Every finding on record at Encore Healthcare and Rehabi of Malvern

Based on interview and record review, the facility failed to report allegations of abuse within the required 2-hour time frame for three (Resident #1, #3, and #4) of four residents involved in incidents reported to the state agency. The findings include: Incident #1 Review of an Incident and Accident (I&A) Report of alleged abuse that was discovered by the facility on March 10th, 2025, at 11:30 AM, was not submitted to the state agency until March 10th, 2025, at 3:56 PM. The incident involved Resident #1 and Resident #7. The alleged incident included Resident #7 threatening Resident #1 due to Resident #1 playing their television too loud and keeping their light on, which agitated Resident #7. The report indicated, [Resident #1] told [an LPN] that [Resident #1's] roommate had threatened [Resident #1]. Review of Resident #1's admission Record indicated the facility admitted Resident #1 with diagnoses which included cognitive communication deficit and recurrent depressive disorder. Review of Resident #1's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/06/2025, revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS also indicated Resident #1 had no identified behaviors, had not exhibited rejection of care, and used a wheelchair to ambulate. Review of Resident #7's admission Record indicated the facility admitted Resident #7 with diagnoses which included disorder affecting memory, thinking and behavior; cognitive communication deficit; anxiety disorder and depression. Review of Resident #7's quarterly MDS with an ARD of 07/07/2025 revealed a BIMS score of five (indicating severe cognitive impairment), a depression score of six (indicating depression was identified), and that Resident #7 exhibited no behaviors or rejection of care. Incident #2 Review of an I&A Report of resident-to-resident alleged abuse, indicated the incident was discovered by the facility on 05/05/2025 at 7:30 AM and was not submitted to the state agency until 05/05/2025 at 12:54 PM. The I&A report alleged physical abuse by Resident #6 to Resident #3. The report indicated, [CNA] was making rounds and changing out urinals when she went into [Resident #3's] room and found resident [Resident #6] in bed with [Resident #3] with [Resident #6's] hand over [Resident #3's] mouth. Review of Resident #3's admission Record indicated the facility admitted Resident #3 with diagnoses which included disorder affecting memory, thinking and behavior with anxiety, hemiplegia and hemiparesis (Hemiplegia is the complete paralysis of one side of the body, while hemiparesis is the partial weakness on one side of the body), and cognitive communication deficit. Review of Resident #3's admission MDS with ARD of 04/04/2025, revealed a BIMS score of three (indicating a severe cognitive deficit), and that Resident #3 exhibited no behaviors. Review of Resident #6's admission Record indicated the facility admitted Resident #6 with diagnoses which included a disorder affecting memory, thinking, and behavior with mood disturbance, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder. Review of Resident #6's quarterly MDS with an ARD of 09/04/2025 revealed a BIMS score of three (indicating severe cognitive impairment), and that Resident #6 exhibited no behaviors. Incident #3 Review of an I&A Report of staff to resident abuse indicated that the incident was discovered on 04/29/2025 at 4:00 PM and was not submitted to the state agency until 04/30/2025 at 11:17 AM. This incident involved Resident #4 and CNA #2. The report indicated, Resident #4 stated that [Resident #4] was going to the bathroom and pushed [Resident #4's] call light and [CNA #2] wasn't able to assist [Resident #4] at the time but told [Resident #4] that if you get up, I'll give you a shot. Review of Resident #4's admission Record indicated the facility admitted Resident #4 with diagnoses which included sensorineural hearing loss (a type of hearing loss caused by damage to the inner ear, the cochlear hair cells, or the auditory nerve,) and cognitive communication deficit. Review of Resident #4's admission MDS revealed a BIMS score of 14(indicating the resident was cognitively intact), and that Resident #4 exhibited no behaviors. During an interview on 11/17/2025 12:02 PM, the Administrator stated she did not follow the regulation mandating a two-hour time frame to report allegations of abuse, stating she, needed to investigate the allegations first. Review of a facility policy titled, Abuse, Neglect and Maltreatment Investigation and Reporting read in part .all allegations of abuse or neglect must be reported according to state and federal law.2 hour limit: if the events that cause the reasonable suspicion include allegations of abuse or serious bodily injury to a resident, the staff must report the suspicion immediately, but no later than 2 hours after forming the suspicion.

Based on interview and facility document review, the facility failed to ensure staff initiated and completed provider orders for one (Resident #6) of two residents reviewed for implementation of psychiatric consult orders. The findings include:Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/2025, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of three, which indicated severe cognitive impairment. The MDS also indicated Resident #6 had diagnoses that included a disorder affecting memory and thinking, anxiety disorder, and depression. A review of Resident #6's Progress Notes indicated the following: On 05/05/2025 at 11:13 AM, an Advanced Practice Registered Nurse's (APRN) note indicated the APRN referred Resident #6 to the Psych team after an incident where Resident #6 initiated physical aggression toward another resident, and Resident #6 had increased confusion and hallucinations. On 05/09/2025 at 2:26 PM, a Nurses Note indicated the resident was referred to Mental health. On 05/09/2025, a Nurses Note titled Dementia/Mental/Supportive Care Referral indicated Resident #6 had increased paranoia and confusion at night and on weekends. In addition, it was indicated the resident was to have a Dementia Care and Mental Health consult as a new patient. There was no evidence of the Mental health (Behavioral health) or Psych team consult being completed. During an interview on 11/18/2025 at 12:00 PM, the APRN indicated the process for new orders included making rounds, entering orders electronically, and then providing a handwritten list to the Licensed Practical Nurse regarding any new orders. The APRN indicated the need to rule out a physical indication for the change in behavior in Resident #6 by completing a urinalysis (UA) prior to the order being placed for a referral to behavioral health. When the UA resulted negative, a new order was entered for a behavioral health consultation on 05/12/2025. On 11/18/2025 at 12:43 PM, the APRN provided a scanned copy of the handwritten note dated 05/12/2025, listing any changes or orders which had been given to facility staff after completing rounds. The note indicated a new order for Resident #6 to be referred to Behavioral Health consultants for dementia and hallucinations. During an interview on 11/18/2025 at 2:45 PM, the Director of Nursing indicated the facility was unable to provide the order for the Behavioral Health consult intended for Resident #6 and the order for the behavioral health consultation was not followed. A review of the Licensed Practical Nurse (LPN) Supervisor Job Description indicated requisitions and arrangements for therapeutic services are to be made per physician orders.

Based on document review, record review, interviews, and facility policy review, the facility failed to ensure a resident was free from resident-to-resident abuse for 1 (Resident #1) of 4 residents reviewed for abuse. Specifically, Resident #2 verbally abused Resident #1 by commenting I am going to kill [pronoun] (Resident #2) on 10/30/2024. Resident #2 was not moved to another room until 11/01/2024 after a second verbal abuse, that resulted in physical abuse. 1. Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 01/31/2025 documented a Brief Interview for Mental Status (BIMS) score of 08, which identified the resident as having moderate cognitive impairment. Diagnoses included: diabetes mellitus (DM), chronic kidney disease, cerebrovascular accident (CVA), cognitive communication deficit, delirium, and obstructive and reflux uropathy. Resident #1 had an indwelling urinary catheter. a. Review of an Incident and Accident (I & A) Information Report, revealed the findings and actions taken documented: On 10/30/2024, the Assistant Director of Nursing (ADON), observed Resident #1 sitting in the common area when Resident #2 came out of Resident #2's room yelling/cussing at Resident #1 with Resident #2's finger pointed in Resident #1's face. Certified Nursing Assistant (CNA) #4 immediately removed Resident #2 from the area. Resident #2 was combative with CNA #4 at this time and told CNA #4 [Resident #2] would kill her [CNA #4]. On 11/01/2024 at 6:09 am, Treatment Nurse #3 observed Resident #2 on Resident #1's side of the room yelling I'm gonna kill [Resident #1], I'm gonna kill [Resident #1] and advancing toward Resident #1. Resident #2 was redirected and moved to another room. b. Review of an I & A Report revealed findings and Actions Taken 11/05/2024 at 11:30 am, CNA #10 observed Resident #1 sitting in the resident's wheelchair outside of the resident's room. CNA #10 witnessed Resident #2 walk over to Resident #1, hit Resident #1 in the face and multiple times in the chest and called Resident #1 a [expletive]. CNA #10 immediately separated the two residents. Resident #2 was immediately placed on one-on-one precautions. Resident #1 was taken aside with other staff for support. c. On 3/5/25 at 1:50 pm, this surveyor interviewed CNA #10 regarding the incident on 11/05/24 between Resident #1 and Resident #2. CNA #10 stated Resident # 2 was coming out of the resident's room and saw Resident #1 sitting outside Resident #1's door. Resident #2 headed in the direction of Resident #1 immediately and began hitting Resident #1 before CNA #10 could make it to Resident #1. The residents were immediately separated. CNA #10 took Resident #2 down the hall and redirected the resident. CNA #10 immediately informed the Administrator. This surveyor asked if she knew what caused the incident. CNA #10 stated Resident #1 and Resident #2 do not get along. Resident #2 had a history of trauma. CNA #10 was aware of this and did not know what caused outbursts. Resident #1 was not verbally abusive and did not say anything to Resident #2. d. On 03/5/25 at 2:08 pm, this surveyor interviewed LPN #9 who was here during the incident. This surveyor asked Licensed Practical Nurse (LPN) #9 if Resident #1 had ever been verbally abusive to her or anyone. LPN #9 stated no. This surveyor asked LPN #9 about the incident on 11/05/24 between Resident #1 and Resident #2. LPN #9 stated she heard someone requesting her assistance down the hall. LPN #9 stated Resident #2 attacked Resident #1 unprovoked. The residents were separated immediately and LPN #9 assessed and observed injuries of bruises only to right arm and left side of face. LPN #9 stated Resident #2 did have a history of childhood trauma. Staff were unaware of what set Resident #2 off. Resident #2 could not stand Resident #1 for some reason. Resident #2 was redirected due to aggressive behavior. e. On 03/06/25 at 2:00 pm, this surveyor interviewed the Director of Nursing (DON) regarding the incident on 11/05/24 between Resident #1 and Resident #2. The DON was not at the facility at the time of this incident. This surveyor asked the DON what the procedure was following a resident-to-resident altercation. The DON said to ensure safety of residents, body audits on all residents and do what you have to keep the residents safe. The DON was not aware of anyone Resident #1 was afraid of, or current issues with other residents. This surveyor asked what steps would be taken if resident to resident altercations occur. The DON said she would ensure the residents were not around each other. This surveyor asked what the DON would do if she did not know who a resident is afraid of. The DON responded, I would investigate, figure out triggers, get labs and mental health evaluation and behavior health referral. This surveyor asked what staff members were involved in the stand-up meetings in the mornings. The DON stated, Department heads and therapy. f. On 03/06/25 at 3:30 pm, this surveyor interviewed the Administrator regarding what was done to protect Resident #1 from Resident #2 ' s verbal abuse. The Administrator said Resident #1 was redirected by CNA #4. Residents #1 and #2 were still roommates on 10/30/24. Resident #2 changed rooms on 11/01/24 after the second verbal abuse altercation. The Administrator stated, Just separated them and gave Resident #2 some time to cool down. g. On 03/07/25 at 8:45 am, this surveyor interviewed Treatment Nurse #3 regarding the physical and verbal abuse from Resident #2 to Resident #1 on 11/05/24. Treatment Nurse #3 said there was no other verbal abuse she could recall. h. On 03/07/25 at 9:09 am, this surveyor interviewed the Assistant Director of Nursing (ADON) regarding the incident on 10/30/24 between Resident #1 and Resident #2 in which the ADON observed Resident #1 sitting in the common area when Resident #2 came out of Resident #2's room yelling and cussing at Resident #1. The ADON stated CNA #4 immediately removed Resident #2 from the area. Resident #2 was combative with CNA #4 at that time and told her Resident #2 would kill her. This surveyor asked why Resident #1 was not removed from the room at that time. The ADON stated it was not fully clear who the anger was directed at. i. On 3/7/25 at 10:30 am, this surveyor interviewed CNA #4 regarding the incident on 10/30/24 between Resident #1 and Resident #2. CNA #4 stated she could not remember the exact date; however, she observed Resident #1 sitting in the common area when Resident #2 came out of the resident's room yelling and cussing at Resident #1 with Resident #2's finger pointed in Resident #1's face. CNA #4 immediately removed Resident #2 from the area and placed the resident on one-on-one supervision. Resident #2 was combative with CNA #4 at that time and told her Resident #2 would kill her. Per CNA #4, Resident #2 was referring to Resident #1. Resident #1 was not removed from the room at that time. j. On 3/7/25 at 11:00 am this surveyor received a policy from the Administrator titled, Abuse, Neglect and Maltreatment Investigation & Reporting. The policy documented in section III .The facility shall take all necessary steps to prevent further potential abuse .

Based on record review and interview, the facility failed to ensure a physician's order for a fall mat was implemented as evidenced by a resident sustaining small collections of blood between the brain and outer covering in the front areas of the brain (bifrontal subdural hematomas) after a fall for 1 (Resident #5) of 3 (Residents #5, #6 and #7) sampled residents reviewed for falls. The findings are: Review of a 7734 Incident and Accident Information form with a status date of 01/24/2025, revealed the prior Director of Nursing was reviewing Resident #5's medical records from a fall with a hospital encounter on 01/15/2025. A computer tomography (CT) scan showed small collections of blood between the brain and its outer covering in the front areas of the brain (bifrontal subdural hematomas). The left hematoma was 5.5 millimeters (mm) in maximum diameter (measurement from one side to the next) and the right hematoma was 2.5 mm in maximum diameter. Review of Resident #5's medical diagnosis screen revealed diagnoses of hemiparesis (partial muscle weakness on one side of the body) and hemiplegia (total paralysis on one side of the body), dementia (a decline in a person's mental thinking affecting daily life), (fracture (break) of unspecified (not clear) part of neck or right femur (part of the thigh bone), and unspecified fracture of sacrum (break in the bone between the two hip bones). Review of the Order Summary Report revealed an order dated 12/14/2024 for a fall mat to right (R) side of bed every shift related to issues thinking and communicating (cognitive communication deficit) and a history of falling. Review of a significant change Minimum Data Set with an Assessment Reference Date of 01/08/2025 revealed Resident #5 has a brief interview for mental status (BIMS) score of 1, which indicates severely cognitively impaired, uses a wheelchair for mobility, requires substantial/maximal assistance for toilet and personal hygiene, dependent for chair/bed-to-chair and tub/shower transfer and had two falls with no injury, no falls with injury and no falls with a major injury since admission/entry or reentry or the prior assessment. Review of Incident and Accident (I and A) reports revealed the following: 12/14/2024 at 10:00 (AM), Certified Nursing Assistant (CNA) [un-named] was walking by resident room and found resident lying on floor on right side of bed after attempting to get out of bed to toilet. The residents' assist rails were up, and the call light was in reach. The fall was unwitnessed, and the resident sustained no injuries. Immediate action: resident was assisted back to bed following peri-care and vital signs/ neuro checks were started. 01/15/2025 at 15:59 (3:59 PM), alerted nurse resident had fallen. Upon the nurse entering room, the resident was lying on the left side, head at the foot of bed, bed was raised high, left side of face was on the floor and the wheelchair was on the other side of nightstand. The resident stated resident was trying to get from the bed to the chair. The resident had knots on the left side of the head. Immediate action: The resident was transferred to a local hospital and the staff were educated to lower the bed to the lowest position. Injury type: hematoma to back of head. 01/17/2025 at 14:02 (2:02 PM), nurse was called to the resident's room by the wound care nurse stating the resident was on the floor again. The resident was on the floor beside the wheelchair (w/c). The CNA stated the resident was assisted to bed approximately 15 minutes prior to the fall and she had provided peri-care for the resident. The fall was unwitnessed, and the resident sustained no injuries. Immediate Action: The resident was checked for injuries, assisted to the w/c per 2 [staff members] and the resident was sitting at the nurses' desk and neuro checks were started. Review of a Computerized Tomography (CT) scan of Resident #5's head without contrast, dated as performed 01/15/2025 at 16:33 (4:33 PM), revealed an impression of small bifrontal subdural hematomas. Review of the care plan dated as revised 01/07/2025 revealed Resident #5 was at risk for falls. Interventions included the following: every 1 hour toileting, initiated 01/09/2025; educated staff to keep bed in lowest position, initiated 01/17/2025; mattress placed at bedside, initiated 01/21/2025; one to one (1:1) with nonclinical staff to call for assistance when the resident is trying to get out of bed and staff education to place mattress to bedside, initiated 02/05/2025 and more frequent checks, initiated 02/13/2025. On 03/06/2025 at 10:59 AM, CNA #1 was interviewed and stated she walked into the resident's room on 01/15/2025, and the resident was lying on the left side, on the floor, with the resident's head at the foot of the bed and the legs at the head of the bed. She stated the resident was saying help and she left the room to get the nurse. She stated the resident had knots on the upper left side of the head. On 03/06/2025 at 11:48 AM, CNA #11 was interviewed and stated Resident #5 was not able to get out of bed without assistance and fell the last time the resident tried. She stated there is a fall mat by the resident's bed. On 03/07/2025, CNA #11 was interviewed and stated Resident #5 was not able to work the bed controls, she had observed the resident's bed not in the lowest position on rounds a few times and thinks she noticed the fall mattress on the resident's floor in February 2025 but was not able to give an exact date. On 03/06/2025, CNA #15 was interviewed and stated Resident #5 was not able to get out of bed without assistance but does try hard and is at risk for falls. She stated the resident did fall some time ago and had a bump on the back of the head. On 03/07/2025 at 10:28 AM, CNA #15 was interviewed and stated Resident #5 was able to use the bed controls when not confused, CNA #15 has noticed the bed not in the lowest position and did not know when the fall mattress was placed on the resident's floor. On 03/07/2025 at 11:02 AM, Licensed Practical Nurse (LPN) #12 was interviewed and stated Resident #5 was not able to use the bed controls and could not recall the exact date the fall mattress was placed on the resident's floor. She confirmed she did receive the order on 12/14/2024 to place a fall mat on the resident's floor. She stated the fall mat was down and then the fall mattress was placed on the resident's floor, but she could not recall when the fall mat was placed. She stated she thinks the fall mat was placed on the resident's floor the day the wound nurse alerted her the resident was on the floor. She stated she informed the CNAs of the order for the fall mat, but did not inform the other nurses or the MDS Coordinator. On 03/07/2025 at 11:19 AM, MDS Coordinators #13 and #14 were interviewed. MDS Coordinator #14 stated the MDS Coordinators revised most of the residents' care plans and other staff contributed. MDS Coordinator #13 stated residents' care plans are updated as needed and every quarter. She stated everything they need from the electronic health records (EHR), including [physician] orders, were gathered for information to be included in the care plan. The MDS Coordinators were asked to review Resident #5's care plan and let this surveyor know when the intervention for a fall mat was placed on the care plan. MDS Coordinator #14 stated the mattress was more recent but did not see where the fall mat was included on the care plan. MDS Coordinator #14 reviewed Resident #5's EHR and stated LPN #12 entered the order for the fall mat, but she did not see the intervention placed on the I and A report. She stated the I and A reports were discussed in morning meeting each day. On 03/07/2025 at 12:24 PM, the prior Director of Nursing (DON) was interviewed by telephone and she stated February 14, 2024, was her last day at the facility. She stated she was not at the facility the day Resident #5 had the fall on 01/15/2025 and returned to the facility on [DATE]. She stated if a nurse enters an order for a fall mat, an in-service would be done to make other staff aware by her. She stated the MDS Coordinator updated the resident's care plan, but other nursing staff made revisions at times. She verified during her time at the facility as DON, the I and A reports were reviewed each morning with upper management. She stated the nurses initiate the I and A report and she would complete the I and A report and do a follow-up on the I and A. On 03/07/2025 at 1:39 PM, the DON was interviewed and stated she started in her role two weeks ago. She stated the MDS Coordinator updates the care plan quarterly and as needed. She stated she completes an in-service to ensure the staff were aware of any new interventions for resident care. The DON was asked who was responsible for ensuring the interventions were implemented and stated she will put the intervention in place and staff rounds daily. She stated she or the Assistant Director of Nursing (ADON) reviews the residents' charts for new orders. The DON stated she or the ADON reviewed the residents progress notes for any new changes but did not indicate physician's orders were reviewed.

