Every finding on record at Interlochen Health and Rehabilitation Center

Based on interview and record review, the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 2 of 6 (Resident #1 and Resident #2) residents reviewed for PASARR. The facility failed to complete and accurately request for PASARR specialized services within the 20-day time fame for Resident #1 and Resident #2 after their Interdisciplinary Team meeting on 4/20/26. This failure could place residents at risk of not receiving needed treatment and services.Findings include:1. Record review of Resident #1's face sheet, dated 7/23/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had the following pertinent diagnosis of Mild Intellectual Disabilities (conditions that are marked by slower learning speeds and some trouble with daily life skills). Record review of Resident #1's MDS Quarterly Assessment, dated 4/18/26, reflected Resident #1 had a moderate cognitive deficit with a BIMS of 8. Record review of Resident #1's Care Plan, with a revision date of 5/6/26, reflected .[Resident #1] has Intellectual Developmental Disabilities & Developmental Disabilities and is PASARR positive Date Initiated: 05/06/2026 Revision on: 05/06/2026 [Resident #1] will have the specialized services recommended by local authority per PASARR SpecializedServices program as needed. Date Initiated: 05/06/2026 Revision on: 05/19/2026 Target Date: 07/22/2026 Specialized Services will be provided per PASARR recommendations. 04/20/2026 [Resident #1] will receive Habilitation Coordination Services through Intellectual Developmental Disabilities Specialized Services.Date Initiated: 05/06/2026 Revision on: 05/19/2026 The Local Authority will be invited Annually to the care plan meeting for review of Specialized Services Date Initiated: 05/06/2026.Record review of Resident #1's Habilitative Service Plan, dated 4/28/26, reflected the following approved PASARR services: Customized Wheelchair, Physical Therapy Assessment, Occupational Therapy Assessment, Speech Therapy Assessment, Physical Therapy Service, Occupational Therapy Service and Speech Therapy Service. An interview and observation with Resident #1 on 7/23/26 at 8:56am revealed she was unable to answer any questions about her services due to her intellectual functioning and not answering the questions coherently. Resident #1 was observed in therapy at the time of the interview. 2. Record review of Resident #2's face sheet, dated 7/23/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had the following pertinent diagnosis of Mild Intellectual Disabilities (conditions that are marked by slower learning speeds and some trouble with daily life skills). Record review of Resident #2's Comprehensive MDS Assessment, dated 4/6/26, reflected Resident #2 was unable to complete a BIMS assessment due to rarely being understood. Record review of Resident #2's Care Plan, with a revision date of 7/10/26, reflected .[Resident #2] has Mental Illness, Intellectual Disability, or Developmental Disabilities and is PASARR positive Date Initiated: 03/31/2026 Revision on: 07/10/2026 [Resident #2] will have the specialized services recommended by local authority per PASARR SpecializedServices program as needed. Date Initiated: 03/31/2026 Revision on: 05/19/2026 Target Date: 07/08/2026 Specialized Services of Habilitation Coordination will be provided per Local Authority recommendations. Date Initiated: 03/31/2026 Revision on: 05/19/2026 The Local Authority will be invited Annually to the care plan meeting for review of Specialized Services. Date Initiated: 03/31/2026.Record review of Resident #2's Habilitative Service Plan, dated 4/28/26, reflected the following approved PASARR services: Customized Wheelchair, Physical Therapy Assessment, Occupational Therapy Assessment, Speech Therapy Assessment, Physical Therapy Service, Occupational Therapy Service and Speech Therapy Service.An interview and observation with Resident #2 on 7/23/26 at 9:49 a.m. revealed he was unwilling to speak to surveyor when approached. Resident #2 moved his hand back and forth and yelled no no when asked if he could answer a few questions. An interview with the Interim DOR on 7/23/26 at 12:23 p.m. revealed she had been interim DOR since 5/18/26 and was not aware Resident #1 and Resident #2 qualified for PASARR level services. The Interim DOR stated she had not attended the Interdisciplinary meeting for Resident #1 and Resident #2 on 4/20/26. The Interim DOR stated she was made aware of their approval for PASARR services at their quarterly Interdisciplinary Meeting held on 7/10/26 by the Local Authority case manager. The Interim DOR stated Resident #1 had been receiving Occupational Therapy, Physical Therapy and Speech Therapy since she was admitted to the facility under Medicare Part B and stated she was transitioning out of Medicare Part B and would start PASARR paid therapy in August of 2026. The Interim DOR stated because the resident was still making progress in therapy she would continue on Medicare Part B until she met her baseline then she would start PASARR therapy. The Interim DOR stated she had not scheduled Resident #1's PASARR evaluations for Physical therapy, Occupational Therapy or Speech Therapy because Resident #1 was not at her baseline of functioning and needed to transition off of Medicare before she completed the evaluations. The Interim DOR stated she was not aware the facility was out of compliance until the evaluations were completed as she believed she had 30 days to complete them from the Interdisciplinary Team Meeting and it had not been 30 days yet since the meeting. The Interim DOR stated the Local Authority confirmed at the Interdisciplinary Meeting on 4/20/26 that she had 30 calendar days to complete the therapy evaluations. The Interim DOR stated she was not aware if the appropriate referrals were made for PASARR after the interdisciplinary meeting on 4/20/26. The Interim DOR stated she was not present at the Interdisciplinary Meeting for Resident #2 on 4/20/26 and was not aware if the referrals were made for PASARR services, however she was present at the Interdisciplinary meeting on 7/10/26 and Resident #2 refused the PASARR services. The Interim DOR stated she had not documentation of the refusal but the case manager from the Local Authority had noted it. The Interim DOR stated she was not aware of how the Local Authority person coded his last meeting, but the facility rehab was in the process of discharging Resident #2 from therapy due to him refusing services. The Interim DOR stated she was only able to convince Resident #2 to accept the specialized wheelchair through PASARR and stated she reached out to the provider the day after the interdisciplinary meeting to request they come to measure the resident and stated it had already occurred. The Interim DOR stated Resident #2 had been receiving Occupational Therapy, Physical Therapy and Speech Therapy since he was admitted to the facility. The Interim DOR stated she had also initiated the customized wheelchair request under PASARR for Resident #2 on 7/11/26. The Interim DOR stated she was not aware she did not have an additional 30 calendar days to complete the therapy evaluations for PASARR after the quarterly Interdisciplinary Meeting. The Interim DOR stated she had gotten on the job training on PASARR services at another facility and was how she learned about PASARR and how to complete the process. The Interim DOR stated she had never been in this position because she always completed the evaluations for therapy for PASARR positive residents immediately after their initial Interdisciplinary Meeting. The Interim DOR stated she not having had PASARR services had not affected the residents because they were receiving more the 3 therapies through Medicare more frequently than allowed on PASARR. The Interim DOR stated the only negative effect on the residents was they were delayed in getting the customized wheelchair and the process to get the customized wheelchair could have started back in April 2026. The Interim DOR stated it was the responsibility of the previous DOR to initiate the process for PASARR after 4/20/26 and because he was no longer at the facility she was unable to state the reason the process was done incorrectly. An interview with MDS Nurse Coordinator A on 7/23/26 at 12:59 p.m. revealed she attended the Interdisciplinary Team Meetings for the residents and inputted the referral information in the Local Authority portal when a resident qualified for PASARR services. MDS Nurse Coordinator A stated the Local Authority case manager would develop the Habilitative Plan during the Interdisciplinary Team Meeting and the case manager would send it to the facility to upload it to the medical record. MDS Nurse Coordinator A stated it was the responsibility of the facility's therapy department to provide the appropriate evaluations and input them into the Local Authority portal for PASARR positive residents. MDS Nurse Coordinator A stated Resident #1 and Resident #2 had their initial Interdisciplinary Team Meeting on 4/20/26 and stated the DOR, at the time, was present at those meetings. MDS Nurse Coordinator A stated she could not see any referrals for services in the portal for Resident #1 and Resident #2 and could not say if the previous DOR completed the evaluations for those residents. MSD Nurse Coordinator A stated Resident #1 had her quarterly Interdisciplinary Team Meeting on 7/10/26 and the Interim DOR was present at the meeting. MDS Nurse Coordinator A recalled being at Resident #2's Interdisciplinary meeting and he refused services. MDS Nurse Coordinator A stated if residents were not referred appropriately for PASARR services the residents could have missed out on state services they may need.Record review of the facility's policy PASARR Level 1 Screen Policy and Procedure, revised 3/6/19, reflected .9. Nursing Facility to Nursing Facility Admissions: The discharging facility is the responsible entity and completes a new PAPER copy of the PASARR Level 1 to send with the individual to the new facility. If the individuals PASARR Evaluation is positive the new PASARR Level 1 would remain positive and a new PASARR Evaluation will be completed by the Local Authority.and An Interdisciplinary Team meeting is required and Specialized Services must be reviewed.

Based on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 6 residents (Resident #3) reviewed for ADLs. The facility failed to assist Resident #3 timely with getting out of bed when requested on 7/23/26. This failure could place residents at risk of skin breakdown and affect their dignity and self-esteem. Findings Include:Record review of Resident #3's face sheet, dated 7/23/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had the following pertinent diagnoses: morbid obesity (weighing 100 pounds or more of your ideal body weight), anxiety disorder (intense, excessive, and persistent worry, fear or dread that are hard to control and interfere with daily life), low back pain, constipation and hypertension (high blood pressure). Record review of Resident #3's Quarterly MDS Assessment, dated 6/8/26, reflected Resident #3 was moderately cognitively impaired with a BIMS of 8. Section GG reflected Resident #3 was dependent on staff for all transfers. Record review of Resident #3's Care Plan, revised on 5/21/26, reflected .[Resident #3] has an ADL Self Care Performance Deficit Date Initiated: 05/05/2026 Revision on: 05/21/2026 Will maintain or improve current level of function through the review date. Date Initiated: 05/05/2026 Revision on: 05/21/2026 Assist with personal hygiene as required: hair, shaving, oral care as needed Date Initiated: 05/05/2026 Bathing: requires staff x2 for assistance Date Initiated: 05/05/2026 Bed Mobility: requires staff x2 for assistance Date Initiated: 05/05/2026 Discuss with family/POA care any concerns related to loss of independence, decline in function. Date Initiated: 05/05/2026 Revision on: 05/21/2026 Praise all efforts at self-care. Date Initiated: 05/05/2026 Physical Therapy/Occupational Therapy evaluation and treatment as per Medical Doctor's orders. Date Initiated: 05/05/2026 The resident is NPO Date Initiated: 05/05/2026 Toilet use: requires staff x2 for assistance Date Initiated: 05/05/2026 Encourage the resident to discuss feelings about self-care deficit. Date Initiated: 05/05/2026 Encourage the resident to participate to the fullest extent possible with each interaction. Date Initiated: 05/05/2026 Encourage the resident to use bell to call for assistance. Date Initiated: 05/05/2026 Monitor/document/report to Medical Doctor PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Date Initiated: 05/05/2026. An interview and observation of Resident #3 in her room on 7/23/26 at 9:36 a.m. revealed she was in bed and had not been out of her bed yet. Resident #3 had her oxygen mask on, and it was difficult to understand her. Resident #3 had a family member on the phone on speaker at the time of the interview. Resident #3's family member stated she was concerned the facility left her loved one in bed all day and had not been getting her out of the bed frequently. The relative of Resident #3 stated she wanted her family member out of bed early at least by 9:00 a.m. and returned to bed after lunch. An observation of Resident #3 on 7/23/26 at 11:22 a.m. revealed two staff members were setting Resident #3 up in her wheelchair. The Hoyer lift was observed in the room behind the wheelchair and the staff members stated they had just gotten Resident #3 out of her bed and into her wheelchair. An interview with CNA B on 7/23/26 at 1:29 p.m. revealed Resident #3 liked to get out of the bed sometimes, but the resident's POA wanted her out of the bed more often than the resident requested. CNA B stated it took time to get Resident #3 out of bed because she was a 2 person assist. CNA B stated she was unsure of how long it should take to get Resident #3 out of bed from the time she requested to get out. An interview with CNA C on 7/23/26 at 1:42 p.m. revealed he was the CNA assigned to Resident #3 and had assisted in transferring Resident #3 out of her bed into her wheelchair. CNA C stated Resident #3 asked him at about 8:20 a.m. when he was bathing her roommate, when he was going to get her out of the bed. CNA C stated he had gotten Resident #3 out of bed around 11:00 a.m. CNA C stated he told Resident #3 he would get her out of her bed when he was done bathing her roommate. CNA C stated he bathed all the residents he was assigned to first then he assisted them with getting them out of their bed. CNA C stated Resident #3 required a 2 person assist with Hoyer Lift and therefore it took him longer to get her out of bed. CNA C stated he did not believe Resident #3 was affected by waiting 3 hours to get out of bed because he explained when he would assist her. CNA C repeated he explained to Resident #3 he would get her out of bed once he finished bathing her roommate and therefore, she should not have been upset about waiting 3 hours to get out of bed.An interview with CNA D on 7/23/26 at 2:02 p.m. revealed she assisted CNA C with transferring Resident #3 out of her bed into the wheelchair around 11:00 a.m. CNA C stated Resident #3 required two people and the Hoyer lift to get her out of bed. CNA C stated it was typical for Resident #3 to have been out of bed by 11:00 a.m. CNA C stated Resident #3 was usually out of bed by 11:00 a.m. because that was when the CNAs were available to help her out of bed. CNA C stated the CNAs had a lot of other residents and must meet their needs as well. CNA C stated Resident #3 never asked her personally to get her out the bed before 11:00 a.m. but her POA has requested Resident #3 be out of bed early. CNA D stated a resident waiting for several hours to get out of bed could make the resident unhappy or frustrated. An interview with Resident #3 on the patio on 7/23/26 at 2:43 p.m. revealed she preferred to be out of her bed and out of her room. Resident #3 stated she liked to get out of her bed early in the morning but that had not been happening. Resident #3 stated she had asked her CNA early morning, when he was assisting her roommate, to get her out the bed but had not recalled the time. Resident #3 stated she waited a very long time to get out of bed today but could not state the length of time she waited. Resident #3 stated she had gotten upset several times for having waited so long to get out of bed that she called her relative to complain. An interview with the Interim DON on 7/23/26 at 3:20 p.m. revealed she was covering at the facility that day but was a DON at another facility. The Interim DON stated the Administrator of the facility was not at the facility but was at a conference. The Interim DON stated the expectation for staff was they assisted residents with getting out of bed as soon as they requested if they were not assisting other residents at the time. The Interim DON stated if the staff were busy and would not be available for a long time then the expectation was staff look for someone available to assist the resident with getting out of bed. The Interim DON stated regarding Resident #3, she expected the staff to assist the residents in getting up as soon as they were free. The Interim DON stated the relative of the resident had expressed her concerns to her that morning and she had already started an in-service on timely transfers. The Interim DON stated it was not okay for a staff member to take 3 hours to get a resident out of their bed when they requested it, unless the staff was truly providing the other resident with a bed bath for 3 hours. The Interim DON stated a long wait for a resident to get out could negatively affect their mood and the residents could have felt like staff had not wanted them out of bed. Record review of the facility's Resident Rights policy, with an unknown revision date, reflected The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the residents. The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source

Based on observation, record review and interviews, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 3 of 3 shower rooms (Shower room [ROOM NUMBER], Shower room [ROOM NUMBER] and Shower room [ROOM NUMBER]), 1 of 4 residents halls (Resident Hall #2), 1 of 3 linen closets (Linen Closet in 200 hall), 1 or 5 resident bed linens (Resident #6) reviewed for clean homelike environment: The facility failed to provide stain free bed linens for Resident #6 on 5/19/26.The facility failed to ensure all shower rooms were visibly clean and free of debris and trash on 5/22/26.The facility failed to ensure Resident Hall 200 was free from urine on the floor on 5/22/26.The facility failed to ensure the bed linens stocked in the Linen Closet in the 200 Hall were stain free. These failures could place residents at risk of exposure to infectious diseases, other unsanitary health hazards and affect their sense of dignity.Findings Include: Record review of Resident #6's Quarterly MDS Assessment completed on 4/24/26 reflected a [AGE] year-old male admitted to the facility on [DATE] with little to no cognitive impairment and a BIMS score of 13. Resident #6 had the following diagnoses: Hypertension (high blood pressure), Diabetes (a chronic condition characterized by high blood sugar and Cerebrovascular Accident (when the blood supply to part of your brain is interrupted or severely reduced). An observation of Resident #6's bed sheets on 5/19/26 at 10:12 p.m. revealed the bed sheet had a large circular grey stain towards the foot of the bed. Resident #6 was groggy due to napping and stated he could not recall when staff last changed his sheets. An interview and observation with the Housekeeping Supervisor on 05/21/2026 at 8:49 a.m. revealed Shower room [ROOM NUMBER], by the front door, had a dirty floor with multiple brown marks, and two unidentified brown small objects on the shower floor. The Housekeeping Supervisor stated she did not know what the brown objects were. Observed a discarded wipe in the corner of the shower floor. The Housekeeping Supervisor stated the aides should have cleaned up after they used the shower room and it was the aides' responsibility to sanitize the showers after every shower. The Housekeeping Supervisor stated she checked the shower rooms twice per day and would clean them if they were visibly dirty. Observation of Shower room [ROOM NUMBER], in the secured unit, revealed a dirty floor with dirt marks and brownish stained tiles in the showers. The Housekeeping Supervisor stated Floor Tech A scrubbed the floors and tiles in the shower rooms every so often and housekeeping staff should have been mopping the floors in the shower rooms at least 2 times per day and as needed. Observation of Shower room [ROOM NUMBER], in the 200 hall, revealed a black wad of hair by the toilet and resident clothing hanging over the shower wall. The Housekeeper Supervisor stated the black wad was a hair ball and she proceeded to pick it up with a paper towel and throw it in the trash. The Housekeeping Supervisor was unable to identify whose clothing was hanging on the shower wall but stated it looked as though someone was about to shower and they were clean clothes. The shower in Shower room [ROOM NUMBER] was observed with two brown spots on the floor that were unidentifiable. Observation at 9:06 a.m. revealed a yellowish colored liquid on the floor in the 200 hall toward the linen closet. The Housekeeping Supervisor stated it was urine and asked housekeeping staff to put up a wet floor sign. Observed two CNAs in the hall near the urine. The Housekeeping Supervisor walked the surveyor to the linen closet in the 200 hall and then went and told staff the urine needed to be cleaned. The Housekeeping Supervisor then put gloves on, got paper towels, cleaned up the urine with the paper towels, and instructed the housekeeper to sanitize the floor. Observed the housekeeper spraying sanitizer and mopping the floor. Observation of the Linen Closet in the 200 hall revealed 2 blankets, 1 fitted sheet and some hospital gowns. Observation of one folded blanket revealeda light brown stain that covered almost half of the blanket while folded. The fitted sheet was also folded and the top had 4 visible grey circular stains. The Housekeeping Supervisor stated the blanket and sheet were clean linens but stained. The Housekeeping Supervisor stated it was not acceptable to use stained linens on residents' beds and she had been replacing the stained linens as she saw them. The Housekeeping Supervisor stated since starting her position in April of 2026 she had been gradually replacing the linens because all the linens at the facility were in bad shape. The Housekeeping Supervisor stated she had ordered sheets and just received them this week and would order blankets this week. The Housekeeping Supervisor stated she had 3 types of staff: housekeeping, a floor tech and laundry. The Housekeeping Supervisor stated housekeeping staff were responsible for cleaning the rooms, hallways and surfaces at the facility. The Housekeeping Supervisor stated Floor Tech A was responsible for scrubbing shower room tiles and floors twice per week. The Housekeeping Supervisor stated Laundry Staff were responsible for washing linens and sorting linens, they also stock linens. The Housekeeping Supervisor stated it was the CNAs job to clean up urine or bodily fluids from the halls and rooms and maintain the cleanliness of the shower rooms after every shower. The Housekeeping Supervisor stated housekeeping staff also cleaned the shower rooms twice per day. The Housekeeping Supervisor stated the risk to the residents of having soiled floors in the hallway and dirty showers was the risk of cross contamination and spread of bacteria. The Housekeeping Supervisor stated staff should not have been using stained linens to make beds because it could make residents feel as though their sheets were dirty and it was a risk of cross contamination. The Housekeeping Supervisor stated the risk to the residents of having urine on the hallway floor was the residents could have slipped. An interview with Floor Tech A on 05/21/2026 at 10:25 a.m. revealed it was his responsibility to scrub the tiles and floors of the shower rooms on Tuesdays and Thursdays. Floor Tech A stated he was using tub and tile spray and used his scrubbing machine. Floor Tech A stated he last scrubbed them on Tuesday (05/19/26) and was waiting on the CNAs to finish the resident showers so he could scrub them today. Floor Tech A stated it was his responsibility to make sure the floors in the shower room were clean. Floor Tech A stated he made rounds all day every day throughout his shift to check the shower rooms for cleanliness. Floor Tech A stated CNAs were supposed to clean up after themselves after they showered residents and residents being showered in dirty showers could have made residents upset. An interview with CNA B on 05/21/2026 at 10:28 a.m. revealed she last changed Resident #6's sheets yesterday when she showered him. CNA B stated she used whatever sheets were available to them and some of the sheets had stains on them. CNA B stated she told Laundry Aide C about the stained sheets, but nothing was done because it was up to the Housekeeping Supervisor to order more sheets. CNA B stated stained sheets could affect the residents because it could make them feel dirty, unclean and they could have gotten upset. CNA B stated when she used the shower rooms before she left, she would put the towels in the dirty clothes, put away all the toiletries and clean the shower chair she used. CNA B would also ensure she cleaned up all the trash and if the resident had a bowel movement during the shower she was responsible for cleaning it up. CNA B stated it was CNAs responsibility to clean up bodily fluids, such as urine and feces and it was not housekeeping's job. CNA B stated anytime there were bodily fluids in the rooms, hallways or showers, housekeeping would spray something over it, the CNA would clean it up and then housekeeping would go after and sanitizer it. CNA B stated the risk of not cleaning bowel movement or urine correctly would have been residents could have slipped or it could have made them sick due to cross contamination and spread of bacteria. An interview with Laundry Aid C on 05/21/2026 at 10:43 a.m. revealed she documented on a daily log the numbers of linen she puts in the linen closets. Laundry Aid C stated they could not use stained linen, and it was her job to make sure stained linens were not sent out to the halls. Laundry Aid C could not state the reason the stained blanket and fitted sheets were in the linen closet because she typically put stained linens aside to show to the Housekeeping Supervisor before she threw it away. Laundry Aid C stated she would show the Housekeeping Supervisors the number of linens she was throwing away so the Housekeeping Supervisor would know how many to order. Laundry Aid C stated she received new sheets this week and she had to wash them before they used them, but noted they were flat sheets. Laundry Aid C stated they received a shipment of washed clothes and fitted sheets today. Laundry Aid C stated stained sheets could affect residents because residents could feel bad about stained sheets and may not want to lay on them. An interview with the Regional Compliance Nurse on 05/21/2026 at 11:17 a.m. revealed it was the responsibility of the nursing staff to clean up bowel movements, urine and bodily fluids from hallways, shower rooms and rooms. The Regional Compliance Nurse stated after the CNAs cleaned up urine/bowel movement, housekeeping would then disinfect the area. The Regional Compliance Nurse stated the risk to the resident of not having had the urine cleaned up immediately would have been the resident could have fallen; they could track it and transfer germs to others. The Regional Compliance Nurse stated it was CNAs' responsibility to clean up after themselves after every resident shower and if bowel movements or bodily fluids were in the shower the CNAs must clean them and notify housekeeping staff. CNA B stated it was the responsibility of housekeeping staff to clean the floors in the shower rooms. The Regional Compliance Nurse stated it was a dignity issue for residents to shower in a dirty shower and if showers were not cleaned after each resident shower it could cause the spread of bacteria and infection. The Regional Compliance Nurse stated staff should not have been using stained sheets on resident beds because it could have affected the resident's sense of dignity. An interview CNA D on 05/21/2026 at 1:19 p.m. revealed she changed residents' sheets if they were wet or soiled and after each shower. CNA D stated sometimes the clean bedding was stained and if it had a big stain, she would look for other linen if it was a small stain she would use it until other linen was available. CNA D stated she had not reported the stained linen to anyone. CNA D stated stained linen could affect the residents' happiness as they could feel down about having had stained sheets. CNA D stated after showers she made sure to clean whatever mess she made to include, removing dirty linen and spraying the area with disinfectant. CNA D stated if there was hair, trash or bowel movement she would clean it up and then notify housekeeping to sanitize. CNA D stated the risk of having a visibly dirty shower would have been a risk of contracting infections or the spread of bacteria. An interview with the Administrator on 05/21/2026 at 2:40 p.m. revealed the expectation of cleanliness for the shower rooms, included them being free of debris, mildew and should have always been clean. The Administrator stated it was the responsibility of the Housekeeping Supervisor to keep the showers clean and the responsibility of the CNAs to clean up urine from halls. The Housekeeping Supervisor and Laundry Aid C should have been keeping track of stained linen and whether they should have been replaced. The Administrator stated she had never told anyone not to order linens. The Administrator stated the Housekeeping Supervisor was new and when she started, she had told the Administrator they needed a lot of linen, and they had been ordering them. The Administrator stated it was not okay for staff to put stained linens on residents' beds. The Administrator stated the risk of having dirty linens and dirty showers would have been violation of their resident rights, it could have been an environmental hazard, cross contamination and infection control issues. Review of the facility's policy Resident Rights with no revision date reflected The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on observation, interviews and record review, the facility failed to store food in accordance with professional standards for the facility's only kitchen observed for food service safety.The facility failed to ensure food items in the facility refrigerators and dry storage were dated and labeled.These failures could place residents at risk for food borne illnesses and food contamination.Findings included:An observation on 05/19/26 at 10:23 AM in the facility's only kitchen revealed the two-door refrigerator contained previously opened two cans of mayonnaise, one can of mustard, one can of pickles that were not dated on the date opened. An observation of the three-door freezer revealed 6 packs of angel food cake in transparent plastic bags that were not dated with the expiration date or labeled with the name of the food item. An observation of the dry storage area revealed three cereal bags stored in transparent plastic bags were not dated with the expiration date and labeled with the name of the food items. An observation and interview on 05/19/2026 at 10:40 AM with the Director of Food and Nutrition revealed she had been working at the facility for 14 years. She walked along and looked at the food items which were not dated inside the two-door refrigerator, not labeled and dated in the three-door freezer and dry storage room. She stated she could not tell if those food items were good to use since they did not have a date reflecting when they were received/taken out of the original packing or opened. She stated the dietary staff followed the 'use by date chart' posted on the kitchen wall to identify and decide how long a food item was safe to use. She stated all dietary staff were responsible for dating and labeling food items once they were received, date when it was taken out of the original packaging, and when it was opened. She stated it was important for the food items to have those dates on them to easily identify if the food was good to use and to discard it by the use by date. She stated not dating, labeling food items would put all residents at risk for food borne illness. She stated all the dietary employees received training and in-services on safe food handling practices. She discarded the food items in the two-door refrigerator which were not dated. An interview on 05/20/2026 at 10:50 AM with the Dietary Cook, she stated she has been working at the facility for 7 years. She stated all the dietary staff were responsible for dating, labeling food items which were stored in the kitchen with date when it was received, and taken out of the original packaging. She stated not dating and labeling food items would put residents at risk for food borne illness. She stated she had received in-services on safe food handling. An interview on 05/20/2026 at 11:36 AM with the Dietary Staff, she stated all the dietary staff were responsible to date and label food items stored in the kitchen as when it was received/opened and taken out of the original packing. She stated not dating, labeling food items would put residents at risk for food borne illness. She stated she had received training on how to safely handle food as part of her hiring process. Review of the undated facility policy titled Food Storage and Supplies Procedure: .Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 resident (Resident #9) of 5 residents reviewed for ADLs. The facility failed to ensure Resident #9 had his fingernails trimmed and cleaned on both hands on 05/19/2026. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and skin breakdown, and a decreased quality of life.Record Review of Resident #9's Quarterly MDS assessment dated [DATE] as a [AGE] year-old male with initial admission date of 05/20/2016 to the facility. His pertinent diagnoses included: dementia (a decline in cognitive abilities, severe enough to interfere with daily life), legal blindness, and cognitive communication deficit. His BIMS score was 14, which indicated Resident #9' cognition was intact. Resident #9 needed maximal assistance with personal hygiene. Review of Resident #9 's Comprehensive Care Plan, revised 03/04/2023 reflected, Focus: [Resident #9] has ADL self-care performance deficit related to impaired mobility.Interventions: . [Resident #9[ requires up to extensive assistance by one staff to perform activity. In an observation and interview on 05/19/2026 at 11:50 AM revealed Resident #9 was lying in his bed. The nails on both hands were approximately 0.3cm in length extending from the tip of his fingers. The nails were discolored, tan and had green brownish colored residue underside. Resident #9 stated he was blind and could not see his fingernails. He stated he did not like his fingernails long and dirty. In an interview on 05/19/26 at 12:04 PM, LVN H stated CNAs and nurses were responsible to clean and cut the residents' nails as needed. LVN H stated did not notice Resident #9's nails. She stated she would do it right then. She stated the risk would be infection control and injury. In an interview on 05/21/2026 at 10:42 AM, the Interim DON stated that her expectation was that ADL care be provided as needed. She stated that CNAs were responsible for providing nail care, including trimming fingernails, unless the resident had a diagnosis of diabetes. She stated that charge nurses were responsible for monitoring this care. The Interim DON stated that residents having long, dirty fingernails could result in skin breakdown and potential of infections. Record review of the facility policy Nail Care, not dated reflected . Nail management is the regular care of . fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails . It includes cleansing, trimming, smoothing . Nail care will be performed regularly and safely. The resident will be free from abnormal nail condition. The resident will be free from infection .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (Medication Cart 100) of 3 medication carts reviewed for pharmacy services. The facility failed to ensure LVN E and LVN F responsible for Medication Cart 100, counted controlled drugs every shift change. This failure could place residents at risk of not having the medication available due to possible drug diversion. Record review and observation on 05/19/26 at 10:31 AM of Medication Cart 100, with LVN G revealed missing signatures for Off nurse for 05/09/2026, 05/12/2026, and 05/17/2026 (6:00 AM to 2:00 PM shift) of the narcotic count sheet. In an interview on 05/21/26 at 10:42 AM, the Interim DON stated she expected nurses to sign the narcotic count sheet at the beginning and at the end of their shift after they completed count with the incoming and off-going nurse. The Interim DON stated if the staff were not signing the narcotic count sheets, she was unable to prove they were counting. The Interim DON stated it was important to ensure a drug diversion did not occur. The Interim DON stated the ADONs would check the carts randomly. In an interview on 05/21/2026 at 11:27 AM, LVN F stated she should have signed the narcotic sheet after counting the narcotics, on 5/12/26 and 5/17/26 at the beginning and at the end of the shift. She stated maybe she got busy and did not go back to sign the count sheet. She stated she knew that she was supposed to sign immediately after the count was done. She stated the risk would be potential for drug diversion. In an interview on 05/21/26 at 11:30 AM, LVN E stated she should have signed the narcotic sheet after counting the narcotics on 05/09/26 at the beginning and at the end of the shift. LVN E stated she counted with the other nurse but she did not remember why she did not sign the count sheet. LVN E stated the failure could potentially cause a drug diversion. Review of the facility's policy Controlled Medication - Administration revised 4/6/26, reflected the following: . At each shift change, a physical inventory of all controlled medications is conducted by two licensed nursesand/or one nurse and a CMA, QMAP, Med Tech or equivalent as allowed by your State regulatory agency and isdocumented on an audit record. Alternatively, the shift change audit may be recorded on accountabilityrecord if there is a designated column for the audit .

Based on observation, interview and record review, the facility failed to ensure that residents received routine and 24-hour emergency dental services for one (Resident #44) of six residents reviewed for the provision of routine/emergency dental services.The facility failed to ensure Resident #44 received routine dental care.This failure could affect residents by placing them at risk of pain, weight loss, infection, difficulty eating and a decline in their quality of life due to unmet dental needs. Record Review of Resident #44's face sheet dated 05/21/26 revealed a [AGE] year-old female with admission date 01/08/26. Her diagnoses included: Dementia (severe decline in mental ability), Muscle Weakness (reduction in ability to exert force), Cognitive Communication Deficit (difficulty with communication caused by disrupted brain functions), Chronic Kidney Disease (damaged kidneys are unable to filter blood), and Alzheimer's Disease (progressive brain disorder).Record review of Resident #44's quarterly MDS assessment, dated 03/16/2026, reflected a BIMS score of 02, which indicated severe cognitive impairment. Section GG0130-Functional Abilities revealed partial/moderate assistance which indicated the helper does less than half the effort for oral hygiene. Review of Resident #44's Care Plan, revised 01/22/2022, reflected Resident #44 required extensive assistance by one staff with personal hygiene and oral care. Record review of Resident #44's electronic health record did not reflect dental services. During an observation and interview on 05/20/2026 at 8:55 a.m., Resident #44 revealed she wanted to go to the dentist. She stated she had not received dental services. She stated she didn't have issues with chewing or drinking. The observation of Resident #44's teeth revealed missing teeth at the top of the mouth and dark colored, missing teeth in the lower part of the mouth and dark gums.During an interview on 05/20/2026 at 11:00 a.m., the Social Worker stated she was responsible for making dental appointments. She stated there was a company that was contracted by the nursing facility for dental services and the dentist or dental hygienist would come to the facility. She stated routine dental appointments were scheduled yearly unless there was a referral for specialized dental services. She stated there wasn't documentation in PCC for routine dental services for Resident #44.During a follow up interview on 5/20/2026 at 1:40 p.m., the Social Worker stated according to the Dental Services policy, Resident #44 had Medicaid and didn't have a payer source for routine dental services. She stated if nursing brought to her attention an emergent dental need, she would try to find alternative sources for Resident #44 to receive dental services. She stated residents were not typically referred for routine dental services.During an interview on 5/21/2026 at 8:50 a.m., the Regional Compliance Nurse stated the Social Worker scheduled routine dental appointments and follow up appointments when needed. She stated routine dental appointments were important to ensure residents did not have pain, cavities, bacteria, and dignity issues. She stated residents' payer source was not a factor to determine if routine dental services were provided. She stated the IDT, which consisted of the Social Worker, nursing, and therapy, were responsible for ensuing residents received routine dental care.During an interview on 5/21/26 at 9:18 a.m., LVN I revealed she noticed Resident #44 had missing teeth. She stated dental issues were reported to the physician or nurse practitioner for an order for a dentist consultation. She stated once the consultation was received, it was given to the Social Worker for a dental appointment. She stated dental services were not relayed to the physician or nurse practitioner regarding Resident #44 since Resident #44 never complained of her teeth or mouth hurting and there were no issues with chewing. She stated she was unsure how often residents should have received routine dental care. She stated the risks of not maintaining routine dental appointments included tooth decay or infection of the gums,She stated the physician or nurse practitioner should have been informed of Resident #44's missing teeth.During an interview on 5/21/2026 at 2:27 p.m., the Administrator stated the Social Worker was responsible for making dental appointments. She stated per the dental services policy routine dental cleaning services were provided for residents upon request or when there were issues pertaining to dental care. She stated the risk to residents who don't maintain routine dental services included gum disease, weight loss, and teeth loss. Record Review of the Dental Services facility policy revealed in part: The Director of Nursing Services, or his/her designee, is responsible for notifying Social Services of a resident's need for dental services. For Medicaid residents, the facility will provide all emergency dental services and those routine dental services to the extent covered under the Medicaid state plan. If any resident is unable to pay for dental services, the facility should attempt to find alternative funding sources or delivery systems so that the resident may receive the services needed to meet their dental needs and maintain his/her highest practicable level of well-being. This can include finding other providers of dental services, such as a dental school or the provision of dental hygiene services on site at a facility.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 resident (Resident #77) of 3 residents observed for infection control. The facility failed to ensure CNA B changed gloves and completed hand hygiene during incontinent care for Resident #77 on 5/20/26. These failures could place residents at risk for infection and cross contamination of pathogens and illness. Record review of Resident #77's Quarterly MDS assessment dated [DATE] reflected Resident #77 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included brain cancer, muscle weakness, and cognitive communication deficit. Resident #77's BIMS score of 6, which indicated Resident #77's cognition was severely impaired. The MDS assessment indicated Resident #77 required maximal assistance with toileting hygiene. Observation on 05/20/26 at 11:53 AM revealed CNA B entered Resident #77's room to provide incontinence care. She washed her hands and donned (put on) gloves, CNA B unfastened Resident #77's brief. She then provided peri-care to the resident, wiping across the resident's pubis bone and then down each groin. Without changing gloves CNA B helped the resident to roll on her side, she wiped the resident's buttock area with peri-wipes, front to back, she then removed the soiled brief and with soiled gloves, placed the clean brief under the resident. She removed and discarded the dirty gloves, she washed her hands and she donned clean gloves. She rolled the resident on her back onto the clean brief. Once finished, she fastened the resident's brief, she covered the resident and she lowered the resident's bed to a low position. She removed and discarded her gloves and washed her hands. In an interview on 05/20/26 at 12:05 PM, CNA B stated she should change her gloves and perform hand hygiene when she went from dirty to clean. She stated failing to provide proper care would expose the residents to infections. In an interview on 05/21/26 at 10:42 AM, the Interim DON stated she expected the staff to remove their gloves and sanitize their hands when going from dirty to clean. She stated CNAs were trained to perform hand hygiene between change of gloves. She stated failure to do so would potentially lead to cross-contamination and possible spread of infection. She stated the ADONs would do random rounds for monitoring. Record review of the facility policy titled Fundamentals of Infection Control Precautions not dated, reflected: . Failure to change gloves between resident contacts is an infection control hazard.

Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 2 halls (Hall 200) reviewed for pest control.1. The facility failed to ensure Hall 200 was free of gnats.2. The facility failed to ensure one room at the south end of the hall was free of gnats.These failures could place residents at risk of infestation of pests and compromise resident health.Findings included: Observation on 01/29/2026 at 9:48 A.M. on the south end of Hall 200 revealed 1 gnat flying around. During an observation and interview on 01/29/2026 at 11:05 A.M. with Resident #2, in her room at the south end of Hall 200, she revealed the gnats had always been an issue. She indicated the gnats were worse, compared to the past. When asked if the gnats bothered her, she said, oh yeah. Resident #2 said she told staff about the gnats, and it could be a topic of conversation for anyone who came into the room. She said as far as she knew the room had been sprayed. This state surveyor counted 3 gnats around Resident #2, and 5 gnats around the sink in the room. Observation of the sink in the room revealed that sink was clean and had no foul odors. Observation on 01/29/2026 at 12:26 P.M. revealed 1 gnat flying around in the north end of Hall 200. Observation on 01/29/2026 at 12:28 P.M. revealed 1 gnat flying around the nurse's station in Hall 200. During an interview on 01/29/2026 at 1:05 P.M. with LVN I, she revealed she saw gnats and was supposed to tell housekeeping if there were gnats in resident rooms. She said pest control had come and sprayed chemicals and it worked. LVN I said the risk of having gnats was they were not good and could fly into residents' mouths, noses, hair, and in their skin. During an interview on 01/269/2026 at 2:56 P.M. with LVN J, she said she saw gnats but not in the whole building. She indicated she saw gnats on a meal tray in a resident room and took the meal tray out of resident's rooms when she saw them. LVN J said maybe food (in the resident rooms) was an issue. She said the risk to residents was it might bite the residents or (residents) would not want to eat the food. She said pest control came when called and she reported pest issues to the administrator. During an interview on 01/29/2026 at 5:45 P.M. with the ADM, she revealed the facility had actively been treating the gnats. She stated the pest control company was recently at the facility and had left treatment for the facility to use to treat the gnats. She said it had been a little better, but it was a known issue and if gnats were seen during rounds the ADM was to notify the (pest control company. Records requested for review on 01/29/2026 at 2:25 P.M. and 02/02/2026 at 2:22 P.M. for the facility's pest control policy and pest control log. The facility only provided the food service department's Insect and Rodent Control policy. A pest control policy for the whole facility and a pest control log was not provided. Record review of the facility's food service department's Insect and Rodent Control policy, dated 2012, reflected: The facility will maintain an effective pest control program in order to provide an insect and vermin free food service department.Procedure:1. Arrangements are made with a reputable company for regular spraying for insects which includes rodent control when required.2. Facility will maintain appropriate screens, close fitting doors, properly sealed water/sewer pipes, structurally maintained walls, baseboards, etc. to prevent entrance access of insects and rodents.3. Sanitation of facility will be maintained per other stated sanitation policies to prevent food sources, breeding places, etc. for insects or rodents.4. Deliveries of food and supplies will be monitored for prevention of insect and rodent access.

Based on interviews and record review the facility failed to develop and implement a baseline care plan for each resident which included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care or ensure a comprehensive care plan was developed in place of the baseline care plan if the comprehensive care plan was developed within 48 hours of a resident's admission for one of three residents (Resident #1) reviewed for baseline care plans. Teh facility failed to develop a baseline care plan within 48 hours of Resident #1's admission. This failure could place residents at risk of not receiving appropriate care upon their admission to the facility. Findings include: Review of Resident #1's face sheet, dated 01/29/26, reflected he was a [AGE] year-old male, admitted on [DATE], with diagnoses of dementia, an anxiety disorder, chronic pain, and metabolic encephalopathy (a brain dysfunction caused by other health condition, which fluctuates and can lead to confusion, memory issues, personality changes, and other problems.) Review of Resident #1's care plan page of his EMR, on 01/29/26 at 10:09 AM, reflected no care plans. Review of Resident #1's MDS page of his EMR reflected his admission MDS was still being edited (due to his recent admission date.) Review of Resident #1's progress notes reflected the following:- admission notes, dated 01/23/26, by LVN C reflected Resident #1 was admitted to the secured unit of the facility, from another nursing facility, lying on a stretcher. The note contained observable information about Resident #1, which included his vital signs at admission, and information indicating he had poor memory, used a wheelchair, and required 2-person assistance for transferring, hygiene and bathing. The notes reflected a skin assessment was done by LVN C, during which various bruising, and small scabs were observed on Resident #1's body.- A note by ADON D: Effective Date: 01/23/2026 (1:44 PM) [TF4] Type: Nursing Note: Late Entry Note Text : A copy of the baseline care plan was provided to the resident A copy of the baseline care plan was provided to the resident representative Date/time provided: 01/27/2026 12:00 AM- Notes from 01/23/26 through 01/29/26 reflected various care concerns, which included, but did not end with Resident #1's fall risk and actual falls, skin tears, hospice service, agitation, and confusion. Review of Resident #1's Baseline Care Plan Acknowledgment form, dated 01/27/26, reflected the resident and his representative were given a copy of the baseline care plan, for his admission on [DATE]. Review of Resident #1's care plan page of his EMR on 01/29/26 at 2:19 PM reflected care plans including, but not limited to care areas of ADLs, medications, skin condition and risks, cognitive status/ dementia, communication, falls and fall risk, and behavioral, all with the date initiated being 01/29/26. An interview on 01/29/26 at 10:15 AM with LVN C revealed she did not know where the baseline care plans were kept, but she did admit Resident #1 and put all his information in his admission note. An interview on 01/29/26 at 11:10 AM with the Regional RN revealed ADON D was the person who provided the baseline care plan acknowledgment to Resident #1's responsible party. She said the way the baseline care plans were made was the staff opened up the care plans in the place the regular care plans were, and did the baseline care plans as they would the regular care plans, and they continued to care plan residents from there, so they were not a separate document from the regular care plans. She looked at the state surveyor's computer screen for Resident #1's care plans and acknowledged there were none. She said she had been working with the staff to do the baseline care plans and had asked them how they were giving an acknowledgement form for care plans to people, if there were no care plans. [TF5] An interview on 01/29/26 at 12:04 PM with ADON D revealed he provided the acknowledgement form to Resident #1's family member, who was his responsible party, after they had met and had a conversation about the resident's plan of care. He said he must have forgotten to put the documentation in, because he was just moving too fast. He said there was no documented baseline care plan, only a verbal one from his meeting with Resident #1's responsible party. He said that was a problem because if it's not documented, you didn't do it, and the care plans contained instructions for the resident's care. He said the baseline care plans were the normal care plans with the information from admission and was a combination of information from the admitting nurse, and he and the DON reviewing the clinical admission information and medications. He said Resident #1 was the same as the state surveyor observed when he admitted , being groggy sometimes, quiet, a high fall risk, and mostly non-verbal. An interview on 01/29/26 at 5:29 PM with ADON E revealed the baseline care plans were important because they were provided to the residents and families in order for them to know what care the resident was getting. The Regional RN explained the admitting nurses did the admitting assessments and also entered some care plans. Review of the facility's undated, policy Base Line Care Plans reflected Completion and implementation of the baseline care plan within 48 hours [TF6] of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. This facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will- Be developed within 48 hours of a resident's admission. Include the minimum healthcare information necessary to properly care for a resident including, but not limited too [sic] Initial goals based on admission orders. o Physician orders. o Dietary orders. o Therapy services. o Social services. o PASARR recommendation, if applicable. The baseline care plan will reflect the resident's stated goals and objectives, and include interventions that address his or her current needs. It will be based on the admission orders, information about the resident available from the transferring provider, and discussion with the resident and resident representative, if applicable. Because the baseline care plan documents the interim approaches for meeting the resident's immediate needs, professional standards of quality care would dictate that it must also reflect changes to approaches, as necessary, resulting from significant changes in condition or needs, occurring prior to development of the comprehensive care plan. Facility staff will implement the interventions to assist the resident to achieve care plan goals and objectives. This facility will provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: The initial goals of the resident. A summary of the resident's medications and dietary instructions. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. Any updated information based on the details of the comprehensive care plan, as necessary. The medical record will contain evidence that the summary was given to the resident and resident.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and interventions to meet a resident's medical and nursing needs that were identified in the comprehensive assessments for 1 of 5 residents (Resident #3) reviewed for care plans.The facility failed to develop a care plan for Resident #3 to address anticoagulant medication use. This failure could place residents at risk for not receiving proper care and services.Findings included:Record review of Resident #3's face sheet, dated 01/29/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident #3 had a primary diagnosis cerebral infarction (blood clot forms in artery, disrupting blood flow to the brain, resulting in stroke). Other pertinent diagnoses included dementia (decline in cognitive function), sepsis (body's overwhelming response to infection, can lead to tissue damage and organ failure), obstructive and reflux uropathy (blockage in the urinary system that prevents normal urine flow), and acute kidney failure (kidneys suddenly lose ability to filter waste products from the blood). Record review of Resident #3's BIMs (a standardized assessment to measure long and short-term memory) assessment, dated 12/12/2025, reflected a score of 3, which indicated severe cognitive impairment. Record review of Resident #8's anticoagulant order, dated 01/29/2026, reflected: Eliquis Oral Tablet 2.5 MG (Apixaban) Give 1 tablet by mouth two time a day for clotOrder status: Active Start date: 08/21/2025. Record review of Resident #3's care plan, revised 12/20/2025, did not reflect a care plan for anticoagulants. Attempted interview on 01/29/2026 at 11:02 A.M. with Resident #3, revealed the resident did not communicate with the state surveyor. During an interview on 01/29/2026 at 4:40 P.M. with the Regional RN, she stated there should be a care plan for anticoagulant medication. The Regional RN said the care plan assisted with letting staff know if the residents had adverse reactions. She discussed interventions would include monitoring the resident every day and CNAs could do that because they looked at the resident's skin every day . During an interview on 01/29/2026 at 4:50 P.M. with ADON E, she revealed she was responsible for part of completing the care plan, which included acute care, antibiotic medications, and falls. She stated signs staff look for in residents who took anticoagulants included signs of bruising and bleeding and it was a part of the tasks for nursing staff to look for bruising and bleeding. ADON E said during rounds in the morning, the ADONs asked questions, which included if anything changed or if there was anything they needed to know about (regarding residents). During an interview on 01/29/2025 at 5:45 P.M. with the ADM, she revealed the risk of not care planning for medications like anticoagulants was residents could be prescribed something they should not be getting or be taking another medication that could result in medication interaction. Record review of the facility's, undated, Comprehensive Care Planning Policy, reflected: Comprehensive Care PlanningThe facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will describe the following - The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and the right to refuse treatmentAny specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASAR (preadmission screening and resident review) and the resident's representative(s)-The resident's goals for admission and desired outcomes.The resident's preference and potential for future discharge. The facility document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.Discharge plans in the comprehensive care plan, as appropriate.Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of three residents (Resident #1) reviewed for supervision. CNA A and CNA B failed to safely transfer Resident #1 when they supported the resident under his arm-pits and with a gait belt while lifting him from the floor to his wheelchair, instead of using a mechanical lift. This failure could place residents at risk of injury.Findings included: Review of Resident #1's face sheet, dated 01/29/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included dementia, an anxiety disorder, chronic pain, and metabolic encephalopathy (a brain dysfunction caused by other health condition, which fluctuates and can lead to confusion, memory issues, personality changes, and other problems.) Review of Resident #1's MDS page of his EMR reflected his admission MDS was still being edited (due to his recent admission date.) Review of Resident #1's care plans, initiated on 01/29/26, reflected care plans which included the following:- ADL self-care deficit, with interventions including two-person assistance bathing and bed mobility.- risk of falls related to dementia, diagnoses, and unfamiliar surroundings, with interventions including two-person assistance with transfers. No assistive devices were referred to in the care plan.-use of, and monitoring for side effects of, antidepressant, anti-psychotic, and anti-anxiety medications Review of Resident #1's progress notes:- admission notes by LVN C on 01/23/26 reflected Resident #1 was admitted to the facility via EMS, on a stretcher, accompanied by a family member. He had large bruises to the fronts and back of his knees, and to his outer thigh area. Resident #1 required two-person assistance for bed mobility (moving himself around in his bed), transferring, dressing, bathing, and hygiene, and one-person assistance for eating, and used incontinence briefs/pads. He used a wheelchair most of the time, but was unable to use devices or comprehend instructions, due to his poor cognition. It was noted that his ability to make daily decisions was poor, and he required reminders, cues, and supervision in planning, organizing, and correcting daily routines. He was alert, had short-term memory problems, and was oriented to person.- A skilled nurse note by LVN F on 01/25/26 reflected Resident #1's bed was lowered for safety (as a precaution against fall injury.)- A skilled nurse note by LVN G on 01/25/26 reflected Resident #1 was combative, agitated, did not call for assistance, and resisted being redirected. The note indicated additional fall precautions (air mattress and fall mat by bed) and close monitoring were put in place.- A nursing progress note by LVN H reflected Resident #1 had an unwitnessed fall and was found next to his bed on the fall mat, with a skin tear on his elbow, but no other injuries. Review of Resident #1's Fall Risk Assessment, effective 01/24/26, reflected he was a high risk for falls due to a history of one to two falls in the past three months, intermittent confusion, being chair-bound, inability to stand, and taking multiple medications which could contribute to fall risk within the past seven days. An observation on 01/29/26 at 9:47 AM revealed Resident #1 was sitting on the floor in the dining area, in front of his wheelchair, and LVN C ran to help him, while calling for CNA A and CNA B to assist. LVN C assessed Resident #1. Found no evidence of injuries, and asked CNA A and CNA B to transfer him back to his chair. The CNAs transferred Resident #1 back to his chair by placing a gait belt on him, getting on either side of him, facing him, both grabbing the gait belt in the back, and using their other arms to place their forearms directly under each of Resident #1's arm pits, and lifting. During the lift, the gait belt slid up Resident #1's back, and the resident appeared to not assist in the transfer at all, causing the CNAs to have to do all of the lifting to place him back in his wheelchair. LVN C took the resident next to the nurses station, and sat down next to Resident #1 who leaned forward in his chair. She told him to sit back, and put her hand on his shoulder, and he sat back. She sat next to him for a few minutes, then went inside the nurses' station to document the incident and make notifications. CNA A stayed near and talked to Resident #1, who appeared sleepy and opened his eyes partially, occasionally, and closed them. During this observation, Resident #1 attempted to stand up again, and CNA A reminded him to sit in his wheelchair, and he sat down. An interview on 01/29/26 at 10:15 AM with LVN C revealed Resident #1 was a two-person transfer, was not weight-bearing, and his assessment after this fall showed no signs of injury. She said she notified the DON, the physician, and the responsible party, after she assessed him, and started neuro checks (monitoring done when someone might have hit their head during a fall.) When asked if the CNAs had done a proper transfer of him from the floor to his wheelchair, she said she thought the CNAs were supposed to cup their arms under his and lift him. During this interview, Resident #1 leaned forward and put his hands on the arms of his wheelchair, as if he was going to stand up, and LVN C put her hand on his shoulder and said We aren't going to get up yet, because you could fall again and the resident leaned back in his chair and relaxed. An interview on 01/29/26 at 10:22 AM with OT revealed she had not met Resident #1, but if a resident fell, the staff was to wait for the nurse to assess the resident. She said if the resident was unable to help staff get them off the floor, the staff would use a gait belt, or the hoyer lift. She said there were various methods of getting someone up, depending on the resident's ability and size, and the staff doing the lift. She said there was a way to assist someone up from behind using the gait belt, if the resident was able to sit themselves up, but she would never go under their arms to lift them. She demonstrated how someone could assist someone from behind, which involved putting their arms around the resident and grasping their hands in front of the resident's chest, but did not put stress on the arms or shoulders. She left to go check on Resident #1. An interview on 01/29/26 at 10:41 AM with the DOR revealed the staff should assess a resident who had fallen while they were on the floor, and they should know their limitations in lifting the resident. He said if the staff were not strong enough to lift using a gait belt, they should go get a mechanical lift, and they should always wait until the nurse had assessed the resident. He said if the lift was outside of the resident's or staff's capabilities of lifting safely using the gait belt, they should use the mechanical lift. He said they did training with staff on safe lifting, to make it safer for the residents and the staff. He said they were to never to lift under the arm pits, because the resident could pull a muscle or dislocate their shoulder. He said the ice storm during the time Resident #1 was admitted had interfered with staffing and therapy's evaluation of some residents, who were normally assessed very soon after admission. An interview on 01/29/26 at 11:16 AM with CNA A revealed she had been a CNA for a long time, and the facility had done training on how to lift safely. She said she was not really sure if the way Resident #1 was lifted was the way he was supposed to be lifted, and she was aware someone could be hurt by lifting them under their armpits. She said Resident #1 had been able to assist in being lifted, but only a little bit, and he was weight-bearing, and they had used the gait belt for most of his weight. She said she saw Resident #1 stand up after he was admitted , so she knew he was able to assist in standing, so the way they lifted him was a judgment call and nobody had told her how to lift him. An interview on 01/2926 at 11:38 AM with CNA B revealed they normally transferred Resident #1 with a gait belt, because he helped, but this time he would not help, so they had to get under his arms to transfer him. She said lifting someone under their arm pit could hurt their shoulder, knock it out of place, or cause a fracture. She said the resident was new to the facility, and she had not expected him to be dead weight but should have used the mechanical lift, which was what they normally did if someone could not stand, or bear weight. She said he was total, meaning he could not do any part of the lift by himself, and sometimes he worked with them on transfers, and sometimes he didn't. She said if they were lifting him with the gait belt, they should have used his pants waistband to steady him, not his arms. An interview on 01/29/26 at 12:04 PM with ADON D revealed Resident #1 was new, and when he admitted he thought the resident was unable to bear weight, and had not noticeably changed since his admission. He said Therapy usually screened new residents very quickly after they admitted , usually the day after the admission, but the lingering icy weather had impacted therapy's staffing, as well. After the nurse did a thorough assessment of the resident, the staff should have used a mechanical lift to get him up, and should never lift someone under the armpits. He said they did in-services and skills check-offs with the CNAs to make sure they knew how to properly transfer residents, and they did cover how to get a resident off the floor. An interview on 01/29/26 at 5:29 PM with the Regional RN and ADON E revealed the Regional RN said there were two or three ways to transfer a man in the situation Resident #1 had been in, and none of them ever involved using the resident's arm. She said they could have pulled the resident's arms out of the sockets. ADON E said lifting a resident the way the CNAs had done, it could cause physical trauma or skin tears. The Regional RN said the staff were trained on how to move a resident, but were currently being trained again. She said it was the ADONs' and nursing management's responsibility to make sure the staff knew how to lift, and how to do it right, and they had done training and skills check-offs on all types of transfers. Review of a CNA Proficiency Audit for CNA A, dated 11/26/25, reflected she performed satisfactorily in one-person assisted, two-person assisted, mechanical lift two-person, and ambulatory resident transfers. Review of a CNA Proficiency Audit for CNA B, dated 11/26/25, reflected she performed satisfactorily in one-person assisted, two-person assisted, mechanical lift two-person, and ambulatory resident transfers. Review of the facility's undated policy Moving a Resident Bed to Chair/ Chair to Bed reflected no mention of what to do when a resident was unable to assist in a transfer, or bear weight. The document did reflect: Purpose: The purposes of this procedure are to allow the resident to be out of his or her bed as much as possible and to provide for safe transferring of the resident. Steps in the Procedure: Note: This procedure may require two (2) persons [.] 9. If moving a resident from bed to chair: [.] b. If transferring the resident to a wheelchair: 1. Be sure the wheels are locked; [.] h. Position a gait belt around the resident's waist and clasp it. Make sure it is tight enough that only a slight hand movement will guide the patient, but not so tight that you cannot firmly grasp the belt without making the patient uncomfortable i. If the resident requires, two persons (one on each side) should grasp the gait belt and gently stand and turn the resident and sit him or her in the chair. j. If the resident can assist in this procedure, stand on the resident's weak side. (Note: Encourage the resident to use his or her strong side and to assist in the procedure as much as possible.) k. Support the resident by placing a gait belt around the resident's waist for you to hold and steady the resident. 1. Instruct the resident to turn so that the back of his or her legs are near the chair. m. Instruct the resident to place his or her hands on the arms of the chair for support. n. Move with the resident. o. Be sure the resident is all the way back in the chair. [.] Review of the facility's undated Fall Policy reflected: Appendix A: Fall Intervention Methods: Environmental [.] Staff must be trained in safe transfer techniques and proper use of body mechanics.

