10 AM with a Manufacturer Representative of the self releasable Velcro alarm belt used in the facility, revealed that the Velcro belts are supposed to fit like the seat belts in a car: not tight, however not visibly loose. There are to be adjusted according to the person's size. Observations done by surveyors on 10/17/11 and 10/18/11 to check for proper placement of self releasable Velcro seat belts with DON, ADON #C and Licensed staff, revealed the following: Observation on 10/17/11 at 12:23 PM, with ADON #C revealed resident #4 was in the dining room sitting in a wheelchair with a self releasable Velcro alarm belt. It was observed that the seat belt was loose and was on top the resident's lap. Observation on 10/18/11 at 10:05 AM, revealed resident #4 was sitting in the dining during an activity and the restorative aide was tossing a ball to residents who were sitting in a circle. It was observed that resident #4 was sliding down the wheelchair and the self releasable Velcro alarm belt was loose. It was observed that two Nurses came to the dining room, pulled the resident up and repositioned the resident. It was observed that the Nurses re-adjusted the resident's seat belt. Observation on 10/18/11 at 12:25 PM, with the DON revealed that resident #4 was sitting in a wheelchair in the dining room and the Velcro belt around her waist was loose and resting on the resident's lap. It was observed that resident #4 became aggressive and attempted to push the staff away when they explained to the resident that they need to adjust the seat belt. Observation on 10/17/11 at 11:23 AM, revealed that CNA attempted to apply the self releasable Velcro alarm belt on resident #6 who was seated in the wheelchair. The CNA stated, "one of the straps is tangled under the wheelchair on the wheel. The CNA reported that the chair alarm was off. The CNA placed the Velcro seat belt. It was observed that the seat belt was loose and was on top of the resident's lap. Observation on 10/18/11 at 11:20 AM, with LVN #H revealed that resident #6 was sitting in her wheelchair right outside her room and the self releasable Velcro alarm belt was loose and resting over her lap. LVN #H confirmed that the chair alarm was turned off. It was observed that resident #6 wheeled herself to her room. Observation on 10/18/11 at 12:25 PM, with DON revealed resident #6 was sitting in a wheelchair in the dining with a self releasable Velcro alarm belt that was loose. Observation on 10/18/11 at 8:55 AM, revealed resident #9 was sitting in a wheelchair in the hallway by her room. It was observed that the Velcro belt around the resident's waist was loose. Observation on 10/17/11 at 11:05 AM, revealed resident #12 was sitting in a wheelchair in the lobby area with a loose Velcro seat belt. Observation on 10/17/11 at 12:12 PM, with ADON #C revealed resident #12 was in the dining room sitting in a wheelchair with a self releasable Velcro alarm belt waiting for lunch to be served. It was observed that the seat belt was loose and was on top the resident's lap. Observation on 10/17/11 at 12:21 PM, with ADON #C revealed resident #13 was in the dining room sitting in a wheelchair with a self releasable Velcro alarm belt. It was observed that the seat belt was loose and was on top the resident's lap. Observation on 10/17/11 at 12:05 PM, revealed resident #14 was sitting in the hallway by her room in a wheelchair with a loose self releasable Velcro alarm belt . Observation on 10/19/11 at 12:21 PM, with ADON #C revealed that resident #14 was sitting in a wheelchair in the dining room and the self releasable Velcro alarm belt was loose. In an interview on 10/17/11 at 12:24 PM, ADON #C reported that after the incident with resident #1 he had compiled a list of those residents who had orders for self releasable belts, lap buddies, Geri-chairs, and clip belts. The ADON stated "that is when we noted that many of the resident's last assessments for Physical Restraint Elimination Assessments had not been done since April 16, 2011. I completed Physical Restraint Elimination Assessments on most of the residents. That is why all of the Physical Restraint Elimination Assessment forms in the resident ' s clinical records are dated 10/03/11 and 10/04/11. I still need to do three more residents. According to the instructions on the Physical Elimination Assessment form restrained individuals should be reviewed at least quarterly to determine whether or not they are candidates for restraint reduction, less restrictive restraining measures, or total restraint elimination. All of these assessments should be completed by the Licensed staff when the MDS nurses schedule the residents for admission, annual, significant change MDS reviews and quarterly reviews. Record review revealed Physician Telephone Order dated 4/14/11 for resident #1 documented, Use Velcro Self Release Belt when up in wheelchair due to poor safety awareness and lack of coordination. Dx Muscular Wasting. Check Q (every) 1 hour and release Q 2 hrs. x 10 minutes for repositioning. This was also documented on the physician's orders [REDACTED]. Record review revealed Consent to Use Restraint/Enabler dated 4/16/11 for resident #1 documented, " Telephone consent obtained for Self Release Velcro Belt 2 Nurses verified consent." Record review revealed Fall Risk assessment dated [DATE] for resident #1 documented a total score of 21. Total score of 10 or higher may represent high risk for falls. Record review revealed Annual MDS dated [DATE] for resident #1 documented in part: Able to verbalize needs. Required extensive assistance of two persons for bed mobility. Extensive assistance of one person with transfers, locomotion on unit, dressing, toilet use and hygiene. Limited assistance of one person with walk in room and corridor, and locomotion off unit. Not steady, only able to stabilize with human assistance when moving from seated to standing position, walking, turning around, moving on and off toilet, and surface to surface transfer (transfer between bed and chair or wheelchair). Record review with ADON #C revealed Care Plan dated 4/12/11 and revised on 9/26/11 for resident #1 documented in part: Resident #1 requires the use of a self release belt AEB (as evidenced by) cognitive impairment and history of falls. This will make staff ready to prevent falls and cause any injuries to resident #1. Record review on 10/17/11 with ADON #C revealed Care Plan dated 4/21/11 and was reviewed last reviewed on 7/6/11 documented in part: Resident requires the use of a seat belt, to prevent Resident from trying to get up without assistance and to prevent fall/injury. Falling forward or sliding out of w/c (wheelchair). Evaluate & re-evaluate for restraint/enabler use, quarterly and PRN (as needed). Monitor for proper positioning and circulatory concerns. Apply and release per order. Check every hour & release q 2 hrs (every two hours) x 10 minutes for repositioning and toileting. In an interview on 10/13/11 at 9:45 AM, LVN #I reported that Resident #1 scooted down the wheelchair and was repositioned by staff on several occasions. She reported that the self releasable Velcro alarm belt was used to prevent Resident #1 from transferring from the wheelchair without assistance. In an interview on 10/14/11 at 11:45 AM, ADON #C reported that CNA # J was the one who told him that the resident #1 would slide underneath the self releasable Velcro alarm belt and out of the wheelchair. CNA #J reported this to me when I was conducting inservice training after the incident with Resident #1. In a telephone interview on 10/14/11 at 3:09 PM, CNA # J reported that she had noticed Resident #1 sliding down in the wheelchair on two different occasions during the 2 PM-10 PM shift within the past 2 weeks and had reported this to LVN #B and LVN #M days before the incident occurred. CNA #J reported that she remembered, after the incident, that on a couple of occasions, before the incident occurred she had seen Resident #1 in bed with the self releasable Velcro alarm belt, and no alarm activated. " That is why I believe that resident #1 would get out of the wheelchair by sliding underneath the seat belt. " CNA #J stated that the resident did this to stay in bed. In an interview on 10/14/11 at 4:00 PM, LVN #B reported that CNA #J had reported to him on one occasion, "I don't remember when", that resident #1 was sliding down while sitting in the wheelchair with seat belt in place. "I instructed the CNA to reposition the resident". LVN #B said he had noticed on several occasions that the self releasable Velcro alarm belt on Resident #1 was too loose. "It's because he's very thin". LVN #B reported that he checked the seat belt once a shift and documented on the MAR (medication administration record) he had checked the seat belt for proper placement. In a telephone interview on 10/27/11 at 2:30 PM, with resident's daughter called to report that she had received a letter from the state about an incident with her father. The resident's daughter reported that she visited her father resident #1 every day. The daughter stated, " I would always find my dad sliding down in the wheelchair with the loose seat belt in place. My father was always very restless, agitated and occasionally confused." Record Review of written statement attached to incident report written by Licensed Vocational Nurse (LVN) #A dated 9/26/11 documented in part: Approximately at 4:25 PM, I was walking down the hall when I saw a resident in room A 18 b on the floor. I went to the room right away to aid the resident. I saw that the resident was choking with the chair belt. His lower body was on the floor and his neck was against the wheel chair. Wheelchair was not tilted over. Wheel chair was stable on the ground. Resident was pale and not responsive; his skin temp was cold to touch. I released the belt as soon as I got to him and tried to get him to respond back. As soon as I released the belt his color started coming back and he started to breath really heavy. I called out for LVN #B to get an oxygen tank. While I stayed with the resident the Central Supply clerk came in the room and helped me lay the resident on the floor. LVN #B got the oxygen to the room and checked the resident's oxygen saturation level. At that time Assistant Director of Nurses (ADON #C) took over and I walked out to help with the paperwork." In an interview on 10/14/11 at 2:30 PM, LVN #A reported that Resident #1 was not usually assigned to her, but the day of the incident she was taking care of half of the residents on hall B, and the other half of the residents, including resident #1, were assigned to LVN # B. She reported that she was the first person to come to Resident #1's aid when she was walking down the hall and happened to glace into Resident #1's room and noticed the lower half of his body resting on the floor and his neck caught in the self releasable Velcro alarm belt . She reported that LVN #B was not in the hallway at that time. LVN #A then confirmed what was in her written statement. LVN #A reported that on several occasions she had noticed CNAs repositioning Resident #1 because he would be sliding down in the wheelchair. She reported that this behavior had been going on " I think since (Resident #1's) admission " . Record Review of written statement attached to incident report written by LVN #B dated 9/26/11 documented in part: LVN #A reported Resident #1 is on the floor. We both went to his room immediately when LVN #A saw w/c alarm belt around resident's neck and unstrapped belt. We carried resident unto our arms. The resident was not responding to verbal commands and was gasping for air while oxygen mask was placed, resident was pale. In an interview on 10/20/11 at 2:25 PM, LVN #B stated that it was reported to him by CNA #J that Resident #1 would slouch down in the wheelchair. LVN #B stated that he did not remember if Resident #1 had a Pommel cushion (a Pommel cushion is used to prevent an individual from sliding down while sitting in a wheelchair) on his wheelchair prior to the incident on 9/26/11. Record review of written statement attached to incident report written by (ADON) #C dated 9/26/11 for documented in part: "I was called to resident's #1 room by Central Supply Clerk. He told me that resident #1 was choking. Upon entering the room, resident was laying on the floor on his back with pillow under his head. Resident was unresponsive, skin was pale and cool to touch. His mouth was open and he was mouth breathing with difficulty. Eyes were open and fixed. I spoke to resident trying to get a response without any success. I then did a sternum rub which caused resident to move slightly and caused his eyes to dilate and tried to focus. Resident did not try to speak. No moaning heard. While performing sternum rub I did notice that there were two read linear marks across resident's throat, from safety seat belt. I did the sternum rub again as resident appeared to become unresponsive again. At no time did resident cease to breath. EMS arrived at 4:39 PM. Record review of undated written statement attached to incident report written by CNA #E documented in part: Later that day I assisted CNA #D to transfer resident #1 to his wheelchair applied the self releasable Velcro alarm belt. We wheeled the resident to the dining room. Record review of undated written statement attached to incident report written by CNA #D documented in part: CNA #E asked me to help her transfer Resident #1 to the wheelchair. We took the resident to the dining room. Record review revealed Physician/NP/PA Communication and Progress Note dated 9/26/11 at 5:15 PM written by LVN #B for resident #1 documented in part: Lost of consciousness secondary to choking on w/c alarm belt. "At 4:23 PM LVN #A was walking towards my cart in A-Hall when she noticed resident #1 was on the floor halfway off the w/c. We immediately ran into room towards resident and upon getting to resident LVN #A noticed w/c alarm belt across (line through around) resident neck choking him. LVN #A immediately unhooked belt. Resident ' s skin color pale and cold to touch. Resident unresponsive but breathing. Resident was positioned on floor on his back. Redness to neck, 2 scrapes on right side of neck area front area. Record review of the EMS report dated 9/26/11 for resident #1 documented in part: Unit was dispatched at 4:30 PM and arrived at facility at 4:35 PM. Chief Complaint: Slipped from chair that had a seat belt. Seat belt was at his neck; Onset of event occurred 15 minutes prior to calling EMS. Primary Symptom: Change in responsiveness. Patient Assessment: AAO (alert and oriented) X 2, Sp O2 (oxygen saturation of patient's blood) 100% O2, respirations 20 regular. Narrative: Pt was an [AGE] year old male who was coming from a nursing home. Staff stated that he was sitting in a wheel chair and slipped down from the chair causing some straps to come to his neck. He was found on the floor. Upon arrival he was found responsive, hypotensive and there were markings to the neck area. He stated no problems. He was transferred to hospital. Record review of Hospital emergency room report dated 9/26/11 at 5:12 PM for resident #1 documented in part: Chief Complaint: Fall Injury. EMS states: found at nursing home with belt around neck/ strap marks noted to neck; pt. currently awake/alert; no apparent respiratory distress noted at this time. Diagnosis: [REDACTED]. The patient sustained neck abrasions, found choking. Record review revealed Physician Telephone Order dated 9/26/11 for resident #1 documented, OK for PT, OT, ST to eval and treat as warranted secondary to Fall Risk. Record review revealed Interdisciplinary Resident Screen dated 9/27/11 for resident #1 documented in part: Fall. Recent Fall/Restraint Assessment. Referred by staff on 9/26/11. Identified Functional Deficit/Diagnosis/Prior Level of Function/comments: Pt. restraint assessed and found to be appropriate provided that Velcro restraint belt is fitted to pt's waist and not left loose. Adjusted belt to fit pt, pt able to adjust self, but not able to slide down in w/c seat. Pt. should be monitored regularly for fit of safety belt and for pt. safety. Record review revealed Physical Restraint Elimination assessment dated [DATE] for resident #1 documented total score of 30 (21-35 Good Candidate) for restraint elimination. Resident is a Candidate for restraint reduction or elimination program. Program to start 9/27/11. Action Plan-to D/C Velcro Belt and place pressure pad alarm. Less restrictive measures to be used pressure alarm pad to w/c. Record review revealed Physician Telephone Order dated 9/27/11 for resident #1 documented, D/C (discontinue) Velcro Belt, OK to place pressure alarm pad on resident's w/c. Record review revealed Fall Risk assessment dated [DATE] for resident #1 documented a total score of 19. Total score of 10 or higher may represent high risk for falls. In an interview on 10/21/11 at 10:51 AM, ADON #C confirmed that he had updated the care plan for resident #1 on 9/26/11 that documented resident #1 was found with seat belt around neck. The ADON reported that he had added to the care plan on 9/26/11 "if in room, resident must be put to bed & door to room left open with call light within reach." The ADON confirmed that the care plan documented seat belt was DC ' d 9/27/11 and pressure alarm pad alarm was placed on w/c. Evaluate & re-evaluate for restraint use quarterly & prn. Monitor for proper positioning and circulatory concerns. Apply & release per orders." Record review on 10/21/11 revealed Care Plan that was last reviewed on 10/11/11 resident #1 documented in part: Resident is a risk for falls as evidenced by cognitive impairment, physical impairment, and poor safety awareness. 