Based on record review and interview, the facility failed to ensure a care plan was revised to include an intervention for a fall mat for a resident who had a fall which resulted in the resident sustaining injuries of small collections of blood between the brain and outer covering in the front areas of the brain (bifrontal subdural hematomas) for 1 (Resident #5) of 3 (Residents #5, #6 and #7) sampled residents whose care plans were reviewed for falls. The findings are: Review of Resident #5's medical diagnosis screen revealed diagnoses of hemiparesis (partial muscle weakness on one side of the body) and hemiplegia (total paralysis on one side of the body), dementia (a decline in a person's mental thinking affecting daily life), fracture (break) of unspecified (not clear) part of neck or right femur (part of the thigh bone), and unspecified fracture of sacrum (break in the bone between the two hip bones). Review of the Order Summary Report revealed an order dated 12/14/2024 for a fall mat to the right (R) side of the bed every shift related to issues with thinking and communicating (cognitive communication deficit) and a history of falling. Review of a significant change Minimum Data Set (MDS) with an Assessment Reference Date of 01/08/2025 revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident was severely cognitively impaired, used a wheelchair for mobility, required substantial/maximal assistance for toilet and personal hygiene, dependent for chair/bed-to-chair and tub/shower transfer and had two falls with no injury, no falls with injury and no falls with a major injury since admission/entry or reentry or the prior assessment. Review of the care plan revised 01/07/2025 revealed, Resident #5 was at risk for falls. Interventions included the following: every one hour toileting, initiated 01/09/2025; educated staff to keep bed in lowest position, initiated 01/17/2025; mattress placed at bedside, initiated 01/21/2025; one to one (1:1) with nonclinical staff to call for assistance when the resident is trying to get out of bed and staff education to place mattress to bedside, initiated 2/5/2025 and more frequent checks, initiated 02/13/2025. Review of an incident and accident (I and A) report dated 01/15/2025 at 15:59 (3:59 PM), revealed aide [Certified Nursing Assistant (CNA)] alerted nurse resident had fallen. Upon the nurse entering room, the resident was lying on the left side, head at the foot of bed, bed was raised high, left side of face was on the floor and the wheelchair was on the other side of nightstand. The resident stated resident was trying to get from the bed to the chair. The resident had knots on the left side of the head. Immediate action: The resident was transferred to a local hospital and the staff were educated to lower the bed to the lowest position. Injury type: hematoma to back of head. On 03/06/2025 at 10:59 AM, CNA #1 was interviewed and stated she walked into the resident's room on 01/15/2025 and the resident was lying on the left side, on the floor, with the resident's head at the foot of the bed and the legs at the head of the bed. She stated the resident was asking for help and she left the room to get the nurse. She stated the resident had knots on the upper left side of the head. On 03/06/2025 at 11:48 AM, CNA #11 was interviewed and stated Resident #5 was not able to get out of bed without assistance and fell the last time the resident tried. She stated there was a fall mat by the resident's bed. On 03/07/2025, CNA #11 was interviewed and stated Resident #5 was not able to work the bed controls, she had observed the resident's bed not in the lowest position on rounds a few times and thought she noticed the fall mattress on the resident's floor in February 2025 but was not able to give an exact date. On 03/06/2025, CNA #15 was interviewed and stated Resident #5 was not able to get out of bed without assistance but did try hard and was at risk for falls. She stated the resident did fall some time ago and had a bump on the back of the head. On 03/07/2025 at 10:28 AM, CNA #15 was interviewed and stated Resident #5 was able to use the bed controls when not confused. CNA #15 had noticed the bed not in the lowest position and did not know when the fall mattress was placed on the resident's floor. On 03/07/2025 at 11:02 AM, Licensed Practical Nurse (LPN) #12 was interviewed and stated Resident #5 was not able to use the bed controls and could not recall the exact date the fall mattress was placed on the resident's floor. She confirmed she did receive the order on 12/14/2024 to place a fall mat on the resident's floor. She stated the fall mat was down and that the fall mattress was placed on the resident's floor, but she could not recall when the fall mat was placed. She stated she thought the fall mat was placed on the resident's floor the day the wound nurse alerted her the resident was on the floor. She stated she informed the CNAs of the order for the fall mat, but did not inform the other nurses or the MDS Coordinator. On 03/07/2025 at 11:19 AM, MDS Coordinators #13 and #14 were interviewed. MDS Coordinator #14 stated the MDS Coordinators revised most of the residents' care plans and other staff contributed. MDS Coordinator #13 stated residents' care plans are updated as needed and every quarter. She stated everything they need from the electronic health records (EHR), including [physician] orders, were gathered for information to be included in the care plan. The MDS Coordinators were asked to review Resident #5's care plan and let this surveyor know when the intervention for a fall mat was placed on the care plan. MDS Coordinator #14 stated the mattress was more recent but did not see where the fall mat was included on the care plan. MDS Coordinator #14 reviewed Resident #5's EHR and stated LPN #12 entered the order for the fall mat, but she did not see the intervention placed on the I and A report. She stated the I and A reports were discussed in morning meeting each day. On 03/07/2025 at 12:24 PM, the prior Director of Nursing (DON) was interviewed by telephone and she stated February 14, 2024, was her last day at the facility. She stated she was not at the facility the day Resident #5 had the fall and returned to the facility on [DATE]. She stated if a nurse enters an order for a fall mat, an in-service would be done to make other staff aware by her. She stated the MDS Coordinator updated the resident's care plan, but other nursing staff made revisions at times. She verified during her time at the facility as DON, the I and A reports were reviewed each morning with upper management. She stated the nurses initiate the I and A report and she would complete the I and A report and do a follow-up on the I and A. On 03/07/2025 at 1:39 PM, the DON was interviewed and stated she started in her role two weeks ago. She stated the MDS Coordinator updates the care plan quarterly and as needed. She stated she completes an in-service to ensure the staff were aware of any new interventions for resident care. The DON was asked who was responsible for ensuring the interventions were implemented and stated she will put the intervention in place and staff rounds daily. On 03/07/2025, the Administrator was asked to provide a policy for revising care plans. On 03/07/2025 at 2:01 PM, the DON stated the facility uses the Resident Assessment Instrument (RAI) manual and the Centers for Medicare and Medicaid Services (CMS) guidelines regarding revising the care plans. She stated the version of the RAI manual the facility has is v (version)1.19.1, effective October 2024.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure dietary staff thoroughly washed their hands and changed gloves when contaminated and before handling food and clean equipment when contaminated; food items stored in the refrigerator, freezer and dry storage area were covered, sealed or dated; expired food items and spices were promptly removed/discarded on or before the expiration or use by date, and hot food items were maintained at 135 degrees Fahrenheit or above for 2 of 2 meals observed. The findings are: 1. On [DATE] at 8:59 AM, an opened box of sausage was observed on a shelf in the walk-in refrigerator. The box was not covered or sealed. 2. On [DATE] at 9:15 AM, the following observations were made on a shelf in the walk-in freezer. a. An opened box of biscuits. The box was not covered or sealed. b. An opened box of chicken fried steak. The box was not covered or sealed. 3. On [DATE] at 9:19 AM, the following observations were made on a shelf in the storage room. a. One container of ground cloves with an expiration date of [DATE]. b. One container of ground thyme with an expiration date of [DATE]. 4. On [DATE] at 9:41 AM, two of two cartons of jelly were observed on a self in the refrigerator, in the nourishment room leading to 400-hall, with an expiration date of [DATE]. On [DATE] at 9:42 AM, the following cartons of desserts were on a shelf in the refrigerator, in the nourishment room leading to 400-hall, there were no dates when the desserts were received: a. Two cartons of strawberry yogurt. b. Two cartons of blueberry yogurt. c. One carton of banana supreme yogurt. d. One carton of protein peach. e. One bowl of cheesecake yogurt. f. One bowl of pumpkin pie. 5. On [DATE] at 10:18 AM, Dietary Aide (DA) #1 removed two sticks of butter from the refrigerator and placed them on the counter. Without washing her hands, she picked up glasses by their rims and placed them on the trays to be used in serving beverages to the residents for lunch. 6. On [DATE] at 10:58 AM, Dietary Aide (DA) #2 pushed plate warmer towards the steam table. Without washing his hands, DA #2 picked up plates and placed them on the counter with his fingers inside of them. DA #2 was interviewed and was asked what he should have done after touching dirty objects and before handling clean equipment, DA #2 stated he should have washed his hands. 7. On [DATE] at 11:14 AM, DC #3 walked out of the refrigerator and then pulled his pants, contaminating his hands. Without washing his hands, he picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents for lunch. DC#2 was interviewed and was asked what he should have done after touching dirty objects and before handling clean equipment, DC #2 stated he knew he should have washed his hands before picking up the blade. 8. On [DATE] at 11:53 AM, DC #3 removed a carton of milk from the refrigerator and placed it on the counter, contaminating his hands. Without washing his hands, DC #3 picked up a clean blade and attached it to the base of the blender. He picked up gloves and placed them on his hands, contaminating the gloves in the process. At 11:55 AM, DC #3 used his contaminated gloved to pick up slices of cornbread to place into a blender. When he was asked what he should have done after touching dirty objects and before handling clean equipment, DC #3 stated he should have washed his hands. 9. On [DATE] at 12:28 PM, the temperatures of the tomato soup checked and read by the Dietary [NAME] (DC) #4 after been heated up in the microwave were: a. First bowl of tomato soup was 121 degrees Fahrenheit, and second bowl of tomato soup was 122 degrees Fahrenheit when served. The above soups were not reheated before being served to the residents who requested tomato soup with their lunch meal. DC #4 was interviewed and was asked what she should she have done when food items are not at the required temperature before being served to the residents, she stated she should have reheated it. 10. On [DATE] at 1:00 PM, Dietary [NAME] (DC) #4 was observed removing a bag of shredded lettuce from the refrigerator and placing it on the counter. DC #4 picked up gloves and placed them on her hands, contaminating the gloves in the process. At 1:03 PM, DC #4 unzipped the bag that contained shredded lettuce and used her contaminated gloved hand to remove shredded lettuce from the bag and placed them on the plates to serve to the residents who requested salad with their noon meal. DC #4 was interviewed and was asked what she should have done after touching dirty objects and before handling clean equipment, DC # 4 stated she should have washed her hands. 11. A review of facility policy titled, Hand Washing and Glove Usage in Food Service, initiated 2016, provided by the Dietary Manager on [DATE] indicated, employees should wash their hands before starting work and after touching anything else like dirty equipment and work surfaces.

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to ensure that nutritionally balanced meals were provided for the residents for 2 of 2 meals observed. The findings are. 1. On 11/18//2024, the menu for noon meal indicated residents on pureed diets were to receive a #6 scoop (2/3 cup) of pureed chicken and dumpling and a #8 scoop (1/2 cup) of pureed cornbread. On 11/18/24 at 12:48 PM, the following observations were made during the noon meal service. a. Dietary Aide (DA) #1 used a #16 scoop (1/4 cup) to serve a single portion of pureed cornbread to the residents on pureed diets, instead of a #8 scoop (1/2 cup). On 11/19/24 at 8:45 AM, DA #1 when asked during an interview what spoon size she had used when serving pureed cornbread to the residents who required pureed diets. DA #1 stated she used the blue scoop (#16) which was equivalent to 1/4 cup to give a single serving to each resident. When asked if she looked at the menu DA #1 confirmed she did not. The kitchen staff always use the blue scoop to serve pureed cornbread. b. DA #1 used a #8 scoop (1/2 cup) to serve a single portion of pureed chicken and dumpling to the residents on pureed diets, instead of a #6 scoop (2/3 cup). At 12:53 PM, DA #1 when asked during an interview what spoon size she had used when serving chicken and dumpling to the residents who required pureed diets. DA #1 stated she made a mistake, by using a #8 scoop to give a single serving to each resident that she should have use #6 scoop instead. 2. On 11/19/2024, the menu for breakfast meal indicated residents on pureed diets were to receive a #8 scoop (1/2 cup) of pureed French toast. On 11/19/2024 at 8:09 AM, DA #1 served a single portion of pureed French toast with a #16 scoop which was equivalent to 1/4 cup, instead of a #8 scoop (1/2 cup). At 10:40 AM, DA #1 when asked during an interview what scoop size she had used when serving pureed French toast to the residents on pureed diets she stated blue scoop (#16) which was equivalent to 1/4 cup. DA #1 stated she knew now she should be looking at the menu before serving meals.

Based on observation, record review, and interview, the facility failed to ensure residents were lowered and raised in a mechanical lift with the rear casters/wheels in the unlocked position to prevent accidents or injury for 1 sampled (Resident #45) resident reviewed for accidents and injuries. Findings include: 1. A review of Medical Diagnoses revealed Resident #45 with diagnoses of Parkinson's, type II diabetes, and Alzheimer's. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/23/2024, indicated a Brief Interview for Mental Status (BIMS) score of 03 (0-7 suggest cognitively impaired). Resident #45 required total care for bathing, dressing, and personal care. a. A review of Resident #45's Care Plan, dated 07/31/2024, revealed Resident #45 was dependent on 2 or more helpers doing all the effort for toileting and transfers using a mechanical lift with a green lift pad. b. Review of the mechanical lift instruction manual page 2 indicated not to lock the casters during lifting. c. On 11/18/2024 at 11:28 AM, Certified Nursing Assistant (CNA) #5 and CNA #6 were observed rolling Resident #45 over the bed in a mechanical lift. CNA #5 locked the rear casters/wheels and left the legs in the open position while lowering and raising Resident #45. The CNAs were asked the process for lowering and raising a resident while in the mechanical lift, and CNA #5 stated that they open the legs so that it keeps the lift from turning over, and the wheels are locked to keep the mechanical lift from rolling and moving on them. CNA #5 confirmed the facility provides mechanical lift training. d. During an interview with the Director of Nursing (DON) on 11/20/24 at 09:24 AM, the DON was asked what process staff are expected to use when lifting and lowering residents with a mechanical lift. The DON stated she would have to look and suspected the legs are to be open when raising and lowering residents for stability. After reviewing a copy of the manual guide on page 2, the DON confirmed that the casters/wheels of the mechanical lift are to remain unlocked when raising and lowering a resident but noted the manual did not explain why. e. On 11/20/24 at 10:12 AM, the Director of Nursing (DON) provided documentation of staff competencies that showed CNA #6 had been trained on the lift.

Based on observation, record review, interview, and facility policy review, it was determined that the facility nursing staff failed to label an anti-anxiety medication stored in the refrigerated narcotic box in the 300-hall medication room with the open and use by date to prevent expired medication from being administered to residents beyond the recommended use by date. The findings include: a. A review of an in-service titled, Narcotic Expiration, dated [DATE], revealed staff are to be mindful of the expiration dates on narcotics by dating bottles when opened, and lorazepam will expire 60 days from the date opened. Review of a policy titled, Medication Storage in the Facility, revised [DATE], revealed to ensure medication potency and purity, certain medications require an expiration date that is shorter than the manufacturers expiration date. The pharmacy will carry a beyond use date that is determined by regulations and the law. Multi dose packaging will have a beyond use date of 60 days. Medications should be dated when the manufacturer ' s seal is broken, and staff should place the date opened on the bottle, and the new date of expiration. b. On [DATE] at 2:51 PM, the Surveyor observed a resident had an unopened bottle of anti-anxiety oral concentrate 2mg/ml (milligram/milliliter), and a second opened bottle of anti-anxiety medication resting in the locked narcotic box in the 300 Hall medication room. The plastic storage bag was dated [DATE] for the open bottle. The Do Not Use Beyond sticker on the bottle and labeled storage bag were not filled out, and the date the medication was opened was not written on the bottle or the plastic bag. Licensed Practical Nurse (LPN) #7 revealed she was not sure when the medication was opened. Narcotic page 15 was started on [DATE], and showed the last dose given was on [DATE]. LPN #7 located the original entry from a retired drug book on page 60, showing the medication was first opened on [DATE]. LPN #7 was unable to confirm how many days anti-anxiety oral concentrate was good from the time opened and would get back to the Surveyor after speaking with the Director of Nursing (DON). c. On [DATE] at 7:45 AM, the Director of Nursing (DON) was asked what process nursing was expected to use to determine when a medication was expired. The DON stated they have spoken with the pharmacist and threw away both bottles of anti-anxiety medication because he told them the medications were past their expected beyond use date including the unopened bottle, and she confirmed the pharmacist told them anti-anxiety oral medication was good for 90 days after opening, but the policy was 60 days. When asked if it was appropriate to administer anti-anxiety medication on [DATE] from a bottle that was opened on [DATE], the DON confirmed that it was not appropriate to administer anti-anxiety medication from a bottle that was opened on [DATE] because it might be less potent and not benefit the resident.