Based on observations, interviews, and record reviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 of 2 (Resident #2) residents reviewed for respiratory care. The facility failed to ensure there were cautionary and safety signs indicating the use of oxygen outside Resident #2's room where oxygen was used. These failures placed the residents at increased risk of injury due to fire hazards.Record Review of Resident #2's admission Record dated 09/04/2025 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of Cerebral Infarction(-stroke), and secondary diagnosis of Chronic Respiratory Failure with Hypoxia (condition where the lungs do not function properly) and Tracheostomy status (Presence of tracheostomy in which a hole is made in the front of the neck to the windpipe, known as the trachea, which a tube is placed to keep it open for breathing).Record Review of Resident #2's Order Summary Report dated 09/04/2025 revealed order for 2 LPM via nasal cannula when trach is capped during the day, oxygen via trach daily every day shift for oxygen related to Chronic Repository Failure with Hypoxia. During an observation and interview on 09/04/2025 at 09:52 AM with Resident #2 revealed she was sitting up on the side of bed, wearing oxygen via nasal cannula connected to an oxygen concentrator running at 2 LPM and Tracheostomy capped off. She did not voice any concerns about her oxygen intake. There was no sign outside her room indicating oxygen use. Interview on 09/04/2025 at 2:11 PM with ADON revealed there was not a set individual responsible for making sure oxygen signage was posted on Resident #2's door. He stated the risk of not having oxygen in use signage was so no one will blow up and not to mix and match chemicals. The importance of oxygen in use signage was to let others know which residents have oxygen. Interview on 09/04/2025 at 3:36 PM with DON revealed, the DON and ADON are responsible for ensuring oxygen in use signage was placed on the Resident's door, to alert staff not to use petroleum jelly around her nose and nothing flammable. The risk was possible harm to the resident. Review of facility's policy and procedure titled, Oxygen Administration undated revealed; 11. Place No SMOKING signs in area when oxygen was administered and stored. Store oxygen cannister in areas free of flammable substances. Avoid the use of electrical appliances in the area of oxygen use as well .

Based on observation, interviews and record reviews the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #1) reviewed for pain management. The facility failed to follow their pain management policy when Resident #1's response to pain medication was not monitored and effectiveness was not recorded.This failure could place residents at risk of uncontrolled pain.Findings included:Record review of Resident #1's admission record, dated 09/04/2025, revealed a [AGE] year-old female who admitted to the facility on [DATE] with type 2 diabetes (a disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels) and dementia (brain disease that alters brain function and causes a cognitive decline). Record review of Resident #1's BIMS assessment, dated 08/27/2025, revealed a score of 2, indicating severe cognitive impairment. Record review of Resident #1's progress notes, dated 09/01/2025, written by LVN H revealed, Resident noted with swelling and bruising on the right wrist, with discoloration observed. Per previous report, findings are possibly related to delayed injury from a recent fall. NP assessed resident during unit visit and provided new orders: X-ray 2-view of right hand and application of ice pack BID x 3 days. Safety maintained; resident monitored for pain and further changes.Record review of Resident #1's Event Follow up note, dated 09/01/2025, written by LVN H revealed, in part .New orders: 2 view x-ray to the right wrist Due to pain /bruising and swellingName of MD/NP notified: [Name] NP Date/time of notification: 09/01/2025 12:00 PMName of RP notified: [Name] Date/time of notification: 09/01/2025 12:00. Record review of Resident #1's progress notes, dated 09/01/2025, written by LVN H at 8:20 PM revealed, Nurse on [shift] following up on X-ray order placed this morning, called X-ray provider, [Provider Name] twice, and received no answer from the receiving end. report given to oncoming nurse to monitor and report on pending stat X RAY to be done.Record review of Resident #1's progress notes, dated 09/01/2025, written at 10:45 PM by LVN G revealed, Resident in bed sleeping with eyes closed after shift report. Respirations even and non-labored. HOB elevated 30-35 degrees. No signs of any respiratory distress or SOB noted. Right wrist swelling and bruising in place as per report received from 0600-2200 (6:00 am - 10:00 pm) shift nurse. No signs or symptoms of any discomfort noted when site lightly palpated. VS- R. 20, O2 Sats 95RA, B/P 133/74, P. 70, T. 97.3. Right wrist elevated to decrease swelling. Resident continues on Ice pack application to sited as ordered while waiting for X-Ray to be done/ report. Bed placed in lowest position with bolsters and floor mat in place for safety. Continue to monitor resident.Record review of Resident #1's progress notes, dated 09/02/2025, written by LVN H at 2:34 PM revealed, Resident's right wrist remains swollen. Ice pack applied as ordered for pain and swelling. Nurse followed up with [Provider Name] regarding X-ray order; confirmed X-ray technician scheduled to arrive today for imaging. [RP, Name] was notified and requested ongoing updates on the resident's progress. Safety and comfort maintained. Will continue to monitor.Record review of radiology report, dated 09/02/2025, revealed RIGHT TIBIA(shinbone)/FIBULA(calf bone) SERIES Findings: Examination of the right tibia/fibula demonstrates no evidence for fracture. There are no bony abnormalities. The soft tissues are unremarkable. IMPRESSION: Negative Study.Record review of Resident #1's progress notes, dated 09/02/2025, written by LVN H at 10:13 PM revealed X-ray results of the resident's right wrist faxed to NP; findings indicate no fracture. NP recommended continued icing and elevation of the arm on a pillow. New order was received to apply a sling to the right hand while the resident is awake. Safety and comfort maintained. Will continue to monitor.Record review of Resident #1's progress notes, dated 09/03/2025, written by LVN G at 4:34 AM revealed, Resident right wrist elevated as tolerated d/t swelling. Bruise intact and clearing. No signs of any discomfort noted when resident wrist assessed. VS- R. 20, O2 Sats 95%RA, B/P 129/77, P. 76, T. 97.4. Bed in lowest position with bolsters in place and floor mat in place and close to bed for safety. Call light in reach.Record review of Resident #1's progress notes, dated 09/03/2025, written by LVN B at 9:53 AM revealed resi alert w/ large bruise to R hand. no SOB or acute resp distress observed. N/O received to send resi to ER of [Hospital Name] in [City] for further evaluation and treatment due to large bruise to R hand. VS taken & WNL w/ 129/77 63 19 97.8 97 and BS 128. Routine ice pack + PP admin w/ positive outcome. EMS was called and transported resi out of facility at 10:05am. resi [RP Name] was informed of resi being transported.Record review of Resident #1's progress notes, dated 09/03/2025, written by the DON at 10:09 AM This Called resident [RP], and received call back, regarding swelling to R wrist. This nurse explained the interventions in place, and I thought to believe could be from delayed injury from previous fall. The [family member] explained that [Resident #1] did not have swelling to hand, she was playing around hitting a family member and playing and laughing with family Friday the [family member] requested the resident be sent to ER [Hospital Name] for Further eval. This nurse notified Nurse to send to ER.Record review of Resident #1's progress notes, dated 09/03/2025, written by LVN H at 4:45 pm revealed Resident returned from [Hospital Name] with diagnosis of closed fracture distal end of R radius (broken right wrist). Seen by NP during rounds; new orders: Tramadol 50 mg PO BID PRN pain, d/c Tylenol 650 mg, start Tylenol 1 g PO q8h PRN pain. Splint to remain on at all times; sling when OOB; wrist brace and thumb spica splint in place. Resident repeatedly removed dressing and sling; nurse reapplied several times. [Family member] notified of resident's return; verbalized availability for contact, will visit tomorrow. Resident resting in bed; safety and comfort maintained.Record review of hospital x-ray results, dated 09/03/2025, revealed the following: Findings: Discontinuity of the cortex of the central articular surface of the distal radius (wrist) seen on the lateral (side) view only. Nondisplaced fracture (bones remain in alignment) of indeterminate age (unknown if new or old) cannot be excluded. No other fractures. Moderate osteoarthritis (common joint condition that causes pain, stiffness) at the radiocarpal (wrist) join t and first carpometacarpal (base of thumb) joint, No dislocation. No lytic (areas of bond destruction that result in holes) or blastic (areas of abnormal growth) lesions. Impression: Nondisplaced fracture of indeterminate age at the distal radius articular surface.Record review of Resident #1's August 2025 MAR revealed the following:- Tylenol Oral Capsule 325 MG Give 2 tablet by mouth two times a day for Pain -D/C Date-09/03/2025. Administered 09/01/2025, 09/02/2025 and 09/03/2025 for AM and PM doses.- Tylenol Oral Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for headache; pain-mild. Pain level 3. Administered on 09/03/2025 administered prn.- Ice pack to the right hand BID FOR Days /Pain and swelling right wrist two times a day for Pain and swelling Apply to right wrist twice a day for 3 days. Administered on 09/01/2025 for the PM dose, on 09/02/2025, and 09/03/2025 for both AM and PM doses, and on 09/04/2025 for AM dose. - Tramadol HCl Oral Tablet 50 MG Give 1 tablet by mouth two times a day for Pain. Administered 09/04/2025 on the AM shift.Record review of Resident #1's pain assessment, dated 09/03/2025, revealed Tylenol 325mg give 2 tabs by mouth BID and prn every 6 hours for headache and mild pain.Record review of Resident #1's August 2025 TAR revealed no pain assessment or follow up for pain medication effectiveness. Record review of Resident #1's order summary revealed the following: - Tylenol Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for headache; pain-mild. Start dated 08/07/2025- Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth two times a day for Pain. Start date 09/04/2025- Keep the Splint on at all times Keep the sling intact when out of bed Wrist Brace and Thumb Spica Splint. Start date 09/03/2025.- Orthopedic Consult to eval and treat closed fracture to distal radius (wrist). Start date 09/03/2025.Record review of intake investigation worksheet priority date 09/03/2025, revealed Resident was sent to hospital on [DATE] and returned same day with a Dx of a hand Fx.Family asked for resident to be sent to hospital due to hand discoloration and swelling on return to the facility the x-ray determined a hand Fx. Still collecting information for investigation. Observation on 09/04/2025 at 10:59 am, in the secure unit revealed Resident #1 was well groomed and dressed sitting up in her w/c at a table in the dining room. Resident #1 was looking at a magazine and did not appear to be in any pain. Resident #1's right arm was in a sling with a plastic bag of ice under the hand. Interview on 09/04/2025 at 11:01 am, MA A stated she did not normally work in the secure unit. She stated she worked yesterday morning in the unit but did not know how Resident #1's injury happened. MA A said Resident #1's hand was swelling, and the nurse already knew about it. She said if she saw any injury or new bruise or swelling on a resident she would report to the nurse immediately. Interview on 09/04/2025 at 11:17 am, LVN B stated she normally works in the secure unit Monday through Friday on the morning shift but was not at work from Friday (08/29/2025) at 2:00pm through Tuesday (09/02/2025). She stated on Wednesday (09/03/2025) she saw a bruise on Resident #1's hand, the x-ray was negative but she was sent out to double check. She said she got an order to send her out, did an assessment and called EMS and the family waited at the hospital. She stated Resident #1 was assessed for pain and has pain medication. LVN B stated Resident #1 was Spanish speaking and used a communication board and she assessed Resident #1's pain by showing an image on her phone and asking if the pain was small, medium or high . LVN B stated if a new injury, swelling or bruise was found she would automatically report it to the DON, Administrator and Doctor if she could not explain the injury or the patient was not able to explain. She stated if there was an order for a stat x-ray they would be there within 4 hours and if not, she would let them know so they could be sent out. Interview on 09/04/2025 at 11:36 AM, CNA C stated she worked over the weekend and did not see any bruising on Resident #1's hand. She said when she came in Monday (09/01/2025), she noticed the bruise and reported to the nurse immediately. Interview on 09/04/2025 at 12:18 PM, the Administrator stated from his understanding it was found Resident #1's hand was swollen. He stated he rounded with the DON yesterday and she brought it to his attention that the RP requested Resident #1 be sent out for an x-ray. The Administrator stated he did see Resident #1's hand before she was sent to hospital and it was swollen with some bruising, but she could move all digits. He stated as he started doing the investigation he realized there were some communication issues between staff and Resident #1's family about what happened. He stated he found out Resident #1's fall was on 08/15/2025, and that was considered a separate incident and could not be tied to the wrist fracture. He stated he had not personally seen the results, but the family said there was a fracture. He said as he started in servicing, asking questions and getting statements, the swelling was found on Monday, a stat x-ray was ordered but the x-ray company never came out. When the x-ray was completed, the x-ray was of the forearm and was negative. He stated the expectation for staff was if a stat x-ray was ordered and not completed within 4 hours they should send the resident out. He said the risk to residents could be continued pain and delay of treatment.Interview on 09/04/2025 at 2:24 PM, the Medical Director stated staff notified him on 09/03/24 that Resident #1 went out and she had a fracture. He stated he was going to round on Resident #1 today. He stated he would order an x-ray, depending on what that shows, would come see the patient, then if something needed to be addressed by orthopedic then send to the emergency room. He stated his expectation for staff was if a stat x-ray was ordered and not done, or if patient was having severe pain then send them out. Interview on 09/04/2025 at 2:49 PM, Resident #1's RP stated on 09/02/2025 around 2:30 pm, the nurse called to inform her of Resident #1's bruises on right hand possibly from a fall on the 15th. The RP said, How could she have bruises? ; she did not see any over the weekend when the whole family came to see her. The RP stated she spoke with the DON who said late injuries were found from the fall on the 15th. The RP stated she requested for Resident #1 to go to the hospital and met her there. The RP stated the hospital physician stated the fracture happened at least 48 hours ago and not three weeks ago. The RP said she went back to the facility with a splint. Interview on 09/04/2025 at 3:03 PM, the NP stated on Monday 09/01/2025, when she rounded at lunch, the nurse had notified her about Resident #1's wrist. The NP stated she contacted the DON, ordered an x-ray and the x-ray came back negative. The NP said the Doctor just looked at the results and the fracture was on the side and if they did not do a lateral or 2 view it would be negative. She said if the order was stat, it should be done within 4 hours. She stated if a stat x-ray was not done within that time, staff should contact her or send the resident out. She said Resident #1's pain was managed with Tylenol and ice. She said she changed the pain medication yesterday, to Tramadol twice a day and increased Tylenol.Interview on 09/04/2025 at 3:26 PM, the DON stated on Monday (09/01/2025) Resident #1's wrist was bruised, LVN H did an event note, contacted the NP and got an order for x-ray. The DON stated she came in the next day (Tuesday) and the x-ray was not done but was ordered. She said she did not know what the delay was, but they ended up getting the x-ray done of the forearm and not the wrist. The DON stated it was ordered stat, but the order did not go through all the way because you have to click send image. The DON stated a stat order has a 4 hour window and if it was not completed within that time frame, the nurse should call and see if they can get an ETA and if not and was an emergency, to send the resident out. She said in this case once the x-ray was not done timely, LVN H should have contacted the provider about next steps. She stated the risk was neglect, and Resident #1's arm could have broken further. She stated a lot of things could have happened to that arm. The DON stated Resident #1 was already on Tylenol and Tramadol was ordered yesterday. She said pain should be assessed every shift and should be documented on the TAR . The DON stated if not residents could be in a lot of pain, have depression or behaviors. She stated for residents that could not verbalize pain, nurses were to use a nonverbal scale and to look at their behaviors, to see what they were doing, if they were depressed, acting out or angry. Interview on 09/04/2025 at 4:21 PM, LVN H stated CNA notified him Monday that Resident #1's wrist was swelling. He stated when she reported to him the NP was here, assessed the resident and she ordered the x-ray and ice pack. He stated it was ordered as stat and he does know how to enter the order correctly in the computer. He stated stat meant within 4 hours and if they were not here within that time he should call the x-ray company and if they don't answer he was to report to management. LVN H stated Resident #1's pain was managed because she had routine Tylenol. He stated Resident #1 denied pain and he used an app on his phone to communicate with the resident. He stated Resident #1 was assessed for pain whenever she was administered meds . He stated in the system, if the medication was scheduled it does not have a place to put a pain level, only on prn medications so they document in the progress notes . He stated residents could be in pain if not assessed for pain or the effectiveness of pain medication. Record review of facility policy titled Pain Management, Assessment Scale undated, revealed the following Complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribe medications, and comfort measures, and all available resources of the facility. Procedure1. Assess resident's physical symptoms of pain, physical complaints, and daily activities. Pain questions based on a resident's communication ability were included in the Admission/readmission and Weekly Nursing Summary.If a resident is non-verbal, the questions will be a PAINAD assessment .If the MDS QM Pain criteria is met, a Pain SBAR will be triggered .There is no QM criteria for a resident who is non-verbal. If a resident scores 7-10 on the PAINAD scale, then a PAIND SBAR will be triggered. It is directed toward residents who are non-verbal or cannot communicate. Administer pain medications as prescribed. Monitor and record medication's effectiveness and side effects.PRN - if the resident complains of pain the nurse will assess, implement relief measures as ordered and/or care planned.9. Have the resident to rate pain on a scale of one to ten with one being the least pain and ten being the worst pain experienced. 1110 nurse may use the pain rating scale when assessing effectiveness of medications and assessing for pain intensity. Utilize the Pain Assessment Tool in documenting the resident's complaint of pain.

Based on observation, interviews and record reviews the facility failed to provide or obtain radiology services to meet the need of its residents for 1 of 1 Residents (Resident #1) reviewed for radiology services. The facility failed to correctly order and follow up on stat x-ray. Resident #1 did not get an x-ray for more than 24 hours after a stat x-ray was ordered. The x-ray performed was performed on the leg instead of the wrist.This failure could place residents at risk of delayed treatment, and pain.Findings included:Record review of Resident #1's admission record, dated 09/04/2025, revealed a [AGE] year-old female who admitted to the facility on [DATE] with type 2 diabetes (a disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels) and dementia (brain disease that alters brain function and causes a cognitive decline). Record review of Resident #1's BIMS assessment, dated 08/27/2025, revealed a score of 2, indicating severe cognitive impairment. Record review of Resident #1's progress notes, dated 09/01/2025, written by LVN H revealed, Resident noted with swelling and bruising on the right wrist, with discoloration observed. Per previous report, findings are possibly related to delayed injury from a recent fall. NP assessed resident during unit visit and provided new orders: X-ray 2-view of right hand and application of ice pack BID x 3 days. Safety maintained; resident monitored for pain and further changes.Record review of Resident #1's Event Follow up note, dated 09/01/2025, written by LVN H revealed, in part .New orders: 2 view x-ray to the right wrist Due to pain /bruising and swellingName of MD/NP notified: [Name] NP Date/time of notification: 09/01/2025 12:00 PMName of RP notified: [Name] Date/time of notification: 09/01/2025 12:00. Record review of Resident #1's progress notes, dated 09/01/2025, written by LVN H at 8:20 PM revealed, Nurse on [shift] following up on X-ray order placed this morning, called X-ray provider, [Provider Name] twice, and received no answer from the receiving end. report given to oncoming nurse to monitor and report on pending stat X RAY to be done.Record review of Resident #1's progress notes, dated 09/02/2025, written by LVN H at 2:34 PM revealed, Resident's right wrist remains swollen. Ice pack applied as ordered for pain and swelling. Nurse followed up with [Provider Name] regarding X-ray order; confirmed X-ray technician scheduled to arrive today for imaging. [RP, Name] was notified and requested ongoing updates on the resident's progress. Safety and comfort maintained. Will continue to monitor.Record review of radiology report, dated 09/02/2025, revealed RIGHT TIBIA(shinbone)/FIBULA(calf bone) SERIES Findings: Examination of the right tibia/fibula demonstrates no evidence for fracture. There are no bony abnormalities. The soft tissues are unremarkable. IMPRESSION: Negative Study.Record review of Resident #1's progress notes, dated 09/02/2025, written by LVN H at 10:13 PM revealed X-ray results of the resident's right wrist faxed to NP; findings indicate no fracture. NP recommended continued icing and elevation of the arm on a pillow. New order was received to apply a sling to the right hand while the resident is awake. Safety and comfort maintained. Will continue to monitor.Record review of Resident #1's progress notes, dated 09/03/2025, written by LVN B at 9:53 AM revealed resi alert w/ large bruise to R hand. no SOB or acute resp distress observed. N/O received to send resi to ER of [Hospital Name] in [City] for further evaluation and treatment due to large bruise to R hand. VS taken & WNL w/ 129/77 63 19 97.8 97 and BS 128. Routine ice pack + PP admin w/ positive outcome. EMS was called and transported resi out of facility at 10:05am. resi [RP Name] was informed of resi being transported.Record review of Resident #1's progress notes, dated 09/03/2025, written by LVN H at 4:45 pm revealed Resident returned from [Hospital Name] with diagnosis of closed fracture distal end of R radius (broken right wrist). Seen by NP during rounds; new orders: Tramadol 50 mg PO BID PRN pain, d/c Tylenol 650 mg, start Tylenol 1 g PO q8h PRN pain. Splint to remain on at all times; sling when OOB; wrist brace and thumb spica splint in place. Resident repeatedly removed dressing and sling; nurse reapplied several times. [Family member] notified of resident's return; verbalized availability for contact, will visit tomorrow. Resident resting in bed; safety and comfort maintained.Record review of hospital x-ray results, dated 09/03/2025, revealed the following: Findings: Discontinuity of the cortex of the central articular surface of the distal radius (wrist) seen on the lateral (side) view only. Nondisplaced fracture (bones remain in alignment) of indeterminate age (unknown if new or old) cannot be excluded. No other fractures. Moderate osteoarthritis (common joint condition that causes pain, stiffness) at the radiocarpal (wrist) join t and first carpometacarpal (base of thumb) joint, No dislocation. No lytic (areas of bond destruction that result in holes) or blastic (areas of abnormal growth) lesions. Impression:Nondisplaced fracture of indeterminate age at the distal radius articular surface.Record review of intake investigation worksheet priority date 09/03/2025, revealed Resident was sent to hospital on [DATE] and returned same day with a Dx of a hand Fx.Family asked for resident to be sent to hospital due to hand discoloration and swelling on return to the facility the x-ray determined a hand Fx. Still collecting information for investigation. Observation on 09/04/2025 at 10:59 am, in the secure unit revealed Resident #1 was well groomed and dressed sitting up in her w/c at a table in the dining room. Resident #1 was looking at a magazine and did not appear to be in any pain. Resident #1's right arm was in a sling with a plastic bag of ice under the hand. Interview on 09/04/2025 at 11:17 am, LVN B stated she normally works in the secure unit Monday through Friday on the morning shift but was not at work from Friday (08/29/2025) at 2:00pm through Tuesday (09/02/2025). She stated on Wednesday (09/03/2025) she saw a bruise on Resident #1's hand, the x-ray was negative but she was sent out to double check. She said she got an order to send her out, did an assessment and called EMS and the family waited at the hospital. She stated if there was an order for a stat x-ray they would be there within 4 hours and if not, she would let them know so they could be sent out. Interview on 09/04/2025 at 12:18 PM, the Administrator stated from his understanding it was found Resident #1's hand was swollen. He stated he rounded with the DON yesterday and she brought it to his attention that the RP requested Resident #1 be sent out for an x-ray. The Administrator stated he did see Resident #1's hand before she was sent to hospital and it was swollen with some bruising, but she could move all digits. He stated as he started doing the investigation he realized there were some communication issues between staff and Resident #1's family about what happened. He stated he found out Resident #1's fall was on 08/15/2025, and that was considered a separate incident and could not be tied to the wrist fracture. He stated he had not personally seen the results, but the family said there was a fracture. He said as he started in servicing, asking questions and getting statements, the swelling was found on Monday, a stat x-ray was ordered but the x-ray company never came out. When the x-ray was completed, the x-ray was of the forearm and was negative. He stated the expectation for staff was if a stat x-ray was ordered and not completed within 4 hours they should send the resident out. He said the risk to residents could be continued pain and delay of treatment. Interview on 09/04/2025 at 2:24 PM, the Medical Director stated staff notified him on 09/03/24 that Resident #1 went out and she had a fracture. He stated he was going to round on Resident #1 today. He stated he would order an x-ray, depending on what that shows, would come see the patient, then if something needed to be addressed by orthopedic then send to the emergency room. He stated his expectation for staff was if a stat xray was ordered and not done, , or if patient was having severe pain then send them out. Interview on 09/04/2025 at 3:03 PM, the NP stated on Monday 09/01/2025, when she rounded at lunch, the nurse had notified her about Resident #1's wrist . The NP stated she contacted the DON, ordered an x-ray and the x-ray came back negative. The NP said the Doctor just looked at the results and the fracture was on the side and if they did not do a lateral or 2 view it would be negative. She said if the order was stat, it should be done within 4 hours. She stated if a stat x-ray was not done within that time, staff should contact her or send the resident out. She said Resident #1's pain was managed with Tylenol and ice. She said she changed the pain medication yesterday, to Tramadol twice a day and increased Tylenol. Interview on 09/04/2025 at 3:26 PM, the DON stated on Monday (09/01/2025) Resident #1's wrist was bruised, LVN H did an event note, contacted the NP and got an order for x-ray. The DON stated she came in the next day (Tuesday) and the x-ray was not done but was ordered. She said she did not know what the delay was, but they ended up getting the x-ray done of the forearm and not the wrist. The DON stated it was ordered stat, but the order did not go through all the way because you have to click send image. The DON stated a stat order has a 4 hour window and if it was not completed within that time frame, the nurse should call and see if they can get an ETA and if not and was an emergency, to send the resident out. She said in this case once the x-ray was not done timely, LVN H should have contacted the provider about next steps. She stated the risk was neglect, and Resident #1's arm could have broken further. She stated a lot of things could have happened to that arm. Interview on 09/04/2025 at 4:21 PM, LVN H stated CNA notified him Monday that Resident #1's wrist was swelling. He stated when she reported to him the NP was here, assessed the resident and she ordered the x-ray and ice pack. He stated it was ordered as stat and he does know how to enter the order correctly in the computer. He stated stat meant within 4 hours and if they were not here within that time he should call the x-ray company and if they don't answer he was to report to management. He stated the risk was they would not know what the injury was and could delay care. The facility did not provide a policy on x-ray services by the time of exit.

Based on interview and record review, the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 1 of 3 residents (Resident #1) reviewed for reporting allegations, in that: The facility failed to submit a provider investigation report an injury of unknown origin for Resident #1 to the State Agency within 5 working days of the incident, which occurred on 07/09/25. This failure placed residents at risk for further abuse and neglect due to delayed investigation.Findings included: Record review of Resident #1's face sheet, undated, revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] after undergoing the procedure Closed Reduction Percutaneous Pinning Right Hip (surgical procedure to treat a femoral neck fracture; realignment of broken bone fragments in the right hip without making a large incision followed by stabilizing the fracture with screws or pins inserted through small punctures). Resident #1 was diagnosed with Right closed Femoral neck fracture (A break in the femoral neck (the part of the thigh bone just below the hip joint) on the right side of the body, without any open wound (closed fracture)). Resident #1 also had past medical diagnoses of Alzheimer's disease (progressive brain disorder that gradually impairs memory, thinking, and behavior), Vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain), hypertension (condition where the force of blood against an artery wall is consistently too high), Alzheimer's dementia with behavioral disturbance (neuropsychiatric symptoms or behavioral and psychological symptoms of dementia that can include agitation, anxiety, depression, aggression, apathy, and psychosis alongside the cognitive decline), osteoporosis (condition that weakens bones, making them more susceptible to fractures), and osteoarthritis (degenerative joint disease that occurs when the protective cartilage cushioning the ends of bones wears down over time). Record review of Resident #1's MDS (a set of standardized assessments done on admission, quarterly, and with a significant change of condition, on each resident) dated 07/11/2025 revealed Resident #1's BIMS (test that is used to get a quick snapshot of how well an individual is functioning cognitively at the moment. A BIMS score can range from 0 to 15, with lower scores indicating a decline in cognitive performance) score was noted to be 04/15 indicating severe cognitive impairment. Resident #1 required reminders, cues, and supervision in planning, organizing, and correcting daily routines as decision making ability was poor. Resident #1 was at risk for falls, impaired gait, balance, impaired cognition, wandering since his admission. Record review of the Provider Investigation Report dated 07/07/2025 and electronically signed on 07/17/2025 at 11:16 AM indicated an allegation of neglect had been reported to the state agency on 07/07/2025 at 9:30 AM, that was received on 07/09/2025 at 11:53 AM, regarding Resident #1. Per [state agency database] search, the provider investigation report was not submitted until 07/17/25, past the 5-day timeframe. Record review of Progress Notes, written by LVN A, revealed the incident occurred on 07/06/2025 at 11:30 AM and involved Resident #1's right hip, which was fractured after an unwitnessed fall. Resident #1 was reported to be found sitting on the floor of the secured unit in the dining room with a chair behind him. The resident was assessed by LVN A and given pain medication from a standing order of Tylenol Extra Strength 500 mg one tablet after reporting he was at a pain level of 02/10. The resident was not able to say what happened other than I think I fell. NP B was notified at 11:56 AM who ordered a STAT x-ray to bilateral hips. X-ray tech noted to be in building at 2:46 PM on 07/06/2025 when the x-ray was taken and results received at 9:42 PM on 07/06/2025 that indicated no fractures seen. Progress notes revealed that neuro checks were completed throughout the afternoon and evening of 07/06/2025 until 10:05 PM, resuming on 07/07/2025 at 6:02 AM. On 07/07/2025 at 07:30 AM LVN C noticed Resident #1 with facial grimacing and his left foot turned outward as he was being pushed in a manual wheelchair by a CNA. LVN C notified NP B that resident was having pain and was being sent to emergency room for further evaluation of bilateral hips. Transfer Notification note dated 07/07/2025 at 8:15 AM indicated Resident #1 was transferred to the hospital by ambulance at 8:30 AM for further evaluation. Follow up on resident status noted to be on 07/09/2025 at 12:14 PM, when facility contacted family and was informed the resident had received surgery. Resident #1 returned and readmitted to the facility on [DATE] in the evening. On 07/22/2025 at 2:10 p.m., in an interview the Administrator revealed that he was responsible for sending the reports to the CII provider number or submitting directly to TULIP. The Administrator revealed that the DON or one of the Regional Resource personnel would be responsible for timely reporting of an incident if he were unavailable. The Administrator stated that he is responsible not only for the timely reporting, but for also ensuring the Provider Investigation Report is submitted timely. The Administrator stated reporting was within 2 hours of an injury of unknown origin, allegation of abuse, neglect, or misappropriation being made, and that the Provider Investigation Report was due 5 days from the date of reporting. The Administrator stated that the risks of not reporting timely could be delay of care, delayed reporting, or potential continuation of abuse or neglect. Record review of the facility's Abuse policy revised 03/29/2028 revealed in part: .it is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect .injuries of unknown origin .and to ensure that all alleged violations .are reported immediately to the Administrator, DON and/or Abuse Prevention Coordinator .will also be reported to the HHSC . Review of Provider Letter PL 2024-14 (Replaces PL 2019-17), issued 08/29/2024, revealed, .report the investigation findings within five working days from the initial report to HHSC .

Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 4 (Resident #2) reviewed for misappropriation of property. The facility failed to ensure Resident #2's debit card was secured from unauthorized use of $11,735 when 25 unauthorized withdrawal transactions occurred between 2-12-2025 and 3-13-2025. This failure could place residents at risk for decreased quality of life, misappropriation of property, and financial hardship. Findings included: Record review of Resident #2's admission record dated 6-10-2025 indicated a [AGE] year-old female admitted to the facility on [DATE] with a primary diagnosis of Gram-Negative Sepsis (a life-threatening response of the body to an infection caused by gram-negative bacteria that is unknown), and secondary diagnoses of morbid obesity, hypokalemia (low levels of potassium in the blood), muscle atrophy (loss of muscle tissue decreasing in size/strength), and kidney failure. Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed that Resident #2 had a BIMS Score of 15 indicating she was cognitively intact. Record review of Resident #2's Care Plan dated 12-9-2024 indicated Resident #2 had an ADL deficit requiring assistance with clothing, personal hygiene, two staff transfers from wheelchair to bed, and toileting. Record review of Resident #2's progress notes revealed the following: 3-24-2025 at 10:08 AM revealed [the former social worker] stated [Resident #2] reported that she had money missing from her bank account. When the [former SW] went to speak to [Resident #2], she did not want to talk about the incident saying I've talked about this all morning, and I don't want to talk about it anymore [because] the bank was investigating the issue. [The former SW] did not ask any more questions but did ask how much money was missing and [Resident #2] said $11,000. -[On] 03.24.2025 two [police]officers arrived at the facility to follow-up on an alleged allegation of resident misappropriation of funds. When the [2 police officers] entered the room of [Resident #2] [Resident #2] said to the police that she didn't need to deal with it and that the bank was taking care of it . and did not want [the police] involved. The police provided the facility with case #L25083P0216. Record review of the facility's admission policy revealed the facility did not offer to protect resident's property or valuable items. Record review of Resident #2's unauthorized ATM cash withdrawals, received from Resident #2's Bank Fraud Investigator, revealed the following in military time (24-hour clock): 2/12/2025 12:25 $405.00 P287233 2/12/2025 12:26 $506.25 P287233 2/13/2025 6:09 $506.25 P287233 2/13/2025 6:11 $405.00 P287233 2/14/2025 6:29 $506.25 P287233 2/14/2025 6:30 $405.00 P287233 2/15/2025 13:34 $506.25 P287233 2/15/2025 13:36 $405.00 P287233 2/17/2025 8:04 $506.25 P287233 2/17/2025 8:05 $405.00 P287233 2/25/2025 9:24 $506.25 P287233 2/25/2025 9:25 $405.00 P287233 2/26/2025 9:47 $506.25 P287233 2/26/2025 9:48 $405.00 P287233 3/3/2025 5:55 $506.25 P287233 3/3/2025 5:56 $405.00 P287233 3/4/2025 6:09 $800.00 PX3658 3/5/2025 9:54 $506.25 P287233 3/5/2025 9:54 $405.00 P287233 3/11/2025 13:02 $506.25 P287233 3/11/2025 13:03 $405.00 P287233 3/12/2025 6:19 $506.25 P287233 3/12/2025 6:20 $405.00 P287233 3/13/2025 8:47 $506.25 P287233 3/13/2025 8:48 $405.00 P287233 In an interview with Resident #2's Bank Fraud Investigator, on 6-10-2025 at 10:30 AM, it was revealed that one of Resident #2's caregivers, who worked at the facility, made 25 (unauthorized) ATM cash withdrawals between 2-12-2025 thru 3-13-2025 totaling $11.735.00. The Bank Fraud Investigator said video footage indicated a black female (Brown hair, brown eyes, medium brown complexion) in burgundy scrubs driving a silver sedan made the cash withdrawals using Resident #2's bank card. The Bank Fraud Investigator said Resident #2 was a caucasian female. In an interview with Resident #2 on 6-10-2025 at 12:00 PM, it was disclosed that Resident #2 informed the facility, at the end of March 2025, that money was missing in her bank account. Resident #2 said the facility contacted the [HHSC] and local police. Resident #2 said the facility did not inform her that they could protect her bank cards from fraud. Resident #2 said she admitted to the facility in December 2024 and received her bank card at the facility. Resident #2 said whoever used her debit card, got the pin # and the debit card, from her room because the debit card was never taken out of her room by her. Resident #2 said she had let one or two staff members use her debit card to get a soft drink out of one of the facility's vending machines, but she does not remember who they were. Resident #2 said she has not left the facility since admission. Resident #2 said whoever used her debit card, without her permission, always put the card back in her room because she never noticed it missing. Resident #2 said the theft of her money, from her debit card, made her feel stupid. Resident #2 said her bank has deactivated the debit card that was fraudulently used. Resident #2 said a new debit card was issued and can only work online. Resident #2 said she has not had any money or property stolen from her since March 2025. Resident #2 said she feels safe now but does not trust people. In an interview with the facility's SW on 6-10-2025 at 4:40 PM, it was revealed the SW has worked at the facility since 4-2025. The SW stated she did not know how the facility would protect resident's property. The SW said there have been in-house investigations and in-services on misappropriation of resident's property to curtail misappropriation from occurring. The SW said she was not familiar with Resident #2's missing money. In an interview with the Administrator on 6-10-2025 at 5:20 PM, it was stated the former SW was informed of Resident #2's missing money on 3-24-2025 and the Administrator was informed after that. The Administrator said he attempted to speak with Resident #2 about her missing money, but Resident #2 refused to talk to him about it. The Administrator said he reported the incident to the State Health and Human Services Commission and the local police. The Administrator said the result of THHSC investigation was unsubstantiated. Information from Resident #2's Bank Fraud Investigator was given to the Administrator. The Administrator said he was going to follow up with the local police department again to see if he could find out who the perpetraitor was. The Administrator said Resident #2 refused to speak with the State and local police when they came to the facility. The Administrator said residents were informed, in their admission packet, that there was a trust fund they could put their money in. The Administrator said, before Resident #2 had money stolen, the facility did not know Resident #2 was keeping her debit card in her room. The Administrator said the facility had lock boxes residents could use to put their valuables in, but it was not mentioned in the admissions packet. The Administrator said that he had not told Resident #2 that she could put her debit card in a lock box but he was going to now. The Administrator said that he was responsible to ensure residents valuables, bank cards, and credit cards were kept safe as much as possible. The Administrator said the potential harm to residents having their property stolen was emotional and financial distress. Record review of the facility's in-service training dated 3-24-2025 revealed they conducted facility wide training on misappropriation of funds. Record review of the facility's Abuse and Neglect policy, undated and titled Abuse/Neglect, stated: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart . Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers .[9] Misappropriation of resident property: means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent . G. Protection - The facility will take necessary measures to protect residents and employees from harm during and following . misappropriation of resident property investigation.

Based on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for one (Resident #1) of four residents reviewed for abuse. The facility failed to ensure CNA A, who was suspended on 05/28/2025 due to Resident #1 alleging CNA A verbally abused Resident #1, did not provide care to Resident #1 when CNA A came back to work after being suspended. This failure could place residents at risk for abuse, neglect, and/or exploitation. Findings included: Record review of Resident #1's face sheet dated 06/10/2025 revealed a [AGE] year-old female admitted to the facility on [DATE] with a readmission on [DATE]. Admitting diagnosis including Multiple Sclerosis (a disease in which the immune system Eats away at the protective covering of nerves); Paraplegia, incomplete (the spinal cord is damaged but not completely severed, allowing for some level of movement or sensation below the injury); Bipolar Disorder, Current Episode Manic Severe with Psychotic Features (occurs when a person experiences an episode of severe mania or depression along with psychotic symptoms and hallucinations causing sudden changes in mood from excessive happiness, joyful to being angry and hostile). Review of Resident #1's quarterly MDS dated [DATE] revealed, a BIMS score of 99, meaning the resident was unable to complete the interview. The MDS also revealed the resident recalls staff's names, faces, and she resides in a nursing facility with memory severely impaired. Resident #1 exhibits physical and verbal behaviors and requires extensive assistance with ADLS. Review of provider investigation report dated 05/28/2025 revealed, An email received on 05/28/2025 at 3:03 PM from the LCSW with the psychological services to the ADM revealed the description of the allegation made by Resident #1 accusing CNA A and CNA B of abuse while attempting to provide ADL care in her room. Investigation Summary: The investigation summary found to be inconclusive. Provider Action Taken: Monitor resident for emotional distress. Post -Investigation: The facility reinstated the alleged perpetrators and conducted in-services including abuse/neglect prevention. Review of an undated witness statement attached to the facility self-report provided by ADM revealed Date of alleged incident: 05/28/2025 LCSW from psychological services notified ADM that Resident #1 reported that two male CNAs providing care to her abused her. Resident #1 alleged that CNA A called the resident a delusional bitch and alleged CNA B fingered her vagina and bottom when in the shower due to boo boo. On 06/10/2025 at 3:15 PM interview with Resident #1 revealed resident did not recall the incident that occurred with the two male CNAs. Resident #1 was speaking about different topics within her conversation. The conversation was hard to follow due to her confused state. Resident #1 was in good spirits, calm, and happy. She was not showing any agitation or aggression. Resident #1 stated she stays in bed most of the time and watches her TV. She voiced no concerns and did not mentioned incident between she and the CNAs. Interview on 06/10/2025 at 3:30 PM with CNA A revealed that he was still providing care for Resident #1 . The facility now required two CNAs to go into the room to care for the resident. CNA A stated that he knows the resident has mental issues and he tries to approach her gently and not upset her. He was only trying to do his job. He enjoyed caring for her but knows that he must be on guard due to her behaviors. CNA A revealed he did not hurt her in any way while providing care. Interview on 06/10/2025 at 3:53 PM, attempted to contact CNA B by phone but was unable to speak with him. Left a message on his voicemail. Interview on 06/10/2025 at 4:20 PM with Administrator revealed the documentation in the investigation was provided by the LCSW with the psychological services for Resident #1. The Administrator stated that there will be two CNAs assigned to Resident #1 when providing care. The Administrator revealed that there would be no male CNAs caring for Resident #1 and two CNAs would provide care. The Administrator stated that both CNAs were suspended and have returned to work. They were not to be assigned to Resident #1 any longer. The Administrator stated if CNA A and CNA B were to continue to provide care to Resident #1, the harm would be resident would be afraid of both CNAs. Interview on 06/10/2025 at 6:00 PM with DON revealed CNA A and CNA B have returned to work. CNA B worked PRN for the facility. The DON stated that CNA A and CNA B were not to provide care or go into Resident #1's room at all. The Charge Nurse for the hall made the room assignments for the CNAs each day. The Charge Nurse had been told not to assign CNA A or CNA B to Resident #1 . The DON stated there would no longer be a male CNA assigned to care for Resident #1. The DON expected both CNAs not to go into Resident #1's room even if to answer her call light. The DON revealed that if CNA A and CNA B continue to provide care to Resident #1, the harm would be resident could experience emotional distress and trauma. On 06/12/2025 at 4:02 PM interview with CNA B revealed that he works PRN for the facility. CNA B revealed that he was not assigned to care for Resident #1 at the time she made the allegation. CNA B has not taken care of Resident #1 since he has returned to work. Record review of facility policy r/t Resident Abuse and Neglect (no policy date noted) revealed in part, Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.

Based on observation, interview, and record review, the facility failed to ensure based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 4 residents reviewed for quality of care. LVN A failed to read an abnormal x-ray result, resulting in Resident #1 experiencing pain with a hip fracture for 2 days before Resident #1 was hospitalized for evaluation. A past noncompliance Immediate Jeopardy was determined to have existed from 4/8/2025 to 4/10/2025. While the IJ was removed on 4/11/2025, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm to resident health or safety due to the facility's need to implement corrective systems. The facility implemented actions that corrected the IJ on 4/11/2025 before the surveyor's entry. This failure could place residents at risk of delayed medical evaluation, treatment, and decrease in quality of care. Findings included: Review of Resident #1's face sheet, dated 4/23/2025, revealed resident was a [AGE] year-old female admitted on [DATE] with diagnoses of muscle weakness, dementia, and hypertension. Review of Resident #1's MDS assessment, dated 2/17/2025, revealed that resident's BIMS score was 4 out of 15 , indicating Resident #1 has low cognitive function. Review of Resident #1's Fall risk assessment, dated 4/5/2025, revealed that Resident #1 had balance problems while walking, decreased muscular coordination, and required use of assistive devices. Review of Resident #1's nursing note, dated 4/5/2025 at 9pm, LVN I documented that Resident #1 on 4/5/2025 during dinner time stood on the door way calling and asking if someone could help her .[Resident #1] said that she fell and was hurting on her left side of the torso. When she was asked how she fell and what she was doing at the time, the resident doesn't know and doesn't remember how it happened. Head to toe assessment was done. LVN I also indicated in this note that NP was notified and X-ray orders were obtained. Order for Tylenol extra strength 500mg tablets by mouth was also placed. Review of Resident #1's nursing note, dated 4/6/2025 at 8pm, LVN I reported and faxed negative X-ray result to NP. Review of Resident #1's nursing note, dated 4/8/2025 at 1:54pm, LVN B performed pain assessment which showed Resident #1 was in pain on her left hip and left waist. LVN B notified NP at 10:17am, LVN B notified Resident 1's family member]at 11:16am, stat X-ray was ordered. Review of nursing note, dated 4/8/2025 at 10:24pm, LVN A stated X-ray result faxed to NP for review no new orders. Review of Resident #1's nursing note, dated 4/10/2025 at 10:18am, LVN B noted [Resident #1] complains of pain to left side of body . Routine pain managements appear to be not effective as resident continues to complain of increased pain . Resident appears to be dragging left leg when attempting to make a step. All previous X-ray results to bilateral hips and waists and chest X-ray were negative. LVN B also noted that NP was consulted, EMS was called, and Resident #1's grandson was notified. Review of hospital record, dated 4/10/2025, revealed that x-ray done on 4/10/2025 at the hospital showed fracture to the left hip. Treatment in the hospital included pain management with Tylenol and Robaxin. Review of Resident #1's bilateral hips X-ray result, dated 4/8/2025, revealed that the impression of her left hip X-ray was stable acute appearing nondisplaced fracture noted of the superior and inferior of the left pubic rami (left pelvic fracture). In an observation and interview on 4/23/2025 at 12:30pm, Resident #1 was sitting in her wheelchair in the dining room. Resident #1 stated that she did not remember why she fell , but she remembered having a fracture. She stated that she was still having some discomfort from the fall, especially when she had to shift herself in the wheelchair. She stated that the pain had been interfering with her activities of daily living but she stated that pain was improving. In an interview on 4/23/2025 at 12:15pm, LVN B stated that on 4/8/2025, LVN B consulted the NP to order a stat X-ray because Resident #1 was still complaining of pain. When she left her shift on 4/8/2025, the result had not come back, so she relayed the message to LVN A to look out for the result. LVN A read the result on the evening of 4/8/2025, and reported to LVN B on morning of 4/9/2025 as negative via verbal reporting. LVN B did not look at the report and only took LVN A's verbal report. LVN B stated that when Resident #1 was sent to the hospital on 4/10/2025, she retrieved the X-ray report on 4/8/2025 from Resident #1's chart and realized that LVN A has misread the result. In an interview on 4/23/2025 at 1pm, the NP stated that she could not remember exactly what happened, but she remembered Resident #1 had 2 negative X-rays. She stated the fax of the second X-ray result on 4/8/2025, never got to her so LVN A called her to read the X-ray result verbally. On 4/23/2025 at 2:45pm, an attempt to interview LVN A via phone was unsuccessful. An Immediate Jeopardy (IJ) was determined to have existed from 4/8/2025 to 4/10/2025. The facility Administrator was provided the Immediate Jeopardy Template on 4/23/2025 at 3:39pm. Review of the facility's Provider Investigation Report, dated 04/11/25, revealed: The charge nurse will notify NP/MD of any changes of condition noted in a resident. If there is no response from either, the charge nurse will call again and if no answer they will send the resident to the ER . . Any fractures must be reported to DON/ADON as soon as the charge nurse becomes aware of them. Along with faxing X-ray results you must call the NP/MD and document notification. . Failure to review X-ray findings timely could delay care and be considered neglect. .ADON/DON will have all labs and X-ray results in the morning meeting to review daily. Labs and X-ray reports must be reviewed upon receipt. This involves reading the whole lab or x-ray report first page to however many pages follow. Once the report is read and there are abnormal findings the physician or NP must be called; this is not an option. After notifying them of the report the nurse is to document MD notification of x-ray report . In an interview on 4/23/2025 at 3:40pm, LVN C, who was a night shift nurse, stated that when he received an x-ray result, he would fax it to NP/MD, then call them to report the result, read every single page on the report, and report to ADON/DON. He stated that the risk of not reading the x-ray result correctly put the residents at risk for more pain and incorrect care. He was in-serviced about reading x-ray results and reporting to NP/MD 2 weeks ago. In an interview on 4/23/2025 at 3:48pm, LVN D, who was a day shift nurse, stated that the process of reporting x-ray result to NP/MD included: receiving the result, reviewing the result by reading all pages, calling NP/MD to report, and faxing the result to NP/MD, reporting to ADON/DON if any results came back abnormal. She stated the risk of reading incorrect results could lead to residents having increased pain, and risk of infection. She stated she was in-serviced a few weeks ago. In an interview on 4/23/2025 at 3:58pm, RN E who was a wound nurse, stated that she had not had to call NP/MD to report an imaging result. She stated she was in-serviced a couple of weeks ago. She stated that the process of report any abnormal labs or imaging results included: receiving the results, if abnormal, notify ADON/DON and NP immediately, read the result every single page, call NP/MD, fax the reports to NP/MD. She also stated that ADON/DON and Administrator met with all nurses to talk about the incident on 4/8/2025. She stated that the in-service included training all nurses to read all pages of reports and fax reports to the correct numbers. In an interview on 4/23/2025 at 4:17pm, LVN F, who usually worked weekend shifts, stated that once he received an anormal lab or abnormal imaging result, he reported to NP/MD and ADON/DON immediately. He also stated that ADON/DON also started going over 24-hour reports with all nurses every morning to look at any abnormal lab results or imaging findings. In an interview on 4/24/2025 at 11:30am, the DON stated that when Resident #1 was sent to the hospital on 4/10/2025, the DON, regional nurse, and all nurses reviewed Resident #1's clinical records to see what they missed and why the Resident #1 continued to have pain. DON stated they realized after looking at the X-ray on 4/8/2025 they had missed the fracture result. LVN A was in-serviced immediately. DON stated that LVN A told her she only saw 1 page of the report and that page stated no fracture, so she reported a negative result to the NP. The DON stated that all nurses were in-serviced immediately. The new process included: all nurses to let the DON know of any abnormal lab or imaging results, and report to NP/MD. ADON and DON would go over each resident's 24-hour report during every morning meeting to review all labs and imaging results. DON also stated that she printed out a sticker listing correct fax numbers for NP and MD at all nurse stations. DON stated that she expected nurses to do their own auditing after they report results to NP/MD and during morning meeting ADON/DON would do second layer of auditing. She stated that the risks to residents included life-threatening injuries, pain, fracture, infection. The facility provided the following in-service training topics: _Pain management, dated 4/10/2025 _Notification of changes, dated 4/10/2025 _Abuse and Neglect, dated 4/10/2025 _Resident Rights, dated 4/10/2025 _Incident reporting/fall assessment, dated 4/10/2025 _Lab and X-ray review and documentation, dated 4/11/2025 The facility also provided 1:1 in-service/coaching record between the DON and LVN A, with topic of X-ray not properly read by nurse and reported incorrect information. Signed and dated by DON & LVN A, dated 4/11/2025. Review of the facility's policy on Notifying Physician of Change in Status , dated 3/11/2023, revealed that The nurse will notify the physician immediately with significant change in status . Abnormal lab, x-ray and other diagnostic reports require physician notification. The IJ was removed on 4/11/2025 because the facility implemented actions that corrected the the IJ prior to 4/23/2025 entry.