7/24/11 found on floor, 9/1/11 found on floor, 9/5/11 found on floor, 9/25/11 found on floor next to bed. Approaches: Velcro Belt while up in w/c. Enabler x 1 on bed. Bed alarm while in bed. 9/27/11 DC ' d belt and change to pressure pad alarm. Record review of the Physician's Progress Notes dated 9/28/11 for resident #1 documented in part: [AGE] year old male with multiple medical issues. Seen today S/P (status [REDACTED]. Sent to hospital and evaluated. Returned same day. Pt. denies pain. Does not remember fall. No distress noted. Diagnosis: [REDACTED]. Alert to self and purpose. Record review of the Provider's Investigation Report dated 9/26/11 at 7:30 PM, documented in part: All devices/restraints were checked by nursing administration. Staff was immediately in-serviced regarding restraint use. All charts were audited for orders, consents, assessments and care plans and updated as needed. On 9/27/11 the IDT reviewed resident #1 for restrain elimination and Velcro belt was discontinued and a pressure pad alarm was placed on w/c. Record review of a written statement written by ADON #C dated 10/19/11 provided to the surveyors on 10/21/11 by the administrator documented in part: On Sept. 26, 2011 after resident #1 was sent out to the hospital for having been choking on his self release belt, ADON #F and I checked every single resident that had a self release seat belt, lap buddy, lap tray and geri-chair. Every single resident on the list that was given to the state surveyor were visually checked by ADON #F and I. I checked all the residents on B & C halls. I made sure that the residents were sitting properly in the wheel chairs or geri-chairs, and that the self release seat belts were secured properly to the wheelchair, that the belts were connected to the alarms, and that the alarms were in good working order. I also checked to make sure that each resident was able to remove the seat belts upon command. Consents, orders for device, and pre-restraint, fall risk, and restraint reduction assessments were checked as well. That is how I came up with the form that was given to the state surveyor, which has all the residents with self release seat belts and other assistive devices. I also inserviced all the staff that was present on that shift as well as the on-coming night shift as to how residents with safety belts/devices while in wheelchairs cannot be left alone in their rooms for any reason, and that any resident with a safety belt/device must be put to bed if taken to their room. That seat belts must be in good working order, batteries in place and alarms working properly, seat belts secured properly and adjusted to resident's size. I did tell the staff to ensure that they were able to slide their hand between the resident and the seat belt to make sure that the belts weren't being applied too tight. The following morning I gave the exact same in-inservice to the morning shift. So all the restraints, seat belts, lap buddies, geri-chairs, and lap trays were inspected on the day of resident's #1 having choked on his self release seat belt and were in good working order. It was hand written on the bottom of the statement by the Administrator, "See hours attached to verify we stayed late that evening." Record review of the attached time cards revealed ADON #C had worked 14.75 hours on 9/26/11, ADON #F worked 15.87 hours on 9/26/11 and the Maintenance Director worked 10.52 hours on 9/26/11. In an interview on 10/21/11 at 10:51 AM, ADON #C reported that the Restraint Elimination assessment dated [DATE] was completed by the DON. The ADON #C stated, "I was not able to find a policy and procedure for the Physical Restraint Elimination Assessment. I even looked at our library were we have all of our policies and procedures. I talked to the Corporate Nurse Consultant who is at the facility, told me that we did not have a written policy and procedure for the use of the Physical Restraint Elimination Assessment. The Nurse Consultant said that the Physical Restraint Elimination Assessment should be completed when orders are given to use a restraint, and reviewed on a quarterly basis with all of the other assessments like the Pain assessment, Elopement assessment, Braden assessment etc. when the nurses are given the schedules (list of residents) notifying them which resident are due for a MDS and Care Plan review. I did not find any other Physical Restraint Elimination Assessment in the resident's thinned record in Medical Records. In an interview on 10/19/11 at 11:50 AM, with the Administrator, DON, and Corporate Nurse Consultant reported that not all self releasable Velcro alarm belt were used as restraints. The Corporate Nurse stated, "some seat belts are used as enablers and the residents are able to release the seat belts, so they are not restraints. We checked all of the seat belts right away to ensure that they were properly placed after the incident on 9/26/11 with resident #1. The Nurse Consultant stated, "Resident #1 was never found with the seat belt around his neck. I have no idea were you all got that information. The marks on resident #1's neck were not reported to us. This is the first time that we heard of him having marks on his neck. So if he did have marks on his neck, they did not last long because EMS did not see any marks on his neck when they came to the facility to take the resident to the hospital. So, I don't see what the issue is about the marks on the resident's neck." In an interview on 10/20/11 at 4:13 PM, with the Administrator, DON and ADON #C reported that ADON #C had check all of the clinical records on 10/18/11 for all of the residents listed on the Restraint/Device Log dated 10/13/11 and had completed most of the of the Physical Restraint Elimination Assessments on most of the residents on 10/03/11 and 10/04/11. The ADON reported that the resident's care plans had also been reviewed and updated as needed. Observation on 10/21/11 at 3:33 PM revealed that dietary supervisor was wheeling Resident #6 to the dining room. The Dietary Supervisor confirmed that Resident #6 's self releasable Velcro alarm belt was loose. In an interview on 10/21/11 at 3:51 PM, ADON #C reported that he had looked at the thinned record for resident #1 and he had not found any other Physical Restraint Elimination Assessment except for the one that was dated 9/27/11. The ADON stated, "a doubled checked the current record and there were no other Physical Restraint Elimination Assessment in the resident's clinical record." In an interview on 10/21/11 at 3:51 PM, ADON #C reported that he had doubled checked the resident's clinical record and the thinned record and he had not found any other Comprehensive Assessment for Enabler Use for resident #1 except for the one that was in the current clinical record dated 4/12/11. In an interview on 10/18/11 at 12:10 AM with a Manufacturer Representative of the Velcro belt used in the facility, revealed that the self releasable Velcro alarm belt are supposed to fit like the belts in a car: not tight, however not visibly loose. They are to be adjusted according to the person's size. In a meeting on 10/18/11 at 12:31 PM with Administrator, DON, ADON #C and Nurse Consultant it was confirmed that the manufacturer installation and use instructions documented that the self releasable Velcro alarm belt was not designed to restrain or hold individuals in position in their chairs. It also documented in part that the chair belt is not suitable for all individuals and that the device is not a substitute for visual monitoring by caregiver. RESIDENT #4: Record review revealed Admission Record documented resident #4 was admitted to the initially admitted to the facility on [DATE] and re-admitted on [DATE]. Record review revealed History & Physical dated 4/26/11 for resident #4 documented in part: [AGE] year old female with [DIAGNOSES REDACTED]. Alert to self. Mental status had declined, becomes agitated at little things. Record review with ADON #C revealed Comprehensive Plan of Care dated 4/22/11 for resident #4 documented in part: Resident requires the use of a Restraint/Enabler: Self Release Velcro Belt. The ADON confirmed that the Care Plan was blank on the section that indicated why the resident needed the Self Release Velcro Belt. The ADON confirmed that the approaches documented in part: Evaluate & re-evaluate for restraint/enabler use, quarterly and PRN. The ADON confirmed that the Care Plan was reviewed on 4/22/11, 7/6/11 and 10/06/11 and it documented continued. Record review revealed admission orders [REDACTED]. Bed alarm. Record review with ADON #C revealed that the Pre-Restraining Assessment that was completed by the DON for resident #4 on 6/03/11 was incomplete. The Pre-Restraining Assessment did not have any information written on the section under Referrals/Recommendations for Interdisciplinary Team Evaluation, Plan of Care Updates, Alternatives to restraints and Next Evaluation date. Referred to Psychologist or Psychiatrist was also blank. Record review revealed Admission MDS dated [DATE] for resident #4 documented in part: Not steady, only able to stabilize with human assistance, moving from sitting to standing position. Mobility Devices-wheelchair. Frequently incontinent of urine and always incontinent of bowel. No behavioral problems. Required extensive assistance of one person with bed mobility, transfers, dressing, toileting, and grooming. Extensive assistance with bathing. Chairfast, with limited assistance with locomotion on and off unit. Eating supervision, set up only. Rejection of care 1-3 days. Record review with MDS Nurse #T revealed a Comprehensive Plan of Care dated 9/11/11 for resident #4 documented in part: Resident #4

Based on interview and record review, it was determined that the facility failed to ensure that residents had the right to be free from any physical restraint imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 9 (ID #1, #4, #5, #6, #9, #10, #12, #13, #14) of 11 residents reviewed for restraints as evidenced by: A. The facility failed to attempt the least restrictive measure prior to using the self releasable Velcro alarm belt for Resident #1 who had a history of [REDACTED]. Resident #1 was not reassessed and no interventions were implemented to identify and evaluate risks and hazards prior to the incident on 9/26/11. Resident #1 was found 9/26/11 unresponsive with the self releasable Velcro alarm belt around his throat, choking him. The resident was sent to the hospital for evaluation and returned the same day. B. There were 9 residents who had loose self releasable Velcro alarm belt. There was no evidence that documented the facility had attempted the use of the least restrictive measures prior to using the self releasable Velcro alarm belt. These failures resulted in an immediate jeopardy that was identified 10/18/11 at 12:40 PM. While the immediate jeopardy was removed on 10/20/11, the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. This failure could place 29 residents identified to have restraints/assistive devices at risk of not receiving the necessary assessment to ensure that each resident attains and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. The findings include: RESIDENT #1: Record review of the facility's Admission Record for resident #1 documented an initial admission date of [DATE] and a re-admission date of [DATE]. A self releasable Velcro alarm belt is attached to the wheelchair and secured around the individual's waist and adjusted to the desired length. The belt is secured together in the front with Velcro and when the resident releases the belt the alarm will activate to alert staff. Record review of the facility's Incident/Accident Report dated 9/26/11 at 4:25 PM, for resident #1 documented in part: Resident was found slid off of wheelchair with the self releasable Velcro alarm belt around throat, choking him. Hematoma around neck, unresponsive. Additional comments: Staff inserviced as to safety belt placement. Wheelchair cushion positioning. Not to be left in room while up in wheelchair with seat belt. The resident was sent to the hospital and returned later to the facility. In an interview on 10/20/11 at 11:10 AM, Licensed Vocational Nurse (LVN) #I reported that resident #1 would "scoot down " in the wheelchair and he would also attempt to transfer without assistance. In an interview on 10/20/11 at 4:15 PM, CNA #U reported that Resident #1 had a tendency to slide down the wheelchair as she had to reposition him a few times. Observation on 10/13/11 at 8:30 AM revealed Resident #1 lying in low bed, said hi and stated his name, verbalized he was feeling well. Observation on 10/19/11 at 10:55 AM, revealed Resident #1 lying in a low bed in his room. His wheelchair was nest to his bed with a pressure pad alarm and pommel cushion. In an interview on 10/13/11 at 10:00 AM, ADON #C reported that resident #1 had a history of [REDACTED].#1 used to have Velcro belt when the resident sat in the wheelchair. ADON #C stated, "Resident #1 had a history of [REDACTED]. I didn't find this out until after the incident. Now resident #1 has a pressure pad alarm on his wheelchair." ADON #C reported that the self releasable Velcro alarm belt was the least restrictive measure attempted. Record review of the Restraint/Device Log provided on 10/13/11 at 11:35 AM by the Director of Nurses (DON) listed 29 residents who were currently at the facility and had orders for a restraint/assistive device. The log documented 22 residents were using Self Release Belts/Velcro Belts/ Harness Belt, Lap Buddies, G/C (Geri-chair) with lap tray, Lap Tray, and Geri-chair. Observations done by surveyors on 10/17/11 and 10/18/11 to check for proper placement of self releasable Velcro seat belts with DON, ADON #C and Licensed staff, revealed the following: Observation on 10/17/11 at 12:23 PM, with ADON #C revealed resident #4 was in the dining room sitting in a wheelchair with a self releasable Velcro alarm belt. It was observed that the seat belt was loose and was on top the resident's lap. Observation on 10/18/11 at 10:05 AM, revealed resident #4 was sitting in the dining during an activity and the restorative aide was tossing a ball to residents who were sitting in a circle. It was observed that resident #4 was sliding down the wheelchair and the self releasable Velcro alarm belt was loose. It was observed that two Nurses came to the dining room, pulled the resident up and repositioned the resident. It was observed that the Nurses re-adjusted the resident's seat belt. Observation on 10/18/11 at 12:25 PM, with the DON revealed that resident #4 was sitting in a wheelchair in the dining room and the Velcro belt around her waist was loose and resting on the resident's lap. It was observed that resident #4 became aggressive and attempted to push the staff away when they explained to the resident that they need to adjust the seat belt. Observation on 10/17/11 at 11:23 AM, revealed that CNA attempted to apply the self releasable Velcro alarm belt on resident #6 who was seated in the wheelchair. The CNA stated, "one of the straps is tangled under the wheelchair on the wheel. The CNA reported that the chair alarm was off. The CNA placed the Velcro seat belt. It was observed that the seat belt was loose and was on top of the resident's lap. Observation on 10/18/11 at 11:20 AM, with LVN #H revealed that resident #6 was sitting in her wheelchair right outside her room and the self releasable Velcro alarm belt was loose and resting over her lap. LVN #H confirmed that the chair alarm was turned off. It was observed that resident #6 wheeled herself to her room. Observation on 