Based on observation and interview, the facility failed to ensure foods stored in the freezer were covered to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, and failed to ensure 1 of 2 ice scoop holders was maintained in clean and sanitary condition to prevent contamination of airborne particles. These failed practices had the potential to affect 83 residents who received meals from the kitchen, (total census: 83) as documented on a list provided by the Dietary Supervisor on 11/07 /2023 at 11:56 AM The findings are: 1. On 11/06/23 at 12:33 PM, Dietary Employee (DE) #1 took a paper plate in the storage room. Without washing her hands, she picked up a clean blade from the clean side of the dish washing machine and placed it on a clean rack to air dry to be used in pureeing food items to be served to the residents for supper meal. 2. On 11/06/23 at 01:00 PM, an opened box of sausage was on a shelf in the freezer. The box was not covered or sealed. 3. On11/06/23 at 01:03 PM, The Dietary Employee (DE) #1 wiped her face and without washing her hands, she picked plates and placed them on the plate warmer. The Surveyor asked DE #1 what she should have done after touching her face before and before handling clean equipment. She stated, Washed my hands. 4. On 11/06/23 at 01:24 PM, the ice scoop holder on the right side of the ice machine in the nourishment room on the 400 Hall had wet pink residue in it. The surveyor asked Dietary Supervisor to wipe the pink residue on the inside corners and the area where the scoop holder was resting. She did so, and the wet pink substance easily transferred to the paper towel. She was asked to describe what was seen in the scoop holder. How often do they clean it? Who uses the ice from the ice machine. She stated, That's the ice the CNAs [Certified Nursing Assistant] use for the water pitchers in the residents' rooms. We clean it once a week. 5. On 11/06/23 at 04:20 PM, Dietary Employee (DE) #1 pushed a cart that contained an ice cream cooler towards the cold side of the steamtable. Without washing her hands, she picked up bowls to be used in portioning food items and placed them on the food counter with her fingers inside the bowls. 6. On 11/06/23 at 04:50 PM, Dietary Employee (DE) #1 was on the tray line assisting with the supper meal. DE #1 picked up condiments and supplements and placed them on the trays. Without washing her hands, she picked up bowls to be used in portioning food items to be served to the residents and placed them on the trays with her fingers inside of them. The Surveyor asked DE #1 what should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 7. A facility policy titled hand washing provided by the Dietary Supervisor on 11/07/2023 at 01:17 PM documented, .1. When to Wash Hands: .After engaging in other activities that contaminate the hands .

Based on observation, record review and interview, the facility failed to ensure potentially hazardous chemicals were stored in a secure location to prevent the potential access to hazardous items for residents who were independently mobile and cognitively impaired; failed to ensure interventions were in place to prevent further falls; and failed to ensure sharps containers were changed when reaching the full line to prevent possible needle sticks and/or removal of used sharps from the sharp's container. These failed practices had the potential to affect 42 residents who ambulated independently or propelled independently, as documented on a list provided by the Administrator on 11/08/23 at 05:07 PM. The findings are: 1. a. On 11/06/23 at 11:04 AM, in 410B's bathroom a 32 ounce bottle of (Disinfectant, Cleaner and Deodorizer) was sitting on the sink. b. Houskeeper #1 was called to the room and as she saw the bottle stated, No this should not be left here. If a resident gets it and swallows it, they could die. c. On 11/09/23 at 11:40 AM, the Housekeeping Supervisor was asked what she expected the staff to do with their cleaning chemicals when they were not in eyesight. The Housekeeping Supervisor responded, The chemical should be put back in the cart and the chemical should remain in sight when not locked up The Housekeeping Supervisor was asked what could happen if a frail vulnerable resident accidentally ingested the chemical or sprayed it in their eyes. The Housekeeping Supervisor stated, They could get poisoned or burned. 2. a. Resident #28 had a fall with major injury documented on the Roster Matrix provided by the Administrator on 11/06/23 at 11:28 AM. On 10/05/23, Resident #28 had a fall which resulted in a hip fracture. A [nonslip mat] was put into place as an intervention to attempt to prevent further falls. On 2/16/23 the intervention was to lower the wheelchair seat to prevent falls. b. On 11/6/23 at 11:24 AM, Resident #28 was sitting in her wheelchair in the Dining Room. The wheelchair seat was not lowered and there was not a [nonslip mat] on her cushion. c. On 11/07/23 at 08:55 AM, during morning observation there was no [nonslip mat] in Resident #28's chair and her wheelchair seat was not lowered. Certified Nursing Assistant (CNA) #4 was asked to look under the resident to see if the [nonslip mat] was in place. The CNA lifted the resident up and stated, It's not there. She's supposed to have it. The CNA was asked if Resident #28s wheelchair had a lowered seat. CNA #4 stated, No, this is a normal wheelchair height. CNA #4 was asked why interventions were put in place and she stated, To prevent falls because they can break bones and worse things could happen. d. A Minimum Data Set with an Assessment Reference Date of 10/11/23 captured a fall. e. A Care Plan dated: 11/11/2022 with a revision date of 11/02/2023 documented, Resident #28 is at risk for falls r/t [related to] her dx [diagnosis] of dementia . 1/5/23- bolster overlay to bed . 10/5/23 - [nonslip mat] to wheelchair . 2/16/23 - Wheelchair seat lowered . f. On 11/08/2023 at 10:06 AM, the Director of Nursing (DON) was asked to check the electronic record for the fall on 2/16/23. The DON stated, Her wheelchair seat should be lowered. I know she was in the wrong wheelchair. [Named CNA #4] told me as well as her [nonslip mat] was not in her chair either. The DON was asked to explain why the interventions were important. The DON stated, They are to help prevent any more falls. 3. a. Resident #44 had a fall on 10/16/2023 and resulted in a right humerus fracture. According to the Care Plan and Progress Note there was no intervention put in place to prevent further falls with further injuries immediately. The first intervention was a referral to therapy on 10/20/23 for an evaluation. b. A Care Plan dated 09/21/23 with a revision date of 10/19/23 documented, [Resident #44] is at risk for falls . 10/16/23- fall mat to right side of bed 10/20/23- referral to therapy Date Initiated: 11/08/2023 with a Revision on: 11/08/2023 . c. On 11/08/2023 at 09:13 AM, Licensed Practical Nurse (LPN) #4 was asked if Resident #44 fell during her shift. LPN #4 stated Yes. LPN #4 was asked what intervention was put in place immediately to prevent further falls. LPN #4 did not answer the question. LPN #4 was asked if she had care planned any immediate intervention to communicate to oncoming shifts. LPN #4 stated I know if it isn't documented, it isn't done. LPN #4 was asked so there was no immediate intervention put in place? LPN #4 stated, No ma'am. d. On 11/08/2023 at 10:06 AM, the DON was asked if she was aware of Resident #44's fall on 10/16/23. The DON stated, Yes. The DON was asked to explain why the interventions were important. The DON stated, They are to help prevent any more falls. The DON was asked to look in the electronic record for Resident #44's immediate intervention. The DON stated, We put a fall mat in place and a referral to therapy. The DON was asked to explain how a fall mat might attempt to prevent a fall. The DON stated, It won't. The DON was asked when the referral to therapy was made. The DON stated, On the 20th twentieth of October. The DON was asked when the evaluation was done. The DON stated, I don't know. 48630 4. a. On 11/07/2023 at 03:17 PM, the Surveyor observed a sharps container on the 200/300 Hall medication cart exceeding the full line. The full sharps container was unable to close the safety flap which left the contents easily accessible and be removed from the container. b. On 11/07/2023 at 03:31 PM, the Surveyor observed LPN #1 place a used insulin needle in the sharps container without the safety flap closing to prevent being able to remove the used needle from the sharp's container. c. On 11/07/2023 at 03:39 PM, the Surveyor observed LPN #1 place a used insulin needle in the sharps container without the safety flap closing to prevent being able to remove the used needle from the sharp's container. d. On 11/07/2023 at 03:58 PM, the Surveyor observed LPN #1 place a used insulin needle in the sharps container without the safety flap closing to prevent being able to remove the used needle from the sharp's container. e. On 11/07/2023 at 04:10 PM, LPN #1 was asked, How often are sharps containers changed? LPN #1 responded, Whenever they need it. LPN #1 was then asked, What is the reasoning for changing the sharps containers? LPN #1 responded, So it does not overflow and so we don't get stuck. LPN #1 was asked, What can happen with the sharps container currently with the amount of sharps that are in there? LPN #1 responded, You could reach in and grab them out. f. On 11/07/2023 at 04:29 PM, the DON was asked, How often are the sharps containers changed? The DON replied, When they have reached the full line. The DON was asked, What is the importance of changing the sharps containers when they reach the full line? The DON replied, To prevent finger sticks. A policy provided by the Administrator on 11/08/23 at 04:18 PM, titled, Accident Hazards Prevention documented, Resident Environment: The environment will be free from accident hazards as is possible .The frailty of some residents increases their vulnerability to hazards in the resident environment and can result in life -threatening injuries .

Surveyor: [NAME], [NAME] Based on observation of medication pass and clinical record review, the facility failed to ensure physician orders were followed to maintain a medication error rate of less than 5%, to prevent potential complications for 2 (Residents #15 and #66) of 2 residents observed during the medication pass. The medication error rate was 9.68%, based on observation of 31 medications administered, plus 1 medication ordered but not administered when timed on the Medication Administration Record (MAR) for a total of 3 errors detected. The findings are: 1. A) Resident (R15) had a Physician's Order for Sucralfate Tablet 1 gram to give 1 tablet by mouth four times a day for gastric protection, take 1 hour before meals and at bedtime. B) On 11/07/23 at 03:05 pm, the Surveyor observed Licensed Practical Nurse (LPN) #6 dissolve a Sucralfate tablet with a small amount of water in a medicine cup then administered the medication with water to R15. C) On 11/08/23 at 11:15 am, the Surveyor asked (LPN) #2 to pull up the Medication Administration Record for R15. LPN #2 was asked to look at the Sucralfate and provide the times this medication was administered on 11/07/23. LPN #2 stated, 5:02 am, 11:05 am, 15:05 [3:05] am, 19:07 [7:07 pm]. The Surveyor asked what time was R15 served breakfast, lunch, and dinner? LPN #2 said I am not sure let me check on that and get back with you. Later, LPN #2 provided a sticky note and stated these are the times they start to serve meals: Breakfast 7:15 AM, lunch 12:15 PM, Dinner 5:15 PM. D) On 11/08/23 at 11:40 am, the Surveyor asked the Director of Nursing (DON) if she could pull up the Medication Administration Record for R15 and she did. The Surveyor asked can you tell me what time R15 can received her 4:00 pm dose of sucralfate? The DON said between three and five pm. The Surveyor asked the DON what about the part of the order that states give 1 hour before meals and at bedtime? The Administrator interjected and stated that end of the hall does not get their tray until five forty five or six pm. The Surveyor asked the DON now knowing the time R15 receives her meal what time should R15 have received her sucralfate? The DON said around four forty five. 46868 2. On 11/07/23 at 4:00 PM, Resident #66 had a scheduled Eliquis 5 mg (milligrams) to be given at 4:00 PM. This medication was not administered. Resident #66 did not have a scheduled Buspar 5 mg at 4:00 PM but was administered the Buspar. a. On 11/06/23 A Physicians order documented Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day related to UNSPECIFIED ATRIAL FIBRILLATION. b. On 09/11/23 a Physicians Order documented BusPIRone HCl [Hydrochloride] Tablet 5 MG. Give 1 tablet by mouth three times a day for anxiety. c. On 11/08/23 at 08:50 AM, the Surveyors checked the medication cart along with LPN #5. Located in the 4:00 PM scheduled medications, was a card of Buspar 5 mg. d. LPN #5 was asked if the card of Buspar was in the wrong scheduled slot and the Surveyors observed the wrong medication being given according to time scheduled, what could have occurred. LPN stated, That would be a medication error. e. On 11/08/23 at 8:59 AM, the Surveyors asked LPN #5 for the Eliquis cards. LPN #5 said the Assistant Director of Nursing (ADON) got them this AM because the order was changed. f. On 11/08/23 at 9:10 AM, Two Cards of Eliquis were in the return bin. According to the MAR, 4 doses were administered. Only 1 tablet was missing. g. On 11/08/23 at 9:11 AM, the DON was asked if any Eliquis might have been given from the emergency box (ER Box). h. The DON stated at 11:18 AM on 11/08/23 that she could not locate any medications given from the ER box. i. On 11/08/23 at 11:20 AM, the DON was asked if there was no Eliquis in the 4:00 PM scheduled time slot and the two Surveyors (2) did not observe Eliquis being administered to explain what had occurred. The DON stated, That would be a medication error. 3. On 11/07/23 at 4:40 PM the DON provided a form titled, PREPARATION AND GENERAL GUIDELINES: MEDICATION ADMINISTRATION GUIDELINES: .4) Five Rights - .right drug .right time .a.compared against the medication administration record (MAR) by reviewing the 5 Rights . c.Complete the preparation of the dose and re-verify the label against the MAR by reviewing the 5 Rights .5. The medication administration record (MAR) is always employed during medication administration .

Based on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained the appearance of cold products and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 15 residents who received meal trays in their rooms on the 100 Hall, 32 residents who received meal trays on the 200 Hall, 18 residents who received meal trays in their room on the 300/400 Halls, and 16 residents who received meal trays in their room on the Retreat Hall, as documented on a list provided by the Dietary Supervisor on 11/07/2023 at 11:56 AM. The findings are: 1. On 11/07/23 at 10:06 AM, the Surveyor asked Resident (R)#37, is hot food hot and cold food cold. Resident stated, Hot food is usually cold. 2. On 11/07/23 at 09:35 AM, the Surveyor asked R#14, is hot food hot and cold food cold. Resident stated, All food is cold. 3. On 11/07/23 at 07:10 AM, an unheated food cart that contained 15 trays for breakfast was delivered to the 100 Hall by Certified Nursing Assistant (CNA) #1. At 07:45 AM, immediately after the last resident was served in their room on the 100 Hall the temperature of the food items on the tray used as a test tray were taken and read by the Dietary Supervisor with the following results: a. Milk - 49 degrees Fahrenheit. b. Ground sausage with gravy - 84 degrees Fahrenheit. 4. On 11/07/23 at 07:30 AM, an unheated food cart that contained 32 trays for breakfast was delivered to the 200 Hall Dining Room by Certified Nursing Assistant #2. At 07:48 AM, immediately after the last resident was served in their room on the 200 Hall, the temperature of the food items on the tray used as test tray were taken and read by the Dietary Supervisor with the following results: a. Milk - 45 degrees Fahrenheit. b. Pureed sausage - 108 degrees Fahrenheit. c. Pureed scrambled eggs - 105 degrees Fahrenheit. d. Sausage - 99 degrees Fahrenheit. e. Pancake - 114 degrees Fahrenheit. 5. On 11/07/23 at 07:48 AM, an unheated food cart that contained 16 trays for breakfast was delivered to the Retreat Hall by the Certified Nursing Assistant #3. At 07:58 AM, immediately after the last resident was served in the dining room on the Retreat Hall, the temperature of the food items on the tray used as test tray were taken and read by the Dietary Supervisor with the following results: a. Milk - 43 degrees Fahrenheit. b. Scrambled eggs - 115 degrees Fahrenheit. c. Pureed eggs - 98 degrees Fahrenheit. d. Ground sausage with gravy - 113 degrees Fahrenheit. 6. On 11/07/23 at 07:59 AM, an unheated food cart that contained 18 trays for breakfast for the 300 and 400 Halls was delivered in front of the nurses' station. The 300 Hall by Certified Nursing Assistant #4. At 08:08 AM, immediately after the last resident was served in their room on the 300 Hall the temperatures of the food items on the tray used as test tray were taken and read by the Dietary Supervisor with the following results: a. Milk - 47 degrees Fahrenheit. b. Scrambled eggs - 98 degrees Fahrenheit.

