Every finding on record at Highland Home

Based on observation, interview, record reviews, and facility policy review, the facility failed to provide adequate supervision to prevent residents from leaving the facility unnoticed and unsupervised for 2 (two) of 7 (seven) residents who were at risk for elopement and wandering. Resident #1 and Resident #2.The facility failed to provide adequate supervision to prevent the elopement of Residents #1 and Resident #2, who had exhibited exit-seeking behaviors. This failure allowed Residents #1 and #2 to exit the facility unnoticed and unsupervised when a visitor was observed on video on 3/24/2026 at 6:20 PM holding the door open for the residents to exit. A nurse immediately responded to the door alarm sounding and went outside down the walkway but did not see the residents. Staff then searched for the residents and found both residents across a four-lane high-capacity highway in front of the facility approximately 528 feet away at 6:33 PM. The weather at the time was cloudy and the temperature was 71 degrees Fahrenheit; both residents were dressed in closed-toe shoes, pants, and long-sleeve shirts.The facility's failure to provide adequate supervision to prevent the elopement of Resident #1 and Resident #2 placed these residents, and other residents at risk for wandering and elopement, in a situation that was likely to cause serious injury, harm, impairment, or death.The SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 3/24/26 and existed at 42 CFR(s): 483.25(d)(1)(2), Free of Accident Hazards/Supervision/Devices (F689), with a Scope and Severity (S/S) of J.The SA notified the facility's Administrator of the IJ and SQC on 3/30/26 at 3:00 PM and provided the Administrator with the IJ template.Based on the facility's implementation of corrective actions on 3/25/26, the SA determined the IJ and SQC to be Past Non-Compliance (PNC), and the IJ was removed as of 03/26/26, prior to the SA's entrance on 3/30/26. Findings Included:Review of the facility policy Elopement/Wandering - Security System with revision date of 03/25 revealed, Policy: To provide a safety system . to implement protective measures to help guard against a resident wandering /eloping from the facility. Residents who are incapable of adequately protecting themselves which are unable to determine when they are at risk for harm by wandering out of the facility, should be placed on the Resident Security System to ensure safety .An interview on 03/30/26 at 9:45 AM with the Administrator (ADM), revealed that on 03/24/26 at approximately 6:10 PM, Resident #1 and Resident #2 exited the facility door on foot. She revealed these two residents were ambulatory, they wandered throughout the facility, often together, and were at risk of elopement. She revealed that they had wander guard bracelets on and when they exited the door to the outside, the alarm sounded and this alerted staff. ADM revealed that Licensed Practical Nurse (LPN) #2, heard the door alarm going off, she alerted other staff and they searched until they found them across the street from the facility. Administrator revealed that a staff member drove across the street in her car and brought the residents back to the facility safely. Administrator revealed that she viewed the video camera coverage and discovered that a visitor entered the facility at 6:20 PM, Resident #1 and Resident #2 walked up to the door and this visitor held the door open for the two ladies, and they walked outside. ADM also revealed that she observed during review of the video that Resident #1 and Resident #2 had approached the door together two or three times prior to this occurrence. An observation on 03/30/26 at 10:05 AM revealed Resident #1 lying in bed awake and she had a wander guard bracelet above her right ankle. Resident could answer simple questions and could not recall that she had been outside the facility on the day of the elopement. On 03/30/26 at 10:20 AM, the State Agency (SA) reviewed video surveillance coverage for the date of 03/24/26 and confirmed that a visitor entered the facility at approximately 6:20 PM, the two residents (Resident #1 and #2) approached the door, and the visitor held the door open for the two ladies, and they walked out of the building. The video camera footage viewed also confirmed that Residents #1 and #2 were brought back into the facility at 6:33 PM accompanied by staff. Resident #1 and Resident #2 were observed to have on long sleeve shirts, pants and closed toe shoes at the time of the elopement. An interview on 03/30/26 at 10:30 AM with the Assistant Administrator, revealed that Resident #1 walked a lot in the facility and most of the time had her purse over her shoulders and stated, Unless you worked there, you would think she was a visitor. He revealed that Resident #2 was more of a follower, a tag along. He revealed that the two mentioned residents were roommates and good friends, and they saw them often walking together throughout the facility. He revealed that they had other residents with wander guard bracelets who they monitored but were wheelchair bound and non-ambulatory.An observation on 03/30/26 at 10:33 AM revealed Resident #2 participating in an activity. She mumbled and could not carry on a normal conversation due to mental status. There was a wander guard bracelet on her right ankle.An interview on 03/30/26 at 10:47 AM with Certified Nursing Assistant (CNA) #1, revealed that she was working on 03/24/26 on a different hall from Resident #1 and Resident #2. She revealed that she was doing trays when she heard a Code W called over the intercom. She revealed that she was panicky and checked all halls and rooms and found out that Residents #1 and #2 had gotten out. She revealed that she ran outside along with two other staff, ran to the end of the walkway and around the corner of the facility and spotted them (Residents #1 and #2) across the street. CNA #1 revealed that the residents had walked outside to the end of the walkway, walked around the right side of the building and crossed the four- lane highway. She revealed that she (CNA #1) ran across the street to where the two residents were and stated, I thanked God nothing happened. She revealed that this was very scary, that people fly up and down that road in their vehicles and she was thankful that Resident #1 and Resident #2 were not hit by a car or worse and stated, I'm so glad we got them back. She revealed that this place is now locked up tight and now if residents get out, it will be because of a staff member who opens the door. CNA #1 revealed that now they change the codes frequently and only staff were allowed to have the codes.An interview on 03/30/26 at 2:15 PM with the Director of Nursing (DON), revealed that on 03/24/26 at 6:45 PM, she received a call from Registered Nurse (RN) Supervisor reporting that Resident #1 and Resident #2 had gotten out of the facility after a visitor held the door open for them. She revealed that when she arrived at the facility, body audits were completed and there were no injuries identified and neither resident could recall what happened. She revealed that they were placed on 1:1 supervision for the rest of the shift. DON revealed that they swept the building to make sure everyone was accounted for, they used the transmitter from the medication cart and checked all wander guard bracelets to ensure proper functioning. She revealed that they also checked all doors in the facility and codes were changed. She revealed that they initiated in-services. DON revealed that they had signage on the door about not allowing residents to exit with visitor and they took an extra step and updated the Kiosk. She revealed that they now made sure everyone who entered the facility checked in on the Kiosk and they added an extra step they had to agree that no resident comes in or out of the facility with them and if they did not choose to accept on the kiosk, it alerted staff to check it out. DON revealed that there were endless risks with the elopement including the timing, the highway was busier during certain times of the day than others and she agreed that Resident #1 and Resident #2 could have been hit by a car, injured or worse. She revealed that she was thankful for staff who acted promptly and had Resident #1 and Resident #2 back safely inside the building in about thirteen minutes. DON revealed that Resident #1 and Resident #2 were always walking in the facility and most of the time together and confirmed that this was the first time they had ever gotten outside. She also revealed that Resident #1 and Resident #2 had wandered to the doors and looked out but they had not noticed them trying to get out. DON revealed that this was terrifying and gave them an unrealistic fear and stated, Our primary goal here is for them to be safe. She revealed that they investigated the incident, they held an Emergency Quality Assurance (QA) Meeting and found the root of the problem. She agreed that if they had increased monitoring in place, it could have prevented Resident #1 and Resident #2 from leaving the building and had they not been allowing visitors to have the door codes, this would not have happened. She revealed that if the staff were the ones with the door codes, they could better monitor who goes in and out of the facility. She stated, We have so many things to be thankful for in this situation.An interview on 03/30/26 at 2:40 PM with the Maintenance Director, revealed that he measured the distance from the exit door that Resident #1 and Resident #2 exited from to the place across the street where they were located and the distance was approximately 528 feet.An interview on 03/30/26 at 2:45 PM with LPN #1, revealed that Resident #1 and Resident #2 were pleasantly confused and they walked around in the facility together a lot. She revealed that on 03/24/26, she was working on the medication cart and heard that Resident #1 and Resident #2 had left the building. She revealed that she immediately went outside, walked to the end of the walkway and saw them across the street and confirmed that they had crossed a four-lane highway. She revealed that things could have been worse, the residents could have fallen, they could have wandered around for hours without being found, or they could have been hit by a car, causing injury or worse. She stated, I'm thankful they didn't get far or get hurt. LPN #1 revealed that she got into the car and drove across the street to get them and returned Resident #1 and Resident #2 back to the facility. She revealed that they checked them out good and they had no injuries.Record review of the facility's final Investigation Report revealed that on Tuesday, March 24, 2026, at approximately 6:20 PM, an incident occurred involving Resident #1 and Resident #2. These two residents were ambulatory and were walking toward the exit door when a visitor entered and held the door open, allowing Resident #1 and #2 to exit the facility door. The residents had Wanderguard bracelets on and immediately the door alarm sounded. In review of the video surveillance, a nurse responded and exited the facility. Additional staff were notified and exited the facility to locate the residents. Resident #1 and Resident #2 were returned back to the facility and assessed for injury or harm with none noted. Record review of Resident #1's Elopement report revealed, Notified per nursing staff that resident not on the B unit and unable to locate resident. All staff notified and searching for resident. RN supervisor went outside B Unit searching for resident. Writer noted car with x (times) 3 (three) staff members and x2 (two) residents getting out of the car. Informed that resident found across the street by (proper name) Nursing Home. Resident assisted back into the building. When asked resident where she was going, resident confused and did not realize she had left out of the building. Resident assisted to room. Body audit conducted. No skin impairment or physical injuries noted at present. Resident placed on 1:1 observation due to elopement risk. Under Predisposing Physiological Factors was documented that she was confused with impaired memory and that she was a wanderer.Record review of Resident #1's Progress Notes dated 03/25/26 at 18:20 (6:20 PM) documented Notified resident not on unit. Unable to locate resident. All staff notified. Resident located outside per staff and assisted back into facility. Resident alert and responsive. Oriented with intermittent confusion noted Body audit conducted. No skin impairment noted. No injuries noted at present Resident placed on 1:1 observation. On call provider notified. RP (Responsible Party) notified. Leadership notified.Record review of Resident #1's Face Sheet revealed an admission date of 04/26/24 with diagnoses that included Unspecified Dementia and Wandering.Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/21/26 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 03 which indicated that she had severe cognitive deficits. Section P of MDS Assessment revealed that Resident #1 had a Wander/elopement alarm in place and it was used daily. Record review of Resident #2's Face Sheet revealed an admission date of 01/14/25 with diagnoses that included Unspecified Dementia and Cognitive Communication Deficit.Record review of Resident #2's MDS with ARD of 01/16/26 under Section C revealed a BIMS Score of 00 which indicated that she had severe cognitive deficits. Under Section P of the MDS Assessment, documentation revealed that Resident #2 had a Wander/elopement alarm in place and it was used daily. Record review of Resident #2's Elopement report dated 03/24/26 at 18:20 (6:20 PM) revealed, Notified per nursing staff that resident not on the B unit and unable to locate resident. All staff notified and searching for resident. RN supervisor went outside B Unit searching for resident. Writer noted car with x3 (three) members and x2 residents getting out of the car. Informed that resident was found across the street by (proper name) Nursing Home. Resident assisted back into the building. When asked resident where she was going, resident did not respond to question. Resident alert and oriented with intermitted confusion. Resident assisted to room. Body audit conducted. No skin impairment or physical injuries noted at present Resident placed on 1:1 observation due to elopement risk. Under Predisposing Physiological Factors was documented that Resident #2 was confused and had impaired memory. It was also documented that she was a wanderer.Record review of Resident #2's Progress Note dated 03/24/26 at 18:20 (6:20 PM) revealed, Notified resident not on unit. Unable to locate resident. All staff notified. Resident located outside per staff and assisted back into facility. Resident is alert and responsive. Oriented with intermittent confusion noted On call provider notified, RP notified. Leadership notified.Immediate Actions: 1. Facility search was conducted on 03/24/26.2. Police notified of missing resident.3. Interviewed staff and residents conducted by Director of Nursing on 03/24/26.4. Medical Director and Residents' Family notified on 03/24/26.5. Wander guard system and facility doors checked by Administrator and Director of Nursing to ensure proper functioning. 6. Resident returned to facility on 03/24/26 at 6:33 PM7. Incident Report completed on 03/24/26.8. Emergency Quality Assurance (QA) Meeting completed on 03/24/26.9. In-service training initiated on 03/24/26 by Director of Nursing with all staff to include elopement policy. Comprehension of training validated by successful response to the quiz presented to each employee. Staff, including contract staff were not allowed to work their next scheduled shift until in-servicing had been completed. The compliance was monitored by Administrator. Corrective Actions Timeline: Review of Monitoring Actions:1.Wanderguard system checks were monitored by Director of Nursing on 03/24/26 and then planned to continue three times weekly for four weeks or until substantial compliance has been attained. 2. Resident behavior for elopement attempts will be monitored via incident reports, observations and communications by Director of Nursing beginning 03/24/26 and to continue weekly for four weeks or until substantial compliance has been attained. 3. The facility QA Committee will meet for the next 4 weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. Corrective Actions Timeline: 1. On March 24, 2026, at approximately 6:20PM., Visitor #1 opened the door on Unit B and allowed Resident #1 and Resident #2 to exit the facility. Resident #1 and Resident #2 were wearing Secure Care wander guard bracelets which initiated the door alarm to sound. Staff Licensed Practical Nurse #1 responded to the door alarm at approximately 6:20 PM and went outside the door immediately to locate Resident #1 and Resident #2. Staff Licensed Practical Nurse #1 returned inside and notified additional staff which consisted of certified nurse aides, and licensed nurses of the absence of Resident #1 and Resident #2. The additional staff responded and exited the facility to locate Resident # 1 and Resident #2. Resident #1 and Resident #2 were located across the street approximately 528 feet from the exit door. At approximately 6:33 p.m., Resident #1 and Resident #2 were escorted back into the facility by the RN Supervisor, Staff Nurse #1 and Certified Nursing Assistant #1 with no harm or injury. Approximately 6:45 p.m., the Director of Nurses and Administrator were notified and enroute to the facility.2. On March 24, 2026, at approximately 7:00 PM, the Administrator reviewed video surveillance and confirmed that a Visitor #1 held the door open on Unit B and allowed Resident #1 and Resident #2 to exit the facility at approximately 6:20 PM. The Director of Nurses contacted the Medical Director on March 24, 2026, at approximately 7:30 PM, and an emergency Quality Assurance meeting was held at that time involving the Medical Director, Director of Nursing, the Administrator, Regional Director, Licensed Practical Nurse #1, Certified Nursing Assistant #2, Certified Nursing Assistant #3, and the Infection Preventionist.3. On March 24, 2026, at approximately 8:00 PM, the Administrator changed the door code on main entry door. On March 24, 2026, at approximately 8:00 PM the Administrator checked all entry doors to ensure signage remained in place to not allow residents to exit facility unaccompanied. All entrance door signage was confirmed to be in place. The Director of Nursing identified 7 (seven) residents at risk and ensured elopement bracelets and transmitters were functional and the doors were locking appropriately. No areas of concern were noted during bracelet, transmitter and doors checks. All were functioning appropriately. The Director of Nursing reviewed care plans of 7 of 101 residents at risk. No areas of concern were noted with the care plan audit. Body audits were performed on Resident #1 and Resident #2 by the Registered Nurse Supervisor and Licensed Practical Nurse #2. On March 24, 2026, audits were conducted including not limited to resident location, risk for elopement, Secure Care wander guard bracelet and function all verified by the Director of Nursing. Additionally, Medical Records conducted an audit on 3/25/2026 updating all care profiles of residents at risk for wandering. On 3/25/2026, the Assistant Administrator began audits of all doors for function and security.On March 24, 2026, In- services were initiated by the Director of Nurses and Staff Development Coordinator with all staff. Inservice topics included the Elopement policy and procedure, Resident Rights, and Incident / Accident Reporting. On March 25, 2026, Elopement Drills (Code W) were conducted on each shift by the Administrator, Director of Nursing and the Staff Development Coordinator. On March 25, 2026, monitoring systems were put in place to sustain compliance. The facility Administrator will have a follow-up QA meeting monthly for two months then quarterly afterwards to ensure sustained compliance. On March 25, 2026, the facility entry screening was updated to include an additional reminder to ensure resident safety. Administration spoke directly with Visitor #1 to confirm visitor policies and procedures. The facility alleges all corrective actions were completed on 3/25/2026 and the Immediate Jeopardy was removed on 3/26/2026. On 03/30/26, the SA validated during the onsite complaint investigation through interviews, observations and record reviews that all corrective actions had been taken by the facility to remove the Immediate Jeopardy and the Immediate Jeopardy was removed on 03/26/26 prior to the SA entrance on 03/30/26.

Based on observation, staff and resident interview, record review, and facility policy review the facility failed to implement care plans for a resident's Activities of Daily Living (ADL) care and a resident's pain medication management for two (2) of 18 resident care plans reviewed. Resident #14 and Resident #53 Findings include: Record review of facility policy titled, Care Plan Process, dated 8/17, revealed, Regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs, in relation to a number of specified areas. The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive person-centered plan of care. The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs. A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. The policy also revealed, The Physician Orders, Medication Administration Record, and Treatment Administration Record are part of the Comprehensive Care Plan. Resident #14 A record review of Resident #14's comprehensive care plan revealed the resident needs assistance with ADL's. Approaches: Assist with ADLs as needed. On 6/17/24 at 12:59 PM, observation and interview with Resident #14 revealed facial hair approximately one-half (1/2) inch to the sides of his cheeks, above his lip, and on his chin and neck. Resident #14's fingernails on bilateral hands were approximately 1/2 inch long and jagged with a brown substance under his nails. The resident stated it's been a long time since he was shaved, and he would like to be shaved and have his nails cut. An interview on 6/18/24 at 3:05 PM, the Assistant Director of Nurses (ADON) confirmed that male residents should be shaven, and all residents' nails cleaned and trimmed. The ADON confirmed Resident #14 care plan was not being followed regarding his ADL care. During an interview on 6/19/24 at 10:25 AM the Minimum Data Set (MDS) nurse revealed she and the MDS Assessment nurses are responsible for developing the resident's care plans and they are developed so the staff will know the resident's needs and how they are to be taken care of. She revealed personal hygiene includes shaving and nail care and it is a standard practice and the Certified Nursing Assistants (CNA) know that. She confirmed if Resident #14 was not shaved, and his nails were not taken care of then the plan of care for his ADL's was not followed. Record review of Resident #14's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Shortness of breath and Muscle Weakness. 41878 Resident #53 Record review of Resident #53's Care Plan revealed a problem/need dated 5/1/24 Resident is at risk for pain. The goal listed for this problem was Resident will have a decrease in pain through next review. Intervention listed as Administer meds as ordered. During an interview on 6/17/24 at 11:55 AM, Resident #53 revealed he had back and joint pain and took prescription pain medication two times a day for comfort and pain relief. He revealed a few weeks ago, the facility was out of his pain medications and he was given an over the counter pain medication which did not help relieve pain as well as the prescribed pain medication. During an interview on 6/19/24 at 9:10 AM, the Director of Nursing (DON) confirmed care plans are developed to guide the staff of the needed care for each resident. She confirmed Resident #53's pain care plan was not followed since the prescription medication for pain relief was not available to be given as ordered. She confirmed there was a documented pain level of ten (10) on the vital sign record dated 5/29/24 at 7:29 AM, and no interventions were documented as given. She confirmed that by the facility not having ordered pain medication, it was not readily available for this resident. She stated the facility failed to follow his developed comprehensive care plan concerning pain management. During an interview on 6/19/24 at 10:19 AM, the MDS Nurse confirmed the facility failed to follow Resident #53's comprehensive care plan for pain management. Record review of Resident #53's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses including Pain. Record review of MDS with Assessment Reference Date (ARD) of 4/30/24, revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.