10/18/11 at 12:25 PM, with DON revealed resident #6 was sitting in a wheelchair in the dining with a self releasable Velcro alarm belt that was loose. Observation on 10/18/11 at 8:55 AM, revealed resident #9 was sitting in a wheelchair in the hallway by her room. It was observed that the Velcro belt around the resident's waist was loose. Observation on 10/17/11 at 11:05 AM, revealed resident #12 was sitting in a wheelchair in the lobby area with a loose Velcro seat belt. Observation on 10/17/11 at 12:12 PM, with ADON #C revealed resident #12 was in the dining room sitting in a wheelchair with a self releasable Velcro alarm belt waiting for lunch to be served. It was observed that the seat belt was loose and was on top the resident's lap. Observation on 10/17/11 at 12:21 PM, with ADON #C revealed resident #13 was in the dining room sitting in a wheelchair with a self releasable Velcro alarm belt. It was observed that the seat belt was loose and was on top the resident's lap. Observation on 10/17/11 at 12:05 PM, revealed resident #14 was sitting in the hallway by her room in a wheelchair with a loose self releasable Velcro alarm belt . Observation on 10/19/11 at 12:21 PM, with ADON #C revealed that resident #14 was sitting in a wheelchair in the dining room and the self releasable Velcro alarm belt was loose. In an interview on 10/17/11 at 12:24 PM, ADON #C reported that after the incident with resident #1 he had compiled a list of those residents who had orders for self releasable belts, lap buddies, Geri-chairs, and clip belts. The ADON stated "that is when we noted that many of the resident's last assessments for Physical Restraint Elimination Assessments had not been done since April 16, 2011. I completed Physical Restraint Elimination Assessments on most of the residents. That is why all of the Physical Restraint Elimination Assessment forms in the resident ' s clinical records are dated 10/03/11 and 10/04/11. I still need to do three more residents. According to the instructions on the Physical Elimination Assessment form restrained individuals should be reviewed at least quarterly to determine whether or not they are candidates for restraint reduction, less restrictive restraining measures, or total restraint elimination. All of these assessments should be completed by the Licensed staff when the MDS nurses schedule the residents for admission, annual, significant change MDS reviews and quarterly reviews. Record review revealed Physician Telephone Order dated 4/14/11 for resident #1 documented, Use Velcro Self Release Belt when up in wheelchair due to poor safety awareness and lack of coordination. Dx Muscular Wasting. Check Q (every) 1 hour and release Q 2 hrs. x 10 minutes for repositioning. This was also documented on the physician's orders [REDACTED]. Record review revealed Consent to Use Restraint/Enabler dated 4/16/11 for resident #1 documented, " Telephone consent obtained for Self Release Velcro Belt 2 Nurses verified consent." Record review revealed Fall Risk assessment dated [DATE] for resident #1 documented a total score of 21. Total score of 10 or higher may represent high risk for falls. Record review revealed Annual MDS dated [DATE] for resident #1 documented in part: Able to verbalize needs. Required extensive assistance of two persons for bed mobility. Extensive assistance of one person with transfers, locomotion on unit, dressing, toilet use and hygiene. Limited assistance of one person with walk in room and corridor, and locomotion off unit. Not steady, only able to stabilize with human assistance when moving from seated to standing position, walking, turning around, moving on and off toilet, and surface to surface transfer (transfer between bed and chair or wheelchair). Record review with ADON #C revealed Care Plan dated 4/12/11 and revised on 9/26/11 for resident #1 documented in part: Resident #1 requires the use of a self release belt AEB (as evidenced by) cognitive impairment and history of falls. This will make staff ready to prevent falls and cause any injuries to resident #1. Record review on 10/17/11 with ADON #C revealed Care Plan dated 4/21/11 and was reviewed last reviewed on 7/6/11 documented in part: Resident requires the use of a seat belt, to prevent Resident from trying to get up without assistance and to prevent fall/injury. Falling forward or sliding out of w/c (wheelchair). Evaluate & re-evaluate for restraint/enabler use, quarterly and PRN (as needed). Monitor for proper positioning and circulatory concerns. Apply and release per order. Check every hour & release q 2 hrs (every two hours) x 10 minutes for repositioning and toileting. In an interview on 10/13/11 at 9:45 AM, LVN #I reported that Resident #1 scooted down the wheelchair and was repositioned by staff on several occasions. She reported that the self releasable Velcro alarm belt was used to prevent Resident #1 from transferring from the wheelchair without assistance. In an interview on 10/14/11 at 11:45 AM, ADON #C reported that CNA # J was the one who told him that the resident #1 would slide underneath the self releasable Velcro alarm belt and out of the wheelchair. CNA #J reported this to me when I was conducting inservice training after the incident with Resident #1. In a telephone interview on 10/14/11 at 3:09 PM, CNA # J reported that she had noticed Resident #1 sliding down in the wheelchair on two different occasions during the 2 PM-10 PM shift within the past 2 weeks and had reported this to LVN #B and LVN #M days before the incident occurred. CNA #J reported that she remembered, after the incident, that on a couple of occasions, before the incident occurred she had seen Resident #1 in bed with the self releasable Velcro alarm belt, and no alarm activated. " That is why I believe that resident #1 would get out of the wheelchair by sliding underneath the seat belt. " CNA #J stated that the resident did this to stay in bed. In an interview on 10/14/11 at 4:00 PM, LVN #B reported that CNA #J had reported to him on one occasion, "I don't remember when", that resident #1 was sliding down while sitting in the wheelchair with seat belt in place. "I instructed the CNA to reposition the resident". LVN #B said he had noticed on several occasions that the self releasable Velcro alarm belt on Resident #1 was too loose. "It's because he's very thin". LVN #B reported that he checked the seat belt once a shift and documented on the MAR (medication administration record) he had checked the seat belt for proper placement. In a telephone interview on 10/27/11 at 2:30 PM, with resident's daughter called to report that she had received a letter from the state about an incident with her father. The resident's daughter reported that she visited her father resident #1 every day. The daughter stated, " I would always find my dad sliding down in the wheelchair with the loose seat belt in place. My father was always very restless, agitated and occasionally confused." Record Review of written statement attached to incident report written by Licensed Vocational Nurse (LVN) #A dated 9/26/11 documented in part: Approximately at 4:25 PM, I was walking down the hall when I saw a resident in room A 18 b on the floor. I went to the room right away to aid the resident. I saw that the resident was choking with the chair belt. His lower body was on the floor and his neck was against the wheel chair. Wheelchair was not tilted over. Wheel chair was stable on the ground. Resident was pale and not responsive; his skin temp was cold to touch. I released the belt as soon as I got to him and tried to get him to respond back. As soon as I released the belt his color started coming back and he started to breath really heavy. I called out for LVN #B to get an oxygen tank. While I stayed with the resident the Central Supply clerk came in the room and helped me lay the resident on the floor. LVN #B got the oxygen to the room and checked the resident's oxygen saturation level. At that time Assistant Director of Nurses (ADON #C) took over and I walked out to help with the paperwork." In an interview on 10/14/11 at 2:30 PM, LVN #A reported that Resident #1 was not usually assigned to her, but the day of the incident she was taking care of half of the residents on hall B, and the other half of the residents, including resident #1, were assigned to LVN # B. She reported that she was the first person to come to Resident #1's aid when she was walking down the hall and happened to glace into Resident #1's room and noticed the lower half of his body resting on the floor and his neck caught in the self releasable Velcro alarm belt . She reported that LVN #B was not in the hallway at that time. LVN #A then confirmed what was in her written statement. LVN #A reported that on several occasions she had noticed CNAs repositioning Resident #1 because he would be sliding down in the wheelchair. She reported that this behavior had been going on " I think since (Resident #1's) admission " . Record Review of written statement attached to incident report written by LVN #B dated 9/26/11 documented in part: LVN #A reported Resident #1 is on the floor. We both went to his room immediately when LVN #A saw w/c alarm belt around resident's neck and unstrapped belt. We carried resident unto our arms. The resident was not responding to verbal commands and was gasping for air while oxygen mask was placed, resident was pale. In an interview on 10/20/11 at 2:25 PM, LVN #B stated that it was reported to him by CNA #J that Resident #1 would slouch down in the wheelchair. LVN #B stated that he did not remember if Resident #1 had a Pommel cushion (a Pommel cushion is used to prevent an individual from sliding down while sitting in a wheelchair) on his wheelchair prior to the incident on 9/26/11. Record review of written statement attached to incident report written by (ADON) #C dated 9/26/11 for documented in part: "I was called to resident's #1 room by Central Supply Clerk. He told me that resident #1 was choking. Upon entering the room, resident was laying on the floor on his back with pillow under his head. Resident was unresponsive, skin was pale and cool to touch. His mouth was open and he was mouth breathing with difficulty. Eyes were open and fixed. I spoke to resident trying to get a response without any success. I then did a sternum rub which caused resident to move slightly and caused his eyes to dilate and tried to focus. Resident did not try to speak. No moaning heard. While performing sternum rub I did notice that there were two read linear marks across resident's throat, from safety seat belt. I did the sternum rub again as resident appeared to become unresponsive again. At no time did resident cease to breath. EMS arrived at 4:39 PM. Record review of undated written statement attached to incident report written by CNA #E documented in part: Later that day I assisted CNA #D to transfer resident #1 to his wheelchair applied the self releasable Velcro alarm belt. We wheeled the resident to the dining room. Record review of undated written statement attached to incident report written by CNA #D documented in part: CNA #E asked me to help her transfer Resident #1 to the wheelchair. We took the resident to the dining room. Record review revealed Physician/NP/PA Communication and Progress Note dated 9/26/11 at 5:15 PM written by LVN #B for resident #1 documented in part: Lost of consciousness secondary to choking on w/c alarm belt. "At 4:23 PM LVN #A was walking towards my cart in A-Hall when she noticed resident #1 was on the floor halfway off the w/c. We immediately ran into room towards resident and upon getting to resident LVN #A noticed w/c alarm belt across (line through around) resident neck choking him. LVN #A immediately unhooked belt. Resident ' s skin color pale and cold to touch. Resident unresponsive but breathing. Resident was positioned on floor on his back. Redness to neck, 2 scrapes on right side of neck area front area. Record review of the EMS report dated 9/26/11 for resident #1 documented in part: Unit was dispatched at 4:30 PM and arrived at facility at 4:35 PM. Chief Complaint: Slipped from chair that had a seat belt. Seat belt was at his neck; Onset of event occurred 15 minutes prior to calling EMS. Primary Symptom: Change in responsiveness. Patient Assessment: AAO (alert and oriented) X 2, Sp O2 (oxygen saturation of patient's blood) 100% O2, respirations 20 regular. Narrative: Pt was an [AGE] year old male who was coming from a nursing home. Staff stated that he was sitting in a wheel chair and slipped down from the chair causing some straps to come to his neck. He was found on the floor. Upon arrival he was found responsive, hypotensive and there were markings to the neck area. He stated no problems. He was transferred to hospital. Record review of Hospital emergency room report dated 9/26/11 at 5:12 PM for resident #1 documented in part: Chief Complaint: Fall Injury. EMS states: found at nursing home with belt around neck/ strap marks noted to neck; pt. currently awake/alert; no apparent respiratory distress noted at this time. Diagnosis: [REDACTED]. The patient sustained neck abrasions, found choking. Record review revealed Physician Telephone Order dated 9/26/11 for resident #1 documented, OK for PT, OT, ST to eval and treat as warranted secondary to Fall Risk. Record review revealed Interdisciplinary Resident Screen dated 9/27/11 for resident #1 documented in part: Fall. Recent Fall/Restraint Assessment. Referred by staff on 9/26/11. Identified Functional Deficit/Diagnosis/Prior Level of Function/comments: Pt. restraint assessed and found to be appropriate provided that Velcro restraint belt is fitted to pt's waist and not left loose. Adjusted belt to fit pt, pt able to adjust self, but not able to slide down in w/c seat. Pt. should be monitored regularly for fit of safety belt and for pt. safety. Record review revealed Physical Restraint Elimination assessment dated [DATE] for resident #1 documented total score of 30 (21-35 Good Candidate) for restraint elimination. Resident is a Candidate for restraint reduction or elimination program. Program to start 9/27/11. Action Plan-to D/C Velcro Belt and place pressure pad alarm. Less restrictive measures to be used pressure alarm pad to w/c. Record review revealed Physician Telephone Order dated 9/27/11 for resident #1 documented, D/C (discontinue) Velcro Belt, OK to place pressure alarm pad on resident's w/c. Record review revealed Fall Risk assessment dated [DATE] for resident #1 documented a total score of 19. Total score of 10 or higher may represent high risk for falls. In an interview on 10/21/11 at 10:51 AM, ADON #C confirmed that he had updated the care plan for resident #1 on 9/26/11 that documented resident #1 was found with seat belt around neck. The ADON reported that he had added to the care plan on 9/26/11 "if in room, resident must be put to bed & door to room left open with call light within reach." The ADON confirmed that the care plan documented seat belt was DC ' d 9/27/11 and pressure alarm pad alarm was placed on w/c. Evaluate & re-evaluate for restraint use quarterly & prn. Monitor for proper positioning and circulatory concerns. Apply & release per orders." Record review on 10/21/11 revealed Care Plan that was last reviewed on 10/11/11 resident #1 documented in part: Resident is a risk for falls as evidenced by cognitive impairment, physical impairment, and poor safety awareness. 