Based on observation, record review, and interview, the facility failed to ensure a multi-resident use glucometer was properly disinfected between use to prevent potential spread of infection for 3 (Residents #51, #56 and #17) sampled residents who had physician orders for capillary blood glucose (CBG) monitoring from hall 200/300 medication cart, as documented on a list provided by the Administrator on 11/8/2023 at 4:29 PM. The findings are: a. On 11/07/2023 at 3:26 PM, during the medication administration observation, Licensed Practical Nurse (LPN) #1 performed a glucose finger stick using a multi resident glucometer on Resident #51. LPN #1 took a [Brand Name] germicidal disposable wipe and wiped the multiple resident glucometer for approximately 30 seconds then placed the glucometer in the top left drawer of the medication cart. Without disinfecting the glucometer or leaving the glucometer wrapped in the wipe to stay exposed to disinfectant for two minutes. b. On 11/07/2023 at 3:32 PM, during the medication administration observation, LPN #1 performed a glucose finger stick using a second multi resident glucometer on Resident #56. LPN #1 took a [Brand Name] germicidal disposable wipe and wiped the glucometer for approximately 30 seconds then placed the glucometer in the top left drawer of the medication cart and moved the first unit to a different compartment. Without disinfecting the glucometer or leaving the glucometer wrapped in the wipe to stay exposed to disinfectant for two minutes. c. On 11/07/2023 at 3:53 PM, the medication administration observation, LPN #1 performed a glucose finger stick using the first multi resident glucometer on Resident #17. LPN #1 took a [Brand Name] germicidal disposable wipe and wiped the multiple resident glucometer for approximately 30 seconds then placed the glucometer in the top left drawer of the medication cart and moved the second unit to a different compartment. Without disinfecting the glucometer or leaving the glucometer wrapped in the wipe to stay exposed to disinfectant for two minutes. d. On 11/07/2023 at 04:25 PM, LPN #1 was asked, How long do you clean the glucometers for between residents? LPN #1 responded, I rub the glucometer for 3-4 minutes. The Surveyor asked, What happens if you do not clean the glucometer for the required disinfection time? LPN #1 responded, You could pass on germs and cause an infection and the resident could be sick with fever and lots of things. e. On 11/07/2023 at 04:29 PM, the Director of Nursing (DON) was asked, What is the procedure you expect your nurses to follow on cleaning glucometers in between residents? The DON responded, All medication carts should have two glucometers. The nurses should clean with [Brand Name] for 30 seconds and set on tissue. Then, the nurse should use the other glucometer. f. On 11/08/2023 at 03:40 PM, the DON provided a [Brand Name] germicidal disposable wipe label that documented, . KILLS [blood borne virus] .PREVIOUSLY SOILED WITH BODY FLUIDS in 2 minutes surfaces/objects likely to be soiled with blood or body fluids . May be used on . blood glucose meters . g. On 11/08/2023 at 03:40 PM, the DON provided a User Instruction Manual for [Brand] Multi Blood Glucose Monitoring System that documented, .Cleaning and Disinfecting: .Super [Brand Name] Germicidal Disposable Wipe . Contact time 2 minute .

Based on record review and interview, the facility failed to ensure bowel movements were occurring to prevent possible complications for 1 (Resident #18) of 1 sampled resident who required assistance with bowel elimination. The failed practice had the potential to affect 2 residents according to a list provided by the Administer on 11/9/23 at 1:45 PM. The findings are: 1. During initial rounds on 11/06/23 at 11:24 AM, during a resident interview, Resident #18 stated, I'm impacted now. a. On 11/07/23 at 12:06 PM, the Surveyor asked the Administrator for a printout of the bowel movement (BM) task records. b. On 11/07/23 at 12:40 PM, the Administrator provided the BM task record. c. During review of the BM Task record documented no BM from October 25th through November 7th, 2023. d. On 11/8/23 at 09:54 AM, Licensed Practical Nurse (LPN) #4 was asked if she was aware of Resident #18 complaining that he had not had a BM. LPN #4 stated Yes, we give him an enema once a week. LPN #4 and this Surveyor searched in the record for active and/or discontinued orders and did not find an order for enemas. e. On 11/8/23 at 9:56 AM, Certified Nursing Assistant (CNA) #5, stated, He never has a bowel movement on us. The nurses have to make sure that happens. The form was shown to the CNA about the incontinence on 11/1/23 and 11/3/23 and asked what it meant. CNA #5 stated, That's where he was incontinent of urine. f. On 11/08/23 at 02:34 PM, the DON was asked to explain the importance of having bowel movements. The DON stated, Its important because a resident can get a bowel perforation or obstruction. The DON was asked what should occur to prevent these possible events. The DON stated, Do an assessment, get a PRN (as needed) from the Doctor or an order for a KUB [kidney, ureter and bladder x-ray]. g. On 11/08/23 at 02:46 PM, the Administer was asked for a policy on the bowel program. The Administrator stated, We don't have a policy for that.

Based on observation, record review and interview, the facility failed to ensure an indwelling catheter tubing was maintained in a fashion to prevent complications of infection for 1 (Resident #8) of 3 (Residents #8, #14, #33) sampled residents who had an indwelling catheter. The findings are: 1. Resident #8 had a diagnosis neurogenic bladder dated 08/08/22, and a history of Acute Urinary Tract Infection dated 11/1/2023. 2. On 11/06/23 at 10:11 AM, Resident #8 was lying in bed. The catheter tubing was touching the floor. 3. On 11/07/23 at 09:37 AM, Resident #8 was sitting in the wheelchair in the Activity Room. The catheter tubing was observed curled up on the floor under the catheter bag. 4. On 11/07/23 at 02:10 PM, Resident #8 was sitting in his wheelchair in the smoking area with the catheter under the wheelchair and the catheter tubing curled up on the concrete porch. 5. A Physicians Order dated 08/08/23 documented Foley Catheter 16 FR [french] with 10 CC [cubic centimeter] balloon record output every shift for neurogenic bladder. 6. The Minimum Data Set with an Assessment Reference Date of 8/16/23 documented resident had a foley catheter. 7. A Care Plan dated 11/14/23 documented . [Resident #8] has a foley catheter r/t [related to] his dx [diagnosis] of neurogenic bladder . [Resident #8] will be/remain free from catheter-related trauma through the review date . 8. On 11/09/23 at 11:31 AM, Certified Nursing Assistant (CNA) #6 was asked, how is a catheter drainage bag supposed to be placed when in a chair? She answered, Underneath the resident not dragging the ground. The Surveyor asked, would it be appropriate for the drainage bag and tubing to be lying on the floor or concrete? She answered, No. The Surveyor asked, what could happen if the tubing isn't placed appropriately? She answered, It can get contaminated or yanked out. 9. On 11/09/23 at 11:54 AM, the Director of Nursing (DON) was asked, how is the catheter tubing supposed to be placed when in a chair or lying in a bed? She answered, Down to the bag. The Surveyor asked, would it be appropriate for the tubing to touch the floor or concrete? She answered, No, the floor is dirty. The Surveyor asked, explain what could happen if the tubing isn't placed appropriately. The DON stated, It would be an Infection Control Issue. 10. On 11/09/23 at 11:58 AM, the Administrator stated, We don't have a catheter policy. We go by standard protocol and Physicians Orders.

Based on observation, record review and interview, the facility failed to ensure a percutaneous endoscopic gastrostomy (PEG) tube was flushed and or auscultated prior to the administration of nutritional supplements for 1 (Resident #18) of 4 (Residents #18, #27, #58, and #63) case mix residents who had enteral feeding tubes. This failed practice had the potential to affect 5 residents who had enteral feeding tubes, as documented on a list of residents provided by the Administrator on 11/08/23 at 5:07 PM. The findings are: a. A Physician's Orders dated 10/20/23 documented, Enteral feed order: Flush Feeding Tube with 60 cc [cubic centimeters] of water per tube q [every] shift. and Check tube placement via auscultation with 10 - 15cc of air before each use (feeding, flushes, bolus, medication administration) every shift 10/20/2023 18:00 . b. On 11/06/23 at 11:24 a.m., Resident # 18 stated, I don't eat a tray because I have a peg tube and I do my own flushes and I give myself a bottle of boost (8 fluid ounces) twice a day. I also put my tube back in when I accidently pull it out. I am the only one that puts anything through it. The resident was asked if the nurses ever flush, auscultate, or aspirate his PEG tube. Resident #18 laughed and stated, NO. I get a pleasure tray, but I let my [family member] eat it. During the Survey, the Surveyor observed Resident #18 getting a tray but not touching it. Resident #18's [family member] was eating out of both trays. c. On 11/8/23 at 09:30 A.M., Licensed Practical Nurse (LPN) #4 was asked if she provided nutrition, or flushes for Resident #18. LPN #4 stated, I have orders to flush it. LPN #4 was asked how much did she flush with. LPN #4 stated, 60 ccs. LPN #4 was asked to explain what could happen without receiving the proper nutrition. LPN #4 stated, They could lose weight and get sick. d. On 11/08/23 at 1:45 PM, the Director of Nursing (DON) was asked if Resident #18 was getting enough nutritional intake, if the Registered Dieticians (RD) recommendations had been followed up on, should there be any orders for the Boost [Nutritional Supplement] and should he be assessed for self-administration of PEG tube feedings. The DON stated, He gets a tray also. I have the Registered Dietitians recommendations on my desk. No, we haven't assessed him for self-administration of PEG tube feedings. On 11/08/23 at 4:18 PM, the Administrator provided a document form titled, Enteral Feeding that did not provide the needed information and had no other policy.

Based on observation, interview and record review, the facility failed to post a precautionary oxygen sign outside the door indicating the use of oxygen for 1 (Resident #21) of 13 sampled residents. This had the potential to affect 22 residents receiving oxygen therapy. The findings are: Resident #21 had a Physician's Order for oxygen therapy 2-4 Liters via nasal cannula as needed for shortness of breath or oxygen saturation below 92% no directions specified for order with an order revision date of 11/6/23. R21 had a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. There was a care plan in place for oxygen therapy, but there was no pertinent information found in quarterly/annual Minimum Data Set in reference to oxygen. On 11/06/23 at 10:51 am, Resident #21 was observed lying in bed with the head of the bed elevated watching television. Oxygen at 2 liters via nasal cannula. There was no precautionary oxygen sign posted at or around the door. On 11/06/23 at 02:45 pm, Resident #21 was observed lying in bed with the head of the bed elevated watching television. Oxygen at 2 liters via nasal cannula. There was no precautionary oxygen sign posted at or around the door. On 11/06/23 at 03:14 pm, Resident #21 was observed lying in bed with the head of the bed elevated, oxygen at 2 liters via nasal cannula. There was no precautionary oxygen sign posted at or around the door. On 11/08/23 at 12:15 pm, observed Resident #21 lying in bed with an oxygen concentrator running at 2 liters, but at that time the resident did not have a nasal cannula in his nostrils. The oxygen tubing was lying across his lap. There was no precautionary oxygen sign posted at or around the bed nor at or around the door. On 11/08/23 at 12:27 pm, observed Licensed Practical Nurse (LPN) #3 walking up the hall with an oxygen sign in hand headed toward Resident #21's room. LPN #3 stated this is the last one I mean the last one. On 11/08/23 at 12:25 pm, the Surveyor asked LPN #3 if a resident is receiving oxygen therapy what precautionary measures should be in place? LPN #3 pointed to a door with an oxygen in use sign posted on it and stated that little red sign on that door. The Surveyor asked LPN #3 can you walk down the hall with me? LPN #3 stated sure. Upon reaching Resident #21's room, the Surveyor asked LPN #3 does anyone in this room receive oxygen therapy? LPN #3 stated yes, the one on the far side. Surveyor asked what is his name? LPN #3 stated Resident #21. The Surveyor asked LPN #3 is there a sign posted on this door? LPN #3 stated no, there is no sign posted on this door. On 11/08/23 at 12:55 pm, the Surveyor asked the Director of Nursing (DON) with the Administrator standing close, if I was walking down the hall how would I know that oxygen was in use before entering the resident's room? The DON stated that little red thing on the door, the Administrator stated red oxygen sign. On 11/08/23 at 04:30 PM, the Surveyor requested an oxygen administration policy from the Administrator but was brought a policy on handling and storage. The Surveyor informed the Administrator that oxygen administration policy is the needed policy. The Administrator stated we do not have an oxygen administration policy, that is all we have.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 5 residents who received pureed diets as documented on the Diet List provided by the Food Service Supervisor on 10/26/23. The findings are: 1. 10/26/23 At 8:40 AM in the resident assist feeding dining area the Resident receiving pureed consistency was noted that the breakfast gravy and biscuits was noted to be thick and was pasty. The eggs were chucky. The eggs were thick enough to cut with a fork. 2. 10/26/23 at 12:55 PM the Food Service Supervisor reviewed the pictures of breakfast that the surveyor had taken, and she stated the eggs are lumpy. 3. 10/26/23 at 12:45 PM In the assist feeding dining area the pureed rice and bread which was served at lunch to the residents with pureed diet consistency was noted to be thick and was pasty. The fork stood up in the rice by itself in the middle of the bowl. C.N.A #1 stated that is a choking hazard. I always look at it and if I feel they will choke on it I don't feed it to them. The C.N.A then moved the residents bowl to the side and stated don't feed her that. 4. 10/26/23 at 12:47 PM LPN #1 stated the pureed food (rice) looks too thick and gummy.

Based on record review and interview, the facility failed to notify the representative of the reason for hospital transfer in writing and in language they could understand for 3 (Residents #24, #77, and #47) of 12 (Residents #21, #24, #47, #48, #49, #61, #65, #71, #77, #278, #279, #280) sampled residents who were transferred to the hospital in the last 120 days, as documented by a list provided by the Administrator on 08/24/22 at 3:25 PM. The findings are: 1. Resident #24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 06/27/22 documented a Staff Interview Mental Status [SAMS] of 01 (indicated cognition severely impaired), required extensive assistance with activities of daily living self-performance skills with one-person physical assist. a. On 08/23/22 at 11:06 AM, the resident was hospitalized on [DATE] for change in condition, discharged [DATE]. MDS coordinator stated, She stayed in the hospital about 30 hours, and they sent her back to us. On 05/18/22 she was admitted to Geri psych. discharged on [DATE]. b. On 08/24/22 at 4:30 PM, there was no written documentation for the reason for hospitalization in a language they could understand for transfer/discharge to the resident or resident responsible party found in the Electronic Health Record (EHR) for 05/18/22 or 07/06/22 hospital admits. 2. Resident #77 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. A Progress Note dated 07/1/22 documented, .Pulse never got above 32. Assistant Director of Nursing (ADON) called Life Net and sent her out to St. [NAME] in Hot Springs . b. A Discharge Return Not Anticipated MDS with an ARD of 07/1/22 documented discharged to an acute hospital. c. A document titled, Arkansas Notice of Emergency Transfer Form, which was in Resident #77's closed record and dated 07/1/20 did not document a reason for transfer to the hospital in writing. d. A Document titled, Hospital Resident Transfer Service OLTC (Office of Long-Term Care) Reg (Regulation) 332, which was provided by the Administrator on 08/24/22 at 03:25 PM did not address providing Notice of Transfer/Discharge to the representative with reason for discharge in writing and in a language they could understand. e. On 08/25/22 at 08:31 AM, The Surveyor asked the Director of Nursing (DON), who was responsible for sending out notice of transfers with the reason for transfer in writing? She answered, The Admissions Coordinator. The Surveyor asked, where is the reason for transfer documented in writing in language that is understood? She answered, In the chart. I don't believe it's documented on that form. Just that they've gone to the hospital. f. On 08/25/22 at 09:16 AM, The Surveyor asked the Admissions Coordinator, Is the date correct on this Arkansas Notice of Emergency Transfer form? She answered No, that's a typo. It should be 2022. Based on record review and interview, the facility failed to notify the representative of the reason for hospital transfer in writing and in language they understand for 3 (Residents #24, 77, and 47) of 12 (Residents #24, 77, 65, 278, 279, 280, 21, 61, 71, 47, 49, 48) sampled residents who were transferred to the hospital in the last 120 days, as documented by a list provided by the Administrator on 08/24/22 at 3:25 PM. The findings are: 2. Resident #77 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. A Progress Note dated 07/01/22 documented, .Pulse never got above 32. ADON (Assistant Director of Nursing) called Life Net and sent her out to hospital in Hot Springs . b. A Discharge Return Not Anticipated MDS with an ARD of 07/01/22 documented discharged to an acute hospital. c. A document titled, Arkansas Notice of Emergency Transfer Form, which was in Resident #77's closed record and dated 07/01/20 did not document a reason for transfer to the hospital in writing. d. A Document titled, Hospital Resident Transfer Service OLTC (Office of Long-Term Care) Reg (Regulation) 332, which was provided by the Administrator on 08/24/22 at 03:25 PM did not address providing Notice of Transfer/Discharge to the representative with reason for discharge in writing and in a language they understand. e. On 08/25/22 at 08:31 AM, The Director of Nursing (DON) was asked, who is responsible for sending out notice of transfers with the reason for transfer in writing? She answered, The Admissions Coordinator. She was asked, where is the reason for transfer documented in writing in language that is understood? She answered, In the chart. I don't believe it's documented on that form. Just that they've gone to the hospital. f. On 08/25/22 at 09:16 AM, the admissions Coordinator was asked, Is the date correct on this Arkansas Notice of Emergency Transfer form? She answered No, that's a typo. It should be 2022. g. On 08/23/22 at 11:06 AM, the resident was hospitalized on [DATE] for change in condition, discharged [DATE]. MDS coordinator stated, She stayed in the hospital about 30 hours, and they sent her back to us. On 05/18/22 she was admitted to Geri Psych. The resident was discharged on [DATE]. 1. Resident #24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 06/27/22 documented a Staff Interview Mental Status [SAMS] of 01 (indicated cognition severely impaired), required extensive assistance with activities of daily living self-performance skills with one-person physical assist. a. As of 08/24/22 at 4:30 PM, there was not any documentation in writing to the reason in a language they can understand for transfer/discharge to the resident or resident responsible party found in the Electronic Health Record (EHR) for 05/18/22 nor for 07/06/22 hospital admits. Resident #47 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS with an ARD 05/02/22 of documented a BIMS of 99 and A SAMS of 3 (Severely impaired-never/rarely made decisions), depends on staff to provide 100% care. 1. On 08/24/22 at 12:20 PM, The MDS Coordinator provided a Transfer / Discharge Notice for Resident #47. 2. Resident #47 was sent to acute care hospital on 08/5/22 and the notice of transport / discharge date d 08/8/22, does not have the reason for the discharge to the hospital written on the discharge notice. 3. On 08/25/22 at 1:35 PM, The Director of Nursing (DON) was asked, Where is the reason that R #47 was send to the hospital written on the discharge notice located at on the form? The DON stated, It's right here. Pointing to the first column (indicated with an X) stating The transfer of discharge is necessary for the resident's welfare and the resident's needs cannot be in the facility . on the form labeled ARKANSAS NOTICE OF EMERGENCY TRANSFER FORM. The DON was asked, Is that the actual reason that R# 47 went to the hospital? The DON stated, No.