Based on observation, interview, and record review, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 (Resident #1) of 4 residents reviewed for quality of care. LVN A failed to read an abnormal x-ray result, resulting in Resident #1 experiencing pain with a hip fracture for 2 days before Resident #1 was hospitalized for evaluation. A past noncompliance Immediate Jeopardy was determined to have existed from 4/8/2025 to 4/10/2025. While the IJ was removed on 4/11/2025, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm to resident health or safety due to the facility's need to implement corrective systems. The facility implemented actions that corrected the IJ on 4/11/2025 before the surveyor's entry. This failure could place residents at risk of delayed medical evaluation, treatment, and decrease in quality of care. Findings included: Review of Resident #1's face sheet, dated 4/23/2025, revealed resident was a [AGE] year-old female admitted on [DATE] with diagnoses of muscle weakness, dementia, and hypertension. Review of Resident #1's MDS assessment, dated 2/17/2025, revealed that resident's BIMS score was 4 out of 15 , indicating Resident #1 has low cognitive function. Review of Resident #1's nursing note, dated 4/8/2025 at 1:54pm, LVN B performed pain assessment which showed Resident #1 was in pain on her left hip and left waist. LVN B notified NP at 10:17am, LVN B notified Resident 1's family member]at 11:16am, stat X-ray was ordered. Review of nursing note, dated 4/8/2025 at 10:24pm, LVN A stated X-ray result faxed to NP for review no new orders. Review of Resident #1's nursing note, dated 4/10/2025 at 10:18am, LVN B noted [Resident #1] complains of pain to left side of body . Routine pain managements appear to be not effective as resident continues to complain of increased pain . Resident appears to be dragging left leg when attempting to make a step. All previous X-ray results to bilateral hips and waists and chest X-ray were negative. LVN B also noted that NP was consulted, EMS was called, and Resident #1's grandson was notified. Review of hospital record, dated 4/10/2025, revealed that x-ray done on 4/10/2025 at the hospital showed fracture to the left hip. Treatment in the hospital included pain management with Tylenol and Robaxin. Review of Resident #1's bilateral hips X-ray result, dated 4/8/2025, revealed that the impression of her left hip X-ray was stable acute appearing nondisplaced fracture noted of the superior and inferior of the left pubic rami (left pelvic fracture). In an observation and interview on 4/23/2025 at 12:30pm, Resident #1 was sitting in her wheelchair in the dining room. Resident #1 stated that she did not remember why she fell , but she remembered having a fracture. She stated that she was still having some discomfort from the fall, especially when she had to shift herself in the wheelchair. She stated that the pain had been interfering with her activities of daily living but she stated that pain was improving. In an interview on 4/23/2025 at 12:15pm, LVN B stated that on 4/8/2025, LVN B consulted the NP to order a stat X-ray because Resident #1 was still complaining of pain. When she left her shift on 4/8/2025, the result had not come back, so she relayed the message to LVN A to look out for the result. LVN A read the result on the evening of 4/8/2025, and reported to LVN B on morning of 4/9/2025 as negative via verbal reporting. LVN B did not look at the report and only took LVN A's verbal report. LVN B stated that when Resident #1 was sent to the hospital on 4/10/2025, she retrieved the X-ray report on 4/8/2025 from Resident #1's chart and realized that LVN A has misread the result. In an interview on 4/23/2025 at 1pm, the NP stated that she could not remember exactly what happened, but she remembered Resident #1 had 2 negative X-rays. She stated the fax of the second X-ray result on 4/8/2025, never got to her so LVN A called her to read the X-ray result verbally. On 4/23/2025 at 2:45pm, an attempt to interview LVN A via phone was unsuccessful. An Immediate Jeopardy (IJ) was determined to have existed from 4/8/2025 to 4/10/2025. The facility Administrator was provided the Immediate Jeopardy Template on 4/23/2025 at 3:39pm. Review of the facility's Provider Investigation Report, dated 04/11/25, revealed: The charge nurse will notify NP/MD of any changes of condition noted in a resident. If there is no response from either, the charge nurse will call again and if no answer they will send the resident to the ER . . Any fractures must be reported to DON/ADON as soon as the charge nurse becomes aware of them. Along with faxing X-ray results you must call the NP/MD and document notification. . Failure to review X-ray findings timely could delay care and be considered neglect. .ADON/DON will have all labs and X-ray results in the morning meeting to review daily. Labs and X-ray reports must be reviewed upon receipt. This involves reading the whole lab or x-ray report first page to however many pages follow. Once the report is read and there are abnormal findings the physician or NP must be called; this is not an option. After notifying them of the report the nurse is to document MD notification of x-ray report . In an interview on 4/23/2025 at 3:40pm, LVN C, who was a night shift nurse, stated that when he received an x-ray result, he would fax it to NP/MD, then call them to report the result, read every single page on the report, and report to ADON/DON. He stated that the risk of not reading the x-ray result correctly put the residents at risk for more pain and incorrect care. He was in-serviced about reading x-ray results and reporting to NP/MD 2 weeks ago. In an interview on 4/23/2025 at 3:48pm, LVN D, who was a day shift nurse, stated that the process of reporting x-ray result to NP/MD included: receiving the result, reviewing the result by reading all pages, calling NP/MD to report, and faxing the result to NP/MD, reporting to ADON/DON if any results came back abnormal. She stated the risk of reading incorrect results could lead to residents having increased pain, and risk of infection. She stated she was in-serviced a few weeks ago. In an interview on 4/23/2025 at 3:58pm, RN E who was a wound nurse, stated that she had not had to call NP/MD to report an imaging result. She stated she was in-serviced a couple of weeks ago. She stated that the process of report any abnormal labs or imaging results included: receiving the results, if abnormal, notify ADON/DON and NP immediately, read the result every single page, call NP/MD, fax the reports to NP/MD. She also stated that ADON/DON and Administrator met with all nurses to talk about the incident on 4/8/2025. She stated that the in-service included training all nurses to read all pages of reports and fax reports to the correct numbers. In an interview on 4/23/2025 at 4:17pm, LVN F, who usually worked weekend shifts, stated that once he received an anormal lab or abnormal imaging result, he reported to NP/MD and ADON/DON immediately. He also stated that ADON/DON also started going over 24-hour reports with all nurses every morning to look at any abnormal lab results or imaging findings. In an interview on 4/24/2025 at 11:30am, the DON stated that when Resident #1 was sent to the hospital on 4/10/2025, the DON, regional nurse, and all nurses reviewed Resident #1's clinical records to see what they missed and why the Resident #1 continued to have pain. DON stated they realized after looking at the X-ray on 4/8/2025 they had missed the fracture result. LVN A was in-serviced immediately. DON stated that LVN A told her she only saw 1 page of the report and that page stated no fracture, so she reported a negative result to the NP. The DON stated that all nurses were in-serviced immediately. The new process included: all nurses to let the DON know of any abnormal lab or imaging results, and report to NP/MD. ADON and DON would go over each resident's 24-hour report during every morning meeting to review all labs and imaging results. DON also stated that she printed out a sticker listing correct fax numbers for NP and MD at all nurse stations. DON stated that she expected nurses to do their own auditing after they report results to NP/MD and during morning meeting ADON/DON would do second layer of auditing. She stated that the risks to residents included life-threatening injuries, pain, fracture, infection. The facility provided the following in-service training topics: _Pain management, dated 4/10/2025 _Notification of changes, dated 4/10/2025 _Abuse and Neglect, dated 4/10/2025 _Resident Rights, dated 4/10/2025 _Incident reporting/fall assessment, dated 4/10/2025 _Lab and X-ray review and documentation, dated 4/11/2025 The facility also provided 1:1 in-service/coaching record between the DON and LVN A, with topic of X-ray not properly read by nurse and reported incorrect information. Signed and dated by DON & LVN A, dated 4/11/2025. Review of the facility's policy on Notifying Physician of Change in Status , dated 3/11/2023, revealed that The nurse will notify the physician immediately with significant change in status . Abnormal lab, x-ray and other diagnostic reports require physician notification. The IJ was removed on 4/11/2025 because the facility implemented actions that corrected the the IJ prior to 4/23/2025 entry.

Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status that was, a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications, for one of three residents (Resident #1) reviewed for notification of changes. 1. The facility failed to immediately notified the physician of a change in condition or decline when Resident #1 experienced shortness of breath and required as needed breathing treatments and oxygen therapy on [DATE] and [DATE]. There was no documented evidence that the facility attempted to notify the physician on [DATE] on 2P - 10P and 10P - 6A shifts or during any shift (6A - 2P, 2P - 10P, 10P - 6A) on [DATE] there was a need to alter treatment significantly, decide to transfer, or discharge Resident #1 to the hospital. On [DATE], Resident #1 was transferred to the ER. Resident #1 was intubated and passed away at the hospital. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems . These failures could place residents at risk of serious injury, harm, impairment, or death . Findings included: Record review of Resident #1's MDS significant change in status assessment, dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had active diagnoses which included COPD (a common lung disease that makes it difficult to breathe) and Other Secondary Pulmonary Hypertension (a chronic condition that occurs when pulmonary hypertension is caused by a known risk factor or underlying disease. [symptoms include Shortness of breath, at first while exercising and eventually while at rest; Blue or gray skin color due to low oxygen levels; Chest pressure or pain; Dizziness or fainting spells; Fast pulse or pounding heartbeat; Fatigue]). Resident #1's most recent re-entry to the facility was [DATE] with a diagnosis which included Displaced Commuted Fracture of Shaft of Right Femur. The MDS assessment reflected no known shortness of breath or trouble breathing with exertion, when sitting at rest, or when lying flat. Record review of Resident #1's Order Summary Report reflected: - Physician written Order date - [DATE]: Administer oxygen at 2 LPM via NC continuously every night for SOB (D/C : [DATE]) - Physician written Order date - [DATE]: Tylenol Oral Tablet 325 Mg (Acetaminophen). Give 2 tablets by mouth every 4 hours as needed for pain. (D/C: [DATE]) - Physician written Order date - [DATE]: Oxygen 2 LPM as needed for SOB - Physician written Order date - [DATE]: Ipratropium-Albuterol Solution 0XXX,d+[DATE].5, 3mg/3mL. 3mL inhale orally via nebulizer every 8 hours as needed for SOB or Wheezing. - Verbal Order date - [DATE]: Acetaminophen-Codeine Oral Tablet ,d+[DATE] mg (Acetaminophen with Codeine) Give 1 tablet by mouth every 6 hours as needed for pain (pain level 7 - 10) for 30 days. Do not exceed >4,000 mg/24 hrs - Verbal Order date - [DATE]: Tramadol Oral Tablet 50 mg. Give 1 tablet by mouth every 8 hours for pain for mild to moderate pain (pain level 1 - 5) - Phone Order date - [DATE]: Send patient to the hospital for SOB for further evaluation and treatment as indicated. Record review of Resident #1's [DATE] TAR reflected he was administered Ipratropium-Albuterol Solution 0XXX,d+[DATE].5, 3mg/3mL. 3mL inhale orally via nebulizer for SOB or Wheezing on [DATE] at 9:09 AM (O2 Sat = 94%) by LVN A; [DATE] at 5:13 PM (O2 Sat = 93%) by LVN B. Both breathing treatments were documented as effective. Record review of Resident #1's care plan, last reviewed [DATE], reflected, [Resident #1] has oxygen therapy PRN (Date initiated: [DATE]). Goal: [Resident #1] will have no s/sx of poor oxygen absorption through the review date (Date initiated: [DATE]; Target Date: [DATE]). Interventions included: Monitor for s/sx of respiratory distress and report to MD PRN; Respirations, pulse oximetry, increased heart rate . lethargy, confusion . accessory muscle usage, skin color (Initiated: [DATE]) Record review of Resident #1's vital signs summary reflected the following. There were not a full set of vitals (Temperature, Pulse, Respirations, Blood Pressure, Oxygen Saturation, and Pain) on [DATE] - [DATE] in the Vitals Summary: Temperature values: [DATE] at 2:34 PM (98.0 F via Forehead [non-contact]) - entered by LVN A Pulse value: [DATE] at 9:44 AM (60 bpm) - entered by LVN A; [DATE] at 7:48 PM (64 bpm) - entered by MA E; [DATE] at 10:21 AM (68 bpm ) - entered by LVN A; [DATE] at 8:19 PM (69 bpm) - entered by MA D; [DATE] at 10:25 AM (90 bpm) - entered by LVN C. Respiration values: [DATE] at 2:34 PM (18 breaths/min ) - entered by LVN A O2 Sats values [Range 96% - 97% on RA]: [DATE] at 9:09 AM (94%; with Oxygen via NC) - entered by LVN A; [DATE] at 5:13 PM (93%; with Oxygen via NC) - entered by LVN B. The amount of oxygen received was not documented. Record review of Resident #1's progress notes reflected: - Nursing Progress Note Effective Date: [DATE] at 2:55 PM, LVN A entered, Resident noted with SOB after coming from therapy, O2 Sat checked 88%, oxygen 2 Liters via nasal canula and breathing treatment administered. O2 Sat rechecked later and was 90 - 91%. NP called and left a message, [RP] also notified. Remain on oxygen therapy and coming nurse notified to continue to monitor. - Nursing Progress Note Effective Date: [DATE] at 10:25 PM, LVN B did not reflect an attempt to contact the MD/NP about Resident #1's O2 Sat at 91% -92% while he received oxygen 3 LPM via NC or when O2 Sat was 90% - 92% during bedtime and that [Resident #1] would not leave the oxygen in place . - Nursing Progress Note Effective Date: [DATE] at 3:10 PM, LVN A did not reflect an attempt to contact the MD/NP that [Resident #1] Continued to monitor resident for SOB, O2 Sat 94 - 96%. Breathing treatment administered and tolerated well. - Nursing Progress Note Effective Date: [DATE] at 9:17 PM, LVN B did not reflect an attempt to contact the MD/NP that [Resident #1] was administered pain meds and breathing treatment. Well tolerated. After therapy and oxygen remains 92% - 93% - Nursing Progress Note Effective Date: [DATE] at 1:30 PM, LVN C entered, [Resident #1] with increased SOB even though he is on 2LPM via NC, BP - ,d+[DATE], P-120, R-22, T-103.1 F. Breathing treatment was administered. Tylenol 500 mg 1 tablet was given for fever at this time. NP was notified via phone and gave order for patient to be sent to [hospital] for further evaluation and treatment as indicated. 911 call was initiated at this time. At 2PM the ambulance left . At 2:05 PM the RP was notified about the change of condition of patient . The ADON was called and updated via voicemail. The 10P - 6A nurse(s) did not enter progress notes that reflected an attempt to contact the MD/NP on [DATE] or [DATE]. Record review of Resident #1's [DATE] MAR/TARs did not reflect administration of pain medications at any time on [DATE] - [DATE]. The MAR/TARs did not reflect a breathing treatment administered on [DATE] or [DATE]. Record review of a SBAR note, dated [DATE], written by LVN C, reflected the primary provider was contacted at 1:50 PM about [Resident #1] with a Respiratory Change-Suspected Infection. BP - ,d+[DATE]; P - 120; R - 22; T - 103.1 F; O2 Sat - 90%; received oxygen at 2lpm via NC. Suspected respiratory infection r/t fever > 102 F, abnormal lung sounds (bilateral lower lobes [sound heard not listed]), and shortness of breath .This started on and/or symptoms first appeared: [DATE] .[breathing treatment(s)] attempted to help resolve . This condition, symptom, or sign has occurred before with antibiotics. Record review of Resident #1's chart did not reflect other SBARs were documented between [DATE] - [DATE] or indicated MD/NP notification. A record review of the 24 Hour Report for [DATE] reflected dated reports [DATE] - [DATE]. The next 24-hour report was undated and reflected remarks related to [Resident #1] Day shift - monitor for SOB; Evening shift - SOB at 9:30 PM, 92%, pain management. There were no remarks for the Night shift. The next 24-hour report was dated [DATE] and reflected remarks related to Resident #1. Day shift - continue to monitor for SOB, O2 94%. There was no remark for the Evening shift. Night shift - monitor SOB. The 24-hour report dated [DATE] reflected Resident #1 was sent out to [hospital] for SOB, elevated temperature, and elevated heart rate. The Night shift entered Monitor SOB. Resident #1 did not return to the facility. Resident #1 passed away at the hospital. Record review of an Occupational Therapy Treatment Encounter Note, dated [DATE], entered by COTA D, reflected, [Resident #1] participated in task presented, but demonstrated increased fatigue and weakness. [Resident #1] continues to demonstrate decline in health and fear of falling while seated in wheelchair. [Resident #1] also demonstrated labored breathing when he is given his utensils to participate in feeding A record review of Resident #1's hospital medical records, dated [DATE], reflected [Resident #1] arrived at the ED on [DATE] at 2:51 PM. The reason for visit reflected Fever and high heart rate for 3 days. The visit diagnoses included Acute hypoxic respiratory failure. The ED provider notes reflected EMS states [facility] staff reported [Resident #1] with worsened confusion from baseline for the past 2 days. EMS states [Resident #1] was noted to be SOB and in mild respiratory distress on arrival and was given an albuterol/Atrovent treatment, 125 mg solumedrol, and 1 Liter bolus fluids enroute. Facility denied any falls or trauma, however history otherwise limited. Initial assessment reflected a temperature of 105 degrees Fahrenheit, heart rate of 170 bpm, lung sounds crackle bilaterally, and was started on BiPAP (a device that helps you breathe) on arrival due to respiratory distress. Resident #1 was intubated [[DATE]] at 5:20 PM. The lowest O2 saturation during intubation was 92%. CPR was initiated on [DATE] at 5:31 PM. Resident #1 ultimately expired. Time of death was called at 6:27 PM. The final diagnosis was Acute hypoxic respiratory failure that led to Cardiac arrest. During an interview on [DATE] at 2:21 PM, the ADON stated she was informed about Resident #1's episodes of shortness of breath on [DATE]. The ADON said interventions were implemented as ordered - supplemental oxygen and breathing treatments as needed. The ADON said no significant concerns were reported to her. The ADON said she expected for nurses to initiate nursing interventions, notify the MD/NP, and notify the RP; as well as notify the ADON and DON . The ADON said vital signs should be monitored daily as ordered and as needed. The ADON said any changes in vital signs, behavior, level of functioning from a resident baseline should be documented and reported. The ADON stated therapy staff would monitor a resident oxygen level of concerned and always communicated with nursing staff. During an interview on [DATE] at 1:56 PM, CNA F stated she worked Friday, [DATE] and Saturday, [DATE], 6A - 2P shifts. CNA F said she notified LVN A on Friday morning that Resident #1 appeared to have difficulty breathing, even with oxygen. CNA F demonstrated shallow breathing and other than normal rise and fall of the chest. CNA F said Resident #1 felt warm to touch. CNA F said LVN A assessed Resident #1 and told [CNA F] he did not have an elevated temperature. During an interview on [DATE] at 2:44 PM, LVN B stated she worked Thursday, [DATE] and Friday, [DATE], 2P - 10P shifts. LVN B stated she received verbal handoff shift report from LVN A on Thursday, [DATE] at 2:00 PM. LVN B said [LVN A] reported Resident #1 had shortness of breath when he returned from therapy, received a breathing treatment, and was on oxygen therapy. [LVN A] said to monitor for shortness of breath. LVN B said she did not notify the MD/NP because she figured LVN A called during the day shift (6A - 2P). LVN B said she checked Resident # 1's vital signs and O2 Sat after occupational therapy and applied oxygen, but there were no other concerns. LVN B said Resident #1's RP visited on [DATE] and requested Resident #1 get up out of bed. LVN B said she tried to explain to the RP that Resident #1 was in bed to be monitored for shortness of breath. LVN B said Resident #1 was assisted up to his wheelchair and went to occupational therapy. LVN B said she had to administer a breathing treatment when Resident #1 returned from therapy after dinner. LVN B denied inspection for abnormal findings such as blue or pale discoloration, labored breathing, or listening to lung sounds. LVN B said unexpected respiratory findings should be reported to the MD/NP immediately included a decreased oxygen saturation of less than 92%, restlessness, and increased difficulty breathing. During an interview on [DATE] at 4:13 PM, LVN C stated she worked Saturday, [DATE], 6A - 10P shift. LVN C stated she received verbal handoff shift report from the overnight nurse to monitor Resident #1 for shortness of breath. LVN C said she inquired if Resident #1 had pneumonia and the nurse stated to monitor for shortness of breath. LVN C said she observed Resident #1 in his room during change of shift walking rounds and he received oxygen via NC. LVN C said she worked weekend doubles and Resident #1 did not receive oxygen continuously the previous weekends. LVN C said she asked the CNA to come get her when ADLs were provided to Resident #1 so she could monitor breathing when repositioned. LVN C said when she assisted with Resident #1's ADLs, she noticed Resident #1 had difficulty breathing. LVN C said she raised the head of the bed when they finished to help Resident #1 breathe a little easier. LVN C said when she checked Resident #1's vital signs after breakfast, and he was breathing fast and had an elevated temperature. LVN C said she administered a breathing treatment, administered Tylenol for the fever, and when Resident #1 did not appear to improve, notified the NP ([DATE] at 1:30 PM), called 911, and transferred Resident #1 to the hospital An attempt to interview the PCP on [DATE] at 1:34 PM was routed to an automated voicemail. A message identified caller, explained purpose of call, and a callback number was left on the voicemail. No callback was received. Interview on [DATE] at 2:23 PM, LVN A stated she worked Thursday, [DATE] and Friday, [DATE], 6A - 2P shifts. LVN A said therapy staff reported on [DATE] Resident #1 had shortness of breath. LVN A said she checked Resident #1's O2 Sats. LVN A said [Resident #1] oxygen level was low (less than 90%) and administered a breathing treatment and applied oxygen via nasal cannula. LVN A said the breathing treatment was effective. LVN A said she left a message for the NP and did not receive a callback before her end of shift at 2 PM. LVN A said she reported to the oncoming nurse (LVN B) to monitor Resident #1 for shortness of breath. LVN A said to monitor meant to watch for signs of shortness of breath, like a low oxygen level. LVN A said the next nurse would be responsible to call the MD/NP if they had concerns to report. LVN A said she checked Resident #1's vital signs and he did not have a temperature. LVN A said she listened to Resident #1's lungs but could not describe what she heard. LVN A said Resident #1's lungs were clear. LVN A said a breathing treatment was administered on [DATE] and it was effective. During an interview on [DATE] at 1:27 PM, the NP indicated it was not unusual not to call back if she received a page from the facility nurse. The NP stated if the nurse did not hear back [from the NP] within 15 minutes, she should have tried to call again. The NP stated Resident #1 had a diagnosis of cardiomegaly (an enlarged heart), COPD (a group of diseases that cause airflow blockage and breathing-related problems), and a medical history of pneumonia that she would have suggested a PRN diuretic and a chest x-ray had she received a call about the change in condition before Saturday, [DATE]. The NP said the suggested treatments would have been ineffective by Saturday ([DATE]) and sending Resident #1 to the hospital for a higher level of care was the best treatment option at the time. The NP stated she may have requested a COVID test if demonstrated temperature and/or cough. A record review of the facility's policy titled, Significant Change in Condition, Response, revised [DATE], reflected 1. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware 4. The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning report Record review of the facility's Notifying the Physician of Change in Status policy, revised [DATE], reflected: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. This facility utilizes the INTERACT tool, Change in Condition - When to Notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Work day notification of the physician. This was determined to be an Immediate Jeopardy (IF) on [DATE] at 5:50 PM. The NFA was notified and was provided with the IJ template on [DATE] at 5:50 PM . The following Plan of Removal submitted by the facility was accepted on [DATE] at 3:17 PM: All residents have the potential to be affected by this deficient practice. Interventions: All residents in the facility were assessed for any change of condition by the DON, ADON and Charge Nurses as of [DATE]. No additional issues were found. DON, ADON will audit all resident nursing notes for a change of condition to ensure notification of changes to the attending physician/nurse partitioner. Completed [DATE]. Going forward the DON/ADON/designee will monitor progress notes for a change in condition and notification to the attending physician/nurse practitioner daily during the morning clinical meeting. All residents with orders for oxygen continuous and as needed had oxygen saturation levels obtained as of [DATE] by the DON/ADON. No additional issues were found. LVN A and LVN B were immediately suspended pending investigation on [DATE]. LVN A and LVN B will not be permitted to return to work or provide care to residents until the following 1:1 in-services have been completed by the DON or Compliance Nurse. Completed [DATE]. Abuse and Neglect-failure to perform and assessment and notify a NP/MD for a resident change in condition could be considered neglect. Performing an assessment and providing care to residents who are experiencing a change in condition or respiratory distress. Notification of change of condition to the physician immediately. If any staff members notice a resident in respiratory distress, they will notify a charge nurse or DON immediately. All charge nurses will notify the NP or the Attending MD after an assessment is performed. If the NP cannot be reached, the Attending or Medical Director will be notified. The medical director was notified by the administrator of this plan on [DATE]. An Ad Hoc QAPI meeting to include the Director and IDT team was held [DATE]. In-services: All charge nurses will be in-serviced by [DATE] by the DON/ ADON regarding the following and all nurses not in-serviced by [DATE] will not be allowed to work their assigned position until completion of these in-services. All PRN staff, new hires, and agency staff will be in-serviced prior to start of their shift. The Administrator, DON and ADON were in-serviced 1: 1 by Compliance Nurse. Abuse and Neglect- failure to perform and assessment and notify a NP/MD for a resident change in condition could be considered neglect. Performing an assessment and providing care to residents who are experiencing a change in condition or respiratory distress including not limited to: 02 saturation on room air or with oxygen and how much oxygen if applicable, skin color, any use of accessory muscle, lung sounds, any purses lip breathing, is the head of the bed flat or elevated. What interventions have you provided to the resident non pharmacological or pharmacological . Notification of the MD and RP. Notification of change of condition to the physician immediately. If any staff members notice a resident in respiratory distress, they will notify a charge nurse or DON immediately. All charge nurses will notify the NP or the Attending MD after an assessment is performed. If the NP cannot be reached, the Attending or Medical Director will be notified. The medical director was notified by the administrator of this plan on [DATE]. An Ad Hoc QAPI meeting to include the Director and IDT team was held [DATE]. Monitoring: The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 times per week, indefinitely to ensure than an assessment was completed for any new or worsened shortness of breath and is communicated to the NP, Attending MD, or Medical Director immediately. Monitoring began [DATE] and will continue x 4 weeks. Monitoring of the POR included the following: During an interview and record review on [DATE] at 2:49 PM, the DON stated she initiated an audit of nurse progress notes to identify actions taken related to shortness of breath, nurse assessment and interventions, provider, and RP notification, and if new orders were received and acted on . Record review revealed recent assessments. Interviews conducted with nurses and CNAs scheduled on the 6A - 2P shift (RN D, LVN J, CNA I and CNA K), on the 2P - 10P shift (LVN H, CNA G, LVN L, CNA N, LVN Q and RN C [recently transitioned from 10P - 6A shift]), and 10P - 6A shift (LVN O, LVN M and CNA P) stated they participated in various in-service trainings. The staff stated topics of discussion included how to recognize a resident's change in condition, physician notification, and documentation. Each nurse stated in their own words the procedure to notify physicians immediately about resident change in condition. Each nurse demonstrated how to perform a respiratory assessment and verbalized abnormal findings. CNAs stated in their own words' signs and symptoms of acute respiratory distress, what must be reported to the charge nurse, and how to ensure oxygen therapy equipment functioned and applied appropriately on the resident. Record review of a QAPI ad hoc meeting minutes, dated [DATE], reflected the QAPI team met to discuss the facility's failure to conduct a respiratory assessment, to notify the physician about a resident's change in condition and steps the facility must take to address the concern. Record review of an in-service conducted by the RCN , dated [DATE] with the NFA, DON and ADON. Objectives of the in-service included Abuse and Neglect; Performing an assessment and providing care to residents who are experiencing a change in condition or respiratory distress; and Notification of change of condition to the physician immediately. Follow-up activities included one-on-one in-service. The NFA was informed the Immediate Jeopardy was removed on [DATE] at 4:30 PM . The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to ensure that residents who needed respiratory care, including tracheostomy care and tracheal suctioning, provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 residents (Resident #1) reviewed for respiratory care . On [DATE] - [DATE], the facility failed to conduct a respiratory assessment for a potential change in condition or decline when Resident #1 experienced shortness of breath and required as needed breathing treatments and oxygen therapy. On [DATE], Resident #1 was transferred to the ER. Resident #1 was intubated and passed away at the hospital. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems . This failure could place residents at risk of not receiving timely medical interventions as needed, which could result in a delay in medical intervention and decline in health or possible worsening of symptoms, including death. Findings included: Record review of Resident #1's MDS significant change in status assessment, dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had active diagnoses which included COPD (a common lung disease that makes it difficult to breathe) and Other Secondary Pulmonary Hypertension (a chronic condition that occurs when pulmonary hypertension is caused by a known risk factor or underlying disease. [symptoms include Shortness of breath, at first while exercising and eventually while at rest; Blue or gray skin color due to low oxygen levels; Chest pressure or pain; Dizziness or fainting spells; Fast pulse or pounding heartbeat; Fatigue]). Resident #1's most recent re-entry to the facility was [DATE] with a diagnosis which included Displaced Commuted Fracture of Shaft of Right Femur. The MDS assessment reflected no known shortness of breath or trouble breathing with exertion, when sitting at rest, or when lying flat. Record review of Resident #1's Order Summary Report reflected: - Physician written Order date - [DATE]: Administer oxygen at 2 LPM via NC continuously every night for SOB (D/C: [DATE]) - Physician written Order date - [DATE]: Tylenol Oral Tablet 325 Mg (Acetaminophen). Give 2 tablets by mouth every 4 hours as needed for pain. (D/C: [DATE]) - Physician written Order date - [DATE]: Oxygen 2 LPM as needed for SOB - Physician written Order date - [DATE]: Ipratropium-Albuterol Solution 0XXX,d+[DATE].5, 3mg/3mL. 3mL inhale orally via nebulizer every 8 hours as needed for SOB or Wheezing. - Verbal Order date - [DATE]: Acetaminophen-Codeine Oral Tablet ,d+[DATE] mg (Acetaminophen w/Codeine) Give 1 tablet by mouth every 6 hours as needed for pain (pain level 7 - 10) for 30 days. Do not exceed >4,000 mg/24 hrs - Verbal Order date - [DATE]: Tramadol Oral Tablet 50 mg. Give 1 tablet by mouth every 8 hours for pain for mild to moderate pain (pain level 1 - 5) - Phone Order date - [DATE]: Send patient to the hospital for SOB for further evaluation and treatment as indicated. Record review of Resident #1's [DATE] TAR reflected he was administered Ipratropium-Albuterol Solution 0XXX,d+[DATE].5, 3mg/3mL. 3mL inhale orally via nebulizer for SOB or Wheezing on [DATE] at 9:09 AM (O2 Sat = 94%) by LVN A; [DATE] at 5:13 PM (O2 Sat = 93%) by LVN B. Both breathing treatments were documented as effective. Record review of Resident #1's care plan, last reviewed [DATE], reflected, [Resident #1] has oxygen therapy PRN (Date initiated: [DATE]). Goal: [Resident #1] will have no s/sx of poor oxygen absorption through the review date (Date initiated: [DATE]; Target Date: [DATE]). Interventions included: Monitor for s/sx of respiratory distress and report to MD PRN; Respirations, pulse oximetry, increased heart rate . lethargy, confusion . accessory muscle usage, skin color (Initiated: [DATE]) Record review of Resident #1's vital signs summary reflected the following. There were not a full set of vitals (Temperature, Pulse, Respirations, Blood Pressure, Oxygen Saturation, and Pain) on [DATE] - [DATE] in the Vitals Summary: Temperature values: [DATE] at 2:34 PM (98.0 F via Forehead [non-contact]) - entered by LVN A Pulse value: [DATE] at 9:44 AM (60 bpm) - entered by LVN A; [DATE] at 7:48 PM (64 bpm) - entered by MA E; [DATE] at 10:21 AM (68 bpm) - entered by LVN A; [DATE] at 8:19 PM (69 bpm) - entered by MA D; [DATE] at 10:25 AM (90 bpm) - entered by LVN C. Respiration values: [DATE] at 2:34 PM (18 breaths/min) - entered by LVN A O2 Sats values [Range 96% - 97% on RA]: [DATE] at 9:09 AM (94%; with Oxygen via NC) - entered by LVN A; [DATE] at 5:13 PM (93%; with Oxygen via NC) - entered by LVN B. The amount of oxygen received was not documented. Record review of Resident #1's progress notes indicated: - Nursing Progress Note Effective Date: [DATE] at 2:55 PM, LVN A entered, Resident noted with SOB after coming from therapy, O2 Sat checked 88%, oxygen 2L via nasal canula and breathing treatment administered. O2 Sat rechecked later and was 90 - 91%. NP called and left a message, [RP] also notified. Remain on oxygen therapy and coming nurse notified to continue to monitor. Nursing Progress Note Effective Date: [DATE] at 10:25 PM, LVN B did not reflect respiratory assessments, vital signs, or an attempt to contact the MD/NP about Resident #1's O2 Sat at 91% -92% while he received oxygen 3 LPM via NC or when O2 Sat was 90% - 92% during bedtime and that [Resident #1] would not leave the oxygen in place . - Nursing Progress Note Effective Date: [DATE] at 3:10 PM, LVN A did not reflect a respiratory assessments, vital signs, or an attempt to contact the MD/NP that [Resident #1] Continued to monitor resident for SOB, O2 Sat 94 - 96%. Breathing treatment administered and tolerated well. - Nursing Progress Note Effective Date: [DATE] at 9:17 PM, LVN B did not reflect respiratory assessments, vital signs, or an attempt to contact the MD/NP that [Resident #1] was administered pain meds and breathing treatment. Well tolerated. After therapy and oxygen remains 92% - 93% - Nursing Progress Note Effective Date: [DATE] at 1:30 PM, LVN C entered, [Resident #1] with increased SOB even though he is on 2LPM via NC, BP - ,d+[DATE], P-120, R-22, T-103.1 F. Breathing treatment was administered. Tylenol 500 mg 1 tablet was given for fever at this time. NP was notified via phone and gave order for patient to be sent to [hospital] for further evaluation and treatment as indicated. 911 call was initiated at this time. At 2PM the ambulance left . At 2:05 PM the RP was notified about the change of condition of patient . The ADON was called and updated via voicemail. The 10P - 6A nurse(s) did not enter progress notes that reflected respiratory assessments, vital signs, or an attempt to contact the MD/NP on [DATE] or [DATE]. Review of Resident #1's [DATE] MAR/TARs did not reflect administration of pain medications at any time on [DATE] - [DATE]. The MAR/TARs did not reflect a breathing treatment administered on [DATE] or [DATE]. Record review of a SBAR note dated [DATE], written by LVN C, revealed the primary provider was contacted at 1:50 PM about [Resident #1] with a Respiratory Change-Suspected Infection. BP - ,d+[DATE]; P - 120; R - 22; T - 103.1 F; O2 Sat - 90%; received oxygen at 2lpm via NC. Suspected respiratory infection r/t fever > 102 F, abnormal lung sounds (bilateral lower lobes [sound heard not listed]), and shortness of breath. This started on and/or symptoms first appeared: [DATE] [breathing treatment(s)] attempted to help resolve This condition, symptom, or sign has occurred before with antibiotics. Record review of Resident #1's chart did not reflect other SBARs were documented between [DATE] - [DATE] or indicated MD/NP notification. A review of the 24 Hour Report for [DATE] revealed dated reports [DATE] - [DATE]. The next 24-hour report was undated and revealed remarks related to [Resident #1] Day shift - monitor for SOB; Evening shift - SOB at 9:30 PM, 92%, pain management. There were no remarks for the Night shift. The next 24-hour report was dated [DATE] and revealed remarks related to Resident #1. Day shift - continue to monitor for SOB, O2 94%. There was no remark for the Evening shift. Night shift - monitor SOB. The 24-hour report dated [DATE] indicated Resident #1 was sent out to [hospital] for SOB, elevated temperature, and elevated heart rate. The Night shift entered Monitor SOB. Resident #1 did not return to the facility. Resident #1 passed away at the hospital. Record review of an Occupational Therapy Treatment Encounter Note, dated [DATE], entered by COTA D, reflected, [Resident #1] participated in task presented, but demonstrated increased fatigue and weakness. [Resident #1] continues to demonstrate decline in health and fear of falling while seated in wheelchair. [Resident #1] also demonstrated labored breathing when he is given his utensils to participate in feeding . A record review of Resident #1's hospital medical records, dated [DATE], reflected [Resident #1] arrived at the ED on [DATE] at 2:51 PM. The reason for visit reflected Fever and high heart rate for 3 days. The visit diagnoses included Acute hypoxic respiratory failure. The ED provider notes reflected EMS states [facility] staff reported [Resident #1] with worsened confusion from baseline for the past 2 days. EMS states [Resident #1] was noted to be SOB and in mild respiratory distress on arrival and was given an albuterol/Atrovent treatment, 125 mg solumedrol, and 1 Liter bolus fluids enroute. Facility denied any falls or trauma, however history otherwise limited. Initial assessment reflected a temperature of 105 degrees Fahrenheit, heart rate of 170 bpm, lung sounds crackle bilaterally, and was started on BiPAP (a device that helps you breathe) on arrival due to respiratory distress. Resident #1 was intubated [[DATE]] at 5:20 PM. The lowest O2 saturation during intubation was 92%. CPR was initiated on [DATE] at 5:31 PM. Resident #1 ultimately expired. Time of death was called at 6:27 PM. The final diagnosis was Acute hypoxic respiratory failure that led to Cardiac arrest. During an interview on [DATE] at 2:21 PM, the ADON stated that she was informed about Resident #1's episodes of shortness of breath on [DATE]. The ADON said that interventions were implemented as ordered - supplemental oxygen and breathing treatments as needed. The ADON said that no significant concerns were reported to her. The ADON said that she expected for nurses to initiate nursing interventions, notify the MD/NP, and notify the RP; as well as notify the ADON and DON. The ADON said that vital signs should be monitored daily as ordered and as needed. The ADON said that any changes in vital signs, behavior, level of functioning from a resident baseline should be documented and reported. The ADON stated that therapy staff would monitor a resident oxygen level of concerned and always communicated with nursing staff. During an interview on [DATE] at 1:56 PM, CNA F stated she worked Friday, [DATE] and Saturday, [DATE], 6A - 2P shifts. CNA F said that she notified LVN A on Friday morning that Resident #1 appeared to have difficulty breathing, even with oxygen. CNA F demonstrated shallow breathing and other than normal rise and fall of the chest. CNA F said that Resident #1 felt warm to touch. CNA F said that LVN A assessed Resident #1 and told [CNA F] that he did not have an elevated temperature. During an interview on [DATE] at 2:44 PM, LVN B stated she worked Thursday, [DATE] and Friday, [DATE], 2P - 10P shifts. LVN B stated that she received verbal handoff shift report from LVN A on Thursday, [DATE] at 2:00 PM. LVN B said that [LVN A] reported that Resident #1 had shortness of breath when he returned from therapy, received a breathing treatment, and was on oxygen therapy. [LVN A] said to monitor for shortness of breath. LVN B said that she did not notify the MD/NP because she figured LVN A called during the day shift (6A - 2P). LVN B said that she checked Resident # 1's vital signs and O2 Sat after occupational therapy and applied oxygen, but there were no other concerns. LVN B said that Resident #1's RP visited on [DATE] and requested Resident #1 get up out of bed. LVN B said that she tried to explain to the RP that Resident #1 was in bed to be monitored for shortness of breath. LVN B said that Resident #1 was assisted up to his wheelchair and went to occupational therapy. LVN B said that she had to administer a breathing treatment when Resident #1 returned from therapy after dinner. LVN B denied inspection for abnormal findings such as blue or pale discoloration, labored breathing, or listening to lung sounds. LVN B said that unexpected respiratory findings that should be reported to the MD/NP immediately included a decreased oxygen saturation of less than 92%, restlessness, and increased difficulty breathing. During an interview on [DATE] at 4:13 PM, LVN C stated she worked Saturday, [DATE], 6A - 10P shift. LVN C stated she received verbal handoff shift report from the overnight nurse to monitor Resident #1 for shortness of breath. LVN C said she inquired if Resident #1 had pneumonia and the nurse stated to monitor for shortness of breath. LVN C said she observed Resident #1 in his room during change of shift walking rounds and he received oxygen via NC. LVN C said she worked weekend doubles and Resident #1 did not receive oxygen continuously the previous weekends. LVN C said she asked the CNA to come get her when ADLs were provided to Resident #1 so she could monitor breathing when repositioned. LVN C said when she assisted with Resident #1's ADLs, she noticed Resident #1 had difficulty breathing. LVN C said she raised the head of the bed when they finished to help Resident #1 breathe a little easier. LVN C said when she checked Resident #1's vital signs after breakfast, and he was breathing fast and had an elevated temperature. LVN C said she administered a breathing treatment, administered Tylenol for the fever, and when Resident #1 did not appear to improve, notified the NP ([DATE] at 1:30 PM), called 911, and transferred Resident #1 to the hospital An attempt to interview the PCP on [DATE] at 1:34 PM was routed to an automated voicemail. A message identified caller, explained purpose of call, and a callback number was left on the voicemail. No callback was received. On [DATE] at 2:23 PM, a return phone call was accepted by LVN A. During a phone interview, LVN A stated she worked Thursday, [DATE] and Friday, [DATE], 6A - 2P shifts. LVN A said that therapy staff reported on [DATE] that Resident #1 had shortness of breath. LVN A said that she checked Resident #1's O2 Sats. LVN A said that [Resident #1] oxygen level was low (less than 90%) and administered a breathing treatment and applied oxygen via nasal cannula. LVN A said that the breathing treatment was effective. LVN A said that she left a message for the NP and did not receive a callback before her end of shift at 2 PM. LVN A said that she reported to the oncoming nurse (LVN B) to monitor Resident #1 for shortness of breath. LVN A said to monitor means to watch for signs of shortness of breath, like a low oxygen level. LVN A said that the next nurse would be responsible to call the MD/NP if they had concerns to report. LVN A said that she checked Resident #1's vital signs and he did not have a temperature. LVN A said that she listened to Resident #1's lungs but could not describe what she heard. LVN A said that Resident #1's lungs were clear. LVN A said that a breathing treatment was administered on [DATE] and it was effective. During an interview on [DATE] at 1:27 PM, the NP indicated it was not unusual not to call back if she received a page from the facility nurse. The NP stated if the nurse did not hear back [from the NP] within 15 minutes, she should have tried to call again. The NP stated Resident #1 had a diagnosis of cardiomegaly (an enlarged heart), COPD (a group of diseases that cause airflow blockage and breathing-related problems), and a medical history of pneumonia that she would have suggested a PRN diuretic and a chest x-ray had she received a call about the change in condition before Saturday, [DATE]. The NP said the suggested treatments would have been ineffective by Saturday ([DATE]) and sending Resident #1 to the hospital for a higher level of care was the best treatment option at the time. The NP stated she may have requested a COVID test if demonstrated temperature and/or cough. A record review of the facility's policy titled, Significant Change in Condition, Response, revised [DATE], reflected Policy: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. Procedure: 1. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to) . new complaints of pain or worsening of pain . 2. The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of exiting orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. 3 . Nursing will provide no less than three (3) days of observation, documentation, and response to any interventions. An attempt to identify the cause for decline, when it occurs . 4. The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning report . 6. Each department notified will perform their own evaluation and assessment to determine if the change requires further intervention and implement actions accordingly This was determined to be an Immediate Jeopardy (IF) on [DATE] at 5:50 PM. The NFA was notified and provided with the IJ template on [DATE] at 5:50 PM . The following Plan of Removal submitted by the facility was accepted on [DATE] at 3:17 PM: All residents have the potential to be affected by this deficient practice. Interventions: All residents in the facility were assessed for any change of condition by the DON, ADON and Charge Nurses as of [DATE]. No additional issues were found. DON, ADON will audit all resident nursing notes for a change of condition to ensure notification of changes to the attending physician/nurse partitioner. Completed [DATE]. Going forward the DON/ADON/designee will monitor progress notes for a change in condition and notification to the attending physician/nurse practitioner daily during the morning clinical meeting. All residents with orders for oxygen continuous and as needed had oxygen saturation levels obtained as of[DATE] by the DON/ADON. No additional issues were found. LVN A and LVN B were immediately suspended pending investigation on [DATE]. LVN A and LVN B will not be permitted to return to work or provide care to residents until the following 1:1 in-services have been completed by the DON or Compliance Nurse. Completed [DATE]. Abuse and Neglect-failure to perform and assessment and notify a NP/MD for a resident change in condition could be considered neglect. Performing an assessment and providing care to residents who are experiencing a change in condition or respiratory distress including not limited to: 02 saturation on room air or with oxygen and how much oxygen if applicable, skin color, any use of accessory muscle, lung sounds, any purses lip breathing, is the head of the bed flat or elevated. What interventions have you provided to the resident nonpharmacological or pharmacological. Notification of the MD and RP. Notifications of changes of conditions test, to include components of a focused respiratory assessment. Notification of change of condition to the physician immediately. If any staff members notice a resident in respiratory distress, they will notify a charge nurse or DON immediately. All charge nurses will notify the NP or the Attending MD after an assessment is performed. If the NP cannot be reached, the Attending or Medical Director will be notified. The medical director was notified by the administrator of this plan on [DATE]. An Ad Hoc QAPI meeting to include the Director and IDT team was held [DATE]. In-services: All charge nurses will be in-serviced by [DATE] by the DON/ ADON regarding the following and all nurses not in-serviced by [DATE] will not be allowed to work their assigned position until completion of these in-services. All PRN staff, new hires, and agency staff will be in-serviced prior to start of their shift. The Administrator, DON and ADON were in-serviced 1: 1 by Compliance Nurse. Abuse and Neglect- failure to perform and assessment and notify a NP/MD for a resident change in condition could be considered neglect. Performing an assessment and providing care to residents who are experiencing a change in condition or respiratory distress including not limited to: 02 saturation on room air or with oxygen and how much oxygen if applicable, skin color, any use of accessory muscle, lung sounds, any purses lip breathing, is the head of the bed flat or elevated. What interventions have you provided to the resident nonpharmacological or pharmacological. Notification of the MD and RP. Notifications of changes of conditions test, to include components of a focused respiratory assessment. Notification of change of condition to the physician immediately. If any staff members notice a resident in respiratory distress, they will notify a charge nurse or DON immediately. All charge nurses will notify the NP or the Attending MD after an assessment is performed. If the NP cannot be reached, the Attending or Medical Director will be notified. The medical director was notified by the administrator of this plan on [DATE]. An Ad Hoc QAPI meeting to include the Director and IDT team was held [DATE]. Monitoring: The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 times per week, indefinitely to ensure than an assessment was completed for any new or worsened shortness of breath and is communicated to the NP, Attending MD, or Medical Director immediately. Monitoring began [DATE] and will continue x 4 weeks. On [DATE] the investigator began monitoring if the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview and record review on [DATE] at 2:49 PM, the DON indicated that she initiated an audit of nurse progress notes to identify actions taken related to shortness of breath, nurse assessment and interventions, provider, and RP notification, and if new orders were received and acted on. Record review revealed recent assessments. Interviews conducted with nurses and CNAs scheduled on the 6A - 2P shift [RN D, LVN J, CNA I and CNA K], on the 2P - 10P shift [LVN H, CNA G, LVN L, CNA N, LVN Q and RN C (recently transitioned from 10P - 6A shift)], and 10P - 6A shift [LVN O, LVN M and CNA P] indicated they participated in various in-service trainings. The staff stated topics of discussion included how to recognize a resident's change in condition, physician notification, and documentation. Each nurse stated in their own words the procedure to notify physicians immediately about resident change in condition. Each nurse demonstrated how to perform a respiratory assessment and verbalized abnormal findings. CNAs stated in their own words' signs and symptoms of acute respiratory distress, what must be reported to the charge nurse, and how to ensure oxygen therapy equipment functioned and applied appropriately on the resident. Record review of a QAPI ad hoc meeting minutes dated [DATE] revealed the QAPI team met to discuss the facility's failure to conduct a respiratory assessment, to notify the physician about a resident's change in condition and steps the facility must take to address the concern. Record review of an in-service conducted by the RCN dated [DATE] with the NFA, DON and ADON. Objectives of the in-service included Abuse and Neglect; Performing an assessment and providing care to residents who are experiencing a change in condition or respiratory distress; and Notification of change of condition to the physician immediately. Follow-up activities included one-on-one in-service. The NFA was informed the Immediate Jeopardy was removed on [DATE] at 4:30 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental and psychosocial needs for 1 of 3 (Residents #1) Residents reviewed for care plans. The facility failed to ensure Resident #1's CNA-J followed care plan interventions for proper supervision and incontinence care. This failure could place resident #1 at risk for injuries. Findings included: Record review of Resident #1's face sheet dated 3/20/24 reflected an [AGE] year-old female admitted on [DATE]. DX: age related cognitive decline, history of falling, other lack of coordination. Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 00. Resident dependent on staff for all activities including eating, oral hygiene, personal hygiene, showers, and bath. Section V listed no falls during the lookback period. Record review of Resident #1's Care plan dated 01/06/24 with related fall on 03/17/24 reflected Resident had was at risk of falls, r/t impaired mobility, impaired coordination, and impaired cognition, weakness, and disease process anticipate needs, call light in reach, educate, and remind staff about safe environment. Dependent on staff to meet needs .Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, impaired vision, bladder and bowel incontinence d/t cognitive impairment, mobility, history of right fibula (calf bone) fracture, pain, dementia, history of falls .care plan for mobility, ADLS, cognitive, and communication. Record review of Resident #1's MD orders dated 03/18/24 reflected Remove sixteen staples in two weeks apply steri-strips one time a day .cleanse sixteen staples to forehead with and pat dry. Apply ointment and may leave open to air until resolved one time a day and one time only until 03/18/24. Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen). Give one tablet by mouth two times a day for pain. Requires extensive assistance from staff for toileting, requires mechanical lift X2 staff assistance to transfer. Record review of Resident #1's MD order to admit to hospice dated 01/05/24 prior to lab draws, x-rays, other consults. No directions specified for order. Record review of Resident #1's fall note dated at 1:27 PM by LVN R reflected falling resident room, hit head, fall from low bed, cognitive impairment, oriented to person, place and time, obeys commands, pupils equal, injury yes, head, bleeding, resident verbal, pain Tylenol 325 mg, don't know what happened hospice was notified on 03/17/24 at 12:41 PM intervention low bed. Record review of Resident #1's fall assessment dated [DATE] reflected low-risk for falls, four by LVN E. Record review of Resident #1's fall assessment dated [DATE] at 9:08 PM by LVN R reflected resident fall risk was low. Record review of Resident #1's PN dated 03/20/24 at 08:30 PM by LVN K Text: 03/18/24 Bolster Mattress requested from '[company name]'. Rep, '{company]' stated it will be delivered as soon as possible. follow up call on 03/20/24 about the bolster Mattress'{company]' stated that it's been ordered and will be delivered soon. Record review of Resident #1's PN dated 03/17/24 at 12:30 PM by LVN R reflected Progress Note Late Entry: Note Text: This writer was notified by the caregiver that resident slide from bed and fall on the floor facing the window side, this nurse immediately went to room and observed PT on the floor lying on the left side, Head to toe assessment done and resident was noted with laceration on the middle of the head measuring 10 cm X 1 cm, this nurse by the help of the caregiver stopped the bleeding and assisted the pt. from the floor assessed her vitals resident was noted with no skin issue' at the time, this writer call 911, notified DON, Family member MD notified, Hospices notified, safety precautions in place bed in the lowest position, floor mat in place call light within reach. Record review of Resident #1's PN dated 03/17/24 time 2:21 PM by LVN-R reflected This nurse was notified by the caregiver that resident slid down from bed to floor and hurt his head and was bleeding from the head and this nurse did first aid and stopped the bleeding, this nurse received an order to send resident to hospital for further evaluation. This nurse notified the DON, family member and message left on voice mail. Record review of Resident #1's PN dated 03/17/24 at 9:05 PM by LVN-R reflected Resident returned from hospital on stretcher by EMS at around 8:45 PM, she was safely transferred to bed by two persons. resident come with sixteen staples on her head which can be removed .this nurse notified the [name] Hospice about the return from hospital, Family member notified Administration notified. DON safety precautions in place, Bed in the lowest position, up 30 to 45 degrees, floormat in place call light within resident reach. Record review of Resident #1's PN dated 03/18/24 at 12:59 PM reflected Progress Note: resting in bed quietly, staples are intact with no bleeding or drainage noted, remains on ABT with NAR .skin warm to touch, turgor (elasticity) is good. accepted fluids and meals well. does not make basic needs known, all needs met by staff. call into hospice pending regarding routine pain meds. Record review of Resident #1's Change of condition completed on 03/17/24 at 2:03 PM reflected functional status change hypothyroidism Dementia Sent pt to Hospital notified. Record review of Resident #1's Kardex ( Kardex is a documentation system that helps nurses organize and access key patient for their care plan.) dated 03/20/24 reflected Educate and remind staff about safe environment Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface .Monitoring In absence of b/p, pulse, respiration. Record review of Resident #1's provider investigation dated 03/18/24 reflected Pertinent Medical Diagnosis: History of falling, Lack of coordination, Cognitive communication deficit .Level of cognition: BIMs 99 indicating she was severely impaired cognitively and was not interviewable.Incident Details to ED Date: 3/18/24 at 9:00 AM Date/Time the incident occurred: 03/17/24 at 2:20 PM. Record Review of Provider Investigation Reported dated 03/19/24 reflected Resident '[Resident#1]' slid out of the bed during incontinent care Witnesses '[CNA-J]' .Assessment The date and time of the assessment: 03/17/24 at 2:20 PM completed by '[LVN-R]' Resident #1 was observed with bleeding from a laceration on the head. LVN-R stated Resident #1 was sent to hospital emergency room for evaluation of injuries .Resident #1 was given sixteen staples. RP, MD & DON were notified. CNA was given counsel and provided 1:1 education on safety awareness while providing incontinent care. Licensed and certified staff were provided education on safety awareness while providing incontinent care. Record review of CNA-J's individual coaching by DON on 03/18/24 reflected on 03/17/24 the following deficient were found, resident safety .this is a reminder of expectations lower resident beds for safety, whenever you back are facing resident .never leave bed elevated if you must turn your back on the resident. Record review of CNA-J's statement dated 03/18/24 reflected I was providing care for the resident, and I had to get her brief off nightstand .I did not lower the bed. As I turned around with my back facing the resident, I heard a loud noise .when I turned back, she had fallen out of the bed hitting her head on the floor, I called nurse who entered room and provided first aid to resident. Record review of in-service dated 03/01/8/24 by DON reflected Fall interventions are found on the resident in Kardex, POC, and task in electronic records documentation attached. In an interview with the ADON on 03/20/24 at 2:20 PM the ADON staff should enter the rooms for incontinent care together, to prevent accidents. ADON said the risk of not providing two staff could result in injuries of the resident falling off the bed. ADON expects both staff to be present, and the ADON, DON, and nurses will continue to monitor and train staff on safe practices. In an interview on 03/20/24 at 2:30 PM with CRN she revealed Resident #1's initial care plan stated Resident #1 required one person for incontinent care. CRN stated this was determined after a fall assessment score of 4 (indicating low-risk). CRN stated Resident #1 was assessed at the hospital by CT scan to assess possible injuries and fractures. The CT scan was negative for fractures. CRN stated the hospital staff performed an UA, and she was prescribed antibiotics for an UTI. CRN stated that the clinical staff (the IDT) reviewed and modified Resident #1's incontinent care task, and interventions for safety. New interventions for Resident #1 include having two staff must be present and positioned on each side of the bed for incontinent care. In an interview on 03/20/24 at 3:04 PM with ADM revealed the expectations of staff were to provide care consistent with resident needs and care plans. ADM stated that CNA-J failed to request additional staff during incontinent while providing care. He stated that the risk of staff failing to follow care plans could result in serious injuries, hospitalization s, and decline in resident level of care. Record review of facility policy dated 10/05/16 titled preventative strategies to prevent fall risk. The goal of fall prevention strategies is to design interventions that maximize fall risk by eliminating or managing contributing factors while keeping or improving the resident's mobility. Procedure: After risk is assessed, individualized nursing care plans will be implemented to prevent falls. The resident and family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects. Medical Strategies: a) Identify residents at risk for falls, b) Identify sign/symptom of underlying disease or medication effect that requires a clinician's attention in order to rule out reversible acute problems, c) Identify chronic medical conditions that may contribute to fall risk and treat appropriately, d) Assess medications, e) Provide PT/OT evaluation and treatment as needed. Rehabilitation Strategies: a) low intensity leg strengthening and weight bearing exercise, b) gait, balance, and transfer training. The policy for care plan was not requested; therefore, it is not listed for record review.