7/24/11 found on floor, 9/1/11 found on floor, 9/5/11 found on floor, 9/25/11 found on floor next to bed. Approaches: Velcro Belt while up in w/c. Enabler x 1 on bed. Bed alarm while in bed. 9/27/11 DC ' d belt and change to pressure pad alarm. Record review of the Physician's Progress Notes dated 9/28/11 for resident #1 documented in part: [AGE] year old male with multiple medical issues. Seen today S/P (status [REDACTED]. Sent to hospital and evaluated. Returned same day. Pt. denies pain. Does not remember fall. No distress noted. Diagnosis: [REDACTED]. Alert to self and purpose. Record review of the Provider's Investigation Report dated 9/26/11 at 7:30 PM, documented in part: All devices/restraints were checked by nursing administration. Staff was immediately in-serviced regarding restraint use. All charts were audited for orders, consents, assessments and care plans and updated as needed. On 9/27/11 the IDT reviewed resident #1 for restrain elimination and Velcro belt was discontinued and a pressure pad alarm was placed on w/c. Record review of a written statement written by ADON #C dated 10/19/11 provided to the surveyors on 10/21/11 by the administrator documented in part: On Sept. 26, 2011 after resident #1 was sent out to the hospital for having been choking on his self release belt, ADON #F and I checked every single resident that had a self release seat belt, lap buddy, lap tray and geri-chair. Every single resident on the list that was given to the state surveyor were visually checked by ADON #F and I. I checked all the residents on B & C halls. I made sure that the residents were sitting properly in the wheel chairs or geri-chairs, and that the self release seat belts were secured properly to the wheelchair, that the belts were connected to the alarms, and that the alarms were in good working order. I also checked to make sure that each resident was able to remove the seat belts upon command. Consents, orders for device, and pre-restraint, fall risk, and restraint reduction assessments were checked as well. That is how I came up with the form that was given to the state surveyor, which has all the residents with self release seat belts and other assistive devices. I also inserviced all the staff that was present on that shift as well as the on-coming night shift as to how residents with safety belts/devices while in wheelchairs cannot be left alone in their rooms for any reason, and that any resident with a safety belt/device must be put to bed if taken to their room. That seat belts must be in good working order, batteries in place and alarms working properly, seat belts secured properly and adjusted to resident's size. I did tell the staff to ensure that they were able to slide their hand between the resident and the seat belt to make sure that the belts weren't being applied too tight. The following morning I gave the exact same in-inservice to the morning shift. So all the restraints, seat belts, lap buddies, geri-chairs, and lap trays were inspected on the day of resident's #1 having choked on his self release seat belt and were in good working order. It was hand written on the bottom of the statement by the Administrator, "See hours attached to verify we stayed late that evening." Record review of the attached time cards revealed ADON #C had worked 14.75 hours on 9/26/11, ADON #F worked 15.87 hours on 9/26/11 and the Maintenance Director worked 10.52 hours on 9/26/11. In an interview on 10/21/11 at 10:51 AM, ADON #C reported that the Restraint Elimination assessment dated [DATE] was completed by the DON. The ADON #C stated, "I was not able to find a policy and procedure for the Physical Restraint Elimination Assessment. I even looked at our library were we have all of our policies and procedures. I talked to the Corporate Nurse Consultant who is at the facility, told me that we did not have a written policy and procedure for the use of the Physical Restraint Elimination Assessment. The Nurse Consultant said that the Physical Restraint Elimination Assessment should be completed when orders are given to use a restraint, and reviewed on a quarterly basis with all of the other assessments like the Pain assessment, Elopement assessment, Braden assessment etc. when the nurses are given the schedules (list of residents) notifying them which resident are due for a MDS and Care Plan review. I did not find any other Physical Restraint Elimination Assessment in the resident's thinned record in Medical Records. In an interview on 10/19/11 at 11:50 AM, with the Administrator, DON, and Corporate Nurse Consultant reported that not all self releasable Velcro alarm belt were used as restraints. The Corporate Nurse stated, "some seat belts are used as enablers and the residents are able to release the seat belts, so they are not restraints. We checked all of the seat belts right away to ensure that they were properly placed after the incident on 9/26/11 with resident #1. The Nurse Consultant stated, "Resident #1 was never found with the seat belt around his neck. I have no idea were you all got that information. The marks on resident #1's neck were not reported to us. This is the first time that we heard of him having marks on his neck. So if he did have marks on his neck, they did not last long because EMS did not see any marks on his neck when they came to the facility to take the resident to the hospital. So, I don't see what the issue is about the marks on the resident's neck." In an interview on 10/20/11 at 4:13 PM, with the Administrator, DON and ADON #C reported that ADON #C had check all of the clinical records on 10/18/11 for all of the residents listed on the Restraint/Device Log dated 10/13/11 and had completed most of the of the Physical Restraint Elimination Assessments on most of the residents on 10/03/11 and 10/04/11. The ADON reported that the resident's care plans had also been reviewed and updated as needed. Observation on 10/21/11 at 3:33 PM revealed that dietary supervisor was wheeling Resident #6 to the dining room. The Dietary Supervisor confirmed that Resident #6 's self releasable Velcro alarm belt was loose. In an interview on 10/21/11 at 3:51 PM, ADON #C reported that he had looked at the thinned record for resident #1 and he had not found any other Physical Restraint Elimination Assessment except for the one that was dated 9/27/11. The ADON stated, "a doubled checked the current record and there were no other Physical Restraint Elimination Assessment in the resident's clinical record." In an interview on 10/21/11 at 3:51 PM, ADON #C reported that he had doubled checked the resident's clinical record and the thinned record and he had not found any other Comprehensive Assessment for Enabler Use for resident #1 except for the one that was in the current clinical record dated 4/12/11. In an interview on 10/18/11 at 12:10 AM with a Manufacturer Representative of the Velcro belt used in the facility, revealed that the self releasable Velcro alarm belt are supposed to fit like the belts in a car: not tight, however not visibly loose. They are to be adjusted according to the person's size. In a meeting on 10/18/11 at 12:31 PM with Administrator, DON, ADON #C and Nurse Consultant it was confirmed that the manufacturer installation and use instructions documented that the self releasable Velcro alarm belt was not designed to restrain or hold individuals in position in their chairs. It also documented in part that the chair belt is not suitable for all individuals and that the device is not a substitute for visual monitoring by caregiver. RESIDENT #4: Record review revealed Admission Record documented resident #4 was admitted to the initially admitted to the facility on [DATE] and re-admitted on [DATE]. Record review revealed History & Physical dated 4/26/11 for resident #4 documented in part: [AGE] year old female with [DIAGNOSES REDACTED]. Alert to self. Mental status had declined, becomes agitated at little things. Record review with ADON #C revealed Comprehensive Plan of Care dated 4/22/11 for resident #4 documented in part: Resident requires the use of a Restraint/Enabler: Self Release Velcro Belt. The ADON confirmed that the Care Plan was blank on the section that indicated why the resident needed the Self Release Velcro Belt. The ADON confirmed that the approaches documented in part: Evaluate & re-evaluate for restraint/enabler use, quarterly and PRN. The ADON confirmed that the Care Plan was reviewed on 4/22/11, 7/6/11 and 10/06/11 and it documented continued. Record review revealed admission orders [REDACTED]. Bed alarm. Record review with ADON #C revealed that the Pre-Restraining Assessment that was completed by the DON for resident #4 on 6/03/11 was incomplete. The Pre-Restraining Assessment did not have any information written on the section under Referrals/Recommendations for Interdisciplinary Team Evaluation, Plan of Care Updates, Alternatives to restraints and Next Evaluation date. Referred to Psychologist or Psychiatrist was also blank. Record review revealed Admission MDS dated [DATE] for resident #4 documented in part: Not steady, only able to stabilize with human assistance, moving from sitting to standing position. Mobility Devices-wheelchair. Frequently incontinent of urine and always incontinent of bowel. No behavioral problems. Required extensive assistance of one person with bed mobility, transfers, dressing, toileting, and grooming. Extensive assistance with bathing. Chairfast, with limited assistance with locomotion on and off unit. Eating supervision, set up only. Rejection of care 1-3 days. Record review with MDS Nurse #T revealed a Comprehensive Plan of Care dated 9/11/11 for resident #4 documented in part: Resident #4 is a risk for falls. The Care Plan documented it was last reviewed on 10/06/11. Approaches documented in part: Encourage resident to ask for assistance of

Based on interview and record review, it was determined that the facility failed to ensure that residents had the right to be free from any physical restraint imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 9 (ID #1, #4, #5, #6, #9, #10, #12, #13, #14) of 11 residents reviewed for restraints as evidenced by: A. The facility failed to attempt the least restrictive measure prior to using the self releasable Velcro alarm belt for Resident #1 who had a history of [REDACTED]. Resident #1 was not reassessed and no interventions were implemented to identify and evaluate risks and hazards prior to the incident on 9/26/11. Resident #1 was found 9/26/11 unresponsive with the self releasable Velcro alarm belt around his throat, choking him. The resident was sent to the hospital for evaluation and returned the same day. B. There were 9 residents who had loose self releasable Velcro alarm belts. There was no evidence that documented the facility had attempted the use of least restrictive measures prior to using the seat belts. These failures resulted in an immediate jeopardy that was identified 10/18/11 at 12:40 PM. While the immediate jeopardy was removed on 10/20/11, the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. These failures placed 29 residents with self-release belts at risk of injury and/or death by not applying the self releasable Velcro alarm belts according to manufacturer 's recommendations. The findings include: RESIDENT #1: Record review of the facility's Admission Record for resident #1 documented an initial admission date of [DATE] and a re-admission date of [DATE]. A self releasable Velcro alarm belt is attached to the wheelchair and secured around the individual's waist and adjusted to the desired length. The belt is secured together in the front with Velcro and when the resident releases the belt the alarm will activate to alert staff. Record review of the facility's Incident/Accident Report dated 9/26/11 at 4:25 PM, for resident #1 documented in part: Resident was found slid off of wheelchair with the self releasable Velcro alarm belt around throat, choking him. Hematoma around neck, unresponsive. Additional comments: Staff inserviced as to safety belt placement. Wheelchair cushion positioning. Not to be left in room while up in wheelchair with seat belt. The resident was sent to the hospital and returned later to the facility. In an interview on 10/20/11 at 11:10 AM, Licensed Vocational Nurse (LVN) #I reported that resident #1 would "scoot down " in the wheelchair and he would also attempt to transfer without assistance. In an interview on 10/20/11 at 4:15 PM, CNA #U reported that Resident #1 had a tendency to slide down the wheelchair as she had to reposition him a few times. Observation on 10/13/11 at 8:30 AM revealed Resident #1 lying in low bed, said hi and stated his name, verbalized he was feeling well. Observation on 10/19/11 at 10:55 AM, revealed Resident #1 lying in a low bed in his room. His wheelchair was nest to his bed with a pressure pad alarm and pommel cushion. In an interview on 10/13/11 at 10:00 AM, ADON #C reported that resident #1 had a history of [REDACTED].#1 used to have Velcro belt when the resident sat in the wheelchair. ADON #C stated, "Resident #1 had a history of [REDACTED]. I didn't find this out until after the incident. Now resident #1 has a pressure pad alarm on his wheelchair." ADON #C reported that the self releasable Velcro alarm belt was the least restrictive measure attempted. Record review of the Restraint/Device Log provided on 10/13/11 at 11:35 AM by the Director of Nurses (DON) listed 29 residents who were currently at the facility and had orders for a restraint/assistive device. The log documented 22 residents were using Self Release Belts/Velcro Belts/ Harness Belt, Lap Buddies, G/C (Geri-chair) with lap tray, Lap Tray, and Geri-chair. Observations done by surveyors on 10/17/11 and 10/18/11 to check for proper placement of self releasable Velcro seat belts with DON, ADON #C and Licensed staff, revealed the following: Observation on 10/17/11 at 12:23 PM, with ADON #C revealed resident #4 was in the dining room sitting in a wheelchair with a self releasable Velcro alarm belt. It was observed that the seat belt was loose and was on top the resident's lap. Observation on 10/18/11 at 10:05 AM, revealed resident #4 was sitting in the dining during an activity and the restorative aide was tossing a ball to residents who were sitting in a circle. It was observed that resident #4 was sliding down the wheelchair and the self releasable Velcro alarm belt was loose. It was observed that two Nurses came to the dining room, pulled the resident up and repositioned the resident. It was observed that the Nurses re-adjusted the resident's seat belt. Observation on 10/18/11 at 12:25 PM, with the DON revealed that resident #4 was sitting in a wheelchair in the dining room and the Velcro belt around her waist was loose and resting on the resident's lap. It was observed that resident #4 became aggressive and attempted to push the staff away when they explained to the resident that they need to adjust the seat belt. Observation on 10/17/11 at 11:23 AM, revealed that CNA attempted to apply the self releasable Velcro alarm belt on resident #6 who was seated in the wheelchair. The CNA stated, "one of the straps is tangled under the wheelchair on the wheel. The CNA reported that the chair alarm was off. The CNA placed the Velcro seat belt. It was observed that the seat belt was loose and was on top of the resident's lap. Observation on 10/18/11 at 11:20 AM, with LVN #H revealed that resident #6 was sitting in her wheelchair right outside her room and the self releasable Velcro alarm belt was loose and resting over her lap. LVN #H confirmed that the chair alarm was turned off. It was observed that resident #6 wheeled herself to her room. Observation on 10/18/11 at 12:25 PM, with DON revealed resident #6 was sitting in a wheelchair in the dining with a self releasable Velcro alarm belt that was loose. Observation on 10/18/11 at 8:55 AM, revealed resident #9 was sitting in a wheelchair in the hallway by her room. It was observed that the Velcro belt around the resident's waist was loose. Observation on 10/17/11 at 11:05 AM, revealed resident #12 was sitting in a wheelchair in the lobby area with a loose Velcro seat belt. Observation on 10/17/11 at 12:12 PM, with ADON #C revealed resident #12 was in the dining room sitting in a wheelchair with a self releasable Velcro alarm belt waiting for lunch to be served. It was observed that the seat belt was loose and was on top the resident's lap. Observation on 10/17/11 at 12:21 PM, with ADON #C revealed resident #13 was in the dining room sitting in a wheelchair with a self releasable Velcro alarm belt. It was observed that the seat belt was loose and was on top the resident's lap. Observation on 10/17/11 at 12:05 PM, revealed resident #14 was sitting in the hallway by her room in a wheelchair with a loose self releasable Velcro alarm belt . Observation on 10/19/11 at 12:21 PM, with ADON #C revealed that resident #14 was sitting in a wheelchair in the dining room and the self releasable Velcro alarm belt was loose. In an interview on 10/17/11 at 12:24 PM, ADON #C reported that after the incident with resident #1 he had compiled a list of those residents who had orders for self releasable belts, lap buddies, Geri-chairs, and clip belts. The ADON stated "that is when we noted that many of the resident's last assessments for Physical Restraint Elimination Assessments had not been done since April 16, 2011. I completed Physical Restraint Elimination Assessments on most of the residents. That is why all of the Physical Restraint Elimination Assessment forms in the resident ' s clinical records are dated 10/03/11 and 10/04/11. I still need to do three more residents. According to the instructions on the Physical Elimination Assessment form restrained individuals should be reviewed at least quarterly to determine whether or not they are candidates for restraint reduction, less restrictive restraining