Based on staff and resident interview, record review, and facility policy review, the facility failed to ensure a resident was free of pain for one (1) of three (3) residents reviewed for pain. Resident #53 Findings include: Record review of facility policy titled, Pain Screen and Management, dated 12/23 revealed, All residents have the right to treatment for pain. Resident preferences are respected when deciding on methods to be used for pain management. Family members are involved when appropriate. The resident's statements are the most valid measurement of pain. Record review of facility policy titled, Medication Ordering, Reordering and Receiving Procedures, dated 12/19, revealed, Reordering Medications . On the established medication check day, the 11-7 (10-6) nurse will check all medications, not just punch cards, and reorder any medications that need to be re-filled. At the end of the shift, after all medications have been checked, the reorder will be faxed to the appropriate pharmacy. A form will be retained in the medication order/reorder binder with the fax confirmation. Checking in Medication Received from the pharmacy via courier. 1. Using the Medication Order/Re-Order Form for re-orders and New Medication Reconciliation form for new orders, compare each medication received to what was ordered, ensuring the resident name, medication, dose, route and frequency are correct. As each medication is checked, nurse places initials and amount received in the column to verify the reconciliation. The pharmacy is to be notified for discrepancies. During interviews with Resident #53 on 6/17/24 at 11:55 AM, and 6/18/24 at 3:30 PM, he stated he had back and joint pain and received prescription pain medication each morning and night to control his pain. He stated several weeks ago the facility did not have his prescription pain medication available, so he was given over the counter medication for his pain control, but that did not completely ease his pain. During an interview on 6/18/24 at 9:45 AM, the Director of Nursing (DON) confirmed the facility ran out of Resident #53's prescription pain medication. She stated the facility's procedure when the resident was running low on pain medication, was to place the reorder sticker from the medication card to the pharmacy form and it would be scanned to the pharmacy. At that point, the pharmacy would review the information and decide if a prescription was needed, and notify the facility or the provider to obtain a prescription. She stated for Resident #53's pain medication, there was a failure in this process and the scanned request was not followed up on by the facility. She stated the resident was given over the counter pain medication and it was documented that it was effective for his pain control. She stated for situations like this, the nurse should notify the on call provider for a now dose order, and obtain the medication from the facility's emergency kit to administer to the resident for pain relief and this was not done. She stated if notified, the provider would send a prescription to the pharmacy and pharmacy would have delivered the medication day or night, but this was also not done. She stated the resident was out of his medication from the evening of 5/27/24 until evening of 5/30/24, when she returned to work and identified the concern. The Nurse Practitioner was notified, a prescription was obtained, and the medication was delivered right away. An interview on 6/18/24 at 1:30 PM, with the Nurse Practitioner (NP) revealed he was notified on 5/29/24 of Resident #53's complaints of pain and withdrawal type symptoms from not receiving his pain medication. When he assessed the resident, he stated his pain was well controlled and clinically, the resident did not exhibit any signs or symptoms of withdrawal. The NP stated that Resident #53 had received Tylenol and it was documented that the medication was effective, and the resident did not verbalize otherwise. He confirmed by his oversight, he failed to provide a prescription to obtain an ordered medication needed for the resident's pain control. During a phone interview on 6/18/24 at 2:15 PM, Licensed Practical Nurse (LPN) #3 revealed the resident's pain medication had been requested but was not delivered to the facility from the pharmacy so he did not have this medication available when needed. She stated she was uncertain of the date but she worked that night and the resident slept well and that next morning he complained of pain and requested his pain medication. She revealed the resident had an order for a prescription pain medication that he could take every eight hours if needed for pain and he would always take one in the morning and one in the evening for his pain management. Since that was unavailable she gave him an over the counter medication to help with his pain but he was not very happy that he did not receive his prescription medication. She stated the resident was concerned about withdrawals and she assessed the resident and he did not have a tremor, vomiting, or any other symptoms of withdrawal. She stated this occurred during the morning shift change and she notified the oncoming nurse to get his meds from the pharmacy when they opened so he would have them available when needed. She stated she did not notify the provider. During a phone interview on 6/18/24 at 4:40 PM, the Registered Pharmacist stated the pharmacy received the faxed medication request from the facility on 5/23/24. This was somehow overlooked, so the pharmacy staff did not follow-up with the provider or the facility. She confirmed it was the responsibility of both the pharmacy and facility to ensure the requests are addressed and since the provider was in the facility almost daily, the prescription should have been obtained from the facility and faxed to the pharmacy. She stated the facility did not notify the pharmacy until 5/30/24 when the prescription was received by the pharmacy and was filled that day and sent out for delivery that evening. She confirmed the oversight led to a delay in resident receiving his medication. An interview with the DON on 6/19/24 at 9:10 AM, revealed the facility failed to have an ordered as-needed (PRN) pain medication available for a resident that experienced frequent pain. She confirmed there was a documented pain level of nine (9) on the vital signs record dated 5/28/24 at 7:38 AM and Acetaminophen was given and documented as effective. She confirmed there was a documented pain level of ten (10) on the vital sign record dated 5/29/24 at 7:29 AM, and no interventions were documented as given. She confirmed the facility failed to administer medication or additional interventions to assist this resident with his pain management. She confirmed the facility failed to ensure his ordered medications were available. She confirmed the facility failed to provided adequate pain management care to a resident with frequent complaints of pain. Record review of Physician Orders revealed orders dated 4/24/24 for Hydrocodone 5 mg (milligrams) - Acetaminophen 325 mg tablet: Give one tablet orally every 8 hours as needed and Acetaminophen 325 mg tablet: Give 2 tablets orally (650 mg total dose) every 6 hours as needed. Record review of Resident #53's Electronic Medication Administration Record (EMAR) revealed on 5/28/24 at 7:39 AM Acetaminophen 325 mg (milligram) tablet - 2 tablets were given for a pain level of 9. The EMAR follow up note for Acetaminophen dated 5/28/24 at 9:20 AM, revealed, Medication was effective. Record review of the Vital Signs Grid for resident revealed on 5/28/24 at 7:38 AM Resident #53 was noted to have a verbal pain scale of 9. Review revealed on 5/29/24 at 7:29 AM, the verbal pain scale was listed as 10. Record review of Medication Reorders form dated 5/23/24, revealed Resident #53's reorder for prescription pain medication was sent to the pharmacy. Record review of a prescription for the pain medication Hydrocodone-APAP 5-325 mg tablet for Resident #53 was faxed to the pharmacy on 5/30/24. Record review of Progress Note dated 5/29/24 at 7:33 AM by LPN #3 revealed, Resident is out of Norco which he requests twice a day for joint pain since 5/27/24 at bedtime. He told CNA that he needed saltine crackers to counter act withdrawal. Record review of Resident #53's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses including Pain. Record review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/30/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.

Based on staff interview, record review and facility policy review, the facility failed to transmit a discharge Minimum Data Set (MDS) Assessment for one (1) of three (3) residents reviewed for discharge MDS assessments. Resident #90 Findings include: Review of the facility policy titled, MDS Process with a revision date of 12/20 revealed, The Assessment Nurse/Nurse Case Manager will set the Assessment Reference Date (ARD) on an allowable date with input from the interdisciplinary team and communicate scheduled assessments to the interdisciplinary team. The RAI (Resident Assessment Instrument) manual is the source document to be used for further MDS coding guidelines, time schedules and requirements. Record review of Resident #90's Face Sheet revealed an admitted [DATE] and a discharge date of [DATE] with a return not anticipated. During an interview on 6/19/24 at 10:05 AM, the MDS Nurse confirmed Resident #90 was admitted to the facility on [DATE] and discharged on [DATE]. She confirmed his discharge MDS was not completed and submitted and is now over 120 days late. She revealed this was omitted in error and has not been completed.

Based on observations, staff and resident interviews, record review, and facility policy review, the facility failed to ensure a resident who required assistance with Activities of Daily Living (ADLs) was assisted with personal hygiene as evidenced by long, jagged nails with brown substance underneath nails and unshaven facial hair for one (1) of three (3) residents reviewed for ADLs. Resident #14 Findings include: Record review of the facility policy titled, Shaving with a revision date of 01/24 revealed Purpose: To provide hygiene in accordance with the resident's preferences and preferred self-image. To provide for the resident's comfort. Record review of the facility policy titled, Nail Care with the latest review date of 01/24, revealed Purpose: To promote cleanliness, safety and a neat appearance. An observation and interview on 6/17/24 at 12:59 PM revealed Resident #14 sitting in his wheelchair, facial hair approximately one-half (1/2) inch to the sides of his cheeks, above his lip, and on his chin and neck. Resident #14's fingernails on bilateral hands were approximately 1/2 inch long and jagged with a brown substance under his nails. The resident revealed it's been a long time since he was shaved, and he would like to be shaved and his nails cut. An observation on 6/18/24 at 8:56 AM, and again at 1:00 PM, revealed Resident #14's appearance remained unchanged from the previous day. During an interview on 6/18/24 at 2:10 PM, Certified Nurse Aide (CNA) #1 revealed she is assigned to Resident #14 today and usually works the hall that he is on. She confirmed the resident gets his showers on Monday, Wednesday, and Fridays and gets a bed bath the other days. She revealed the showers and bed baths include shaving and nail care if the resident is not a diabetic. CNA #1 stated, To be honest with you, I don't know if the resident is diabetic. I have never shaved him or done his nailcare. An interview and observation on 6/18/24 at 2:35 PM, Licensed Practical Nurse (LPN) #1 revealed Resident #14 is not a diabetic and the CNAs are responsible for shaving him and doing his nail care. She confirmed the resident needed to be shaved and his nails were long and jagged. She confirmed with his long fingernails that he could scratch his skin and cause a skin tear. In an interview on 6/18/24 at 3:05 PM, the Assistant Director of Nurses (ADON) confirmed the male residents should be shaved and all residents' nails cleaned and trimmed. Record review of Resident #14's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Shortness of breath and Muscle Weakness.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to label and store an aerosol nebulizer mask in a manner that prevented possible contamination of the device for one (1) of 27 nebulizers in the facility. Resident #98 Findings Include: Record review of the facility policy titled Infection Control Oxygen Equipment Cleaning with a revision date of 8/2021 revealed when not in use, store the mask/cannula in a plastic bag clearly labeled with the resident's name and date. An observation and interview with Resident #98 on 6/17/2024 at 12:39 PM, revealed a nebulizer machine was sitting on the bedside dresser, with an unbagged and undated nebulizer mask and tubing lying on top of the machine. The resident revealed she did use the mask, but she was unsure how often. An observation on 6/18/2024 at 2:08 PM, of Resident #98's room, revealed a nebulizer machine sitting on the bedside dresser with an unbagged and undated nebulizer mask and tubing draped over the machine. Record review of Resident #98's June 2024 Medication Administration Record (MAR) revealed an order dated 2/1/2024, Ipratropium 0.5 mg (milligram)-albuterol 3 mg (milligrams) (2.5 mg [milligram] base)/3 ml (milliliter) nebulization soln (solution): Give 3 milliliter(s) using nebulizer four times daily. An interview with Licensed Practical Nurse (LPN) #2 on 6/18/2024 at 2:16 PM, revealed Resident #98 did use the nebulizer machine daily. She revealed the nebulizer tubing and mask usually have a date on it. She confirmed she was responsible for ensuring the nebulizer mask was placed back in a bag and that the tubing was dated. An interview with the Director of Nursing (DON) on 6/18/2024 10:55 AM, confirmed the nebulizer mask should be dated. She stated they change out the mask and tubing every week on Tuesday and a date should be placed on the mask and tubing at that time. Record review of the Face Sheet revealed the facility admitted Resident #98 on 2/1/2024 with medical diagnoses which included Aftercare following joint replacement surgery and Unspecified Dementia.

Based on observation, staff interview, and facility policy review, the facility failed to store controlled substances in a permanently affixed locked compartment inside the refrigerator for one (1) of two (2) medication storage rooms observed. Findings Include: Review of the facility policy titled Controlled Drug Emergency Safe Protocol with a revision date of 6/17 revealed, Protocol: . Refrigerated controlled substances will be kept in a refrigerator lock box with the key stored in the Controlled Drug Emergency Safe. An observation of medication storage room [ROOM NUMBER], on 6/19/2024 at 8:16 AM, revealed a small black refrigerator that contained a large tan lock box with four (4) boxes of liquid lorazepam concentrate. The refrigerator also held a small clear box that contained three (3) injectable vials of lorazepam, which was secured with a yellow sealed tab. Both boxes were not permanently affixed and could be picked up and removed from the refrigerator. An interview on 6/19/2024 at 8:19 AM, with Licensed Practical Nurse (LPN) #1, revealed the tan and clear lock boxes were for the storage of controlled drugs that must be refrigerated. She confirmed the boxes contained lorazepam and were not permanently affixed, which could result in someone removing the boxes. An interview with the Director of Nursing (DON) on 6/19/2024 at 9:20 AM, confirmed the lock boxes were not permanently affixed and acknowledged that it should be to ensure the safety of the controlled drugs.

Based on staff interview, record review, and facility policy review, the facility failed to accurately document the administration of the prn (as needed) pain medication in the electronic medication system for one (1) of three (3) residents reviewed for pain. Resident #53 Findings include: Record review of facility policy titled, Drug Administration and Documentation, dated 12/23, revealed, The complete act of administration entails removing an individual dose from a previously dispensed, properly labeled container (including a unit dose container), verifying it with the physician's orders, giving the individual dose to the proper resident, and promptly recording the time and dose given. The policy also revealed, Chart each resident's medications on the MAR (Medication Administration Record) immediately after it is administered, as well as any administration special requirements as they are obtained, and any refused or withheld medication. PRN (as needed) medications will be documented on the MAR and the reason for giving as well as the result/response for each dose given will be noted in the clinical record. Record review of facility policy titled, Pain Screen and Management, dated 12/23, revealed, When the resident is medicated with prescribed medication or treated as ordered, documentation of medication or treatment is done on the electronic Medication Administration Record (eMAR) or the electronic Treatment Administration Record (eTAR). The policy also revealed, The eMar will reflect resident usage of medication as a treatment modality and screening is completed on admission/readmission and in the observation period of each MDS. Documentation requirements for chronic pain management focus on the following: eMAR documentation, use of as needed (PRN) medication, review and revision of care plan as appropriate. Record review of Resident #53's Individual Resident Narcotic Record from 4/25/24 - 6/18/24 revealed 98 doses of his prescription pain medications were used from his medication supply cards received from pharmacy. Record review and comparison of the eMAR and the Individual Resident Narcotic Record for Resident #53 revealed 47 of these 98 doses were not documented in his eMAR. During an interview with the Director of Nursing (DON) and the Administrator on 6/19/24 at 9:10 AM, the DON revealed the Electronic Medication Administration Record (eMAR) did not accurately reflect the medications Resident #53 received according to the Individual Resident Narcotic Record. She confirmed the narcotic record revealed the resident received his narcotic pain medication two times a day, but the EMAR did not reflect this. The Administrator confirmed that it was unacceptable that out of approximately 98 doses of narcotic medication given to Resident #53 that was signed out on the narcotic sheet, 47 of these doses were not documented on the eMAR. The DON confirmed the eMAR should provide accurate information of the medications the resident had taken for appropriate treatment and management of the resident's care, and the inaccurate documentation on this resident's eMAR did not meet that standard. She stated the eMAR revealed the resident often went days without pain medications, when in reality, he received it two times a day. The DON confirmed the facility failed to accurately document the administration of the resident's pain medication into the eMAR system and that could lead to medication errors and inaccurate treatment plans. Record review of Physician Orders revealed orders dated 4/24/24 for Hydrocodone 5 mg (milligrams) - Acetaminophen 325 mg tablet: Give one tablet orally every 8 hours as needed and Acetaminophen 325 mg tablet: Give 2 tablets orally (650 mg total dose) every 6 hours as needed. Record review of Resident #53's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses including Pain. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/30/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.

Based on staff interview, record review and facility policy review the facility failed to complete the residents Minimum Data Set assessments timely according to the Resident Assessment Instrument (RAI) guidelines for six (6) of 16 residents reviewed for annual assessment. Resident's #15, #32, #79, #88, #92, and #104. Findings include: A record review of the facility's policy titled Resident Assessment, revealed, An assessment will be completed on each resident utilizing the MDS .The reason for the assessment, schedule and timeframe's will be according to the guidance of the Resident Instrument RAI Manual RESIDENT # 15 Record review of Resident #15's Annual Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 01/27/23 revealed the assessment closure was 03/07/23, which indicated the assessment closure date was late. Record review of Resident #15's Face Sheet revealed the resident was admitted to the facility on [DATE]. RESIDENT# 32 Record review of Resident #32's Annual MDS with an ARD of 01/20/23 revealed the assessment was closed on 02/27/23, which indicated the assessment closure was late. Record review of Resident #32's Face Sheet revealed the resident was admitted to the facility on [DATE]. RESIDENT# 79 Record review of Resident #79's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/24/23, revealed the assessment was closed on 3/8/23, which indicated the assessment was more than 14 days after the ARD. Record review of Resident #79's Face Sheet revealed an admitted [DATE]. RESIDENT # 88 Record review of Resident 88's Annual MDS with an ARD of 01/25/23, revealed the assessment was closed on 02/23/23 , which indicated the assessment completion date was more than 14 days after the ARD. Record review of Resident # 88's Face Sheet revealed an admitted [DATE]. RESIDENT #92 Record review of Resident #92's Annual MDS with an ARD of 01/20/23 revealed the assessment was closed on 02/22/23 and transmitted on 03/03/23, which indicated that the assessment closure was late. Record review of Resident #92's Face Sheet revealed the resident was admitted to the facility on [DATE]. RESIDENT #104 Record review of Resident #104's Annual MDS with an ARD of 01/24/23 revealed the assessment was closed on 3/7/23 which indicated the assessment closure was late. Record review of Resident #104's Face Sheet revealed the resident was admitted to the facility on [DATE]. On 3/9/23 at 11:15 AM, during an interview with the MDS Coordinator, MDS Assessment Nurse #1 and MDS Nurse #2 confirmed they were behind on their MDS assessments. The MDS coordinator reviewed the MDS validation reports with State Agents (SA) present and confirmed that according to the dates of the assessment completion they were late. The MDS Coordinator revealed that at one point they had five staff members, went down to four staff members and about two months ago one of their staff members went out on medical leave which left them with three staff members. The MDS Coordinator revealed that they have 6 or 7 admissions a day and have to do those assessments along with completing Medicare charting on all skilled residents daily with the facility currently having 40. The MDS Coordinator revealed that she had not told anyone that they were behind on their MDS assessments but should have. She revealed that the purpose of the MDS assessment was to capture all of the information on the resident's that help indicate what care is needed for the residents and payment for the facility. She revealed that if the MDS was not completed timely then the resident might not get proper care. MDS Nurse #2 revealed that she had a conversation on Monday 3/6/23 with the Director of Nurse (DON) regarding getting some overtime so she can come in and get caught up on some work. MDS Nurse #2 revealed that the DON ask what they could do to help and that they would need to be looking for someone to help them get caught up. On 3/9/23 at 11:45 AM, during an interview with the DON and the Administrator revealed that the DON denied having a conversation with MDS Nurse #2 regarding the MDS department being behind and needing help. The DON revealed no one had ever mentioned being late with their assessments. The DON revealed that she had conversations in passing with MDS Nurse #2 regarding MDS being busy but had no idea they were that bad behind and if she had known she would have gotten them some help. The DON confirmed that the MDS nurses also do daily Medicare charting on all skilled residents, which is time consuming. The Administrator revealed that the MDS coordinator attends the morning stand up meetings and had never mentioned that they were behind. The Administrator stated, I can't deny they are short staffed in the MDS department. The Administrator confirmed they had four (4) staff members in MDS until about two months ago, but stated, I've never done MDS and Medicare charting, so I do not know how long it would take to get it done. The DON stated, I am no MDS guru. She confirmed they were short staffed in the MDS department. 47157

Based on staff interview, record review and facility policy review the facility failed to complete the residents Minimum Data Set (MDS) assessments timely according to the Resident Assessment Instrument (RAI) guidelines for nine (9) of 16 residents reviewed for quarterly assessment. Resident's #6, 20, 31, 36, 39, 49, 58, 60, and 93. Findings include: A record review of the facility's policy titled Resident Assessment revealed an assessment will be completed on each resident utilizing the MDS .The reason for the assessment, schedule and timeframe's will be according to the guidance of the Resident Instrument RAI Manual. Resident # 6 Record review of Resident # 6's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/24/23, revealed the assessment was closed on 2/22/23 , which indicated the assessment completion date was more than 14 days after the ARD. Review of Resident #6's Face Sheet revealed an admitted [DATE]. Resident #20 Record review of Resident #20's Quarterly MDS with an ARD of 01/20/23 revealed the assessment was closed on 02/22/23, which indicated the assessment closure was late. Record review of Resident #20's Face Sheet revealed the resident was admitted to the facility on [DATE]. Resident #31 Record review of Resident 31's Quarterly MDS with an ARD of 01/24/23, revealed the assessment was closed on 03/06/23, which indicated the assessment completion date was more than 14 days after the ARD. Review of Resident #31's Face Sheet reveled an admitted [DATE]. Resident # 36 Record review of Resident #36's Quarterly MDS with an ARD of 01/23/23 revealed the assessment was closed on 03/02/23 which indicated the assessment closure was late. Record review of Resident #36's Face Sheet revealed the resident was admitted to the facility on [DATE]. Resident #39 Record review of Resident #39's Quarterly MDS with an ARD of 01/25/23, revealed the assessment was closed on 2/22/23, which indicated the assessment completion date was more than 14 days after the ARD. Record review of Resident #39's Face Sheet revealed an admitted [DATE]. Resident # 49 Record review of Resident # 49's Quarterly MDS with an ARD of 01/24/23, revealed the assessment was closed on 3/01/23, which indicated the assessment completion date was more than 14 days after the ARD. Record review of Resident # 49's face sheet revealed an admitted [DATE]. Resident #58 Record review of Resident #58's Quarterly MDS with an ARD of 01/18/23 revealed the assessment was closed on 02/22/23, which indicated the assessment closure was late. Record review of Resident #58's Face Sheet revealed the resident was admitted to the facility on [DATE]. Resident #60 Record review of Resident # 60 's Quarterly MDS with an ARD of 01/25/23, revealed the assessment was closed on 2/22/23, which indicated the assessment completion date was more than 14 days after the ARD. Review of Resident # 60's Face Sheet revealed an admitted [DATE]. Resident #93 Record review of Resident #93's Quarterly MDS with an ARD of 01/27/23 revealed the assessment was closed on 03/01/23, which indicated the assessment closure was late. Record review of Resident #93's Face Sheet revealed the resident was admitted to the facility on [DATE]. During an interview on 3/9/23 at 11:15 AM, with the MDS Coordinator, MDS Assessment Nurse #1 and MDS Nurse #2 confirmed they were behind on their MDS assessments. The MDS coordinator reviewed the MDS validation reports with State Agents (SA) present and confirmed that according to the dates of the assessment completion and transmission that they were late. The MDS Coordinator stated that at one point they had five staff members, went down to four staff members and about two months ago one of their staff members went out on medical leave which left them with three staff members. The MDS Coordinator stated that they have six or seven admissions a day and have to do those assessments along with completing Medicare charting on all skilled residents daily with the facility currently having 40. The MDS Coordinator revealed that she had not told anyone that they were behind on their MDS assessments but should have. She stated that the purpose of the MDS assessment was to capture all of the information on the resident's that help indicate what care is needed for the residents and payment for the facility. She revealed that if the MDS was not completed timely then the resident might not get proper care. MDS Nurse #2 revealed that she had a conversation on Monday 3/6/23 with the Director of Nurse (DON) regarding getting some overtime so she can come in and get caught up on some work. MDS Nurse #2 stated that the DON asked what they could do to help and that they would need to be looking for someone to help them get caught up. During an interview on 3/9/23 at 11:45 AM with the DON and the Administrator revealed that the DON denied having a conversation with MDS Nurse #2 regarding the MDS department being behind and needing help. The DON stated no one had ever mentioned being late with their assessments. The DON revealed that she had conversations in passing with MDS Nurse #2 regarding MDS being busy but had no idea they were that far behind and if she had known she would have got them some help. The DON confirmed that the MDS nurses also do daily Medicare charting on all skilled residents, which is time consuming. The Administrator revealed that the MDS coordinator attends the morning stand up meetings and had never mentioned that they were behind. The Administrator stated, I can't deny they are short staffed in the MDS department. The Administrator confirmed they had 4 staff members in MDS until about 2 months ago, but stated, I've never done MDS and Medicare charting so I do not know how long it would take to get it done. The DON stated, I am no MDS guru and confirmed they were short staffed in the MDS department. The DON revealed that MDS assessments are how the facility gets reimbursed. 47157