Based on observation, interviews, and record review, the facility failed to ensure resident environment remained as free of accidents hazards as possible: and each resident recieved adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Resident #1's CNA-J followed care plan interventions for proper supervision and incontinence care. This failure could place resident #1 at risk for injuries. Findings included: Record review of Resident #1's face sheet dated 3/20/24 reflected an [AGE] year-old female admitted on [DATE]. DX: age related cognitive decline, history of falling, other lack of coordination. Record review of Resident #1's quarterly MDS dated [DATE] reflected a BIMS score of 00. Resident dependent on staff for all activities including eating, oral hygiene, personal hygiene, showers, and bath. Section V listed no falls during the lookback period. Record review of Resident #1's Care plan dated 01/06/24 with related fall on 03/17/24 reflected Resident had was at risk of falls, r/t impaired mobility, impaired coordination, and impaired cognition, weakness, and disease process anticipate needs, call light in reach, educate, and remind staff about safe environment. Dependent on staff to meet needs .Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, impaired vision, bladder and bowel incontinence d/t cognitive impairment, mobility, history of right fibula (calf bone) fracture, pain, dementia, history of falls .care plan for mobility, ADLS, cognitive, and communication. Record review of Resident #1's MD orders dated 03/18/24 reflected Remove sixteen staples in two weeks apply steri-strips one time a day .cleanse sixteen staples to forehead with and pat dry. Apply ointment and may leave open to air until resolved one time a day and one time only until 03/18/24. Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen). Give one tablet by mouth two times a day for pain. Requires extensive assistance from staff for toileting, requires mechanical lift X2 staff assistance to transfer. Record review of Resident #1's MD order to admit to hospice dated 01/05/24 prior to lab draws, x-rays, other consults. No directions specified for order. Record review of Resident #1's fall note dated at 1:27 PM by LVN R reflected falling resident room, hit head, fall from low bed, cognitive impairment, oriented to person, place and time, obeys commands, pupils equal, injury yes, head, bleeding, resident verbal, pain Tylenol 325 mg, don't know what happened hospice was notified on 03/17/24 at 12:41 PM intervention low bed. Record review of Resident #1's fall assessment dated [DATE] reflected low-risk for falls, four by LVN E. Record review of Resident #1's fall assessment dated [DATE] at 9:08 PM by LVN R reflected resident fall risk was low. Record review of Resident #1's PN dated 03/20/24 at 08:30 PM by LVN K Text: 03/18/24 Bolster Mattress requested from '[company name]'. Rep, '{company]' stated it will be delivered as soon as possible. follow up call on 03/20/24 about the bolster Mattress'{company]' stated that it's been ordered and will be delivered soon. Record review of Resident #1's PN dated 03/17/24 at 12:30 PM by LVN R reflected Progress Note Late Entry: Note Text: This writer was notified by the caregiver that resident slide from bed and fall on the floor facing the window side, this nurse immediately went to room and observed PT on the floor lying on the left side, Head to toe assessment done and resident was noted with laceration on the middle of the head measuring 10 cm X 1 cm, this nurse by the help of the caregiver stopped the bleeding and assisted the pt. from the floor assessed her vitals resident was noted with no skin issue' at the time, this writer call 911, notified DON, Family member MD notified, Hospices notified, safety precautions in place bed in the lowest position, floor mat in place call light within reach. Record review of Resident #1's PN dated 03/17/24 time 2:21 PM by LVN-R reflected This nurse was notified by the caregiver that resident slid down from bed to floor and hurt his head and was bleeding from the head and this nurse did first aid and stopped the bleeding, this nurse received an order to send resident to hospital for further evaluation. This nurse notified the DON, family member and message left on voice mail. Record review of Resident #1's PN dated 03/17/24 at 9:05 PM by LVN-R reflected Resident returned from hospital on stretcher by EMS at around 8:45 PM, she was safely transferred to bed by two persons. resident come with sixteen staples on her head which can be removed .this nurse notified the [name] Hospice about the return from hospital, Family member notified Administration notified. DON safety precautions in place, Bed in the lowest position, up 30 to 45 degrees, floormat in place call light within resident reach. Record review of Resident #1's PN dated 03/18/24 at 12:59 PM reflected Progress Note: resting in bed quietly, staples are intact with no bleeding or drainage noted, remains on ABT with NAR .skin warm to touch, turgor (elasticity) is good. accepted fluids and meals well. does not make basic needs known, all needs met by staff. call into hospice pending regarding routine pain meds. Record review of Resident #1's Change of condition completed on 03/17/24 at 2:03 PM reflected functional status change hypothyroidism Dementia Sent pt to Hospital notified. Record review of Resident #1's Kardex ( Kardex is a documentation system that helps nurses organize and access key patient for their care plan.) dated 03/20/24 reflected Educate and remind staff about safe environment Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface .Monitoring In absence of b/p, pulse, respiration. Record review of Resident #1's provider investigation dated 03/18/24 reflected Pertinent Medical Diagnosis: History of falling, Lack of coordination, Cognitive communication deficit .Level of cognition: BIMs 99 indicating she was severely impaired cognitively and was not interviewable.Incident Details to ED Date: 3/18/24 at 9:00 AM Date/Time the incident occurred: 03/17/24 at 2:20 PM. Record Review of Provider Investigation Reported dated 03/19/24 reflected Resident '[Resident#1]' slid out of the bed during incontinent care Witnesses '[CNA-J]' .Assessment The date and time of the assessment: 03/17/24 at 2:20 PM completed by '[LVN-R]' Resident #1 was observed with bleeding from a laceration on the head. LVN-R stated Resident #1 was sent to hospital emergency room for evaluation of injuries .Resident #1 was given sixteen staples. RP, MD & DON were notified. CNA was given counsel and provided 1:1 education on safety awareness while providing incontinent care. Licensed and certified staff were provided education on safety awareness while providing incontinent care. Record review of CNA-J's individual coaching by DON on 03/18/24 reflected on 03/17/24 the following deficient were found, resident safety .this is a reminder of expectations lower resident beds for safety, whenever you back are facing resident .never leave bed elevated if you must turn your back on the resident. Record review of CNA-J's statement dated 03/18/24 reflected I was providing care for the resident, and I had to get her brief off nightstand .I did not lower the bed. As I turned around with my back facing the resident, I heard a loud noise .when I turned back, she had fallen out of the bed hitting her head on the floor, I called nurse who entered room and provided first aid to resident. Record review of in-service dated 03/01/8/24 by DON reflected Fall interventions are found on the resident in Kardex, POC, and task in electronic records documentation attached. In an interview with the ADON on 03/20/24 at 2:20 PM the ADON staff should enter the rooms for incontinent care together, to prevent accidents. ADON said the risk of not providing two staff could result in injuries of the resident falling off the bed. ADON expects both staff to be present, and the ADON, DON, and nurses will continue to monitor and train staff on safe practices. In an interview on 03/20/24 at 2:30 PM with CRN she revealed Resident #1's initial care plan stated Resident #1 required one person for incontinent care. CRN stated this was determined after a fall assessment score of 4 (indicating low-risk). CRN stated Resident #1 was assessed at the hospital by CT scan to assess possible injuries and fractures. The CT scan was negative for fractures. CRN stated the hospital staff performed an UA, and she was prescribed antibiotics for an UTI. CRN stated that the clinical staff (the IDT) reviewed and modified Resident #1's incontinent care task, and interventions for safety. New interventions for Resident #1 include having two staff must be present and positioned on each side of the bed for incontinent care. In an interview on 03/20/24 at 3:04 PM with ADM revealed the expectations of staff were to provide care consistent with resident needs and care plans. ADM stated that CNA-J failed to request additional staff during incontinent while providing care. He stated that the risk of staff failing to follow care plans could result in serious injuries, hospitalization s, and decline in resident level of care. Record review of facility policy dated 10/05/16 titled preventative strategies to prevent fall risk. The goal of fall prevention strategies is to design interventions that maximize fall risk by eliminating or managing contributing factors while keeping or improving the resident's mobility. Procedure: After risk is assessed, individualized nursing care plans will be implemented to prevent falls. The resident and family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehabilitation programs to improve functional ability, and care monitoring of medication side effects. Medical Strategies: a) Identify residents at risk for falls, b) Identify sign/symptom of underlying disease or medication effect that requires a clinician's attention in order to rule out reversible acute problems, c) Identify chronic medical conditions that may contribute to fall risk and treat appropriately, d) Assess medications, e) Provide PT/OT evaluation and treatment as needed. Rehabilitation Strategies: a) low intensity leg strengthening and weight bearing exercise, b) gait, balance, and transfer training. The policy for care plan was not requested; therefore, it is not listed for record review.

Based on interviews, and record review, the facility failed to ensure the resident environment was free of accident hazards and failed to ensure each resident received adequate supervision and assistance to prevent accidents for 1 of 4 (Resident #9) residents reviewed for accidents and hazards. The facility failed to implement new and effective interventions for Resident #9 who had an unwitnessed fall on 04/28/23 that resulted in the resident having a large subdural hematoma. Resident #9 required admission to the ICU for monitoring of intercranial pressure and had large amount of bleeding. The resident had a history of falls with injury. Resident #9 was currently taking blood thinner . An Immediate Jeopardy (IJ) was identified on 05/17/23. While the IJ was removed on 05/18/23, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. These failures placed residents at risk of incidents such as falls which could result in physical harm, injury, emotional distress, or even death. Findings included: A review of Resident #9's face sheet dated 04/12/23, revealed a [AGE] year-old female. She was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #9's diagnoses included Dementia, Muscle weakness, and cognitive communication deficit. A review of Resident #9's active physician orders for April 2023 revealed Resident #9 may wear a helmet for safety while awake. Monitor/assess skin for breakdown with the start date of 04/04/23 every shift. Observation on 05/10/23 at 10:04 am revealed Resident #9 located in the secure unit with a blue padded helmet, ambulating throughout the unit. Review of Resident #9's care plan last revised on 11/18/22 revealed Resident #9 was at risk of falls. The care plan included interventions . A review of the care plan revealed no evidence of Resident #9 utilizing a helmet to prevent further injury from a fall. The interventions reflected, anticipate and meet the resident needs. Ensure the resident is provided a safe environment, with even floors, free from spills and or clutter. A review of an Event Report dated 04/10/23 for Resident #9 revealed she was found laying on the floor bleeding from the back of her head and had a big hematoma. There was no evidence the helmet was worn by Resident #9's before the injury. The Report was completed by LVN B. Review of the hospital records dated 04/10/23 for Resident #9 revealed she was admitted to the hospital following a fall. The resident was diagnoses with a minor head injury, with a laceration of occipital scalp. Resident #9's head was treated with sutures. A review of the Incident/Accident report dated 04/28/23 revealed Resident #9 had an unwitnessed fall in the dining room. Resident #9 had a large hematoma to the back of the head, with a large amount of bleeding. There was no evidence Resident #9 wore a helmet during the fall . The Incident/Accident report was completed by LVN A. An interview with LVN A on 05/17/23 at 11:31 am revealed Resident #9 did not have on a helmet during the fall on 04/28/23. Review of the Incident report log dated 05/17/23 for Resident #9 revealed she suffered falls on 03/17/23, 03/28/23, 04/10/23 and 04/28/23. Review of Resident #9 hospital record dated 04/28/23 revealed she was admitted to the hospital with the diagnoses of subdural hematoma. CT scan of Resident #9's head revealed acute left parietal subdural hematoma measuring up to 7 mm in thickness with mass effect causing 2 mm of left to right midline shift an no herniation. Resident #9 was prescribed a blood thinner (Eliquis) for Atrial Fibrillation. An interview with LVN B on 05/10/23 at 10:47 am revealed she had worked with Resident #9 since being in the secure unit. LVN B stated Resident #9 often wandered throughout the secure unit. Resident #9 had suffered several falls in which she had hit her head causing bleeding. LVN B revealed she completed the Event Report dated 04/10/23. When Resident #9 was located on the floor, the helmet was not on the resident. LVN B revealed Resident #9 would often remove the helmet, and staff had been instructed to place the helmet back on Resident #9 once it had been removed. LVN B stated because of Resident'#9's diagnosis, it was difficult to ensure Resident #9 kept the helmet on . She was not aware Resident #9's care plan did not address the helmet and that the resident removed the helmet. She had not been informed of any new interventions to prevent Resident #9 from falling. An interview with CNA C on 05/10/23 at 11:04 am revealed Resident #9 would wander throughout the secure unit. Resident #9 had suffered several falls. The redirection of Resident #9 was unsuccessful because of her diagnosis of Dementia. She was not aware Resident #9's care plan was not being updated to reflect the helmet should be worn. She revealed all the staff knew the helmet must be worn by Resident #9 when she was out of bed. An interview with the DON on 05/10/23 at 12:57 pm revealed she was responsible for updating the resident's care plans when there had been a change in condition or new orders. The DON revealed Resident #9's care plan had not been updated to include the utilization of the helmet. Resident #9's care plan had not been updated with new interventions after the 04/28/23 fall. Following the fall on 04/10/23 the facility updated the care plan to reflect moving Resident #9 closer to the nurses' station, but no new interventions had been added. An additional interview with the DON on 05/17/23 at 11:21 am revealed the facility had not evaluated the effectiveness of the fall prevention methods. The DON revealed she had not included any new interventions after the fall on 04/28/23, in which Resident #9 had a fall and suffered a hematoma to the back of the head with bleeding. The DON instructed the staff to continue the same interventions. Resident #9 had been ordered to wear a helmet, and the start date of the order was 04/04/23. The DON revealed that after Resident #9 took off the helmet, the facility staff were not documenting and notifying her of the helmet being off. A review of Resident #9's Fall Risk assessment dated [DATE] revealed she was at high risk of falls. Resident #9 had a history of falls. Resident #9 had 3 or more falls in the past 3 months. No previous fall assessments were provided. Review of the facility's Preventive Strategies to Reduce Fall Risk policy dated 10/05/16 revealed After risk is assessed, individualized nursing care plan will be implemented to prevent falls. The resident and family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehab programs to improve functional ability, and careful monitoring of medication side effects. The facility Administrator and DON were notified on 05/17/23 at 11:19 am that an IJ situation had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on 05/17/23. After several revisions, the final Plan of Removal was accepted on 05/17/23 at 4:07 pm. The plan of removal included the following: Plan to remove Immediate Jeopardy Resident #9 continues to reside in the facility in the secured unit Resident #9 was screened by the Rehab Director on 5/17/23 for proper fitting of the helmet Resident #9 is to wear the helmet while awake, monitor/assess skin for breakdown every shift If Resident #9 removes the helmet, staff will re-direct and re-apply the helmet On 4/10/23, resident #9 had an unwitnessed fall with a hematoma to the back of her head. The resident was sent out to the emergency room . The resident returned to the facility the same day with staples to the back of the head On 4/28/23, resident #9 had an unwitnessed fall with a hematoma to the back of her head. The resident returned to the facility on [DATE] and signed up for hospice services Resident 9's fall care plan was reviewed for fall interventions on 5/17/2023 by the DON. Resident 9# fall risk assessment was updated on 5/17/2023 by the Director of Nursing DON/ADON / Designee began updating all resident fall risk assessments on 5/17. Any resident identified at risk for falls with injuries will have new and effective interventions in place DON/ADON/ Designee began reviewing and updating all resident fall care plans for interventions on 5/17/23. The following in-services were initiated by the Regional Compliance nurse and DON on 5/17/2023. Any staff member not present or in-serviced on 5/17/2023 will not be allowed to assume their duties until in-serviced. o Licensed Nurses: 1. Implementing interventions to minimize the risk of falls. 2. Fall Prevention Policy The DON or designee will in-service nursing staff on 5/17/23 regarding when resident #9 uses the helmet and what to do when resident #9 removes the helmet. Any staff member not present or in-serviced will not be allowed to assume their duties until in-serviced A Fall risk assessment will be completed on all new admissions or re-admissions after a fall has occurred. The MD was notified of the immediate jeopardy situation on 5/17/2023 at 12:19 pm. Ad Hoc QAPI meeting will be held on 5/17/23 to discuss the IJ and review the plan of removal Monitoring: DON and Administrator will review all fall during the morning meeting to ensure appropriate interventions have been implemented. Monitoring will occur 5 days per week for a minimum of 6 weeks. DON and Administrator will review all fall during the weekly Standard of Care Meeting to ensure appropriate interventions have been implemented. Monitoring will occur weekly for a minimum of 6 weeks. Above will be reviewed during the facility's monthly QA meeting for no less than 60 days, or until the Administrator determines substantial compliance has been achieved and maintained. Monitoring of the Plan to lower the Immediately Jeopardy: Observation on 05/17/23 and 05/18/23 of Resident #9 revealed the resident had a helmet on her head. Resident #9 was located near the nurses station. Record review of In-services education regarding Resident #9's use of Helmet, started on 05/17/23. Record review of Inservice education regarding Implementing interventions to minimize the risk of falls started on 05/17/23. A review of Resident #9's care plan revealed the plan had been updated with interventions to include the resident must wear a helmet when not in bed. Resident would be involved in activities more. The staff must redirect and placed the helmet back on the resident is the helmet is taken off. Interviews on 05/17/23 and 05/18/23 with LVN A, LVN B, LVN D, CNA C, CNA D, CNA F, LVN J, CNA K, CNA M, LVN H, and CNA T that worked on each of the facility's shifts, revealed the facility staff had been educated regarding identifying residents with falls. Implementation of fall interventions, Resident #9 fall interventions, Resident #9 fused of the helmet, and notification of Resident #9 's helmet being taken off. The Nurses were informed following the falls the care plans must be updated with interventions after each fall. The interventions will be communicated to the aides. An interview with the DON on 05/18/23 at 11:09 am revealed the care plans with interventions will be updated following each resident's falls. The staff was educated that Resident #9 must wear a helmet while out of bed. The DON will be notified if Resident #9 took off the helmet. Resident #9 and other residents with falls will have interventions added after each fall. An interview with the Administrator on 05/18/23 at 11:41 am revealed all residents of the facility were assessed for falls. The resident's care plans were updated with interventions. Resident #9's care plan was updated to include interventions. The Administrator will review all falls during the morning meeting to ensure appropriate interventions have been implemented. The administrator will monitor any falls to ensure fall prevention interventions were added. The Administrator will review all falls during the weekly Standard of Care Meeting to ensure appropriate interventions have been implemented. Monitoring will occur weekly for a minimum of 6 weeks. The Administrator and DON were notified the IJ was removed on 05/18/23 at 11:52 am. However, the facility remained out of compliance at the severity of the level of actual harm that is not immediate jeopardy and a scope of isolation due to the facility needing more time to monitor the plan of correction effectiveness.

Based on observation, interview, and record review the facility failed to ensure each resident was free from neglect for one (Resident #1) of three residents reviewed for neglect. The facility failed to adequately monitor Resident #1 and ensure his WanderGuard bracelet (signaling device) was functioning properly. As a result, the resident eloped from the facility on [DATE] in the evening, and he was returned by the police department on [DATE] at 4:55 PM. An Immediate Jeopardy was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm, and a scope of pattern because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. This failure resulted in Resident #1 eloping from the facility and placed the other two additional residents identified as being at risk for elopement and utilizing the WanderGuard system also at risk for elopement, serious injuries, and/or death. Findings included: 1. Review of Face Sheet for Resident #1, dated [DATE], reflected he was a [AGE] year-old male originally admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment for Resident #1 dated [DATE] reflected he had severe cognitive impairment. Delusional behavior was also indicated. Review of Resident #1's Medication Review Report dated [DATE] revealed an active physician order [REDACTED]. Review of Resident #1's TAR for the month of [DATE] reflected the nurse was to check the WanderGuard function and placement to the resident's right arm every shift for elopement. The WanderGuard was scheduled to be checked at 6:00 AM, 2:00 PM, 10:00 PM. It was initialed as being completed for the dates [DATE] through [DATE] (the date he eloped). Review of Resident #1's Care Plan's revealed a care plan for potential/actual safety related to dementia with initiation date of [DATE]. The goal reflected: Resident #1 will be observed for wandering/elopement behavior and other safety concerns and will remain safe within the facility thru next review. Identified interventions reflected the following: Initiate safety checks as indicated, observe for exit seeking behaviors and provide diversion activities, observe frequently during increased wandering to ensure safety, and WanderGuard or other electronic safety devices as deemed necessary by observation. 2. Interview with the Administrator on [DATE] at 3:26 PM revealed that information obtained from the hospital prior to Resident #1 being admitted reflected that he had been found on railroad tracks and then admitted to the hospital through the emergency room . She said out of safety, they placed the WanderGuard system on Resident #1 on admission. 3. Review of the facility Provider Investigation Report dated [DATE] and signed by the Administrator revealed the following: Resident #1 was independently ambulatory, non-interviewable, and incapable of making informed decisions, had a history of [REDACTED]. The description of the allegation revealed staff became aware at 10:00 PM of missing resident during shift change rounds. The Provider Response revealed the following: 10:00 PM - staff notices resident is missing when oncoming nurse does rounds 10:00 PM - staff begin search for resident in other rooms on unit 10:10 PM - staff calls CODE WHITE (missing resident) 10:11 PM - staff calls Administrator, DON, ADON, and begin search of courtyards and outside perimeter 10:15 PM - staff calls family and MD 10:40 PM - Administration arrives - calls in department heads and begins official search, makes police report [DATE] at 12:15 AM - Initiate wander and elopement in-service 12:30 AM - SILVER alert (public notification to broadcast information about missing persons) issued by police department The Investigation Summary reflected: Based on investigation, staff was aware of an acute change in behavior related to verbal aggression when staff attempted to redirect resident in the dining room on [DATE]. U/A was ordered and obtained on [DATE]. On [DATE] there were no new behaviors noted and no s/s that alerted staff to possible elopement of resident. Staff alerted to possible missing resident at shift change on [DATE] at 10:00 PM . Resident returned by police department on [DATE] at 4:55 PM. No acute distress noted. Provider Action Taken Post-Investigation revealed: Resident transferred to room on secured unit for safety and close monitoring of wandering. Continue on Keflex for 7 days BID for [DIAGNOSES REDACTED]. Review of witness statement included in the Facility Investigation revealed a signed witness statement dated [DATE] from LVN N .last seen the resident at approximately 8 PM. He was in the hallway walking toward the nursing station. He was alert and walking with steady gait. Pleasant affect. I seen no indication of him leaving. He has not shown any signs of wandering. Review of witness statement included in the Facility Investigation revealed a signed witness statement dated [DATE] from LVN F .came to work at 9:45 PM, while making my rounds, I noticed Resident #1 was not in his bed. I continued to make rounds. At the end, I looked for him throughout the facility and could not find him. I then, notified the primary nurse caring for him. We began our search at that point. 4. Observation of Resident #1 on [DATE] at 4:40 PM revealed he was sitting at dining room table in the locked unit. 5. Interview with the Administrator on [DATE] at 10:30 AM revealed Resident #1 had been immediately transferred to the locked unit after being returned to the facility on [DATE]. Interview with the DON on [DATE] at 10:54 AM revealed Resident #1 had a WanderGuard in place at the time he eloped. She stated the WanderGuard was placed on Resident #1 due to a history of wandering prior to his admission when at a Wal-Mart with a friend and reportedly he was missing for two days. She said they determined during the elopement investigation that his Wander Guard was not functioning. They also identified there were different types of WanderGuard bracelets (90-day and one-year). She stated they only had 90-day systems in the facility and determined his must have been no longer been working at the time he eloped. She stated Resident #1 was out of the facility for about 15 hours and was located at a school playground approximately two miles from the facility. She said a full head to toe assessment was performed when he returned to the facility and no injuries were identified. She stated he was also sent to the hospital for a full evaluation and the hospital diagnosed him with a UTI. Interview with the Administrator on [DATE] at 11:15 AM revealed once she began conducting the facility investigation, she determined that no staff had heard the alarm system go off. She said she then began testing the doors with the WanderGuard tester and it was not working. She stated she called the representative for the alarm company and was informed the tester the facility had was not the accurate tester for the current system the facility had in place. She had three new testers sent out to the facility a few days later and began checking all the doors with the new testers and they worked. She stated she then tested the WanderGuard bracelet that had been removed from Resident #1, and it did not alarm, therefore she knew it was not functioning. During her facility investigation, she identified there were two different devices (90-day and one-year devices). She stated Resident #1 had a 90-day device, and based on the order date of his WanderGuard ([DATE]) and the date of his elopement, she assumed it had expired and that was why it did not alarm. Typed and signed statement provided by the Administrator dated [DATE] revealed: Upon finding our that the resident had eloped, Administrator asked members present upon finding out he was missing if they heard the wanderguard system alert and/or any emergency exit doors alarm. No staff member present could identify hearing the alarm system alert. When Administrator went to test the doors, the wanderguard tester was not working and Administrator reached out to wanderguard system. Advised that the wanderguard tester was not accurate for the current system we used and we had three new testers sent to facility. Based on the date of placement on Resident #1, and the date of the elopement, and no staff member being able to recall an alarm alerting to his exit, it was concluded that the wanderguard had expired. Interview with the Administrator on [DATE] at 3:26 PM revealed that prior to the elopement incident, no one had been assigned the responsibility for checking the testers, but now everyone should be notifying her as soon as the testers do not work in the manner they should. She also stated she believed the nurses were probably taking residents over to the door to see if the alarms would work prior to the testers being available and being used. Interview with LVN C on [DATE] at 2:55 PM revealed she worked with Resident #1 prior to his elopement. She stated she would check WanderGuards to make sure they were on the residents' arms every shift and throughout her shift. She stated she would walk the residents to the door to make sure the WanderGuards would work about once a week and that the alarm would go off when residents got close to the door. She stated the Unit Managers were responsible for checking the WanderGuards with the testers and that she was only responsible for checking to make sure the WanderGuards were on the resident. Interview with Unit Mgr. D on [DATE] at 1:52 PM revealed she had been taking residents over to the doors to make sure the WanderGuards were working prior to the facility getting the tester box. She said the alarms would not go off when the resident got close to the door, but if the resident pushed on the door or manipulated the door, the alarms would go off. She stated the tester box was new and the facility had just gotten it after Resident #1 eloped. Interview with LVN A on [DATE] at 1:20 PM revealed she worked a hall with two residents with WanderGuards, and that she took them to the door every shift to make sure the device was working. She stated the device would make the doors lock down when the resident got close to the door and would only alarm when they actually opened the doors. She stated she had a device now on the medication cart to use to check the WanderGuards, but had not been trained on how to use the device. Interview with LVN B on [DATE] at 2:52 PM revealed she would take residents with WanderGuards over to the door to make sure they were working. She had received no training on using a tester box. 6. The facility's current policy for Abuse and Neglect Prohibition with a revision date of [DATE] reflected: Each resident has the right to be free from mistreatment, neglect, abuse, exploitation, involuntary seclusion, corporal punishment, physical or chemical restraint not required to treat the resident's medical symptoms, injuries of unknown origin, and misappropriation of resident property. .Neglect means a failure of the facility, its employees or service providers to provide goods or services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . 7. The facility's current policy for Elopement Management with a revision date of [DATE] reflected: .7. If a signaling device is determined to be an appropriate safety device and is placed on the resident, the facility is to: .b. Obtain a physician's orders [REDACTED].> i. Check placement of the signaling device every shift. The Licensed Nurse will verify the presence of the signaling device and document on the Treatment Administration Record (TAR) or on a separate log and maintained by the facility for 12 months. ii. Check the function of the signaling device daily using the tester box. The Licensed Nurse will verify that the signaling device is functioning and document on the TAR on a separate log and maintained by the facility for 12 months . c. The Licensed Nurse will immediately replace the signaling device if the device fails the function test. .15. The facility is to develop a consistent method for tracking the expiration of devices and ensure devices are replaced prior to expiration . 8. The facility's current policy for Testing the WanderGuard system with a revision date of February 2010 reflected: .1. Nursing staff will perform daily checks to verify the operation of the signaling device using a signaling device tester . 9. An Immediate Jeopardy was identified on [DATE] at 4:24 PM. The Administrator and DON were notified, and a Plan of Removal was requested at that time. 10. The revised Plan of Removal was accepted on [DATE] at 5:07 PM. It reflected the following steps taken to remove the immediacy: -Education provided to Director of Nurses and Asst. Director of Nurses on [DATE] at 5:15pm by Administrator, for the use of the WanderGuard tester to test the function of the WanderGuard and to test the door function. -Floor nurses were educated by DON and ADON related to how and when to properly test the function of the WanderGuard and who to notify in case of a system malfunction, starting on [DATE] at 6:00pm and ongoing through [DATE]. -Nurses will check WanderGuard function every shift and the door once per day. -Additional WanderGuards are located on each nurses' cart outside of the secured unit (100, 200 front, 200 back nurses carts) to ensure continuity of care in the case of expiration or malfunction of the system. -Nurses will successfully demonstrate proper use of WanderGuard tester on both resident WanderGuards and doors. -Skills check off list for WanderGuard testing and door function testing. -The remaining nurses, who have not received their training, cannot work until they have successfully demonstrated competency in WanderGuard checks. -The 100 hall nurse on 10pm-6am shift will be responsible for checking proper functioning of the door and will document it on the Door Function Test form located at the 100 hall nurses station. -Door Function Form to be utilized every night on 10p-6a shift by 100 hall nurse. 11. Interview with the DON on [DATE] at 9:49 AM revealed she supervised staff by return demonstration and randomly questioning to validate understanding. She stated she did not believe there was a system in place to check the doors and the WanderGuard bracelets for functionality prior to this incident. The DON believed the nursing staff were only checking for placement and not for functioning of the bracelet. She further stated she had delegated training of the new testers to Unit Mgr. D when they arrived, but had learned Unit Mgr. D had forgotten to do the training with the staff; therefore it had not been completed. The DON stated she had learned from this experience to trust, but verify. 12. Interview with Unit Mgr. D on [DATE] at 10:13 AM revealed she had been given the tester by the DON and instructed to educate all the nursing staff on the use of the tester after Resident #1 had been returned to the facility by the police department. She stated she was having to work a cart on that day because someone had called in and she placed the tester in a drawer at the nurses station and totally forgot about it. She stated she had not trained anyone prior to the IJ being identified. 13. Interview with the Administrator on [DATE] at 10:24 AM revealed she believed the IJ was caused due to the WanderGuard having expired and the facility not having a system in place to identify the date it should be changed, and also due to a lack of knowledge of the nurse's. She also stated due to the fact they typically used the WanderGuard system on a resident who was a short-term stay resident, also led to the confusion. She stated education had been completed with the DON and ADON and nursing staff on checking placement and functioning of the WanderGuards as well as start and stop dates had been added to the TAR to alert staff of the need to replace the WanderGuards. She said they would continue to be more vigilant on the awareness of the WanderGuard system and would continue education on the proper way to test the WanderGuards with the use of the tester so as to not desensitize the residents and nurses to the alarms by walking the residents by the doors and making them alarm. 14. Interview with the Medical Director on [DATE] at 10:45 AM revealed the facility had notified him soon after the IJ was called and he was sorry that it had occurred, but did not believe it reflected how the facility operated. He stated the facility notified him when Resident #1 had eloped from the facility and he came to the facility and assisted with the search as best he could. He stated the facility communicated with him very well regarding resident care issues and that he attended and participated in all the facility's Quality Assurance meetings. 15. On [DATE] at 11:00 AM, a list was provided by the DON reflecting all nurses had been in-serviced on how to properly test the WanderGuard system on the residents and the door system with the use of the testers and who to report if the equipment did not function properly with the exception of two that were out on leave and out of town and two other PRN nurses. Return demonstration post-tests were also provided. She stated all nurses would be in-serviced prior to being allowed to return to work. 16. On [DATE] and [DATE], thirteen individual staff interviews were conducted. Staff were asked to explain how they check the WanderGuard systems on the residents, how often they are checked, and where the documentation is maintained. They were also asked to explain how the doors of the facility were checked, how often they were checked, where the documentation was maintained, and what they were to do if any of the items were not functioning and who to report. All employees interviewed were able to correctly answer questions. The employees were as follows: - Day Shift (6:00 AM to 2:00 PM): LVN A, LVN B, and RN M - Day Shift (8:30 AM to 5:30 PM): Unit Mgr. L and ADON - Evening Shift (2:00 PM to 10:00 PM): LVN C and LVN E - Night Shift (10:00 PM to 6:00 AM): LVN F, LVN G, and LVN H - Double Weekend Shift: LVN K - PRN Staff: LVN I and LVN J 17. On [DATE] at 2:33 PM the Administrator and DON were informed the IJ was removed. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm, and at a scope of pattern because the facility was continuing to in-service staff and monitor the effectiveness of the Plan of Removal. 18. A list provided by the Administrator on [DATE] at 2:00 PM revealed there were two residents in the facility with a WanderGuard in place who did not reside in the locked unit. Resident #1 had been placed in the locked unit.

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent neglect of residents for one (Resident #1) of three residents reviewed for neglect. The facility failed to adequately monitor Resident #1 and ensure his WanderGuard bracelet (signaling device) was functioning properly. As a result, the resident eloped from the facility on [DATE] in the evening, and he was returned by the police department on [DATE] at 4:55 PM. An Immediate Jeopardy was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm, and a scope of pattern because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. This failure resulted in Resident #1 eloping from the facility and placed the other two additional residents identified as being at risk for elopement and utilizing the WanderGuard system also at risk for elopement, serious injuries, and/or death. Findings included: 1. The facility's current policy for Abuse and Neglect Prohibition with a revision date of [DATE] reflected: Each resident has the right to be free from mistreatment, neglect, abuse, exploitation, involuntary seclusion, corporal punishment, physical or chemical restraint not required to treat the resident's medical symptoms, injuries of unknown origin, and misappropriation of resident property. .Neglect means a failure of the facility, its employees or service providers to provide goods or services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . The facility's current policy for Elopement Management with a revision date of [DATE] reflected: .7. If a signaling device is determined to be an appropriate safety device and is placed on the resident, the facility is to: .b. Obtain a physician's orders [REDACTED].> i. Check placement of the signaling device every shift. The Licensed Nurse will verify the presence of the signaling device and document on the Treatment Administration Record (TAR) or on a separate log and maintained by the facility for 12 months. ii. Check the function of the signaling device daily using the tester box. The Licensed Nurse will verify that the signaling device is functioning and document on the TAR on a separate log and maintained by the facility for 12 months . c. The Licensed Nurse will immediately replace the signaling device if the device fails the function test. .15. The facility is to develop a consistent method for tracking the expiration of devices and ensure devices are replaced prior to expiration . The facility's current policy for Testing the WanderGuard system with a revision date of February 2010 reflected: .1. Nursing staff will perform daily checks to verify the operation of the signaling device using a signaling device tester . 2. Review of Face Sheet for Resident #1, dated [DATE], reflected he was a [AGE] year-old male originally admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment for Resident #1 dated [DATE] reflected he had severe cognitive impairment. Delusional behavior was also indicated. Review of Resident #1's Medication Review Report dated [DATE] revealed an active physician order [REDACTED]. Review of Resident #1's TAR for the month of [DATE] reflected the nurse was to check the WanderGuard function and placement to the resident's right arm every shift for elopement. The WanderGuard was scheduled to be checked at 6:00 AM, 2:00 PM, and 10:00 PM. It was initialed as being completed for the dates [DATE] through [DATE] (the date he eloped). Review of Resident #1's Care Plan's revealed a care plan for potential/actual safety related to dementia with initiation date of [DATE]. The goal reflected: Resident #1 will be observed for wandering/elopement behavior and other safety concerns and will remain safe within the facility thru next review. Identified interventions reflected the following: Initiate safety checks as indicated, observe for exit seeking behaviors and provide diversion activities, observe frequently during increased wandering to ensure safety, and WanderGuard or other electronic safety devices as deemed necessary by observation. 3. Interview with the Administrator on [DATE] at 3:26 PM revealed that information obtained from the hospital prior to Resident #1 being admitted reflected that he had been found on railroad tracks and then admitted to the hospital through the emergency room . She said out of safety, they placed the WanderGuard system on Resident #1 on admission. 4. Review of the facility Provider Investigation Report dated [DATE] and signed by the Administrator revealed the following: Resident #1 was independently ambulatory, non-interviewable, and incapable of making informed decisions and had a history of [REDACTED]. The description of the allegation revealed staff became aware at 10:00 PM of missing resident during shift change rounds. The Provider Response revealed the following: 10:00 PM - staff notices resident is missing when oncoming nurse does rounds 10:00 PM - staff begin search for resident in other rooms on unit 10:10 PM - staff calls CODE WHITE (missing resident) 10:11 PM - staff calls Administrator, DON, ADON, and begin search of courtyards and outside perimeter 10:15 PM - staff calls family and MD 10:40 PM - Administration arrives - calls in department heads and begins official search, makes police report [DATE] at 12:15 AM - Initiate wander and elopement in-service 12:30 AM - SILVER alert (public notification to broadcast information about missing persons) issued by police department The Investigation Summary reflected: Based on investigation, staff was aware of an acute change in behavior related to verbal aggression when staff attempted to redirect resident in the dining room on [DATE]. U/A was ordered and obtained on [DATE]. On [DATE] there were no new behaviors noted and no s/s that alerted staff to possible elopement of resident. Staff alerted to possible missing resident at shift change on [DATE] at 10:00 PM . Resident returned by police department on [DATE] at 4:55 PM. No acute distress noted. Provider Action Taken Post-Investigation revealed: Resident transferred to room on secured unit for safety and close monitoring of wandering. Continue on Keflex for 7 days BID for [DIAGNOSES REDACTED]. Review of witness statement included in the Facility Investigation revealed a signed witness statement dated [DATE] from LVN N .last seen the resident at approximately 8 PM. He was in the hallway walking toward the nursing station. He was alert and walking with steady gait. Pleasant affect. I seen no indication of him leaving. He has not shown any signs of wandering. Review of witness statement included in the Facility Investigation revealed a signed witness statement dated [DATE] from LVN F .came to work at 9:45 PM, while making my rounds, I noticed Resident #1 was not in his bed. I continued to make rounds. At the end, I looked for him throughout the facility and could not find him. I then, notified the primary nurse caring for him. We began our search at that point. 5. Observation of Resident #1 on [DATE] at 4:40 PM revealed he was sitting at dining room table in the locked unit. 6. Interview with the Administrator on [DATE] at 10:30 AM revealed Resident #1 had been immediately transferred to the locked unit after being returned to the facility on [DATE]. Interview with the DON on [DATE] at 10:54 AM revealed Resident #1 had a WanderGuard in place at the time he eloped. She stated the WanderGuard was placed on Resident #1 due to a history of wandering prior to his admission when at a Wal-Mart with a friend and reportedly he was missing for two days. She said they determined during the elopement investigation that his Wander Guard was not functioning. They also identified there were different types of WanderGuard bracelets (90-day and one-year). She stated they only had 90-day systems in the facility and determined his must have been no longer been working at the time he eloped. She stated Resident #1 was out of the facility for about 15 hours and was located at a school playground approximately two miles from the facility. She said a full head to toe assessment was performed when he returned to the facility and no injuries were identified. She stated he was also sent to the hospital for a full evaluation and the hospital diagnosed him with a UTI. Interview with the Administrator on [DATE] at 11:15 AM revealed once she began conducting the facility investigation, she determined that no staff had heard the alarm system go off. She said she then began testing the doors with the WanderGuard tester and it was not working. She stated she called the representative for the alarm company and was informed the tester the facility had was not the accurate tester for the current system the facility had in place. She had three new testers sent out to the facility a few days later and began checking all the doors with the new testers and they worked. She stated she then tested the WanderGuard bracelet that had been removed from Resident #1, and it did not alarm, therefore she knew it was not functioning. During her facility investigation, she identified there were two different devices (90-day and one-year devices). She stated Resident #1 had a 90-day device, and based on the order date of his WanderGuard ([DATE]) and the date of his elopement, she assumed it had expired and that was why it did not alarm. Typed and signed statement provided by the Administrator dated [DATE] revealed: Upon finding our that the resident had eloped, Administrator asked members present upon finding out he was missing if they heard the wanderguard system alert and/or any emergency exit doors alarm. No staff member present could identify hearing the alarm system alert. When Administrator went to test the doors, the wanderguard tester was not working and Administrator reached out to wanderguard system. Advised that the wanderguard tester was not accurate for the current system we used and we had three new testers sent to facility. Based on the date of placement on Resident #1, and the date of the elopement, and no staff member being able to recall an alarm alerting to his exit, it was concluded that the wanderguard had expired. Interview with the Administrator on [DATE] at 3:26 PM revealed that prior to the elopement incident, no one had been assigned the responsibility for checking the testers, but now everyone should be notifying her as soon as the testers do not work in the manner they should. She also stated she believed the nurses were probably taking residents over to the door to see if the alarms would work prior to the testers being available and being used. Interview with LVN C on [DATE] at 2:55 PM revealed she worked with Resident #1 prior to his elopement. She stated she would check WanderGuards to make sure they were on the residents' arms every shift and throughout her shift. She stated she would walk the residents to the door to make sure the WanderGuards would work about once a week and that the alarm would go off when the resident got close to the door. She stated the Unit Managers were responsible for checking the WanderGuards with the testers and that she was only responsible for checking to make sure the WanderGuards were on the resident. Interview with Unit Mgr. D on [DATE] at 1:52 PM revealed she had been taking residents over to the doors to make sure the WanderGuards were working prior to the facility getting the tester box. She said the alarms would not go off when the resident got close to the door, but if the resident pushed on the door or manipulated the door, the alarms would go off. She stated the tester box was new and the facility had just gotten it after Resident #1 eloped. Interview with LVN A on [DATE] at 1:20 PM revealed she worked a hall with two residents with WanderGuards, and that she took them to the door every shift to make sure the device was working. She stated the device would make the doors lock down when the resident got close to the door and would only alarm when they actually opened the doors. She stated she had a device now on the medication cart to use to check the WanderGuards, but had not been trained on how to use the device. Interview with LVN B on [DATE] at 2:52 PM revealed she would take residents with WanderGuards over to the door to make sure they were working. She had received no training on using a tester box. 7. An Immediate Jeopardy was identified on [DATE] at 4:24 PM. The Administrator and DON were notified, and a Plan of Removal was requested at that time. 8. The revised Plan of Removal was accepted on [DATE] at 5:07 PM. It reflected the following steps taken to remove the immediacy: -Education provided to Director of Nurses and Asst. Director of Nurses on [DATE] at 5:15pm by Administrator, for the use of the WanderGuard tester to test the function of the WanderGuard and to test the door function. -Floor nurses were educated by DON and ADON related to how and when to properly test the function of the WanderGuard and who to notify in case of a system malfunction, starting on [DATE] at 6:00pm and ongoing through [DATE]. -Nurses will check WanderGuard function every shift and the door once per day. -Additional WanderGuards are located on each nurses' cart outside of the secured unit (100, 200 front, 200 back nurses carts) to ensure continuity of care in the case of expiration or malfunction of the system. -Nurses will successfully demonstrate proper use of WanderGuard tester on both resident WanderGuards and doors. -Skills check off list for WanderGuard testing and door function testing. -The remaining nurses, who have not received their training, cannot work until they have successfully demonstrated competency in WanderGuard checks. -The 100 hall nurse on 10pm-6am shift will be responsible for checking proper functioning of the door and will document it on the Door Function Test form located at the 100 hall nurses station. -Door Function Form to be utilized every night on 10p-6a shift by 100 hall nurse. 9. Interview with the DON on [DATE] at 9:49 AM revealed she supervised staff by return demonstration and randomly questioning to validate understanding. She stated she did not believe there was a system in place to check the doors and the WanderGuard bracelets for functionality prior to this incident. The DON believed the nursing staff were only checking for placement and not for functioning of the bracelet. She further stated she had delegated training of the new testers to Unit Mgr. D when they arrived, but had learned Unit Mgr. D had forgotten to do the training with the staff; therefore it had not been completed. The DON stated she had learned from this experience to trust, but verify. 10. Interview with Unit Mgr. D on [DATE] at 10:13 AM revealed she had been given the tester by the DON and instructed to educate all the nursing staff on the use of the tester after Resident #1 had been returned to the facility by the police department. She stated she was having to work a cart on that day because someone had called in and she placed the tester in a drawer at the nurses station and totally forgot about it. She stated she had not trained anyone prior to the IJ being identified. 11. Interview with the Administrator on [DATE] at 10:24 AM revealed she believed the IJ was caused due to the WanderGuard having expired and the facility not having a system in place to identify the date it should be changed, and also due to a lack of knowledge of the nurse's. She also stated due to the fact they typically used the WanderGuard system on a resident who was a short-term stay resident, also led to the confusion. She stated education had been completed with the DON and ADON and nursing staff on checking placement and functioning of the WanderGuards as well as start and stop dates had been added to the TAR to alert staff of the need to replace the WanderGuards. She said they would continue to be more vigilant on the awareness of the WanderGuard system and would continue education on the proper way to test the WanderGuards with the use of the tester so as to not desensitize the residents and nurses to the alarms by walking the residents by the doors and making them alarm. 12. Interview with the Medical Director on [DATE] at 10:45 AM revealed the facility had notified him soon after the IJ was called and he was sorry that it had occurred, but did not believe it reflected how the facility operated. He stated the facility notified him when Resident #1 had eloped from the facility and he came to the facility and assisted with the search as best he could. He stated the facility communicated with him very well regarding resident care issues and that he attended and participated in all the facility's Quality Assurance meetings. 13. On [DATE] at 11:00 AM, a list was provided by the DON reflecting all nurses had been in-serviced on how to properly test the WanderGuard system on the residents and the door system with the use of the testers and who to report if the equipment did not function properly with the exception of two that were out on leave and out of town and two other PRN nurses. Return demonstration post-tests were also provided. She stated all nurses would be in-serviced prior to being allowed to return to work. 14. On [DATE] and [DATE], thirteen individual staff interviews were conducted. Staff were asked to explain how they check the WanderGuard systems on the residents, how often they are checked, and where the documentation is maintained. They were also asked to explain how the doors of the facility were checked, how often they were checked, where the documentation was maintained, and what they were to do if any of the items were not functioning and who to report. All employees interviewed were able to correctly answer questions. The employees were as follows: - Day Shift (6:00 AM to 2:00 PM): LVN A, LVN B, and RN M - Day Shift (8:30 AM to 5:30 PM): Unit Mgr. L and ADON - Evening Shift (2:00 PM to 10:00 PM): LVN C and LVN E - Night Shift (10:00 PM to 6:00 AM): LVN F, LVN G, and LVN H - Double Weekend Shift: LVN K - PRN Staff: LVN I and LVN J 15. On [DATE] at 2:33 PM the Administrator and DON were informed the IJ was removed. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm, and at a scope of pattern because the facility was continuing to in-service staff and monitor the effectiveness of the Plan of Removal. 16. A list provided by the Administrator on [DATE] at 2:00 PM revealed there were two residents in the facility with a WanderGuard in place who did not reside in the locked unit. Resident #1 had been placed in the locked unit.