measures, or total restraint elimination. All of these assessments should be completed by the Licensed staff when the MDS nurses schedule the residents for admission, annual, significant change MDS reviews and quarterly reviews. Record review revealed Physician Telephone Order dated 4/14/11 for resident #1 documented, Use Velcro Self Release Belt when up in wheelchair due to poor safety awareness and lack of coordination. Dx Muscular Wasting. Check Q (every) 1 hour and release Q 2 hrs. x 10 minutes for repositioning. This was also documented on the physician's orders [REDACTED]. Record review revealed Consent to Use Restraint/Enabler dated 4/16/11 for resident #1 documented, " Telephone consent obtained for Self Release Velcro Belt 2 Nurses verified consent." Record review revealed Fall Risk assessment dated [DATE] for resident #1 documented a total score of 21. Total score of 10 or higher may represent high risk for falls. Record review revealed Annual MDS dated [DATE] for resident #1 documented in part: Able to verbalize needs. Required extensive assistance of two persons for bed mobility. Extensive assistance of one person with transfers, locomotion on unit, dressing, toilet use and hygiene. Limited assistance of one person with walk in room and corridor, and locomotion off unit. Not steady, only able to stabilize with human assistance when moving from seated to standing position, walking, turning around, moving on and off toilet, and surface to surface transfer (transfer between bed and chair or wheelchair). Record review with ADON #C revealed Care Plan dated 4/12/11 and revised on 9/26/11 for resident #1 documented in part: Resident #1 requires the use of a self release belt AEB (as evidenced by) cognitive impairment and history of falls. This will make staff ready to prevent falls and cause any injuries to resident #1. Record review on 10/17/11 with ADON #C revealed Care Plan dated 4/21/11 and was reviewed last reviewed on 7/6/11 documented in part: Resident requires the use of a seat belt, to prevent Resident from trying to get up without assistance and to prevent fall/injury. Falling forward or sliding out of w/c (wheelchair). Evaluate & re-evaluate for restraint/enabler use, quarterly and PRN (as needed). Monitor for proper positioning and circulatory concerns. Apply and release per order. Check every hour & release q 2 hrs (every two hours) x 10 minutes for repositioning and toileting. In an interview on 10/13/11 at 9:45 AM, LVN #I reported that Resident #1 scooted down the wheelchair and was repositioned by staff on several occasions. She reported that the self releasable Velcro alarm belt was used to prevent Resident #1 from transferring from the wheelchair without assistance. In an interview on 10/14/11 at 11:45 AM, ADON #C reported that CNA # J was the one who told him that the resident #1 would slide underneath the self releasable Velcro alarm belt and out of the wheelchair. CNA #J reported this to me when I was conducting inservice training after the incident with Resident #1. In a telephone interview on 10/14/11 at 3:09 PM, CNA # J reported that she had noticed Resident #1 sliding down in the wheelchair on two different occasions during the 2 PM-10 PM shift within the past 2 weeks and had reported this to LVN #B and LVN #M days before the incident occurred. CNA #J reported that she remembered, after the incident, that on a couple of occasions, before the incident occurred she had seen Resident #1 in bed with the self releasable Velcro alarm belt, and no alarm activated. " That is why I believe that resident #1 would get out of the wheelchair by sliding underneath the seat belt. " CNA #J stated that the resident did this to stay in bed. In an interview on 10/14/11 at 4:00 PM, LVN #B reported that CNA #J had reported to him on one occasion, "I don't remember when", that resident #1 was sliding down while sitting in the wheelchair with seat belt in place. "I instructed the CNA to reposition the resident". LVN #B said he had noticed on several occasions that the self releasable Velcro alarm belt on Resident #1 was too loose. "It's because he's very thin". LVN #B reported that he checked the seat belt once a shift and documented on the MAR (medication administration record) he had checked the seat belt for proper placement. In a telephone interview on 10/27/11 at 2:30 PM, with resident's daughter called to report that she had received a letter from the state about an incident with her father. The resident's daughter reported that she visited her father resident #1 every day. The daughter stated, " I would always find my dad sliding down in the wheelchair with the loose seat belt in place. My father was always very restless, agitated and occasionally confused." Record Review of written statement attached to incident report written by Licensed Vocational Nurse (LVN) #A dated 9/26/11 documented in part: Approximately at 4:25 PM, I was walking down the hall when I saw a resident in room A 18 b on the floor. I went to the room right away to aid the resident. I saw that the resident was choking with the chair belt. His lower body was on the floor and his neck was against the wheel chair. Wheelchair was not tilted over. Wheel chair was stable on the ground. Resident was pale and not responsive; his skin temp was cold to touch. I released the belt as soon as I got to him and tried to get him to respond back. As soon as I released the belt his color started coming back and he started to breath really heavy. I called out for LVN #B to get an oxygen tank. While I stayed with the resident the Central Supply clerk came in the room and helped me lay the resident on the floor. LVN #B got the oxygen to the room and checked the resident's oxygen saturation level. At that time Assistant Director of Nurses (ADON #C) took over and I walked out to help with the paperwork." In an interview on 10/14/11 at 2:30 PM, LVN #A reported that Resident #1 was not usually assigned to her, but the day of the incident she was taking care of half of the residents on hall B, and the other half of the residents, including resident #1, were assigned to LVN # B. She reported that she was the first person to come to Resident #1's aid when she was walking down the hall and happened to glace into Resident #1's room and noticed the lower half of his body resting on the floor and his neck caught in the self releasable Velcro alarm belt . She reported that LVN #B was not in the hallway at that time. LVN #A then confirmed what was in her written statement. LVN #A reported that on several occasions she had noticed CNAs repositioning Resident #1 because he would be sliding down in the wheelchair. She reported that this behavior had been going on " I think since (Resident #1's) admission " . Record Review of written statement attached to incident report written by LVN #B dated 9/26/11 documented in part: LVN #A reported Resident #1 is on the floor. We both went to his room immediately when LVN #A saw w/c alarm belt around resident's neck and unstrapped belt. We carried resident unto our arms. The resident was not responding to verbal commands and was gasping for air while oxygen mask was placed, resident was pale. In an interview on 10/20/11 at 2:25 PM, LVN #B stated that it was reported to him by CNA #J that Resident #1 would slouch down in the wheelchair. LVN #B stated that he did not remember if Resident #1 had a Pommel cushion (a Pommel cushion is used to prevent an individual from sliding down while sitting in a wheelchair) on his wheelchair prior to the incident on 9/26/11. Record review of written statement attached to incident report written by (ADON) #C dated 9/26/11 for documented in part: "I was called to resident's #1 room by Central Supply Clerk. He told me that resident #1 was choking. Upon entering the room, resident was laying on the floor on his back with pillow under his head. Resident was unresponsive, skin was pale and cool to touch. His mouth was open and he was mouth breathing with difficulty. Eyes were open and fixed. I spoke to resident trying to get a response without any success. I then did a sternum rub which caused resident to move slightly and caused his eyes to dilate and tried to focus. Resident did not try to speak. No moaning heard. While performing sternum rub I did notice that there were two read linear marks across resident's throat, from safety seat belt. I did the sternum rub again as resident appeared to become unresponsive again. At no time did resident cease to breath. EMS arrived at 4:39 PM. Record review of undated written statement attached to incident report written by CNA #E documented in part: Later that day I assisted CNA #D to transfer resident #1 to his wheelchair applied the self releasable Velcro alarm belt. We wheeled the resident to the dining room. Record review of undated written statement attached to incident report written by CNA #D documented in part: CNA #E asked me to help her transfer Resident #1 to the wheelchair. We took the resident to the dining room. Record review revealed Physician/NP/PA Communication and Progress Note dated 9/26/11 at 5:15 PM written by LVN #B for resident #1 documented in part: Lost of consciousness secondary to choking on w/c alarm belt. "At 4:23 PM LVN #A was walking towards my cart in A-Hall when she noticed resident #1 was on the floor halfway off the w/c. We immediately ran into room towards resident and upon getting to resident LVN #A noticed w/c alarm belt across (line through around) resident neck choking him. LVN #A immediately unhooked belt. Resident ' s skin color pale and cold to touch. Resident unresponsive but breathing. Resident was positioned on floor on his back. Redness to neck, 2 scrapes on right side of neck area front area. Record review of the EMS report dated 9/26/11 for resident #1 documented in part: Unit was dispatched at 4:30 PM and arrived at facility at 4:35 PM. Chief Complaint: Slipped from chair that had a seat belt. Seat belt was at his neck; Onset of event occurred 15 minutes prior to calling EMS. Primary Symptom: Change in responsiveness. Patient Assessment: AAO (alert and oriented) X 2, Sp O2 (oxygen saturation of patient's blood) 100% O2, respirations 20 regular. Narrative: Pt was an [AGE] year old male who was coming from a nursing home. Staff stated that he was sitting in a wheel chair and slipped down from the chair causing some straps to come to his neck. He was found on the floor. Upon arrival he was found responsive, hypotensive and there were markings to the neck area. He stated no problems. He was transferred to hospital. Record review of Hospital emergency room report dated 9/26/11 at 5:12 PM for resident #1 documented in part: Chief Complaint: Fall Injury. EMS states: found at nursing home with belt around neck/ strap marks noted to neck; pt. currently awake/alert; no apparent respiratory distress noted at this time. Diagnosis: [REDACTED]. The patient sustained neck abrasions, found choking. Record review revealed Physician Telephone Order dated 9/26/11 for resident #1 documented, OK for PT, OT, ST to eval and treat as warranted secondary to Fall Risk. Record review revealed Interdisciplinary Resident Screen dated 9/27/11 for resident #1 documented in part: Fall. Recent Fall/Restraint Assessment. Referred by staff on 9/26/11. Identified Functional Deficit/Diagnosis/Prior Level of Function/comments: Pt. restraint assessed and found to be appropriate provided that Velcro restraint belt is fitted to pt's waist and not left loose. Adjusted belt to fit pt, pt able to adjust self, but not able to slide down in w/c seat. Pt. should be monitored regularly for fit of safety belt and for pt. safety. Record review revealed Physical Restraint Elimination assessment dated [DATE] for resident #1 documented total score of 30 (21-35 Good Candidate) for restraint elimination. Resident is a Candidate for restraint reduction or elimination program. Program to start 9/27/11. Action Plan-to D/C Velcro Belt and place pressure pad alarm. Less restrictive measures to be used pressure alarm pad to w/c. Record review revealed Physician Telephone Order dated 9/27/11 for resident #1 documented, D/C (discontinue) Velcro Belt, OK to place pressure alarm pad on resident's w/c. Record review revealed Fall Risk assessment dated [DATE] for resident #1 documented a total score of 19. Total score of 10 or higher may represent high risk for falls. In an interview on 10/21/11 at 10:51 AM, ADON #C confirmed that he had updated the care plan for resident #1 on 9/26/11 that documented resident #1 was found with seat belt around neck. The ADON reported that he had added to the care plan on 9/26/11 "if in room, resident must be put to bed & door to room left open with call light within reach." The ADON confirmed that the care plan documented seat belt was DC ' d 9/27/11 and pressure alarm pad alarm was placed on w/c. Evaluate & re-evaluate for restraint use quarterly & prn. Monitor for proper positioning and circulatory concerns. Apply & release per orders." Record review on 10/21/11 revealed Care Plan that was last reviewed on 10/11/11 resident #1 documented in part: Resident is a risk for falls as evidenced by cognitive impairment, physical impairment, and poor safety awareness. 7/24/11 found on floor, 9/1/11 found on floor, 9/5/11 found on floor, 9/25/11 found on floor next to bed. Approaches: Velcro Belt while up in w/c. Enabler x 1 on bed. Bed alarm while in bed. 9/27/11 DC ' d belt and change to pressure pad alarm. Record review of the Physician's Progress Notes dated 9/28/11 for resident #1 documented in part: [AGE] year old male with multiple medical issues. Seen today S/P (status [REDACTED]. Sent to hospital and evaluated. Returned same day. Pt. denies pain. Does not remember fall. No distress noted. Diagnosis: [REDACTED]. Alert to self and purpose. Record review of the Provider's Investigation Report dated 9/26/11 at 7:30 PM, documented in part: All devices/restraints were checked by nursing administration. Staff was immediately in-serviced regarding restraint use. All charts were audited for orders, consents, assessments and care plans and updated as needed. On 9/27/11 the IDT reviewed resident #1 for restrain elimination and Velcro belt was discontinued and a pressure pad alarm was placed on w/c. Record review of a written statement written by ADON #C dated 10/19/11 provided to the surveyors on 10/21/11 by the administrator documented in part: On Sept. 26, 2011 after resident #1 was sent out to the hospital for having been choking on his self release belt, ADON #F and I checked every single resident that had a self release seat belt, lap buddy, lap tray and geri-chair. Every single resident on the list that was given to the state surveyor were visually checked by ADON #F and I. I checked all the residents on B & C halls. I made sure that the residents were sitting properly in the wheel chairs or geri-chairs, and that the self release seat belts were secured properly to the wheelchair, that the belts were connected to the alarms, and that the alarms were in good working order. I also checked to make sure that each resident was able to remove the seat belts upon command. Consents, orders for device, and pre-restraint, fall risk, and restraint reduction assessments were checked as well. That is how I came up with the form that was given to the state surveyor, which has all the residents with self release seat belts and other assistive devices. I also inserviced all the staff that was present on that shift as well as the on-coming night shift as to how residents with safety belts/devices while in wheelchairs cannot be left alone in their rooms for any reason, and that any resident with a safety belt/device must be put to bed if taken to their room. That seat belts must be in good working order, batteries in place and alarms working properly, seat belts secured properly and adjusted to resident's size. I did tell the staff to ensure that they were able to slide their hand between the resident and the seat belt to make sure that the belts weren't being applied too tight. The following morning I gave the exact same in-inservice to the morning shift. So all the restraints, seat belts, lap buddies, geri-chairs, and lap trays were inspected on the day of resident's #1 having choked on his self release seat belt and were in good working order. It was hand written on the bottom of the statement by the Administrator, "See hours attached to verify we stayed late that evening." Record review of the attached time cards revealed ADON #C had worked 14.75 hours on 9/26/11, ADON #F worked 15.87 hours on 9/26/11 and the Maintenance Director worked 10.52 hours on 9/26/11. In an interview on 10/21/11 at 10:51 