Based on staff interview, record review and facility policy review the facility failed to transmit the residents Minimum Data Set assessments timely according to the Resident Assessment Instrument (RAI) guidelines for 16 of 16 residents reviewed for assessment. Resident's 6, 15, 20, 24, 31, 32, 36, 39, 49, 58, 60, 79, 88, 92, 93, and 104. Findings include: A record review of the facility's policy titled, Resident Assessment revealed an assessment will be completed on each resident utilizing the MDS .The reason for the assessment ,schedule and timeframes will be according to the guidance of the Resident Instrument RAI Manual. Resident #6 Record review of Resident # 6's Quarterly MDS with an Assessment Reference Date (ARD) of 01/24/23, revealed the assessment was transmitted on 3/03/23, which indicated the assessment transmission date was more than 14 days after the ARD. Reviw of Resident # 6's Face Sheet revealed an admitted [DATE]. Resident # 15 Record review of Resident #15's MDS with an Assessment Reference Date (ARD) of 01/27/23 revealed that the assessment closure was 03/07/23 and transmitted on 03/08/23, which indicated the assessment closure date and transmission date were late. Record review of Resident #15's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Major Depressive Disorder. Resident #20 Record review of Resident #20's MDS with an ARD of 01/20/23 revealed the assessment was closed on 02/22/23 and transmitted on 03/03/23, which indicated the assessment closure and the transmission were late. Record review of Resident #20 ' s Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Old Myocardial Infarction and Anxiety Disorder. Resident #24 Record review of Resident #24's MDS with an ARD of 01/20/23 revealed the assessment was closed on 02/27/23 and transmitted on 03/03/23, which indicated the assessment closure and the transmission were late. Record review of Resident #24's Face Sheet revealed the resident was admitted to the facility on [DATE]. Resident #31 Record review of Resident 31's Quarterly MDS with an ARD of 01/24/23, revealed the assessment was transmitted on 3/8/23, which indicated the assessment transmission date was more than 14 days after the ARD. Review of Resident # 31's Face Sheet with an admitted [DATE]. Resident # 32 Record review of Resident #32's MDS with an ARD of 01/20/23 revealed the assessment was closed on 02/27/23 and transmitted on 03/03/23, which indicated the assessment closure and the transmission were late. Record review of Resident #32's Face Sheet revealed the resident was admitted to the facility on [DATE]. Resident # 36 Record review of Resident #36's MDS with an ARD of 01/23/23 revealed the assessment was closed on 03/02/23 and transmitted on 03/03/23, which indicated the assessment closure and the transmission were late. Record review of Resident #36's Face Sheet revealed the resident was admitted to the facility on [DATE]. Resident #39 Record review of Resident #39's Quarterly MDS with an ARD of 01/25/23, revealed the assessment was transmitted on 3/03/23, which indicated the assessment transmission date was than 14 days after the ARD. Review of Resident # 39's Face Sheet revealed an admitted [DATE]. Resident # 49 Record review of Resident # 49's Quarterly MDS with an ARD of 01/24/23, revealed the assessment was transmitted on 3/03/23, which indicated the assessment completion date was more than 14 days after the ARD. Review of Resident # 49's Face Sheet revealed an admitted [DATE]. Resident #58 Record review of Resident #58's MDS with an ARD of 01/18/23 revealed the assessment was closed on 02/22/23 and transmitted on 3/3/23, which indicated the assessment closure and transmission were late. Record review of Resident #58's Face Sheet revealed the resident was admitted to the facility on [DATE]. Resident #60 Record review of Resident # 60 's Quarterly Minimum Data Set with an ARD of 01/25/23, revealed the assessment was transmitted on 3/03/23 , which indicated the assessment completion date was more than 14 days after the ARD. Review of Resident # 60's Face Sheet revealed an admitted [DATE]. Resident #79 Record review of Resident #79's Annual MDS with an ARD of 01/24/23 and as of 3/08/23 had not been transmitted, which indicated the assessment assessment was more than 14 days after the ARD. Review of Resident # 79's Face Sheet revealed an admitted [DATE]. Resident #88 Record review of Resident 88's Annual MDS with an ARD of 01/25/23, revealed the assessment was transmitted on 3/3/23, which indicated the assessment transmission date was more than 14 days after the ARD. Review of Resident # 88's Face Sheet revealed an admitted [DATE]. Resident #92 Record review of Resident #92's MDS with an ARD of 01/20/23 revealed the assessment was closed on 02/22/23 and transmitted on 03/03/23, which indicated that the assessment closure and transmission were late. Record review of Resident #92's Face Sheet revealed the resident was admitted to the facility on [DATE]. Resident #93 Record review of Resident #93's MDS with an ARD of 01/27/23 revealed the assessment was closed on 03/01/23 and transmitted on 3/3/23, which indicated the assessment closure and transmission were late. Record review of Resident #93's Face Sheet revealed the resident was admitted to the facility on [DATE]. Resident #104 Record review of Resident #104's MDS with an ARD of 01/24/23 revealed the assessment was closed on 3/7/23 and transmitted on 03/08/23, which indicated the assessment closure and the transmission were late. Record review of Resident #104's Face Sheet revealed the resident was admitted to the facility on [DATE]. An interview on 3/9/23 at 11:15 AM with the Minimum Data Set (MDS) Coordinator, MDS Assessment Nurse #1 and MDS Nurse #2 confirmed they were behind on their MDS assessments and transmissions. The MDS coordinator reviewed the MDS validation reports with State Agents (SA) present and confirmed that according to the dates of the assessment completion and transmission that they were late. The MDS Coordinator revealed that at one point they had five staff members, went down to four staff members and about two months ago one of their staff members went out on medical leave which left them with three staff members. The MDS Coordinator revealed that they have 6 or 7 admissions a day and have to do those assessments along with completing Medicare charting on all skilled residents daily with the facility currently having 40 The MDS Coordinator revealed that she had not told anyone that they were behind on their MDS assessments or transmissions but should have. She revealed that the purpose of the MDS assessment was to capture all of the information on the resident's that help indicate what care is needed for the residents and payment for the facility. She revealed that if the MDS was not completed timely then the resident might not get proper care. MDS Nurse #2 revealed that she had a conversation on Monday 3/6/23 with the Director of Nurse (DON) regarding getting some overtime so she can come in and get caught up on some work. MDS Nurse #2 revealed that the DON ask what they could do to help and that they would need to be looking for someone to help them get caught up. An interview on 3/9/23 at 11:45 AM with the DON and the Administrator revealed that the DON denied having a conversation with MDS Nurse #2 regarding the MDS department being behind and needing help. The DON revealed no one had ever mentioned being late with their assessments. The DON revealed that she had conversations in passing with MDS Nurse #2 regarding MDS being busy but had no idea they were that bad behind and if she had known she would have got them some help. The DON confirmed that the MDS nurses also do daily Medicare charting on all skilled residents, which is time consuming. The Administrator revealed that the MDS coordinator attends the morning stand up meetings and had never mentioned that they were behind. The Administrator stated, I can't deny they are short staffed in the MDS department. The Administrator confirmed they had 4 staff members in MDS until about 2 months ago, but stated, I've never done MDS and Medicare charting so I do not know how long it would take to get it done. The DON stated, I am no MDS guru and confirmed they were short staffed in the MDS department. The DON revealed that MDS assessments are how the facility gets reimbursed. 47157

Based on staff interview, record review , and facility policy review, the facility failed to send a written notice of resident transfer, including the reason for transfer, to the hospital, to the resident or resident representative (RR) for two (2) of five (5) residents reviewed for transfer. Resident #25 and #73. Findings include: Review of the facility policy titled, Notice Of Hospital Transfer/Therapeutic Leave with a review date of 08/21 revealed, .#2. When a resident is transferred to the hospital, or goes out on therapeutic leave, a copy of the completed form (notice) is provided to the resident, specifying the duration of the bed-hold according to the state plan, and the facility's policy regarding bed-hold periods. In case of emergency transfer, notice at the time of transfer means that the family or resident representative are provided with written notification within 24 hours of the transfer. The requirement is met if the resident's copy of the notice is sent with other papers accompanying the resident to the hospital. The staff member completing the transfer paperwork should complete the location, time, and date section of the form. A copy of the completed form should also be forwarded to the Accounts Manager. The Accounts Manager will contact the Resident Representative and complete the Verification of telephone notice within 24 hours. The Accounts Manager will also mail a copy of the Notice of Hospital Transfer/Therapeutic Leave form for signature by the Resident Representative if the Representative is not available to sign on the day they are contacted. A copy of the completed form should be retained in the resident's Administrative folder . Resident #25 Review of Resident #25's record revealed she was transferred to the hospital on 1/16/23 due to facial drooping and inability to follow commands and returned to the facility on [DATE]. Record review did not indicate a written transfer notification form was sent to the RR. On 3/8/23 at 10:00 AM, an interview with Licensed Practical Nurse (LPN) #1 revealed the floor nurses are responsible for the completion of the transfer/discharge form and a copy is always sent with the resident to the hospital. She stated she is not sure who is responsible for mailing a copy to the RR. On 03/08/23 at 10:30 AM, an interview with the Accounts Manager revealed that a notification of transfer/discharge form was not mailed to the RR of Resident #25. She stated the nurse on the floor would have prepared the transfer form and sent a copy with the resident to the hospital and she would have called the RR the following day and sent an e-mail notification to the Ombudsman. On 3/08/23 at 11:05 AM, an interview with the Administrator revealed the facility does not mail out written notification of transfer/discharge. She stated that the nurses complete the form, and the form is always sent with the resident. She stated that the family is called and notified at the time of transfer and that the Accounts Office calls the RR the following day. On 3/8/23 at 12:05 PM, an interview with the Administrator revealed that after speaking with the Business Office they have been mailing out written notifications of the transfer/discharge forms. She stated that they send them out first class mail not certified, therefore, they have no evidence that the form was mailed as a copy was not retained for the resident's administrative folder. The Administrator provided an incomplete form with no title that she stated was retained by the Business Office that listed Resident #25's name, the date, and the name of the hospital that the resident was transported to. The Administrator confirmed that this document was insufficient and lacking all the details the facility should have provided to the RR. She also confirmed that the form should have explained the reason for the transfer as well as listing the date it was mailed and the facility should have retained a copy for the resident's folder. Record review of Resident #25's Face Sheet revealed she was admitted to the facility on [DATE] with the medical diagnoses that included displaced Intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, Anxiety unspecified, and Frequent falls. Record review of Resident #25's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/30/23 revealed a Brief Interview for Mental Status (BIMS) score of one (1) which indicated the resident is severely cognitively impaired. Resident #73 Record review of the nurses notes dated 12/29/22 revealed Resident #73 was transferred to the hospital on 12/28/22 and returned to facility on 1/2/23. Record review of the notice of hospital/therapeutic leave form related to the hospitalization transfer revealed the form was not completed. An interview, on 03/08/23 at 10:20 AM, with the Accounts Manager revealed they do mail the forms to the RR and call the family the next day. The nurses are responsible for filling out the forms and they are sent out with the resident to the hospital. The Accounts Manager confirmed that she had no proof that she had mailed the form to the RR. She stated that the nurses are supposed to fill out the form and get it to her, but she does not always get them. She stated that the form she mails out addresses transfers. An interview on 03/08/23 at 10:30 AM, with the Nurse Manager confirmed the nurses are responsible for filling out the notice of hospital transfer form. She stated they should be filled out and given to the business office. She confirmed that Resident #73's transfer form was not filled out. During an interview and record review, on 03/08/23 at 11:50 AM, the Administrator confirmed the notice of hospital transfer/leave form for Resident #73 was not filled out. An interview on 03/09/23 at 09:14 AM, with the Administrator confirmed they have an issue with the transfer forms and are addressing the forms. Record review of the facility Face Sheet for Resident #73 revealed an admitted [DATE] with diagnoses including Acute Post Hemorrhagic Anemia, Cerebral Infarction with right dominant side Hemiplegia, Unspecified Dementia, Cognitive Communication Deficit. Record review of the MDS with an ARD of 12/12/2022 revealed a BIMS score of 5 which indicated Resident #73's cognitive status was severely impaired. 47874

Based on staff interview, record review , and facility policy review the facility failed to notify the resident or resident representative (RR) in writing of the bed hold for a resident transferred to an acute care facility for one (1) of five (5) residents reviewed for bed hold. Resident #73. Findings include: Review of the facility policy titled, Notice of Hospital Transfer/Therapeutic Leave, with a latest review date of 08/21 revealed when a resident is transferred to the hospital, or goes out on therapeutic leave, a copy of the completed form (notice) is provided to the resident, specifying the duration of the bed hold according to the state plan, and the facilities policy regarding bed-hold periods. In case of an emergency transfer, notice at the time of transfer means that the family or resident representative are provided with written notification within 24 hours of the transfer. The requirement is met if the resident's copy of the notice is sent with other papers accompanying the resident to the hospital. The staff member completing the transfer paperwork should complete the location, time, and date section of the form. A copy of the completed form should also be forwarded to the Accounts Manager. The Accounts Manager will contact the Resident Representative and complete the Verification of phone notice within 24 hours. The Account Manager will also mail a copy of the Notice of Hospital Transfer/Therapeutic Leave form for signature by the Resident Representative if the Resident Representative is not available to sign on the day they are contacted. A copy of the completed form should be retained in the residents Administrative folder. Findings include: Record review review of the nurses notes dated 12/29/22 revealed Resident #73 was transferred to the hospital on 12/28/22. Record review of the NOTICE OF HOSPITAL TRANSFER/THERAPEUTIC LEAVE form related to the hospitalization transfer of Resident #73 revealed the form was not completed. The form contained only the name of the resident and the resident representative at the top of the page and an undated signature of the resident representative near the bottom of the page following a statement, I do not agree to pay for uncovered days. An interview on 03/08/23 at 10:20 AM, with the Accounts Manager revealed they do mail the forms to the responsible party and call the family the next day. The nurses are responsible for filling out the forms and they are sent out with the resident to the hospital. The Accounts Manager confirmed that she had no proof that she had mailed the form. She stated that the nurses are supposed to fill out the form and get it to her but she does not always get them. She stated that the form she mails out addresses transfer. An interview on 03/08/23 at 10:30 AM with the nurse manager confirmed the nurses are responsible for filling out the notice of hospital transfer form. She stated they should be filled out and given to the business office. She confirmed that Resident #73's transfer form was not filled out. During an interview and record review, on 03/08/23 at 11:50 AM, the administrator confirmed the notice of hospital transfer form for Resident #73 was not filled out. An interview on 03/09/23 at 9:00 AM, with the Accounts Manager confirmed she did not know what the bed hold rate was or that the family was to be informed the of amount and informed if there was a change. During an interview on 03/09/23 at 09:14 AM, the Administrator stated that they have an issue with the transfer forms and are addressing the forms. Record review of the facility Face Sheet for Resident #73 revealed an admitted [DATE] with diagnoses including Acute Post Hemorrhagic Anemia, and Cerebral Infarction with right dominant side Hemiplegia. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/2022 revealed a Brief Interview for Mental Status (BIMS) score of 5 which indicated Resident #73's cognitive status was severely impaired.

Based on resident and staff interview, record review and facility policy review the facility failed to develop a person centered comprehensive care plan for residents with a language deficit and respiratory care for three (3) of 34 resident care plans reviewed. Residents #7, #24, and #98. Findings include: A record review of the facility's policy titled Care Plan Process, revised 08/17, Step# 9: The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs, including culturally-competent and trauma-informed as well as, these items or services that would be required but are not due to the exercise of resident rights (refusal). Resident #7 An observation on 3/06/23 at 10:12 AM, revealed a nebulizer machine with mask and tubing laying on bedside table not in storage bag. A record review of the comprehensive care plans for Resident # 7, revealed there was no care plan addressing nebulizer therapy needs. A record review of Resident #7's physician's orders revealed an order dated 11/30/22, IPRATALBUTEROL 0.5-3(2.5) MG (milligrams) ML (milliliter) INHALATION VIA NEBULIZER DAILY IN THE MORNING AND AT BEDTIME SOB (shortness of breath)/WHEEZING and an order dated 10/14/22 IPRAT-ALBUTEROL 0.5-3(2.5) MG ML INHALATION VIA NEBULIZER EVERY 6 HOURS AS NEEDED SOB/WHEEZING. A record review of the March 2023 Electronic Medication Record (E-MAR), revealed Resident # 7 received scheduled IPRAT-ALBUTEROL 0.5-3(2.5)MG ml Inhalation Nebulizer daily in the morning and at bedtime for SOB/Wheezing from the 1st through the 7th of March. An interview with Minimum Data Set (MDS) RN Assessment Nurse on 03/08/23 at 01:41 PM, revealed Resident #7 should have a care plan addressing any respiratory therapy and she is unsure why it was not care planned. Record review of Resident #7's Face Sheet revealed he was admitted on [DATE] with diagnoses of Cerebral Infarction, Heart Failure, and Chronic Obstructive Pulmonary Disease. Record review of the MDS Section C with an Assessment Reference Date (ARD) of 3/08/23 revealed Resident # 7 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact. Resident #24 An observation and interview on 3/6/23 at 12:00 PM, revealed that Resident #24 was sitting up in a wheelchair in her room watching TV. On interview the resident answered with a single repetitive word, used inflection in her voice, hand gestures and nodding of her head to answer simple yes and no questions. Record review of Resident #24's care plans revealed the resident did not have language deficit care plan. An interview on 3/7/23 at 2:30 PM, with Certified Nurse Assistant (CNA) #1 and CNA #2 revealed that until you get use to Resident #24 it is sometimes difficult to understand her, but she makes her wants and needs known by pointing. An interview on 3/8/23 at 2:00 PM with the Director of Nurses (DON) revealed that Resident #24 has a diagnosis of a language deficit She confirmed the resident is hard to communicate with, but if you give her time, you can usually understand her. She revealed that the resident should have a communication care plan but did not. She revealed the purpose of the care plan would be to provide education to the staff on how to care for the resident since she has the communication deficit. She revealed that MDS is responsible for putting in the care plans. An interview on 3/9/23 at 10:32 AM, with the MDS Coordinator confirmed that Resident #24 has a language deficit diagnosis but does not have a language deficit care plan. She confirmed that the resident should have a language deficit care plan and that MDS would have been responsible for putting that care plan in. She confirmed that the purpose of the care plan was for the staff to know how to communicate with the resident and with the care plan not being completed then the staff may not know how to communicate with her. Record review of Resident #24's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Other Speech/Language Deficit following Unspecified Cerebral Vascular Disease. Record review of Resident #24's MDS with an ARD of 01/20/23 revealed in Section B that the resident had speech that was unclear and was sometimes understood, with ability being limited to making concrete request and in Section C a BIMS score of 14, which indicates the resident is cognitively intact. Resident #98 An observation on 03/07/23 at 8:19 AM, revealed a nebulizer mask lying inside the opening of the nebulizer machine. A record review of the comprehensive care plans for Resident #98, revealed no care plan addressing nebulizer therapy needs. A record review of the physician's orders, revealed an order dated 10/14/22 IPRAT ALBUTEROL 0.5-3(2.5) MG ML INHALATION VIA NEBULIZER EVERY 4 HOURS AS NEEDED SOB/WHEEZING. An interview with MDS Registered Nurse/Assessment Nurse on 03/08/23 at 01:41 PM, revealed Resident #7 should have a care plan addressing any respiratory therapy and she is unsure as to why it was not care planned. An interview with the DON on 03/08/23 11:50 AM, she revealed she was unable to find a care plan for respiratory treatments. Record review of Resident # 98's Face Sheet revealed he was admitted on [DATE] with diagnoses of Cerebral Infarction, Hyperlipidemia, and Hypertensive Crisis. Record review of the MDS Section C with an ARD of 1/8/23 revealed Resident # 98 had a BIMS score of 6, indicating he was severely cognitively impaired. An interview with the MDS Coordinator on 03/08/23 at 1:48 PM, revealed the purpose of the comprehensive care plan was to form care specific to each resident's needs, and confirmed that possible concerns from not developing a care plan is lack of appropriate resident centered care and not meeting the resident's needs. An interview with the Corporate Quality Improvement Nurse on 03/08/23 at 02:13 PM, revealed the purpose of the care plan is to direct staff of the person centered care and needs of the resident and concerns of not developing the care plan is residents may not receive the specific individualized care necessary they need to meet their needs. 47157