Complaint # (AR 869) was substantiated, all or in part, with these findings. Based on observation, record review and interview, the facility failed to ensure mechanical lift transfers were conducted with the level of assistance and number of staff specified on the plan of care, to prevent accidents / injuries for 2 (Residents #1 and #3) of 2 case mix residents who required mechanical lift transfers. This failed practice resulted in past immediate jeopardy, which caused or could have caused serious harm, injury or death for Resident #3, who fell from the sling of the mechanical lift while it was raised, resulting in a closed fracture to the left hip, and Resident #1, who fell from the sling of the mechanical lift while it was raised, resulting in a fall to the floor. The failed practice also had the potential to cause more than minimal harm to 19 residents who required mechanical lift transfers, as documented on a list provided by the Nurse Consultant on 4/13/17. The facility removed the immediate jeopardy and corrected the failed practices on 3/6/17, prior to the survey. The Administrator was informed of the past immediate jeopardy condition on 4/13/17. The findings are: 1. Resident #3 had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/1/17 documented the resident scored 9 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), required extensive physical assistance from two staff members for bed mobility, transfers and toileting, balance was not steady, only able to stabilize with staff assistance and had impairment in Range of Motion (ROM) on one side of the lower extremities. a. The Comprehensive Care Plan dated as initiated on 7/12/16 documented, .I am at risk for falls r/t (related to) RBKA (Right Below Knee Amputation), Legal Blindness, Poor Safety Awareness, impaired mobility, and medication regimen .Remind me to ask for assist for all transfers .I am to be transferred with a Vander lift for all transfers. I require two staff members to assist with all transfers . The Care Guide for Certified Nursing Assistants (CNAs) (not dated) and provided by the Administrator on 4/13/17 at 9:40 a.m., documented, .(Resident #3) - 2 CNA / Hoyer / Large Full Body sling only . 2 staff members for all bed changes on night shift / floor mat on resident's right side . b. A Nurse's Note dated 2/8/17 documented, .called to resident's room per (Licensed Practical Nurse (LPN) #1) and found resident lying on floor on back between legs of Hoyer Lift, (CNA #1) reported, 'I was putting her to bed and she slid out of the sling, I tried to catch her and ease her to the floor, she didn't land hard.' Resident alert, oriented x (times) 2, c/o (complains of) left hip pain upon movement, DON (Director of Nursing) immediately notified of the incident, (Emergency Services) called for transport to (Hospital) for evaluation of hip pain, APRN (Advanced Practice Registered Nurse) was notified. (LPN #2) notified family .No acute distress present . This note was signed by the Assistant Director of Nursing (ADON). A Nurse's Note dated 2/8/17 at 4:58 p.m. documented, .Report from (Hospital) resident has broken left hip and is being admitted to the hospital . This note was signed by LPN #1. c. A Resident Incident Report dated 2/8/17 documented, .Narrative of incident and description of injuries: Called to resident's room per (LPN #1), found resident lying on floor between legs of Hoyer lift on back. (CNA #1) stated, 'I was putting her to bed when she slid out of the sling, I tried to catch her and ease her to the floor, she didn't land hard'. Resident c/o pain to left hip on movement. Immediate Actions Taken: Sent to ER (emergency room ) for evaluation of left hip pain .(CNA #1) reported she was transferring with mechanical lift and noticed lift pad was not in correct position and was attempting to lower the resident back down into chair resident leaned forward and slid out of sling. Staff in-serviced on use of slings and all lift transfers are a 2-person transfer. (CNA #1) terminated for not following poc (Plan of Care) of resident transfer .Immediate Post-Incident Action: Use of Full Body sling only for transfer, 2 staff members to be present with all mechanical lift transfers . An Office of Long Term Care (OLTC) Witness Statement Form dated 2/8/17 at 1:30 p.m. and signed by CNA #1 documented, .I was transferring (Resident #3) to her bed from her chair, as I was moving her I had seen her sling was not under her good. I was putting her back down and as I was doing that she went forwards and fell out. I caught her before she hit the ground, laying her down slowly. She did not hit her head, but she did hit her hip on the leg of the lift . d. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property and (&) Exploitation of Residents in Long Term Care Facilities, Division of Medical Service (DMS) form 762 dated 3/3/17 documented, Date and Time of Incident: 2/8/17 at 1:25 p.m. Date and Time of Discovery: 2/8/17 at 1:25 p.m. Type of Incident: Neglect .Name of Involved Resident: (Resident #3) .Physical Functional Level/Impairment: Totally Dependent for all care .Mental Functional Level: Confusion at times .Primary Diagnosis: [REDACTED].Section II - Complete Description of Incident: Resident was transferred by mechanical lift on 2/8/17, with one CNA present. Resident leaned forward while being transferred and slid off of lift pad. CNA tried to catch her before hitting the floor. However, her hip did hit the leg of the mechanical lift, resulting in a fracture. (Resident #3) is alert and oriented x 2. (Resident #3) requires a mechanical lift with 2 person assist. (CNA #1) reported to Director of Nursing on 2/8/17 that she did transfer resident without another employee and did not look at the care guide prior to transfer. Resident transferred to hospital for evaluation of left hip pain on 2/8/17. On 2/8/17 report from hospital that (Resident #3) would be admitted with left hip fracture. (CNA #1) was hired on 1/24/17 and received a 4 day orientation. A check-off sheet was in progress, but not completed due to termination on 2/8/17. (Resident #3's) care plan and the Kiosk care guide did state that the resident was a mechanical lift with two person assist on the day of the incident 2/8/17. Internal investigation was done on 2/8/17. On 3/3/17 upon review of incident for the month of February incident was determined that it needed to be reported to OLTC (Office of Long Term Care) at that time .Section III-Findings and Actions Taken .Medical Condition on (Resident #3), she is alert and oriented x 2 with episodes of confusion. Able to voice needs, Incontinent of Bowel and Bladder, Legally Blind, Right BKA (Below Knee Amputation), CHF (Congestive Heart Failure) and HTN (Hypertension). Totally Dependent for all ADLs (activities of daily living) . e. A hospital Discharge Summary dated 2/15/17 documented Resident #3 was discharged from the hospital and returned to the facility with a primary [DIAGNOSES REDACTED]. f. On 4/13/17 at 10:50 a.m., the Nurse Consultant was asked about Resident #3's fall from the mechanical lift sling and stated, On 2/8/17, the resident was transferred with a mechanical lift and there was only one CNA present. (CNA #1) admitted to the DON and ADON that she was by herself. At that point, the DON questioned her in the office and she was terminated at that point. She had put the sling under the resident and lifted her, but the sling was not positioned properly and before the CNA could get it back down, she slid from the sling. She was asked, Was there anything wrong with the sling? She stated, No. g. On 4/13/17 at 3:18 p.m., the ADON was asked about Resident #3's fall from the mechanical lift sling and stated, (LPN #1) was on that day and is no longer employed here. I was here that day and wrote the I & A (Incident and Accident Report). I went down and looked at the resident and found her lying on the floor between the legs of the Hoyer lift. She complained of pain in her left hip so we did not move her. We waited on the EMTs (Emergency Medical Technicians). She had no other complaints, I immediately called the APRN and the DON and her family. (CNA #1) reported that she had lifted her up out of the Geri chair and noticed the sling was wrong and before she could get her back down the resident leaned forward and slid out of the sling. At that point, I asked her who was assisting her with the transfer and she said no one, that it was just her. I asked her if she understood that it takes 2 people with a mechanical lift and she said yes, she knew that but she was told by another staff member it was ok. The DON had come here at that time and took over the investigation. I did the in-service and the I&A report. I began monitoring the mechanical lift transfers on 2/9/17. 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/17/17 documented the resident scored 8 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), required extensive physical assistance from two plus staff members for bed mobility, transfer and toileting, and had functional limitation in range of motion on both sides of the lower extremities. a. The Comprehensive Care Plan dated as initiated on 2/23/16 documented, .Problem Onset: 2/23/16 .I require a mechanical lift for transfers. I AM A TWO PERSON ASSIST . Remind me to ask for assist for all transfers .Remind me during sling transfers to remain still during transfer while in sling . The Care Guide for CNAs dated 4/11/17, provided by the Administrator on 4/13/17 at 9:40 a.m., documented, .(Resident #1) - 2 CNA / Hoyer / full body sling - large / recumbent with pommel cushion / bed bolsters . b. A DMS form 762 dated 2/14/17 documented, .Date and Time of Incident: 2/14/17 at 3:51 p.m. Type of Incident: Neglect .Name of Involved Resident: (Resident #1) .Physical Functional Level / Impairment: Totally Dependent on Staff for ADLs . Mental Functional level: Confusion at times .Primary Diagnosis: [REDACTED].Section II: On 2/14/17, CNA (Certified Nursing Assistant) transferring resident from wheelchair to bed, using mechanical lift, resident, who is a double amputee, shifted his weight suddenly to the left side to retrieve his can of Skoal, causing sling to swing suddenly, flipping resident out of the sling, to the floor. resident sustained [REDACTED]. Wrist was x-rayed in facility, x-ray was negative for fracture, no injuries noted. (Resident #1) is alert and oriented x 3 with periods of confusion. (Resident #1) requires a mechanical lift with 2 person assist. On 2/14/17 upon ADON entering room there were 4 CNAs, (CNAs #2, #3, #4, and #5). ADON asked (CNA #2) if she had two people during transfer and (CNA #2) reported to her that she did. At that time, In-service was given to staff to remove Skoal from resident prior to transfer. (LPN #3) obtained a witness statement from (CNA #2) regarding the incident. (CNA #2) was hired on 10/31/11 and received a 4 day orientation. An orientation check off sheet was in the personnel file and dated 10/31/11. (Resident #1) Care plan and the Kiosk Care guide did state that resident was a mechanical lift with two person assist on the day of the incident 2/14/17 . On 3/5/17 (DON) was informed by (CNA #5) that she did not assist (CNA #2) with (Resident #1)'s mechanical lift transfer on 2/14/17 incident. (CNA #5) reports that she was down the hallway when (CNA #2) called for her to come into room because (Resident #1) was on the floor. On 3/6/17 DON began to contact (CNA #2), (CNA #3) and (CNA #4) provided witness statements to DON that they did not assist (CNA #2) with transferring (Resident #1) via mechanical lift on date of incident 2/14/17 . c. An X-Ray Report dated 2/14/17 documented, .Wrist Complete (1 View) Lat (lateral)Right .Reason: Fall .Findings: The patient has a hand deformity and was reportedly unable to cooperate with positioning. There is no definite acute fracture. Further evaluation is limited . Impression: No significant abnormality is apparent at the right wrist on this limited exam . d. An In-Service Training Report dated 2/14/17 at 5:30 p.m. documented, .Subjects Covered: Transferring of Resident with Hoyer lift and removal of Skoal from Resident prior to transfer . CNA #2's signature was documented on this report. e. As of 4/13/17, CNA #2's personnel file contained an Arkansas Department of Health and Human Services Arkansas LTCF (Long Term Care Facility) Nursing Assistant Trainee Task Performance Record dated 10/31/11, which documented, .(CNA #2) .Using a portable mechanical resident lift .Satisfactory Performance Date: 10/31/11 . There was no documentation in the employee's personnel record to indicate the CNA's competence with mechanical lift transfers was monitored more recently than 10/13/11. An In-Service Training Report dated 5/16/16 from 1:30 p.m. to 2:30 p.m. documented, .Employee Group present: LPN / CNA .Subjects Covered: .Remember to always check the slings before you use them, Transfer Techniques - Care Guide Books - Discussion . This document was signed by 31 CNAs and 13 LPNs. CNA #2's signature was included on this document. The in-service documentation did not indicate that return demonstrations were conducted during the training to ensure staff competency with transfer techniques f. On 4/13/17 at 2:30 p.m., the resident was sitting in a wheelchair in the doorway to his room. The resident had a mechanical lift sling under him. He was asked, What happened when you fell from the lift? He stated, She (CNA #2) lifted me up too high, and I reached for my Skoal and then fell . They did an x-ray and I wasn't hurt. g. On 4/13/17 at 10:10 a.m., Registered Nurse Consultant (RN) #2 was asked about the resident's fall from the lift sling on 2/14/17. She stated, The resident was lifted up in a sling when he reached out of the side for his can of Skoal. Apparently, he would hide the Skoal from them, because he wasn't supposed to have it. When they were transferring him and he reached for it because it fell out, the lift got off balance. He did not have any injuries and was x-rayed without fractures. There was one CNA in there, and she went to get help. When the Assistant Director of Nursing (ADON) went in there, three CNAs were in the room. (CNA #2) lied and said she was not alone, but we found out later that she was by herself. The in-services we did at the time were about the Skoal, and we have in-serviced since for two staff members to be present with a lift. Once we found out during the Incident & Accident investigation, I started checking things out, and she admitted that she was alone at the time, so they let her go at that point. 3. An In-Service Training Report dated 2/8/17 at 2:00 p.m. documented, .Facility: (Name) .Subject Covered: Transfer with mechanical lift is ALWAYS a 2 person assist transfer . This document was signed by seven CNAs and one LPN. CNA #2, the staff member involved in (Resident #1's) incident, was not documented as having attended this in-service. 4. The facility's, Transfer of a Resident Using a Hoyer Lift Policy and Procedure, provided by the Administrator on 4/13/17 at 3:50 p.m., documented, .Purpose: To provide resident safety with transfers. Policy: The facility will provide the resident a safe and easy method of transferring when they are unable to do so themselves. Procedure: 1. Two people should assist in transfer involved in resident being lifted via Hoyer Lift . 8. Resident should always be over base of support . 5. The facility removed the immediate jeopardy and corrected the failed practices on 3/6/17, prior to the survey, as evidenced by the following: a. For Resident #3: The (DMS) form 762 dated 3/3/17 documented CNA #1, who performed Resident #3's transfer with no assistance was suspended on 2/8/17 and, .All staff present on 2/8/17 in-serviced on use of mechanical lift with 2-person assist. Abuse and neglect was in-serviced in monthly meeting on 3/6/17. Check offs were initiated on all direct care staff with return demonstration. On 3/6/17, all lift slings were inspected with no negative findings noted. On 2/7/17 and 3/7/17 mechanical lift was inspected with no neg (negative) findings. Mechanical lift inspected weekly with no neg findings. Plan of Action implemented DON / Designee will monitor mechanical lift transfers daily 5 x (times per) week x (times) 2 weeks, then 3x weekly x 4 weeks or until compliance. Maintenance supervisor to monitor mechanical lift weekly for safety. All new hires effective 3/7/17 will have documented check offs regarding mechanical lift transfers . On 4/13/17 at 9:50 a.m. Resident #3 was resting in bed with bolsters and a specialty mattress in place. A fall mat was on the left side of the bed. CNA #9 and CNA #11 entered the room with the Hoyer lift to transfer the resident to the shower cart. The transfer was conducted safely and correctly, without incident. b. For Resident #1: The DMS form 762 dated 2/14/17 documented, .On 3/6/17 DON / Designee started check offs on all direct care staff for mechanical lift transfers with return demonstration. On 3/6/17, all lift slings were inspected with no negative findings. Mechanical lift continues to be inspected weekly by maintenance. On 3/6/17 in-services began for all nursing staff on completing incident reports and obtaining witness statements from all employees involved. On 3/7/17 therapy screen was performed for w/c (wheelchair) positioning and safe transfer techniques. Transfer sling replaced from amputee sling to a full body sling . On 4/13/17 at 2:30 p.m., Resident #1 was sitting in a wheelchair in the doorway to his room. The resident had a mechanical lift sling under him. He was asked, regarding mechanical lift transfers, Do they use two people every time now? He stated, Oh, yeah. c. An In-Service Training Report dated 2/20/17 at 1:30 p.m. to 2:30 p.m. documented, .Employee Group present: CNA / LPNs .Subject covered: .Transfer methods - use of mechanical lifts . This document was signed by 29 CNAs (including CNA #2) and 8 LPNs. d. Initial Education and Competency Checklists dated from 3/6/17 through 4/5/17 were provided by the Nurse Consultant on 4/13/17 at 12:29 p.m. and documented, .Topic/Equipment: Mechanical Lift (ALWAYS A TWO PERSON ASSIST) . Identifies components of the lift: Identifies Power on/off switch, battery location, placement and panel, Lift base spreader handle, 3 modes for operating, Emergency Off and release, identify weight capacity .Sling Use and Operation: Examine the sling for durability (tears, loose threads or seams), loop positions, demonstrate proper sling placement to patient, demonstrate putting sling under patient (lateral and seated), demonstrate sling leg positions, Demonstrate use of limb lift .Portable Lift Operation: lock wheels - when?, Demonstrate position of lift over patient, Demonstrate proper sling/loop attachment, Demonstrate operation/transfer of patient: Loops secure, lifting the patient in the sling, moving portable life with patient, lowering patient to receiving surface, Demonstrate sling removal . Verbal Verification and Return Demonstration were both checked as having been completed for 29 CNAs, 17 LPNs and 6 RNs. e. A Mechanical Lift Transfer Observation sheet received from the Nurse Consultant on 4/13/17 at 2:40 p.m. documented observations of staff successfully conducting mechanical lift transfers were initiated on 2/9/17 and continued as of 4/13/17. f. On 4/13/17, CNAs and LPNs who were on duty in the facility were asked if it was ever acceptable for staff to conduct a mechanical lift transfers without the assistance of a second staff member. Their responses were as follows: At 12:01 p.m., CNA #6 stated, No. At 12:04 p.m., CNA #7 stated, No, ma'am. At 12:09 p.m., CNA #8 stated, Oh, no. At 12:11 p.m., CNA #9 stated, No. At 12:14 p.m., CNA #10 stated, No, ma'am. At 12:35 p.m., LPN #4 stated, No, I tell them (CNAs) that I will help them, so they won't have to be by themselves with a transfer. At 12:46 p.m., LPN #3 stated, Never. At 1:05 p.m., LPN #5 stated, No.