AM, ADON #C reported that the Restraint Elimination assessment dated [DATE] was completed by the DON. The ADON #C stated, "I was not able to find a policy and procedure for the Physical Restraint Elimination Assessment. I even looked at our library were we have all of our policies and procedures. I talked to the Corporate Nurse Consultant who is at the facility, told me that we did not have a written policy and procedure for the use of the Physical Restraint Elimination Assessment. The Nurse Consultant said that the Physical Restraint Elimination Assessment should be completed when orders are given to use a restraint, and reviewed on a quarterly basis with all of the other assessments like the Pain assessment, Elopement assessment, Braden assessment etc. when the nurses are given the schedules (list of residents) notifying them which resident are due for a MDS and Care Plan review. I did not find any other Physical Restraint Elimination Assessment in the resident's thinned record in Medical Records. In an interview on 10/19/11 at 11:50 AM, with the Administrator, DON, and Corporate Nurse Consultant reported that not all self releasable Velcro alarm belt were used as restraints. The Corporate Nurse stated, "some seat belts are used as enablers and the residents are able to release the seat belts, so they are not restraints. We checked all of the seat belts right away to ensure that they were properly placed after the incident on 9/26/11 with resident #1. The Nurse Consultant stated, "Resident #1 was never found with the seat belt around his neck. I have no idea were you all got that information. The marks on resident #1's neck were not reported to us. This is the first time that we heard of him having marks on his neck. So if he did have marks on his neck, they did not last long because EMS did not see any marks on his neck when they came to the facility to take the resident to the hospital. So, I don't see what the issue is about the marks on the resident's neck." In an interview on 10/20/11 at 4:13 PM, with the Administrator, DON and ADON #C reported that ADON #C had check all of the clinical records on 10/18/11 for all of the residents listed on the Restraint/Device Log dated 10/13/11 and had completed most of the of the Physical Restraint Elimination Assessments on most of the residents on 10/03/11 and 10/04/11. The ADON reported that the resident's care plans had also been reviewed and updated as needed. Observation on 10/21/11 at 3:33 PM revealed that dietary supervisor was wheeling Resident #6 to the dining room. The Dietary Supervisor confirmed that Resident #6 's self releasable Velcro alarm belt was loose. In an interview on 10/21/11 at 3:51 PM, ADON #C reported that he had looked at the thinned record for resident #1 and he had not found any other Physical Restraint Elimination Assessment except for the one that was dated 9/27/11. The ADON stated, "a doubled checked the current record and there were no other Physical Restraint Elimination Assessment in the resident's clinical record." In an interview on 10/21/11 at 3:51 PM, ADON #C reported that he had doubled checked the resident's clinical record and the thinned record and he had not found any other Comprehensive Assessment for Enabler Use for resident #1 except for the one that was in the current clinical record dated 4/12/11. In an interview on 10/18/11 at 12:10 AM with a Manufacturer Representative of the Velcro belt used in the facility, revealed that the self releasable Velcro alarm belt are supposed to fit like the belts in a car: not tight, however not visibly loose. They are to be adjusted according to the person's size. In a meeting on 10/18/11 at 12:31 PM with Administrator, DON, ADON #C and Nurse Consultant it was confirmed that the manufacturer installation and use instructions documented that the self releasable Velcro alarm belt was not designed to restrain or hold individuals in position in their chairs. It also documented in part that the chair belt is not suitable for all individuals and that the device is not a substitute for visual monitoring by caregiver. RESIDENT #4: Record review revealed Admission Record documented resident #4 was admitted to the initially admitted to the facility on [DATE] and re-admitted on [DATE]. Record review revealed History & Physical dated 4/26/11 for resident #4 documented in part: [AGE] year old female with [DIAGNOSES REDACTED]. Alert to self. Mental status had declined, becomes agitated at little things. Record review with ADON #C revealed Comprehensive Plan of Care dated 4/22/11 for resident #4 documented in part: Resident requires the use of a Restraint/Enabler: Self Release Velcro Belt. The ADON confirmed that the Care Plan was blank on the section that indicated why the resident needed the Self Release Velcro Belt. The ADON confirmed that the approaches documented in part: Evaluate & re-evaluate for restraint/enabler use, quarterly and PRN. The ADON confirmed that the Care Plan was reviewed on 4/22/11, 7/6/11 and 10/06/11 and it documented continued. Record review revealed admission orders [REDACTED]. Bed alarm. Record review with ADON #C revealed that the Pre-Restraining Assessment that was completed by the DON for resident #4 on 6/03/11 was incomplete. The Pre-Restraining Assessment did not have any information written on the section under Referrals/Recommendations for Interdisciplinary Team Evaluation, Plan of Care Updates, Alternatives to restraints and Next Evaluation date. Referred to Psychologist or Psychiatrist was also blank. Record review revealed Admission MDS dated [DATE] for resident #4 documented in part: Not steady, only able to stabilize with human assistance, moving from sitting to standing position. Mobility Devices-wheelchair. Frequently incontinent of urine and always incontinent of bowel. No behavioral problems. Required extensive assistance of one person with bed mobility, transfers, dressing, toileting, and grooming. Extensive assistance with bathing. Chairfast, with limited assistance with locomotion on and off unit. Eating supervision, set up only. Rejection of care 1-3 days. Record review with MDS Nurse #T revealed a Comprehensive Plan of Care dated 9/11/11 for resident #4 documented in part: Resident #4 is a risk for falls. The Care Plan documented it was last reviewed on 10/06/11. Approaches documented in part: Encourage resident to ask for assistance of staff. Ensure that self release Velcro safety belt is in place. Record review with MDS Nurse #T revealed a Comprehensive Plan of Care dated 9/25/11 for resident #4 documented in part: Resident #4 requires the use of self release belt to help prevent to get u

Based on interview and record review, it was determined that the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well being in accordance with the comprehensive assessment and plan of care for 1 (ID#1) of 5 sampled residents reviewed for a change of condition. A. Certified Nurse Aide (CNA) # A failed to notify Licensed Vocational Nurse (LVN) #F on 3/10/11 and 3/11/11 when resident #1 was resisting care and was having pain to the right leg with any type of movement. B. LVN #G failed to accurately assess resident #1 on 3/11/11, when resident kept grabbing her right leg and would not put weight on her leg and would not pivot while being transferred from the wheelchair to the bed. C. LVN #F failed to accurately assess resident #1 on 3/11/11 when LVN # G reported to her that resident #1 was grabbing her right leg and thigh with movement.. D. Licensed staff failed to accurately assess and administer pain medication to resident #1 according to physician's orders [REDACTED]. E. On 3/12/11 resident #1 was transferred to the hospital with a [DIAGNOSES REDACTED]. Resident #1 experienced unrelieved pain for 3 days. These failures resulted in an immediate jeopardy that was identified on 3/30/11. While the immediate jeopardy was removed on 4/01/11, the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. These failures could affect 41 residents at the facility on a pain management program, by not accurately assessing and administering pain medication as ordered. The findings include: 1. Review of Record of Admission, documented resident #1 was an [AGE] year old female admitted to the nursing facility on 6/01/09. Review of the Annual History & Physical dated 6/30/10 documented resident #1 was admitted with [DIAGNOSES REDACTED]. Record review revealed Physician's Recap dated 1/27/11 for resident #1 documented in part: [MEDICATION NAME] 650 mg Liquid Oral every 4 hours as needed for Elevated Temperature/Pain; [MEDICATION NAME] 650 mg Tablets Oral give two of the 325 mg tablets every 6 hours as needed for Elevated Temperature/Pain. Record review revealed Care Plan reviewed 2/10/11 for resident #1 documented in part: Resident is prone to pain/discomfort; monitor for s/s (signs/symptoms) of increased pain/discomfort; assess resident for possible causes and give meds; Notify MD if c/o pain for medication orders; 2/10/11 Tylenol per MD orders. Record review revealed Quarterly MDS (Minimum Data Set) dated 2/17/11 for resident #1 documented in part: Unclear speech, Usually understood, Rarely/Never understands others; Short Term/Long Term Memory Problems; Physical/Verbal behavioral symptoms directed toward others; Limited assistance with bed mobility, transfers, walk in corridor, locomotion off the unit, toilet use, personal hygiene, extensive assistance with bathing, and supervision with eating; uses wheelchair/walker; not steady with moving from seated to standing position, walking, turning around, moving on and off toilet, surface to surface transfer; frequently incontinent of bowel/bladder; No Pain. Record review revealed Psychiatric Evaluation dated 3/07/11 for resident #1 documented in part: "Chief Complaint: Pt. with aggressive behavior, agitated. Pt. will strike peers and staff out of the blue. Pt. seen wheeling her w/c by the hall. I try to approach her & ask her where she is going, states is none of my business. Goes into peers rooms, she is pushed out. Diagnostic Impression: Dementia, [MEDICAL CONDITION] & Alzheimer's type with disturbance of behavior. Depressio[DIAGNOSES REDACTED] of Dementia, [MEDICAL CONDITION] Disorder, [MEDICAL CONDITIONS], and [MEDICAL CONDITION]." Record review of the Psychoactive Drug Monthly Flow Record dated March 2011 for resident #1 did not have any documentation of behaviors. Record review of the Medication Administration (MAR) dated March 2011 for resident #1 documented "3/12/11, Multi-vitamin with minerals, Ramipril 0.5 mg by mouth, Calcium with Vitamin D, [MEDICATION NAME] Sodium 125 mg, [MEDICATION NAME] Sodium, Memantine HCL, [MEDICATION NAME] HCL had been administered at 8:00 AM." The MAR indicated [REDACTED]. Ramipril is used to treat hypertension. [MEDICATION NAME] Sodium is used treat [MEDICAL CONDITION] and [MEDICAL CONDITION] Affective disorder. [MEDICATION NAME] Sodium is used to treat constipation. [MEDICATION NAME] HCL is used to treat diabetes. Record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]#1 complained of pain to the right leg. No additional information was brought forth during the survey process. Record review of the The Pain Management Assessment attached to the MAR indicated [REDACTED]. No additional information was brought forth during the survey process. 2. In an interview on 3/28/11 at 11:21 AM, resident's #1 roommate stated, "I saw resident #1 fall down in the evening, I do not remember when or the time. She was moving herself, from the wheelchair to the bed and she missed it and sat on the floor. I turned on the call light and 2 females came and picked her up and put her in bed." 3. In an interview on 3/29/11 at 9:42 AM, Certified Nurse Aide (CNA) #A reported that she had worked on the 2-10 shift on Thursday 3/10/11 and resident #1 was one of the residents that had been assigned to her on that day. CNA #A stated "I noted that resident #1 would push my hands away when I attempted to touch her or to move her and would moan and say Oh, Oh, Oh. The resident appeared to be having pain to the right hip area when she was turned to the side. On that day, I noted that resident #1 was more resistant to allowing me to touch her or move her. I also noted that when I attempted to stand her up, she did not want to put weight on her feet and kept her hands over her private parts. When I sat her down in her wheelchair, I noted that the resident kept holding on to her right leg. I did not report this to the nurse, because I thought that it was just one of those days, when resident #1 would appear afraid to stand up. On Friday 3/11/11 at the change of shift, I was informed by the 6-2 CNAs, that they had not gotten the resident out of bed during their shift because the resident was having too much pain to the right leg with any type of movement. At approximately 2:30 PM-3:00 PM, I went to change the resident's pull-up and she complained of pain when she was moved. I did not report this to the nurse. That day at approximately 5:40 PM-6:00 PM, the resident was sitting in her wheelchair by the dining room area and the Evening Supervisor, LVN #G, informed me that resident #1 smelled like feces and needed to be changed. LVN #G assisted me to put the resident back to bed, because resident #1 continued to complain of pain to the right leg with movement. I also noted that resident #1 continued to hold on to her right leg with any type of movement and continued to moan and say "Oh, Oh, Oh. LVN #G checked the resident and we did not see any redness or bruises. On that day, I tried to only move resident #1 when necessary because of the pain to the right leg. I also remember that on that day, the resident had not swallowed her pills and so I went to notify the LVN #F." 4. In an interview on 3/28/11 at 8:00 AM, LVN #B reported that on Friday 3/11/11 resident #1 was sleeping most of the day. On that day she ate her meals in bed. "The doctor was adjusting the doses of [MEDICATION NAME] and [MEDICATION NAME] because the medications were making the resident too sleepy. The CNAs did not report to me that resident #1 was having pain. Resident #1 was confuse and required moderate assistance with Activities of Daily Living (ADLs)." [MEDICATION NAME] is used to treat [MEDICAL CONDITION]; treatment of [REDACTED]. [MEDICATION NAME] is used to treat depression. 5. Record review of Nurse's Note dated 3/13/11 written by LVN #I documented, "Late entry for 3/11/11 resident #1 seem lethargic and shaky notified physician of resident's condition, inquired afternoon nurse about resident's condition said she was fine. There had been changes in the resident's meds, I also notified physician about these changes, he said to observe resident, her VS (vital signs) were taken & were WNL (within normal limits)." However the Nurses's Note dated 3/13/11 did not document that LVN #I had notified the physician on 3/11/11 that resident #1 was complaining of pain to the right leg with movement and kept grabbing her legs. No additional information was brought forth during the survey process. 6. In an interview on 3/28/11 at 2:44 PM, LVN #G reported that she had worked on the 2-10 as the Evening Supervisor on Friday 3/11/11. LVN #G stated, "On Friday 3/11/11 resident #1 was wheeling herself around in her room but kept grabbing her right leg. I also noted that resident # 1 kept leaning to the right side in her wheelchair. When I assisted CNA #A to transfer resident #1 from the wheelchair to the bed after dinner. I noted that the resident would not put any weight on the right leg and would not pivot. We removed her pants and I checked her legs. I checked the capillary refills and pedal pulses. The resident was able to move her legs on her own and kept pulling away when I attempted to touch her right leg. That is why I did not check for ROM (range of motion) because she was able to move her legs on her own. I did not notice any bruises or redness. I did not document my assessment in the resident's clinical record." 