Based on observation, resident and staff interview, record review and facility policy review the facility failed to properly store nebulizer mask and tubing in a storage bag for two (2) of nine (9) residents reviewed for respiratory care. Residents # 7 and #98. Findings include: A record review of the facility's policy titled Nebulizer, revised 10/17, Revealed Purpose: 1.) To administer bronchial medications and humidifying agents into the lungs. 2.) To assist in loosening secretions .Cleaning Equipment: 4.) Store in a clean plastic bag . Resident #7 An observation on 3/06/23 at 10:12 AM, revealed nebulizer mask and tubing laying on the bedside table and was not in a storage bag. An observation and interview with Resident #7 on 3/7/23 at 11:00 AM, revealed the nebulizer mask was sitting on a box on bedside table. Resident #7 revealed she had her nebulizer in a bag before but not in a good while. An observation with Licensed Practical Nurse (LPN) #2 on 3/7/23 at 1:10 PM, she confirmed Resident #7's nebulizer mask was lying on the nebulizer machine and confirmed it should be in a storage bag when not in use. LPN #2 removed the nebulizer mask from the room. LPN # 2 also revealed possible complications of improper storage is respiratory infections. A record review of Resident#7's Physician Orders dated 11/30/22, revealed IPRAT-ALBUTEROL 0.5-3(2.5)MG ML INHALATION VIA NEBULIZER DAILY IN THE MORNING AND AT BEDTIME SOB/WHEEZING and an order dated 10/14/22 IPRAT-ALBUTEROL 0.5-3(2.5)MG ML INHALATION VIA NEBULIZER EVERY 6 HOURS AS NEEDED SOB/WHEEZING. A record review of the March 2023 Electronic Medication Record(E-MAR), revealed Resident # 7 received scheduled IPRAT-ALBUTEROL 0.5-3(2.5)MG ml Inhalation Nebulizer daily in the morning and at bedtime for SOB/Wheezing from the 1st through the 7th of March 2023. Record review of Resident #7's Face Sheet revealed he was admitted on [DATE] with diagnoses of Cerebral Infarction, Heart Failure, and Chronic obstructive pulmonary disease. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 3/08/23 revealed Resident # 7 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she was cognitively intact. Resident #98 An observation on 03/06/23 at 10:30 AM, revealed a nebulizer mask was laying on the bedside table and not in a storage bag. An observation on 03/07/23 at 8:19 AM, revealed the nebulizer mask was laying inside the opening of the nebulizer machine and was not in a storage bag. An observation with LPN #2 on 03/07/23 at 1:00 PM, confirmed Resident # 98's nebulizer mask was laying on the nebulizer machine and it should be in a storage bag when not in use. LPN #2 removed the nebulizer mask from the room. LPN # 2 also revealed possible complications of improper storage is respiratory infections. A record review of the Physician Orders, revealed an order dated 10/14/22 IPRAT-ALBUTEROL 0.5-3(2.5) MG ML INHALATION VIA NEBULIZER EVERY 4 HOURS AS NEEDED SOB/WHEEZING. A record review of the March 2023 E-MAR revealed Resident # 98 receives did not receive any nebulizer treatments from the 1st through the 7th of March 2023. An interview with the Director of Nursing (DON) on 3/7/23 at 1:30 PM, revealed that oxygen and nebulizer masks and tubing should be stored in a storage bag when not in use for infection control concerns and confirmed possible complications of improper storage is Respiratory infection. An interview with the Corporate Quality Improvement Nurse on 03/07/23 at 1:35 PM, revealed oxygen and nebulizer tubing and masks should be stored in a storage bag and a possible complication of improper storage is infections and accidents. An interview with LPN #1 on 03/08/23 at 11:00 AM, revealed the oxygen and nebulizer tubing should be changed out weekly, labeled and dated and stored in a storage bag. An interview with the Administrator on 03/08/23 11:55 AM, she revealed she is not medical, but a possible concern of improper nebulizer storage and tubing change is infections. An interview with the Infection Control Nurse (ICN) on 03/09/23 08:10 AM, revealed nebulizer tubing and masks should be stored in a bag when not in use and if it was not stored in a bag staff are not following the policy. The ICN confirmed possible concerns from not storing the nebulizers appropriately is bacterial infections. Record review of Resident #98's Face Sheet revealed he was admitted on [DATE] with diagnoses of Cerebral Infarction, Hyperlipidemia, and Hypertensive Crisis. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 1/8/23 revealed Resident # 98 had a Brief Interview for Mental Status (BIMS) score of 6, indicating he was severely cognitively impaired.

Based on observations, staff interviews, record review and facility policy review the facility failed to provide documentation or a diagnosis supporting the use of an anti-psychotic medication for one (1) of three (3) residents reviewed for unnecessary psychotropic medications. Resident #42 Findings include: Record review of the facility policy Psychotropic Medications with a revision date of 10/22, revealed, A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior .Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record . An observation on 3/6/23 at 12:20 PM, revealed Resident #42 sitting in her wheelchair in her room with her daughter present, no behaviors noted. An observation on 3/7/23 at 9:15 AM, revealed Resident #42 sitting in her room with her daughter present, no behaviors noted. An interview on 3/7/23 at 2:15 PM, with Certified Nurse Assistant (CNA) #1 revealed she has not known Resident #42 to have any behaviors. She revealed she is usually a pleasant lady and is up out of her room a lot. She revealed the resident allows her to provide care without any issues. An interview on 3/8/23 at 11:45 AM, with Social Services #1 revealed she has never known Resident #42 to have any sort of behaviors. An interview on 3/8/23 at 2:40 PM, with the Director of Nurses (DON) confirmed that Resident #42 does not have behaviors. She revealed the resident gets aggravated with her family when they come and stay too long, but besides that she has no real behaviors. She confirmed that Resident #42 had an order for Seroquel due to the family requesting that she be put on Seroquel. She revealed the family asked the Nurse Practitioner (NP) in 01/2023 to increase the Seroquel from 25 milligrams (mg) to 50 mg because they said the resident was getting more agitated. She revealed that there was no progress note indicating that was the reason for the increase in Seroquel in 01/2023. She confirmed the resident did not have a diagnosis of psychosis and her dementia diagnosis was with no behaviors. She also confirmed that on the residents most recent Minimum Data Set (MDS) Section D and E revealed the resident had no mood or behavior issues. She revealed that the resident receiving an anti-psychotic without having a diagnosis or behavior needs could cause the resident to be lethargic. An interview on 3/8/23 at 3:00 PM, with the NP confirmed she wrote the order to increase Resident #42's Seroquel from 25 mg to 50 mg in 01/23 because the family informed her on her rounds that the resident had increased agitation with the staff and was refusing care such as having her vital signs taken. She revealed that no staff member informed her that the resident was having behaviors or was agitated and she never addressed it with them. She revealed the resident did not have psychotic behaviors. She confirmed that she had not written a progress note when she increased the resident's Seroquel at the family's request in 01/2023. When the State Agent (SA) asked if there would have been a different medication she could have tried instead of Seroquel, she stated possibly. She revealed that if the resident received Seroquel and did not need it then she could be overly sedated and it could lower her blood pressure and change her vital signs. Record review of Resident #42's Physician Orders with an order date of 2/3/2023 revealedSeroquel 50 mg 1 tablet by mouth twice daily psychosis, monitor for target behaviors, psychotic episodes. Record review of Resident #42's Electronic Medication Administration Record for 02/2023 and 03/2023 revealed the resident was receiving Seroquel 50 mg 1 tablet by mouth twice daily/psychosis at 9:00 AM and 7:00 PM. Record review of the facilities Interdisciplinary Team Psychotropic Dashboard for December 2022, January 2023 and February 2023 indicated the resident needed a diagnosis code for Seroquel. Record review of Resident #42's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnosis that included Unspecified dementia, unspecified severity without behaviors/psychosis/mood/anxiety. The current diagnosis list did not include a diagnosis of Psychosis. Record review of Resident #42's Minimum Data Set with an Assessment Reference Date of 12/09/22 revealed in Section D that the resident had no mood issues, in Section E that the resident had no behaviors and in Section C a Brief Interview for Mental Status score of 4, which indicates that the resident has severe cognitive impairment.

Based on observation, interview, and record review, the facility failed to ensure Resident #3 was given choices concerning feeding schedules that are important to the resident and Responsible Party (RP), such as feeding times of his percutaneous gastrostomy tube (PEG) feedings for one (1) of two (2) residents reviewed with PEG feedings. Findings include: On 01/03/23 at 1400 an interview with Resident #3's RP revealed the family has not been pleased with the care resident is receiving. The RP stated the facility failed to administer PEG feedings in a timely manner. The RP explained she had waited for the 12 PM feeding for approximately 30 minutes before going to the nurses' station and requesting that the feeding be administered. Resident's RP stated Resident #3 was supposed to get bolus feedings at 0500, 0800, 1200, 1700, and 2000. PR stated she had tried to discuss this with the facility staff but they just looked at her. She stated she was afraid that Resident #3 would begin to lose weight if his feeding were not given on time. She stated she wished she could just take him home. Observation at this time revealed an open case of Isosource 1.5 cal 250 milliliter (ml) in Resident #3's room. An interview on 01/03/23 at 1505 with Licensed Practical Nurse (LPN) #1 revealed she worked the 700 hall medication cart and provided necessary nutritional needs including tube feedings to the residents on the 700 hall including Resident #3. LPN #1 stated she administers both continuous peg feedings and bolus peg feeding. LPN #1 stated she had a 1 hour window, 30 minutes before and 30 minutes after, in which to administer feedings and medications. On 01/03/23 at 1520 an observation with LPN #1 of the supply room for the nurses' station revealed a sufficient supply of continuous feeding bags and piston syringes. When examining the cartons of bolus feeding cases, the observation revealed 6 cases and 5 individual cartons of Isosource 1.5 cal feedings. Interview with LPN #1 revealed that depending on the nurse working, a nurse may pull a carton of feeding from the supply room or use a carton of feeding in a resident's room supply. She explained it was the preference of the nurse on duty. Observation on 01/04/23 at 0910 on 700 hall revealed staff performing tube feedings and med administration. Nurse administering meds was LPN #1. When asked if Resident #3 had received his 0800 medications and 0800 tube feeding, LPN #1 stated, No, I haven't gotten to him yet. LPN #1 confirmed resident was awaiting feeding, then stated resident does not get any meds at this time. LPN stated that residents who receive their meals by mouth (PO) receive their meals from 7:30-8:30 AM. LPN stated Resident #3 was in physical therapy, but did not receive his PEG meal prior to going. Observation of the 700 hall at this time also revealed the smell of breakfast foods and residents finishing their meals. Interview on 01/04/23 0920 with Resident #2 revealed she had no concerns and that she had eaten breakfast already. At 0934 on 01/04/23, observation revealed Resident #3 was returned by staff to his room and left alone in wheelchair. Resident #3 interviewed and responded appropriately. When asked if he had received therapy for swallowing issues, he said yes and they (therapy) did a good job. He stated he had to make sounds and yawns for the therapist. He stated he was hungry and thirsty and began talking about foods that he planned to eat when he was discharged home. Observation on 01/04/23 at 1000 revealed LPN #1 arrived in room to give meds and 0800 PEG feeding. This was 2 hours after order to give at 0800. Resident #3 received one carton of Isosource 1.5 and 200 cc of water via tube. LPN #1 explained she was just now giving Resident #1 he's 0800 PEG feeding due to him going to physical therapy before she could get to him. Record review of Resident #3's physician orders revealed an order for Isosource 1.5 cal bolus feeding- one carton (250 ml) per peg tube 5 X Day. Order start date 12/31/22. Record review of the resident's eMAR revealed times of administration were listed as 5 AM, 8 AM, 12 PM, 4 PM, 8 PM. Interview on 01/03/23 at 1455 with Dietary Manager (DM) revealed the facility nurses obtain orders for the tube feedings based off of physician's orders. The DM stated the Registered Dietician (RD) consults with the facility and visits the facility weekly. DM stated that RD calculates calories needed for each resident and would consult the physician for changes if needed.

Based on observation, interview, policy review, and record review, the facility failed to develop a baseline care plan that contained dietary orders feeding amount or times to administer Percutaneous Gastrostomy (PEG) feedings for one (1) of three (3) resident care plans reviewed, Resident #3. Findings Include: Review of the facilities policy on baseline care plans revealed a policy titled, Care Plan Process revised 08/17, that read The facility shall develop and implement a Baseline Care plan and Summary for each resident that includes instructions needed to provide effective and person-centered care . The baseline care plan shall: . include the minimum healthcare information necessary to properly care for a resident immediately upon their admission, which address resident-specific health and safety concerns including . Physician orders and Dietary orders. Record review of Baseline Care Plan for Resident #3 revealed under Nutritional Status/Diet, Goal: Maintain stable weight, NPO/Peg tube, Diet as ordered, Fluid Consistency, monitor meal %'s, Report problems to Charge Nurse, Malnutrition/Risk for malnutrition, Isosource 1.5 Bolus. Review revealed the care plan failed to address the amount of Isosource bolus or the times it should be administered. An interview with Resident #3's Representative (RP) on 01/03/23 at 1400 revealed the family has not been pleased with the care resident is receiving and the failure to administer PEG (Percutaneous Tube) feedings in a timely manner. The RP stated it was her understanding that Resident #3 was supposed to get bolus feedings at 0500, 0800, 1200, 1700, and 2000. Record review of Resident #3's orders revealed a physician order for Isosource 1.5 cal bolus feeding- one carton (250 ml) per peg tube 5 X Day. Order start date 12/31/22. Record review of the resident's eMAR revealed times of administration were listed as 5 AM, 8 AM, 12 PM, 4 PM, 8 PM.

Based on observation, interview, policy review, and record review, the facility failed to administer an extended release medication per professional standards as evidenced by crushing the extended release medication to administer per gastrostomy tube for one (1) of three (3) resident's reviewed, Resident #3. Findings include: Review of the facility policy titled, Crushing Medications, revised 10/17, revealed, 1. Some medications such as capsules or enteric-coated tablets are not to be crushed or chewed. Review of Mucinex Drug Facts under Directions revealed Do not crush, chew, or break tablet. On 01/04/23 at 100, Licensed Practical Nurse (LPN) #1 stated Resident #3 received a baby aspirin and a Mucinex. LPN #1 checked placement of PEG tube with no concerns noted. LPN pulled ASA (Aspirin) 81 milligram (mg) and crushed then pulled Mucinex ER 600 mg and crushed it. The medications were administered separately with 30 cubic centimeters (cc) flush between each med. The Resident then received 200 cc of water via tube. An interview on 01/04/23 at 1020 with LPN #1 revealed when questioned about crushing the extended release Mucinex, the LPN stated, He's NPO (nothing by mouth), so I had to crush it to get the medication down the tube. 01/04/23 at 1025 with Registered Nurse (RN) Charge Nurse revealed the facility received an order for Mucinex for Resident #3 on 01/02/23 for congestion. The RN Charge Nurse stated the facility did not have any liquid Mucinex for administering via PEG tube. Record review of Resident #3 revealed a physician order for Mucinex ER 600 milligram (mg) tablet one per peg twice a day X 7 days/congestion. The order start date was 01/02/23. Record review of the resident's eMAR revealed time of administration was listed as 8:00 AM. Interview at 01/04/23 at 11:00 AM revealed Resident #3's physician stated he did not foresee any consequences from the one time dose of Mucinex. He also stated that the facility had request an order for Tussin DM from his Nurse Practitioner within the past hour. Interview 01/04/23 at 12:00 PM with Director of Nurses (DON) revealed there was policies for administering medications and confirmed an extended-release medication should not have been crushed. Resident #3 was admitted to the facility on [DATE].

Based on record review, staff interview, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) for Hospice, for two (2) of 21 residents reviewed, Resident #30 and Resident #44. Findings include: Record review of the facility's Resident MDS Assessment policy, dated 9/19, revealed The Registered Nurse is responsible for verifying the completion of the assessment. The completed assessment guide the staff in identifying key information about the resident and serves as a a basis for identifying resident specific issues and objectives in order to develop a care plan. The assessment will describe the resident's physical and mental deficits, strengths and the requirements of assistance to meet their needs. The assessment will also identify risk factors associated with possible functional decline and describe the resident's objectives for maintaining or improving their functional abilities. Resident #44 Review of Resident #44's Significant Change MDS, with an Assessment Reference Date (ARD) of 6/11/19, revealed Hospice was not marked. Record review of the Quarterly MDS with an ARD of 9/6/19, revealed [MEDICAL TREATMENT] was not marked. On 10/29/19 at 4:10 PM, during an interview, Licensed Practical Nurse (LPN) #1/MDS Nurse confirmed Resident # 44 had an order to be admitted to Hospice on 6/5/19. The MDS Nurse stated the significant change MDS on 6/11/19, and the quarterly MDS on 9/6/19, did not have Hospice coded. LPN #1 stated Hospice should have been coded and they will have to do a modification. On 10/29/19 at 4:20 PM an interview with LPN #2 confirmed she completed the MDS with an Assessment Reference Date (ARD) of 6/11/19 and 9/6/19. LPN # 2 confirmed that she did not code Resident #44 was receiving treatment by Hospice. LPN #2 revealed she did the significant change MDS on 6/11/19, because Resident #44 was admitted to Hospice, but did not mark Hospice in section O. LPN #2 revealed she gets her information for the MDS from the resident's chart and reviewing the orders, and must have just missed that section. Review of the current physician's orders [REDACTED]. Resident #30 Review of Resident #30's Quarterly MDS, with an ARD of 9/5/19, revealed Hospice was not marked. On 10/30/19 at 1:05 PM, during an interview, Licensed Practical Nurse (LPN) #3/Minimum Data Set (MDS) Nurse confirmed she completed the MDS, with an ARD of 9/5/2019. LPN #3 confirmed she did not code the MDS to reflect Resident #30 was receiving treatment by Hospice. LPN #3 stated I just missed it. She stated Hospice should have been marked. Review of the current physician's orders [REDACTED].#30 to Hospice with a [DIAGNOSES REDACTED].

Based on record review and staff interview, the facility failed to identify, address and initiate adequate interventions to prevent dehydration for one (1) of nine (9) residents reviewed. Resident #1 was admitted to a local hospital with the [DIAGNOSES REDACTED]. Findings include: Resident #1 A review of Resident #1's care plan failed to ensure Resident # 1 had appropriate interventions in place to prevent dehydration. A care plan for the administration of IV fluids was initiated on 3/2/14, one day prior to Resident #1's transfer to a local hospital. There was no documented evidence of any interventions in the proceeding days of an alternate hydration plan. On 9/19/14/at 2:50 PM, the Director of Nursing confirmed there was not a care plan addressing fluid needs prior to 3/2/14. A review of Resident #1's record revealed the facility admitted the resident on 5/3/11 with [DIAGNOSES REDACTED]. There was no documented evidence that Resident #1's hydration status had been addressed after it was noted that the resident was sleeping more and the resident's intake had decreased.