Complaint # was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure that staff did not use soft belt/roll belt restraints that were contraindicated for residents who were at risk for sliding beneath the devices and becoming suspended and assessments were completed by qualified staff who could identify any contraindication for use, a resident was assessed for the appropriateness of the soft belt/roll belt after a fall and interventions developed to decrease the potential for falls for 6 (Resident #s 8, 9, 10, 11, 12 and 13) and a restraint was applied per manufacturers' instructions for 1 (Resident #8) of 6 case mix residents (Resident #s 8, 9, 10, 11, 12 and 13) who were assessed to slide down in the wheelchair, had a history of [REDACTED].#s 8, 9, 10, 11, 12 and 13, who were assessed to slide down while in a wheel chair, had a history of [REDACTED]. The failed practice also had a potential for more than minimal harm for 6 other residents at the facility with orders for belt restraints according to a list provided by the Director of Nursing on 11/1/10. The facility was informed of the Immediate Jeopardy on 11/2/10 at 4:55 p.m. The findings are: 1. The Posey Application Instruction Sheet for the Posey Soft Belt provided by the Director of Nursing on 11/1/10 documented, "Contraindications: Contraindications include but are not limited to the following conditions: Aggressive, combative, agitated or suicidal patients who do not receive constant monitoring. ...Discontinue use immediately if the patient is able to slide forward or down underneath the device. They could slide far enough under the device to become suspended, resulting in chest compression and suffocation." 2. The Application Instructions Sheet for the Posey Roll Belt provided by the Assistant Director of Nursing (ADON) on 11/2/10 at 4:45 p.m. documented, "Contraindications: Contraindications include but are not limited to the following conditions: Aggressive, combative, agitated or suicidal patients. ...Discontinue use immediately if the patient is able to slide forward or down underneath the device. They could slide far enough under the device to become suspended resulting in chest compression and suffocation. ... WARNING: ...All siderails MUST be in the up position when using restraints. If necessary, use a siderail cover, especially with spit siderails to prevent the patient's body from going under, around, through or between the siderails." 3. Resident #10 had [DIAGNOSES REDACTED]. a. The Physical Restraint Elimination assessment dated [DATE] documented, "Sitting Balance: Leans to a side, forward, backward; Slides down. ...Behavior / Mood: Combative / Severely Agitated." b. A Pre-Restraining Assessment form (no date) documented, "This form has been developed to adequately assess all aspects of the resident's well-being (physical, mental, emotional, environmental and social considerations) prior to the use of either medication interventions or physical restraining devices in order to identify the least restrictive intervention. It is to be completed by a nurse or a licensed physical / occupational therapist. " The form was divided into three sections: Physical and Mental considerations (answers were yes or no, identified by an x in the appropriate column); Emotional, Environmental and Social Considerations (answers were yes or no identified by an x in the appropriate column)and Referrals/Recommendations (this section had dates, handwritten information and yes and no answers). In the section titled Physical and Mental considerations the form documented, " ...Recovery of Balance While Sitting: Forward: Yes. Backward: Yes. Sideways: Yes. Balance When Sitting: Slides Down: No. Slumps: No ..." In the section titled Referrals/Recommendations documented, " Interdisciplinary team Evaluation: Date 12/9/09 Recommendation: Roll belt while in bed s/b (soft belt) while (up) in wc (wheel chair) to prevent attempts to amb (ambulate) (alone) while unable physically. ... " (written in an open area on the form was; " 6/28/10 soft belt while (up) in w/c (D/C (discontinue) 6/7/10). " The form had no date for the next evaluation and the form was signed by Restorative Aide #1. c. The Physical Restraint Elimination assessment dated [DATE] documented, "Sitting Balance: Leans to a side, forward, backward; Slides down. ...Behavior / Mood: Combative / Severely Agitated." d. A Physicians order dated 6/28/10 documented, "Roll belt when in bed and a soft belt in a chair to prevent attempts to ambulate alone while physically unable due to Parkinson." e. The Care Plan documented, "6/26/10 ... Problems: Falls, actual. Date/Review: 9/6/10 fall noted. Con't (continue) interventions." The interventions column documented, "4 - N - (Problem #4 for Nursing) Restraint reapplied 6/28/10 per orders. Reduction unsuccessful. 5- N - Ensure proper w/c in use." f. The quarterly MDS with an assessment reference date of 7/23/10 documented the resident had moderately impaired cognitive skills for daily decision making, no behaviors, had falls in the past 31 to 180 days and used a trunk restraint on a daily basis. g. An Incident and Accident Report dated 8/26/10 at 2:00 p.m. documented, "While in w/c(wheel chair) (with) soft belt in use as ordered, he reached for a wet floor sign and flipped w/c over onto it's R (Right) side causing X (times) 2 skin tear." Under Additional comments and/or steps taken to prevent recurrence there was no documentation on the form and no. h. The Care Plan with a review date of 9/6/10 documented, " ...Con't (continue) interventions. ... " i. An Incident and Accident Report dated 10/14/10 at 6:30 p.m. documented, "(Resident) (up) in w/c in small DH (dining hall) - Flipped w/c over backwards. ...Was a restraint in use? Yes: Soft belt in w/c." A diagram of the human body was circled on the top of the head with an arrow pointing to "Type of Injury: 3. Abrasion." The words "3 cm (centimeter) diam. (diameter)" was written on the line with the arrow. Under the section titled Additional comments and/or steps taken to prevent recurrence, there was no documentation on the form. j. The Care Plan updated 10/14/10 documented , " ...Fall noted ...." k. The Physical Restraint Elimination assessment dated [DATE] documented, "Sitting Balance: Leans to a side, forward, backward; Slides down. ...Behavior / Mood: Combative / Severely Agitated." l. On 11/1/10 at 1:23 p.m. and 3:50 p.m., the resident was in a wheelchair wearing a soft belt restraint across the lap. There was no device in the chair to reduce the risk of sliding down and there were no anti-tipping devices on the wheel chair to reduce the risk of the wheel chair tipping over. m. On 11/1/10 at 9:40 p.m., the resident was in the bed with a roll belt around the abdomen and quick release knots tied to the bed frame. n. On 11/2/10 at 10:37 a.m., the resident was in a wheelchair with a soft belt restraint across the abdomen. There was no anti-tipping device on the wheelchair and no device used in the chair to prevent the resident from sliding down. o. On 11/2/10 at 3:00 p.m., the DON and Assistant Director of Nursing (ADON) were asked, "What interventions were attempted prior to the application of the restraint?" A written summary was produced by the DON. The summary documented , "Skilled Therapy was provided 11/2/09; MD (physician) review of medications 11/21/09; Tilt wheelchair seat 11/21/09; Physician Notified 11/23/09; EMD (Electronic Monitoring Device) at all times 11/30/09; Soft Belt 12/2/09; Restraint Reduction Attempt 6/26/10; Reduction Unsuccessful." The DON was asked, "The Resident is assessed to slide down. Is there any device in the chair to minimize the potential of sliding?" The DON stated, "I don't know." The DON was asked, "Are there anti-tipping devices on the wheelchair?" The DON stated, "No." 4. Resident #11 had [DIAGNOSES REDACTED]. The quarterly MDS with an assessment reference date of 7/25/10 documented the resident had moderately impaired cognitive skills for daily decision making, had short term and long term memory problems, and used a trunk restraint daily. a. The Physical Restraint Elimination assessment dated [DATE] and 7/26/10 documented, "Sitting Balance: Leans to a side, forward, backward. Slides Down." b. A physician's orders [REDACTED]." c. Nurse's Notes dated 8/3/10 documented, "Staff reports (resident) frequently attempts to get out of bed during HS (night time) hours. Climbs around side rails and frequent skin tears, discoloration from rubbing against rails results. Orders to D/C (discontinue) SRs (side rails) + (and) use roll belt while in bed to prevent attempts to ambulate alone while physically unable d/t (due to) dementia + physical condition. Son aware. Continue with soft belt restraint orders." d. An Incident / Accident Report dated 9/22/10 at 2:45 p.m. documented, "Soft belt adjuster became loose allowing resident to slide out of wheelchair on buttocks." The form documented steps taken to prevent recurrence, "soft belt was immediately replaced." e. The Physical Restraint assessment dated [DATE] documented, "Sitting Balance: Leans to a side, forward, backward. Slides Down. ... Behavior/Mood: Combative / Severely Agitated Combative during ADL (Activities of Daily Living) care." f. On 11/1/10 at 1:35 p.m. and 4:15 p.m., the resident was in a wheelchair with a soft belt restraint in place. The resident was sitting on an incontinent pad. There was no device in the chair to prevent the resident from sliding down. g. On 11/1/10 at 9:20 p.m., the resident was in bed with both padded side rails down. A roll belt restraint was attached to the frame of the bed on both sides with a quick release knot. The soft belt was not attached to the resident. The resident was lying on the restraint. h. On 11/2/10 at 9:55 a.m., the resident was in a wheelchair with a soft belt restraint in place. The resident was sitting on an incontinent pad. There was no device in the wheelchair to prevent the resident from sliding down. i. On 11/2/10 at 3:10 p.m., the DON and ADON were asked, "What interventions were implemented before the soft belt restraint?" The DON presented a summary of interventions which documented, "2/7/10: Fall. In chair in general population, not in room. 2/12/10: Contact Guard Assistance. 2/22/10: Tilt w/c (wheelchair) seat, sensor pad at all times, restorative program. 2/26/10 : Soft belt ordered. 8/3/10: Roll belt ordered d/t (due to) frequent attempts to get out of bed." The ADON was asked, "What is 'contact guard assistance'?" The ADON stated, "The staff watch the resident and remind them not to get up or to assist them when needed." The DON was asked, "The Restraint Elimination assessment documented that the resident slides down in the chair. The Manufacturers instructions for the use of a soft belt documents that this type of restraint is contraindicated in residents that slide down. Is there anything in the chair to prevent the resident from sliding?" The DON stated, "I don't know." 5. Resident #9 had [DIAGNOSES REDACTED]. a. The Pre-Restraining Assessment form (not dated) documented, "This form has been developed to adequately assess all aspects of the resident's well-being (physical, mental, emotional, environmental and social considerations) prior to the use of either medication interventions or physical restraining devices in order to identify the least restrictive intervention. It is to be completed by a nurse or a licensed physical /occupational therapist. ... Balance When Sitting: Falls forward: No. Falls/ leans sideways: Yes. Slides down: No. Slumps: No..." The section marked "Interdisciplinary Team Evaluation" was dated 4/1/10 documented recommendations: " R/B (roll belt) to be used while in bed to prevent attempts to Amb. (ambulate) alone while physically unable. " An unsigned hand written note at the bottom of the form documented, "Soft belt to be used while (up) in w/c (wheelchair). " The from was signed by Restorative Aide #1. b. The Physical Restraint Elimination Assessment form completed by the Assistant Director of Nursing (ADON) on 4/1/10, 4/12/10 and 7/22/10 documented, "Sitting Balance: Leans to a side, forward, backward. Slides Down." c. An Incident / Accident Report dated 7/25/10 at 8:30 p.m. documented, "Resident noted lying in floor next to bed, roll belt remained tied in bed, c/o (complains of) severe L (left) hip pain and lower back pain." The form documented the resident was sent to the emergency room . Under the section titled Additional comments and/or steps taken to prevent recurrence, there was no documentation on the form. d. A physician's orders [REDACTED]." e. The quarterly Minimum Data Set (MDS) with an assessment reference date of 10/19/10 documented the resident had a Brief Interview of Mental Status (BIMS) score of 6 which indicates severe impairment, had no behavioral symptoms and required the use of a trunk restraint in bed and in a chair. f. An Incident / Accident Report dated 8/16/10 at 10:00 p.m. documented, "(Resident) fell out of bed (got out of RB (roll belt))...." Under the section titled Additional comments and/or steps taken to prevent recurrence, there was no documentation on the form. g. The Care Plan with updated entry dated 8/16/10 documented, "Fall ...8/16/10 Fall noted. 3-11 CNAs (Certified Nursing Assistants) inserviced in proper application per manufacturer's guideline of roll belt." h. On 11/1/10 at 2:15 p.m. and 3:20 p.m., the resident was in a wheelchair with a belt restraint across the abdomen, crossed in the back and looped on the kick-spurs of the wheelchair. The resident was sitting on an incontinent pad. There was no device in the chair to minimize the potential for sliding down in the chair. i. On 11/1/10 at 9:34 p.m., the resident was in the bed on an air mattress with a roll belt around the abdomen, and the straps tied to the bed frame with quick release knots. j. On 11/2/10 at 9:25 a.m., the resident was in a wheelchair with a soft belt around the abdomen and crossed and looped around the kick spurs of the wheelchair. The resident was sitting on an incontinent pad. There was no device was in the chair to prevent sliding. k. On 11/2/10 at 11:00 a.m., the resident was in a wheelchair in his/her room with a soft belt across the lap and crossed in the back and looped over the kick spurs. The resident was leaning forward with his/her buttocks at the edge of the wheelchair going through the bedside table that belonged to the resident's roommate. The resident was sitting on an incontinent pad. There was no device was in the chair to prevent sliding down. l. On 11/2/10 at 3:10 p.m., the Director of Nursing (DON) was asked, "This resident was assessed to slide down on the Restraint Elimination Form. The Manufacturer's instructions documented not to use this restraint if the resident slides down. What interventions are in place to prevent the resident from sliding down while wearing this restraint?" The DON stated, "I don't know." 6. Resident #12 had [DIAGNOSES REDACTED]. a. The Pre-Restraining Assessment form (not dated) documented, "This form has been developed to adequately assess all aspects of the resident's well-being (physical, mental, emotional, environmental and social considerations) prior to the use of either medication interventions or physical restraining devices in order to identify the least restrictive intervention. It is to be completed by a nurse or a licensed physical / occupational therapist. ... Recovery Balance (while sitting): Forward, backward, sideways. Balance when sitting: slides down ..." The Physical Restraint Elimination assessment dated [DATE] documented, " Sitting Balance: Leans to a side, forward, backward. Slides down." There were no documented attempts at reducing the restraints since 5/13/10. The form was signed by Restorative Aide #1 b. A Physician order [REDACTED]." c. An Incident / Accident Report dated 7/7/10 at 10:00 p.m. documented, "(Resident) untied roll belt, got up out of bed and attempted walking toward bathroom + fell hitting head on floor." There were no steps taken to prevent recurrence documented. Under the section titled Additional comments and/or steps taken to prevent recurrence, there was no documentation on the form. d. The quarterly MDS with an assessment reference date of 8/1/10 documented the resident had moderately impaired cognitive skills for daily decision making, had wandering and socially inappropriate behavior, and had a trunk restraint on a daily basis. e. The Care Plan updated dated 4/27/10 and updated 5/7/10, 5/21/10, 8/4/10, 8/6/10 documented, "Physical Restraint: Roll belt while in bed, soft belt while up in w/c to prevent attempts to amb (ambulate) along while physically unable. Intervention: 1. Maintain Dignity. 