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of seven residents reviewed for accidents and supervision. The facility failed to ensure Resident #1 was adequately supervised and that his WanderGuard was properly functioning. As a result, he eloped from the facility on [DATE] in the evening and he was returned by the police department on [DATE] at 4:55 PM. An Immediate Jeopardy was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm, and a scope of pattern because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. This failure resulted in Resident #1 eloping from the facility and placed the other two additional residents identified as being at risk for elopement and utilizing the WanderGuard system also at risk for elopement, serious injuries, and/or death. Findings included: 1. Review of Face Sheet for Resident #1, dated [DATE], reflected he was a [AGE] year-old male originally admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment for Resident #1 dated [DATE] reflected he had severe cognitive impairment. Delusional behavior was also indicated. Review of Resident #1's Medication Review Report dated [DATE] revealed an active physician order [REDACTED]. Review of Resident #1's TAR for the month of [DATE] reflected the nurse was to check the WanderGuard function and placement to the resident's right arm every shift for elopement. The WanderGuard was scheduled to be checked at 6:00 AM, 2:00 PM, and 10:00 PM. It was initialed as being completed for the dates [DATE] through [DATE] (date he eloped). Review of Resident #1's Care Plan's revealed a care plan for potential/actual safety related to dementia with initiation date of [DATE]. The goal reflected: Resident #1 will be observed for wandering/elopement behavior and other safety concerns and will remain safe within the facility thru next review. Identified interventions reflected the following: Initiate safety checks as indicated, observe for exit seeking behaviors and provide diversion activities, observe frequently during increased wandering to ensure safety, and WanderGuard or other electronic safety devices as deemed necessary by observation. 2. Interview with the Administrator on [DATE] at 3:26 PM revealed that information obtained from the hospital prior to Resident #1 being admitted reflected that he had been found on railroad tracks and then admitted to the hospital through the emergency room . She said out of safety, they placed the WanderGuard system on Resident #1 on admission. 3. Review of the facility Provider Investigation Report dated [DATE] and signed by the Administrator revealed the following: Resident #1 was independently ambulatory, non-interviewable, and incapable of making informed decisions and had a history of [REDACTED]. The description of the allegation revealed staff became aware at 10:00 PM of missing resident during shift change rounds. The Provider Response revealed the following: 10:00 PM - staff notices resident is missing when oncoming nurse does rounds 10:00 PM - staff begin search for resident in other rooms on unit 10:10 PM - staff calls CODE WHITE (missing resident) 10:11 PM - staff calls Administrator, DON, ADON, and begin search of courtyards and outside perimeter 10:15 PM - staff calls family and MD 10:40 PM - Administration arrives - calls in department heads and begins official search, makes police report [DATE] at 12:15 AM - Initiate wander and elopement in-service 12:30 AM - SILVER alert (public notification to broadcast information about missing persons) issued by police department The Investigation Summary reflected: Based on investigation, staff was aware of an acute change in behavior related to verbal aggression when staff attempted to redirect resident in the dining room on [DATE]. U/A was ordered and obtained on [DATE]. On [DATE] there were no new behaviors noted and no s/s that alerted staff to possible elopement of resident. Staff alerted to possible missing resident at shift change on [DATE] at 10:00 PM . Resident returned by police department on [DATE] at 4:55 PM. No acute distress noted. Provider Action Taken Post-Investigation revealed: Resident transferred to room on secured unit for safety and close monitoring of wandering. Continue on Keflex for 7 days BID for [DIAGNOSES REDACTED]. Review of witness statement included in the Facility Investigation revealed a signed witness statement dated [DATE] from LVN N .last seen the resident at approximately 8 PM. He was in the hallway walking toward the nursing station. He was alert and walking with steady gait. Pleasant affect. I seen no indication of him leaving. He has not shown any signs of wandering. Review of witness statement included in the Facility Investigation revealed a signed witness statement dated [DATE] from LVN F .came to work at 9:45 PM, while making my rounds, I noticed Resident #1 was not in his bed. I continued to make rounds. At the end, I looked for him throughout the facility and could not find him. I then, notified the primary nurse caring for him. We began our search at that point. 4. Observation of Resident #1 on [DATE] at 4:40 PM revealed he was sitting at dining room table in the locked unit. 5. Interview with the Administrator on [DATE] at 10:30 AM revealed Resident #1 had been immediately transferred to the locked unit after being returned to the facility on [DATE]. Interview with the DON on [DATE] at 10:54 AM revealed Resident #1 had a WanderGuard in place at the time he eloped. She stated the WanderGuard was placed on Resident #1 due to a history of wandering prior to his admission when at a Wal-Mart with a friend and reportedly he was missing for two days. She said they determined during the elopement investigation that his Wander Guard was not functioning. They also identified there were different types of WanderGuard bracelets (90-day and one-year). She stated they only had 90-day systems in the facility and determined his must have been no longer been working at the time he eloped. She stated Resident #1 was out of the facility for about 15 hours and was located at a school playground approximately two miles from the facility. She said a full head to toe assessment was performed when he returned to the facility and no injuries were identified. She stated he was also sent to the hospital for a full evaluation and the hospital diagnosed him with a UTI. Interview with the Administrator on [DATE] at 11:15 AM revealed once she began conducting the facility investigation, she determined that no staff had heard the alarm system go off. She said she then began testing the doors with the WanderGuard tester and it was not working. She stated she called the representative for the alarm company and was informed the tester the facility had was not the accurate tester for the current system the facility had in place. She had three new testers sent out to the facility a few days later and began checking all the doors with the new testers and they worked. She stated she then tested the WanderGuard bracelet that had been removed from Resident #1, and it did not alarm, therefore she knew it was not functioning. During her facility investigation, she identified there were two different devices (90-day and one-year devices). She stated Resident #1 had a 90-day device, and based on the order date of his WanderGuard ([DATE]) and the date of his elopement, she assumed it had expired and that was why it did not alarm. Typed and signed statement provided by the Administrator dated [DATE] revealed: Upon finding our that the resident had eloped, Administrator asked members present upon finding out he was missing if they heard the wanderguard system alert and/or any emergency exit doors alarm. No staff member present could identify hearing the alarm system alert. When Administrator went to test the doors, the wanderguard tester was not working and Administrator reached out to wanderguard system. Advised that the wanderguard tester was not accurate for the current system we used and we had three new testers sent to facility. Based on the date of placement on Resident #1, and the date of the elopement, and no staff member being able to recall an alarm alerting to his exit, it was concluded that the wanderguard had expired. Interview with the Administrator on [DATE] at 3:26 PM revealed that prior to the elopement incident, no one had been assigned the responsibility for checking the testers, but now everyone should be notifying her as soon as the testers do not work in the manner they should. She also stated she believed the nurses were probably taking residents over to the door to see if the alarms would work prior to the testers being available and being used. Interview with LVN C on [DATE] at 2:55 PM revealed she worked with Resident #1 prior to his elopement. She stated she would check WanderGuards to make sure they were on the residents' arms every shift and throughout her shift. She stated she would walk the residents to the door to make sure the WanderGuards would work about once a week and that the alarm would go off when the resident got close to the door. She stated the Unit Managers were responsible for checking the WanderGuards with the testers and that she was only responsible for checking to make sure the WanderGuards were on the resident. Interview with Unit Mgr. D on [DATE] at 1:52 PM revealed she had been taking residents over to the doors to make sure the WanderGuards were working prior to the facility getting the tester box. She said the alarms would not go off when the resident got close to the door, but if the resident pushed on the door or manipulated the door, the alarms would go off. She stated the tester box was new and the facility had just gotten it after Resident #1 eloped. Interview with LVN A on [DATE] at 1:20 PM revealed she worked a hall with two residents with WanderGuards, and that she took them to the door every shift to make sure the device was working. She stated the device would make the doors lock down when the resident got close to the door and would only alarm when they actually opened the doors. She stated she had a device now on the medication cart to use to check the WanderGuards, but had not been trained on how to use the device. Interview with LVN B on [DATE] at 2:52 PM revealed she would take residents with WanderGuards over to the door to make sure they were working. She had received no training on using a tester box. 6. The facility's current policy for Elopement Management with a revision date of [DATE] reflected: .7. If a signaling device is determined to be an appropriate safety device and is placed on the resident, the facility is to: .b. Obtain a physician's orders [REDACTED].> i. Check placement of the signaling device every shift. The Licensed Nurse will verify the presence of the signaling device and document on the Treatment Administration Record (TAR) or on a separate log and maintained by the facility for 12 months. ii. Check the function of the signaling device daily using the tester box. The Licensed Nurse will verify that the signaling device is functioning and document on the TAR on a separate log and maintained by the facility for 12 months . c. The Licensed Nurse will immediately replace the signaling device if the device fails the function test. .15. The facility is to develop a consistent method for tracking the expiration of devices and ensure devices are replaced prior to expiration . 7. The facility's current policy for Testing the WanderGuard system with a revision date of February 2010 reflected: .1. Nursing staff will perform daily checks to verify the operation of the signaling device using a signaling device tester . 8. An Immediate Jeopardy was identified on [DATE] at 4:24 PM. The Administrator and DON were notified, and a Plan of Removal was requested at that time. 9. The revised Plan of Removal was accepted on [DATE] at 5:07 PM. It reflected the following steps taken to remove the immediacy: -Education provided to Director of Nurses and Asst. Director of Nurses on [DATE] at 5:15pm by Administrator, for the use of the WanderGuard tester to test the function of the WanderGuard and to test the door function. -Floor nurses were educated by DON and ADON related to how and when to properly test the function of the WanderGuard and who to notify in case of a system malfunction, starting on [DATE] at 6:00pm and ongoing through [DATE]. -Nurses will check WanderGuard function every shift and the door once per day. -Additional WanderGuards are located on each nurses' cart outside of the secured unit (100, 200 front, 200 back nurses carts) to ensure continuity of care in the case of expiration or malfunction of the system. -Nurses will successfully demonstrate proper use of WanderGuard tester on both resident WanderGuards and doors. -Skills check off list for WanderGuard testing and door function testing. -The remaining nurses, who have not received their training, cannot work until they have successfully demonstrated competency in WanderGuard checks. -The 100 hall nurse on 10pm-6am shift will be responsible for checking proper functioning of the door and will document it on the Door Function Test form located at the 100 hall nurses station. -Door Function Form to be utilized every night on 10p-6a shift by 100 hall nurse. 10. Interview with the DON on [DATE] at 9:49 AM revealed she supervised staff by return demonstration and randomly questioning to validate understanding. She stated she did not believe there was a system in place to check the doors and the WanderGuard bracelets for functionality prior to this incident. The DON believed the nursing staff were only checking for placement and not for functioning of the bracelet. She further stated she had delegated training of the new testers to Unit Mgr. D when they arrived, but had learned Unit Mgr. D had forgotten to do the training with the staff; therefore it had not been completed. The DON stated she had learned from this experience to trust, but verify. 11. Interview with Unit Mgr. D on [DATE] at 10:13 AM revealed she had been given the tester by the DON and instructed to educate all the nursing staff on the use of the tester after Resident #1 had been returned to the facility by the police department. She stated she was having to work a cart on that day because someone had called in and she placed the tester in a drawer at the nurses station and totally forgot about it. She stated she had not trained anyone prior to the IJ being identified. 12. Interview with the Administrator on [DATE] at 10:24 AM revealed she believed the IJ was caused due to the WanderGuard having expired and the facility not having a system in place to identify the date it should be changed, and also due to a lack of knowledge of the nurse's. She also stated due to the fact they typically used the WanderGuard system on a resident who was a short-term stay resident, also led to the confusion. She stated education had been completed with the DON and ADON and nursing staff on checking placement and functioning of the WanderGuards as well as start and stop dates had been added to the TAR to alert staff of the need to replace the WanderGuards. She said they would continue to be more vigilant on the awareness of the WanderGuard system and would continue education on the proper way to test the WanderGuards with the use of the tester so as to not desensitize the residents and nurses to the alarms by walking the residents by the doors and making them alarm. 13. Interview with the Medical Director on [DATE] at 10:45 AM revealed the facility had notified him soon after the IJ was called and he was sorry that it had occurred, but did not believe it reflected how the facility operated. He stated the facility notified him when Resident #1 had eloped from the facility and he came to the facility and assisted with the search as best he could. He stated the facility communicated with him very well regarding resident care issues and that he attended and participated in all the facility's Quality Assurance meetings. 14. On [DATE] at 11:00 AM, a list was provided by the DON reflecting all nurses had been in-serviced on how to properly test the WanderGuard system on the residents and the door system with the use of the testers and who to report if the equipment did not function properly with the exception of two that were out on leave and out of town and two other PRN nurses. Return demonstration post-tests were also provided. She stated all nurses would be in-serviced prior to being allowed to return to work. 15. On [DATE] and [DATE], thirteen individual staff interviews were conducted. Staff were asked to explain how they check the WanderGuard systems on the residents, how often they are checked, and where the documentation is maintained. They were also asked to explain how the doors of the facility were checked, how often they were checked, where the documentation was maintained, and what they were to do if any of the items were not functioning and who to report. All employees interviewed were able to correctly answer questions. The employees were as follows: - Day Shift (6:00 AM to 2:00 PM): LVN A, LVN B, and RN M - Day Shift (8:30 AM to 5:30 PM): Unit Mgr. L and ADON - Evening Shift (2:00 PM to 10:00 PM): LVN C and LVN E - Night Shift (10:00 PM to 6:00 AM): LVN F, LVN G, and LVN H - Double Weekend Shift: LVN K - PRN Staff: LVN I and LVN J 16. On [DATE] at 2:33 PM the Administrator and DON were informed the IJ was removed. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm, and at a scope of pattern because the facility was continuing to in-service staff and monitor the effectiveness of the Plan of Removal. 17. A list provided by the Administrator on [DATE] at 2:00 PM revealed there were two residents in the facility with a WanderGuard in place who did not reside in the locked unit. Resident #1 had been placed in the locked unit.

Based on interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one (Resident #1) of three residents reviewed for neglect. The Administrator and DON failed to have knowledge of current WanderGuard system and equipment and failed to train the staff on WanderGuard equipment. An Immediate Jeopardy was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm, and a scope of pattern because the facility was continuing to in-service staff and was monitoring the effectiveness of the Plan of Removal. These failures resulted in neglect for Resident #1 and could have resulted in more serious injuries and/or death and placed the other two residents identified at risk for elopement and utilizing the WanderGuard system also at risk for neglect, serious injuries, and/or death. Findings included: 1. Interview with the Administrator on [DATE] at 3:26 PM revealed that information obtained from the hospital prior to Resident #1 being admitted reflected that he had been found on railroad tracks and then admitted to the hospital through the emergency room . She said out of safety, they placed the WanderGuard system on Resident #1 on admission. Interview with the DON on [DATE] at 10:54 AM revealed Resident #1 had a WanderGuard in place at the time he eloped. She stated the WanderGuard was placed on Resident #1 due to a history of wandering prior to his admission when at a Wal-Mart with a friend and reportedly he was missing for two days. She said they determined during the elopement investigation that his Wander Guard was not functioning. They also identified there were different types of WanderGuard bracelets (90-day and one-year). She stated they only had 90-day systems in the facility and determined his must have been no longer been working at the time he eloped. She stated Resident #1 was out of the facility for about 15 hours and was located at a school playground approximately two miles from the facility. She said a full head to toe assessment was performed when he returned to the facility and no injuries were identified. She stated he was also sent to the hospital for a full evaluation and the hospital diagnosed him with a UTI. Interview with the Administrator on [DATE] at 11:15 AM revealed once she began conducting the facility investigation, she determined that no staff had heard the alarm system go off. She said she then began testing the doors with the WanderGuard tester and it was not working. She stated she called the representative for the alarm company and was informed the tester the facility had was not the accurate tester for the current system the facility had in place. She had three new testers sent out to the facility a few days later and began checking all the doors with the new testers and they worked. She stated she then tested the WanderGuard bracelet that had been removed from Resident #1, and it did not alarm, therefore she knew it was not functioning. During her facility investigation, she identified there were two different devices (90-day and one-year devices). She stated Resident #1 had a 90-day device, and based on the order date of his WanderGuard ([DATE]) and the date of his elopement, she assumed it had expired and that was why it did not alarm. Typed and signed statement provided by the Administrator dated [DATE] revealed: Upon finding our that the resident had eloped, Administrator asked members present upon finding out he was missing if they heard the wanderguard system alert and/or any emergency exit doors alarm. No staff member present could identify hearing the alarm system alert. When Administrator went to test the doors, the wanderguard tester was not working and Administrator reached out to wanderguard system. Advised that the wanderguard tester was not accurate for the current system we used and we had three new testers sent to facility. Based on the date of placement on Resident #1, and the date of the elopement, and no staff member being able to recall an alarm alerting to his exit, it was concluded that the wanderguard had expired. Interview with the Administrator on [DATE] at 3:26 PM revealed that prior to the elopement incident, no one had been assigned the responsibility for checking the testers, but now everyone should be notifying her as soon as the testers do not work in the manner they should. She also stated she believed the nurses were probably taking residents over to the door to see if the alarms would work prior to the testers being available and being used. Interview with LVN C on [DATE] at 2:55 PM revealed she worked with Resident #1 prior to his elopement. She stated she would check WanderGuards to make sure they were on the residents' arms every shift and throughout her shift. She stated she would walk the residents to the door to make sure the WanderGuards would work about once a week and that the alarm would go off when residents got close to the door. She stated the Unit Managers were responsible for checking the WanderGuards with the testers and that she was only responsible for checking to make sure the WanderGuards were on the resident. Interview with Unit Mgr. D on [DATE] at 1:52 PM revealed she had been taking residents over to the doors to make sure the WanderGuards were working prior to the facility getting the tester box. She said the alarms would not go off when the resident got close to the door, but if the resident pushed on the door or manipulated the door, the alarms would go off. She stated the tester box was new and the facility had just gotten it after Resident #1 eloped. Interview with LVN A on [DATE] at 1:20 PM revealed she worked a hall with two residents with WanderGuards, and that she took them to the door every shift to make sure the device was working. She stated the device would make the doors lock down when the resident got close to the door and would only alarm when they actually opened the doors. She stated she had a device now on the medication cart to use to check the WanderGuards, but had not been trained on how to use the device. Interview with LVN B on [DATE] at 2:52 PM revealed she would take residents with WanderGuards over to the door to make sure they were working. She had received no training on using a tester box. 2. Review of the facility Provider Investigation Report dated [DATE] and signed by the Administrator revealed the following: Resident #1 was independently ambulatory, non-interviewable, and incapable of making informed decisions, had a history of [REDACTED]. The description of the allegation revealed staff became aware at 10:00 PM of missing resident during shift change rounds. The Provider Response revealed the following: 10:00 PM - staff notices resident is missing when oncoming nurse does rounds 10:00 PM - staff begin search for resident in other rooms on unit 10:10 PM - staff calls CODE WHITE (missing resident) 10:11 PM - staff calls Administrator, DON, ADON, and begin search of courtyards and outside perimeter 10:15 PM - staff calls family and MD 10:40 PM - Administration arrives - calls in department heads and begins official search, makes police report [DATE] at 12:15 AM - Initiate wander and elopement in-service 12:30 AM - SILVER alert (public notification to broadcast information about missing persons) issued by police department The Investigation Summary reflected: Based on investigation, staff was aware of an acute change in behavior related to verbal aggression when staff attempted to redirect resident in the dining room on [DATE]. U/A was ordered and obtained on [DATE]. On [DATE] there were no new behaviors noted and no s/s that alerted staff to possible elopement of resident. Staff alerted to possible missing resident at shift change on [DATE] at 10:00 PM . Resident returned by police department on [DATE] at 4:55 PM. No acute distress noted. Provider Action Taken Post-Investigation revealed: Resident transferred to room on secured unit for safety and close monitoring of wandering. Continue on Keflex for 7 days BID for [DIAGNOSES REDACTED]. Review of witness statement included in the Facility Investigation revealed a signed witness statement dated [DATE] from LVN N .last seen the resident at approximately 8 PM. He was in the hallway walking toward the nursing station. He was alert and walking with steady gait. Pleasant affect. I seen no indication of him leaving. He has not shown any signs of wandering. Review of witness statement included in the Facility Investigation revealed a signed witness statement dated [DATE] from LVN F .came to work at 9:45 PM, while making my rounds, I noticed Resident #1 was not in his bed. I continued to make rounds. At the end, I looked for him throughout the facility and could not find him. I then, notified the primary nurse caring for him. We began our search at that point. 3. Interview with the Administrator on [DATE] at 10:30 AM revealed Resident #1 had been immediately transferred to the locked unit after being returned to the facility on [DATE]. 4. Observation of Resident #1 on [DATE] at 4:40 PM revealed he was sitting at dining room table in the locked unit. 5. The facility's current policy for Abuse and Neglect Prohibition with a revision date of [DATE] reflected: Each resident has the right to be free from mistreatment, neglect, abuse, exploitation, involuntary seclusion, corporal punishment, physical or chemical restraint not required to treat the resident's medical symptoms, injuries of unknown origin, and misappropriation of resident property. .Neglect means a failure of the facility, its employees or service providers to provide goods or services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . .Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property is at risk for occurring . 6. The facility's current policy for Elopement Management with a revision date of [DATE] reflected: .7. If a signaling device is determined to be an appropriate safety device and is placed on the resident, the facility is to: .b. Obtain a physician's orders [REDACTED].> i. Check placement of the signaling device every shift. The Licensed Nurse will verify the presence of the signaling device and document on the Treatment Administration Record (TAR) or on a separate log and maintained by the facility for 12 months. ii. Check the function of the signaling device daily using the tester box. The Licensed Nurse will verify that the signaling device is functioning and document on the TAR on a separate log and maintained by the facility for 12 months . c. The Licensed Nurse will immediately replace the signaling device if the device fails the function test. .15. The facility is to develop a consistent method for tracking the expiration of devices and ensure devices are replaced prior to expiration . 7. The facility's current policy for Testing the WanderGuard system with a revision date of February 2010 reflected: .1. Nursing staff will perform daily checks to verify the operation of the signaling device using a signaling device tester . 8. An Immediate Jeopardy was identified on [DATE] at 4:24 PM. The Administrator and DON were notified, and a Plan of Removal was requested at that time. 9. The revised Plan of Removal was accepted on [DATE] at 5:07 PM. It reflected the following steps taken to remove the immediacy: -Education provided to Director of Nurses and Asst. Director of Nurses on [DATE] at 5:15pm by Administrator, for the use of the WanderGuard tester to test the function of the WanderGuard and to test the door function. -Floor nurses were educated by DON and ADON related to how and when to properly test the function of the WanderGuard and who to notify in case of a system malfunction, starting on [DATE] at 6:00pm and ongoing through [DATE]. -Nurses will check WanderGuard function every shift and the door once per day. -Additional WanderGuards are located on each nurses' cart outside of the secured unit (100, 200 front, 200 back nurses carts) to ensure continuity of care in the case of expiration or malfunction of the system. -Nurses will successfully demonstrate proper use of WanderGuard tester on both resident WanderGuards and doors. -Skills check off list for WanderGuard testing and door function testing. -The remaining nurses, who have not received their training, cannot work until they have successfully demonstrated competency in WanderGuard checks. -The 100 hall nurse on 10pm-6am shift will be responsible for checking proper functioning of the door and will document it on the Door Function Test form located at the 100 hall nurses station. -Door Function Form to be utilized every night on 10p-6a shift by 100 hall nurse. 10. Interview with the DON on [DATE] at 9:49 AM revealed she supervised staff by return demonstration and randomly questioning to validate understanding. She stated she did not believe there was a system in place to check the doors and the WanderGuard bracelets for functionality prior to this incident. The DON believed the nursing staff were only checking for placement and not for functioning of the bracelet. She further stated she had delegated training of the new testers to Unit Mgr. D when they arrived, but had learned Unit Mgr. D had forgotten to do the training with the staff; therefore it had not been completed. The DON stated she had learned from this experience to trust, but verify. 11. Interview with Unit Mgr. D on [DATE] at 10:13 AM revealed she had been given the tester by the DON and instructed to educate all the nursing staff on the use of the tester after Resident #1 had been returned to the facility by the police department. She stated she was having to work a cart on that day because someone had called in and she placed the tester in a drawer at the nurses station and totally forgot about it. She stated she had not trained anyone prior to the IJ being identified. 12. Interview with the Administrator on [DATE] at 10:24 AM revealed she believed the IJ was caused due to the WanderGuard having expired and the facility not having a system in place to identify the date it should be changed, and also due to a lack of knowledge of the nurse's. She also stated due to the fact they typically used the WanderGuard system on a resident who was a short-term stay resident, also led to the confusion. She stated education had been completed with the DON and ADON and nursing staff on checking placement and functioning of the WanderGuards as well as start and stop dates had been added to the TAR to alert staff of the need to replace the WanderGuards. She said they would continue to be more vigilant on the awareness of the WanderGuard system and would continue education on the proper way to test the WanderGuards with the use of the tester so as to not desensitize the residents and nurses to the alarms by walking the residents by the doors and making them alarm. 13. Interview with the Medical Director on [DATE] at 10:45 AM revealed the facility had notified him soon after the IJ was called and he was sorry that it had occurred, but did not believe it reflected how the facility operated. He stated the facility notified him when Resident #1 had eloped from the facility and he came to the facility and assisted with the search as best he could. He stated the facility communicated with him very well regarding resident care issues and that he attended and participated in all the facility's Quality Assurance meetings. 14. On [DATE] at 11:00 AM, a list was provided by the DON reflecting all nurses had been in-serviced on how to properly test the WanderGuard system on the residents and the door system with the use of the testers and who to report if the equipment did not function properly with the exception of two that were out on leave and out of town and two other PRN nurses. Return demonstration post-tests were also provided. She stated all nurses would be in-serviced prior to being allowed to return to work. 15. On [DATE] and [DATE], thirteen individual staff interviews were conducted. Staff were asked to explain how they check the WanderGuard systems on the residents, how often they are checked, and where the documentation is maintained. They were also asked to explain how the doors of the facility were checked, how often they were checked, where the documentation was maintained, and what they were to do if any of the items were not functioning and who to report. All employees interviewed were able to correctly answer questions. The employees were as follows: - Day Shift (6:00 AM to 2:00 PM): LVN A, LVN B, and RN M - Day Shift (8:30 AM to 5:30 PM): Unit Mgr. L and ADON - Evening Shift (2:00 PM to 10:00 PM): LVN C and LVN E - Night Shift (10:00 PM to 6:00 AM): LVN F, LVN G, and LVN H - Double Weekend Shift: LVN K - PRN Staff: LVN I and LVN J 16. On [DATE] at 2:33 PM the Administrator and DON were informed the IJ was removed. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with potential for more than minimum harm, and at a scope of pattern because the facility was continuing to in-service staff and monitor the effectiveness of the Plan of Removal. 17. A list provided by the Administrator on [DATE] at 2:00 PM revealed there were two residents in the facility with a WanderGuard in place who did not reside in the locked unit. Resident #1 had been placed in the locked unit.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care, for two (Residents #2 and #3) of 12 residents reviewed for pain management. 1. The facility failed to ensure Resident #2's physician-ordered pain medications, [MEDICATION NAME] and [MEDICATION NAME], were administered and/or available on 05/22/16, 05/25/16, 05/28/16, and 06/19/16. Resident #2 reported experiencing severe, unrelieved pain on the days she did not receive her physician-ordered pain medications. 2. The facility failed to ensure Resident #3's physician-ordered pain medication, Soma, was administered and/or available on 06/10/16. Resident #3 reported experiencing severe, unrelieved pain when she did not receive her physician-ordered pain medication. These failures placed the 43 residents who had moderate/severe pain at risk for unrelieved pain, distress, and a decreased quality of life. Findings included: 1. Resident #2's MDS assessment, dated 05/16/16, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had moderately impaired cognitive skills and was able to understand and be understood by others. The resident received a scheduled pain medication regimen, a PRN pain medication regimen, and non-medication interventions for pain. The resident's pain was almost constantly present, limited her day-to-day activities, and limited her ability to sleep at night. Her pain rating was 9 on a scale of 0-10 with zero being no pain and ten as the worst pain imaginable. Resident #2's physician orders, dated 05/09/16, reflected apply [MEDICATION NAME] (opioid [MEDICATION NAME]) patch 75 mcg/hour every 72 hours [MEDICATION NAME] related to chronic pai[DIAGNOSES REDACTED]. Resident #2's Comprehensive Plan of Care, review date 05/10/16, with revision on 05/20/16, reflected the resident had chronic pain related to gout. The care planned approaches included anticipating the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions post administration, review for compliance and alleviation of symptoms, review dosing schedules, review resident satisfaction with the results, review impact on functional ability and cognition. Observe and report changes in usual routine, sleep patterns, decrease in functional ability, and decrease in range of motion. Observe and document for side effects of the pain medication, and report occurrences to the physician. A physician's orders [REDACTED]. Resident #2's May 2016 MAR revealed on 05/22/16 at 9:24 p.m. she was scheduled to receive [MEDICATION NAME] 75 mcg/hour. LVN F documented #8 on the MAR, which was the facility's code for the medication not being available. An interview with LVN G on 06/21/16 at 12:37 p.m. revealed #8 when documented on a resident's MAR meant the facility did not have the medication available to give to the resident. She stated the process to obtain the medication was to notify the pharmacy. Resident #2's progress notes dated 05/22/16 at 9:24 p.m. reflected LVN F contacted the Physician to obtain a triplicate prescription for [MEDICATION NAME]. LVN F did not document a pain assessment for Resident #2. Resident #2's May 2016 MAR reflected on 05/25/16 at 10:41 p.m. the resident was scheduled to receive her [MEDICATION NAME] 75 mcg/hour. LVN D documented #8 on the MAR. Resident #2's progress notes dated 05/25/16 at 10:41 p.m. reflected LVN D documented the [MEDICATION NAME] was not dispensed from the pharmacy. LVN D did not document a pain assessment for Resident #2. An interview with LVN D on 06/29/16 at 2:45 p.m. revealed she did not give Resident #2 her [MEDICATION NAME] on 05/25/16 because the medication had not been dispensed from the pharmacy. She stated she repositioned the resident for comfort, and she did not document a pain assessment because the resident was not in pain. Resident #2's progress notes dated 05/25/16 at 2:13 a.m. reflected LVN E documented the resident activated her call light, and the nurse told the resident she would be there at 2:00 a.m. to give her [MEDICATION NAME]. The resident stated the medication could be given before that time. Resident #2's May 2016 MAR reflected on 05/25/16 at 2:00 a.m. LVN E gave the resident [MEDICATION NAME] HCL 100 mg extended release tablet. A review of the MAR revealed the last dose of [MEDICATION NAME] HCL 100 mg extended release tablet had been given to Resident #2 on 05/24/16 at 2:00 a.m. by LVN E. The MAR reflected [MEDICATION NAME] HCL 100 mg extended release tablet could be administered every six hours as needed for pain. Resident's #2's May 2016 Physician order [REDACTED]. Resident #2's May 2016 MAR reflected on 05/28/16 at 12:00 p.m. Resident #2 was scheduled to receive [MEDICATION NAME] HCL 100 mg extended release tablet. LVN C documented #7 on the resident's MAR, which was the facility's code for medication not given due to vital signs. Resident #2's May 2016 MAR reflected on 05/28/16 at 6:00 p.m. Resident #2 was scheduled to receive [MEDICATION NAME] HCL 100 mg extended release tablet. LVN C documented #7 on the resident's MAR. LVN C did not document a pain assessment for Resident #2. An interview with LVN C on 06/29/16 at 2:30 p.m. revealed the [MEDICATION NAME] doses were not available from the pharmacy, and she notified the Physician to obtain a triplicate prescription for the medication. LVN C stated she did not document a pain assessment for Resident #2 because the resident was not in pain. Resident #2's June 2016 MAR for 06/19/16 revealed the resident was scheduled to receive her [MEDICATION NAME] 75 mcg/hour every 72 hours [MEDICATION NAME] related to chronic pai[DIAGNOSES REDACTED]. LVN F documented the dose as given on the MAR at 10:03 a.m. on 06/19/16. Review of the Narcotic count sheet for Resident #2 revealed the resident did not receive the [MEDICATION NAME] on 06/19/16; instead, she received it on 06/20/16 at 9:00 a.m. from LVN G. An interview with LVN F was attempted on 06/29/16 at 1:19 p.m. regarding the [MEDICATION NAME] not being administered to Resident #2 on 05/22/16 and 06/19/16. The attempt was unsuccessful, and LVN F did not call back at a different time as requested. An observation and interview on 06/29/16 at 8:45 a.m. revealed Resident #2 lying in bed. She stated when she did not receive her [MEDICATION NAME] and [MEDICATION NAME] as ordered her pain level spiked to a level eight on a scale of 0-10 with zero being no pain and ten as the worst pain imaginable. She reported she could not remember what time she requested her dose of [MEDICATION NAME] on 05/25/16 from LVN E. An observation and interview on 06/21/16 at 9:05 a.m. revealed Resident #2 sitting up in bed reviewing her personal clinical records. She grimaced when she repositioned and moved herself in the bed. She stated she suffered from chronic pain. She stated she was admitted to the facility on [DATE] and wanted to leave the facility as soon as possible. Resident #2 revealed she had been reviewing her clinical records and knew she missed receiving doses of her pain medication, but the facility had documented that she had received them. An observation on 06/21/16 at 11:02 a.m. revealed Resident #2 lying in bed and talking on the phone. She grimaced when she moved in bed. An interview with LVN E was attempted on 06/29/16 at 10:18 a.m., 1:15 p.m., and 2:25 p.m. regarding the [MEDICATION NAME] dose on 05/25/16 for Resident #2. LVN E failed to answer the telephone and failed to return the call. An interview with LVN D on 06/21/16 at 4:00 p.m. revealed [MEDICATION NAME] was available in the facility's emergency kit. LVN D stated prior to running out of a medication, when there were about 10 doses left, the nurse should contact the pharmacy for a refill. LVN D revealed a pain assessment should be documented for residents experiencing pain on the MAR and progress notes. LVN D stated she did not know if there was a facility policy and procedure for re-ordering medications from the pharmacy. An interview with LVN H on 06/21/16 at 4:07 p.m. revealed [MEDICATION NAME]es were not available in the facility emergency kit. She stated she could call the Physician to get a triplicate prescription for the medication and get it from the pharmacy when they came to the facility. LVN H stated the pharmacy usually came to the facility two times a day. LVN H revealed a pain assessment for a resident was documented on a scale of 0-10 before and after pain medication was administered. An interview with the DON on 06/21/16 at 1:45 p.m. revealed she did not know why the [MEDICATION NAME] for Resident #2 was administered on 06/20/16 instead of the ordered date of 06/19/16. She stated when #8 was documented on the MAR it meant other and maybe the medication was not given because it was not available from pharmacy. She reported when #7 was documented on the MAR it meant the medication was not administered due to vital signs being out of parameters. The DON revealed the physician was supposed to be contacted if a medication was not given. She was not able to show documentation that the physician was notified regarding the [MEDICATION NAME] ordered for 06/19/16. She stated she would investigate to determine why the [MEDICATION NAME] was not given as ordered on [DATE] and why the physician was not notified. An interview with the DON on 06/21/16 at 3:15 p.m. revealed LVN F documented the [MEDICATION NAME] as given on the resident's MAR on 06/19/16 at 10:03 a.m. but forgot to actually give the dose to Resident #2. The DON stated she had started disciplinary action regarding the error with LVN F. The DON was questioned about the other dates in which Resident #2 did not receive her [MEDICATION NAME] and [MEDICATION NAME] as ordered and the DON stated she would have to investigate the [MEDICATION NAME] issue further, but the resident did not receive the ordered doses of the [MEDICATION NAME] on 05/22/16 and 05/25/16 because the dose was not available from the pharmacy until 05/26/16. The DON revealed she did not think the facility had a policy available regarding what the nurse was to do if the resident needed a pain medication, and it was not available at the facility. The facility Narcotic/Controlled Substances Emergency Box's List of Medications on 06/21/16 revealed eight doses of [MEDICATION NAME] 50 mg were kept in the box. An observation of the facility Narcotic/Controlled Substances Emergency box on 06/29/16 at 4:30 p.m. revealed the box was locked and required a code from the pharmacy to open it. The narcotic count sheet was located inside the box with the narcotic medications. An interview with the DON on 06/21/16 at 4:30 p.m. revealed she spoke with the regional office, and they could not find a policy for giving a resident a pain medication when it was not available at the facility. The DON stated there was no policy available from the pharmacy to give medications from the emergency kit. She reported she did an in-service with the nurses telling them to reorder medication five to seven days in advance. The DON stated the current procedure was if a resident had an order for [REDACTED]. If the pharmacy did not have a triplicate prescription from the physician, they would not give the nurse the code to access the emergency kit to give a dose. The DON revealed nurses were not able to give any resident a substitution narcotic pain medication without a triplicate prescription from the physician, and it could take up to two days to get a triplicate prescription from the physician. The DON stated the nurse could get a physician's orders [REDACTED]. 2. Resident #3's MDS assessment, dated 05/16/16, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had moderately impaired cognitive skills and was able to understand and be understood by others. The resident received a scheduled pain medication regimen, a PRN pain medication regimen, and non-medication interventions for pain. The resident's pain was occasionally present with a rating of seven on a scale of 0-10 with zero being no pain and ten as the worst pain imaginable. Resident #3's Comprehensive Plan of Care, review date 03/02/16, reflected the resident had chronic pain related to spinal stenosis and diabetic [MEDICAL CONDITION]. The care planned approaches included administer [MEDICATION NAME] medications as ordered, observe and document the effectiveness of pain interventions post administration, observe, document, and report adverse reactions to [MEDICATION NAME] therapy. Resident #3's Physician Order, dated 03/08/16, [MEDICATION NAME](muscle relaxer) 350 mg by mouth every eight hours related to muscle weakness. An observation and interview on 06/29/16 at 8:45 a.m. revealed Resident #3 lying in bed. She stated she took multiple medications for pain, and the facility ran out of her medications a couple of times. Resident #3 revealed when the facility ran out of her pain medication they had to call the pharmacy to get a dose from the emergency box. She stated when the facility ran out of her medication the last time, it took a couple of hours to get her pain medication which caused her pain level to spike to a 10 on a scale of 0-10 with zero being no pain and ten as the worst pain imaginable. Resident #3's June 2016 MAR reflected on 06/10/16 at 6:00 a.m. the resident was scheduled to [MEDICATION NAME] mg. LVN M documented #8 on the MAR. LVN M did not document a pain assessment at 6:00 a.m. An interview with LVN M on 06/30/16 at 10:10 a.m. revealed she could not remember the incident regarding Resident #3's pain medication not being available on 06/10/16. She explained that she was new to the facility, and she had heard that obtaining needed medications from the pharmacy had been an issue at the facility. Resident #3's June 2016 MAR reflected on 06/10/16 at 2:00 p.m. the resident was scheduled to [MEDICATION NAME] mg. LVN N documented #8 on the MAR. An interview with LVN N on 06/29/16 at 4:07 p.m. revealed Resident #3'[MEDICATION NAME] not available from the pharmacy. LVN N stated she was able to give a dose of [MEDICATION NAME] 5-325 mg to the resident instead of the ordered dose of Soma. The [MEDICATION NAME] 5-325 mg was administered at 11:40 a.m. An interview with the Nurse Practitioner on 06/29/16 at 10:55 a.m. revealed staff sometimes notified her if a medication was not available and sometimes they did not. She stated she faxed the triplicate prescriptions to the pharmacy when needed for narcotics and often the nurses would notify her stating the pharmacy did not receive the triplicate. She stated she would re-fax the triplicate to the facility in order for the nurses to fax it to the pharmacy. She stated this caused a delay in the amount of time it took for the resident to receive the needed medication. She reported the issue had gotten worse over the last month. She stated she was nervous concerning the problem and talked to the Administrator about her concerns every day. The Administrator reported to her she was working on the problem. An interview with the Medical Director on 06/29/16 at 11:40 a.m. revealed he was aware of the problem the facility was experiencing with residents not receiving the medications in a timely manner. He stated he told the Administrator four to five days ago that the nursing staff needed to have a meeting with the pharmacy in order to fix the problem. An interview with the DON on 06/29/16 at 12:45 p.m. revealed a meeting was being planned with the Nurse Practitioner and pharmacy to address the issue of residents not receiving their pain medications in a timely manner. She revealed an in-service was conducted with the nurses on 06/23/16 outlining the process to assess and document pain levels for the residents. An interview with the Administrator on 06/29/16 at 1:32 p.m. revealed she was aware residents were not receiving their medications in a timely manner. She stated she was scheduling a meeting with the pharmacy to address the issue. An interview with the Director of Pharmacy Services on 06/29/16 at 4:50 p.m. revealed he was not aware of any issues regarding the facility not receiving medications in a timely manner or any issues regarding receiving triplicate prescriptions from the facility. He stated he had not been notified of any issues at the facility and was not aware of any meeting being scheduled with the facility. An interview with the Administrator and Director of Clinical Services on 06/29/16 at 5:00 p.m. revealed the Administrator had not yet contacted the Pharmacy, but she planned to do so. The Director of Clinical Services revealed she planned to do a pharmacy audit. An interview with the Administrator on 06/29/16 at 5:40 p.m. revealed she scheduled a meeting for Tuesday 07/05/16 with the pharmacy. The Resident Census and Conditions of Residents Form CMS-672, signed and dated by LVN O on 06/29/16, reflected 43 people were on a pain management program.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of two (Residents #2 and #3) of 12 residents reviewed for pharmaceutical services. 1. The facility failed to ensure Resident #2's physician-ordered pain medications, Fentanyl patch and Tramadol, were administered and/or available on 05/22/16, 05/25/16, 05/28/16, and 06/19/16. Resident #2 reported experiencing severe, unrelieved pain on the days she did not receive her physician-ordered pain medications. 2. The facility failed to ensure Resident #3's physician-ordered pain medication, Soma, was administered and/or available on 06/10/16. Resident #3 reported experiencing severe, unrelieved pain when she did not receive her physician-ordered pain medication. These failures placed the 43 residents who had moderate/severe pain at risk for unrelieved pain, distress, and a decreased quality of life. Findings included: 1. Resident #2's MDS assessment, dated 05/16/16, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had moderately impaired cognitive skills and was able to understand and be understood by others. The resident received a scheduled pain medication regimen, a PRN pain medication regimen, and non-medication interventions for pain. The resident's pain was almost constantly present, limited her day-to-day activities, and limited her ability to sleep at night. Her pain rating was 9 on a scale of 0-10 with zero being no pain and ten as the worst pain imaginable. Resident #2's physician orders, dated 05/09/16, reflected apply Fentanyl (opioid analgesic) patch 75 mcg/hour every 72 hours transdermally related to chronic pai[DIAGNOSES REDACTED]. Resident #2's Comprehensive Plan of Care, review date 05/10/16, with revision on 05/20/16, reflected the resident had chronic pain related to gout. The care planned approaches included anticipating the resident's need for pain relief and respond immediately to any complaint of pain. Evaluate the effectiveness of pain interventions post administration, review for compliance and alleviation of symptoms, review dosing schedules, review resident satisfaction with the results, review impact on functional ability and cognition. Observe and report changes in usual routine, sleep patterns, decrease in functional ability, and decrease in range of motion. Observe and document for side effects of the pain medication, and report occurrences to the physician. A physician's orders [REDACTED]. Resident #2's May 2016 MAR revealed on 05/22/16 at 9:24 p.m. she was scheduled to receive Fentanyl patch 75 mcg/hour. LVN F documented #8 on the MAR, which was the facility's code for the medication not being available. An interview with LVN G on 06/21/16 at 12:37 p.m. revealed #8 when documented on a resident's MAR meant the facility did not have the medication available to give to the resident. She stated the process to obtain the medication was to notify the pharmacy. Resident #2's progress notes dated 05/22/16 at 9:24 p.m. reflected LVN F contacted the Physician to obtain a triplicate prescription for Fentanyl patch. LVN F did not document a pain assessment for Resident #2. Resident #2's May 2016 MAR reflected on 05/25/16 at 10:41 p.m. the resident was scheduled to receive her Fentanyl patch 75 mcg/hour. LVN D documented #8 on the MAR. Resident #2's progress notes dated 05/25/16 at 10:41 p.m. reflected LVN D documented the Fentanyl patch was not dispensed from the pharmacy. LVN D did not document a pain assessment for Resident #2. An interview with LVN D on 06/29/16 at 2:45 p.m. revealed she did not give Resident #2 her Fentanyl patch on 05/25/16 because the medication had not been dispensed from the pharmacy. She stated she repositioned the resident for comfort, and she did not document a pain assessment because the resident was not in pain. Resident #2's progress notes dated 05/25/16 at 2:13 a.m. reflected LVN E documented the resident activated her call light, and the nurse told the resident she would be there at 2:00 a.m. to give her Tramadol. The resident stated the medication could be given before that time. Resident #2's May 2016 MAR reflected on 05/25/16 at 2:00 a.m. LVN E gave the resident Tramadol HCL 100 mg extended release tablet. A review of the MAR revealed the last dose of Tramadol HCL 100 mg extended release tablet had been given to Resident #2 on 05/24/16 at 2:00 a.m. by LVN E. The MAR reflected Tramadol HCL 100 mg extended release tablet could be administered every six hours as needed for pain. Resident's #2's May 2016 Physician order [REDACTED]. Resident #2's May 2016 MAR reflected on 05/28/16 at 12:00 p.m. Resident #2 was scheduled to receive Tramadol HCL 100 mg extended release tablet. LVN C documented #7 on the resident's MAR, which was the facility's code for medication not given due to vital signs. Resident #2's May 2016 MAR reflected on 05/28/16 at 6:00 p.m. Resident #2 was scheduled to receive Tramadol HCL 100 mg extended release tablet. LVN C documented #7 on the resident's MAR. LVN C did not document a pain assessment for Resident #2. An interview with LVN C on 06/29/16 at 2:30 p.m. revealed the Tramadol doses were not available from the pharmacy, and she notified the Physician to obtain a triplicate prescription for the medication. LVN C stated she did not document a pain assessment for Resident #2 because the resident was not in pain. Resident #2's June 2016 MAR for 06/19/16 revealed the resident was scheduled to receive her Fentanyl patch 75 mcg/hour every 72 hours transdermally related to chronic pai[DIAGNOSES REDACTED]. LVN F documented the dose as given on the MAR at 10:03 a.m. on 06/19/16. Review of the Narcotic count sheet for Resident #2 revealed the resident did not receive the Fentanyl patch on 06/19/16; instead, she received it on 06/20/16 at 9:00 a.m. from LVN G. An interview with LVN F was attempted on 06/29/16 at 1:19 p.m. regarding the Fentanyl patch not being administered to Resident #2 on 05/22/16 and 06/19/16. The attempt was unsuccessful, and LVN F did not call back at a different time as requested. An observation and interview on 06/29/16 at 8:45 a.m. revealed Resident #2 lying in bed. She stated when she did not receive her Fentanyl patch and Tramadol as ordered her pain level spiked to a level eight on a scale of 0-10 with zero being no pain and ten as the worst pain imaginable. She reported she could not remember what time she requested her dose of Tramadol on 05/25/16 from LVN E. An observation and interview on 06/21/16 at 9:05 a.m. revealed Resident #2 sitting up in bed reviewing her personal clinical records. She grimaced when she repositioned and moved herself in the bed. She stated she suffered from chronic pain. She stated she was admitted to the facility on [DATE] and wanted to leave the facility as soon as possible. Resident #2 revealed she had been reviewing her clinical records and knew she missed receiving doses of her pain medication, but the facility had documented that she had received them. An observation on 06/21/16 at 11:02 a.m. revealed Resident #2 lying in bed and talking on the phone. She grimaced when she moved in bed. An interview with LVN E was attempted on 06/29/16 at 10:18 a.m., 1:15 p.m., and 2:25 p.m. regarding the Tramadol dose on 05/25/16 for Resident #2. LVN E failed to answer the telephone and failed to return the call. An interview with LVN D on 06/21/16 at 4:00 p.m. revealed Tramadol was available in the facility's emergency kit. LVN D stated prior to running out of a medication, when there were about 10 doses left, the nurse should contact the pharmacy for a refill. LVN D revealed a pain assessment should be documented for residents experiencing pain on the MAR and progress notes. LVN D stated she did not know if there was a facility policy and procedure for re-ordering medications from the pharmacy. An interview with LVN H on 06/21/16 at 4:07 p.m. revealed Fentanyl patches were not available in the facility emergency kit. She stated she could call the Physician to get a triplicate prescription for the medication and get it from the pharmacy when they came to the facility. LVN H stated the pharmacy usually came to the facility two times a day. LVN H revealed a pain assessment for a resident was documented on a scale of 0-10 before and after pain medication was administered. An interview with the DON on 06/21/16 at 1:45 p.m. revealed she did not know why the Fentanyl patch for Resident #2 was administered on 06/20/16 instead of the ordered date of 06/19/16. She stated when #8 was documented on the MAR it meant other and maybe the medication was not given because it was not available from pharmacy. She reported when #7 was documented on the MAR it meant the medication was not administered due to vital signs being out of parameters. The DON revealed the physician was supposed to be contacted if a medication was not given. She was not able to show documentation that the physician was notified regarding the Fentanyl patch ordered for 06/19/16. She stated she would investigate to determine why the Fentanyl patch was not given as ordered on [DATE] and why the physician was not notified. An interview with the DON on 06/21/16 at 3:15 p.m. revealed LVN F documented the Fentanyl patch as given on the resident's MAR on 06/19/16 at 10:03 a.m. but forgot to actually give the dose to Resident #2. The DON stated she had started disciplinary action regarding the error with LVN F. The DON was questioned about the other dates in which Resident #2 did not receive her Fentanyl patch and Tramadol as ordered and the DON stated she would have to investigate the Tramadol issue further, but the resident did not receive the ordered doses of the Fentanyl patch on 05/22/16 and 05/25/16 because the dose was not available from the pharmacy until 05/26/16. The DON revealed she did not think the facility had a policy available regarding what the nurse was to do if the resident needed a pain medication, and it was not available at the facility. The facility Narcotic/Controlled Substances Emergency Box's List of Medications on 06/21/16 revealed eight doses of Tramadol 50 mg were kept in the box. An observation of the facility Narcotic/Controlled Substances Emergency box on 06/29/16 at 4:30 p.m. revealed the box was locked and required a code from the pharmacy to open it. The narcotic count sheet was located inside the box with the narcotic medications. An interview with the DON on 06/21/16 at 4:30 p.m. revealed she spoke with the regional office, and they could not find a policy for giving a resident a pain medication when it was not available at the facility. The DON stated there was no policy available from the pharmacy to give medications from the emergency kit. She reported she did an in-service with the nurses telling them to reorder medication five to seven days in advance. The DON stated the current procedure was if a resident had an order for [REDACTED]. If the pharmacy did not have a triplicate prescription from the physician, they would not give the nurse the code to access the emergency kit to give a dose. The DON revealed nurses were not able to give any resident a substitution narcotic pain medication without a triplicate prescription from the physician, and it could take up to two days to get a triplicate prescription from the physician. The DON stated the nurse could get a physician's orders [REDACTED]. 2. Resident #3's MDS assessment, dated 05/16/16, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had moderately impaired cognitive skills and was able to understand and be understood by others. The resident received a scheduled pain medication regimen, a PRN pain medication regimen, and non-medication interventions for pain. The resident's pain was occasionally present with a rating of seven on a scale of 0-10 with zero being no pain and ten as the worst pain imaginable. Resident #3's Comprehensive Plan of Care, review date 03/02/16, reflected the resident had chronic pain related to spinal stenosis and diabetic neuropathy. The care planned approaches included administer analgesic medications as ordered, observe and document the effectiveness of pain interventions post administration, observe, document, and report adverse reactions to analgesic therapy. Resident #3's Physician Order, dated 03/08/16, reflected Soma (muscle relaxer) 350 mg by mouth every eight hours related to muscle weakness. An observation and interview on 06/29/16 at 8:45 a.m. revealed Resident #3 lying in bed. She stated she took multiple medications for pain, and the facility ran out of her medications a couple of times. Resident #3 revealed when the facility ran out of her pain medication they had to call the pharmacy to get a dose from the emergency box. She stated when the facility ran out of her medication the last time, it took a couple of hours to get her pain medication which caused her pain level to spike to a 10 on a scale of 0-10 with zero being no pain and ten as the worst pain imaginable. Resident #3's June 2016 MAR reflected on 06/10/16 at 6:00 a.m. the resident was scheduled to receive Soma 350 mg. LVN M documented #8 on the MAR. LVN M did not document a pain assessment at 6:00 a.m. An interview with LVN M on 06/30/16 at 10:10 a.m. revealed she could not remember the incident regarding Resident #3's pain medication not being available on 06/10/16. She explained that she was new to the facility, and she had heard that obtaining needed medications from the pharmacy had been an issue at the facility. Resident #3's June 2016 MAR reflected on 06/10/16 at 2:00 p.m. the resident was scheduled to receive Soma 350 mg. LVN N documented #8 on the MAR. An interview with LVN N on 06/29/16 at 4:07 p.m. revealed Resident #3's Soma was not available from the pharmacy. LVN N stated she was able to give a dose of Percocet 5-325 mg to the resident instead of the ordered dose of Soma. The Percocet 5-325 mg was administered at 11:40 a.m. An interview with the Nurse Practitioner on 06/29/16 at 10:55 a.m. revealed staff sometimes notified her if a medication was not available and sometimes they did not. She stated she faxed the triplicate prescriptions to the pharmacy when needed for narcotics and often the nurses would notify her stating the pharmacy did not receive the triplicate. She stated she would re-fax the triplicate to the facility in order for the nurses to fax it to the pharmacy. She stated this caused a delay in the amount of time it took for the resident to receive the needed medication. She reported the issue had gotten worse over the last month. She stated she was nervous concerning the problem and talked to the Administrator about her concerns every day. The Administrator reported to her she was working on the problem. An interview with the Medical Director on 06/29/16 at 11:40 a.m. revealed he was aware of the problem the facility was experiencing with residents not receiving the medications in a timely manner. He stated he told the Administrator four to five days ago that the nursing staff needed to have a meeting with the pharmacy in order to fix the problem. An interview with the DON on 06/29/16 at 12:45 p.m. revealed a meeting was being planned with the Nurse Practitioner and pharmacy to address the issue of residents not receiving their pain medications in a timely manner. She revealed an in-service was conducted with the nurses on 06/23/16 outlining the process to assess and document pain levels for the residents. An interview with the Administrator on 06/29/16 at 1:32 p.m. revealed she was aware residents were not receiving their medications in a timely manner. She stated she was scheduling a meeting with the pharmacy to address the issue. An interview with the Director of Pharmacy Services on 06/29/16 at 4:50 p.m. revealed he was not aware of any issues regarding the facility not receiving medications in a timely manner or any issues regarding receiving triplicate prescriptions from the facility. He stated he had not been notified of any issues at the facility and was not aware of any meeting being scheduled with the facility. An interview with the Administrator and Director of Clinical Services on 06/29/16 at 5:00 p.m. revealed the Administrator had not yet contacted the Pharmacy, but she planned to do so. The Director of Clinical Services revealed she planned to do a pharmacy audit. An interview with the Administrator on 06/29/16 at 5:40 p.m. revealed she scheduled a meeting for Tuesday 07/05/16 with the pharmacy. The Resident Census and Conditions of Residents Form CMS-672, signed and dated by LVN O on 06/29/16, reflected 43 people were on a pain management program.