Based on record review, policy review, staff interview, family interview and physician interview, the facility failed to address and maintain an adequate hydration status when Resident # 1 had a change in condition which resulted in a transfer to a local hospital for severe dehydration for one (1) of nine (9) residents reviewed. Findings include: A review of the facility's policy entitled "Hydration" read, "Objective: It is the objective of the facility to provide each resident with the amount of fluid intake to maintain proper hydration and health. For those residents where adequate fluid is difficult to maintain, alternate treatment such as gelatin, ice creams and popsicles will be offered. Residents at risk: Low weights; Severe cognitive or functional impairments; Dementia in which resident forgets to drink; or refusal of fluids." Under Nursing Measures the document states, "Residents with low body weight exhibiting signs/symptoms of illnesses (i.e., poor skin turgor, dehydration, decreased food/fluid intake, residents with UTIs, failure to thrive, etc.) will be placed on I&O at the discretion of the DON/ADON."Resident #1 Resident #1 Resident #1 was transferred to a local hospital on [DATE]. A review of the hospital's History and Physical stated, "transferred from nursing home because of change in mental status and decrease in responsiveness over the last 48 hours. This was initially attributed to sedative the patient had received a few days prior, but decreased responsiveness continued even after sedatives were discontinued." Under the Physical Examination portion of the H&P for skin stated, "There is marked loss of skin turgor and generalized dryness. Mucous membrane also appears dry." Further review of the History and Physical listed [DIAGNOSES REDACTED].[MEDICAL CONDITION] secondary to urinary tract infection. 2. Severe dehydration with water deficit of about 3 to 4 liters. 3. Acute kidney injury, likely prerenal. 4. [MEDICAL CONDITION]. 5. Protein-calorie malnutrition." A review of hospital obtained laboratory results dated [DATE] at 8:39 AM revealed a critical high sodium of 164, a high BUN of 122 and a high creatinine of 3.4. A review of facility's Progress/Admit Note, dated 2/12/14, stated the resident was having "worsening calling out "help me, help me" since son had requested [MEDICATION NAME] be D/C'd (discontinued)". The Nurse Practitioner, for the resident's attending physician, initiated an order for [REDACTED]. A review of a nurse's note, dated 2/12/14 at 1:31 PM, revealed an entry which read, "FNP (Family Nurse Practitioner) gave N.O. (new order) for [MEDICATION NAME] ([MEDICATION NAME]) 3.75 (mg) tab take one PO (by mouth) tid (three times a day) for anxiety, hold for increased sedation." A review of Resident #1's Medication Administration Record [REDACTED]. A review of the Meal Intake Roster for Resident #1 revealed during the month of January 2014 the resident was accepting 50 to 75% for most meals. After receiving the new medication of [MEDICATION NAME] on 2/12/14, Resident #1's intake of meals had declined to 25 to 50% at most meals. On or about 2/24/14 Resident #1's acceptance of meals had further declined and she was only taking in 0 to 25% of almost every meal offered. The meal roster further revealed the resident was often sleeping during the times snacks were offered. A nurse's note, dated 2/26/14 at 11:11 AM, read, "Nurses 7/3 and 3/11 report resident is sleeping too much when given 3.25 mg [MEDICATION NAME], which is to be given (tid). Family approached staff today and said they want her off medication immediately because all she has done is sleep. [MEDICATION NAME] dc'd per family request upon MD notification." A nurse's note, dated 2/28/14 at 3:43 PM, read, "Resident appears to have recent decline in LOC (level of consciousness) and Activity." A nurse's note on 3/2/14 at 2:52 PM, read, "Supervisor notified FNP about resident not eating and sleeping so much. Gave orders for c-xray (chest xray) to R/O pnuemonia, U/A with C&S, Normal Saline 100 cc IV, and [MEDICATION NAME] 1 gram IM X 2 days. RP in room with resident. U/A collected, tolerated well." The nurse's note, dated 3/3/14 at 7:02 AM, stated, "Resident to transfer to (local hospital) per (local ambulance company) by RP (Responsible Party) request. Resident unresponsive. Unable to wake up. RP in room with resident all night. Resident exited the facility per gurney. ADON notified. Nurse Practitioner aware of the situation." A review of the "RD Nutrition Assessment" dated 2/13/14 calculated Resident #1's fluid needs as 1500-1670 ml of fluid daily. There was no documentation of how much fluid resident #1 received. Interview on 9/18/14 at 3:15 PM with Licensed Practical Nurse (LPN) #1 revealed she had been off for several days prior to 3/1/14. LPN #1 stated when she returned to work that Resident #1 had a noticeable change in condition. She (Resident #1) was no longer routinely calling out "help me". The resident was no longer consuming meals as before. LPN #1 stated she did remember the resident's family member being present on 3/2/14 at the resident's bedside for the entire 3 to 11 shift. On 9/18/14 at 3:30 PM, an interview with LPN #2 revealed Resident #1 had a recent decline in condition. On 9/18/14 at 3:45 PM an interview with Registered Nurse #1 revealed during the month of March 2014, she was working weekends only. RN #1 stated when she came in on 3/1/14, she had no knowledge Resident #1 had a change in condition. RN #1 stated the next day on 3/2/14, an IV was started and one (1) liter of fluid was administered. On 9/19/14 at 12:10 PM an interview with Resident #1's family member confirmed the resident had a significant decline over the last "week to 10 days". The family member stated while visiting Resident #1 on 3/2/14, he was unable to wake her up. The family member stated she would not wake up to eat or drink. The family member confirmed the facility did call the doctor and get orders to start an IV. The family member stated after one bag of fluid, the resident still would not respond, so he stayed at her bedside all night. The family member stated the next morning of 3/3/14 he had to request the facility to send the resident to the hospital. On 9/19/14 at 2:30 PM and interview with CNA #1 revealed Resident #1 required assistance with meals and was not able to feed herself prior to the decline in condition. On 9/19/14 at 2:50 PM an interview with the Administrator and the Director of Nursing confirmed an Intake/Output (I&O) was not obtained for Resident #1. Both further confirmed that I&O's were not obtained unless the resident has feeding tubes, or on a fluid restriction or has other medical conditions where an I&O is needed. Record review revealed Resident #1's record revealed the facility admitted the resident on 5/3/11 with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) was coded with a BIMS score of 6 which indicated the resident had severe cognitive deficits. The MDS was coded with a weight of 99 pounds with no recent weight loss or gain. There was no documented evidence that Resident #1's hydration status had been addressed after it was noted that the resident was sleeping more and the resident's intake had decreased.

Based on observation, record review, staff interview and policy review, the facility failed to ensure that appropriate measures were in place to monitor the use of restraints for one (1) of eight (8) totaled sampled Residents reviewed (Resident #5), and three (3) of four (4) Unsampled Resident's reviewed (Unsampled Resident A, Unsampled Resident B, and Unsampled Resident C). The facility failed to have consistent monitoring in place for the use of restraints. Staff were allowed to chart that the restraints were checked and released at any time during the shift. There was also incomplete documentation regarding the checking and releasing of restraints. Based on additional information and a partially extended survey on 02/15-16/11, the facility failed to provide documentation that the least restrictive devices/measures failed to work prior to restraint usage for two (2) of eight (8) totaled sampled residents (Resident #7 and Resident #8). The facility had no documentation that there was an assessed need for a seat belt restraint or which type of restraint was appropriate to meet the needs prior to residents being placed in a restraint. Resident #5 had a soft waist restraint in use while seated in a wheelchair on 11/16/10. Resident #5 was found with the restraint around her neck and she was sitting on the floor in front of the wheelchair. Resident #5 had redness to her neck and back. On 11/17/10, a crotch restraint was ordered. On 12/31/10, Resident #5 was found hanging from her wheelchair with the crotch restraint in place. She had not made contact with the floor when she was found. No injury was identified. After the incident on 12/31/10, there were no new safety interventions implemented regarding the use of a restraint or device documented. Unsampled Resident A had an order on 12/29/10 for a soft waist restraint. There was no documentation that the restraint was checked every 30 minutes and released every two (2) hours as stated in the care plan. Unsampled Resident B had an order on 07/07/10 for a soft waist restraint. There was no documentation that the soft waist restraint was checked every 30 minutes and released every two (2) hours as stated on the care plan. Unsampled Resident C had an order on 11/01/10 for a soft waist restraint when up in wheelchair. On 11/22/10, the soft waist restraint was discontinued and a lap tray was ordered. There was no documentation that the lap tray was checked every 30 minutes and released every two (2) hours as ordered by the Physician and as stated on the care plan. Resident #7 had no documentation that the least restrictive devices/measures failed to work prior to restraint usage. The facility had no documentation that there was an assessed need for a seat belt restraint or which type of restraint was appropriate to meet his needs prior to being placed in a restraint on 2/4/11 . Resident #8 had no documentation that the least restrictive devices/measures failed to work prior to restraint usage. The facility had no documentation that there was an assessed need for a soft waist belt restraint, a seat belt restraint or which type of restraint was appropriate to meet her needs prior to being place in a restraint on 01/29/11 . The facility's failed to ensure that four (4) Residents with restraints were checked every 30 minutes and released every two (2) hours, and failed to ensure that Resident #5 was not found on two (2) occasions hanging from the wheelchair with a restraint in place. This put the residents at risk for serious injury, harm, impairment, or death and was determined to be an Immediate Jeopardy (IJ) at a Level K on 01/06/11 at 02:05 p.m. The Administrator and Director of Nursing (DON) were notified on 01/06/11 at 02:05 p.m. of the Substandard Quality of Care an Immediate Jeopardy (IJ). Based on Administrative review by Centers for Medicare and Medicaid Services (CMS) on 02/15/11, other additional information and a partially extended survey was conducted on 02/15-16/11. During the investigation the facility was found not to be in compliance with the Requirements for Participation in Medicare and Medicaid. It was determined that Substandard Quality of Care (SQC) and/or Immediate Jeopardy (IJ) (at a "K" level) was identified to exist on 01/06/11 at 02:05 p.m. The IJ is considered to be on going. The Administrator and the Director of Nursing were notified of the on going IJ on 02/16/11 at 7:30 p.m. The facility provided an Allegation of Compliance (AoC) on 01/07/11 at 11:00 a.m. and amended the AoC on 01/21/11. Based on CMS Administrative review on 02/15/11, the AoC was determined not acceptable. The IJ was not removed upon exit from the facility on 02/16/11 and is on going. Findings Include: Resident #5 Record review revealed that Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/08/10 revealed that the Brief Interview for Mental Status (BIMS) was not conducted due to the Resident being rarely/never understood. The Resident was coded as having both short term and long term memory problems. Resident #5 was coded as being moderately impaired in cognitive skills for daily decision making with decisions being poor and cues/supervision required. In Section D0500 of the MDS, Resident #5 was identified as "Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that she has been moving around a lot more than usual." Review of Section P of the 14 day MDS for Resident #5 revealed that a trunk restraint was used daily in chair or out of bed. Review of the Care Plan dated 10/26/2010 for Resident #5 revealed the following Approaches: "Monitor restraints every 30 minutes and release every 2 hours" and "SOFT WAIST CROTCH RESTRAINT WHILE RESIDENT UP IN WHEELCHAIR." (Crotch restraint that is used by the facility is a "Cushion Slider Belt". Review of the Nurses Notes for Resident #5 revealed: On 11/16/2010 at 9:58 p.m. "Resident was found by Housekeeping in room on the floor. She was trying to get out of her wheelchair but she could not because she had on a lap belt, but she wiggled herself enough and slid through the belt and it caught her by her neck and she was sitting on the floor with the lap belt around her neck. VS (vital signs) were stable no c/o (complaints of) pain. Her neck is a little red from where the belt caught her around her neck and on the back of her neck where it was up against the wheelchair seat. MD (Medical Doctor) and family notified." On 11/17/2010 at 2:43 p.m. "Resident sliding down in wheelchair with lap tray on, called (Name of Physician) who ordered soft waist restraint. Resident very confused and attempts to stand without assistance. Will continue to monitor. Resident requires therapy for muscle weakness and lack of coordination." Review of Incident Reports for Resident #5 revealed: On 11/16/10 at 07:20 p.m. "Narrative of Incident and Description of Injuries" revealed: "Resident tried to free herself from the restraint by sliding under the lapbelt and it caught her around her neck once she got on the floor. no (No) injury, chest and neck a little reddened where the belt was rubbing against her neck." Review of the "RESIDENT INCIDENT FOLLOWUP" dated 11/18/10 revealed: "Resident tried to free herself from the restraint by sliding under the lapbelt and it caught her around her neck once she got on the floor." "No apparent injury, resident is noncompliant with safety interventions. Soft waist restraint d/c'd (discontinued) with crotch restraint to be implemented. Therapy to fall screen, continue to encourage compliance with safety interventions." Review of the "Restraint Necessity/Positioning Device Worksheet" dated 11/18/10 revealed: "Sitting Balance: falls or leans." "Ambulation /Transfers: Leans Forward." "Specific medical symptom that requires a device: Poor balance with gait, sitting, & (and) transfer, lack of coordination, Leaning." Review of the "Restraint Necessity/Positioning Device Worksheet" dated 11/24/10 revealed: "Sitting Balance: Falls or leans." "Leans forward." "Poor balance with gait, sitting & transfer." "Lack of Coordination" and "Muscle weakness" "Restraints in chair/out of bed: trunk restraint used daily." "If other restraint used in chair describe: Laptray to wheelchair changed to soft waist restraint on 11/7/10. Soft waist restraint changed to soft crotch restraint on 11/17/10." "Comments for Restraint /Positioning Device Usage: Resident has unsteady gait and balance. She has muscle weakness and lack of coordination. She has a history of falls and has made attempts to transfer without assist. Laptray applied to wheelchair on 11-3-10. Restraint changed to soft waist crotch restraint. Restraint (Restraint) changed on 11/17/10 to soft crotch restraint." Review of the PHYSICIAN ORDERS for Resident #5 revealed: On 11/3/10 "Lap Tray while resident up in wheelchair." On 11/7/10 "Soft waist restraint while up in w/c (wheelchair) r/t (related to) sliding down in w/c and confusion." On 11/17/2010 at 8:52 p.m. "Soft crotch restraint while up in wheel chair d/t (due to) history of falls." On 11/24/10 "Apply soft waist crotch restraint to w/c at all times while up in chair; check circulation q (every) 30 min (minutes), release q 2 hrs (hours) & PRN (as needed) toileting & exercises." Review of a typed document provided by the Director of Nursing revealed: "(Name of Resident #5) was admitted on [DATE] with no restraint ordered. On 11/3/2010 order received for lap tray to wheelchair while up in wheelchair per (Name of Physician). Then on 11/4/2010 order was received for low bed with matts to both sides of bed per (Dr); later that day order was received from (Name of Physician) to apply bed alarm. On 11/7/2010 order was received for soft waist restraint per (Name of Physician) related to sliding down in wheelchair due to confusion. On 11/12/2010 order was received from (Name of Physician) to D/C lap tray and do not place resident in recliner. Then on 11/17/2010 order was received from (Name of Physician) to apply soft crotch restraint while up in chair due to hx (history) of falls. On 11/20/2010 Resident was transferred to hospital related to [MEDICAL CONDITION] activity. She returned on 11/24/2010 and orders for crotch restraint, bed alarms, and low bed with matts to both sides were continued upon readmit per (Name of Physician)." Review of the Nurse's Note's for Resident #5 dated 12/31/2010 revealed: "5:17 p.m. CNA CALLED NURSE TO ROOM AT 4:20 p.m., SHE FOUND RESIDENT HANGING FROM HER WHEELCHAIR BY HER RESTRAINT. SHE HAD NOT MADE CONTACT WITH THE FLOOR. SHE HAD NO APPARENT INJURIES; HER BACK WAS A LITTLE RED FROM BEING PRESSED UP AGAINST THE WHEELCHAIR. MD AND RP NOTIFIED OF INCIDENT. SHE HAD NO C/O PAIN, VITALS WERE STABLE. WILL CONTINUE TO MONITOR RESIDENT FOR ANY CHANGES." Review of the "RESIDENT INCIDENT FOLLOW-UP" dated 01/04/11, for incident on 12/31/10 revealed: "Resident was found hanging by her crotch from her wheelchair restraint, resident attempting to get up from w/c." On "1/4/2011 NO APPARENT INJURY NOTED, THERAPY TO SCREEN FALL, ENSURE RESTRAINT IS PROPERLY APPLIED WITH SNUG FIT, ENCOURAGE RESIDENT NOT TO ATTEMPT TO RELEASE RESTRAINT OR TRANSFER WITHOUT ASSISTANCE." Review of the "Restraint Release Report Roster " for Resident #5 revealed that the restraint was not checked for "circulation q (every) 30 min (minutes), released q 2 hrs (hours) & PRN (as needed) for toileting & exercises." The documentation revealed that on 12/14/10 the restraint was checked at 12:03 a.m.; 12:04 p.m.; 12:06 p.m.; 02:59 p.m.; and 10:29 p.m. The documentation for 12/31/10 revealed that the restraint was checked at 12:39 a.m. and 04:55 p.m. Interview on 01/06/11 at 12:10 p.m. with the Director of Nursing (DON) revealed that the staff should chart throughout the shift as task are performed. She stated that the restraint documentation should be charted at the end of the shift. There was no documented evidence that therapy staff had recommended the usage of the lap belt or the crotch restraint. There was not documentation of any other measures that were implemented to prevent Resident #5 from being found hanging from a restraint again after the first incident with the waist restraint. Interview with Licensed Practical Nurse (LPN) #2 on 01/05/10 at 03:15 p.m. revealed that since 12/31/10, they had not changed anything for Resident #5. LPN #2 stated that they just try to keep a closer eye on Resident #5. LPN #2 stated that they try to keep her at the desk to monitor, and take her to the dining room for dinner, then to her room. LPN #2 stated that the lap tray worked for a while then they changed to the soft waist restraint. LPN #2 stated that when Resident #5 was found that it was "not to the point of cutting off her wind." LPN #2 stated that Resident #5's arm was still above the belt. Interview with the DON on 01/06/11 at 09:30 a.m. revealed that Resident #5 slid under the soft waist restraint. The DON stated: "She does not have much control; does not know; wiggles a lot; has anxiety; slides; and does not have strong trunk control." The DON stated that the Medicare Nurses does the restraint assessments. Observation on 01/07/11 at 7:45 a.m. revealed that Resident #5 was seated in a wheelchair with a crotch restraint in place. Unsampled Resident A Record review revealed that Unsampled Resident A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 12/06/10 revealed that Unsampled Resident A had a BIMS score of "15" which means that Unsampled Resident A was cognitively intact. Section P of the MDS indicated that a trunk restraint was used daily. A review of the "Restraint Necessity/Positioning Device Worksheet" dated 11/30/10 revealed that Unsampled Resident A "falls, leans, and slumps." A review of the Physician's Order dated 12/29/10 for Unsampled Resident A revealed: "Soft waist restraint when up in w/c for muscle weakness and lack of coordination to prevent falls, release every two (2) hours for toileting (toileting) and ROM (Range of Motion). Monitor q 30 mins for safety q shift." Review of the Care Plan with a "Problem Onset Date" of 12/29/2010 for Unsampled Resident A revealed: "Check on resident at least Q 30 minutes and release Q 2 hours, exercise. Document interventions." Review of the documentation for Unsampled Resident A revealed that the restraint was not checked at least every 30 minutes and released every two (2) hours with exercise as the care plan directed. The documentation revealed that on 12/30/10 the restraint was checked at 04:17 p.m.; 06:33 a.m.; 10:52 a.m.; and 04:09 p.m. On 12/31/10, the restraint documentation was completed at 06:41 a.m.; 10:45 a.m.; and at 04:58 p.m. The documentation did not have evidence that the restraint was checked as the care plan directed. UNSAMPLED RESIDENT B Record review revealed that Unsampled Resident B was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 12/10/10 revealed that Unsampled Resident B was severely impaired in cognitive skills for daily decision making. The MDS indicated that Unsampled Resident B used a trunk restraint daily. Review of the Physician Orders revealed an order for [REDACTED]. Check q 30 min. and release q 2 hrs. for ROM and toileting." The Care Plan had an intervention stating: "Check restraint q 30 minutes to ensure proper fit and resident's comfort. Release q 2 hrs and prn (as needed) for toileting and repositioning with skin audits." Review of the "Positioning Device/Restraint Necessity Worksheet" dated 12/10/10 revealed: "The resident falls or leans, slides down and was able to maintain sitting balance and leans forward. There was no documented evidence provided that the restraint for Unsampled Resident B was checked according to physician orders or the care plan except on 11/13/10 at 05:00 a.m. Observation of Unsampled Resident B on 01/06/11 at 11:00 a.m. revealed the resident was seated in a wheelchair with a soft waist restraint in place. UNSAMPLED RESIDENT C Record review revealed that Unsampled Resident C was admitted to the facility on 11/01/10 with [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 11/14/10 revealed that Unsampled Resident C was moderately impaired in cognitive skills for daily decision making. Observation on 01/06/11 at 04:30 p.m. revealed that Unsampled Resident C was seated in a wheel chair with a lap tray in place. Review of the Physician Orders for Unsampled Resident C revealed an order dated 11/01/10 stating: "Soft waist restraint while up in w/c r/t (related to) muscle weakness and lack of coordination. Check q 30 min. and release q 2 hrs for toileting and ROM exercises." Another order dated 11/22/10 revealed: " Lap tray while up in wheelchair r/t muscle weakness and lack of coordination. Check q 30 min. and release q 2 hrs for toileting and ROM exercises." Review of the "Restraint Necessity/Positioning Device Worksheet" dated 11/01/10 revealed that a trunk restraint was used daily. Other restraint used documented on 11/01/10 as "Soft waist restraint while up in wheelchair;" and "restraint changed to Laptray on 11/22/10." A measure documented as being attempted prior to restraint usage was marked as "therapy". Review of the "Restraint Release Report Roster" dated 11/1/10 thru 11/30/10 and 12/01/10 did not reveal that Unsampled Resident C's restraint was monitored every 30 minutes and released every two (2) hours for toileting and ROM exercises as ordered by the Physician and as indicated on the care plan. Interview with CNA #5 on 01/06/11 at 11:05 a.m. revealed: "We chart one (1) time for the entire shift. We chart before lunch, charting for the entire shift at that time." CNA #5 stated that they would only document one (1) time on each shift, even if the shift had not been completed. CNA #5 stated that they were instructed to document to reflect that the restraints were checked as ordered but, only document one (1) time during the shift, and that it did not matter what time they documented. Interview on 01/20/11 at 4:00 p.m. with the Administrator and the Director of Nursing (DON) revealed that the crotch restraint is one (1) restraint. It has a tie around the waist and crotch area. They stated that they did not have any pommel cushions in the facility. Review of the facility policy "Abuse/Neglect Reporting" with the latest revision date of 12/10 revealed that Neglect is defined as: "A failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.". "(3) In the event of any evidence involving mistreatment, exploitation, neglect or abuse, including injuries of unknown source, an occurrence will be reported immediately to the Administrator of the facility, who will immediately notify the Regional and the appropriate state officials per state guidelines. (4) The facility will thoroughly investigate all alleged violations under the direct supervision of the Administrator. The facility will take all necessary steps to prevent further potential abuse while the investigation is in progress. Any employee of the facility suspected of abuse or neglect will be suspended pending investigation until such time as the facility investigation is complete. Review of the "ADL's - 24 Hour Nursing Care Sheets" with an original date of 11/00 revealed: "Restraint Type" - When a restraint is placed on a resident, the certified nursing assistant is to check to see that the restraint is not tied too tightly. The CNA is to check the restraint every 30 minutes, and release the resident every two hours...". "The CNA assigned is to chart their initials in the spaces provided. This is stating the restraint has been observed every 30 minutes and released every two hours". "ADL sheets cannot be corrected (blanks filled in ) after leaving your shift and filled in before leaving the shift only if CNA can factually remember what care was done." Review of the "Charting" policy with a revision date of 08/10 revealed: "(8) ADL charting must be done by CNAs on a daily, per shift basis. ADLs must be individualized to the specific resident's needs and plan of care." Review of the "Restraints Policy" with the latest revision date of 07/10 revealed: " Before a restraint may be used, the following steps must be followed unless it is an emergency situation: (2) Remove, if possible, the causes of these symptom. This may include taking care of special needs, increased rehabilitation and restorative nursing, modifying the environment and increasing supervision. (5) The resident and the family of each resident are informed of the plan of care for restraint use at the time a decision to use a restraint is made. Consent forms must be signed at this time informing residents and family of risks and benefits of restraint use. Review of the manufacturer's instructions for the "Cushion Slider Belt" revealed: "Indications - The Skil-Care Cushion Slider Belt is recommended for use with a patient who: slides down in the wheelchair; Requires a safety belt while seated in the wheelchair; and Requires a reminder not to leave the wheelchair without assistance." "Contraindications for Use - Do not use this device for a patient who: Requires posture support; has a history of easily removing belt-style, vest style, and poncho-style restraints; and is in a geri-chair, lounge chair, or bed. This device is intended for wheelchair use only." Instructions for the correct way of applying the restraint was also included. Review of the manufacturer's instructions for the soft waist belt restraint (Adjusta-Loop Cushion Belt) revealed that it is indicated for use with a patient who requires a safety belt while seated in the wheelchair; Requires a reminder not to leave the wheelchair without assistance." "Contraindications for Use - Do not use this device for a patient who: Slides down in the wheelchair; requires posture support; has a history of easily removing belt - style; vest-style; and poncho-style restraints; Is in a geri-chair or lounge chair. This device is intended for wheelchair use only." Instructions are also included for the correct way to apply the restraint. The facility failed to provide documentation that the least restrictive devices/measures failed to work prior to restraint usage for two (2) of eight (8) sampled residents (Residents #7 and #8). The facility had no documentation that there was an assessed need for a seat belt restraint or which type of restraint was appropriate to meet the needs prior to residents being placed in a restraint. Resident #7 Resident #7 was admitted to the facility and had a [DIAGNOSES REDACTED]. Observation on 2/16/11 at 8:50 a.m. revealed Resident #7 sitting in a wheel chair in front of Nurse Station #A. He was alert and confused to time and place. Resident #7 had a seat belt restraint in place and was not able to unbuckle the seatbelt restraint without assistance. Review of Resident #7's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/10 revealed a cognitive skills for daily decision making severely impaired with short and long term memory problems. No physical restraints were in use. Review of "OT Screen" dated 2/2/11 revealed "Pt (patient) D/C'd (discontinued) from skill OT services & is without significant change noted in functional status at this time. Pt's agitation and confusion cont (continue) to impede safety. Pt may benefit from increased supervision due to impulsivity." Review of "Resident Incident Report" dated 2/2/11 at 9:00 a.m. revealed "Narrative of incident: Resident was found on floor lying on left side. He stated he was not hurting any where. When asked what he was doing when he fell . He stated he had to get to the pentagon fast and got out of bed. Left knee gave out and he fell . There was some redness noted on left hip and left side of face. No bruising noted, skin intact." Review of Resident #7's "Physician's Telephone Order" dated: 2/2/11 3:06 p.m. "Low bed with mat". 2/2/11 3:23 p.m. "Promat alarm to bed at all times. Check proper placement and functioning. Report malfunction to supervisor or charge nurse." 2/4/11 7-3 (p.m.) "seat belt to w/c (wheel chair) when resident OOB (out of bed) r/t (related to) muscle weakness and lack of coordination." Review of Resident #7's "Safety Device/Physical Restraint Consent" dated 2/4/11 revealed a signed consent for use of a "seat belt to w/c". Review of the "Departmental Notes" revealed: 2/3/11 at 4:22 p.m. "Spoke with RP (responsible party) earlier regarding residents falls and agitation during the night asked RP if we could move resident closer to the nursing station, RP stated "No, I do not want him moved. Upon assessment no injury was noted, xrays of left hip and humerus were negative. Resident is on low bed with mat to floor. Alarm to bed. Spoke with staff about making more frequent rounds when resident in his room. Continue to observe." 2/4/11 at 4:52 a.m. "No c/o (complaint) of pain. No distress noted. (No additional Departmental Notes dated 2/4/11)." Review of the "Restraint Necessity/Positioning Device Worksheet" revealed: 12/9/10 "No restraint used at this time". 2/15/11 "Date device first applied: 2/11/11. Measures attempted prior to restraint usage- Therapy, Frequent Monitoring. Comments for Restraint/Positioning Device Usage: Seat belt while up in w/c r/t lack of coordination and muscle weakness". Review of the "Restraint Release Report Roster" revealed documentation that Resident #7 had a restraint in place from 2/4/11 through 2/16/11 . Interview on 2/16/11 at 6:00 p.m. with Licensed Practical Nurse (LPN) #6 revealed that "I did the restraint worksheet on 2/15/11. The device/seat belt was applied on 2/11/11 for his safety. I've been doing these assessments since 12/10. The worksheet/assessment should be done prior to applying the safety device(restraint)." At this time the Director of Nursing (DON) stated "We realized that it (worksheet/assessment) wasn't done through one of our audits of the restraints." Interview with the Director of Nursing (DON) on 2/16/11 at 5:40 p.m. confirmed that a restraint assessment/worksheet which assessed the need for a restraint and the appropriate type of restraint to meet his needs had not been done prior to Resident #7 being placed in a seat belt restraint on 2/4/11 The facility provided no documentation that the least restrictive devices/measures failed to work prior to restraint usage. The facility had no documentation that there was an assessed need for a seat belt restraint or which type of restraint was appropriate to meet his needs prior to being place in a restraint on 2/4/11 . Resident #8 Resident #8 was admitted to the facility and had a [DIAGNOSES REDACTED]. Observation of Resident #8 was not conducted. Resident #8 was discharged from the facility to a local hospital on [DATE]. Review of Resident #8's five (5) day MDS with an ARD of 1/31/11 revealed a cognitive skills for daily decision making moderately impaired with short and long term memory problems. Review of the "Departmental Notes" revealed: 1/27/11 at 9:03 p.m."Resident found sitting up on floor beside bed on R (right) side of bed between bed & BSC (bed side commode). Resident moaning. Upon questioning per nurse, resident reports soreness-type pain of femur. Resident does c/o (complain of) pain of LLQ (left lower quadrant). N.O. (new order) received for xray of L. (left) hip & pelvis stat." 1/28/11 at 4:34 p.m. "F/u (follow up) with resident s/p (status [REDACTED]. Resident could not recall exactly where she was going except to sit in her wheel chair. Resident denies any pain or discomfort related to fall. No injury was noted by writer. Order was received to d/c (discontinue) full length side rails and a new order for a low bed with mat to floor/alarm to bed received. Therapy will screen, reoriented resident to use of call light and encouraged her to use it if she needs assistance. Resident did verbalize she would call for assistance if needed." 1/29/11 on 9:32 a.m. "At 0745 while making rounds, found resident in low bed with blue matt beside bed. Bed alarm in place and functioning. Eyes opens. Able to state name. Disoriented to time and place. Reoriented. Mobile via w/c propelled by staff. Taken to dining room for breakfast. New order for soft waist restraint while up in w/c. RP called and discussed new order. Agreed to restraint." Review of Resident #8's medical record revealed "Physician's Telephone Order" dated "1/29/11 9:11 a.m. Soft waist belt while up in w/c (wheel chair) r/t (related to) muscle wakn (sic) Lack of coordination. Check Q (every) 30 minutes and re (sic) 2 (two) hrs (hours) PRN (as needed) for toileting/exercising/ROM (range of motion)". "1/31/11 3:44 p.m. Seatbelt when up in wheel chair related to muscle weakness and lack of coordination." Review of the "Resident Incident Report" dated 1/27/11 at 7:40 p.m. revealed "Narrative of incident- phone call received from another resident's wife stating her husband had called her and said that he thought he heard someone fall & call out for help. Resident found in floor in her room (across the hall from calling resident). Resident c/o (complaints of) LLQ (left lower quadrant) pain upon palpation and soreness- type pain of L (left) femur. Xray of left hip/pelvis ordered." Review of the "Portable Xray" report revealed: 1/27/11 "Exam: Lt (left) hip with pelvis. Impression: No fractures or dislocations." 1/31/11 "Exam: Lt. hip with pelvis. Impression: comparison: 1/27/11. There is superior dislocation of the entire hip prosthesis to include the acetabular portion." Review of "Restraint Necessity/Positioning Device Worksheet" revealed: "1/27/11 No restraint in use at this time". "1/31/11- If other restraint used in chair describe: Seatbelt while up in wheel chair related to muscle weakness and lack of coordination. Date device first applied: 1/31/11." Review of the "Safety Device/Physical Restraint Consent" dated 1/31/11 revealed a consent for a "seat belt". Review of the "EMAR" (electronic medication administration record) revealed that a "soft waist belt while up in w/c r/t muscle wakness (sic) and lack of coordination" with a start date of 1/29/11 was documented as started "1/29/11 3:00 p.m." Review of the "OT Screen" dated 2/1/11 revealed "Pt fell from bed. Pt now in low bed with mat. Pt also has self release soft belt on while in w/c to prevent fall." Interview on 2/16/11 at 1:00 p.m. with Resident #8's Responsible Party revealed: "They said they put the soft waist restraint on to keep her from falling. She did fall about two (2) days before that, out of bed. They did an xray and it was ok then two (2) days later she went to the hospital for xray and that xray said it was a dislocated hip. There was only one report of her falling out of bed before the first set of xrays. She ended up having surgery. I had asked them to check in there on her every hour. She could tell you if she needed to go to the bathroom but she had Alzheimer's and couldn't remember how to push the call button." Interview on 2/16/11 at 1:15 p.m. with the DON revealed "I documented on her (Resident #8) on 1/28/11 at 4:34 p.m. I did a post fall status and discontinued the full length side rails. I got a doctor's order for the low bed with