2. Maintain proper body alignment. ... 6. Ensure safety precautions. ... Falls: At risk for falls due to : 1. fell within the past 30 days. 2. Use of psychotropic drugs. 3. Use of physical restraints. Intervention: 1. Monitor for balance changes..." f. An Incident / Accident Report dated 8/13/10 at 7:00 p.m. documented, "Called to room per staff d/t (due to) (Resident) being on the floor. Observed next to her bed sitting on buttocks. Roll belt untied..." There were no steps taken to prevent recurrence documented on the report. Under the section titled Additional comments and/or steps taken to prevent recurrence, there was no documentation on the form. g. Nurse's Notes dated 10/22/10 at 5:15 p.m. documented, "Had behavior change. Behavior was very agitated, biting, hitting, kicking, pinching, twisting arms and was attempting to do this to other residents. Attempted to give P.O. (oral) Ativan 0.25 mg (milligram), spit out into CNA's (Certified Nursing Assistant) face and on floor. Called Hospice ... And RN called back and said to administer Lorazepam 1/2 ml (milliliter) IM (intramuscular) then 4 hours later give oral Ativan...To administer injection it took 3 personnel in order for her to receive the Ativan I.M..." h. Nurse's Notes dated 10/25/10 at 4:50 p.m. documented, "(Resident #12) CNAs informed me of (Resident) fighting and hitting them as well as biting...New orders for Ativan 1mg I.M. now + (and) to repeat X (times) 1 if needed in 2 (hours) q (every) 24 (hours). (Resident) received Ativan 1mg IM to R (right) shoulder..." i. Nurse's Notes dated 10/26/10 documented, "Trying to get up out of bed on several occasions. Has roll belt on for prevention of falls per Dr. (doctor) orders. Resident has increased agitation ..." j. Nurse's Notes dated 10/29/10 documented, "(Increased) agitation. Had to give IM Ativan 0.5 ml. Administered Left Arm. Three personnel to help give injection. ... Was trying to bite and rip clothes off people and other residents. Pulled fire alarm ..." k. On 11/1/10 at 1:45 p.m., the resident was in the dining room in a wheelchair with a soft belt restraint across the lap. The resident was sitting on an incontinent pad. There was no device in the chair to prevent the resident from sliding down. l. The Nurse's Notes dated 11/1/10 at 3:30 p.m. documented, "Received Ativan P.O. (by mouth) at 3:30 p.m. for (increased) agitation and combative, clawing and grabbing other people, not letting go. Took p.o. medication and threw cup of water at the other nurse. Will continue to monitor." m. On 11/1/10 at 4:35 p.m., the resident was observed by the surveyor in a small sitting area at the beginning of the 500 hallway. There were no staff in visual range of the resident. The resident was in a wheelchair with a soft belt restraint across the lap. The resident was sitting on an incontinent pad. There was no device in the chair to prevent the resident from sliding down in the chair. The resident had no shoes on both feet. A white canvas shoe was under a chair in the sitting area. The resident slid down in the wheelchair and stretched her right foot out and slid the shoe onto her right foot. The resident pulled herself back up in the chair, but was seated onto the edge of the wheelchair seat. n. On 11/1/10 at 4:40 p.m., Licensed Practical Nurse (LPN) #1 came up to the Resident and stated, "You've lost your shoe. Let me take you to the room to find it." LPN #1 was asked, "Does the Resident slide down (in the wheelchair) often?" LPN #1 stated, "She does sometimes." o. On 11/1/10 at 9:35 p.m., the resident was in the bed with a roll belt across her abdomen, crossed in the back, and tied to the bed frame. p. On 11/2/10 at 10:55 a.m., the resident was in a wheelchair with a soft belt restraint across her abdomen. The resident was sitting on an incontinent pad. There was no device in the wheelchair to prevent the resident from sliding down. q. On 10/2/10 at 2:45 p.m., the DON and ADON reviewed a summary of interventions used prior to the application of restraints. The DON stated, "We haven't done any other interventions for (Resident's name)." The DON was asked, "The resident was assessed to slide down in the chair. Have there been any interventions used to minimize the potential for sliding?" The DON stated, "I don't know." 7. Resident #13 had [DIAGNOSES REDACTED]. The quarterly MDS with an assessment reference date of 8/9/10 documented the resident had moderately impaired cognitive skills for daily decision making, had behavioral symptoms of wandering, physically abusive and resists care, required assistance with transfers and had fallen within the past 31 to 180 days. a. An Incident / Accident Report dated 10/4/10 documented, "Found in another resident's room laying on back ..." b. A Physician Telephone Order dated 10/4/10 documented, "Soft belt restraint to be used while in w/c to prevent attempts to ambulate alone. Physically unable." c. The Pre-Restraining assessment dated [DATE] and signed by Restorative Aide #1 documented the resident did not slide down or slump, and resident leaned forward, backward and sideways. The Restraint Elimination assessment dated [DATE], documented the resident leaned to a side, forward, and backward, and slides down or slumps in the chair. d. On 11/1/10 at 1:50 p.m., and 11/1/10 at 4:20 p.m., the resident was in a wheel chair with a soft belt restraint in place. The resident was sitting on an incontinent pad, and no device was in the chair to minimize the risk of sliding down. e. On 11/2/10 at 10:30 p.m., the resident was in the wheelchair with a soft belt restraint on with no device in the chair to prevent the resident from sliding down. f. On 11/2/10 at 3:15 p.m., the DON was asked, "The Restraint Reduction assessment has documented the resident slides down. The product guidelines document that the product use should stop immediately if a resident slides down. Are there any devices in the resident's wheelchair to prevent the resident from sliding down with the restraint? " The DON stated, "I don ' t know." 8. Resident #8 had [DIAGNOSES REDACTED]. a. The pre-restraining assessment dated [DATE] documented: "soft belt (s/b) while up in w/c, roll belt (r/b) while in bed." The physical restraint elimination assessment dated [DATE] documented: "Leans to a side, forward, backward. Slides down. Combative/Severely agitated." b. A physician's orders [REDACTED]." c. An Incident/Accident report dated 6/10/10 at 2:45 a.m. documented, "Physical restraint: Type- Roll Belt. Resident climbed out of bed onto floor causing an abrasion to the lower left (L) leg. The Plan of care updated on 6/10/10 documented, "#5 added-Nursing staff to assure restraints applied correctly." d. An Incident/Accident report dated 7/11//10 at 11:30 a.m. documented, "Physical restraint: Type- Soft Belt Resident noted in floor, soft belt attached to w/c-got out of restraint." The Plan of care updated on 7/11//10 documented, "#6 added-PT (Physical Therapy) to eval (evaluate) for Part B. Resident attempting to ambulate and working herself out of restraints." e. The Minimum Data Set ((MDS) dated [DATE] documented the resident was moderately impaired in cognitive skills for daily decision making, required limited assistance of one person for bed mobility and transfers, required extensive assistance of two person for toilet use, was unable to balance while standing without physical help, fell in the past 31-180 days, had full bed rails on all open sides of bed and had a trunk restraint. f. The Plan of Care with a review date of 9/24/10 documented, "Physical Restraint: Use of roll belt in bed, soft belt while up in w/c (wheel chair) to prevent attempts to amb(ambulate) alone while unable physically. Intervention: Ensure safety. Monitor for decline in skin, cognitive, agitation, mood, physical functions and body control. ....Problem: Falls,Actual, Intervention: Roll belt and soft belt restraints as ordered. Nursing staff to assure restraints applied correctly. Resident (R) attempting to ambulate and (+) working herself out of restraints." g. An Incident/Accident report dated 10/14/10 at 2:00 a.m. documented, " Physical restraint: Type- Roll Belt. Resident sat up in bed putting both legs under the rail causing a 1/2 centimeter (cm) times (x) 14 1/2 cm discolored area to the top of L leg." h. On 11/1/10 at 1:37 p.m. and 2:25 p.m., the resident was in a wheelchair sitting on a cloth incontinent pad with a soft belt restraint positioned across the diaphragm, the straps were under the armrests and attached at the kick spurs at the back of the wheel chair. The belt was not secured at the juncture of the frame to prevent the belt from sliding upward. e. On 11/1/10 at 2:30 p.m., the Assistant Director of Nursing (ADON) was in the resident's room and was asked if the soft belt restraint was applied properly. She replied, "We have this care planned to loop over the sides instead of down under the chair because she slides down under it if it is applied the right way." The ADON repositioned the resident by lifting and positioning the residents so her hips where at the back of the wheel chair. f. On 11/2/10 at 3:10 p.m., the DON was asked if the resident was assessed to slide down on the Restraint Elimination Sheet and the Manufactures instructions documented not to use this type of restraint if the resident slides down, what intervention are in place to prevent the resident from sliding down?" The DON stated, "I don't know." g. On 11/4/10 at 11:25 a.m., Physical Therapy Assistant (PTA) #1 was asked, "Do you recall the ADON asking you about the application of the restraint to (Resident #8)?" PTA#1 stated, "I went to the internet and printed a copy of the Posey Application Instructions and showed them the pictures. I probably told them that it went under the arm rests and over the side plate. It looked like that in the picture." PTA #1 was asked, "Did you read the instructions and contraindications about this restraint?" PTA #1 stated, "No, that's the Nursing program. I do not do restraints." The PTA #1 was asked, "Was the resident referred to Physical Therapy?" PTA#1 stated, "No, she was not." 9. On 11/4/10, RNA #1 was asked, "What training have you had to do assessments for the resident's well being (identified on the Pre-restraining assessment form) and to identify the least restrictive intervention?" RNA #1 stated, "No training just from the previous RNA. She did those forms and taught me to do them. I get the restraint orders and I do the pre-restraining assessment using those. They pass the pink slip (telephone orders) to me and then I fill out the pre-restraining assessment. Then I put it on the chart. Then I fill out the Physical Restraint Elimination Assessment, the front part, and give it to the ADON. I observe the residents and score what I see." 10. On 10/5/10 the DON was asked, "Were you aware of the contraindications for the use of the soft belt and roll belt restraints?" The DON stated, "I read the instructions, but only the part about applying the restraint." The DON was asked, "Were you aware that the Restorative Aide was performing the pre-restraining assessments and restraint elimination assessments?" The DON stated, "Yes, but that's how it's been done ever since I've been here. I did not know the restorative aide would not be qualified to do that." 11. The Immediate Jeopardy was removed on 11/3/10 at 10:05 a.m. and the scope and severity was decreased to an E when the facility implement the following Plan of Removal: a. All residents currently with the use of roll belt and soft belt restraints were immediately assessed for use of these types of restraints. MD's (Medical Doctor) of all affected residents were immediately notified of the contraindications of the use of these restraints according to manufacturers ' guidelines and orders for new interventions were put into place. Interventions include the use of low beds, the use of electronic monitoring devices, anti-tip bars, the use of positioning cushions to prevent sliding while up in wheelchairs and the use of tilt wheelchairs, staff education and monitoring of residents. This will be completed by 7:00 p.m. on 11/2/10, restraints were immediately reassessed and found to be inappropriate for 6 of the affected residents. b. Immediate staff education on fall prevention, contraindications for use of restraints, and interventions for ensuring resident safety, instruction on type of restraint and appropriate application of those restraints, was begun immediately by DON/ADON on 11/2/10 before anyone will be allowed to work on the floor. Intervention sheets were provided to staff by DON. c. Residents will be viewed by a licensed nurse every hour for the first 24 hours, and every 2 hours thereafter, to ensure compliance with interventions implemented at this time." B. Based on observation, interview and record review, the facility failed to ensure the plan of care was consistently implemented to provide supervision when outdoors 8 (Residents #1, 2 and 8-13)case mix residents who were at risk for falls. This failed practice had the potential to affect 15 residents in the facility who were at risk for falls according to the list provided by the DON on 11/5/10. The findings are: Resident # 1 had [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident had modified independence in cognitive skills for daily decision making, was independent and required no physical help from staff for bed mobility, transfers, and locomotion on and off unit, required partial physical support for balance while standing, had no functional limitation in range of motion or loss of voluntary movement and had fallen in the past 30 days and the last 31-180 days. 1. The Rap Summary dated 3/24/10 documented, "At Risk for Falls due to: Use of Psychotropi