Based on interview and record review, it was determined the facility failed to implement policies and procedures that prohibit neglect for two (Residents #1 and #2) of eight residents reviewed for neglect. 1. Resident #1 had swelling and bruising to her leg on 09/27/14. CNA A reported it to RN C. On 09/28/14, CNA D failed to transfer Resident #1 via a mechanical lift. CNA D saw a bruise on the resident's leg and reported it to the nurse, who assessed the resident and notified the NP. On 09/29/14 Resident #1 was diagnosed with [REDACTED]. Resident #1 was sent to the emergency roiagnom on [DATE]. 2. CNA I failed to have the assistance of another staff member when she transferred Resident #2 via a mechanical lift. Resident #2 was injured during the transfer and sustained fractures involving mid-tibia and fibula. These failures could affect the other 31 residents, who needed the assistance of two staff for transfers and/or needed the Hoyer lift for transfers, by placing them at risk for severe injury, including fractures. Findings included: 1. Resident #1's face sheet, dated 12/14/13, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses, which included [MEDICAL CONDITION] of Leg, Muscular Disuse Atrophy, Hypertension, Abnormality of gait, Debility and Dementia. Resident #1's Resident Transfer Evaluation, dated 05/27/14, reflected a score of eight which indicated caregiver performed 50% of the task or greater and the equipment needed was a Mechanical Lift. Resident #1's comprehensive MDS assessment, dated 08/30/14, reflected her cognitive skills for daily decision making were severely impaired, and she did not ambulate. Resident #1 required two or more persons' physical assistance with bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. She was totally dependent on staff for bathing. The MDS assessment reflected her balance during transitions from surface-to-surface was not steady, and she was only able to stabilize with staff assistance. Resident #1's care plan, initiated on 08/08/14 and reviewed by the facility on 08/30/14, reflected the resident was dependent on staff for transfers, but did not indicate how many staff were required for assistance or if a mechanical lift was required. The approaches included encourage independence, assist with ADLs as needed, and assist with transfers as needed. Resident #1's undated Resident Care Cardex worksheet reflected she was partial weight bearing and needed two persons' assistance with transfers. Review of Resident #1's "SBAR Communication Form," dated 09/28/14, completed and signed by LVN G, revealed, "...noted a bruise area to residents rt (right) leg and resident c/o (complained of) pain when area moved and touched. Writer assessed resident rt lower leg skin area noted to be slightly swollen, tight, warm to touch, noted bruised to area c (with) what appeared to look like formation of blisters (clusters) or broken veins. Both feet and ankles c (with) 3+ (plus) [MEDICAL CONDITION]. Resident c/o pain to rt leg when moved or touched. Call placed to...NP... notified of change in condition to rt leg (shin) new order recd (received) for chest x-ray arterial & (and) venous Doppler...CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel)...Resident to be on bedrest. O2 (oxygen) sat (saturation) Q (every) 2 (hours). Residents (family member) notified." Interview with LVN G on 10/15/14 at 1:39 PM, revealed the bruising and swelling were reported to her by CNA D on 09/28/14. LVN G stated she assessed the resident and noted swelling, discoloration to the shin area and also when she tried to move the leg the resident complained of pain. LVN G stated she notified NP E of what she observed and was given orders. She stated Resident #1 was a two person transfer; however, some staff used a Hoyer lift. Resident #1 Nurse's Notes revealed on 09/29/14 at 9:00 AM, "...doppler done on pts.(patient's) right extremities (lower) checking for possible [MEDICAL CONDITIONS]; results were positive. Dr notified of results...." Resident #1's Nurse's Notes, dated 09/29/14 and not timed, reflected, "New orders given to RN on duty...On complete bedrest until further notice per Dx (diagnosis) of [MEDICAL CONDITIONS] to R (right) femoral vain (sic)... Also STAT (immediately) xray to R (right) femoral & (and) ankle..." Interview with NP E via telephone on 10/15/14 at 2:54 PM revealed he received notification of Resident #1's swelling and gave orders as appropriate. He stated the second notification he received was when he ordered the x-ray of the leg. In a subsequent interview on 10/16/14 at 10:51 AM, NP E stated he received calls from the facility and wanted to follow up with the DADS surveyor. He stated he had nothing different to say, aside from the fact that he was not sure if the facility initially notified him of the bruising. He stated bruising can often happen with blood clots. He stated based on the information he was given initially there was nothing to suggest an immediate x-ray was needed. He stated, "No point tenderness to the area," was mentioned to him which would have caused him to order an x-ray immediately. He stated they relied on the nurses to "paint the picture of the patient" and during the first call he received there was no data presented which required an immediate x-ray. Resident #1's Radiology Report, date of service 09/29/14, reflected, "There is a fracture involving mid tibial shaft with slight lateral displacement. Proximal fibular shaft fracture without displacement or callus seen...Conclusion: Acute right lower leg fractures." Interview with Provider F (X-ray provider), via telephone on 10/20/14 at 10:50 AM, revealed an X-ray order for "Tibia/Fibula AP (anteroposterior view) and LAT (lateral view), right" was received on 09/29/14 at 8:59 PM, X-ray was taken on 09/30/14 at 12:28 AM, and result faxed to the facility on [DATE] at 1:00 AM. Resident #1's Physician Discharge summary, unsigned and dated 09/30/14, reflected she was discharged on [DATE], and transferred to the ER to be evaluated. The facility's Provider Investigation Report, reported to DADS on 09/30/14, reflected an incident occurred on 09/28/14 Resident #1 had an injury of unknown source. The report also reflected Resident #1's functional ability was "total assistance" and she was not independently ambulatory. On 09/28/14 at 5:30 PM, bruising and swelling was observed by a family member and CNA D. The physician was notified and a chest X-ray, Doppler study (a test to check for blood clots), and labs were ordered. Resident #1 had a [MEDICAL CONDITION] (blood clot) confirmed on 09/29/14. The report's Description of the injury reflected the resident sustained [REDACTED]. Proximal fibular shaft fracture without displacement. The report's Investigation Summary reflected, "Resident is unable to be interviewed due to altered mental status. Family was present in the room at 5:30 pm on 9/28/14 and did not notice any incident, however did notice bruising to the right leg which was confirmed by (CNA D) at the same time. (CNA D) did immediately report the bruising to the charge nurse. Based on staff interviews, it has been determined that the bruising probably did not occur on Friday or Saturday. In addition, there was no causative factor that could be identified. The investigation has not revealed any negiligence (sic) and/or abuse on the part of staff. The resident does have history of [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. The resident has also had both hips replaced. Investigation Findings...Inconclusive...Provider Action Taken Post-Investigation Resident transported to hospital for further evaluation Education initiated on lift and transfer program and abuse/neglect as a precautionary measure." Further review of the Provider Investigation Report revealed interviews with CNAs A and B, and they noticed swelling to Resident #1's right leg on Saturday, 09/27/14. CNA A reported the swelling to the charge nurse. Interview with CNA A via telephone on 10/15/14 at 2:15 PM revealed she worked the 10:00 PM to 6:00 AM shift on 09/27/14. She stated she noticed the swelling and the bruise to Resident #1's leg during her shift on 09/27/14, when she was getting ready to reposition the resident. She stated she went and got her co-worker, CNA B, to assist her when she saw the injury, and both saw the bruise. She stated she reported this to RN C. Interview with CNA B via telephone on 10/20/14 at 1:11 PM, revealed she worked the 10:00 PM to 6:00 AM shift on 09/27/14. She stated she did not work with Resident #1; however, CNA A came to her and asked her for assistance in repositioning. She stated they observed there was something wrong with Resident #1's leg and CNA A went to report it to the charge nurse, RN C. Interview with RN C via telephone on 10/20/14 at 1:15 PM, revealed no one reported any swelling or bruising to Resident #1's leg on 09/27/14 to her. She stated she was made aware of the injury on 09/28/14 as she had to monitor oxygen levels for Resident #1. She stated she believed she also gave Resident #1 a pain pill. She stated Resident #1 was "hard to communicate with;" however, she thought the resident had a "little bit of pain," per her facial expressions. She stated Resident #1 was also talking, but she could not be understood. She stated the resident's roommate kept saying, "Be quiet. Be quiet," to the resident. Interview with CNA D via telephone on 10/15/14 at 2:07 PM, revealed he saw the bruise on Resident #1's leg when he placed her into bed after dinner on 09/28/14. He stated he used a gait belt and the resident's family member told him he was supposed to use a Hoyer lift to transfer the resident. He stated he notified the nurse immediately of the bruise. CNA D revealed he did not know what type of a transfer Resident #1 was; however, he had been a CNA for [AGE] years and he knew how to transfer a resident. He stated he later found out from the Cardex folder Resident #1 required a two person Hoyer transfer. He denied knowing how Resident #1 sustained the fracture. Interview with the DON on 10/15/14 at 9:49 AM, revealed she started working for the facility on 10/13/14. She denied having any knowledge of the incident. She stated she felt they followed the physician's orders [REDACTED]. Interview with the ADM on 10/16/14 at 9:40 AM, revealed she could not come to a conclusion about how the injury occurred. She stated everyone insisted nothing happened with Resident #1 during a transfer. She stated she did not know when the injury occurred. Regarding the staff who observed the swelling on 09/27/14, the ADM stated she believed RN C told her nothing was reported to her. She stated she felt CNAs A and B thought they were in trouble and stated they saw the swelling to not get in trouble. She stated the staff were in-serviced on Abuse/Neglect and transfers. 2. Resident #2's face sheet, dated 10/30/13, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #2's care plan, initiated on 12/23/11 and reviewed by the facility on 07/31/14, reflected the resident required the total assistance of two persons with transfers and the Hoyer lift was to be used. The care plan also reflected an additional problem area of [DIAGNOSES REDACTED].#2 was at risk for spontaneous fractures/falls. The approaches were to give medications as ordered, monitor with labs and X-rays and to assist resident carefully when providing care. Resident #2's comprehensive MDS assessment, dated 08/04/14, reflected she required two or more persons' physical assistance with bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. She was totally dependent on staff for bathing. The assessment also reflected Resident #2's upper and lower extremities range of motion was impaired. The facility's Provider Investigation Report, reported to DADS on 10/10/14, reflected an incident of possible neglect involving Resident #2 on 10/09/14. Resident #2's functional ability was "total assistance" and she was not independently ambulatory. On 10/09/14 at 1:45 PM, CNA I reported she transferred Resident #2 with the Hoyer lift and the resident's leg hit the bar on the lift and the resident's left foot got caught on the bar. Description of the Injury reflected Resident #2 sustained tibia and fibula fractures of the left leg. CNA I was suspended pending the investigation and later terminated. Resident #2 returned from the hospital with a soft cast and an order to follow up with an orthopedic specialist. A follow up revealed there was no need for "any intervention, symptomatic care only." The summary of the Investigation reflected the findings were conclusive. The Provider Action Taken Post-Investigation reflected skills/competencies were initiated with direct care staff, categories assigned for each resident indicating transfer status and color coded stickers placed outside residents' doors for easy identification, cardex and transfer evaluations reviewed for accuracy and equipment inspected for any malfunction and none noted. Interview with LVN H on 10/16/14 at 12:05 PM revealed CNA I reported to her Resident #2's knee was slightly swollen. LVN H stated CNA I admitted she transferred the resident with the Hoyer lift alone and the resident's leg hit the Hoyer lift. LVN H stated she assessed the resident and called the physician immediately to obtain an order for [REDACTED]. Interview with CNA I was attempted via telephone on 10/16/14 at 12:30 PM, with no success. Interview with the ADM on 10/16/14 at 2:45 PM, revealed CNA I was suspended during the investigation and officially terminated on 10/15/14. The ADM stated CNA I admitted she did a one person transfer using the Hoyer lift with Resident #2, which caused the fracture. The ADM also stated CNA I admitted she had transferred residents using the Hoyer lift by herself before. 3. Review of the facility's Lift, Transfer and Repositioning Policy, dated 2010 and presented by the ADM as current policy and procedures, revealed the following: "...2. Policy...Facility policy requires two staff members to assist when lifting with mechanical lifting devices... 3. Procedures...K. Direct Care Staff will be responsible for the following: a. Complying with this policy and the Lift and Transfer Guide...b. Lifting and transferring residents in accordance with the residents' plans of care...c. Using proper techniques when lifting and transferring residents...d. Lifting and transferring residents with assistance of 2 staff members...f. Notifying Department Managers...Administrator or designee of any injury sustained while lifting or transferring residents or of any noncompliance by other staff related to resident lifting or transfers..." Review of the facility's current Abuse and Neglect Prohibition policy, revised June 2013, revealed "Each resident has the right to be free from...neglect...injuries of unknown origin...Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect...." 4. The facility's resident roster, dated 10/15/14, reflected 32 residents needed two persons' assistance with transfers and/or the Hoyer lift, including Resident #2.

Based on interview and record review, it was determined the facility failed to implement written policies and procedures that prohibit neglect for two residents (Residents #1 and #2) of eight residents reviewed for neglect. 1. Resident #1 had swelling and bruising to her leg on 09/27/14. CNA A reported it to RN C. On 09/28/14, CNA D failed to transfer Resident #1 via a mechanical lift. CNA D saw a bruise on the resident's leg and reported it to the nurse, who assessed the resident and notified the NP. On 09/29/14 Resident #1 was diagnosed with [REDACTED]. Resident #1 was sent to the emergency roiagnom on [DATE]. 2. CNA I failed to have the assistance of another staff member when she transferred Resident #2 via a mechanical lift. Resident #2 was injured during the transfer and sustained fractures involving mid-tibia and fibula. These failures could affect the other 31 residents, who needed the assistance of two staff for transfers and/or needed the Hoyer lift for transfers, by placing them at risk for severe injury, including fractures. Findings included: 1. Review of the facility's current Abuse and Neglect Prohibition policy, revised June 2013, revealed "Each resident has the right to be free from...neglect...injuries of unknown origin...Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect...." 2. Resident #1's face sheet, dated 12/14/13, reflected she was an [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses, which included [MEDICAL CONDITION] of Leg, Muscular Disuse Atrophy, Hypertension, Abnormality of gait, Debility and Dementia. Resident #1's Resident Transfer Evaluation, dated 05/27/14, reflected a score of eight which indicated caregiver performed 50% of the task or greater and the equipment needed was a Mechanical Lift. Resident #1's comprehensive MDS assessment, dated 08/30/14, reflected her cognitive skills for daily decision making were severely impaired, and she did not ambulate. Resident #1 required two or more persons' physical assistance with bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. She was totally dependent on staff for bathing. The MDS assessment reflected her balance during transitions from surface-to-surface was not steady, and she was only able to stabilize with staff assistance. Resident #1's care plan, initiated on 08/08/14 and reviewed by the facility on 08/30/14, reflected the resident was dependent on staff for transfers, but did not indicate how many staff were required for assistance or if a mechanical lift was required. The approaches included encourage independence, assist with ADLs as needed, and assist with transfers as needed. Resident #1's undated Resident Care Cardex worksheet reflected she was partial weight bearing and needed two persons' assistance with transfers. Review of Resident #1's "SBAR Communication Form," dated 09/28/14, completed and signed by LVN G, revealed, "...noted a bruise area to residents rt (right) leg and resident c/o (complained of) pain when area moved and touched. Writer assessed resident rt lower leg skin area noted to be slightly swollen, tight, warm to touch, noted bruised to area c (with) what appeared to look like formation of blisters (clusters) or broken veins. Both feet and ankles c (with) 3+ (plus) [MEDICAL CONDITION]. Resident c/o pain to rt leg when moved or touched. Call placed to...NP... notified of change in condition to rt leg (shin) new order recd (received) for chest x-ray arterial & (and) venous Doppler...CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel)...Resident to be on bedrest. O2 (oxygen) sat (saturation) Q (every) 2 (hours). Residents (family member) notified." Interview with LVN G on 10/15/14 at 1:39 PM, revealed the bruising and swelling were reported to her by CNA D on 09/28/14. LVN G stated she assessed the resident and noted swelling, discoloration to the shin area and also when she tried to move the leg the resident complained of pain. LVN G stated she notified NP E of what she observed and was given orders. She stated Resident #1 was a two person transfer; however, some staff used a Hoyer lift. Resident #1 Nurse's Notes revealed on 09/29/14 at 9:00 AM, "...doppler done on pts.(patient's) right extremities (lower) checking for possible [MEDICAL CONDITIONS]; results were positive. Dr notified of results...." Resident #1's Nurse's Notes, dated 09/29/14 and not timed, reflected, "New orders given to RN on duty...On complete bedrest until further notice per Dx (diagnosis) of [MEDICAL CONDITIONS] to R (right) femoral vain (sic)... Also STAT (immediately) xray to R (right) femoral & (and) ankle..." Interview with NP E via telephone on 10/15/14 at 2:54 PM revealed he received notification of Resident #1's swelling and gave orders as appropriate. He stated the second notification he received was when he ordered the x-ray of the leg. In a subsequent interview on 10/16/14 at 10:51 AM, NP E stated he received calls from the facility and wanted to follow up with the DADS surveyor. He stated he had nothing different to say, aside from the fact that he was not sure if the facility initially notified him of the bruising. He stated bruising can often happen with blood clots. He stated based on the information he was given initially there was nothing to suggest an immediate x-ray was needed. He stated, "No point tenderness to the area," was mentioned to him which would have caused him to order an x-ray immediately. He stated they relied on the nurses to "paint the picture of the patient" and during the first call he received there was no data presented which required an immediate x-ray. Resident #1's Radiology Report, date of service 09/29/14, reflected, "There is a fracture involving mid tibial shaft with slight lateral displacement. Proximal fibular shaft fracture without displacement or callus seen...Conclusion: Acute right lower leg fractures." Interview with Provider F (X-ray provider), via telephone on 10/20/14 at 10:50 AM, revealed an X-ray order for "Tibia/Fibula AP (anteroposterior view) and LAT (lateral view), right" was received on 09/29/14 at 8:59 PM, X-ray was taken on 09/30/14 at 12:28 AM, and result faxed to the facility on [DATE] at 1:00 AM. Resident #1's Physician Discharge summary, unsigned and dated 09/30/14, reflected she was discharged on [DATE], and transferred to the ER to be evaluated. The facility's Provider Investigation Report, reported to DADS on 09/30/14, reflected an incident occurred on 09/28/14 Resident #1 had an injury of unknown source. The report also reflected Resident #1's functional ability was "total assistance" and she was not independently ambulatory. On 09/28/14 at 5:30 PM, bruising and swelling was observed by a family member and CNA D. The physician was notified and a chest X-ray, Doppler study (a test to check for blood clots), and labs were ordered. Resident #1 had a [MEDICAL CONDITION] (blood clot) confirmed on 09/29/14. The report's Description of the injury reflected the resident sustained [REDACTED]. Proximal fibular shaft fracture without displacement. The report's Investigation Summary reflected, "Resident is unable to be interviewed due to altered mental status. Family was present in the room at 5:30 pm on 9/28/14 and did not notice any incident, however did notice bruising to the right leg which was confirmed by (CNA D) at the same time. (CNA D) did immediately report the bruising to the charge nurse. Based on staff interviews, it has been determined that the bruising probably did not occur on Friday or Saturday. In addition, there was no causative factor that could be identified. The investigation has not revealed any negiligence (sic) and/or abuse on the part of staff. The resident does have history of [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. The resident has also had both hips replaced. Investigation Findings...Inconclusive...Provider Action Taken Post-Investigation Resident transported to hospital for further evaluation Education initiated on lift and transfer program and abuse/neglect as a precautionary measure." Further review of the Provider Investigation Report revealed interviews with CNAs A and B, and they noticed swelling to Resident #1's right leg on Saturday, 09/27/14. CNA A reported the swelling to the charge nurse. Interview with CNA A via telephone on 10/15/14 at 2:15 PM revealed she worked the 10:00 PM to 6:00 AM shift on 09/27/14. She stated she noticed the swelling and the bruise to Resident #1's leg during her shift on 09/27/14, when she was getting ready to reposition the resident. She stated she went and got her co-worker, CNA B, to assist her when she saw the injury, and both saw the bruise. She stated she reported this to RN C. Interview with CNA B via telephone on 10/20/14 at 1:11 PM, revealed she worked the 10:00 PM to 6:00 AM shift on 09/27/14. She stated she did not work with Resident #1; however, CNA A came to her and asked her for assistance in repositioning. She stated they observed there was something wrong with Resident #1's leg and CNA A went to report it to the charge nurse, RN C. Interview with RN C via telephone on 10/20/14 at 1:15 PM, revealed no one reported any swelling or bruising to Resident #1's leg on 09/27/14 to her. She stated she was made aware of the injury on 09/28/14 as she had to monitor oxygen levels for Resident #1. She stated she believed she also gave Resident #1 a pain pill. She stated Resident #1 was "hard to communicate with;" however, she thought the resident had a "little bit of pain," per her facial expressions. She stated Resident #1 was also talking, but she could not be understood. She stated the resident's roommate kept saying, "Be quiet. Be quiet," to the resident. Interview with CNA D via telephone on 10/15/14 at 2:07 PM, revealed he saw the bruise on Resident #1's leg when he placed her into bed after dinner on 09/28/14. He stated he used a gait belt and the resident's family member told him he was supposed to use a Hoyer lift to transfer the resident. He stated he notified the nurse immediately of the bruise. CNA D revealed he did not know what type of a transfer Resident #1 was; however, he had been a CNA for [AGE] years and he knew how to transfer a resident. He stated he later found out from the Cardex folder Resident #1 required a two person Hoyer transfer. He denied knowing how Resident #1 sustained the fracture. Interview with the DON on 10/15/14 at 9:49 AM, revealed she started working for the facility on 10/13/14. She denied having any knowledge of the incident. She stated she felt they followed the physician's orders [REDACTED]. Interview with the ADM on 10/16/14 at 9:40 AM, revealed she could not come to a conclusion about how the injury occurred. She stated everyone insisted nothing happened with Resident #1 during a transfer. She stated she did not know when the injury occurred. Regarding the staff who observed the swelling on 09/27/14, the ADM stated she believed RN C told her nothing was reported to her. She stated she felt CNAs A and B thought they were in trouble and stated they saw the swelling to not get in trouble. She stated the staff were in-serviced on Abuse/Neglect and transfers. 3. Resident #2's face sheet, dated 10/30/13, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #2's care plan, initiated on 12/23/11 and reviewed by the facility on 07/31/14, reflected the resident required the total assistance of two persons with transfers and the Hoyer lift was to be used. The care plan also reflected an additional problem area of [DIAGNOSES REDACTED].#2 was at risk for spontaneous fractures/falls. The approaches were to give medications as ordered, monitor with labs and X-rays and to assist resident carefully when providing care. Resident #2's comprehensive MDS assessment, dated 08/04/14, reflected she required two or more persons' physical assistance with bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. She was totally dependent on staff for bathing. The assessment also reflected Resident #2's upper and lower extremities range of motion was impaired. The facility's Provider Investigation Report, reported to DADS on 10/10/14, reflected an incident of possible neglect involving Resident #2 on 10/09/14. Resident #2's functional ability was "total assistance" and she was not independently ambulatory. On 10/09/14 at 1:45 PM, CNA I reported she transferred Resident #2 with the Hoyer lift and the resident's leg hit the bar on the lift and the resident's left foot got caught on the bar. Description of the Injury reflected Resident #2 sustained tibia and fibula fractures of the left leg. CNA I was suspended pending the investigation and later terminated. Resident #2 returned from the hospital with a soft cast and an order to follow up with an orthopedic specialist. A follow up revealed there was no need for "any intervention, symptomatic care only." The summary of the Investigation reflected the findings were conclusive. The Provider Action Taken Post-Investigation reflected skills/competencies were initiated with direct care staff, categories assigned for each resident indicating transfer status and color coded stickers placed outside residents' doors for easy identification, cardex and transfer evaluations reviewed for accuracy and equipment inspected for any malfunction and none noted. Interview with LVN H on 10/16/14 at 12:05 PM revealed CNA I reported to her Resident #2's knee was slightly swollen. LVN H stated CNA I admitted she transferred the resident with the Hoyer lift alone and the resident's leg hit the Hoyer lift. LVN H stated she assessed the resident and called the physician immediately to obtain an order for [REDACTED]. Interview with CNA I was attempted via telephone on 10/16/14 at 12:30 PM, with no success. Interview with the ADM on 10/16/14 at 2:45 PM, revealed CNA I was suspended during the investigation and officially terminated on 10/15/14. The ADM stated CNA I admitted she did a one person transfer using the Hoyer lift with Resident #2, which caused the fracture. The ADM also stated CNA I admitted she had transferred residents using the Hoyer lift by herself before. 4. Review of the facility's Lift, Transfer and Repositioning Policy, dated 2010 and presented by the ADM as current policy and procedures, revealed the following: "...2. Policy...Facility policy requires two staff members to assist when lifting with mechanical lifting devices... 3. Procedures...K. Direct Care Staff will be responsible for the following: a. Complying with this policy and the Lift and Transfer Guide...b. Lifting and transferring residents in accordance with the residents' plans of care...c. Using proper techniques when lifting and transferring residents...d. Lifting and transferring residents with assistance of 2 staff members...f. Notifying Department Managers...Administrator or designee of any injury sustained while lifting or transferring residents or of any noncompliance by other staff related to resident lifting or transfers..." 5. The facility's resident roster, dated 10/15/14, reflected 32 residents needed two persons' assistance with transfers and/or the Hoyer lift, including Resident #2.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #2) of eight residents reviewed for accidents and supervision. CNA I failed to have the assistance of another staff member when she transferred Resident #2 via a mechanical lift. Resident #2 was injured during the transfer and sustained fractures involving her mid-tibia (shinbone) and fibula (outer and smaller bone of the leg from the ankle to the knee). These failures could affect the other 31 residents, who needed the assistance of two staff for transfers and/or needed the Hoyer lift for transfers, by placing them at risk for severe injury, including fractures. Findings included: Resident #2's face sheet, dated 10/30/13, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #2's care plan, initiated on 12/23/11 and reviewed by the facility on 07/31/14, reflected the resident required the total assistance of two persons with transfers and the Hoyer lift was to be used. The care plan also reflected an additional problem area of [DIAGNOSES REDACTED].#2 was at risk for spontaneous fractures/falls. The approaches were to give medications as ordered, monitor with labs and X-rays and to assist resident carefully when providing care. Resident #2's comprehensive MDS assessment, dated 08/04/14, reflected she required two or more persons' physical assistance with bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. She was totally dependent on staff for bathing. The assessment also reflected Resident #2's upper and lower extremities range of motion was impaired. The facility's Provider Investigation Report, reported to DADS on 10/10/14, reflected an incident of possible neglect involving Resident #2 on 10/09/14. Resident #2's functional ability was "total assistance" and she was not independently ambulatory. On 10/09/14 at 1:45 PM, CNA I reported she transferred Resident #2 with the Hoyer lift and the resident's leg hit the bar on the lift and the resident's left foot got caught on the bar. Description of the Injury reflected Resident #2 sustained tibia and fibula fractures of the left leg. CNA I was suspended pending the investigation and later terminated. Resident #2 returned from the hospital with a soft cast and an order to follow up with an orthopedic specialist. A follow up revealed there was no need for "any intervention, symptomatic care only." The summary of the Investigation reflected the findings were conclusive. The Provider Action Taken Post-Investigation reflected skills/competencies were initiated with direct care staff, categories assigned for each resident indicating transfer status and color coded stickers placed outside residents' doors for easy identification, cardex and transfer evaluations reviewed for accuracy and equipment inspected for any malfunction and none noted. Interview with LVN H on 10/16/14 at 12:05 PM revealed CNA I reported to her Resident #2's knee was slightly swollen. LVN H stated CNA I admitted she transferred the resident with the Hoyer lift alone and the resident's leg hit the Hoyer lift. LVN H stated she assessed the resident and called the physician immediately to obtain an order for [REDACTED]. Interview with CNA I was attempted via telephone on 10/16/14 at 12:30 PM, with no success. Interview with the ADM on 10/16/14 at 2:45 PM, revealed CNA I was suspended during the investigation and officially terminated on 10/15/14. The ADM stated CNA I admitted she did a one person transfer using the Hoyer lift with Resident #2, which caused the fracture. The ADM also stated CNA I admitted she had transferred residents using the Hoyer lift by herself before. Review of the facility's Lift, Transfer and Repositioning Policy, dated 2010 and presented by the ADM as current policy and procedures, revealed the following: "...2. Policy...Facility policy requires two staff members to assist when lifting with mechanical lifting devices... 3. Procedures...K. Direct Care Staff will be responsible for the following: a. Complying with this policy and the Lift and Transfer Guide...b. Lifting and transferring residents in accordance with the residents' plans of care...c. Using proper techniques when lifting and transferring residents...d. Lifting and transferring residents with assistance of 2 staff members...f. Notifying Department Managers...Administrator or designee of any injury sustained while lifting or transferring residents or of any noncompliance by other staff related to resident lifting or transfers..." The facility's resident roster, dated 10/15/14, reflected 32 residents needed two persons' assistance with transfers and/or the Hoyer lift, including Resident #2.

Based on observation, interview, and record review, it was determined the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive plan of care, by failing to assess and manage pain for two (Residents #3 and #4) of eight residents reviewed for pain management. 1) Resident #3 was assessed as having pain on admission on 09/08/11. Despite having a prn order for pain, the resident did not receive the Narco ordered for pain relief. The resident reported he had back pain and his medication was not working on three (09/27/11, 09/28/11, and 09/29/11) of three days. When provided pain medication, facility staff did not follow-up to assess effectiveness of the medication. After surveyor inquiry, Resident #3 received orders for routine [MEDICATION NAME] (narcotic [MEDICATION NAME]) every six hours and every four hours prn. 2) Resident #4 reported she was in pain and moaned due to the pain in her back and in her legs. CNAs B and C did not report her pain to the nurses. LVN A did not assess the resident for pain and did not follow-up to evaluate the effectiveness of the resident's pain medication leaving the resident with unrelieved episodes of pain. These failures affected Residents #3 and #4 causing episodes of unrelieved pain and discomfort and could affect the facility's 25 residents, identified as being on a pain management program, placing them at risk for unrelieved pain when staff failed to assess and treat them for pain and did not follow-up to assess whether their pain was relieved, resulting in the potential for continued unrelieved pain, having a negative impact on their health and quality of life. Findings included: 1) Resident #3's Nursing Admission assessment dated [DATE] and signed by LVN E reflected the resident was alert and oriented to person and place, and his speech was clear. Resident #3's Face Sheet dated 09/08/11 reflected the following Diagnoses: [REDACTED]. The BIMS (Bried Interview for Mental Status) Interview from the MDS assessment dated [DATE] reflected Resident #3, with a score of 13, was cognitively intact. Observation on 09/28/11 at 7:50 a.m. revealed Resident #3 was in bed, awake and complaining of low back pain. He stated, "It (his back) hurts real bad." When asked if he had received pain medication, Resident #3 stated he had asked his nurse but had not yet received medication. Observation on 09/28/11 at 9:00 a.m. revealed Resident #3 was in bed. He stated he had received his pain medication but the pain remained and was at a level five intensity (on a scale of one to ten with ten being the least and ten being the worst). When asked if his nurse had come back around to evaluate the effectiveness of the medication, he stated, "No. She hasn't." Observation on 09/28/11 at 11:00 a.m. revealed Resident #3 was out of bed in his wheelchair at physical therapy. When asked how his back was feeling, he stated the pain was not gone, and it was a level five intensity. Observation on 09/29/11 at approximately 9:30 a.m. revealed Resident #3 was out of bed in his wheelchair at physical therapy. He stated his low back hurt. The surveyor informed his nurse, LVN A, he was in pain. Observation on 09/29/11 at 10:30 a.m. revealed Resident #3 was in bed. He stated he received pain medication "about an hour ago" and still had pain. When asked if the nurse had been back to check on him, he stated, "No." When asked to show the surveyor the location of the pain, Resident #3 pointed to his lumbar spine. In an interview with LVN A on 09/29/11 at 10:30 a.m., she was asked if she had evaluated Resident #3's response to the pain medication she administered. She stated she had. When asked what Resident #3 told her, she stated, "Well I saw him go out to smoke, and he looked just fine to me." When asked if she had asked him how he felt, LVN A responded, "I saw him go to Physical Therapy (PT) after he smoked, and he looked fine to me." When asked if she had asked him how his pain was a third time, LVN A responded, "Yes. I did." When asked how he responded, LVN A stated Resident #3 said he "was fine." When the surveyor asked LVN A about the location of Resident #3's pain, LVN A responded, "His left leg." In an interview with the DON on 09/29/11 at approximately 11:25 a.m., she stated the "Nurses need to re-assess pain after they give medication. They need to document it on the MAR, the pain sheet and the 24-hour report." When asked if she expected the nurses to assess pain characteristics such as location, quality, and duration as well as intensity, the DON responded, "Yes." When asked if Resident #3's low back pain had been addressed, the DON stated, "Yes. The PA ordered a stat x-ray for the spine, and he has an order for [REDACTED]. During an interview on 09/30/11 at 11:30 a.m., the DON stated Resident #3 was recently put on routine pain medication, and it took a while for the pain medication to start working and become effective. She was asked what pain management the resident was receiving in the mean time, and she stated the resident was on a PRN medication. The DON confirmed Resident #3 was admitted about 20 days ago with diagnoses, which included pain and a history of pain. She stated Resident #3 was a mail carrier for [AGE] years and had a back injury as well as [MEDICAL CONDITION]. The DON was asked if the facility's pain assessment included identifying what kind of pain a resident was having such as muscle verses bone verses nerve pain; and targeting that kind of pain with the appropriate medication. She stated, "No," and said the NP had seen him and decided on the medication. The DON stated Resident #3 was now on routine pain medication. Before this week, he was on a PRN pain medication. She stated on 09/27/11 at 7:00 a.m., Resident #3 requested pain medication and he received it. The DON was asked if there was documentation of a follow-up on 09/27/11 after Resident #3 had received his 7:00 a.m. pain medication. She stated, "No. The follow-up was not documented." Review of a Pain Evaluation dated 09/08/11 and signed by LVN E revealed Resident #3 was asked if he had been in pain at any time during the last five days. He had responded, "Yes, frequently." The evaluation further reflected at the time of admission, Resident #3 had a pain level of "seven" (according to the Universal Pain Assessment Tool, a level seven "hurts a whole lot"). The evaluation further reflected the pain as "aching" and Tylenol relieved the pain. Review of a Physical Therapy Evaluation dated 09/09/11 and signed by the Physical Therapist revealed Resident #3 had A pain level of "seven - eight." Review of Resident #3's MAR for September 2011 revealed on 09/08/11 he did not receive the PRN pain medication ordered, although documentation reflected he was in significant pain. Review of Resident #3's current Comprehensive Care plans revealed there was no care plan, which addressed the resident's pain until 09/30/11. Review of a Nurses Note dated 09/10/11 and signed by RN N revealed Resident #3 complained of "pain in back 10/10 (ten out of ten)." Review of the Twenty Four Hour Report dated 09/10/11 revealed Resident #3 "c/o back pain." Review of Resident #3's MAR for 09/10/11 revealed he did not receive the ordered PRN pain medication after he complained of back pain. Review of Resident #3's [MEDICATION NAME]/Apap (10/325 mg tablet) narcotic sign-out sheet revealed there was no medication signed out for Resident #3 on 09/08/11 or 09/10/11. Review of a sign-out sheet for the controlled substances emergency kit provided by the DON on 09/30/11 revealed there was no medication signed out for Resident #3 on 09/10/11. Resident #3's Physician's Telephone Order dated 09/10/11 and signed by RN N reflected the following orders: "Bilateral Renal US (ultrasound), KUB (kidney, ureter, bladder scan),[MEDICATION NAME] 10/325 mg take 1-2 PO Q 4 (hours) PRN for pain." In the upper right hand corner of the order it reflected, "Stat (immediately) for back pain." A Nurses Note dated 09/10/11 and signed by RN N reflected the Bilateral Renal Ultrasound and KUB were performed and a new order for "in and out catheterization every six hours as needed for urine retention" was ordered for Resident #3. Review of a Nurses Note dated 09/11/11 and signed by RN N revealed Resident #3 "c/o pain in back, medication given." Review of the Narcotic sign-out sheet for Resident #3 revealed no medication was signed out on 09/11/11. Review of the controlled substances emergency kit revealed there were no medications signed out for Resident #3 on 09/11/11. Review of Resident #3's Narcotic Sign out sheet for [MEDICATION NAME]/APAP 10/325 mg revealed medication was signed out on 09/13/11, 09/16/11, 09/19/11, 09/20/11, 09/22/11 and 09/23/11 but were NOT documented as given on the resident's September 2011 MAR. A Psychiatric Evaluation dated 09/20/11 reflected Resident #3 had experienced "decreased sleep d/t back pain," was alert, oriented to self, age, month and place. The evaluation further reflected his thought process was intact. [MEDICATION NAME] 30 mg per day for depression/pain was prescribed. Review of a Urinalysis result dated 09/23/11 revealed Resident #3 did not have a UTI. Resident #3's Physician's Telephone Order dated 09/29/11 and signed by ADON R reflected "Stat x-ray of Lumbar Spine and [MEDICATION NAME] Area." A second Physician's Telephone Order for Resident #3 dated 09/29/11 and signed by LVN E reflected, "[MEDICATION NAME] 10/325 mg 1 tab by mouth every six hours routine" and "Continue [MEDICATION NAME] 10/325 1 to 2 tabs by mouth every four hours as needed for pain." Review of Resident #3's Radiology Report dated 09/29/11 revealed, "mild [MEDICAL CONDITIONS] of the lumbar and [MEDICATION NAME] spine, and mild [MEDICAL CONDITION] change of the [MEDICATION NAME] spine is seen as evidenced by Osteophytic spurring." 2) Review of the Quarterly MDS assessment dated [DATE] revealed Resident #4 was admitted to the facility on [DATE]. Resident #4 was moderately cognitively impaired, had an indwelling catheter, was incontinent of bowel, and was totally dependent on staff for all ADLs. [DIAGNOSES REDACTED].ypertension,H On 09/27/11 at 12:20 p.m., observation of Resident #4 revealed she was being assisted by CNA C to roll onto her left side. Resident #4 was observed telling CNA C her back was hurting. Observation on 09/27/11 at 1:10 p.m. revealed Resident #4 was seated in her wheelchair. CNA C was observed feeding the resident. The surveyor asked Resident #4 if her back still hurt. Resident #4 said her back still hurt. At that time CNA C stated, "Her low back hurts." Observation on 09/27/11 at 2:11 p.m. revealed Resident #4 was moaning and touching her lower back with her right hand. Resident #4 stated, "My low back hurts, and my tailbone hurts too." On 09/27/11 at 2:20 p.m., the surveyor queried whether LVN A was notified Resident #4 was complaining of pain. LVN A said no one had reported to her the resident was in pain. LVN A then stated, "I just gave her [MEDICATION NAME] ([MEDICATION NAME]), her routine pain medication." Observation on 09/27/11 at 3:00 p.m. revealed Resident #4 was still seated in her wheelchair. At that time Resident #4 told the surveyor, "My back hurts." Review of the 24 Hour Report/Change Of Condition Report dated 09/27/11 revealed no documented evidence Resident #4 was experiencing pain. Resident #4's Physician's Telephone Orders dated 08/26/11 reflected an order for [REDACTED]. Review of Resident #4's Care Plan - Pain, dated 09/01/11, revealed "Problem - Potential for pain related to Chronic disease process ...Approaches - Observe resident for signs and symptoms of pain, including verbal expressions and non-verbal expressions (facial grimacing, bracing, restlessness, rubbing, other) ...Notify physician if interventions are not consistently effective." There was no care plan in the residents' entire clinical record for actual pain or discomfort. Observation on 09/28/11 at 9:30 a.m. revealed LVN A was administering Resident #4's medications via [DEVICE]. During that time, LVN A asked Resident #4 if she was having any pain. Resident #4 said her back and left foot was hurting. LVN A told Resident #4 she was administering her pain medication. LVN A subsequently gave the resident [MEDICATION NAME] via the [DEVICE]. Observation of LVN A prior to and while giving Resident #4's pain medication revealed she did not assess the resident's pain per the 1-10 pain scale or any other type of pain scale. Resident #4's MAR for September 2011 reflected to Monitor: Pain Scale Q shift W/ Results (+) = Pain, (-) = No Pain. From 09/01/11 until 09/27/11, documentation reflected all three shifts had placed a (-) sign in the box, which indicated Resident #4 had not experienced pain. On 09/28/11 at 9:45 a.m., LVN A told the surveyor she had not assessed Resident #4 for pain, because the pain assessment form was changed approximately two months ago. LVN A said the resident's pain level was assessed every shift. LVN A said a (+) sign was documented for pain and a (-) sign was documented for no pain. LVN A stated, "I like the old form better. We used to assess for pain, give the pain medication, then go back one hour later and assess using the pain scale." On 09/29/11 at 9:10 a.m. Resident #4 was observed lying in her bed moaning. She told the surveyor, "I am in severe back pain right now." Interview with CNA B during this time revealed Resident #4 had told CNA B earlier that morning her back was "hurting bad." CNA B said she had not reported the resident's back pain because she always complained her back hurts. CNA B also said she repositioned the resident for comfort because the resident complained her pain extended into both of her legs. The surveyor then went and notified LVN A the resident was in pain. LVN A then walked into Resident #4's room. Resident #4 immediately told LVN A, "My back is killing me." LVN A told the resident she would give her some pain medication. On 09/29/11 at 1:45 p.m., during an interview with CNA C, she revealed she had not reported Resident #4's complaints of back pain on 09/27/11 to LVN A. "I usually tell the nurse the resident's back hurts when I get her up but she (LVN A) tells me she gets routine pain medication. So, I don't always tell her." On 09/29/11 at 9:55 a.m., interview with the facility DON revealed all nurse aides were in-serviced to report to the nurse if residents complain they are in pain. The DON said a Thermometer Pain Scale form was placed in front of every resident's MAR for the nurses to use to assess the resident's pain levels. The DON said if a resident has pain then a (+) sign is placed in the designated box on the MAR and then the nurses should assess the resident's pain level using the Thermometer Pain Scale. Review of the Thermometer Pain Scale indicated a pain evaluation from 1-10 (2 mild pain, 4 moderate pain, 6 severe pain, 8 very severe pain, 10 worst possible pain). On 09/29/11 at 11:35 a.m. interview with the DON revealed she became aware last Friday 09/23/11) the nurses were not using the 1-10 pain scale. The DON said the prn flow sheets were placed in the resident's MAR the day before. The DON said the nurse should be documenting how affective routine pain medication was and documenting the pain severity on the back of the MAR. 3) The facility's Pain Management Practice Guidelines reflected "...5. Each resident identified for pain will have a Pain Management Care Plan... will have individualized interventions related to that resident's individual control of pain management. The Care Plan should include pharmacological and non-pharmacological pain management interventions... 7. The licensed Nurse will communicate any new onset of resident pain or change in resident pain throughout the 24 Hour Report process... 9. The Pain Management Care Plan with interventions will be up-dated as indicated... 10. The staff will implement the Care Plan, monitor the resident, and administer therapeutic interventions for pain, if ordered...12 Documentation for the Pain Medication Administration record is as follows: Record the pain scale using the Faces Rating Scale 1-10... Record the pharmacological interventions attempted... Record the follow -up observations post intervention." 4) The CMS form 672 (Resident Census and Condition of Residents) signed by the DON and dated 09/27/11 reflected 25 residents were on a pain management program.