CI MS #8916 and CI MS #8917 Based on observation, record review, staff interview and policy review, the facility failed to ensure: (1) That appropriate measures were in place to monitor the use of restraints for one (1) of eight (8) totaled sampled Resident's reviewed (Resident #5), and three (3) of four (4) Unsampled Residents reviewed (Unsampled Resident A, Unsampled Resident B, and Unsampled Resident C); (2) That staff charted that restraints were checked every 30 minutes and released every two (2) hours as ordered. Staff were allowed to chart that the residents were checked and released at any time during the shift.; (3) That chair alarms were in place as ordered by the Physician (Resident #1); (4) That Resident #1 was eating her meals in the dining room for safety measures as ordered by the Physician; and (5) That the correct number of staff were utilized when transferring Residents (Resident #2) to prevent an avoidable accident. Resident #1 had a history of [REDACTED]. It was determined that the chair alarm was not in place as ordered by the Physician. Resident #1 was also eating her dinner meal in her room and not in the dining room as ordered. Resident #1 was transferred to the hospital and diagnosed with [REDACTED]. Resident #1 had a decline in her health status after the fall which resulted in dysphagia and elevated blood pressure. Resident #1 remained in the hospital until [DATE] and then was transferred to an inpatient hospice unit. Resident #1 expired on [DATE] with the cause of death listed on the "Certificate of Death" as "Bilateral Subdural Hematoma due to or as a consequence of a fall from the wheelchair." Resident #2 was identified to require the use of a lift and three (3) person assistance with transfers. Resident #2 required two (2) person assistance with Activities of Daily Living (ADL's). Resident #2 had a fall on [DATE] and sustained a fracture to the left radius/humerus. On [DATE], Resident #2 had a fall from the bed, when the Nursing Assistant was attempting to transfer her without assistance. Resident #2 sustained a reddened area to the right temporal area of the forehead and a bruise to the right thumb. Resident #5 had a history of [REDACTED]. On [DATE] a soft crotch restraint was ordered. On [DATE], Resident #5 was found hanging out of the wheelchair with the crotch restraint in place. There was incomplete documentation of monitoring Resident #5 during the use of the restraints by checking every 30 minutes and releasing every 2 hours. There was no documentation that supervision was increased or other methods to ensure that Resident #5 did not sustain additional falls or injuries from the use of the restraint. Unsampled Resident A, Unsampled Resident B, and Unsampled Resident C, had soft waist restraints in use. There was incomplete documentation that the soft waist restraints were checked every 30 minutes and released every two (2) hours as ordered. There were 174 falls identified by the facility occurring in a six (6) month time frame, from [DATE] through [DATE]. There were 28 Residents identified using restraints in the facility on the "Resident Census and Condition" completed on [DATE]. The facility's failure to ensure that chair alarms were in place as ordered by the Physician; failure to ensure that Resident #1 was eating her meals in the dining room for safety measures as ordered by the Physician; failure to ensure consistent monitoring was in place for the checking and releasing of restraints; failure to ensure that the documentation was correct for the checking and monitoring of the restraints due to staff being allowed to document anytime during the shift for the entire shift; and failure to ensure that the correct number of staff were utilized when transferring Residents put 28 Resident's with restraints; Resident's with bed chair alarms; and resident's requiring the use of three (3) or more staff for transfers using a lift at risk for serious injury, harm, impairment, or death was deemed as an Immediate Jeopardy. Based on Administrative review by Centers for Medicare and Medicaid Services (CMS) on [DATE], other additional information and a partially extended survey was conducted on ,[DATE]-,[DATE]. During the investigation the facility was found not to be in compliance with the Requirements for Participation in Medicare and Medicaid. It was determined that Substandard Quality of Care (SQC) and/or Immediate Jeopardy (IJ) (at a "K" level) was identified to exist on [DATE] at 02:05 p.m. The IJ is considered to be on going. The Administrator and the Director of Nursing were notified of the on going IJ on [DATE] at 7:30 p.m. The facility provided an Allegation of Compliance (AoC) on [DATE] at 11:00 a.m. and amended the AoC on [DATE]. Based on CMS Administrative review on [DATE], the AoC was determined not acceptable. The IJ was not removed upon exit from the facility on [DATE] and is on going. Findings Include: Cross refer findings to F-221 for the facility's failure to ensure that Resident's using restraints were checked every 30 minutes and released every two (2) hours; and failure to ensure that chair alarms were in place. Cross refer findings to F-281 for the facility's failure to ensure that professional standards of practice were followed regarding implementing Physician orders [REDACTED]. Cross refer findings to F-323 for the facility's failure to ensure physician's orders [REDACTED].

CI MS #8916 and CI MS #8917 Based on record review, staff interview and policy review, the facility failed to ensure that professional standards of quality were implemented regarding following physician's orders [REDACTED].#1, Resident #2, and Resident #5), and three (3) of four (4) Unsampled Residents (Unsampled Resident A, Unsampled Resident B, and Unsampled Resident C). The facility failed to ensure: (1) Residents had chair alarms in place as ordered by the Physician (Resident #1); (2) That Resident #1 was eating her meals in the dining room for safety measures as ordered by the Physician; (3) Consistent monitoring was in place for the checking and releasing of restraints as ordered by the Physician and/or that was on the care plan; (4) That the documentation was correct for the checking and monitoring of the restraints due to staff being allowed to document anytime during the shift for the entire shift; (Resident #5, Unsampled A, Unsampled Resident B, and Unsampled Resident C); (5) That the correct number of staff were utilized when transferring Residents (Resident #2) as stated on the care plan to prevent an avoidable accident; and (6) That physician's orders [REDACTED]. Resident #1 sustained a fall on [DATE] at 8:10 p.m. with a closed head injury. CNA #4 was making rounds and found patient on bathroom floor. She reported incident to LPN #2 who reported to supervisor. Orders received for Neuro checks and patient monitoring. Documentation revealed a knot on back of head on right side which was reddish blue in color, 1 ? " (inch) long, 1 inch wide. There was no documented evidence provided that confirmed that neuro check were performed as ordered for Resident #1 after the fall on [DATE]. Resident #1 sustained a fall on [DATE] which resulted in hospitalization . It was determined that the chair alarm was not in place as ordered by the Physician. Resident #1 was also eating her dinner meal in her room and not in the dining room as ordered. Resident #1 was transferred to the hospital and diagnosed with [REDACTED]. Resident #1 had a decline in her health status after the fall which resulted in dysphagia and elevated blood pressure. Resident #1 remained in the hospital until [DATE] and then was transferred to an inpatient hospice unit. Resident #1 expired on [DATE] with the cause of death listed on the "Certificate of Death" as "Bilateral Subdural Hematoma due to or as a consequence of a fall from the wheelchair" due to a fall from the wheelchair. Resident #2 had a history of [REDACTED]. On [DATE], a Nursing Assistant was attempting to transfer Resident #2 without assistance. Resident #2 fell and sustained a reddened area to the right temporal area of the forehead and a bruise to the right thumb. Resident #5 had a soft waist restraint in use while seated in a wheelchair on [DATE]. Resident #5 was found with the restraint around her neck and she was sitting on the floor in front of the wheelchair. Resident #5 had redness to her neck and back. On [DATE], a crotch restraint was ordered. On [DATE], Resident #5 was found hanging from her wheelchair with the crotch restraint in place. She had not made contact with the floor when she was found. No injury was identified. After the incident on [DATE], there were no new safety interventions implemented regarding the use of a restraint or device documented. Unsampled Resident A had an order on [DATE] for a soft waist restraint. There was no documentation that the restraint was checked every 30 minutes and released every two (2) hours as stated in the care plan. Unsampled Resident B had an order on for a soft waist restraint. There was no documentation that the soft waist restraint was checked every 30 minutes and released every two (2) hours as stated on the care plan. Unsampled Resident C had an order on [DATE] for a soft waist restraint when up in wheelchair. On [DATE], the soft waist restraint was discontinued and a lap tray was ordered. There was no documentation that the lap tray was checked every 30 minutes and released every two (2) hours as ordered by the Physician and as stated on the care plan. The facility's failure to ensure that professional standards of quality were implemented regarding the application of chair alarms, monitoring of restraints, and using the correct number of staff for transfers put all 18 Resident's identified using bed/chair alarms; 28 resident's using restraints and all Resident's requiring transfers with three (3) persons at risk for serious injury, harm, impairment, or death and was determined to be an Immediate Jeopardy. Based on Administrative review by Centers for Medicare and Medicaid Services (CMS) on [DATE], other additional information and a partially extended survey was conducted on ,[DATE]-,[DATE]. During the investigation the facility was found not to be in compliance with the Requirements for Participation in Medicare and Medicaid. It was determined that Substandard Quality of Care (SQC) and/or Immediate Jeopardy (IJ) (at a "K" level) was identified to exist on [DATE] at 02:05 p.m. The IJ is considered to be on going. The Administrator and the Director of Nursing were notified of the on going IJ on [DATE] at 7:30 p.m. The facility provided an Allegation of Compliance (AoC) on [DATE] at 11:00 a.m. and amended the AoC on [DATE]. Based on CMS Administrative review on [DATE], the AoC was determined not acceptable. The IJ was not removed upon exit from the facility on [DATE] and is on going. Findings Include: Cross refer findings to F-221 for the facility's failure to ensure that restraints were monitored as ordered and/or as care planned. Cross refer findings to F-323 for the facility's failure to ensure that physician's orders [REDACTED].