Complaint # was substantiated (all or in part) with these findings: Based on observation, record review and interview, Nursing Administration failed to ensure that restraint assessments were performed by qualified personnel, and failed to ensure that soft belt/roll belt restraints were not used when contraindicated for residents assessed to slide down in the wheelchair or bed for 6 (Residents # 8, 9, 10, 11, 12, and 13) of 6 case mix residents with restraints. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury, impairment or death to Resident #s 8, 9, 10, 11, 12 and 13, who were assessed to slide down while in a wheel chair, had a history of [REDACTED]. The failed practice also had a potential to cause more than minimal harm for 6 other residents at the facility with orders for belt restraints according to a list provided by the Director of Nursing on 11/1/10. The facility was informed of the Immediate Jeopardy on 11/2/10 at 4:55 p.m. The findings are: 1. The Posey Application Instruction Sheet for the Posey Soft Belt provided by the Director of Nursing on 11/1/10 documented, "Contraindications: Contraindications include but are not limited to the following conditions: Aggressive, combative, agitated or suicidal patients who do not receive constant monitoring. ...Discontinue use immediately if the patient is able to slide forward or down underneath the device. They could slide far enough under the device to become suspended, resulting in chest compression and suffocation." 2. The Application Instructions Sheet for the Posey Roll Belt provided by the Assistant Director of Nursing (ADON) on 11/2/10 at 4:45 p.m. documented, "Contraindications: Contraindications include but are not limited to the following conditions: Aggressive, combative, agitated or suicidal patients. ...Discontinue use immediately if the patient is able to slide forward or down underneath the device. They could slide far enough under the device to become suspended resulting in chest compression and suffocation. ... WARNING: ...All siderails MUST be in the up position when using restraints. If necessary, use a siderail cover, especially with split siderails to prevent the patient's body from going under, around, through or between the siderails." 3. The Job Description for Director of Nursing provided on 11/5/10 at 11:30 a.m. documented, "Job Summary: Directs the nursing care needed by the residents to attain the highest practicable physical, mental and psychosocial well being. ... 2. Resident Assessment and Care Planning. ... " Items A-E crossed off with the hand written word "Over-see" above this item. 4. Resident #10 had [DIAGNOSES REDACTED]. a. The Physical Restraint Elimination assessment dated [DATE] documented, "Sitting Balance: Leans to a side, forward, backward; Slides down. ...Behavior / Mood: Combative / Severely Agitated." b. A Pre-Restraining Assessment form (no date) documented, "This form has been developed to adequately assess all aspects of the resident's well-being (physical, mental, emotional, environmental and social considerations) prior to the use of either medication interventions or physical restraining devices in order to identify the least restrictive intervention. It is to be completed by a nurse or a licensed physical / occupational therapist. " The form was divided into three sections: Physical and Mental considerations (answers were yes or no, identified by an x in the appropriate column); Emotional, Environmental and Social Considerations (answers were yes or no identified by an x in the appropriate column)and Referrals/Recommendations (this section had dates, handwritten information and yes and no answers). In the section titled Physical and Mental considerations the form documented, " ...Recovery of Balance While Sitting: Forward: Yes. Backward: Yes. Sideways: Yes. Balance When Sitting: Slides Down: No. Slumps: No ..." In the section titled Referrals/Recommendations documented, " Interdisciplinary team Evaluation: Date 12/9/09 Recommendation: Roll belt while in bed s/b (soft belt) while (up) in wc (wheel chair) to prevent attempts to amb (ambulate) (alone) while unable physically. ... " (written in an open area on the form was; " 6/28/10 soft belt while (up) in w/c (D/C (discontinue) 6/7/10). " The form had no date for the next evaluation and the form was signed by Restorative Aide #1. c. The Physical Restraint Elimination assessment dated [DATE] documented, "Sitting Balance: Leans to a side, forward, backward; Slides down. ...Behavior / Mood: Combative / Severely Agitated." d. A Physicians order dated 6/28/10 documented, "Roll belt when in bed and a soft belt in a chair to prevent attempts to ambulate alone while physically unable due to Parkinson." e. The Care Plan documented, "6/26/10 ... Problems: Falls, actual. Date/Review: 9/6/10 fall noted. Con't (continue) interventions." The interventions column documented, "4 - N - (Problem #4 for Nursing) Restraint reapplied 6/28/10 per orders. Reduction unsuccessful. 5- N - Ensure proper w/c in use." f. The quarterly MDS with an assessment reference date of 7/23/10 documented the resident had moderately impaired cognitive skills for daily decision making, no behaviors, had falls in the past 31 to 180 days and used a trunk restraint on a daily basis. g. An Incident and Accident Report dated 8/26/10 at 2:00 p.m. documented, "While in w/c(wheel chair) (with) soft belt in use as ordered, he reached for a wet floor sign and flipped w/c over onto it's R (Right) side causing X (times) 2 skin tear." Under Additional comments and/or steps taken to prevent recurrence there was no documentation on the form and no. h. The Care Plan with a review date of 9/6/10 documented, " ...Con't (continue) interventions. ... " i. An Incident and Accident Report dated 10/14/10 at 6:30 p.m. documented, "(Resident) (up) in w/c in small DH (dining hall) - Flipped w/c over backwards. ...Was a restraint in use? Yes: Soft belt in w/c." A diagram of the human body was circled on the top of the head with an arrow pointing to "Type of Injury: 3. Abrasion." The words "3 cm (centimeter) diam. (diameter)" was written on the line with the arrow. Under the section titled Additional comments and/or steps taken to prevent recurrence, there was no documentation on the form. j. The Care Plan updated 10/14/10 documented , " ...Fall noted ...." k. The Physical Restraint Elimination assessment dated [DATE] documented, "Sitting Balance: Leans to a side, forward, backward; Slides down. ...Behavior / Mood: Combative / Severely Agitated." l. On 11/1/10 at 1:23 p.m. and 3:50 p.m., the resident was in a wheelchair wearing a soft belt restraint across the lap. There was no device in the chair to reduce the risk of sliding down and there were no anti-tipping devices on the wheel chair to reduce the risk of the wheel chair tipping over. m. On 11/1/10 at 9:40 p.m., the resident was in the bed with a roll belt around the abdomen and quick release knots tied to the bed frame. n. On 11/2/10 at 10:37 a.m., the resident was in a wheelchair with a soft belt restraint across the abdomen. There was no anti-tipping device on the wheelchair and no device used in the chair to prevent the resident from sliding down. o. On 11/2/10 at 3:00 p.m., the DON and Assistant Director of Nursing (ADON) were asked, "What interventions were attempted prior to the application of the restraint?" A written summary was produced by the DON. The summary documented , "Skilled Therapy was provided 11/2/09; MD (physician) review of medications 11/21/09; Tilt wheelchair seat 11/21/09; Physician Notified 11/23/09; EMD (Electronic Monitoring Device) at all times 11/30/09; Soft Belt 12/2/09; Restraint Reduction Attempt 6/26/10; Reduction Unsuccessful." The DON was asked, "The Resident is assessed to slide down. Is there any device in the chair to minimize the potential of sliding?" The DON stated, "I don't know." The DON was asked, "Are there anti-tipping devices on the wheelchair?" The DON stated, "No." 5. Resident #11 had [DIAGNOSES REDACTED]. The quarterly MDS with an assessment reference date of 7/25/10 documented the resident had moderately impaired cognitive skills for daily decision making, had short term and long term memory problems, and used a trunk restraint daily. a. The Physical Restraint Elimination assessment dated [DATE] and 7/26/10 documented, "Sitting Balance: Leans to a side, forward, backward. Slides Down." b. A physician's orders [REDACTED]." c. Nurse's Notes dated 8/3/10 documented, "Staff reports (resident) frequently attempts to get out of bed during HS (night time) hours. Climbs around side rails and frequent skin tears, discoloration from rubbing against rails results. Orders to D/C (discontinue) SRs (side rails) + (and) use roll belt while in bed to prevent attempts to ambulate alone while physically unable d/t (due to) dementia + physical condition. Son aware. Continue with soft belt restraint orders." d. An Incident / Accident Report dated 9/22/10 at 2:45 p.m. documented, "Soft belt adjuster became loose allowing resident to slide out of wheelchair on buttocks." The form documented steps taken to prevent recurrence, "soft belt was immediately replaced." e. The Physical Restraint assessment dated [DATE] documented, "Sitting Balance: Leans to a side, forward, backward. Slides Down. ... Behavior/Mood: Combative / Severely Agitated Combative during ADL (Activities of Daily Living) care." f. On 11/1/10 at 1:35 p.m. and 4:15 p.m., the resident was in a wheelchair with a soft belt restraint in place. The resident was sitting on an incontinent pad. There was no device in the chair to prevent the resident from sliding down. g. On 11/1/10 at 9:20 p.m., the resident was in bed with both padded side rails down. A roll belt restraint was attached to the frame of the bed on both sides with a quick release knot. The soft belt was not attached to the resident. The resident was lying on the restraint. h. On 11/2/10 at 9:55 a.m., the resident was in a wheelchair with a soft belt restraint in place. The resident was sitting on an incontinent pad. There was no device in the wheelchair to prevent the resident from sliding down. i. On 11/2/10 at 3:10 p.m., the DON and ADON were asked, "What interventions were implemented before the soft belt restraint?" The DON presented a summary of interventions which documented, "2/7/10: Fall. In chair in general population, not in room. 2/12/10: Contact Guard Assistance. 2/22/10: Tilt w/c (wheelchair) seat, sensor pad at all times, restorative program. 2/26/10 : Soft belt ordered. 8/3/10: Roll belt ordered d/t (due to) frequent attempts to get out of bed." The ADON was asked, "What is 'contact guard assistance'?" The ADON stated, "The staff watch the resident and remind them not to get up or to assist them when needed." The DON was asked, "The Restraint Elimination assessment documented that the resident slides down in the chair. The Manufacturers instructions for the use of a soft belt documents that this type of restraint is contraindicated in residents that slide down. Is there anything in the chair to prevent the resident from sliding?" The DON stated, "I don't know." 6. Resident #9 had [DIAGNOSES REDACTED]. a. The Pre-Restraining Assessment form (not dated) documented, "This form has been developed to adequately assess all aspects of the resident's well-being (physical, mental, emotional, environmental and social considerations) prior to the use of either medication interventions or physical restraining devices in order to identify the least restrictive intervention. It is to be completed by a nurse or a licensed physical /occupational therapist. ... Balance When Sitting: Falls forward: No. Falls/ leans sideways: Yes. Slides down: No. Slumps: No..." The section marked "Interdisciplinary Team Evaluation" was dated 4/1/10 documented recommendations: " R/B (roll belt) to be used while in bed to prevent attempts to Amb. (ambulate) alone while physically unable. " An unsigned hand written note at the bottom of the form documented, "Soft belt to be used while (up) in w/c (wheelchair). " The from was signed by Restorative Aide #1. b. The Physical Restraint Elimination Assessment form completed by the Assistant Director of Nursing (ADON) on 4/1/10, 4/12/10 and 7/22/10 documented, "Sitting Balance: Leans to a side, forward, backward. Slides Down." c. An Incident / Accident Report dated 7/25/10 at 8:30 p.m. documented, "Resident noted lying in floor next to bed, roll belt remained tied in bed, c/o (complains of) severe L (left) hip pain and lower back pain." The form documented the resident was sent to the emergency room . Under the section titled Additional comments and/or steps taken to prevent recurrence, there was no documentation on the form. d. A physician's orders [REDACTED]." e. The quarterly Minimum Data Set (MDS) with an assessment reference date of 10/19/10 documented the resident had a Brief Interview of Mental Status (BIMS) score of 6 which indicates severe impairment, had no behavioral symptoms and required the use of a trunk restraint in bed and in a chair. f. An Incident / Accident Report dated 8/16/10 at 10:00 p.m. documented, "(Resident) fell out of bed (got out of RB (roll belt))...." Under the section titled Additional comments and/or steps taken to prevent recurrence, there was no documentation on the form. g. The Care Plan with updated entry dated 8/16/10 documented, "Fall ...8/16/10 Fall noted. 3-11 CNAs (Certified Nursing Assistants) inserviced in proper application per manufacturer's guideline of roll belt." h. On 11/1/10 at 2:15 p.m. and 3:20 p.m., the resident was in a wheelchair with a belt restraint across the abdomen, crossed in the back and looped on the kick-spurs of the wheelchair. The resident was sitting on an incontinent pad. There was no device in the chair to minimize the potential for sliding down in the chair. i. On 11/1/10 at 9:34 p.m., the resident was in the bed on an air mattress with a roll belt around the abdomen, and the straps tied to the bed frame with quick release knots. j. On 11/2/10 at 9:25 a.m., the resident was in a wheelchair with a soft belt around the abdomen and crossed and looped around the kick spurs of the wheelchair. The resident was sitting on an incontinent pad. There was no device was in the chair to prevent sliding. k. On 11/2/10 at 11:00 a.m., the resident was in a wheelchair in his/her room with a soft belt across the lap and crossed in the back and looped over the kick spurs. The resident was leaning forward with his/her buttocks at the edge of the wheelchair going through the bedside table that belonged to the resident's roommate. The resident was sitting on an incontinent pad. There was no device was in the chair to prevent sliding down. l. On 11/2/10 at 3:10 p.m., the Director of Nursing (DON) was asked, "This resident was assessed to slide down on the Restraint Elimination Form. The Manufacturer's instructions documented not to use this restraint if the resident slides down. What interventions are in place to prevent the resident from sliding down while wearing this restraint?" The DON stated, "I don't know." 7. Resident #12 had [DIAGNOSES REDACTED]. a. The Pre-Restraining Assessment form (not dated) documented, "This form has been developed to adequately assess all aspects of the resident's well-being (physical, mental, emotional, environmental and social considerations) prior to the use of either medication interventions or physical restraining devices in order to identify the least restrictive intervention. It is to be completed by a nurse or a licensed physical / occupational therapist. ... Recovery Balance (while sitting): Forward, backward, sideways. Balance when sitting: slides down ..." The Physical Restraint Elimination assessment dated [DATE] documented, " Sitting Balance: Leans to a side, forward, backward. Slides down." There were no documented attempts at reducing the restraints since 5/13/10. The form was signed by Restorative Aide #1 b. A Physician order [REDACTED]." c. An Incident / Accident Report dated 7/7/10 at 10:00 p.m. documented, "(Resident) untied roll belt, got up out of bed and attempted walking toward bathroom + fell hitting head on floor." There were no steps taken to prevent recurrence documented. Under the section titled Additional comments and/or steps taken to prevent recurrence, there was no documentation on the form. d. The quarterly MDS with an assessment reference date of 8/1/10 documented the resident had moderately impaired cognitive skills for daily decision making, had wandering and socially inappropriate behavior, and had a trunk restraint on a daily basis. e. The Care Plan updated dated 4/27/10 and updated 5/7/10, 5/21/10, 8/4/10, 8/6/10 documented, "Physical Restraint: Roll belt while in bed, soft belt while up in w/c to prevent attempts to amb (ambulate) along while physically unable. Intervention: 1. Maintain Dignity. 2. Maintain proper body alignment. ... 6. Ensure safety precautions. ... Falls: At risk for falls due to : 1. fell within the past 30 days. 2. Use of [MEDICAL CONDITION] drugs. 3. Use of physical restraints. Intervention: 1. Monitor for balance changes..." f. An Incident / Accident Report dated 8/13/10 at 7:00 p.m. documented, "Called to room per staff d/t (due to) (Resident) being on the floor. Observed next to her bed sitting on buttocks. Roll belt untied..." There were no steps taken to prevent recurrence documented on the report. Under the section titled Additional comments and/or steps taken to prevent recurrence, there was no documentation on the form. g. Nurse's Notes dated 10/22/10 at 5:15 p.m. documented, "Had behavior change. Behavior was very agitated, biting, hitting, kicking, pinching, twisting arms and was attempting to do this to other residents. Attempted to give P.O. (oral) [MEDICATION NAME] 0.25 mg (milligram), spit out into CNA's (Certified Nursing Assistant) face and on floor. Called Hospice ... And RN called back and said to administer [MEDICATION NAME] 1/2 ml (milliliter) IM (intramuscular) then 4 hours later give oral [MEDICATION NAME] administer injection it took 3 personnel in order for her to receive the [MEDICATION NAME] I.M..." h. Nurse's Notes dated 10/25/10 at 4:50 p.m. documented, "(Resident #12) CNAs informed me of (Resident) fighting and hitting them as well as biting...New orders for [MEDICATION NAME] 1mg I.M. now + (and) to repeat X (times) 1 if needed in 2 (hours) q (every) 24 (hours). (Resident) received [MEDICATION NAME] 1mg IM to R (right) shoulder..." i. Nurse's Notes dated 10/26/10 documented, "Trying to get up out of bed on several occasions. Has roll belt on for prevention of falls per Dr. (doctor) orders. Resident has increased agitation ..." j. Nurse's Notes dated 10/29/10 documented, "(Increased) agitation. Had to give IM [MEDICATION NAME] 0.5 ml. Administered Left Arm. Three personnel to help give injection. ... Was trying to bite and rip clothes off people and other residents. Pulled fire alarm ..." k. On 11/1/10 at 1:45 p.m., the resident was in the dining room in a wheelchair with a soft belt restraint across the lap. The resident was sitting on an incontinent pad. There was no device in the chair to prevent the resident from sliding down. l. The Nurse's Notes dated 11/1/10 at 3:30 p.m. documented, "Received [MEDICATION NAME] P.O. (by mouth) at 3:30 p.m. for (increased) agitation and combative, clawing and grabbing other people, not letting go. Took p.o. medication and threw cup of water at the other nurse. Will continue to monitor." m. On 11/1/10 at 4:35 p.m., the resident was observed by the surveyor in a small sitting area at the beginning of the 500 hallway. There were no staff in visual range of the resident. The resident was in a wheelchair with a soft belt restraint across the lap. The resident was sitting on an incontinent pad. There was no device in the chair to prevent the resident from sliding down in the chair. The resident had no shoes on both feet. A white canvas shoe was under a chair in the sitting area. The resident slid down in the wheelchair and stretched her right foot out and slid the shoe onto her right foot. The resident pulled herself back up in the chair, but was seated onto the edge of the wheelchair seat. n. On 11/1/10 at 4:40 p.m., Licensed Practical Nurse (LPN) #1 came up to the Resident and stated, "You've lost your shoe. Let me take you to the room to find it." LPN #1 was asked, "Does the Resident slide down (in the wheelchair) often?" LPN #1 stated, "She does sometimes." o. On 11/1/10 at 9:35 p.m., the resident was in the bed with a roll belt across her abdomen, crossed in the back, and tied to the bed frame. p. On 11/2/10 at 10:55 a.m., the resident was in a wheelchair with a soft belt restraint across her abdomen. The resident was sitting on an incontinent pad. There was no device in the wheelchair to prevent the resident from sliding down. q. On 10/2/10 at 2:45 p.m., the DON and ADON reviewed a summary of interventions used prior to the application of restraints. The DON stated, "We haven't done any other interventions for (Resident's name)." The DON was asked, "The resident was assessed to slide down in the chair. Have there been any interventions used to minimize the potential for sliding?" The DON stated, "I don't know." 8. Resident #13 had [DIAGNOSES REDACTED]. The quarterly MDS with an assessment reference date of 8/9/10 documented the resident had moderately impaired cognitive skills for daily decision making, had behavioral symptoms of wandering, physically abusive and resists care, required assistance with transfers and had fallen within the past 31 to 180 days. a. An Incident / Accident Report dated 10/4/10 documented, "Found in another resident's room laying on back ..." b. A Physician Telephone Order dated 10/4/10 documented, "Soft belt restraint to be used while in w/c to prevent attempts to ambulate alone. Physically unable." c. The Pre-Restraining assessment dated [DATE] and signed by Restorative Aide #1 documented the resident did not slide down or slump, and resident leaned forward, backward and sideways. The Restraint Elimination assessment dated [DATE], documented the resident leaned to a side, forward, and backward, and slides down or slumps in the chair. d. On 11/1/10 at 1:50 p.m., and 11/1/10 at 4:20 p.m., the resident was in a wheel chair with a soft belt restraint in place. The resident was sitting on an incontinent pad, and no device was in the chair to minimize the risk of sliding down. e. On 11/2/10 at 10:30 p.m., the resident was in the wheelchair with a soft belt restraint on with no device in the chair to prevent the resident from sliding down. f. On 11/2/10 at 3:15 p.m., the DON was asked, "The Restraint Reduction assessment has documented the resident slides down. The product guidelines document that the product use should stop immediately if a resident slides down. Are there any devices in the resident's wheelchair to prevent the resident from sliding down with the restraint? " The DON stated, "I don ' t know." 8. Resident #8 had [DIAGNOSES REDACTED]. a. The pre-restraining assessment dated [DATE] documented: "soft belt (s/b) while up in w/c, roll belt (r/b) while in bed." The physical restraint elimination assessment dated [DATE] documented: "Leans to a side, forward, backward. Slides down. Combative/Severely agitated." b. A physician's orders [REDACTED]." c. An Incident/Accident report dated 6/10/10 at 2:45 a.m. documented, "Physical restraint: Type- Roll Belt. Resident climbed out of bed onto floor causing an abrasion to the lower left (L) leg. The Plan of care updated on 6/10/10 documented, "#5 added-Nursing staff to assure restraints applied correctly." d. An Incident/Accident report dated 7/11//10 at 11:30 a.m. documented, "Physical restraint: Type- Soft Belt Resident noted in floor, soft belt attached to w/c-got out of restraint." The Plan of care updated on 7/11//10 documented, "#6 added-PT (Physical Therapy) to eval (evaluate) for Part B. Resident attempting to ambulate and working herself out of restraints." e. The Minimum Data Set ((MDS) dated [DATE] documented the resident was moderately impaired in cognitive skills for daily decision making, required limited assistance of one person for bed mobility and transfers, required extensive assistance of two person for toilet use, was unable to balance while standing without physical help, fell in the past 31-180 days, had full bed rails on all open sides of bed and had a trunk restraint. f. The Plan of Care with a review date of 9/24/10 documented, "Physical Restraint: Use of roll belt in bed, soft belt while up in w/c (wheel chair) to prevent attempts to amb(ambulate) alone while unable physically. Intervention: Ensure safety. Monitor for decline in skin, cognitive, agitation, mood, physical functions and body control. ....Problem: Falls,Actual, Intervention: Roll belt and soft belt restraints as ordered. Nursing staff to assure restraints applied correctly. Resident (R) attempting to ambulate and (+) working herself out of restraints." g. An Incident/Accident report dated 10/14/10 at 2:00 a.m. documented, " Physical restraint: Type- Roll Belt. Resident sat up in bed putting both legs under the rail causing a 1/2 centimeter (cm) times (x) 14 1/2 cm discolored area to the top of L leg." h. On 11/1/10 at 1:37 p.m. and 2:25 p.m., the resident was in a wheelchair sitting on a cloth incontinent pad with a soft belt restraint positioned across the diaphragm, the straps were under the armrests and attached at the kick spurs at the back of the wheel chair. The belt was not secured at the juncture of the frame to prevent the belt from sliding upward. e. On 11/1/10 at 2:30 p.m., the Assistant Director of Nursing (ADON) was in the resident's room and was asked if the soft belt restraint was applied properly. She replied, "We have this care planned to loop over the sides instead of down under the chair because she slides down under it if it is applied the right way." The ADON repositioned the resident by lifting and positioning the residents so her hips where at the back of the wheel chair. f. On 11/2/10 at 3:10 p.m., the DON was asked if the resident was assessed to slide down on the Restraint Elimination Sheet and the Manufactures instructions documented not to use this type of restraint if the resident slides down, what intervention are in place to prevent the resident from sliding down?" The DON stated, "I don't know." g. On 11/4/10 at 11:25 a.m., Physical Therapy Assistant (PTA) #1 was asked, "Do you recall the ADON asking you about the application of the restraint to (Resident #8)?" PTA#1 stated, "I went to the internet and printed a copy of the Posey Application Instructions and showed them the pictures. I probably told them that it went under the arm rests and over the side plate. It looked like that in the picture." PTA #1 was asked, "Did you read the instructions and contraindications about this restraint?" PTA #1 stated, "No, that's the Nursing program. I do not do restraints." The PTA #1 was asked, "Was the resident referred to Physical Therapy?" PTA#1 stated, "No, she was not." 10. On 11/4/10, RNA #1 was asked, "What training have you had to do assessments for the resident's well being (identified on the Pre-restraining assessment form) and to identify the least restrictive intervention?" RNA #1 stated, "No training just from the previous RNA. She did those forms and taught me to do them. I get the restraint orders and I do the pre-restraining assessment using those. They pass the pink slip (telephone orders) to me and then I fill out the pre-restraining assessment. Then I put it on the chart. Then I fill out the Physical Restraint Elimination Assessment, the front part, and give it to the ADON. I observe the residents and score what I see." 11. On 10/5/10 the DON was asked, "Were you aware of the contraindications for the use of the soft belt and roll belt restraints?" The DON stated, "I read the instructions, but only the part about applying the restraint." The DON was asked, "Were you aware that the Restorative Aide was performing the pre-restraining assessments and restraint elimination assessments?" The DON stated, "Yes, but that's how it's been done ever since I've been here. I did not know the restorative aide would not be qualified to do that." 12. The Immediate Jeopardy was removed on 11/3/10 at 10:05 a.m. and the scope and severity was decreased to an E when the facility implement the following Plan of Removal: a. All residents currently with the use of roll belt and soft belt restraints were immediately assessed for use of these types of restraints. MD's (Medical Doctor) of all affected residents were immediately notified of the contraindications of the use of these restraints according to manufacturers ' guidelines and orders for new interventions were put into place. Interventions include the use of low beds, the use of electronic monitoring devices, anti-tip bars, the use of positioning cushions to prevent sliding while up in wheelchairs and the use of tilt wheelchairs, staff education and monitoring of residents. This will be completed by 7:00 p.m. on 11/2/10, restraints were immediately reassessed and found to be inappropriate for 6 of the affected residents. b. Immediate staff education on fall prevention, contraindications for use of restraints, and interventions for ensuring resident safety, instruction on type of restraint and appropriate application of those restraints, was begun immediately by DON/ADON on 11/2/10 before anyone will be allowed to work on the floor. Intervention sheets were provided to staff by DON. c. Residents will be viewed by a licensed nurse every hour for the first 24 hours, and every 2 hours thereafter, to ensure compliance with interventions implemented at this time."