Based on observation, interview and record review, the facility failed to ensure the physician was immediately consulted for one (Resident #19) of 21 residents reviewed when the resident fell and x-ray results determined there was a fracture. Resident #19 had an unwitnessed fall, which resulted in pain and the inability to bear weight on her right leg on 09/12/10 at approximately 4:30 p.m. LVN A called the physician's nurse practitioner and got an order for [REDACTED]. This failure could affect the facility's 105 residents, including Resident #19, and placed them at risk for sustaining an injury and not receiving immediate treatment, preventing the potential of continued pain, clot formation, infection and disability, reducing measurably the resident's quality of life. Findings included: Initial tour on 09/21/10 at 10:15 a.m. with ADON F revealed Resident #19 was admitted to the hospital "about three weeks ago" for a fracture of her "femur." Resident #19 was found beside her bed with bed sheets tangled around her legs at the time of the fracture. ADON F revealed Resident #19 did not walk, was transferred using a gait belt with assistance of one staff member, was non-interviewable, required total assistance with ADLs, was incontinent of bowel and bladder, and required assistance in eating her pureed food. Resident #19's current MDS assessment (Significant Change in Status) dated 08/17/10 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #19 was severely impaired for cognitive skills for daily decision making. Resident #19 required extensive assistance from two plus staff members with transfers, locomotion on the unit, dressing, toilet use, and personal hygiene. Resident #19's primary mode of locomotion was by a wheelchair, pushed by a staff member. The MDS reflected Resident #19 had experienced a fall in the past 30 days, but did not have a [MEDICAL CONDITION] in the past 180 days. Review of Resident #19's History and Physical dated 08/03/10 and completed by the NP when she was readmitted from a hospitalization revealed, "Pt has multiple complex medical conditions including status [REDACTED]." Review of Resident #19's RESIDENT TRANSFER EVALUATION dated 09/03/10 revealed the resident had a total score of nine, which placed her in "Category 3: (score 9-14) Caregiver performs 50% of the task or greater. Equipment: Mechanical Lift (Total Body/Sling or Stand Assist as appropriate)...." Review of Resident #19's Comprehensive care plan dated 09/03/10 revealed the facility identified the resident's risk for falls and revealed, "...Res. continues to be at risk for falls but has become more alert and is able to stand with assist X 2 to transfer...." Review of Resident #19's INCIDENT/ACCIDENT REPORT dated 09/12/10 at 5:30 p.m. revealed the resident was "found sitting on the floor by her bed with bed sheet wrapped around her legs - unattended. Assisted back into her bed - able to bear wt on L (left) leg, but not on R (right) leg - R leg pulled up as if contractured (sic) - c/o pain to R femur area. Able to MAE (move all extremities) ... C/o (complaint of) pain to R femur area...." Review of LVN A's written statement dated 09/12/10 and attached to the Incident/Accident Report revealed, "Was called to pt's (Resident #19's) room to find her sitting on the floor by her bed with bed sheet wrapped around her legs. Assisted per 2 (people) back to bed. Unable to bear wt on her R leg - looks pulled up as if contractured (sic) - c/o pain to R femur area when asked 3 different times. Xrays (sic) of R hip & R femur ordered." Interview on 09/22/10 at 1:00 p.m. with LVN A revealed she worked on the 6:00 a.m. to 6:00 p.m. shift on 09/12/10. MA D called her to Resident #19's room on 09/12/10. She observed Resident #19 on the floor with the bed sheets wrapped around her legs. Resident #19 could not bear weight on her right leg, but could on her left leg. Resident #19 pointed at her right leg when asked if she was in pain, and said, "Yes." Resident #19 then contradicted herself and said, "No." LVN A said Resident #19 had Dementia. LVN A then stated, "I didn't know what she was feeling." LVN A stated Resident #19's right leg was "bent at the knee," but after the resident was transferred to her bed it "looked normal." LVN A thought the incident occurred around 5:30 p.m., but she said MA D thought it was earlier. LVN A revealed she didn't look at the clock. LVN A revealed she called for an x-ray on Resident #19's right lower extremity. When LVN A was queried as to the decision to not send the resident to the emergency room , and she stated she needed to do "finger sticks and insulins," because it was almost dinner time for the residents. Resident #19 "settled down" after she was transferred to her bed. When LVN A was asked what type of emergency would prompt her to send a resident to the emergency room , she stated, "Respiratory arrest, [MEDICAL CONDITION] and an open fracture. With a closed fracture you don't know if it's broken so I wouldn't send them out until after an x-ray confirmed it." When LVN A was asked what kind of complications could result from a [MEDICAL CONDITION], she stated, "fat embolism, nerve damage, vascular compromise and impaired circulation." When asked how a resident's leg might look if their hip was fractured, she stated, "It could have external rotation, maybe shorter, can't bear weight and complain of pain." LVN A stated she reported the incident to RN C at the end of shift report (at approximately 6:00 p.m.). Review of Resident #19's Physician's Telephone Orders dated 09/12/10 at 4:35 p.m. revealed, "X-ray R leg R/O (rule out) fx (fracture)." Review of Resident #19's NURSING DAILY SKILLED SUMMARY dated 09/12/10 at 5:30 p.m. revealed, "Resident found sitting on the floor by her bed, bed sheet wrapped around her legs. Assisted back to bed unable to bear wt on R leg - R leg is contractured (sic). Neuro is WNL (within normal limits). Able to bear wt (weight) on L leg and moves extremities... 6:15 p (p.m.) X-ray ordered for R hip and R femur..." NP H was notified and ordered [MEDICATION NAME] (pain medication)... 8:30 p X-ray done with nurse assisting technician to position pt. Nurse explained to x-ray tech that resident has contracture to R leg. Pt did not show any signs of pain... 10:15 p x-ray returned for more pictures, stated that she did not get enough for viewing. Nurse assisted x-ray technician to position pt. for x-ray. Pt asleep throughout positioning. Neuro checks WNL..." The notes reflected the nurse instructed the RCS (Resident Care Specialist - CNA) to be "careful during pericare and call for assistance with turning pt. 3:30 am (a.m.) x-ray results called into nurse...." RN C faxed the x-ray results to NP H. Review of Resident #19's Physician's Telephone Order dated 09/12/10 at 6:30 p.m. revealed an order for [REDACTED]. Review of Resident #19's x-ray report with a date of service 09/12/10 and faxed to the facility on [DATE] at 12:18 a.m. revealed, "...RIGHT HIP UNILATERAL: There is a right intertrochanteric fracture with modest displacement. Mild callous formation is seen. The joint shows no dislocation. Pubic rami are intact. [MEDICAL CONDITION] is present ... RIGHT FEMUR: The femur shows [MEDICAL CONDITION]. There is a right intertrochanteric fracture with modest displacement. Mild callous formation is seen. The joint shows no dislocation. Pubic rami are intact. The remainder of the femur is intact...." Interview on 09/22/10 at 1:15 p.m. with RN C stated she worked the 6:00 p.m. (09/12/10) to 6:00 a.m. (09/13/10) shift. RN C said Resident #19 did not appear to be in pain when she assessed her. RN C revealed she received a verbal report from the local x-ray company at approximately 3:30 a.m., and at that time she learned the x-ray report had been faxed to the facility earlier that morning. RN C stated she did not call NP H with the x-ray report; instead she faxed the x-ray report to NP H. RN C said she should have called NP H stating, "I don't know why I didn't." RN C revealed when she gave report at approximately 6:00 a.m. 09/13/10 to LVN B, LVN B made the decision to send Resident #19 to the emergency room . Interview on 09/24/10 at 10:00 a.m. with RN C revealed she did not send Resident #19 to the emergency room after receiving the x-ray report reflecting a fracture because she was waiting on NP H to call back with orders. When RN C was asked what complications could occur as a result of a [MEDICAL CONDITION], she replied, "Bleeding, blood clots and long term disability." RN C stated the x-ray report didn't sound "that urgent." RN C stated she was very busy that night and had sent another resident to the emergency room . RN C stated, "I took on too much. It will never happen again." Interview with X-Ray CSR from the local x-ray company on 09/24/10 at 9:40 a.m. revealed the call for an x-ray for Resident #19 came in on 09/12/10 at 4:48 p.m. and was listed as a "normal case." The x-ray technician was dispatched "five minutes later." X-ray reports were on auto-fax, and were faxed to a facility immediately after receiving the report. A verbal report was given by phone afterwards to confirm receipt of the faxed report. Resident #19's verbal report was given at 2:00 a.m. on 09/13/10 to RN C. The local x-ray company had used the auto-fax for the "last three months." Interview with LVN B on 09/23/10 at 12:25 p.m. revealed she worked the 6:00 a.m. to 6:00 p.m. shift on 09/13/10. When she received report from RN C regarding Resident #19, and learned the resident had a [MEDICAL CONDITION], she decided to send her to the emergency room . Resident #19 was sent to a local emergency room at approximately 7:00 a.m. LVN B stated she looked at the x-ray report, and thought, "Why is she still here?" Interview with ADON F on 09/23/10 at 2:40 p.m. revealed she learned Resident #19 had a right [MEDICAL CONDITION] from LVN B on the morning of 09/13/10. ADON F stated she did not know why Resident #19 was not sent to the emergency room immediately. ADON F stated, "I would have sent her out when the resident couldn't bear weight. I still don't understand why she wasn't sent out. I would have sent her out without a physician's orders [REDACTED]." Interview with a local Hospital Social Worker on 09/22/10 at 2:15 p.m. revealed Resident #19 was checked into the emergency roiagnom on [DATE] at 8:30 a.m. Resident #19 had right hip surgery with an open reduction with internal fixation on 09/17/10. Interview with the DON on 09/22/10 at 4:50 p.m. regarding Resident #19's fall revealed, "The nurse should call the physician and see what he wants to do." The DON was queried about possible complications of a [MEDICAL CONDITION]. She stated, "Pain, deformities, they could throw a clot and eventually die if it goes to the lung or organs." The DON revealed LVN A "did an assessment and did order x-rays." The DON stated, "I don't want to say the nurse did anything wrong." When asked how she could ensure delay in treatment and notification of changes would not be repeated with another resident, the DON stated, "When things happen, I talk to them (staff) about what we need to do. As their leader I give recommendations. I didn't document the conversations." The DON said RN C "should have called the doctor when she got the x-ray report. You can't depend on a fax especially at three in the morning. You have to call the doctor." Untitled and undated notes signed by the DON regarding Resident #19's fractured right hip were provided to the surveyors to review. The notes reflected, "...After staff interviews it was determined that the fall was not caused by staff or negligence. It was identified that staff in-service needed to be given for a clear picture on what items needed to be called to nurse management and/or Administrator. Also, that the staff members involved needed additional training on incidents ie when to notify physician, supervisor, process for x-ray results, etc. This in-service was completed on Wednesday, September 15 (2010)." Interview on 09/22/10 at 1:30 p.m. with LVN M revealed when the surveyor asked LVN M if a [MEDICAL CONDITION] was an emergency she replied, "Of course." LVN M stated , with a [MEDICAL CONDITION], there could be internal bleeding and the resident could go into shock. LVN M revealed a resident with a [MEDICAL CONDITION] would complain of pain, may have rotation of the leg, and the leg could appear shorter. If a [MEDICAL CONDITION] was suspected, LVN M would send the resident to the emergency room even if there was not an x-ray. Review of Resident #19's INCIDENT/ACCIDENT INVESTIGATION FOLLOW-UP from 09/12/10 revealed: "...PAST INTERVENTIONS ATTEMPTED... falling star program, bed chair alarm, low bed position. RECOMMENDATIONS/NEW INTERVENTIONS Will re-evaluate resident when she returns from hosp...." An undated note included reflected, "...After interviewing the staff there were no signs of neglect. The resident was properly positioned in bed and the bed in proper position. The resident had hardly any muscle mass and has dx of [MEDICAL CONDITION], which exposed her to higher risk for injury." Review of an Attendance Form for "Fall Intervention" dated 09/15/10 listed a total of two employees, LVN A and MA D, in attendance. The form reflected, "Inservice Regarding falls. Assessment of Res (resident) that has fallen is first. If Resident is not standing as she usually does or it is noticed that she is not bearing weight on one foot, verbalizing pain or facial grimacing after/before phy. (physician) notified this Resident can and should be sent to the hospital. This is a Nursing Assessment." On 09/28/10 the facility provided DISCIPLINARY ACTION RECORDs on LVN A and RN C to the surveyor by fax, regarding Resident #19. Review of LVN A's DISCIPLINARY ACTION RECORD dated 09/26/10, 14 days after Resident #19 had an un-witnessed fall, revealed, "...On 9/12/10 Charge Nurse during her 6A-6P shift had a Resident fall out of bed. (Resident #19) was assessed by charge nurse and according to I/A report when Res. was assisted to a standing position she said 'ouch' and would not bear wt on one leg. Charge nurse did not follow policy by using Resources available to her when she was not able to reach the Nurse Practitioner. Charge Nurse wrote order for x-ray but did not specify STAT. Also did not notify Nurse Manager on Duty, DON or Administrator. Employee Statement: To be completed by employee. In the past, I was informed not to call 'on call' personnel. Didn't think to notify mgr (manager) on duty, DON, or administrator @ this time; just 'sailing my ship.' The nurse practitioner had told us to 'use your head, use your common sense, you're a nurse with a license' When calling her in the past; I was just using my head & common sense. Corrective Action: To be completed by Supervisor. Be specific, include goals and timetable for follow-up. Charge Nurse will set up time for education with SDC no later than Tue 9/28/10...." Review of RN C's DISCIPLINARY ACTION RECORD dated 9/26/10, 14 days after Resident #19 had an un-witnessed fall resulting in a [MEDICAL CONDITION], revealed "...Charge Nurse did not follow policy with notification to manager on duty, DON or Administrator Regarding the Res. fall. Even after (local x-ray company) called the results to the Charge Nurse no attempt was made to get the Res. to the hospital... Corrective Action: To be completed by Supervisor... Employee will set up time with SDC by 9-28-10 for education...." The facility provided CMS form 672 dated 09/21/10 and signed by the DON which reflected 83 residents that required assistance from one to two staff members for transfers; and 13 residents were dependent on staff for transfers. The DON also provided a list of eight residents, who received in-house fractures from March 2010 to 09/24/10 on 09/24/10.

Based on interview and record review, it was determined the facility failed to implement the facility's policies and procedures to prohibit neglect for two (Residents #12 and #19) of twenty-one residents reviewed for neglect. 1) Resident #19 had an unwitnessed fall, which resulted in pain and the inability to bear weight on her right leg on 09/12/10 at approximately 4:30 p.m. LVN A called the physician's nurse practitioner and got an order for [REDACTED]. The Department of Aging and Disability Services was not notified of the incident. 2) Resident #12 was assessed as requiring a two-person assist with transfers. CNA E attempted to assist the resident alone, even after the resident requested more assistance, and dropped the resident on the floor. The resident suffered a fracture to her left, lower leg as a result of the fall. The Department of Aging and Disability Services was not notified of the incident. These failures could affect the facility's 96 residents, who required assistance from staff with transfers, including Residents #12 and #19, and placed them at risk for falls, fractures, abrasions, bruises, pain and mental anguish. Findings included: 1) Initial tour on 09/21/10 at 10:15 a.m. with ADON F revealed Resident #19 was admitted to the hospital "about three weeks ago" for a fracture of her "femur." Resident #19 was found beside her bed with bed sheets tangled around her legs at the time of the fracture. ADON F revealed Resident #19 did not walk, was transferred using a gait belt with assistance of one staff member, was non-interviewable, required total assistance with ADLs, was incontinent of bowel and bladder, and required assistance in eating her pureed food. Resident #19's current MDS assessment (Significant Change in Status) dated 08/17/10 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #19 was severely impaired for cognitive skills for daily decision making. Resident #19 required extensive assistance from two plus staff members with transfers, locomotion on the unit, dressing, toilet use, and personal hygiene. Resident #19's primary mode of locomotion was by a wheelchair, pushed by a staff member. The MDS reflected Resident #19 had experienced a fall in the past 30 days, but did not have a [MEDICAL CONDITION] in the past 180 days. Review of Resident #19's History and Physical dated 08/03/10 and completed by the NP when she was readmitted from a hospitalization revealed, "Pt has multiple complex medical conditions including status [REDACTED]." Review of Resident #19's RESIDENT TRANSFER EVALUATION dated 09/03/10 revealed the resident had a total score of nine, which placed her in "Category 3: (score 9-14) Caregiver performs 50% of the task or greater. Equipment: Mechanical Lift (Total Body/Sling or Stand Assist as appropriate)...." Review of Resident #19's Comprehensive care plan dated 09/03/10 revealed the facility identified the resident's risk for falls and revealed, "...Res. continues to be at risk for falls but has become more alert and is able to stand with assist X 2 to transfer...." Review of Resident #19's INCIDENT/ACCIDENT REPORT dated 09/12/10 at 5:30 p.m. revealed the resident was "found sitting on the floor by her bed with bed sheet wrapped around her legs - unattended. Assisted back into her bed - able to bear wt on L (left) leg, but not on R (right) leg - R leg pulled up as if contractured (sic) - c/o pain to R femur area. Able to MAE (move all extremities) ... C/o (complaint of) pain to R femur area...." Review of LVN A's written statement dated 09/12/10 and attached to the Incident/Accident Report revealed, "Was called to pt's (Resident #19's) room to find her sitting on the floor by her bed with bed sheet wrapped around her legs. Assisted per 2 (people) back to bed. Unable to bear wt on her R leg - looks pulled up as if contractured (sic) - c/o pain to R femur area when asked 3 different times. Xrays (sic) of R hip & R femur ordered." Interview on 09/22/10 at 1:00 p.m. with LVN A revealed she worked on the 6:00 a.m. to 6:00 p.m. shift on 09/12/10. MA D called her to Resident #19's room on 09/12/10. She observed Resident #19 on the floor with the bed sheets wrapped around her legs. Resident #19 could not bear weight on her right leg, but could on her left leg. Resident #19 pointed at her right leg when asked if she was in pain, and said, "Yes." Resident #19 then contradicted herself and said, "No." LVN A said Resident #19 had Dementia. LVN A then stated, "I didn't know what she was feeling." LVN A stated Resident #19's right leg was "bent at the knee," but after the resident was transferred to her bed it "looked normal." LVN A thought the incident occurred around 5:30 p.m., but she said MA D thought it was earlier. LVN A revealed she didn't look at the clock. LVN A revealed she called for an x-ray on Resident #19's right lower extremity. When LVN A was queried as to the decision to not send the resident to the emergency room , and she stated she needed to do "finger sticks and insulins," because it was almost dinner time for the residents. Resident #19 "settled down" after she was transferred to her bed. When LVN A was asked what type of emergency would prompt her to send a resident to the emergency room , she stated, "Respiratory arrest, [MEDICAL CONDITION] and an open fracture. With a closed fracture you don't know if it's broken so I wouldn't send them out until after an x-ray confirmed it." When LVN A was asked what kind of complications could result from a [MEDICAL CONDITION], she stated, "fat embolism, nerve damage, vascular compromise and impaired circulation." When asked how a resident's leg might look if their hip was fractured, she stated, "It could have external rotation, maybe shorter, can't bear weight and complain of pain." LVN A stated she reported the incident to RN C at the end of shift report (at approximately 6:00 p.m.). Review of Resident #19's Physician's Telephone Orders dated 09/12/10 at 4:35 p.m. revealed, "X-ray R leg R/O (rule out) fx (fracture)." Review of Resident #19's NURSING DAILY SKILLED SUMMARY dated 09/12/10 at 5:30 p.m. revealed, "Resident found sitting on the floor by her bed, bed sheet wrapped around her legs. Assisted back to bed unable to bear wt on R leg - R leg is contractured (sic). Neuro is WNL (within normal limits). Able to bear wt (weight) on L leg and moves extremities... 6:15 p (p.m.) X-ray ordered for R hip and R femur..." NP H was notified and ordered [MEDICATION NAME] (pain medication)... 8:30 p X-ray done with nurse assisting technician to position pt. Nurse explained to x-ray tech that resident has contracture to R leg. Pt did not show any signs of pain... 10:15 p x-ray returned for more pictures, stated that she did not get enough for viewing. Nurse assisted x-ray technician to position pt. for x-ray. Pt asleep throughout positioning. Neuro checks WNL..." The notes reflected the nurse instructed the RCS (Resident Care Specialist - CNA) to be "careful during pericare and call for assistance with turning pt. 3:30 am (a.m.) x-ray results called into nurse...." RN C faxed the x-ray results to NP H. Review of Resident #19's Physician's Telephone Order dated 09/12/10 at 6:30 p.m. revealed an order for [REDACTED]. Review of Resident #19's x-ray report with a date of service 09/12/10 and faxed to the facility on [DATE] at 12:18 a.m. revealed, "...RIGHT HIP UNILATERAL: There is a right intertrochanteric fracture with modest displacement. Mild callous formation is seen. The joint shows no dislocation. Pubic rami are intact. [MEDICAL CONDITION] is present ... RIGHT FEMUR: The femur shows [MEDICAL CONDITION]. There is a right intertrochanteric fracture with modest displacement. Mild callous formation is seen. The joint shows no dislocation. Pubic rami are intact. The remainder of the femur is intact...." Interview on 09/22/10 at 1:15 p.m. with RN C stated she worked the 6:00 p.m. (09/12/10) to 6:00 a.m. (09/13/10) shift. RN C said Resident #19 did not appear to be in pain when she assessed her. RN C revealed she received a verbal report from the local x-ray company at approximately 3:30 a.m., and at that time she learned the x-ray report had been faxed to the facility earlier that morning. RN C stated she did not call NP H with the x-ray report; instead she faxed the x-ray report to NP H. RN C said she should have called NP H stating, "I don't know why I didn't." RN C revealed when she gave report at approximately 6:00 a.m. 09/13/10 to LVN B, LVN B made the decision to send Resident #19 to the emergency room . Interview on 09/24/10 at 10:00 a.m. with RN C revealed she did not send Resident #19 to the emergency room after receiving the x-ray report reflecting a fracture because she was waiting on NP H to call back with orders. When RN C was asked what complications could occur as a result of a [MEDICAL CONDITION], she replied, "Bleeding, blood clots and long term disability." RN C stated the x-ray report didn't sound "that urgent." RN C stated she was very busy that night and had sent another resident to the emergency room . RN C stated, "I took on too much. It will never happen again." Interview with X-Ray CSR from the local x-ray company on 09/24/10 at 9:40 a.m. revealed the call for an x-ray for Resident #19 came in on 09/12/10 at 4:48 p.m. and was listed as a "normal case." The x-ray technician was dispatched "five minutes later." X-ray reports were on auto-fax, and were faxed to a facility immediately after receiving the report. A verbal report was given by phone afterwards to confirm receipt of the faxed report. Resident #19's verbal report was given at 2:00 a.m. on 09/13/10 to RN C. The local x-ray company had used the auto-fax for the "last three months." Interview with LVN B on 09/23/10 at 12:25 p.m. revealed she worked the 6:00 a.m. to 6:00 p.m. shift on 09/13/10. When she received report from RN C regarding Resident #19, and learned the resident had a [MEDICAL CONDITION], she decided to send her to the emergency room . Resident #19 was sent to a local emergency room at approximately 7:00 a.m. LVN B stated she looked at the x-ray report, and thought, "Why is she still here?" Interview with ADON F on 09/23/10 at 2:40 p.m. revealed she learned Resident #19 had a right [MEDICAL CONDITION] from LVN B on the morning of 09/13/10. ADON F stated she did not know why Resident #19 was not sent to the emergency room immediately. ADON F stated, "I would have sent her out when the resident couldn't bear weight. I still don't understand why she wasn't sent out. I would have sent her out without a physician's orders [REDACTED]." Interview with a local Hospital Social Worker on 09/22/10 at 2:15 p.m. revealed Resident #19 was checked into the emergency roiagnom on [DATE] at 8:30 a.m. Resident #19 had right hip surgery with an open reduction with internal fixation on 09/17/10. Interview with the DON on 09/22/10 at 4:50 p.m. regarding Resident #19's fall revealed, "The nurse should call the physician and see what he wants to do." The DON was queried about possible complications of a [MEDICAL CONDITION]. She stated, "Pain, deformities, they could throw a clot and eventually die if it goes to the lung or organs." The DON revealed LVN A "did an assessment and did order x-rays." The DON stated, "I don't want to say the nurse did anything wrong." When asked how she could ensure delay in treatment and notification of changes would not be repeated with another resident, the DON stated, "When things happen, I talk to them (staff) about what we need to do. As their leader I give recommendations. I didn't document the conversations." The DON said RN C "should have called the doctor when she got the x-ray report. You can't depend on a fax especially at three in the morning. You have to call the doctor." Untitled and undated notes signed by the DON regarding Resident #19's fractured right hip were provided to the surveyors to review. The notes reflected, "...After staff interviews it was determined that the fall was not caused by staff or negligence. It was identified that staff in-service needed to be given for a clear picture on what items needed to be called to nurse management and/or Administrator. Also, that the staff members involved needed additional training on incidents ie when to notify physician, supervisor, process for x-ray results, etc. This in-service was completed on Wednesday, September 15 (2010)." Interview on 09/22/10 at 1:30 p.m. with LVN M revealed when the surveyor asked LVN M if a [MEDICAL CONDITION] was an emergency she replied, "Of course." LVN M stated , with a [MEDICAL CONDITION], there could be internal bleeding and the resident could go into shock. LVN M revealed a resident with a [MEDICAL CONDITION] would complain of pain, may have rotation of the leg, and the leg could appear shorter. If a [MEDICAL CONDITION] was suspected, LVN M would send the resident to the emergency room even if there was not an x-ray. Review of Resident #19's INCIDENT/ACCIDENT INVESTIGATION FOLLOW-UP from 09/12/10 revealed: "...PAST INTERVENTIONS ATTEMPTED... falling star program, bed chair alarm, low bed position. RECOMMENDATIONS/NEW INTERVENTIONS Will re-evaluate resident when she returns from hosp...." An undated note included reflected, "...After interviewing the staff there were no signs of neglect. The resident was properly positioned in bed and the bed in proper position. The resident had hardly any muscle mass and has dx of [MEDICAL CONDITION], which exposed her to higher risk for injury." Review of an Attendance Form for "Fall Intervention" dated 09/15/10 listed a total of two employees, LVN A and MA D, in attendance. The form reflected, "Inservice Regarding falls. Assessment of Res (resident) that has fallen is first. If Resident is not standing as she usually does or it is noticed that she is not bearing weight on one foot, verbalizing pain or facial grimacing after/before phy. (physician) notified this Resident can and should be sent to the hospital. This is a Nursing Assessment." On 09/28/10 the facility provided DISCIPLINARY ACTION RECORDs on LVN A and RN C to the surveyor by fax, regarding Resident #19. Review of LVN A's DISCIPLINARY ACTION RECORD dated 09/26/10, 14 days after Resident #19 had an un-witnessed fall, revealed, "...On 9/12/10 Charge Nurse during her 6A-6P shift had a Resident fall out of bed. (Resident #19) was assessed by charge nurse and according to I/A report when Res. was assisted to a standing position she said 'ouch' and would not bear wt on one leg. Charge nurse did not follow policy by using Resources available to her when she was not able to reach the Nurse Practitioner. Charge Nurse wrote order for x-ray but did not specify STAT. Also did not notify Nurse Manager on Duty, DON or Administrator. Employee Statement: To be completed by employee. In the past, I was informed not to call 'on call' personnel. Didn't think to notify mgr (manager) on duty, DON, or administrator @ this time; just 'sailing my ship.' The nurse practitioner had told us to 'use your head, use your common sense, you're a nurse with a license' When calling her in the past; I was just using my head & common sense. Corrective Action: To be completed by Supervisor. Be specific, include goals and timetable for follow-up. Charge Nurse will set up time for education with SDC no later than Tue 9/28/10...." Review of RN C's DISCIPLINARY ACTION RECORD dated 9/26/10, 14 days after Resident #19 had an un-witnessed fall resulting in a [MEDICAL CONDITION], revealed "...Charge Nurse did not follow policy with notification to manager on duty, DON or Administrator Regarding the Res. fall. Even after (local x-ray company) called the results to the Charge Nurse no attempt was made to get the Res. to the hospital... Corrective Action: To be completed by Supervisor... Employee will set up time with SDC by 9-28-10 for education...." 2) Initial tour on 09/21/10 at 10:20 p.m. with ADON F revealed Resident #12 required transfers with a mechanical lift, did not walk, was incontinent of bowel and bladder, was alert and oriented to person, place and time; and had a fall approximately a month ago which resulted in a left tibia (lower leg) fracture. When ADON F was asked if Resident #12 had behaviors, she said, "She cries, looks for sympathy and has a pity thing." Resident #12 was observed with a fracture boot on her left lower leg. Resident #12's facility face sheet dated 09/24/10 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #12's admission MDS assessment dated [DATE] revealed the resident was independent for cognitive skills for daily decision-making and required extensive assistance from two plus staff members for bed mobility, transfers, toilet use, and personal hygiene. Resident #12's mode of locomotion was by wheelchair pushed by another person. Resident #12's ADL self-performance had deteriorated, and the resident was receiving Physical and Occupational Therapies. Review of Resident #12's COMPREHENSIVE PLAN of CARE for ADL Functions dated 06/16/10 revealed, "Transfers: ext (extensive) X 2 Assist: Hoyer (mechanical lift)...." Interview on 09/21/10 at 12:25 p.m. with Resident #12 revealed she was a retired Registered Nurse. When Resident #12 was asked by the surveyor how she fractured her left lower leg, she said on the day of the incident, she told CNA E she needed to use the bed side commode. Resident #12 revealed she asked CNA E to get some help before transferring her from her chair to the bedside commode, but CNA E ignored her request. CNA E placed the gait belt around Resident #12's waist, and instead of holding onto the gait belt at the resident's sides, she grasped the gait belt with both hands in front of the resident. Resident #12 revealed since she was an RN, she knew CNA E was supposed to place her hands on the gait belt on each side of her waist. Resident #12 revealed CNA E assisted her into a standing position, and when the resident became unsteady, CNA E panicked and jerked her in an upward motion, but then dropped her onto the floor. She stated she landed in a sitting position with her left leg folded under her. Resident #12 stated she was able to remove her left leg from underneath her. Resident #12 added she was screaming, and CNA E and "someone else" came into the room and tried to "shush me." Resident #12 stated she told them CNA E dropped her. Resident #12 stated she did not think CNA E intentionally dropped her. Resident #12 said she no longer wanted any staff members except PT G to transfer her. Review of a written statement from PT G attached to the Incident/Accident Report dated 08/23/10 revealed, "PT called to pt's room to assist with floor transfer per pt request. Upon entering, PT saw pt in long-sitting on floor in front of bedside commode. Pt states 'they dropped me.' Pt in distress with yelling and moaning...." Review of ADON F's written statement attached to the Incident/Accident Report dated 08/23/10 revealed, "When I entered (Resident #12's) room to see how she was and what happened, she said the girl had the gait belt around me and she was very strong and lifted her off her feet and when she came down her legs were like wet noodles and the girl sat her on the floor. She said she was in a sitting position and moved her leg from under her. She started saying, 'Make sure you tell them exactly what happened'...." Review of Resident #12's PHYSICIAN's TELEPHONE ORDERS dated 08/23/10 at 11:35 a.m. revealed an order for [REDACTED]. Review of Resident #12's x-ray result dated 08/23/10 at 1:49 p.m. revealed, "...LEFT KNEE: There is a fracture involving left proximal fibula with no displacement. The joint shows no dislocation. There is no joint effusion. [MEDICAL CONDITION] is present. IMPRESSION: Acute left proximal fibula fracture as described above. LEFT TIBIA/FIBULA: There is a fracture involving the proximal fibula with no displacement. The knee and ankle joints are intact in alignment. [MEDICAL CONDITION] is present. IMPRESSION: Acute left lower leg fracture as described ...." Interview with LVN M on 09/22/10 at 1:30 p.m. revealed on the morning of 08/23/10 she heard Resident #12 screaming. LVN M entered Resident #12's room and found her on the floor in a sitting position with her legs out in front of her. Resident #12 told LVN M her leg had been under her. Resident #12 stated CNA E dropped her. Resident #12 complained that her left leg hurt. The resident would not allow anyone to transfer her to her bed except for PT G. PT G and another staff member used a mechanical lift to transfer the resident to her bed. (LVN M did not identify the other staff member.) LVN M called and reported the incident to the resident's physician and obtained an order for [REDACTED]. Each nurse's station had a fax machine where an x-ray report could be faxed. Interview with PT G on 09/22/10 at 2:10 p.m. revealed he entered Resident #12's room on 08/23/10 to assist the resident with a transfer. Resident #12 was sitting on the floor with her legs in front of her. He stated the resident was tearful and complained that her legs hurt her. Resident #12 told PT G when she fell , her leg folded under her. Resident #12 said, "They dropped me. They dropped me." PT G stated the resident told CNA E it was not her fault. PT G and another staff member, who was no longer at the facility, assisted in transferring Resident #12 into her bed with a mechanical lift. PT G revealed Resident #12 was fearful. He stated, "Now she won't let anyone transfer her but me." PT G revealed the resident was walking with him approximately 100 feet with stand by assistance before the fall. PT G was asked how many staff members were required to assist Resident #12 with gait belt transfers prior to the fall. He replied, "Probably one CNA, but if having a bad day, she would need two staff to assist." Interview with CNA E on 09/22/10 at 2:45 p.m. revealed she worked on a PRN (as needed) basis. On 08/23/10 Resident #12 requested help in transferring from her chair to the bed side commode. CNA E revealed she placed the gait belt around Resident #12's waist, held onto both sides of the gait belt, counted to three and Resident #12 pushed up from her chair. Resident #12 "held onto her walker" but began to fall. CNA E said at that time she "eased" the resident down into a "squatting position." CNA E stated the resident began to "yell at that time." Interview on 09/22/10 at 4:50 p.m. with the DON revealed she and ADON F talked with Resident #12 after the incident, because PT G had told them Resident #12 said she was dropped. The DON stated, "She (Resident #12) didn't mention she was dropped." Referring to the conversation with Resident #12, the DON stated, "I didn't write it down." Review of Resident #12's NURSING DAILY SKILLED SUMMARY forms revealed Resident #12 required "limited assistance" with transfers on 06/20/10, 07/11/10, and 08/13/10, 08/14/10 and 08/20/10. Resident #12 required extensive assistance with transfers on 06/21/10, 06/30/10, 07/01/10, 07/12/10, 07/26/10, 07/28/10, 08/08/10, 08/21/10, 08/22/10, and 08/23/10. Interview with LVN M on 09/23/10 at 12:30 p.m. revealed Resident #12 "fluctuates" from day-to-day on the amount of assistance required for transfers. On some days, Resident #12 required "limited assistance" with a one-person, gait belt transfer, and other days she required "extensive assistance" with two-person transfers. LVN M stated, "She (Resident #12) doesn't stay the same; she's weaker some days more than others." Interview with the Administrator and the DON on 09/23/10 at 2:00 p.m. revealed, based on Resident #12's latest Care Plan and Cardex, Resident #12 required one person assistance with gait belt transfers prior to her fall. When queried about Resident #12's MDS assessment reflecting the resident required extensive assistance with two staff members for transfers, the DON replied, "Well, that's how you have to code an MDS. If the resident falls one time you have to code it that way." The Administrator and the DON were informed PT G and LVN M stated prior to the Resident #12's fall, some days the resident required limited assistance with one person gait belt transfers, and other days she required extensive assistance with two person gait belt transfers. The Administrator and the DON were asked how the staff knew if Resident #12 was having a good or a bad day? The Administer and DON did not answer. 3) Review of the facility's current Abuse & Neglect Prohibition policy dated February 2010 revealed, "...Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect...The facility will report all allegations and substantiated occurrences of abuse, neglect, injuries of unknown origin, and misappropriation of property to the state agency and law enforcement officials as designated by state law...." Review of Perry and Potter's Clinical Nursing Skills & Techniques, Fifth Edition, Copyright 2004, chapter 27, Body Mechanics, Transfer, and Positioning, pages 808 and 810 revealed, "...Expected outcome following completion of procedure:... Client transfers without injury... Rationale... Proper techniques avoid injury... Transfer belt is grasped at client's side to provide movement of client at center of gravity...." Review of the facility's current Gait Belt Use policy dated February 2010 revealed, "...If, during the course of care, it becomes necessary to provide lift/transfer assistance in a manner other than that specified in the resident's plan of care, the caregiver will contact his/her supervisor prior to the lift/transfer...." Review of the facility's current Changes in Resident Condition policy dated June 2008 revealed, "The resident, attending physician and legal representative or designated member are notified when changes in condition or certain events occur...For life-threatening events: Call 911 if initial assessment indicates that such action is necessary...." "...Broken Bone. If more pressure is put on a bone than it can stand, it will split or break. A break of any size is called a fracture. If the broken bone punctures the skin, it is called an open fracture (compound fracture). A stress fracture is a hairline crack in the bone that develops because of repeated or prolonged forces against the bone. Considerations: It is hard to tell a dislocated bone from a broken bone. However, both are emergency situations, and the basic first aid steps are the same ... Symptoms: A visibly out-of-place or misshapen limb or joint, swelling, bruising, or bleeding, intense pain, numbness and tingling, broken skin with bone protruding, limited mobility or inability to move a limb... Keep the person still and calm, examine the person closely for other injuries, In most cases, if medical help responds quickly, allow the medical personnel to take further action, If the skin is broken, it should be treated immediately to prevent infection... If needed, immobilize the broken bone with a splint or sling... Immobilize the area both above and below the injured bone, Apply ice packs to reduce pain and swelling, Take steps to prevent shock Lay the person flat, elevate the feet about 12 inches above the head, and cover the person with a coat or blanket. However, DO NOT move the person if a head, neck, or back injury is suspected, CHECK BLOOD CIRCULATION Check the person's blood circulation. Press firmly over the skin beyond the fracture site. (For example, if the fracture is in the leg, press on the foot). It should first blanch white and then "pink up" in about two seconds. Other signs that circulation is inadequate include pale or blue skin, numbness or tingling, and loss of pulse. If circulation is poor and trained personnel are NOT quickly available, try to realign the limb into a normal resting position. This will reduce swelling, pain, and damage to the tissues from lack of blood ... DO NOT move the person unless the broken bone is stable, DO NOT move a person with an injured hip, pelvis, or upper leg unless it is absolutely necessary. If you must move the person, pull the person to safety by his clothes (such as by the shoulders of a shirt, a belt, or pant-legs). DO NOT move a person who has a possible spine injury, DO NOT attempt to straighten a bone or change its position unless blood circulation appears hampered, DO NOT try to reposition a suspected spine injury. DO NOT test a bone's ability to move ...Call 911 if: There is a suspected broken bone in the head, neck, or back, There is a suspected broken bone in the hip, pelvis, or upper leg, You cannot completely immobilize the injury at the scene by yourself, There is severe bleeding, An area below the injured joint is pale, cold, clammy, or blue, There is a bone projecting through the skin...." (Retrieved at <http://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm>. on 09/28/10) "[MEDICAL CONDITION] is a condition in which a blood clot blood clotforms in a vein that is deep inside the body. [MEDICAL CONDITIONS] mainly affects the large veins in the lower leg and thigh. The clot can block blood flow and cause swelling and pain. When a clot breaks off and moves through the bloodstream, this is called an embolism. An embolism can get stuck in the brain, lungs, heart, or other area, leading to severe damage. Blood clots may form when something slows or changes the flow of blood in the veins. Risk factors include:...Fractures Fractures in the pelvis or legs ... Recent surgery (especially hip, knee, or female reproductive organ surgery)[MEDICAL CONDITION] are most common in adults over age 60, but can occur at any age ... Treatment Your doctor will give you medicine to thin your blood (called an anticoagulant). This will keep more clots from forming or old ones from getting bigger. These drugs cannot dissolve existing clots...Possible Complications A blood clot can break free in the leg and travel to the lungs (pulmonary [MEDICATION NAME]) or anywhere else in the body, and can be life threatening. Rapid treatment of [REDACTED]." (Retrieved at <http://www.nlm.nih.gov/medlineplus/ency/article/ 6.htm> on 09/28/10) 4) The facility provided CMS form 672 dated 09/21/10 and signed by the DON which reflected 83 residents that required assistance from one to two staff members for transfers; and 13 residents were dependent on staff for transfers. The DON also provided a list of eight residents, who received in-house fractures from March 2010 to 09/24/10 on 09/24/10.

Based on interview and record review, it was determined the facility failed to ensure violations of neglect for two (Residents #12 and #19) of 21 residents reviewed for neglect, were immediately reported to the Department of Aging and Disability Services. Based on interview and record review, it was determined the facility failed to implement the facility's policies and procedures to prohibit neglect for two (Resident #12 and #19) of twenty-one residents reviewed for neglect. 1) Resident #19 had an unwitnessed fall, which resulted in pain and the inability to bear weight on her right leg on 09/12/10 at approximately 4:30 p.m. LVN A called the physician's nurse practitioner and got an order for [REDACTED]. The Department of Aging and Disability Services was not notified of the incident. 2) Resident #12 was assessed as requiring a two-person assist with transfers. CNA E attempted to assist the resident alone, even after the resident requested more assistance, and dropped the resident on the floor. The resident suffered a fracture to her left, lower leg as a result of the fall. The Department of Aging and Disability Services was not notified of the incident. These failures could affect the facility's 96 residents, who required assistance from staff with transfers, including Residents #12 and #19, and placed them at risk for falls, fractures, abrasions, bruises, pain and mental anguish. Findings included: 1) Initial tour on 09/21/10 at 10:15 a.m. with ADON F revealed Resident #19 was admitted to the hospital "about three weeks ago" for a fracture of her "femur." Resident #19 was found beside her bed with bed sheets tangled around her legs at the time of the fracture. ADON F revealed Resident #19 did not walk, was transferred using a gait belt with assistance of one staff member, was non-interviewable, required total assistance with ADLs, was incontinent of bowel and bladder, and required assistance in eating her pureed food. Resident #19's current MDS assessment (Significant Change in Status) dated 08/17/10 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #19 was severely impaired for cognitive skills for daily decision making. Resident #19 required extensive assistance from two plus staff members with transfers, locomotion on the unit, dressing, toilet use, and personal hygiene. Resident #19's primary mode of locomotion was by a wheelchair, pushed by a staff member. The MDS reflected Resident #19 had experienced a fall in the past 30 days, but did not have a [MEDICAL CONDITION] in the past 180 days. Review of Resident #19's History and Physical dated 08/03/10 and completed by the NP when she was readmitted from a hospitalization revealed, "Pt has multiple complex medical conditions including status [REDACTED]." Review of Resident #19's RESIDENT TRANSFER EVALUATION dated 09/03/10 revealed the resident had a total score of nine, which placed her in "Category 3: (score 9-14) Caregiver performs 50% of the task or greater. Equipment: Mechanical Lift (Total Body/Sling or Stand Assist as appropriate)...." Review of Resident #19's Comprehensive care plan dated 09/03/10 revealed the facility identified the resident's risk for falls and revealed, "...Res. continues to be at risk for falls but has become more alert and is able to stand with assist X 2 to transfer...." Review of Resident #19's INCIDENT/ACCIDENT REPORT dated 09/12/10 at 5:30 p.m. revealed the resident was "found sitting on the floor by her bed with bed sheet wrapped around her legs - unattended. Assisted back into her bed - able to bear wt on L (left) leg, but not on R (right) leg - R leg pulled up as if contractured (sic) - c/o pain to R femur area. Able to MAE (move all extremities) ... C/o (complaint of) pain to R femur area...." Review of LVN A's written statement dated 09/12/10 and attached to the Incident/Accident Report revealed, "Was called to pt's (Resident #19's) room to find her sitting on the floor by her bed with bed sheet wrapped around her legs. Assisted per 2 (people) back to bed. Unable to bear wt on her R leg - looks pulled up as if contractured (sic) - c/o pain to R femur area when asked 3 different times. Xrays (sic) of R hip & R femur ordered." Interview on 09/22/10 at 1:00 p.m. with LVN A revealed she worked on the 6:00 a.m. to 6:00 p.m. shift on 09/12/10. MA D called her to Resident #19's room on 09/12/10. She observed Resident #19 on the floor with the bed sheets wrapped around her legs. Resident #19 could not bear weight on her right leg, but could on her left leg. Resident #19 pointed at her right leg when asked if she was in pain, and said, "Yes." Resident #19 then contradicted herself and said, "No." LVN A said Resident #19 had Dementia. LVN A then stated, "I didn't know what she was feeling." LVN A stated Resident #19's right leg was "bent at the knee," but after the resident was transferred to her bed it "looked normal." LVN A thought the incident occurred around 5:30 p.m., but she said MA D thought it was earlier. LVN A revealed she didn't look at the clock. LVN A revealed she called for an x-ray on Resident #19's right lower extremity. When LVN A was queried as to the decision to not send the resident to the emergency room , and she stated she needed to do "finger sticks and insulins," because it was almost dinner time for the residents. Resident #19 "settled down" after she was transferred to her bed. When LVN A was asked what type of emergency would prompt her to send a resident to the emergency room , she stated, "Respiratory arrest, [MEDICAL CONDITION] and an open fracture. With a closed fracture you don't know if it's broken so I wouldn't send them out until after an x-ray confirmed it." When LVN A was asked what kind of complications could result from a [MEDICAL CONDITION], she stated, "fat embolism, nerve damage, vascular compromise and impaired circulation." When asked how a resident's leg might look if their hip was fractured, she stated, "It could have external rotation, maybe shorter, can't bear weight and complain of pain." LVN A stated she reported the incident to RN C at the end of shift report (at approximately 6:00 p.m.). Review of Resident #19's Physician's Telephone Orders dated 09/12/10 at 4:35 p.m. revealed, "X-ray R leg R/O (rule out) fx (fracture)." Review of Resident #19's NURSING DAILY SKILLED SUMMARY dated 09/12/10 at 5:30 p.m. revealed, "Resident found sitting on the floor by her bed, bed sheet wrapped around her legs. Assisted back to bed unable to bear wt on R leg - R leg is contractured (sic). Neuro is WNL (within normal limits). Able to bear wt (weight) on L leg and moves extremities... 6:15 p (p.m.) X-ray ordered for R hip and R femur..." NP H was notified and ordered [MEDICATION NAME] (pain medication)... 8:30 p X-ray done with nurse assisting technician to position pt. Nurse explained to x-ray tech that resident has contracture to R leg. Pt did not show any signs of pain... 10:15 p x-ray returned for more pictures, stated that she did not get enough for viewing. Nurse assisted x-ray technician to position pt. for x-ray. Pt asleep throughout positioning. Neuro checks WNL..." The notes reflected the nurse instructed the RCS (Resident Care Specialist - CNA) to be "careful during pericare and call for assistance with turning pt. 3:30 am (a.m.) x-ray results called into nurse...." RN C faxed the x-ray results to NP H. Review of Resident #19's Physician's Telephone Order dated 09/12/10 at 6:30 p.m. revealed an order for [REDACTED]. Review of Resident #19's x-ray report with a date of service 09/12/10 and faxed to the facility on [DATE] at 12:18 a.m. revealed, "...RIGHT HIP UNILATERAL: There is a right intertrochanteric fracture with modest displacement. Mild callous formation is seen. The joint shows no dislocation. Pubic rami are intact. [MEDICAL CONDITION] is present ... RIGHT FEMUR: The femur shows [MEDICAL CONDITION]. There is a right intertrochanteric fracture with modest displacement. Mild callous formation is seen. The joint shows no dislocation. Pubic rami are intact. The remainder of the femur is intact...." Interview on 09/22/10 at 1:15 p.m. with RN C stated she worked the 6:00 p.m. (09/12/10) to 6:00 a.m. (09/13/10) shift. RN C said Resident #19 did not appear to be in pain when she assessed her. RN C revealed she received a verbal report from the local x-ray company at approximately 3:30 a.m., and at that time she learned the x-ray report had been faxed to the facility earlier that morning. RN C stated she did not call NP H with the x-ray report; instead she faxed the x-ray report to NP H. RN C said she should have called NP H stating, "I don't know why I didn't." RN C revealed when she gave report at approximately 6:00 a.m. 09/13/10 to LVN B, LVN B made the decision to send Resident #19 to the emergency room . Interview on 09/24/10 at 10:00 a.m. with RN C revealed she did not send Resident #19 to the emergency room after receiving the x-ray report reflecting a fracture because she was waiting on NP H to call back with orders. When RN C was asked what complications could occur as a result of a [MEDICAL CONDITION], she replied, "Bleeding, blood clots and long term disability." RN C stated the x-ray report didn't sound "that urgent." RN C stated she was very busy that night and had sent another resident to the emergency room . RN C stated, "I took on too much. It will never happen again." Interview with X-Ray CSR from the local x-ray company on 09/24/10 at 9:40 a.m. revealed the call for an x-ray for Resident #19 came in on 09/12/10 at 4:48 p.m. and was listed as a "normal case." The x-ray technician was dispatched "five minutes later." X-ray reports were on auto-fax, and were faxed to a facility immediately after receiving the report. A verbal report was given by phone afterwards to confirm receipt of the faxed report. Resident #19's verbal report was given at 2:00 a.m. on 09/13/10 to RN C. The local x-ray company had used the auto-fax for the "last three months." Interview with LVN B on 09/23/10 at 12:25 p.m. revealed she worked the 6:00 a.m. to 6:00 p.m. shift on 09/13/10. When she received report from RN C regarding Resident #19, and learned the resident had a [MEDICAL CONDITION], she decided to send her to the emergency room . Resident #19 was sent to a local emergency room at approximately 7:00 a.m. LVN B stated she looked at the x-ray report, and thought, "Why is she still here?" Interview with ADON F on 09/23/10 at 2:40 p.m. revealed she learned Resident #19 had a right [MEDICAL CONDITION] from LVN B on the morning of 09/13/10. ADON F stated she did not know why Resident #19 was not sent to the emergency room immediately. ADON F stated, "I would have sent her out when the resident couldn't bear weight. I still don't understand why she wasn't sent out. I would have sent her out without a physician's orders [REDACTED]." Interview with a local Hospital Social Worker on 09/22/10 at 2:15 p.m. revealed Resident #19 was checked into the emergency roiagnom on [DATE] at 8:30 a.m. Resident #19 had right hip surgery with an open reduction with internal fixation on 09/17/10. Interview with the DON on 09/22/10 at 4:50 p.m. regarding Resident #19's fall revealed, "The nurse should call the physician and see what he wants to do." The DON was queried about possible complications of a [MEDICAL CONDITION]. She stated, "Pain, deformities, they could throw a clot and eventually die if it goes to the lung or organs." The DON revealed LVN A "did an assessment and did order x-rays." The DON stated, "I don't want to say the nurse did anything wrong." When asked how she could ensure delay in treatment and notification of changes would not be repeated with another resident, the DON stated, "When things happen, I talk to them (staff) about what we need to do. As their leader I give recommendations. I didn't document the conversations." The DON said RN C "should have called the doctor when she got the x-ray report. You can't depend on a fax especially at three in the morning. You have to call the doctor." Untitled and undated notes signed by the DON regarding Resident #19's fractured right hip were provided to the surveyors to review. The notes reflected, "...After staff interviews it was determined that the fall was not caused by staff or negligence. It was identified that staff in-service needed to be given for a clear picture on what items needed to be called to nurse management and/or Administrator. Also, that the staff members involved needed additional training on incidents ie when to notify physician, supervisor, process for x-ray results, etc. This in-service was completed on Wednesday, September 15 (2010)." Interview on 09/22/10 at 1:30 p.m. with LVN M revealed when the surveyor asked LVN M if a [MEDICAL CONDITION] was an emergency she replied, "Of course." LVN M stated , with a [MEDICAL CONDITION], there could be internal bleeding and the resident could go into shock. LVN M revealed a resident with a [MEDICAL CONDITION] would complain of pain, may have rotation of the leg, and the leg could appear shorter. If a [MEDICAL CONDITION] was suspected, LVN M would send the resident to the emergency room even if there was not an x-ray. Review of Resident #19's INCIDENT/ACCIDENT INVESTIGATION FOLLOW-UP from 09/12/10 revealed: "...PAST INTERVENTIONS ATTEMPTED... falling star program, bed chair alarm, low bed position. RECOMMENDATIONS/NEW INTERVENTIONS Will re-evaluate resident when she returns from hosp...." An undated note included reflected, "...After interviewing the staff there were no signs of neglect. The resident was properly positioned in bed and the bed in proper position. The resident had hardly any muscle mass and has dx of [MEDICAL CONDITION], which exposed her to higher risk for injury." Review of an Attendance Form for "Fall Intervention" dated 09/15/10 listed a total of two employees, LVN A and MA D, in attendance. The form reflected, "Inservice Regarding falls. Assessment of Res (resident) that has fallen is first. If Resident is not standing as she usually does or it is noticed that she is not bearing weight on one foot, verbalizing pain or facial grimacing after/before phy. (physician) notified this Resident can and should be sent to the hospital. This is a Nursing Assessment." On 09/28/10 the facility provided DISCIPLINARY ACTION RECORDs on LVN A and RN C to the surveyor by fax, regarding Resident #19. Review of LVN A's DISCIPLINARY ACTION RECORD dated 09/26/10, 14 days after Resident #19 had an un-witnessed fall, revealed, "...On 9/12/10 Charge Nurse during her 6A-6P shift had a Resident fall out of bed. (Resident #19) was assessed by charge nurse and according to I/A report when Res. was assisted to a standing position she said 'ouch' and would not bear wt on one leg. Charge nurse did not follow policy by using Resources available to her when she was not able to reach the Nurse Practitioner. Charge Nurse wrote order for x-ray but did not specify STAT. Also did not notify Nurse Manager on Duty, DON or Administrator. Employee Statement: To be completed by employee. In the past, I was informed not to call 'on call' personnel. Didn't think to notify mgr (manager) on duty, DON, or administrator @ this time; just 'sailing my ship.' The nurse practitioner had told us to 'use your head, use your common sense, you're a nurse with a license' When calling her in the past; I was just using my head & common sense. Corrective Action: To be completed by Supervisor. Be specific, include goals and timetable for follow-up. Charge Nurse will set up time for education with SDC no later than Tue 9/28/10...." Review of RN C's DISCIPLINARY ACTION RECORD dated 9/26/10, 14 days after Resident #19 had an un-witnessed fall resulting in a [MEDICAL CONDITION], revealed "...Charge Nurse did not follow policy with notification to manager on duty, DON or Administrator Regarding the Res. fall. Even after (local x-ray company) called the results to the Charge Nurse no attempt was made to get the Res. to the hospital... Corrective Action: To be completed by Supervisor... Employee will set up time with SDC by 9-28-10 for education...." 2) Initial tour on 09/21/10 at 10:20 p.m. with ADON F revealed Resident #12 required transfers with a mechanical lift, did not walk, was incontinent of bowel and bladder, was alert and oriented to person, place and time; and had a fall approximately a month ago which resulted in a left tibia (lower leg) fracture. When ADON F was asked if Resident #12 had behaviors, she said, "She cries, looks for sympathy and has a pity thing." Resident #12 was observed with a fracture boot on her left lower leg. Resident #12's facility face sheet dated 09/24/10 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #12's admission MDS assessment dated [DATE] revealed the resident was independent for cognitive skills for daily decision-making and required extensive assistance from two plus staff members for bed mobility, transfers, toilet use, and personal hygiene. Resident #12's mode of locomotion was by wheelchair pushed by another person. Resident #12's ADL self-performance had deteriorated, and the resident was receiving Physical and Occupational Therapies. Review of Resident #12's COMPREHENSIVE PLAN of CARE for ADL Functions dated 06/16/10 revealed, "Transfers: ext (extensive) X 2 Assist: Hoyer (mechanical lift)...." Interview on 09/21/10 at 12:25 p.m. with Resident #12 revealed she was a retired Registered Nurse. When Resident #12 was asked by the surveyor how she fractured her left lower leg, she said on the day of the incident, she told CNA E she needed to use the bed side commode. Resident #12 revealed she asked CNA E to get some help before transferring her from her chair to the bedside commode, but CNA E ignored her request. CNA E placed the gait belt around Resident #12's waist, and instead of holding onto the gait belt at the resident's sides, she grasped the gait belt with both hands in front of the resident. Resident #12 revealed since she was an RN, she knew CNA E was supposed to place her hands on the gait belt on each side of her waist. Resident #12 revealed CNA E assisted her into a standing position, and when the resident became unsteady, CNA E panicked and jerked her in an upward motion, but then dropped her onto the floor. She stated she landed in a sitting position with her left leg folded under her. Resident #12 stated she was able to remove her left leg from underneath her. Resident #12 added she was screaming, and CNA E and "someone else" came into the room and tried to "shush me." Resident #12 stated she told them CNA E dropped her. Resident #12 stated she did not think CNA E intentionally dropped her. Resident #12 said she no longer wanted any staff members except PT G to transfer her. Review of a written statement from PT G attached to the Incident/Accident Report dated 08/23/10 revealed, "PT called to pt's room to assist with floor transfer per pt request. Upon entering, PT saw pt in long-sitting on floor in front of bedside commode. Pt states 'they dropped me.' Pt in distress with yelling and moaning...." Review of ADON F's written statement attached to the Incident/Accident Report dated 08/23/10 revealed, "When I entered (Resident #12's) room to see how she was and what happened, she said the girl had the gait belt around me and she was very strong and lifted her off her feet and when she came down her legs were like wet noodles and the girl sat her on the floor. She said she was in a sitting position and moved her leg from under her. She started saying, 'Make sure you tell them exactly what happened'...." Review of Resident #12's PHYSICIAN's TELEPHONE ORDERS dated 08/23/10 at 11:35 a.m. revealed an order for [REDACTED]. Review of Resident #12's x-ray result dated 08/23/10 at 1:49 p.m. revealed, "...LEFT KNEE: There is a fracture involving left proximal fibula with no displacement. The joint shows no dislocation. There is no joint effusion. [MEDICAL CONDITION] is present. IMPRESSION: Acute left proximal fibula fracture as described above. LEFT TIBIA/FIBULA: There is a fracture involving the proximal fibula with no displacement. The knee and ankle joints are intact in alignment. [MEDICAL CONDITION] is present. IMPRESSION: Acute left lower leg fracture as described ...." Interview with LVN M on 09/22/10 at 1:30 p.m. revealed on the morning of 08/23/10 she heard Resident #12 screaming. LVN M entered Resident #12's room and found her on the floor in a sitting position with her legs out in front of her. Resident #12 told LVN M her leg had been under her. Resident #12 stated CNA E dropped her. Resident #12 complained that her left leg hurt. The resident would not allow anyone to transfer her to her bed except for PT G. PT G and another staff member used a mechanical lift to transfer the resident to her bed. (LVN M did not identify the other staff member.) LVN M called and reported the incident to the resident's physician and obtained an order for [REDACTED]. Each nurse's station had a fax machine where an x-ray report could be faxed. Interview with PT G on 09/22/10 at 2:10 p.m. revealed he entered Resident #12's room on 08/23/10 to assist the resident with a transfer. Resident #12 was sitting on the floor with her legs in front of her. He stated the resident was tearful and complained that her legs hurt her. Resident #12 told PT G when she fell , her leg folded under her. Resident #12 said, "They dropped me. They dropped me." PT G stated the resident told CNA E it was not her fault. PT G and another staff member, who was no longer at the facility, assisted in transferring Resident #12 into her bed with a mechanical lift. PT G revealed Resident #12 was fearful. He stated, "Now she won't let anyone transfer her but me." PT G revealed the resident was walking with him approximately 100 feet with stand by assistance before the fall. PT G was asked how many staff members were required to assist Resident #12 with gait belt transfers prior to the fall. He replied, "Probably one CNA, but if having a bad day, she would need two staff to assist." Interview with CNA E on 09/22/10 at 2:45 p.m. revealed she worked on a PRN (as needed) basis. On 08/23/10 Resident #12 requested help in transferring from her chair to the bed side commode. CNA E revealed she placed the gait belt around Resident #12's waist, held onto both sides of the gait belt, counted to three and Resident #12 pushed up from her chair. Resident #12 "held onto her walker" but began to fall. CNA E said at that time she "eased" the resident down into a "squatting position." CNA E stated the resident began to "yell at that time." Interview on 09/22/10 at 4:50 p.m. with the DON revealed she and ADON F talked with Resident #12 after the incident, because PT G had told them Resident #12 said she was dropped. The DON stated, "She (Resident #12) didn't mention she was dropped." Referring to the conversation with Resident #12, the DON stated, "I didn't write it down." Review of Resident #12's NURSING DAILY SKILLED SUMMARY forms revealed Resident #12 required "limited assistance" with transfers on 06/20/10, 07/11/10, and 08/13/10, 08/14/10 and 08/20/10. Resident #12 required extensive assistance with transfers on 06/21/10, 06/30/10, 07/01/10, 07/12/10, 07/26/10, 07/28/10, 08/08/10, 08/21/10, 08/22/10, and 08/23/10. Interview with LVN M on 09/23/10 at 12:30 p.m. revealed Resident #12 "fluctuates" from day-to-day on the amount of assistance required for transfers. On some days, Resident #12 required "limited assistance" with a one-person, gait belt transfer, and other days she required "extensive assistance" with two-person transfers. LVN M stated, "She (Resident #12) doesn't stay the same; she's weaker some days more than others." Interview with the Administrator and the DON on 09/23/10 at 2:00 p.m. revealed, based on Resident #12's latest Care Plan and Cardex, Resident #12 required one person assistance with gait belt transfers prior to her fall. When queried about Resident #12's MDS assessment reflecting the resident required extensive assistance with two staff members for transfers, the DON replied, "Well, that's how you have to code an MDS. If the resident falls one time you have to code it that way." The Administrator and the DON were informed PT G and LVN M stated prior to the Resident #12's fall, some days the resident required limited assistance with one person gait belt transfers, and other days she required extensive assistance with two person gait belt transfers. The Administrator and the DON were asked how the staff knew if Resident #12 was having a good or a bad day? The Administer and DON did not answer. 3) Review of Perry and Potter's Clinical Nursing Skills & Techniques, Fifth Edition, Copyright 2004, chapter 27, Body Mechanics, Transfer, and Positioning, pages 808 and 810 revealed, "...Expected outcome following completion of procedure:... Client transfers without injury... Rationale... Proper techniques avoid injury... Transfer belt is grasped at client's side to provide movement of client at center of gravity...." "...Broken Bone. If more pressure is put on a bone than it can stand, it will split or break. A break of any size is called a fracture. If the broken bone punctures the skin, it is called an open fracture (compound fracture). A stress fracture is a hairline crack in the bone that develops because of repeated or prolonged forces against the bone. Considerations: It is hard to tell a dislocated bone from a broken bone. However, both are emergency situations, and the basic first aid steps are the same ... Symptoms: A visibly out-of-place or misshapen limb or joint, swelling, bruising, or bleeding, intense pain, numbness and tingling, broken skin with bone protruding, limited mobility or inability to move a limb... Keep the person still and calm, examine the person closely for other injuries, In most cases, if medical help responds quickly, allow the medical personnel to take further action, If the skin is broken, it should be treated immediately to prevent infection... If needed, immobilize the broken bone with a splint or sling... Immobilize the area both above and below the injured bone, Apply ice packs to reduce pain and swelling, Take steps to prevent shock Lay the person flat, elevate the feet about 12 inches above the head, and cover the person with a coat or blanket. However, DO NOT move the person if a head, neck, or back injury is suspected, CHECK BLOOD CIRCULATION Check the person's blood circulation. Press firmly over the skin beyond the fracture site. (For example, if the fracture is in the leg, press on the foot). It should first blanch white and then "pink up" in about two seconds. Other signs that circulation is inadequate include pale or blue skin, numbness or tingling, and loss of pulse. If circulation is poor and trained personnel are NOT quickly available, try to realign the limb into a normal resting position. This will reduce swelling, pain, and damage to the tissues from lack of blood ... DO NOT move the person unless the broken bone is stable, DO NOT move a person with an injured hip, pelvis, or upper leg unless it is absolutely necessary. If you must move the person, pull the person to safety by his clothes (such as by the shoulders of a shirt, a belt, or pant-legs). DO NOT move a person who has a possible spine injury, DO NOT attempt to straighten a bone or change its position unless blood circulation appears hampered, DO NOT try to reposition a suspected spine injury. DO NOT test a bone's ability to move ...Call 911 if: There is a suspected broken bone in the head, neck, or back, There is a suspected broken bone in the hip, pelvis, or upper leg, You cannot completely immobilize the injury at the scene by yourself, There is severe bleeding, An area below the injured joint is pale, cold, clammy, or blue, There is a bone projecting through the skin...." (Retrieved at <http://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm>. on 09/28/10) "[MEDICAL CONDITION] is a condition in which a blood clot blood clotforms in a vein that is deep inside the body. [MEDICAL CONDITIONS] mainly affects the large veins in the lower leg and thigh. The clot can block blood flow and cause swelling and pain. When a clot breaks off and moves through the bloodstream, this is called an embolism. An embolism can get stuck in the brain, lungs, heart, or other area, leading to severe damage. Blood clots may form when something slows or changes the flow of blood in the veins. Risk factors include:...Fractures Fractures in the pelvis or legs ... Recent surgery (especially hip, knee, or female reproductive organ surgery)[MEDICAL CONDITION] are most common in adults over age 60, but can occur at any age ... Treatment Your doctor will give you medicine to thin your blood (called an anticoagulant). This will keep more clots from forming or old ones from getting bigger. These drugs cannot dissolve existing clots...Possible Complications A blood clot can break free in the leg and travel to the lungs (pulmonary [MEDICATION NAME]) or anywhere else in the body, and can be life threatening. Rapid treatment of [REDACTED]." (Retrieved at <http://www.nlm.nih.gov/medlineplus/ency/article/ 6.htm> on 09/28/10) Review of the facility's current Gait Belt Use policy dated February 2010 revealed, "...If, during the course of care, it becomes necessary to provide lift/transfer assistance in a manner other than that specified in the resident's plan of care, the caregiver will contact his/her supervisor prior to the lift/transfer...." Review of the facility's current Changes in Resident Condition policy dated June 2008 revealed, "The resident, attending physician and legal representative or designated member are notified when changes in condition or certain events occur...For life-threatening events: Call 911 if initial assessment indicates that such action is necessary...." Review of the facility's current Abuse & Neglect Prohibition policy dated February 2010 revealed, "...Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect...The facility will report all allegations and substantiated occurrences of abuse, neglect, injuries of unknown origin, and misappropriation of property to the state agency and law enforcement officials as designated by state law...." 4) The facility provided CMS form 672 dated 09/21/10 and signed by the DON which reflected 83 residents that required assistance from one to two staff members for transfers; and 13 residents were dependent on staff for transfers. The DON also provided a list of eight residents, who received in-house fractures from March 2010 to 09/24/10 on 09/24/10.