Based on the complaint survey results dated [DATE], the facility failed to ensure that professional standards of quality were implemented regarding following physician's orders [REDACTED].#1, Resident #2, and Resident #5), and three (3) of four (4) Unsampled Residents (Unsampled Resident A, Unsampled Resident B, and Unsampled Resident C). The facility failed to ensure: (1) Residents had chair alarms in place as ordered by the Physician (Resident #1); (2) That Resident #1 was eating her meals in the dining room for safety measures as ordered by the Physician; (3) Consistent monitoring was in place for the checking and releasing of restraints as ordered by the Physician and/or that was on the care plan; (4) That the documentation was correct for the checking and monitoring of the restraints due to staff being allowed to document anytime during the shift for the entire shift; (Resident #5, Unsampled A, Unsampled Resident B, and Unsampled Resident C); (5) That the correct number of staff were utilized when transferring Residents (Resident #2) as stated on the care plan to prevent an avoidable accident; and (6) That physician's orders [REDACTED]. Resident #1 sustained a fall on [DATE] at 8:10 p.m. with a closed head injury. CNA #4 was making rounds and found patient on bathroom floor. She reported incident to LPN #2 who reported to supervisor. Orders received for Neuro checks and patient monitoring. Documentation revealed a knot on back of head on right side which was reddish blue in color, 1 ? " (inch) long, 1 inch wide. There was no documented evidence provided that confirmed that neuro check were performed as ordered for Resident #1 after the fall on [DATE]. Resident #1 sustained a fall on [DATE] which resulted in hospitalization . It was determined that the chair alarm was not in place as ordered by the Physician. Resident #1 was also eating her dinner meal in her room and not in the dining room as ordered. Resident #1 was transferred to the hospital and diagnosed with [REDACTED]. Resident #1 had a decline in her health status after the fall which resulted in dysphagia and elevated blood pressure. Resident #1 remained in the hospital until [DATE] and then was transferred to an inpatient hospice unit. Resident #1 expired on [DATE] with the cause of death listed on the "Certificate of Death" as "Bilateral Subdural Hematoma due to or as a consequence of a fall from the wheelchair" due to a fall from the wheelchair. Resident #2 had a history of [REDACTED]. On [DATE], a Nursing Assistant was attempting to transfer Resident #2 without assistance. Resident #2 fell and sustained a reddened area to the right temporal area of the forehead and a bruise to the right thumb. Resident #5 had a soft waist restraint in use while seated in a wheelchair on [DATE]. Resident #5 was found with the restraint around her neck and she was sitting on the floor in front of the wheelchair. Resident #5 had redness to her neck and back. On [DATE], a crotch restraint was ordered. On [DATE], Resident #5 was found hanging from her wheelchair with the crotch restraint in place. She had not made contact with the floor when she was found. No injury was identified. After the incident on [DATE], there were no new safety interventions implemented regarding the use of a restraint or device documented. Unsampled Resident A had an order on [DATE] for a soft waist restraint. There was no documentation that the restraint was checked every 30 minutes and released every two (2) hours as stated in the care plan. Unsampled Resident B had an order on for a soft waist restraint. There was no documentation that the soft waist restraint was checked every 30 minutes and released every two (2) hours as stated on the care plan. Unsampled Resident C had an order on [DATE] for a soft waist restraint when up in wheelchair. On [DATE], the soft waist restraint was discontinued and a lap tray was ordered. There was no documentation that the lap tray was checked every 30 minutes and released every two (2) hours as ordered by the Physician and as stated on the care plan. The facility's failure to ensure that professional standards of quality were implemented regarding the application of chair alarms, monitoring of restraints, and using the correct number of staff for transfers put all 18 Resident's identified using bed/chair alarms; 28 resident's using restraints and all Resident's requiring transfers with three (3) persons at risk for serious injury, harm, impairment, or death and was determined to be an Immediate Jeopardy. This was deemed as an Immediate Jeopardy to exist on [DATE] at 02:05 p.m. The IJ began on [DATE] and determined to be removed on [DATE] during the complaint revisit survey of ,[DATE]-,[DATE]. The credible allegation was validated on ,[DATE]-,[DATE]. Findings Include: The facility provided a third (3rd) Allegation of Compliance (AoC) on [DATE]. CMS accepted the AoC and authorized the State Agency (SA) to conduct the revisit. Review of the AoC : "To address the findings of the [DATE] complaint survey and the corresponding persons noted to have been affected for the regulatory requirement F-281, 483.20 (k) (3) (i) Comprehensive Care plans, Highland Home offers the following allegation of compliance. Resident #1 was transferred to the hospital on [DATE] with a [DIAGNOSES REDACTED].#1 was admitted to an inpatient hospice unit where she later expired on [DATE] due to a [DIAGNOSES REDACTED]. On [DATE] Resident #5 was re-evaluated and placed in an upright Geri-chair with a lap tray. On [DATE] Resident #5 was again evaluated and placed in a reclining Geri-chair with Dycem. Resident #5 expired on [DATE] with the cause of death stated on the Death Certificate to be "End Stage [MEDICAL CONDITION]". On [DATE], a physician's orders [REDACTED]. At this time the physician's orders [REDACTED]. On [DATE], a physician's orders [REDACTED]. At this time the physician's orders [REDACTED]. Effective [DATE] the documentation reflecting that the physician ordered restraint has been monitored at least every thirty (30) minutes and released at least every two (2) hours for Unsampled Resident C is being reviewed by the Director of Nursing and/or designee. Resident #2 was assessed on [DATE] with a new Lift/Transfer Assistance Screening form being completed. Upon completion of the assessment and the Lift/Transfer Assistance Screening form the determination was made that the current level of assistance required for Resident #2 is two (2) person or more when a mechanical lift is not being used. Resident #2 has not had any further incidents to date resulting from transfers. The staff member who was noted to have transferred Resident #2 without the proper number of persons was disciplined in accordance with the facility's Progressive Discipline Policy. On [DATE], the Quality Assurance Nurse reviewed the medical records for those residents having an incident as of [DATE] which required the completion of a neurological observation. At this time it was determined that there were 24 affected residents. Each affected resident received a neurological evaluation on [DATE]-[DATE] by a Licensed Practical Nurse with no adverse findings noted. The physician's were notified on [DATE]-[DATE] of the individual's incomplete neurological observation as well as the neurological evaluation completed on [DATE]-[DATE]. An in-service for All Registered Nurses and Licensed Practical Nurses covering the facility's policy regarding the completion of neurological observations was completed on [DATE]-[DATE]. The Director of Nurses and/or designee will review all incident/accident reports and verify that required neurological observations have been completed. No further orders have been written specifically designating that all meals be eaten in the dinning (dining) room. It will be the responsibility of the Director of Nurses and/or designee to ensure that all new physician's orders [REDACTED]. The Weekend RN Supervisor and/or designee will review all new physician orders [REDACTED]. The facility's software program for Electronic Charting was modified by Provider Professional Services, Inc. on [DATE] to include restraint monitoring documentation for the end of each shift. Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants and Nursing Assistant were in-serviced on [DATE] by the Regional Director regarding the simultaneous restraint documentation requirements reflecting that each restraint has been monitored at least every thirty (30) minutes and released at least every two (2) hours. None of the above mentioned employee classifications will be allowed to work until they have been in-serviced regarding the required restraint documentation. All Agency staff are required to receive an in-service by a Registered Nurse/Licensed Practical Nurse prior to the beginning of each shift regarding simultaneous documentation of restraint monitoring as well as other appropriate policies and procedures. No agency staff will be allowed to work until the above mention in-service has been completed and documented. The facility's policy on restraint usage was reviewed by members of the Quality Improvement and Assessment Committee, Regional Supervisor and the QA Nurse on [DATE] and determined to meet the standards of practice. The facility's policies and procedures regarding restraint usage were reviewed by the Quality Improvement and Assessment Committee on [DATE]. At this time it was not deemed necessary to revise the facility's current policy and procedure but emphasized the importance of the Therapy team's participation in the initial safety device/restraint review process. A therapist will complete an initial screen to accompany the High Risk Management Committee's Restraint Necessity/Positioning Device Worksheet. The therapy screen along with the Restraint Necessity/Positioning Device Worksheet will be considered by The High Risk Management Committee to determine the most resident appropriate and least restrictive measure and/or device. A Directed In-service was completed on [DATE]-[DATE] by a Registered Nurse who is an employee of Provider Professional Services Inc. whose purpose is to provide teaching and training services to skilled nursing facilities. These in-services were provided to all Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants and Nursing Assistants and covered the topics of restraints (observation, release and documentation), personal alarms, abuse and neglect, lifts and transfers, accidents, resident rights, physician orders [REDACTED]. regarding restraints, restraint application with demonstration of the soft waist crotch restraint, personal alarms, lift usage with demonstration of the stand lift and the total lift and transfers. A "1 on 1" demonstration was provided to all Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistant and Nursing Assistants on the proper application of restraints on [DATE]-[DATE] for all Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants and Nursing Assistants by the Assistant Director of Nursing and/or the Staff Development Nurse requiring each employee to provide a return demonstration as per the manufacturer's instruction. Registered Nurses and/or Licensed Practical Nurses will observe restraint usage/documentation throughout their scheduled shift as well as documentation at the end of each shift to verify that all safety checks and releases have been properly completed. A Registered Nurse completed an in-service for all Assessment Nurses covering physician orders, safety devices and restraints and the importance of consistent follow through with resident's plan of care was conducted by a Registered Nurse on [DATE]." The aforementioned information is as quoted in AoC #3. A survey was conducted on ,[DATE]-,[DATE] to validate the Allegation of Compliance (AoC). The validation of the Credible Allegation of Compliance was accomplished through observation, interview and record review. The facility provided evidence that the facility had implemented the corrective actions listed in the AoC. Observations, record reviews and staff interviews were performed to include the application, releasing and monitoring of restraints by staff. Interviews were conducted with multiple staff on [DATE] and [DATE] in regards to Restraint Application and demonstration, Abuse/Neglect, Transfers, Accidents, Resident Rights, Lifts -to include sit to stand and whole body, Physician Orders, Neurological Checks and Personal Alarms. The multiple staff interviewed included the disciplines of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nursing Assistants (CNAs), Therapy Staff, Administration, Consultants, Agency Certified Nursing Assistants, Assistant Activity Staff, and Assessment Nurses. Staff were able to verify that they were provided training and inservices on the aforementioned topics. Resident #2 record was reviewed and observations were made of a sit to stand transfer with the assistance of two Certified Nursing Assistants. Unsampled Resident A was discharged to the hospital on [DATE] with a [DIAGNOSES REDACTED]. At the time of the survey the residents return to the facility was anticipated. Orders on the medical record revealed that on [DATE] a seatbelt had been ordered, on [DATE] the seatbelt was discontinued and a drop seat was added to the Residents chair. Unsampled Resident B was observed in the facility in the activity area with no restraint present. The medical record revealed physician order [REDACTED]. On [DATE] a drop seat and pommel cushion was added to the wheelchair and those devices were observed on [DATE]. On [DATE] at 03:45 p.m. a transfer of the resident was observed by two CNA's with no concerns noted. Unsampled Resident C was observed sitting in a wheelchair in the day room with activities in progress. A blue lap tray was present on the wheelchair. Record review revealed that the lap tray was for positioning due to the resident leaning forward. Release of the restraints were observed while the residents participated in group activities and at the meal time. The documentation for Unsampled Resident C revealed that the restraint was monitored every 30 minutes and released every 2 hours as ordered by the physician. The facility's Allegation of Compliance was reviewed with the facility Administrator to ensure that all components of the AOC had been performed and documented. Directed Inservice training for staff to include Agency Staff was conducted by a Registered Nurse. The inservices included the topics of Resident Abuse, Abuse /Neglect Reporting, Residents Rights Violation Policy, Fall Management Protocol, Fall Intervention Protocol, Lifting Policy, Restraints, Accident /Incident Reporting and Identification of Residents. Staff were interviewed to assess the knowledge of topics covered and to verify inservice. The attendance of all staff was verified by a list of all staff employed by the facility as well as a list of Agency staff, which included 6 CNA's. Inservice signature sheets were reviewed for Inservices for the Interdisciplinary team -Therapy Team Inserviced related to the initial screening and interdisciplinary team approach regarding restraints/devices and evaluation and application as well as High Risk Committee Participation. Review of a document from Provider Professional Services, Inc. dated [DATE] revealed: "Updates to the available Smart Charting time codes in AHT (American Health Tech) were implemented on [DATE]. The time code initiated restricts early documentation for monitoring restraints". The document was signed by the President of Provider Professional Services. A document provided by the facility Administrator revealed: "(name of facility) has updated the electronic charting program to allow for staff to make a single entry at the end of each shift which documents that individual restraints have been checked every 30 minutes and released every 2 hours. This was accomplished by contracting the software company (American Healthtech) and having them give us the proper code to utilize when entering restraints into the program." Review of a notebook with the title Restraints revealed hand documented evidence that the staff were monitoring the restraints every thirty minutes. The time frames were in increments of 30 minutes and released every two hours and required the initialing by the staff to indicate they had monitored the restraint. If the resident was in bed and had no restraint that would be indicated by an X instead of the signature. Review of a document "Rounds Flow Record" revealed that residents with Restraints and Alarms were randomly observed with no issues noted for correction. Those documents were dated [DATE], [DATE], [DATE] and [DATE]. Review of a documented titled "All new physician orders [REDACTED]. Based on verification of the facility's corrective actions that was validated by staff interviews, observation, record review and inservice reviews, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on [DATE] to a " E " level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Improvement and Assessment Committee.