7. In an interview on 3/28/11 at 2:48 PM, CNA #H reported that she had worked on Friday 3/11/11 on the 10-6 shift. CNA #H stated "resident #1 was attempting to get out of bed, so I asked one of the other CNAs to help me get the resident up to sit in her wheelchair. I called one of the other CNA, for help because resident #1 was not bearing weight and was very heavy. Resident #1 complained of pain even to touch. The resident would say Oh, Oh, Oh when moved or touched. I reported this right away to LVN #I." 8. In an interview on 3/28/11 at 3:45 PM, LVN #I reported that she had worked on the night shift Friday 3/11/11. "I did notice that resident #1 was not her usual self when she was sitting in her wheelchair. She looked pale. I knew something was wrong, she usually wheels herself around in her wheelchair and that night she just sat there, she looked out of it. She was lethargic. So, I called the doctor and he gave orders to hold her new meds that had been ordered to control her behavioral problems." Record review of Nurse's Note dated 3/13/11 written by LVN #I documented, "Late entry for 3/11/11 resident #1 seem lethargic and shaky notified physician of resident's condition, inquired afternoon nurse about resident's condition said she was fine. There had been changes in the resident's meds, I also notified physician about these changes, he said to observe resident, her VS (vital signs) were taken & were WNL (within normal limits)." However the Nurses's Note dated 3/13/11 did not document that LVN #I had notified the physician on 3/11/11 that resident #1 was complaining of pain to the right leg with movement and kept grabbing her legs. No additional information was brought forth during the survey process. 9. In an interview on 3/29/11 at 3:00 PM, (LVN) #F reported that resident #1 was confused and was unable to verbalize needs. LVN #F stated, "We noted that resident was more sleepy in the mornings when she was started on [MEDICATION NAME] and [MEDICATION NAME]. On Friday 3/11/11, LVN #B reported to me at the change of shift that resident #1 was very quiet during breakfast and was falling asleep in her wheelchair. On that day, I remember that the resident #1 was sitting up in her wheelchair and ate her supper in the dining room. I was informed by the Evening Supervisor LVN #G, that she and CNA #A had put resident #1 back to bed and had noted that resident #1 was grabbing her right leg and thigh when she was moved. The supervisor reported to me, that resident #1 was able to move the right leg. I assessed the resident and noted that she was able to move her legs on her own when I checked the range of motion, but I did not document my assessment in the resident's clinical record. I do not remember if resident was medicated for pain. I did not notify the doctor. On that day during the change of shift, I heard when CNA #H report to the LVN #I, that resident #1 was complaining of a lot of pain to the right leg when she was moved. CNA#H reported that the resident was saying oh, oh, oh when she was moved. I heard LVN #I tell the CNA #H, that she was going to call the physician." Record review revealed Nurses Notes dated 3/14/11 written by LVN #F for resident #1 documented, "Thursday 2-10, resident #1 had no c/o pain or discomforts. Ate dinner in dining room and was observed walking in room without w/c (wheelchair). Resident #1 took meds without any problems and was put to bed without any problems.'' Record review revealed Nurses Notes dated 3/14/11 written by LVN #F for resident #1 documented, "Friday (3/11/11) on the 2-10, resident #1 was complaining of pain to her right leg. Inspected right leg found no problems, but did keep grabbing leg while in bed. Ate dinner well and took meds without any problems. Was not observed walking this day. At around 10:00 PM, was brought to nurses station by CNA who observed her trying to get out of bed. Was in pain and grabbing at both legs at this time. Vitals were taken and night nurse was to contact MD." 10. In an interview on 3/28/11 at 9:28 AM, CNA #E reported that on Saturday 3/12/11 CNA #B had asked her to help her change resident #1 because the resident would not allow her to move her and was resisting care. CNA #E stated, "As soon as we touched resident #1, she yelled loudly and appeared to be in a lot of pain and kept her hands over her private parts when she was moved to provide incontinent care. After we finished changing the resident, CNA #B went to notify LVN #D that resident was complaining of very bad pain." 11. In an interview on 3/28/11 at 1:39 PM, LVN #D reported that she had worked on Saturday 3/12/11 and was assigned to resident #1. LVN #D stated, "The resident was lethargic on that day when I arrived at 6:00 AM. Resident #1 was sitting in the dining room in her wheelchair, with her head on the table. I initially called the doctor on that day, to see if we could hold her medications because she was lethargic. I instructed the CNAs to put resident in bed. The CNAs reported to me, that resident #1 had pain when she was put back to bed and would not allow them to touch her. When I assessed resident #1, she was combative and kept pulling away when I attempted to check the ROM. I called the physician and he gave orders for x-rays. When I assisted the x-ray tech to position the resident's legs for the x-ray, I noted that one leg was shorter than the other. Record review revealed Nurse's Note dated 3/12/11 at 9:00 AM, written by LVN #D for resident #1 documented, "Resident lethargic, up in w/c, keeps falling to side of the w/c-will not sit straight. In D/R (dining room) with head on table, unable to eat, unable to take meds. Resident put to bed, resting quietly. Attending physician called and was transferred to doctor on call, reported pt's condition, new orders given." Record review of Physician/NP/PA Communication and Progress Note dated 3/12/11 at 9:00 AM, written by Licensed Vocational Nurse (LVN) # D for resident #1 documented in part: Resident complaining of pain to right knee, right tibia, right hip, and pelvic area, started this morning. Has gotten worse when moving or turning resident. Refusing to eat or drink. Request: X-Ray. Record review revealed Physician's Telephone Order dated 3/12/11 for resident #1 documented, "Hold [MEDICATION NAME] 200 mg one hour before dinner and [MEDICATION NAME] 100 mg po Q AM (every morning) x 48 hours due to pt. (patient) very lethargic. Hold [MEDICATION NAME] 100 mg po in AM one hour before meal. Record review revealed Progress Note dated 3/12/11 written by LVN #D documented in part: At 10:00 AM, was called to patient's room by CNA, stated resident complaining of pain when turned to be cleaned. Checked resident, c/o (complained of) pain to right leg. C/O of severe pain when doing ROM (range of motion) to right lower extremity. The right leg is shorter than the left. On call doctor called, x-ray ordered. Called mobile x-ray company. 11:30 AM, x-ray done results pending. Resident refusing pain medication and trying to hit staff. 12:30 PM, refused to eat lunch. Attempted to feed her but refused. Resting quietly. 2:00 PM, in bed resting quietly at this time. 3:00 PM, X-ray results in conclusion-Acute Right [MEDICAL CONDITION]. Physician called new orders to transfer to hospital. 4:30 PM, Ambulance Attendants here, transferred resident to hospital by stretcher." 12. In an interview on 3/29/11 at 4:49 PM, CNA #C reported that she had worked on Saturday 3/12/11 on the 6-2 shift and resident #1 was one of the residents that had been assigned to her on that day. CNA #C stated, "on that day, I noted that resident #1 was in a deep sleep and I went to notify LVN #D. LVN #D told me to serve resident #1 her breakfast tray in bed. I remember that on that day, the resident did not eat, because she was having too much pain. The resident would cry and yell loudly each time that she was moved. The resident was more resisitant than usual on that day and would not allow me to touch her when I attempted to touch her legs. The resident would push me away when I attempted to change her because she was soiled with urine and feces, so I went to ask another CNA to come and help me change resident #1. At approximately 8:30 AM-9:00 AM, we noted that the resident would have very bad pain with any type of movement, especially when she was turned to the right side. We had noted that the resident's legs were rigid and would not bend her legs. I went to notify the nurse after we finished changing the resident. On that day, for the rest of our shift, we tried not to move her as much as we could, because she continued to have very bad pain and would cry, moan, and yell with any type of movement." CNA #C reported that resident #1 was confused and was not able to verbalize needs. 13. In an interview on 3/29/11 at 4:30 PM, facility's Administrator reported in the presence of the Corporate Nurse Consultant and Director of Nurses (DON) that he had conducted the incident investigation for resident #1. "Resident #1's roommate reported that she had seen when resident #1 had sustained a fall in their room. I did not follow up to see who had assisted resident #1 to get up from the floor. I guess that I should have followed up on this, but I did not. I was not aware, that the Certified Nurse Aides (CNAs) had noted that resident #1 was complaining of pain to the right leg for several days and had not reported the change of condition to the nurses." 14. In a Telephone interview on 3/30/11 at 9:41 AM, on call Physician stated, "they called Friday (3/11/11) to report that resident #1 had fallen and gotten up by herself. Don't recall them telling me, about her being lethargic or pain being intense. The pain that was there did not warrant x-ray or hospital visit. Sounded like muscle sprain or something not intense. I don't remember the exact time. On Saturday (3/12/11) they called back, to report resident #1 was having a lot of pain, more intense and give orders for x-ray." 15. Record review of facility's 24 Hour Report/Change of Condition Report dated 3/09/11 documented resident #1 Evening Shift - "abusive towards other resident, Right Leg Pain; 3/12/11 Day Shift - Lethargic-MD called; c/o pain to right lower extremity." 16. Record review of the facility's Provider Investigation Report dated 3/17/11 for resident #1 documented date of incident 3/12/11 at 9:00 AM. Description of Assessment: "Complained to Nurse Aide. Nurse verified possible fracture. Mobile x-ray verified fracture, 4:30 PM EMS. Transported to hospital. Investigation Summary: Room mate stated resident had fallen the day before. Resident got up by herself. No staff were informed of fall by resident or room mate. When the pain was reported, resident was unable to verify how she might suffered fracture. She does have a history of falling prior to coming to nursing home. She does have [MEDICAL CONDITION], one leg was shorter that the other upon admission. She does have [MEDICAL CONDITION], Abnormal Posture, Muscle Disuse Atrophy, Lack of Coordination, Symbolic Dysfunction, Diabetes. Record review revealed Incident/Accident Report dated 3/12/11 for resident #1 documented in part: "Was called to room by CNA stated resident complained of pain to right lower extremity when turned to change. C/O of severe pain when doing ROM. Noted right leg shorter than left leg. Resident Pain to right lower extremity unable to say what happened." 17. Record review revealed X-ray reported dated 3/12/11 faxed to the facility at 3:01 PM, for resident #1 documented "Results: There is a right subcapital fracture with slight displacement. The joint shows no dislocation. [MEDICAL CONDITION] is present. Conclusion: Acute right [MEDICAL CONDITION]." 18. Hospital emergency room Report dated 3/12/11 at 4:59 PM, documented, "Patient restless and agitated at this time; attempting to get out of bed, calmed patient back into laying down. Noted to be confused, grimacing, moaning, resistant to movement, restless." Assessment at 5:15 PM, Facial grimacing, rigid, knees pulled up. Pulling away, and striking out. Hospital X-ray report dated 3/12/11 for resident #1 documented Single AP view the pelvis shows a foreshortening of the right femoral neck consistent with a femoral neck fracture. Fracture appears to be within the mid femoral neck with slight impaction. Acetabulum appears to remain intact. Trochanters appear intact. Hospital History & Physical dated 3/13/11 for resident #1 documented in part: Chief Complaint: [MEDICAL CONDITION]; [DIAGNOSES REDACTED]. 19. Record review of facility's policy and procedure on Pain Management dated November 2009 provided by DON on 4/01/11 documented in part: Policy: All residents shall be assessed for pain factors and history upon admission to the facility and subsequently thereafter according to the findings of the assessment. All residents shall receive treatment for [REDACTED]. Procedure: Licensed Nursing Staff will complete the "Pain Data Collection Tool" on admission, readmission, quarterly and any change in condition that has the potential to cause pain. For the residents who has difficulty communicating due to cognitive impairment as indicated on the MDS, the LN shall access for physical signs of pain such as grimacing, limping, changes in vital signs, or behavioral changes (loud outbursts, pulling or pushing away, striking out) by utilizing the "Pain Collection Tool for Use in Advance Cognitive Impairment." The licensed nurse shall administer medications and treatments as prescribed by the physician to provide safe and effective pain relief. The pain shall be re-evaluated thirty minutes to one hour after medication administration for effectiveness and document in the medical record, or on a specified alternate schedule when appropriate depending on the type of pain and medication administered. The "Pain Management Flow Sheet" shall be completed each time a "PRN" pain medications is administered for acute as well as breakthrough chronic pain and reviewed weekly to determine if the resident's pain is adequately controlled by occasional "PRN" pain medications and if not, would a regular regimen of routine pain medications be more appropriate. The physician shall be notified when any type of prescribed medications management regimen is not effective in relieving the resident's pain. 20. Record review of the facility's policy and procedure that was undated on Condition Change of The Resident (Observe, Recording and Reporting) provided by Director of Nurses (DON) on 4/01/11 documented in part: Responsibility: Licensed Nurse; Purpose: To observe, record and report any condition change to the attending physician so proper treatment will be implemented. Procedure: After all resident falls, injuries or condition change, monitor the following: Observe for swelling and discoloration; Observe for personality changes; Observe for alteration in consciousness; Observe for gait, posture or balance disorder; Observe for proper reflexes. Document all observations and findings in the nurses notes. Recognition of Change of Condition-Criteria: Resident eats or drinks less than usual, is sleepier, more confused or more agitated, needs more help with ADLs, complains of pain. An immediate jeopardy was identified and the Administrator was notified on 3/30/11 at 10:42 AM. The facility's Plan of Action was accepted on 3/30/11 at 4:16 PM and contained the following: Facility did not follow policy and procedure for assessment of residents, notification of physician and follow up with physician, and pain management. 1) Licensed Nurses will be inserviced on the INTERACT II SBAR and Care Path Tool as part of their assessment for Change of Condition. Completed 3/30/11 1.2) Licensed Nurses will be inserviced on the INTERACT II Change of Condition guidelines which includes when to notify the physician or his agent. Completed 3/30/11 1.3) Based on the criteria of the Change of Condition guide for immediate notification, the nurse will attempt this notification two times with 15 minutes as the timeline between each call. If there is no response from the physician or his agent, the nurse will send the resident 911. Completed 3/30/11 2) 100 % Pain Assessment audit of current residents. Completed 3/30/11 3) Inservice Certified Nurse Aides, Restorative Nurse Aides on the INTERACT II Early Warning Tool and reporting changes in condition to licensed nurses using the tool. Completed 3/30/11 4) Inservice 1:1 with the nurses involved on March 11 evening shift and March 12 night and day shifts. Completed 3/30/11 5) Resident MN will be assessed for pain every shift until fracture healed. Completed 3/30/11 6) Identify only 1 other resident currently with fracture. Completed 3/30/11 7) Licensed Nurses will not work on the floor until they receive inservices listed in #1 above. Completed 3/30/11 8) CNAs will not work on the floor until they receive inservices on the INTERACT II Early Warning Tool, and on reporting changes of condition to licensed nurse using the tool. Completed 3/30/11 The plan was accepted and the Immediate Jeopardy was removed at 9:30 AM on 4/01/11, when the surveyors confirmed through observations, interviews, and record reviews that the measures listed above had been implemented. While the immediate jeopardy was removed on 4/01/11, the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. The universe was obtained from a list of 41 residents on Pain Management provided by DON on 4/01/11.

Based on interview and record review, the facility failed to immediately consult with the physician and notify the resident's legal representative, when a significant change in condition was assessed for 1 (ID #1) of 5 sampled residents. Resident #1 went for at least 12 hours, when resident started to complain to the right leg before the physician was consulted. Resident #1 was diagnosed with [REDACTED]. A. Licensed Vocational Nurse (LVN) #G failed to consult with the attending Physician on 3/11/11, when she observed that resident #1 kept grabbing her right leg and would not put any weight on it while being transferred from the wheelchair to the bed. B. LVN #F failed to consult with the attending Physician on 3/11/11, when LVN #G reported to her that resident #1 was grabbing her the right leg and thigh with movement. C. LVN #I failed to consult with the attending physician on 3/11/11 on the 10-6 shift when resident #1 was complaining of pain to the right leg. D. LVN #D failed to consult with the attending physician on 3/12/11 on the 6-2 shift when resident #1 was unable to take her medication. E. Failed to notify the resident's responsible party when resident #1 was transferred to the hospital on [DATE] with a fractured right hip. These failures resulted in an immediate jeopardy, that was identified on 3/30/11. While the immediate jeopardy was removed on 4/01/11, the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy at a pattern as the implemented systems needed to be monitored and evaluated for effectiveness. The facility's failure could affect 135 residents at the facility by not promptly consulting with the attending physician when residents have a change in condition. The findings include: 1. Review of Record of Admission documented resident #1 was an [AGE] year old female admitted to the nursing facility on 6/01/09. Review of the Annual History & Physical dated 6/30/10 documented resident #1 was admitted with [DIAGNOSES REDACTED]. Record review revealed Physician's Recap dated 1/27/11 for resident #1 documented in part: [MEDICATION NAME] 650 mg Liquid Oral every 4 hours as needed for Elevated Temperature/Pain; [MEDICATION NAME] 650 mg Tablets Oral give two of the 325 mg tablets every 6 hours as needed for Elevated Temperature/Pain. Record review revealed Care Plan reviewed 2/10/11 for resident #1 documented in part: Resident is prone to pain/discomfort; monitor for s/s (signs/symptoms) of increased pain/discomfort; assess resident for possible causes and give meds; Notify MD if c/o pain for medication orders; 2/10/11 Tylenol per MD orders. Record review revealed Quarterly MDS (Minimum Data Set) dated 2/17/11 for resident #1 documented in part: Unclear speech, Usually understood, Rarely/Never understands others; Short Term/Long Term Memory Problems; Physical/Verbal behavioral symptoms directed toward others; Limited assistance with bed mobility, transfers, walk in corridor, locomotion off the unit, toilet use, personal hygiene, extensive assistance with bathing, and supervision with eating; uses wheelchair/walker; not steady with moving from seated to standing position, walking, turning around, moving on and off toilet, surface to surface transfer; frequently incontinent of bowel/bladder; No Pain. Record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]#1 complained of pain to the right leg. No additional information was brought forth during the survey process. Record review of the The Pain Management Assessment attached to the MAR indicated [REDACTED]. No additional information was brought forth during the survey process. 2. In an interview on 3/29/11 at 9:42 AM, Certified Nurse Aide (CNA) #A reported that she had worked on the 2-10 shift on Thursday 3/10/11 and resident #1 was one of the residents that had been assigned to her on that day. CNA #A stated "I noted that resident #1 would push my hands away when I attempted to touch her or to move her and would moan and say Oh, Oh, Oh. The resident appeared to be having pain to the right hip area when she was turned to the side. On that day, I noted that resident #1 was more resistant to allowing me to touch her or move her. I also noted that when I attempted to stand her up, she did not want to put weight on her feet and kept her hands over her private parts. When I sat her down in her wheelchair, I noted that the resident kept holding on to her right leg. I did not report this to the nurse, because I thought that it was just one of those days, when resident #1 would appear afraid to stand up. On Friday 3/11/11 at the change of shift, I was informed by the 6-2 CNAs, that they had not gotten the resident out of bed during their shift because the resident was having too much pain to the right leg with any type of movement. At approximately 2:30 PM-3:00 PM, I went to change the resident's pull-up and she complained of pain when she was moved. I did not report this to the nurse. That day at approximately 5:40 PM-6:00 PM, the resident was sitting in her wheelchair by the dining room area and the Evening Supervisor, LVN #G, informed me that resident #1 smelled like feces and needed to be changed. LVN #G assisted me to put the resident back to bed, because resident #1 continued to complain of pain to the right leg with movement. I also noted that resident #1 continued to hold on to her right leg with any type of movement and continued to moan and say "Oh, Oh, Oh. LVN #G checked the resident and we did not see any redness or bruises. On that day, I tried to only move resident #1 when necessary because of the pain to the right leg. I also remember that on that day, the resident had not swallowed her pills and so I went to notify the LVN #F." 3. In an interview on 3/28/11 at 2:44 PM, LVN #G reported that she had worked on the 2-10 as the Evening Supervisor on Friday 3/11/11. LVN #G stated, "On Friday 3/11/11 resident #1 was wheeling herself around in her room but kept grabbing her right leg. I also noted that resident # 1 kept leaning to the right side in her wheelchair. When I assisted CNA #A to transfer resident #1 from the wheelchair to the bed after dinner. I noted that the resident would not put any weight on the right leg and would not pivot. We removed her pants and I checked her legs. I checked the capillary refills and pedal pulses. The resident was able to move her legs on her own and kept pulling away when I attempted to touch her right leg. That is why I did not check for ROM (range of motion) because she was able to move her legs on her own. I did not notice any bruises or redness. I did not document my assessment in the resident's clinical record." 4. In an interview on 3/29/11 at 3:00 PM, (LVN) #F reported that resident #1 was confused and was unable to verbalize needs. LVN #F stated, "We noted that resident was more sleepy in the mornings when she was started on [MEDICATION NAME] and [MEDICATION NAME]. On Friday 3/11/11, LVN #B reported to me at the change of shift that resident #1 was very quiet during breakfast and was falling asleep in her wheelchair. On that day, I remember that the resident #1 was sitting up in her wheelchair and ate her supper in the dining room. I was informed by the Evening Supervisor LVN #G, that she and CNA #A had put resident #1 back to bed and had noted that resident #1 was grabbing her right leg and thigh when she was moved. The supervisor reported to me, that resident #1 was able to move the right leg. I assessed the resident and noted that she was able to move her legs on her own when I checked the range of motion, but I did not document my assessment in the resident's clinical record. I do not remember if resident was medicated for pain. I did not notify the doctor. On that day during the change of shift, I heard when CNA #H report to the LVN #I, that resident #1 was complaining of a lot of pain to the right leg when she was moved. CNA#H reported that the resident was saying oh, oh, oh when she was moved. I heard LVN #I tell the CNA #H, that she was going to call the physician." Record review revealed Nurses Notes dated 3/14/11 written by LVN #F for resident #1 documented, "Friday (3/11/11) on the 2-10, resident #1 was complaining of pain to her right leg. Inspected right leg found no problems, but did keep grabbing leg while in bed. Ate dinner well and took meds without any problems. Was not observed walking this day. At around 10:00 PM, was brought to nurses station by CNA who observed her trying to get out of bed. Was in pain and grabbing at both legs at this time. Vitals were taken and night nurse was to contact MD." 5. In an interview on 3/28/11 at 2:48 PM, CNA #H reported that she had worked on Friday 3/11/11 on the 10-6 shift. CNA #H stated "resident #1 was attempting to get out of bed, so I asked one of the other CNAs to help me get the resident up to sit in her wheelchair. I called one of the other CNA, for help because resident #1 was not bearing weight and was very heavy. Resident #1 complained of pain even to touch. The resident would say Oh, Oh, Oh when moved or touched. I reported this right away to LVN #I." 6. In an interview on 3/28/11 at 3:45 PM, LVN #I reported that she had worked on the night shift Friday 3/11/11. "I did notice that resident #1 was not her usual self when she was sitting in her wheelchair. She looked pale. I knew something was wrong, she usually wheels herself around in her wheelchair and that night she just sat there, she looked out of it. She was lethargic. So, I called the doctor and he gave orders to hold her new meds that had been ordered to control her behavioral problems." Record review of Nurse's Note dated 3/13/11 written by LVN #I documented, "Late entry for 3/11/11 resident #1 seem lethargic and shaky notified physician of resident's condition, inquired afternoon nurse about resident's condition said she was fine. There had been changes in the resident's meds, I also notified physician about these changes, he said to observe resident, her VS (vital signs) were taken & were WNL (within normal limits)." However the Nurses's Note dated 3/13/11 did not document that LVN #I had notified the physician on 3/11/11 that resident #1 was complaining of pain to the right leg with movement and kept grabbing her legs. No additional information was brought forth during the survey process. 7. Record review revealed written statement by facility's Administrator, dated 3/29/11 at 5:00 PM, documented "Nurse called Friday (3/11/11) don't remember time, pain involved, new orders. Saturday (3/12/11), LVN #D called. X-ray ordered. Night nurse called next morning, pain was more intense. X-ray came back Saturday (3/12/11)-fracture. Doctor was told roommate saw resident #1 fell off bed, got herself up. Friday (3/12/11) in pain, not intense per nurse next morning more pain, x-ray ordered, fracture, sent her hospital." In a Telephone interview on 3/30/11 at 9:41 AM, on call Physician stated, "they called Friday (3/11/11) to report that resident #1 had fallen and gotten up by herself. Don't recall them telling me, about her being lethargic or pain being intense. The pain that was there did not warrant x-ray or hospital visit. Sounded like muscle sprain or something not intense. I don't remember the exact time. On Saturday (3/12/11) they called back, to report resident #1 was having a lot of pain, more intense and give orders for x-ray." 8. In an interview on 3/28/11 at 1:39 PM, LVN #D reported that she had worked on Saturday 3/12/11 and was assigned to resident #1. LVN #D stated, "The resident was lethargic on that day when I arrived at 6:00 AM. Resident #1 was sitting in the dining room in her wheelchair, with her head on the table. I initially called the doctor on that day, to see if we could hold her medications because she was lethargic. I instructed the CNAs to put resident in bed. The CNAs reported to me, that resident #1 had pain when she was put back to bed and would not allow them to touch her. When I assessed resident #1, she was combative and kept pulling away when I attempted to check the ROM. I called the physician and he gave orders for x-rays. When I assisted the x-ray tech to position the resident's legs for the x-ray, I noted that one leg was shorter than the other." 9. Hospital emergency room Report dated 3/12/11 at 4:59 PM, documented, "Patient restless and agitated at this time; attempting to get out of bed, calmed patient back into laying down. Noted to be confused, grimacing, moaning, resistant to movement, restless." Assessment at 5:15 PM, Facial grimacing, rigid, knees pulled up. Pulling away, and striking out. 10. Record review of the facility's policy and procedure that was undated on Condition Change of The Resident (Observe, Recording and Reporting) provided by Director of Nurses (DON) on 4/01/11 documented in part: Responsibility: Licensed Nurse; Purpose: To observe, record and report any condition change to the attending physician so proper treatment will be implemented. An immediate jeopardy was identified and the Administrator was notified on 3/30/11 at 10:42 AM. The facility's Plan of Action was accepted on 3/30/11 at 4:16 PM and contained the following: Facility did not follow policy and procedure for assessment of residents, notification of physician and follow up with physician, and pain management. 1) Licensed Nurses will be inserviced on the INTERACT II SBAR and Care Path Tool as part of their assessment for Change of Condition. Completed 3/30/11 1.2) Licensed Nurses will be inserviced on the INTERACT II Change of Condition guidelines which includes when to notify the physician or his agent. Completed 3/30/11 1.3) Based on the criteria of the Change of Condition guide for immediate notification, the nurse will attempt this notification two times with 15 minutes as the timeline between each call. If there is no response from the physician or his agent, the nurse will send the resident 911. Completed 3/30/11 2) 100 % Pain Assessment audit of current residents. Completed 3/30/11 3) Inservice Certified Nurse Aides, Restorative Nurse Aides on the INTERACT II Early Warning Tool and reporting changes in condition to licensed nurses using the tool. Completed 3/30/11 4) Inservice 1:1 with the nurses involved on March 11 evening shift and March 12 night and day shifts. Completed 3/30/11 5) Resident MN will be assessed for pain every shift until fracture healed. Completed 3/30/11 6) Identify only 1 other resident currently with fracture. Completed 3/30/11 7) Licensed Nurses will not work on the floor until they receive inservices listed in #1 above. Completed 3/30/11 8) CNAs will not work on the floor until they receive inservices on the INTERACT II Early Warning Tool, and on reporting changes of condition to licensed nurse using the tool. Completed 3/30/11 The plan was accepted and the Immediate Jeopardy was removed at 9:30 AM on 4/01/11, when the surveyors confirmed through observations, interviews, and record reviews that the measures listed above had been implemented. While the immediate jeopardy was removed on 4/01/11, the facility remained out of compliance at a scope and severity level of actual harm that is not immediate jeopardy at a pattern, as the implemented systems needed to be monitored and evaluated for effectiveness. The universe was obtained from a statement written by the Director of Nurses dated 4/01/11 documented in part: "41 residents had been identified on Pain Management system."