CI MS #8916 and CI MS #8917 Based on record review, staff interview and policy review, the facility failed to ensure that three (3) of eight (8) totaled sampled Residents (Resident #1, Resident #2, and Resident #5) and three (3) of four (4) Unsampled Residents (Unsampled Resident A, Unsampled Resident B, and Unsampled Resident C); had chair alarms in place as ordered by the Physician (Resident #1); to ensure that Resident #1 was eating her meals in the dining room for safety measures as ordered by the Physician; failed to ensure consistent monitoring was in place for the checking and releasing of restraints; to ensure that the documentation was correct for the checking and monitoring of the restraints due to staff being allowed to document anytime during the shift for the entire shift; (Resident #5, Unsampled A, Unsampled Resident B, and Unsampled Resident C); and failed to ensure that the correct number of staff were utilized when transferring residents (Resident #2) to prevent an avoidable accident. Resident #1 sustained a fall on [DATE] at 8:10 p.m. with a closed head injury. CNA #4 was making rounds and found patient on bathroom floor. She reported incident to LPN #2 who reported to the supervisor. Orders received for Neuro checks and patient monitoring. Documentation revealed a knot on back right side of the head which was reddish blue in color, 1 ? " (inch) long, 1 inch wide. There was no documented evidence provided that confirmed that neuro check were performed as ordered for Resident #1 after the fall on [DATE]. Resident #1 had a history of [REDACTED]. It was determined that the chair alarm was not in place as ordered by the Physician. Resident #1 was also eating her dinner meal in her room and not in the dining room as ordered. Resident #1 was transferred to the hospital and diagnosed with [REDACTED]. Resident #1 had a decline in her health status after the fall which resulted in dysphagia and elevated blood pressure. Resident #1 remained in the hospital until [DATE] and then was transferred to an inpatient hospice unit. Resident #1 expired on [DATE] with the cause of death listed on the "Certificate of Death" as "Bilateral Subdural Hematoma due to or as a consequence of a fall from the wheelchair". Resident #2 was identified to require the use of a lift and three (3) person assistance with transfers. Resident #2 required two (2) person assistance with Activities of Daily Living (ADL's). Resident #2 had a fall on [DATE] and sustained a fracture to the left radius/humerus. On [DATE], Resident #2 had a fall from the bed, when the Nursing Assistant was attempting to transfer her without assistance. Resident #2 sustained a reddened area to the right temporal area of the forehead and a bruise to the right thumb. Resident #5 had a history of [REDACTED]. On [DATE] a soft crotch restraint was ordered. On [DATE], Resident #5 was found hanging out of the wheelchair with the crotch restraint in place. There was incomplete documentation of monitoring Resident #5 during the use of the restraints by checking every 30 minutes and releasing every two (2) hours. There was no documentation that supervision was increased or other methods to ensure that Resident #5 did not sustain additional falls or injuries from the use of the restraint. Unsampled Resident A, Unsampled Resident B, and Unsampled Resident C, had soft waist restraints in use. There was incomplete documentation that the soft waist restraints were checked every 30 minutes and released every two (2) hours as ordered. There were 174 falls identified by the facility occurring in a six (6) month time frame, from [DATE] through [DATE]. There were 28 Residents identified using restraints in the facility on the "Resident Census and Condition" completed on [DATE]. There were 18 Residents Identified using chair alarms. The facility's failure (1) to ensure that chair alarms were in place as ordered by the Physician; (2) failure to ensure that Resident #1 was eating her meals in the dining room for safety measures as ordered by the Physician; (3) failure to ensure consistent monitoring in place for the checking and releasing of restraints; (4) failure to ensure that the documentation was correct for the checking and monitoring of the restraints due to staff being allowed to document anytime during the shift for the entire shift; and (5) failure to ensure that the correct number of staff were utilized when transferring Residents put 28 Resident's with restraints; 19 Resident's with bed chair alarms; and all resident's requiring the use of three (3) or more staff for transfers using a lift at risk for serious injury, harm, impairment, or death was deemed as an Immediate Jeopardy. A Complaint Investigation (CI) began on [DATE] and concluded on *[DATE]*. During the investigation the facility was found not to be in compliance with the Requirements for Participation in Medicare and Medicaid. It was determined that Substandard Quality of Care (SQC) and/or Immediate Jeopardy (IJ) (at a "K" level) was identified to exist on [DATE] at 02:05 p.m. to begin on [DATE] when Resident #1 had a fall and sustained a closed head injury with no evidence that neuro checks were performed as ordered. The IJ is considered to be on going. The Administrator and the Director of Nursing were notified of the on going IJ on [DATE] at 7:30 p.m. The facility provided an Allegation of Compliance (AoC) on [DATE] at 11:00 a.m. and amended the AoC on [DATE]. Based on CMS Administrative review on [DATE], the AoC was determined not acceptable. The IJ was not removed upon exit from the facility on [DATE] and is on going. Findings Include: Resident #1 Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 did not receive psychotropic medications. Review of the Minimum Data Set (MDS) with with an Assessment Reference Date (ARD) of [DATE] revealed that Resident #1 was independent in cognitive skills for daily decision making. Resident #1 required limited assistance of one (1) person to physically assist with bed mobility, transfers, walking in room, dressing and toileting. Resident #1 was coded as having a fall in the past 30 days and the past 31 to 180 days. Review of Resident #1's care plan with a problem onset date of [DATE] revealed: "Resident has a potential for falls r/t (related to) muscle weakness, lack of coordination, history of falls, and use of anti-depressant medication. "The last reported FALL ON [DATE] & [DATE]." There was a handwritten notation on the care plan stating: " Fall Noted [DATE] Fall Screen, Encourage resident to call for assistance." On " [DATE] - Cont (continue) POC (Plan of Care);" "Fall noted [DATE] Fall Screen." On "[DATE] - Chair Alarm when in w/c (wheelchair) and in recliner. Check for proper functioning of alarm q (every) shift & PRN (as needed)." A notation on another care plan for Resident #1 stated: " [DATE] Applied Dycem to w/c seat." There was no documented evidence provided that Dycem was applied to the seat of the wheelchair for Resident #1. A care plan was presented which read " [DATE] -Noncompliance: removes Dycem from w/c seat." Some of the approaches stated: "Document non-compliance. Evaluate any adverse effects from refusals. Notify MD as needed. Return at a later time and offer to place Dycem back in her w/c to make her seating more secured. Educate resident/family on risks of refusals." The target dates for the care plan were documented as [DATE] and [DATE]. There was no documented evidence that the non compliance in using the Dycem was documented. There was no documented evidence that the facility staff returned at a later time to offer to place the Dycem back in the wheelchair. Interview with RN #4 on [DATE] at 02:30 p.m. revealed that when the Dycem was initially used Resident #1 was excited about using it. Resident #1 was known to take the Dycem out and wash it. RN #4 stated that Resident #5 could stand up, take the Dycem out of the chair, wash it, hang it up to dry, and put it back in the chair. The facility obtained another piece of Dycem so that Resident #1 could alternate it while it was being washed. There was no documentation of this information on the care plan. Review of "Incident Reports" revealed that Resident #1 had experienced a fall on [DATE] at 8:10 p.m. with the type of injury documented as: "closed head injury." The narrative of the incident and description of injuries stated: "(Name of CNA #4) was making rounds and found patient on bathroom floor. She reported incident to (LPN #2) who reported to supervisor. I assessed patient. She stated she was transferring from toilet to wheelchair and fell . She hit the back of her head but not sure what she hit head on. Explained that MD would be called and she may have to go to hosp (hospital) pt refused going to hosp. Said that was a last resort. Orders received for Neuro checks and monitor pt. Knot on back of head on right side. Reddish blue in color, 1 ? " (inch) long, 1 inch wide." There was no documented evidence provided that confirmed that neuro check were performed as ordered for Resident #1 after the fall on [DATE]. Review of the facility policy "Head Trauma" with an original date of ,[DATE] revealed: " NOTE: Observe vital signs and neuro checks for no less than three days. Obtain and document neurological signs for 72 hours. The neurological signs should be done every 15 minutes times four then every 30 minutes times four and then every hour times four, then each shift for the remainder of the 72 if stable. " Interview with the DON on [DATE] at 01:40 p.m. confirmed that there were no documented neuro checks. Review of an "Incident Report" revealed that Resident #1 had a sustained an unwitnessed fall on [DATE] which resulted in a "dime-sized bruise on the upper left lip; four (4) superficial lacerations on right anterior lower arm...". The "Immediate Actions Taken" stated: "pt (patient) is assessed for fx (fracture), then assisted back into chair, gauze is applied to laceration of R (right) arm and nurse held in place to provide staunch bleeding (due to Plavix use)." Review of the Nursing Notes for [DATE] at 4:25 p.m. revealed that Resident #1 stated that she was standing while she was pulling her pants down and lost her balance and fell ." "Neuro checks started." Review of the "Neurological Observations Head Injury Sheet" for Resident #1 dated [DATE] revealed that neuro checks for three (3) of the four (4) hourly checks did not include LOC (Level of Consciousness); Pupils and Hand Grasp; and was not signed by a Nurse. The "every shift" checks that began on the 07:00 a.m. to 03:00 p.m. shift, and the 03:00 p.m. to 11:00 p.m. shift had no documented evidence the the blood pressure, pulse, respirations, temperature, LOC, Pupils or Hand Grasp were checked, and there was no Nurse's signature. The last documentation was on [DATE] on the 11:00 p.m. to 07:00 a.m. shift. There were eight (8) shift reports that had no documented evidence that the blood pressure, pulse, respirations temperature, LOC, Pupils or Hand Grasp were checked, and there was no Nurse's signatures. Review of the "Resident Incident Report" dated [DATE] at 07:46 PM revealed: "Incident Type: Fall w/(with) head injury." "Type of Injury: Closed head injury, Laceration, superficial." "Narrative of incident and description of injuries: " "pt (patient) was found on floor beside foot of bed with face down toward floor and fresh blood noted on floor. Wheelchair was locked in place in front of recliner, trash can had been overturned, and tray table pushed toward head of bed with telephone found on floor beside chair. Pt. found aaox3 (awake, alert, oriented times three), but denies knowledge of how she got onto floor. No blood noted on the bed, table, or other furniture. Bright red blood noted puddle on carpet beneath facial injury was not congealed. Ping-pong ball sized hematoma noted above R (right) outside edge of eyebrow with 2 mm (millimeter) superficial laceration noted at site. Dried blood noted at opening of nares, but no gross injury noted at nose, blood noted at gumline of upper front teeth, but nurse was unable to ascertain state of injury. No obvious fracture or dislocation noted upon body inspection per RN (Registered Nurse)." Review of the handwritten documentation by Certified Nursing Assistant (CNA) #2 revealed: "I, (name of CNA), went to (Name of Resident #1) room to assist her to the bathroom, After (Resident #1) used the rest room I assisted her to brush her teeth. Then I pushed (Resident #1) into her room next to her recliner. I asked (Name of Resident #1) was she ready to go to bed are (or) did she want to sit in her recliner. She said No. Therefor(e) I left her in her wheelchair with her call light and locked her wheelchair. Her bed alarm was on her bed and the other alarm was on her recliner." Review of the Personnel File for CNA #2 revealed that employment with the facility was terminated with an effective date of [DATE] noted. The termination was documented as "Violation of P & P (Policy and Procedure), Not Following ADL's (Activities of Daily Living)." The facility marked that the CNA was not eligible for rehire. Review of Nurses Notes for Resident #1 revealed: On [DATE] at 1:30 p.m. "CP (Care Plan) meeting c (name of resident) and daughter (name of daughter). Discussed recent falls. (Resident #1 and daughter) agreed to use of chair alarm to alert staff of attempts to alert staff of attempts of transferring s (without) assistance. Therapy participated in discussion & will monitor need to continue use during therapy sessions." On [DATE] at 3:15 p.m. "New order rec'd (received) for Chair Alarm. New order to dining room for all meals. " On [DATE] at 7:45 p.m. "pt (patient) found lying face down on floor @ (at) foot of bed c (with) R (right) arm draped over bases of bed. Small pool of bright red blood noted on carpet beneath pt's face. Resp. (respirations) even et (and) unlabored s (without) wheezing noted. Pt AAO X 3 et responsive appropriately upon nurse's verbal stimuli- pt recites name, DOB (date of birth) et current date upon command. Pt displays (+) {positive} ROM (range of motion) of all extremities upon command. Body audit performed per nurse c (with) 0 (no) gross deformity or fracture noted, except for growing hematoma noted @ R eyebrow. Approx (approximately) 2 mm superficial laceration noted upon ping pong ball sized hematoma c (with) bright red blood oozing from site. Fresh blood cleaned from pt's nose et both nares s (without) evidence of origin of blood- no new bld (blood) appearing as blood cleaned from face. Fresh blood noted @ upper gum line above front teeth, but nurse is unable to ascertain origin @ this time. Pt turns head spontaneously @ nurses voice. Cool wet compress applied to hematoma to staunch bleeding et swelling. (Name of LPN #7) is instructed to call ambulance et physician at this time. Upon questioning pt denies knowing how she got onto floor. Pt c/o facial pain and c/o R shoulder pain @ this time. NO bruising noted @ shoulder or back. Room assessment reveals w/c facing recliner in locked position, telephone sitting on floor beside recliner, overbed tray table situated @ a slant onto bedside c tray et waterglass intact on surface. Resident was found c head @ foot of bed et was laying face down @45 degree angle to bed on L (left) side of bed c legs outstretched. Alarms intact @ bed et recliner et call light is draped onto tray table. Alarms not sounding @ this time. Pt responds to question of pain describing facial brow pain as soreness of 8 (eight) on ,[DATE] (one to ten) pain scale." At 1955 (07:55 p.m.) "first response rescuers x 3 arrived @ scene et ice is applied gingerly to hematoma @ (R ) eyebrow per rescuer while awaiting AMR (ambulance) to arrive. Rescuers notified of pt vs (vital signs) per nurse BP (Blood Pressure) ,[DATE], T (Temperature) 98.7 P (pulse) 77 R (Respirations) 20. Resp continue to be even et unlabored. Apical pulse regular rate & rhythm." At 2030 (08:30 p.m.) "(Name of Ambulance) paramedic & EMT (Emergency Medical Technician) arrived. Pt is transferred to gurney per paramedic & rescuer using bed underpad s (without) transfer board use or cervical immobilization. Pt tolerated transfer s c/o pain, but blanket was applied for warmth." At 2100 (09:00 p.m.) pt is released in care of (Name of Ambulance) for transfer to emergency room of (Name of Hospital) for further eval (evaluation) & tx (treatment) via gurney in ambulance. Transfer papers released to (Name of Ambulance paramedic." Review of a Physician's Order dated [DATE] stated: "Send to (Name of Hospital) ER (emergency room ) for evaluation fall with head injury." Review of the "RESIDENT INCIDENT FOLLOWUP" dated [DATE] revealed: " Resident is currently hospitalized ." Review of the Emergency Department Chart dated [DATE] at 09:22 p.m. revealed the following documentation for Resident #1: " Chief Complaint - Abrasion to left forearm. Soft tissue injury to left forearm. Head injury. Injury to upper portion of face. Wound/laceration to upper portion of face." " Skin - There is pain and swelling over the following areas: face, right forearm and posterior aspect of right upper arm. " "There is pain and swelling noted over the right side of forehead. " "Clinical History of Present Illness Problems occurred at fall at nursing home. " "Hematoma to right eye due to fall." "Lost balance and fell ." "Results - CT (Computerized Tomography) Head w/o (without) contrast- I have reviewed the radiologist's report for this film. Brain imaging study shows evidence of traumatic intracranial bleeding. Subdural hematoma noted." "Disposition - Patient admitted to hospital. Patient was examined and/or treated in the Emergency Department. admitted to Critical Care Unit or add CCU." Review of the "Discharge Summary" from the hospital dated [DATE] revealed: "This [AGE] year-old Caucasian female presented following a fall in the nursing home in which she sustained a concussion, bilateral subdural hematomas as well as significant soft tissue [DIAGNOSES REDACTED] injury. She has a significant past history of Parkinson's Disease, B12 Deficiency, Gastroesophageal Reflux Disease, Multiple Transient Ischemic Attacks, Glaucoma and dementia. She was admitted to the Neurosurgical Intensive Care for observation and within several days had returned to baseline neurologically; however, she had persistent evidence of failure to thrive and after extensive discussions with her family, it was felt that supportive care only and arrangements for hospice would be most appropriate. This was arranged on [DATE] and she was transferred to Hospice (name of Hospice) for comfort care." Review of the "CERTIFICATION OF DEATH" for Resident #1 revealed a date of death as [DATE] at 10:15 a.m. with the cause of death being noted as " BILATERAL SUBDURAL HEMATOMA - TRAUMATIC DUE TO OR AS A CONSEQUENCE OF FALL FROM WHEELCHAIR (NOT WITNESSED)." The portion of the Certificate of Death stated to "Use if Death NOT due to natural causes" revealed: "31a. ACCIDENT, SUICIDE, HOMICIDE, PENDING INVESTIGATION OR UNDETERMINED (Specify) ACCIDENT. (31b). DATE OF INJURY (Month, Day, Year) [DATE]; (31c.) HOUR OF INJURY +/- 7:46 PM; (31d). DESCRIBE HOW OR BY WHAT MEANS INJURY OCCURRED fell WHILE GOING FROM CHAIR TO BED. (31e). INJURY AT WORK (Yes or No) NO; (31f). PLACE OF INJURY NURSING HOME." Interview with a family member of Resident #1 on [DATE] at 06:34 p.m. revealed that on the Thursday ([DATE]) before the "major fall" she had attended a care plan meeting with one (1) Nurse and the Social Worker. She stated that a representative from Physical Therapy came into the meeting near the end of the meeting. She stated at that meeting it was discussed that a fall monitor was going to be put in place and that the resident would be taken to the dining room for all meals. She stated on the night of the fall the resident had her meal in her room. She stated the fall caused major problems with swallowing and the resident could not eat or drink afterwards. She was admitted to the Hospice facility on Friday ([DATE]) and the resident expired the following Wednesday ([DATE]). An additional interview with a family member of Resident #1 on [DATE] at 08:35 a.m. revealed that she had seen the Dycem sometimes on the wheelchair in place and sometimes the Dycem was not in place. When she visited and did not see the Dycem in place she would contact the nursing staff and ask them where it was. She stated Resident #1 would not have removed the Dycem because she was cognitive enough to know it was for her safety. The family member confirmed that she had not seen the alarm on the wheelchair in place at times. Interview was conducted with RN #5 on [DATE] at 11:05 a.m. and revealed that she was at the care plan meeting with the family member and that she had placed the clip alarm on the resident herself the day of the care plan meeting,which was [DATE]. RN #5 stated that she had written the Physician order for [REDACTED]. Check for proper functioning of alarm q shift & PRN " and " Dining Room for all meals starting [DATE] @ breakfast." RN #5 confirmed that the "Dining Room for all meals" was not on the careplan. There was no documented evidence that Resident #1 was taken to the Dining Room for all meals after the order was written on [DATE]. Interview on [DATE] at 2:35 p.m. with RN #1 (RN Supervisor) revealed that she was working the day that Resident #1 sustained the fall and was transferred to the hospital. RN #1 stated that Resident #1 had the Promat on her bed and in recliner. RN #1 stated that Resident #1 was supposed to have it in her wheelchair but did not at the time. RN #1 stated that when she entered the Room, Resident #1's was lying on the floor with her face toward the end of the bed. Resident #1's arm was at an angle, blood was noted. RN #1 rolled Resident #1 over on the floor and then called for assistance. RN #1 stated that Resident #1 was alert but could not remember what happened. She observed a knot on Resident #1's head and bleeding to the gums. RN #1 stated that there was no blood except directly below the forehead that was no congealed. She stated that Resident #1 was on blood thinners. RN #1 stated that the ambulance service arrived and Resident #1 was transported to the hospital. RN #1 stated that CNA #2 was assigned to Resident #1 that day. CNA #2 took Resident #1's meal tray to her room. CNA #2 left Resident #1 seated in the wheelchair. RN #1 stated that CNA #2 went on break and CNA #1 was the person who found Resident #1 on the floor. Requests were made for documentation for how chair alarms were checked for functioning and no documentation was provided to indicate how the chair alarms were checked for functioning. Interview with the DON on [DATE] at 03:30 p.m. confirmed that the facility had no policy for the checking of the functioning of the alarms. Interview on [DATE] at 4:15 p.m. with the ADON revealed that the information regarding Resident #1 being in the dining room for meals should have been on the ADL record. She stated that the slip is sent to the Dietary department so that they would know which cart to put the tray on. Interview on [DATE] at 4:30 p.m. with the DON confirmed that the information regarding Resident #1 going to the dining room for meals never got on the ADL record or the care plan. There was no documentation that Resident #1 ever ate her meals in the dining room. She also confirmed that there was no documentation regarding the counseling of the family or resident regarding the use of the Dycem. Interview on [DATE] at 5:00 p.m. with the MDS Nurse revealed that they had given Resident #1 two Dycems, one (1) was white and the other was blue. The MDS Nurse stated that she did not know if Resident #1 removed the Dycem from her chair or if she used it. Resident #5 Record review revealed that Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5 was administered Remeron 15 mg every day from [DATE] - [DATE] for appetite stimulant. Venlafazine HCL SR 225 mg (Effexor) every day from [DATE]-[DATE]. It was reduced to 75 mg every day from [DATE]-[DATE], given for depression. Review of the 14 day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed that the Brief Interview for Mental Status (BIMS) was not conducted due to the resident being rarely/never understood. The Resident was coded as having both a short term and long term memory problem. Resident #5 was coded as being moderately impaired in cognitive skills for daily decision making with decisions being poor and cues/supervision required. Resident #5 was identified as " Moving or speaking so slowly that other people have noticed. Or the opposite-being so fidgety or restless that she has been moving around a lot more than usual." Review of Section P of the 14 day MDS for Resident #5 revealed that a trunk restraint was used daily in chair or out of bed. Review of the Care Plan with a "Problem Onset" date of [DATE] for Resident #5 revealed the following problem: "At risk for falls r/t right hip fx (fracture)." "Approaches: "SOFT WAIST CROTCH RESTRAINT WHILE RESIDENT UP IN WHEELCHAIR." Another problem listed on the care plan with an implementation date of [DATE] revealed a problem stating: "Potential for injury - trunk restraint soft waist crotch restraint to w/c while up in chair." An approach stated: " Monitor restraints every 30 minutes and release every 2 hours for exercise. Document interventions." Review of the Nurses Notes for Resident #5 revealed: On [DATE] at 2:42 p.m. "Resident sliding down in wheelchair with lap tray on, called (name of Physician), who ordered soft waist restraint. Resident requires therapy for muscle weakness and lack of coordination." On [DATE] at 9:00 p.m. "Nurse entered resident's room in response to bed alarm sounding. Pt found sitting on mat on floor on L (left) side of bed leaning against the bed mattress. Resident reports she slid to mate while attempting to retrieve television remote control.". On [DATE] at 8:37 a.m. "(Name of Nurse) heard the resident's bed alarm and went immediately to the room to find the resident on her knees on blue mat, bed was in lowest position with blue mats on each side and call light in reach, no injuries noted but will continue to monitor, remind resident to use call light when needing assistance...". On [DATE] at 4:00 p.m. (Name of staff) were in another resident's room when they heard a loud noise and looked across the hall into (Resident Rm #). The resident had fallen out of the lounge chair and hit the back of her head on the w/c. They immediately rushed into the resident's room. The resident has a dime sized raised area on the back of her head...". MD (medical doctor) notified. Resident is not to be in lounge chair only in w/c with soft waist restraint or in bed at lowest position with mats on each side with bed alarm at all times per MD request.". On [DATE] at 9:58 p.m. "Resident was found by Housekeeping in room on the floor. She was trying to get out of her wheelchair but she could not because she had on a lap belt, but she wiggled herself enough and slid through the belt and it caught her by her neck and she was sitting on the floor with the lap belt around her neck. VS (vital signs) were stable no c/o (complaints of) pain. Her neck is a little red from where the belt caught her around her neck and on the back of her neck where it was up against the wheelchair seat. MD (Medical Doctor) and family notified." Interview with Housekeeper #1 on [DATE] at 03:10 p.m. revealed that she heard Resident #5 call for help. Housekeeper #1 entered the room and called for nursing staff to come and help. Housekeeper #1 then continued on with her housekeeping duties. On [DATE] at 2:43 p.m. "Resident sliding down in wheelchair with lap tray on, called Dr. (name) who ordered soft waist restraint. Resident very confused and attempts to stand without assistance. Will continue to monitor. Resident requires therapy for muscle weakness and lack of coordination." Review of Incident Reports for Resident #5 revealed: On [DATE] at 9:00 a.m. the "Narrative of Incident and Description of Injuries" stated: "Resident found sitting on floor upright on mat on floor leaning against side of bed. Bed in lowest position, call light at pillow, bed alarm functioning and in operation at this time." " No apparent injury. Pt exhibits arom (active range of motion) of all extremities upon command without c/o (complaints of) pain." Review of the "Narrative of Incident and Description of Injuries" revealed that on [DATE] at 4:00 p.m. Resident fell and hit her head on the wheelchair. This information was written in a signed statement by the NA. There was documentation that Resident #5 had "small dime sized raised area on back of head." Review of the "Resident Incident Follow Up" revealed that the Immediate Actions taken were: "Assessed for injuries, began neurochecks and continue to monitor." The injury stated: "noted on occipital area of scalp a mottled, dark purple area approx (approximately) 4.0 cm with raised area at center approx 0.3 cm x 0.5 cm; tender on palpitation." On [DATE] at 07:20 p.m. "Narrative of Incident and Description of Injuries" revealed: "Resident tried to free herself from the restraint by sliding under the lapbelt and it caught her around her neck once she got on the floor. no (No) injury, chest and neck a little reddened where the belt was rubbing against her neck." Review of the "RESIDENT INCIDENT FOLLOWUP" dated [DATE] revealed: "Resident tried to free herself from the restraint by sliding under the lapbelt and it caught her around her neck once she got on the floor." "No apparent injury, resident is noncompliant with safety interventions. Soft waist restraint d/c ' d (discontinued) with crotch restraint to be implemented. Therapy to fall screen, continue to encourage compliance with safety interventions." Review of the "Resident Incident Report" dated [DATE] at 1:46 p.m. revealed: "Resident was on matt at bedside from low bed. (Name of CNA) called the nurse to room, Resident was observed on matt at bedside with a skin tear to right forearm moves ext (extremities) well no c/o pain or discomfort. MD notified no new orders resident assisted back to be by staff x 2. When resident asked how she got oob (out of bed) she said I don't know." "Skin tear with steri strips applied". The "Narrative of Investigation" stated: "Assessed Resident S/P (status [REDACTED]. When questioned resident as to what happened Resident indicated that she had rolled off bed and caught arm on bed frame. Upon assess of bed, mattress was noted to be slid all the way to the wall exposing about a 3 inch wide area of the bed frame. Mattress was readjusted and frame padded to help protect skin. Review of the "Restraint Necessity/Positioning Device Worksheet" dated [DATE] revealed: "Sitting Balance: falls or leans." "Ambulation /Transfers: Leans Forward." "Specific medical symptom that requires a device: Poor balance with gait, sitting, & (and) transfer, lack of coordination, Leaning." Review of the "Restraint Necessity/Positioning Device Worksheet" dated [DATE] revealed: "Sitting Balance: Falls or leans." "Leans forward." "Poor balance with gait, sitting & transfer." " Lack of Coordination;" and " Muscle weakness." "Restraints in chair/out of bed: trunk restraint used daily." " If other restraint used in chair describe: Laptray to wheelchair changed to soft waist restraint on ,[DATE]/

CI MS #8916 and CI MS #8917 Based on record review, staff interview and policy review the facility failed to ensure that the Quality Assurance Committee consisted of the Director of Nursing (DON), a Physician, and at least three (3) other staff members. The facility failed to ensure that the Quality Assurance Committee functioned effectively in monitoring the use of bed/chair alarms for three (3) of eight (8) totaled sampled Residents (Resident #1, Resident #2, and Resident #5), and three (3) of four (4) Unsampled Resident's (Unsampled Resident A, Unsampled Resident B, and Unsampled Resident C); failed to ensure that Resident's were eating in the dining room as ordered for safety measures (Resident #1); failed to ensure that restraints were being checked and released as ordered (Resident #5, Unsampled Resident A, Unsampled Resident B, and Unsampled Resident C); and failed to ensure that the correct number of staff were utilized when transferring Resident #2 to prevent an avoidable accident The facility's failure to ensure that QA met quarterly to include all pertinent personnel and identified areas of concern with an effective action plan regarding the use and monitoring of restraints; the monitoring of chair alarms; and to ensure that staff transferred resident's with the correct number of people, put all 19 Resident's with bed chair alarms, 28 residents with restraints, and all resident's requiring the use of three (3) or more staff for transfers at risk for serious injury, harm, impairment, or death and was deemed as an Immediate Jeopardy (IJ). The facility held it's Quarterly Quality Assessment and Improvement Committee Meeting covering the 4th quarter of 2010 on 01/26/11. Based on Administrative review by Centers for Medicare and Medicaid Services (CMS) on 02/15/11, other additional information and a partially extended survey was conducted on 02/15-16/11. During the investigation the facility was found not to be in compliance with the Requirements for Participation in Medicare and Medicaid. It was determined that Substandard Quality of Care (SQC) and/or Immediate Jeopardy (IJ) (at a "K" level) was identified to exist on 01/06/11 at 02:05 p.m. The IJ is considered to be on going. The Administrator and the Director of Nursing were notified of the on going IJ on 02/16/11 at 7:30 p.m. The facility provided an Allegation of Compliance (AoC) on 01/07/11 at 11:00 a.m. and amended the AoC on 01/21/11. Based on CMS Administrative review on 02/15/11, the AoC was determined not acceptable. The IJ was not removed upon exit from the facility on 02/16/11 and is on going. Findings Include: Cross refer findings to F-221 for the facility's failure to ensure that restraints were monitored effectively. Cross refer findings to F-224 for the facility's failure to ensure that Resident's were free from neglect. Cross refer findings to F-281 for the facility's failure to ensure that Physician's orders were implemented for the use of a chair alarm; checking and releasing restraints; and failing to ensure that the correct number of staff was implemented when transferring a resident. Cross refer findings to F-323 for the facility's failure to ensure that Residents with restraints were monitored; chair alarms were in place as ordered; and the required number of staff were used when transferring a Resident to prevent an avoidable accident. Review of the facility policy "Quality Improvement Committee" with an effective date of 04/06 and with a revision date of 08/08 revealed: "Composition of the QA & IC shall include: Administrator; Medical Director; Director of Nursing Services (DON); Consulting Pharmacist; And at least two other facility staff persons. (Other facility staff person include Housekeeping, Maintenance, Social Services, Activities, Dietary and Account Manager." Record review revealed that the last annual survey was conducted from 05/18/10 thru 05/20/10. The documentation reviewed since the last survey revealed that the QA committee met on 08/19/10 and 10/26/10. The signatures indicated that the Consultant Pharmacist did not attend either meeting. The 10/26/10 meeting was attended by the DON, a Physician and the Administrator. That meeting did not include the Consultant Pharmacist or two (2) other facility staff persons. Interview with the DON on 01/06/11 at 09:30 a.m. revealed that the facility staff discusses all incidents in the morning standup meeting. Interview with the Medical Director on 01/06/11 at 11:34 a.m. revealed that the facility does have a fall meeting that he attends. The facility Administrator had indicated that he would provide the documentation from the morning stand up meetings and/or fall meetings. By the end of survey no documentation had been provided. There was no documented evidence provided that the facility was aggressively researching the numbers of falls that had occurred in the previous six months, 07/01/10 thru 01/01/11, which totaled 174. Interview with the Regional Director on 02/15/11 at 02:30 p.m., revealed that the facility held it's Quarterly Quality Assessment and Improvement Committee Meeting covering the 4th quarter of 2010 on 01/26/11.