Based on interview and record review, it was determined the facility failed to implement the facility's written policies and procedures to prohibit neglect for two (Resident #12 and #19) of twenty-one residents reviewed for neglect. 1) Resident #19 had an unwitnessed fall, which resulted in pain and the inability to bear weight on her right leg on 09/12/10 at approximately 4:30 p.m. LVN A called the physician's nurse practitioner and got an order for [REDACTED]. The Department of Aging and Disability Services was not notified of the incident. 2) Resident #12 was assessed as requiring a two-person assist with transfers. CNA E attempted to assist the resident alone, even after the resident requested more assistance, and dropped the resident on the floor. The resident suffered a fracture to her left, lower leg as a result of the fall. The Department of Aging and Disability Services was not notified of the incident. These failures could affect the facility's 96 residents, who required assistance from staff with transfers, including Residents #12 and #19, and placed them at risk for falls, fractures, abrasions, bruises, pain and mental anguish. Findings included: Review of the facility's current Abuse & Neglect Prohibition policy dated February 2010 revealed, "...Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect...The facility will report all allegations and substantiated occurrences of abuse, neglect, injuries of unknown origin, and misappropriation of property to the state agency and law enforcement officials as designated by state law...." 1) Initial tour on 09/21/10 at 10:15 a.m. with ADON F revealed Resident #19 was admitted to the hospital "about three weeks ago" for a fracture of her "femur." Resident #19 was found beside her bed with bed sheets tangled around her legs at the time of the fracture. ADON F revealed Resident #19 did not walk, was transferred using a gait belt with assistance of one staff member, was non-interviewable, required total assistance with ADLs, was incontinent of bowel and bladder, and required assistance in eating her pureed food. Resident #19's current MDS assessment (Significant Change in Status) dated 08/17/10 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #19 was severely impaired for cognitive skills for daily decision making. Resident #19 required extensive assistance from two plus staff members with transfers, locomotion on the unit, dressing, toilet use, and personal hygiene. Resident #19's primary mode of locomotion was by a wheelchair, pushed by a staff member. The MDS reflected Resident #19 had experienced a fall in the past 30 days, but did not have a [MEDICAL CONDITION] in the past 180 days. Review of Resident #19's History and Physical dated 08/03/10 and completed by the NP when she was readmitted from a hospitalization revealed, "Pt has multiple complex medical conditions including status [REDACTED]." Review of Resident #19's RESIDENT TRANSFER EVALUATION dated 09/03/10 revealed the resident had a total score of nine, which placed her in "Category 3: (score 9-14) Caregiver performs 50% of the task or greater. Equipment: Mechanical Lift (Total Body/Sling or Stand Assist as appropriate)...." Review of Resident #19's Comprehensive care plan dated 09/03/10 revealed the facility identified the resident's risk for falls and revealed, "...Res. continues to be at risk for falls but has become more alert and is able to stand with assist X 2 to transfer...." Review of Resident #19's INCIDENT/ACCIDENT REPORT dated 09/12/10 at 5:30 p.m. revealed the resident was "found sitting on the floor by her bed with bed sheet wrapped around her legs - unattended. Assisted back into her bed - able to bear wt on L (left) leg, but not on R (right) leg - R leg pulled up as if contractured (sic) - c/o pain to R femur area. Able to MAE (move all extremities) ... C/o (complaint of) pain to R femur area...." Review of LVN A's written statement dated 09/12/10 and attached to the Incident/Accident Report revealed, "Was called to pt's (Resident #19's) room to find her sitting on the floor by her bed with bed sheet wrapped around her legs. Assisted per 2 (people) back to bed. Unable to bear wt on her R leg - looks pulled up as if contractured (sic) - c/o pain to R femur area when asked 3 different times. Xrays (sic) of R hip & R femur ordered." Interview on 09/22/10 at 1:00 p.m. with LVN A revealed she worked on the 6:00 a.m. to 6:00 p.m. shift on 09/12/10. MA D called her to Resident #19's room on 09/12/10. She observed Resident #19 on the floor with the bed sheets wrapped around her legs. Resident #19 could not bear weight on her right leg, but could on her left leg. Resident #19 pointed at her right leg when asked if she was in pain, and said, "Yes." Resident #19 then contradicted herself and said, "No." LVN A said Resident #19 had Dementia. LVN A then stated, "I didn't know what she was feeling." LVN A stated Resident #19's right leg was "bent at the knee," but after the resident was transferred to her bed it "looked normal." LVN A thought the incident occurred around 5:30 p.m., but she said MA D thought it was earlier. LVN A revealed she didn't look at the clock. LVN A revealed she called for an x-ray on Resident #19's right lower extremity. When LVN A was queried as to the decision to not send the resident to the emergency room , and she stated she needed to do "finger sticks and insulins," because it was almost dinner time for the residents. Resident #19 "settled down" after she was transferred to her bed. When LVN A was asked what type of emergency would prompt her to send a resident to the emergency room , she stated, "Respiratory arrest, [MEDICAL CONDITION] and an open fracture. With a closed fracture you don't know if it's broken so I wouldn't send them out until after an x-ray confirmed it." When LVN A was asked what kind of complications could result from a [MEDICAL CONDITION], she stated, "fat embolism, nerve damage, vascular compromise and impaired circulation." When asked how a resident's leg might look if their hip was fractured, she stated, "It could have external rotation, maybe shorter, can't bear weight and complain of pain." LVN A stated she reported the incident to RN C at the end of shift report (at approximately 6:00 p.m.). Review of Resident #19's Physician's Telephone Orders dated 09/12/10 at 4:35 p.m. revealed, "X-ray R leg R/O (rule out) fx (fracture)." Review of Resident #19's NURSING DAILY SKILLED SUMMARY dated 09/12/10 at 5:30 p.m. revealed, "Resident found sitting on the floor by her bed, bed sheet wrapped around her legs. Assisted back to bed unable to bear wt on R leg - R leg is contractured (sic). Neuro is WNL (within normal limits). Able to bear wt (weight) on L leg and moves extremities... 6:15 p (p.m.) X-ray ordered for R hip and R femur..." NP H was notified and ordered [MEDICATION NAME] (pain medication)... 8:30 p X-ray done with nurse assisting technician to position pt. Nurse explained to x-ray tech that resident has contracture to R leg. Pt did not show any signs of pain... 10:15 p x-ray returned for more pictures, stated that she did not get enough for viewing. Nurse assisted x-ray technician to position pt. for x-ray. Pt asleep throughout positioning. Neuro checks WNL..." The notes reflected the nurse instructed the RCS (Resident Care Specialist - CNA) to be "careful during pericare and call for assistance with turning pt. 3:30 am (a.m.) x-ray results called into nurse...." RN C faxed the x-ray results to NP H. Review of Resident #19's Physician's Telephone Order dated 09/12/10 at 6:30 p.m. revealed an order for [REDACTED]. Review of Resident #19's x-ray report with a date of service 09/12/10 and faxed to the facility on [DATE] at 12:18 a.m. revealed, "...RIGHT HIP UNILATERAL: There is a right intertrochanteric fracture with modest displacement. Mild callous formation is seen. The joint shows no dislocation. Pubic rami are intact. [MEDICAL CONDITION] is present ... RIGHT FEMUR: The femur shows [MEDICAL CONDITION]. There is a right intertrochanteric fracture with modest displacement. Mild callous formation is seen. The joint shows no dislocation. Pubic rami are intact. The remainder of the femur is intact...." Interview on 09/22/10 at 1:15 p.m. with RN C stated she worked the 6:00 p.m. (09/12/10) to 6:00 a.m. (09/13/10) shift. RN C said Resident #19 did not appear to be in pain when she assessed her. RN C revealed she received a verbal report from the local x-ray company at approximately 3:30 a.m., and at that time she learned the x-ray report had been faxed to the facility earlier that morning. RN C stated she did not call NP H with the x-ray report; instead she faxed the x-ray report to NP H. RN C said she should have called NP H stating, "I don't know why I didn't." RN C revealed when she gave report at approximately 6:00 a.m. 09/13/10 to LVN B, LVN B made the decision to send Resident #19 to the emergency room . Interview on 09/24/10 at 10:00 a.m. with RN C revealed she did not send Resident #19 to the emergency room after receiving the x-ray report reflecting a fracture because she was waiting on NP H to call back with orders. When RN C was asked what complications could occur as a result of a [MEDICAL CONDITION], she replied, "Bleeding, blood clots and long term disability." RN C stated the x-ray report didn't sound "that urgent." RN C stated she was very busy that night and had sent another resident to the emergency room . RN C stated, "I took on too much. It will never happen again." Interview with X-Ray CSR from the local x-ray company on 09/24/10 at 9:40 a.m. revealed the call for an x-ray for Resident #19 came in on 09/12/10 at 4:48 p.m. and was listed as a "normal case." The x-ray technician was dispatched "five minutes later." X-ray reports were on auto-fax, and were faxed to a facility immediately after receiving the report. A verbal report was given by phone afterwards to confirm receipt of the faxed report. Resident #19's verbal report was given at 2:00 a.m. on 09/13/10 to RN C. The local x-ray company had used the auto-fax for the "last three months." Interview with LVN B on 09/23/10 at 12:25 p.m. revealed she worked the 6:00 a.m. to 6:00 p.m. shift on 09/13/10. When she received report from RN C regarding Resident #19, and learned the resident had a [MEDICAL CONDITION], she decided to send her to the emergency room . Resident #19 was sent to a local emergency room at approximately 7:00 a.m. LVN B stated she looked at the x-ray report, and thought, "Why is she still here?" Interview with ADON F on 09/23/10 at 2:40 p.m. revealed she learned Resident #19 had a right [MEDICAL CONDITION] from LVN B on the morning of 09/13/10. ADON F stated she did not know why Resident #19 was not sent to the emergency room immediately. ADON F stated, "I would have sent her out when the resident couldn't bear weight. I still don't understand why she wasn't sent out. I would have sent her out without a physician's orders [REDACTED]." Interview with a local Hospital Social Worker on 09/22/10 at 2:15 p.m. revealed Resident #19 was checked into the emergency roiagnom on [DATE] at 8:30 a.m. Resident #19 had right hip surgery with an open reduction with internal fixation on 09/17/10. Interview with the DON on 09/22/10 at 4:50 p.m. regarding Resident #19's fall revealed, "The nurse should call the physician and see what he wants to do." The DON was queried about possible complications of a [MEDICAL CONDITION]. She stated, "Pain, deformities, they could throw a clot and eventually die if it goes to the lung or organs." The DON revealed LVN A "did an assessment and did order x-rays." The DON stated, "I don't want to say the nurse did anything wrong." When asked how she could ensure delay in treatment and notification of changes would not be repeated with another resident, the DON stated, "When things happen, I talk to them (staff) about what we need to do. As their leader I give recommendations. I didn't document the conversations." The DON said RN C "should have called the doctor when she got the x-ray report. You can't depend on a fax especially at three in the morning. You have to call the doctor." Untitled and undated notes signed by the DON regarding Resident #19's fractured right hip were provided to the surveyors to review. The notes reflected, "...After staff interviews it was determined that the fall was not caused by staff or negligence. It was identified that staff in-service needed to be given for a clear picture on what items needed to be called to nurse management and/or Administrator. Also, that the staff members involved needed additional training on incidents ie when to notify physician, supervisor, process for x-ray results, etc. This in-service was completed on Wednesday, September 15 (2010)." Interview on 09/22/10 at 1:30 p.m. with LVN M revealed when the surveyor asked LVN M if a [MEDICAL CONDITION] was an emergency she replied, "Of course." LVN M stated , with a [MEDICAL CONDITION], there could be internal bleeding and the resident could go into shock. LVN M revealed a resident with a [MEDICAL CONDITION] would complain of pain, may have rotation of the leg, and the leg could appear shorter. If a [MEDICAL CONDITION] was suspected, LVN M would send the resident to the emergency room even if there was not an x-ray. Review of Resident #19's INCIDENT/ACCIDENT INVESTIGATION FOLLOW-UP from 09/12/10 revealed: "...PAST INTERVENTIONS ATTEMPTED... falling star program, bed chair alarm, low bed position. RECOMMENDATIONS/NEW INTERVENTIONS Will re-evaluate resident when she returns from hosp...." An undated note included reflected, "...After interviewing the staff there were no signs of neglect. The resident was properly positioned in bed and the bed in proper position. The resident had hardly any muscle mass and has dx of [MEDICAL CONDITION], which exposed her to higher risk for injury." Review of an Attendance Form for "Fall Intervention" dated 09/15/10 listed a total of two employees, LVN A and MA D, in attendance. The form reflected, "Inservice Regarding falls. Assessment of Res (resident) that has fallen is first. If Resident is not standing as she usually does or it is noticed that she is not bearing weight on one foot, verbalizing pain or facial grimacing after/before phy. (physician) notified this Resident can and should be sent to the hospital. This is a Nursing Assessment." On 09/28/10 the facility provided DISCIPLINARY ACTION RECORDs on LVN A and RN C to the surveyor by fax, regarding Resident #19. Review of LVN A's DISCIPLINARY ACTION RECORD dated 09/26/10, 14 days after Resident #19 had an un-witnessed fall, revealed, "...On 9/12/10 Charge Nurse during her 6A-6P shift had a Resident fall out of bed. (Resident #19) was assessed by charge nurse and according to I/A report when Res. was assisted to a standing position she said 'ouch' and would not bear wt on one leg. Charge nurse did not follow policy by using Resources available to her when she was not able to reach the Nurse Practitioner. Charge Nurse wrote order for x-ray but did not specify STAT. Also did not notify Nurse Manager on Duty, DON or Administrator. Employee Statement: To be completed by employee. In the past, I was informed not to call 'on call' personnel. Didn't think to notify mgr (manager) on duty, DON, or administrator @ this time; just 'sailing my ship.' The nurse practitioner had told us to 'use your head, use your common sense, you're a nurse with a license' When calling her in the past; I was just using my head & common sense. Corrective Action: To be completed by Supervisor. Be specific, include goals and timetable for follow-up. Charge Nurse will set up time for education with SDC no later than Tue 9/28/10...." Review of RN C's DISCIPLINARY ACTION RECORD dated 9/26/10, 14 days after Resident #19 had an un-witnessed fall resulting in a [MEDICAL CONDITION], revealed "...Charge Nurse did not follow policy with notification to manager on duty, DON or Administrator Regarding the Res. fall. Even after (local x-ray company) called the results to the Charge Nurse no attempt was made to get the Res. to the hospital... Corrective Action: To be completed by Supervisor... Employee will set up time with SDC by 9-28-10 for education...." 2) Initial tour on 09/21/10 at 10:20 p.m. with ADON F revealed Resident #12 required transfers with a mechanical lift, did not walk, was incontinent of bowel and bladder, was alert and oriented to person, place and time; and had a fall approximately a month ago which resulted in a left tibia (lower leg) fracture. When ADON F was asked if Resident #12 had behaviors, she said, "She cries, looks for sympathy and has a pity thing." Resident #12 was observed with a fracture boot on her left lower leg. Resident #12's facility face sheet dated 09/24/10 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #12's admission MDS assessment dated [DATE] revealed the resident was independent for cognitive skills for daily decision-making and required extensive assistance from two plus staff members for bed mobility, transfers, toilet use, and personal hygiene. Resident #12's mode of locomotion was by wheelchair pushed by another person. Resident #12's ADL self-performance had deteriorated, and the resident was receiving Physical and Occupational Therapies. Review of Resident #12's COMPREHENSIVE PLAN of CARE for ADL Functions dated 06/16/10 revealed, "Transfers: ext (extensive) X 2 Assist: Hoyer (mechanical lift)...." Interview on 09/21/10 at 12:25 p.m. with Resident #12 revealed she was a retired Registered Nurse. When Resident #12 was asked by the surveyor how she fractured her left lower leg, she said on the day of the incident, she told CNA E she needed to use the bed side commode. Resident #12 revealed she asked CNA E to get some help before transferring her from her chair to the bedside commode, but CNA E ignored her request. CNA E placed the gait belt around Resident #12's waist, and instead of holding onto the gait belt at the resident's sides, she grasped the gait belt with both hands in front of the resident. Resident #12 revealed since she was an RN, she knew CNA E was supposed to place her hands on the gait belt on each side of her waist. Resident #12 revealed CNA E assisted her into a standing position, and when the resident became unsteady, CNA E panicked and jerked her in an upward motion, but then dropped her onto the floor. She stated she landed in a sitting position with her left leg folded under her. Resident #12 stated she was able to remove her left leg from underneath her. Resident #12 added she was screaming, and CNA E and "someone else" came into the room and tried to "shush me." Resident #12 stated she told them CNA E dropped her. Resident #12 stated she did not think CNA E intentionally dropped her. Resident #12 said she no longer wanted any staff members except PT G to transfer her. Review of a written statement from PT G attached to the Incident/Accident Report dated 08/23/10 revealed, "PT called to pt's room to assist with floor transfer per pt request. Upon entering, PT saw pt in long-sitting on floor in front of bedside commode. Pt states 'they dropped me.' Pt in distress with yelling and moaning...." Review of ADON F's written statement attached to the Incident/Accident Report dated 08/23/10 revealed, "When I entered (Resident #12's) room to see how she was and what happened, she said the girl had the gait belt around me and she was very strong and lifted her off her feet and when she came down her legs were like wet noodles and the girl sat her on the floor. She said she was in a sitting position and moved her leg from under her. She started saying, 'Make sure you tell them exactly what happened'...." Review of Resident #12's PHYSICIAN's TELEPHONE ORDERS dated 08/23/10 at 11:35 a.m. revealed an order for [REDACTED]. Review of Resident #12's x-ray result dated 08/23/10 at 1:49 p.m. revealed, "...LEFT KNEE: There is a fracture involving left proximal fibula with no displacement. The joint shows no dislocation. There is no joint effusion. [MEDICAL CONDITION] is present. IMPRESSION: Acute left proximal fibula fracture as described above. LEFT TIBIA/FIBULA: There is a fracture involving the proximal fibula with no displacement. The knee and ankle joints are intact in alignment. [MEDICAL CONDITION] is present. IMPRESSION: Acute left lower leg fracture as described ...." Interview with LVN M on 09/22/10 at 1:30 p.m. revealed on the morning of 08/23/10 she heard Resident #12 screaming. LVN M entered Resident #12's room and found her on the floor in a sitting position with her legs out in front of her. Resident #12 told LVN M her leg had been under her. Resident #12 stated CNA E dropped her. Resident #12 complained that her left leg hurt. The resident would not allow anyone to transfer her to her bed except for PT G. PT G and another staff member used a mechanical lift to transfer the resident to her bed. (LVN M did not identify the other staff member.) LVN M called and reported the incident to the resident's physician and obtained an order for [REDACTED]. Each nurse's station had a fax machine where an x-ray report could be faxed. Interview with PT G on 09/22/10 at 2:10 p.m. revealed he entered Resident #12's room on 08/23/10 to assist the resident with a transfer. Resident #12 was sitting on the floor with her legs in front of her. He stated the resident was tearful and complained that her legs hurt her. Resident #12 told PT G when she fell , her leg folded under her. Resident #12 said, "They dropped me. They dropped me." PT G stated the resident told CNA E it was not her fault. PT G and another staff member, who was no longer at the facility, assisted in transferring Resident #12 into her bed with a mechanical lift. PT G revealed Resident #12 was fearful. He stated, "Now she won't let anyone transfer her but me." PT G revealed the resident was walking with him approximately 100 feet with stand by assistance before the fall. PT G was asked how many staff members were required to assist Resident #12 with gait belt transfers prior to the fall. He replied, "Probably one CNA, but if having a bad day, she would need two staff to assist." Interview with CNA E on 09/22/10 at 2:45 p.m. revealed she worked on a PRN (as needed) basis. On 08/23/10 Resident #12 requested help in transferring from her chair to the bed side commode. CNA E revealed she placed the gait belt around Resident #12's waist, held onto both sides of the gait belt, counted to three and Resident #12 pushed up from her chair. Resident #12 "held onto her walker" but began to fall. CNA E said at that time she "eased" the resident down into a "squatting position." CNA E stated the resident began to "yell at that time." Interview on 09/22/10 at 4:50 p.m. with the DON revealed she and ADON F talked with Resident #12 after the incident, because PT G had told them Resident #12 said she was dropped. The DON stated, "She (Resident #12) didn't mention she was dropped." Referring to the conversation with Resident #12, the DON stated, "I didn't write it down." Review of Resident #12's NURSING DAILY SKILLED SUMMARY forms revealed Resident #12 required "limited assistance" with transfers on 06/20/10, 07/11/10, and 08/13/10, 08/14/10 and 08/20/10. Resident #12 required extensive assistance with transfers on 06/21/10, 06/30/10, 07/01/10, 07/12/10, 07/26/10, 07/28/10, 08/08/10, 08/21/10, 08/22/10, and 08/23/10. Interview with LVN M on 09/23/10 at 12:30 p.m. revealed Resident #12 "fluctuates" from day-to-day on the amount of assistance required for transfers. On some days, Resident #12 required "limited assistance" with a one-person, gait belt transfer, and other days she required "extensive assistance" with two-person transfers. LVN M stated, "She (Resident #12) doesn't stay the same; she's weaker some days more than others." Interview with the Administrator and the DON on 09/23/10 at 2:00 p.m. revealed, based on Resident #12's latest Care Plan and Cardex, Resident #12 required one person assistance with gait belt transfers prior to her fall. When queried about Resident #12's MDS assessment reflecting the resident required extensive assistance with two staff members for transfers, the DON replied, "Well, that's how you have to code an MDS. If the resident falls one time you have to code it that way." The Administrator and the DON were informed PT G and LVN M stated prior to the Resident #12's fall, some days the resident required limited assistance with one person gait belt transfers, and other days she required extensive assistance with two person gait belt transfers. The Administrator and the DON were asked how the staff knew if Resident #12 was having a good or a bad day? The Administer and DON did not answer. 3) Review of Perry and Potter's Clinical Nursing Skills & Techniques, Fifth Edition, Copyright 2004, chapter 27, Body Mechanics, Transfer, and Positioning, pages 808 and 810 revealed, "...Expected outcome following completion of procedure:... Client transfers without injury... Rationale... Proper techniques avoid injury... Transfer belt is grasped at client's side to provide movement of client at center of gravity...." Review of the facility's current Gait Belt Use policy dated February 2010 revealed, "...If, during the course of care, it becomes necessary to provide lift/transfer assistance in a manner other than that specified in the resident's plan of care, the caregiver will contact his/her supervisor prior to the lift/transfer...." Review of the facility's current Changes in Resident Condition policy dated June 2008 revealed, "The resident, attending physician and legal representative or designated member are notified when changes in condition or certain events occur...For life-threatening events: Call 911 if initial assessment indicates that such action is necessary...." "...Broken Bone. If more pressure is put on a bone than it can stand, it will split or break. A break of any size is called a fracture. If the broken bone punctures the skin, it is called an open fracture (compound fracture). A stress fracture is a hairline crack in the bone that develops because of repeated or prolonged forces against the bone. Considerations: It is hard to tell a dislocated bone from a broken bone. However, both are emergency situations, and the basic first aid steps are the same ... Symptoms: A visibly out-of-place or misshapen limb or joint, swelling, bruising, or bleeding, intense pain, numbness and tingling, broken skin with bone protruding, limited mobility or inability to move a limb... Keep the person still and calm, examine the person closely for other injuries, In most cases, if medical help responds quickly, allow the medical personnel to take further action, If the skin is broken, it should be treated immediately to prevent infection... If needed, immobilize the broken bone with a splint or sling... Immobilize the area both above and below the injured bone, Apply ice packs to reduce pain and swelling, Take steps to prevent shock Lay the person flat, elevate the feet about 12 inches above the head, and cover the person with a coat or blanket. However, DO NOT move the person if a head, neck, or back injury is suspected, CHECK BLOOD CIRCULATION Check the person's blood circulation. Press firmly over the skin beyond the fracture site. (For example, if the fracture is in the leg, press on the foot). It should first blanch white and then "pink up" in about two seconds. Other signs that circulation is inadequate include pale or blue skin, numbness or tingling, and loss of pulse. If circulation is poor and trained personnel are NOT quickly available, try to realign the limb into a normal resting position. This will reduce swelling, pain, and damage to the tissues from lack of blood ... DO NOT move the person unless the broken bone is stable, DO NOT move a person with an injured hip, pelvis, or upper leg unless it is absolutely necessary. If you must move the person, pull the person to safety by his clothes (such as by the shoulders of a shirt, a belt, or pant-legs). DO NOT move a person who has a possible spine injury, DO NOT attempt to straighten a bone or change its position unless blood circulation appears hampered, DO NOT try to reposition a suspected spine injury. DO NOT test a bone's ability to move ...Call 911 if: There is a suspected broken bone in the head, neck, or back, There is a suspected broken bone in the hip, pelvis, or upper leg, You cannot completely immobilize the injury at the scene by yourself, There is severe bleeding, An area below the injured joint is pale, cold, clammy, or blue, There is a bone projecting through the skin...." (Retrieved at <http://www.nlm.nih.gov/medlineplus/ency/article/ 1.htm>. on 09/28/10) "[MEDICAL CONDITION] is a condition in which a blood clot blood clotforms in a vein that is deep inside the body. [MEDICAL CONDITIONS] mainly affects the large veins in the lower leg and thigh. The clot can block blood flow and cause swelling and pain. When a clot breaks off and moves through the bloodstream, this is called an embolism. An embolism can get stuck in the brain, lungs, heart, or other area, leading to severe damage. Blood clots may form when something slows or changes the flow of blood in the veins. Risk factors include:...Fractures Fractures in the pelvis or legs ... Recent surgery (especially hip, knee, or female reproductive organ surgery)[MEDICAL CONDITION] are most common in adults over age 60, but can occur at any age ... Treatment Your doctor will give you medicine to thin your blood (called an anticoagulant). This will keep more clots from forming or old ones from getting bigger. These drugs cannot dissolve existing clots...Possible Complications A blood clot can break free in the leg and travel to the lungs (pulmonary [MEDICATION NAME]) or anywhere else in the body, and can be life threatening. Rapid treatment of [REDACTED]." (Retrieved at <http://www.nlm.nih.gov/medlineplus/ency/article/ 6.htm> on 09/28/10) 4) The facility provided CMS form 672 dated 09/21/10 and signed by the DON which reflected 83 residents that required assistance from one to two staff members for transfers; and 13 residents were dependent on staff for transfers. The DON also provided a list of eight residents, who received in-house fractures from March 2010 to 09/24/10 on 09/24/10.

Based on observation, interview and record review, it was determined the facility failed to ensure one (Resident #3) of five residents reviewed for pain, received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure one (Resident #4) of 21 sampled residents reveiwed for Advance Directives had identified Resident #4 as having a DNR from 08/26/10 to 09/23/10 (28 days) until surveyor inquiry. 1) Resident #3 experienced pain as evidenced by moaning, groaning, crying, and verbalization. The physician orders [REDACTED]. The facility failed to carry out these orders from 07/21/10 until surveyor inquiry on 09/23/10. Facility staff did not consistently assess and document the resident's pain to ensure optimal pain management and to provide comfort to the resident, leaving the resident with unrelieved episodes of pain during wound care. Following surveyor inquiry, the resident was reassessed for pain and new orders were received to provide the resident pain relief and a care plan was initiated. These failures could affect the facility's 15 residents, who were identified as being on a pain management program, including Resident #3, and placed them at risk for unrelieved pain when staff failed to assess and treat them for pain, resulting in continued unrelieved pain, having a negative impact on their health and well-being and quality of life. 2) Resident #4 had an Advance Directive for a Do Not Resuscitate Order, which was dated 08/26/20. The facility was unaware the resident had a DNR and his clinical record reflected he was to be provided emergency measures in the event he was found nonresponsive and without a pulse or respirations. This failure could affect the facility's 52 residents with Advance Directives, including Resident 34, and placed them at risk for not having their decision for a DNR to not be followed and allow emergency measures to take place. Findings included: 1) Observation during initial tour with ADON N on 09/21/10 at 9:20 a.m. revealed Resident #3 was in bed crying, moaning, and muttering. Resident #3 was being administered oxygen via nasal cannula at two liters a minute. Fiber Source gastrostomy ([DEVICE]) feeding was infusing at 80 ml an hour. Resident #3 was observed with contractures of her hands, legs, and feet. She had a cloth hand roll placed in her left hand. In an interview at that time, ADON N stated Resident #3 was on Hospice due to end stage [MEDICAL CONDITION]. ADON N stated Resident #3 had two Stage III pressure ulcers on each side of her buttocks. During observation of the resident's pressure ulcers, ADON N rolled Resident #3 to her left side. During positioning, Resident #3 cried out even more loudly. Review of the significant change MDS assessment dated [DATE] revealed Resident #3, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The assessment reflected Resident #3 was severely impaired with cognitive skills for daily decision-making and required total assistance from staff for all ADLs. The MDS assessment also reflected Resident #3 had moderate pain less than daily. Review of Resident #3's Physician's Telephone Orders, dated 07/21/10 at 1:30 p.m. revealed an order for [REDACTED]." Review of Resident #3's Nursing Daily Skilled Summary, dated 07/21/10 at 12:30 p.m. revealed, "hospice nurse in facility, received new order for Oxyfast 20 mg/ml, give 0.5 ml (10 mg) SL daily 30 minutes prior to wound care and every 4 hours prn for mild to moderate pain." Observation on 09/21/10 at 1:55 p.m. revealed Resident #3 was lying on her back in bed. She was observed crying out loud, groaning, and muttering. When the surveyor asked the resident if she were "hurting," the resident cried louder. Observation on 09/22/10 at 7:50 a.m. revealed the hospice aide was giving Resident #3 a bed bath. The resident was crying and muttering. Her arms and legs were observed to be quivering. Resident #3 was incontinent of bowel, and the hospice aide rolled the resident on her left side to clean her buttocks. At that time, the resident yelled loudly and continued crying. The hospice aide was asked by the surveyor if the resident had received any pain medication before her care. The aide stated she did not know but thought she got some routine pain medication. The resident cried, moaned, muttered and her arms and legs quivered the entire time she received care from the hospice aide, which was all observed by the surveyor. On 09/22/10 at 10:15 a.m. Resident #3 was observed lying in her bed crying, muttering and moaning. At 10:30 a.m. the resident was observed lying in her bed crying and muttering even more loudly. On 09/22/10 at 10:40 a.m., LVN P was observed standing outside Resident #3's room by the door. The surveyor asked LVN P if Resident #3 was given any medication for pain. LVN P stated the resident received [MEDICATION NAME] ([MEDICATION NAME] pain medication) routinely twice a day. When asked how she knew whether the pain medication was effective or not, LVN P stated, if the resident cried out a lot or was moaning, she gave the resident [MEDICATION NAME] pain medication prn. After surveyor inquiry, LVN P stated she was going to give Resident #3 pain medication "now," because she could hear the resident crying. The surveyor inquired if the resident was given pain medication before her wound care yesterday (09/21/10). LVN P revealed she did wound care for Resident #3 around noontime yesterday, because the treatment nurse was out sick. LVN P stated she did not administer the pain medication, [MEDICATION NAME], before her treatment. LVN P stated she did not give the pain medication, because the resident was not crying and was quiet all day. The surveyor asked LVN P if Resident #3 had a physician's orders [REDACTED]. LVN P stated she did not know, but she knew she had a prn order for pain medication. Immediately following the interview with LVN P, the nurse was observed to administer the resident pain medication sublingually (liquid drops under the tongue). Observation on 09/22/10 at 4:30 p.m. revealed CNA R and CNA S were providing incontinent care for Resident #3. The surveyor queried both nurse aides if they knew when the resident was in pain. Both nurse aides stated when the resident cried and moaned, they thought she was in pain. Both nurse aides stated they told the charge nurse when the resident was crying and moaning, but neither was aware if the resident was given any pain medication. In an interview on 09/23/10 at 1:55 p.m., CNA Q stated she was aware Resident #3 might be in pain when the resident moaned during care. CNA Q stated, "I don't want to do it." CNA Q stated all nurse aides rotate and work on different halls so they do not constantly care for the same residents. CNA Q then stated she remembered reporting to the charge nurse "once," when she thought Resident #3 was in pain. Review of Resident #3's Nurse's Notes in the active clinical record revealed no documentation about the resident repeatedly crying, moaning or muttering in pain or whether she required the use of PRN pain medication. Further review revealed no documentation the resident received pain medication as ordered by the physician before her wound care. The Nursing Weekly/Monthly Summary, dated 08/18/10, for Resident #3 reflected, "Pain...Resident moans, unable to differentiate if in pain or moaning is behavioral." A review of Resident #3's entire clinical record on 09/22/10 revealed no evidence of pain assessments being conducted. Review of a Weekly Pressure Ulcer Record, dated 09/08/10, revealed Resident #3 had a 4 cm x 4.5 cm pressure ulcer with 1.5 cm depth (tunneling) with serous drainage and was to be pre-medicated for pain prior to wound care. Further review of the Weekly Pressure Ulcer Records for the months of July, August and September 2010 reflected there was no documentation Resident #3 was pre-medicated for pain before her wound care other than on 09/08/10. Review of the Individual Control Drug Record label for Resident #3's count sheet revealed, "[MEDICATION NAME] HCL 20 mg/1 ml (substituted for Oxyfast) administer 0.5 ml (10 mg) sublingually 30 minutes before wound care and every 4 hours as needed for pain." Further review revealed the pain medication was signed out for administration for the entire month of July 2010 only three times, on 07/22/10 at 1:45 p.m.; 07/28/10 at 11:00 a.m.; and 07/30/10 at 2:00 p.m. Note: Physician order [REDACTED]. The count sheet reflected Resident #3 received only 17 of the 31 physician-ordered doses of [MEDICATION NAME] in August 2010. They were administered as follows: 08/02/10 at 8:00 a.m.; 08/03/10 at 8:00 a.m.; 08/04/10 at 10:00 a.m.; 08/06/10 at 11:00 a.m. and at 9:00 p.m.; 08/10/10 at 8:00 a.m.; 08/11/10 at 10:00 a.m.; 08/13/10 at 8:00 a.m.; 08/16/10 at 2:00 p.m.; 08/17/10 at 2:00 p.m.; 08/18/10 at 10:30 a.m.; 08/19/10 at 3:00 p.m.; 08/20/10 at 2:00 p.m.; 08/23/10 at 7:30 (a.m. or p.m. not specified); 08/25/10, at 10:00 (a.m. or p.m. not specified); 08/26/10 at 2:00 p.m.; and 08/30/10 at 2:00 p.m.. The count sheet reflected in September 2010, 09/01/10 through 09/21/10, Resident #3 received seven of the 21 physician-ordered doses of [MEDICATION NAME]. They were administered as follows: 09/06/10 at 8:30 a.m.; 09/07/10 at 2:00 p.m.; 09/08/10 at 7:30 a.m.; 09/08/10 at 11:00 a.m.; 09/09/10 at 9:30 a.m.; 09/14/10 at 9:00 a.m.; and 09/15/10 at 11:45 a.m. Resident #3's MAR for July 2010 reflected Resident #3 was administered Oxyfast pain medication before wound care on 07/22/10. There was no other documentation indicating Resident #3 had received pain medication before her wound care or prn for pain. Resident #3's MAR for August 2010 reflected during the entire month there was no documentation indicating the resident was administered [MEDICATION NAME] (Oxyfast) pain medication before her wound care or prn for pain. Resident #3's MAR for September 2010 reflected the resident was administered her pain medication on the following dates: 09/06/10 at 8:00 a.m. for wound care; 09/07/10 at 2:00 p.m. for wound care; 09/08/10 at 7:30 a.m. for pain; 09/08/10 at 11:00 a.m. for pain; 09/09/10 at 9:30 a.m. for wound care; 09/15/10 at 11:45 a.m. for wound care; and 09/17/10 at 9:00 a.m. for pain. Review of Wound Care Pain Medication Administration Record for September 2010 for Resident #3 revealed the order for [MEDICATION NAME] 20 mg/ml, 0.5 ml (10 mg) SL 30 minutes before wound care was included on the record. Entries, dated 09/02/10 and 09/09/10, reflected [MEDICATION NAME] 0.5 ml was administered to Resident #3. The Wong-Baker Faces Pain Rating Scale Score (measures pain intensity on a scale 1 - 10 and is used for cognitively-impaired residents and assesses facial expressions and body posturing to assess pain) was blank. A review of Resident #3's entire clinical record on 09/22/10 revealed no further Wound Care Pain Medication Administration Record in the record. In an interview on 09/23/10 at 9:45 a.m. LVN P revealed she did not know why the pain medication was not documented on the MAR or Wound Care Pain Medication Administration Record every time it was signed out on the narcotic count sheet as given. LVN P stated, "Just forgot." LVN P revealed Resident #3's [MEDICATION NAME] routine pain medication was discontinued "today." A new physician's orders [REDACTED]. On 09/23/10 at 12:15 p.m. ADON N revealed she had phoned Hospice yesterday and requested Resident #3 be re-evaluated for pain. ADON N stated the hospice nurse re-evaluated Resident #3 yesterday evening, and new physician orders [REDACTED]. On 09/23/10 at 1:58 p.m. ADON N revealed she found Resident #3's Nursing Admission Pain Assessment in her thinned records. Review of the pain assessment, dated 05/12/10, revealed entries: "Location/Origin of Pain - resident's left hip (status [REDACTED]." ADON N stated Resident #3 was sent to the hospital for her [DEVICE] placement and a second Admission Pain Assessment was done after re-admission. Review of the Admission Pain Assessment, dated 06/05/10, revealed entries: "Location/Origin of Pain - [DEVICE] placement - right hip - wound; What Relieves Pain - unable to say; What makes pain worse - movement." Physician's Telephone Order, dated 09/22/10 at 8:00 p.m. for Resident #3 reflected, "[MEDICATION NAME] HCL (20 mg/ml) 0.5 ml SL Q (every) 8 hours; [MEDICATION NAME] HCL (20 mg/ml) 0.5 ml SL Q 4 hours prn pain/SOB (shortness of breath); [MEDICATION NAME] HCL (20 mg/ml) 0.5 ml SL 30 minutes before wound care; DC (discontinue) [MEDICATION NAME]." Observation on 09/23/10 at 10:30 a.m. revealed the facility's only Treatment Nurse was providing wound for Resident #3. The treatment nurse stated she told the nurses to pre-medicate the resident for pain 30 minutes before she started her wound treatment. Resident #3 was observed to be calm and quiet during her wound care. The Treatment Nurse stated she was aware when the resident was in pain because she cried, moaned and had facial grimacing. The Treatment Nurse also revealed the resident could understand what she said to her and would frequently answer "yes or no." The Treatment Nurse asked Resident #3 if she was hurting. The resident was observed opening her eyes and stated, "No." The Treatment Nurse stated the resident had been medicated with pain medication, so she was not hurting. The surveyor queried the treatment nurse if she told the nurse to medicate Resident #3 30 minutes before she provided the resident's wound care. The Treatment Nurse revealed she did. The surveyor queried the treatment nurse if she was always aware the resident had been pre-medicated for pain. The Treatment Nurse stated, "No." The Treatment nurse stated Resident #3's wound care was not done at a specific time every day; there was no certain time wound care was provided, but wound care was done every day as ordered. A review of Resident #3's entire clinical record on 09/23/10 revealed there was no care plan in place addressing Resident #3's pain management. In an interview on 09/23/10 at 1:00 p.m., the surveyor queried the Treatment Nurse if she had a care plan in place for Resident #3 to be pre-medicated for pain 30 minutes before her wound treatment. The Treatment Nurse revealed she did not have a care plan in place for pain; only for wound care. In an interview with ADON N on 09/23/10 at 1:25 p.m., the ADON revealed she had only worked at the facility for two months. ADON N stated she was unable to locate a care plan addressing Resident #3's pain so she did a care plan addressing the resident's pain management that day. Review of Care Plan - Pain, dated 09/23/10, revealed, "...Approaches - Administer [MEDICATION NAME] as ordered; Observe resident for signs and symptoms of pain, including verbal expressions and non verbal expressions (facial grimacing, bracing, restlessness); Medicate resident for pain prior to treatments and therapy if indicated." In an interview on 09/24/10 at 11:52 a.m. with the facility DON, the surveyor queried how she thought Resident #3 missed her pre-medicated pain medication 30 minutes before her wound care. The DON revealed when the physician's orders [REDACTED]. The DON revealed instead of transcribing two different orders for pain; one for administering pain medication 30 minutes before wound care and one every 4 hours prn pain, the nurse had handwritten the orders together on the MAR. Then under the MAR's Hour heading, she made a handwritten entry PRN which caused the nurses to believe the medication was only ordered prn. The DON also stated it was the duty of the ADON to check daily and make sure physician's orders [REDACTED]. She revealed ADON N was not working at the facility when the medication order was transcribed incorrectly onto the MAR. The DON stated she would personally follow-up and make sure new orders were monitored daily for transcription errors. 2) Review of the facility's most recent policy and procedure for Pain Management, dated February 2010, and provided by the Administrator revealed: "1. Upon admission, residents will be assessed for pain by using the Nursing Admission assessment Form. 2. Residents will be screened for pain by using the monthly Summary (Briggs) and the Pain Evaluation quarterly, annually and with a significant change and/or new onset of pain. a. Pain intensity and pain relief will be evaluated and re-evaluated at regular intervals. b. These evaluations will be used by the IDT to decide the appropriate therapeutic intervention, which may include pharmacological and non-pharmacological techniques. 3. Additionally, any resident report of inadequate pain control or identified with a new onset of pain, displays new signs or symptoms of pain, or identified through RAI process or otherwise will have a full evaluation of the pain conducted using the Pain Evaluation Form. 4. Following the pain evaluation, notify the physician of the findings and document on the Change of Condition/SBAR form (Briggs). Implement new orders as received. 5. Each resident identified for pain will have a Pain Management Care Plan (Briggs). The Care Plan will have individualized interventions related to that resident's individual control of pain management. The Care Plan should include both pharmacological and non-pharmacological pain management interventions. 6. The Licensed Nurse will implement a PRN Pain Medication Administration Record in the Medication Administration Record (MAR) binder for documentation of pain, interventions, and outcomes for all PRN pain medication. 9. The Pain Management Care Plan (Briggs) with interventions will be updated as indicated and discussed at the IDT stand up meetings, as needed. 10. The staff will implement the Care Plan, monitor the resident, and administer therapeutic interventions for pain, if ordered. 11. The Licensed Nurse when administering scheduled or routine pain medications, will record the drug administration on the routine MAR. Note: Effectiveness of routinely scheduled pain medications may be documented on the back of the MAR or a brief note may be written each day in the nurses' notes. If the resident is case managed or receiving skilled services, the note may be written on the Nursing Daily Summary. 12. The Licensed Nurse, when administering PRN Pain Medication Administration Record is as follows: - Record the pain scale using the Faces Rating 1 - 10. - Record the pharmacological interventions attempted. - Record the non-pharmacological interventions attempted. - Record the follow-up observations post intervention. If resident is asleep or resting, document it as an observation." 3) A review of the face sheet dated 08/05/10, revealed Resident #4 was admitted to the facility on [DATE]. The responsible party was reflected as a family member. A review of the Physician order [REDACTED]. These Physician order [REDACTED]." A review of the Physician's Telephone Orders dated 08/25/10, revealed the following order: "Resident to be evaluated by ____ Hospice Service." A review of the Physician's Telephone Orders dated 08/26/10, revealed the following order: "admitted to ____ Hospice." A review of the Physician's Telephone Orders dated 08/26/10, revealed the following order: "D/C pt. from skilled OT 2 (secondary) pt admitted to Hospice." A review of the Admission MDS assessment dated [DATE], revealed the following regarding Resident #4: had a durable power of attorney/financial and family member was responsible; had no DNR; was moderately impaired in cognitive skills for daily decision-making; heard with minimal difficulty when not is quiet sitting; made self understood and was usually able to understand; had no indicators of depression, anxiety and sad mood; had no behavior symptoms; required extensive assistance with bed mobility, locomotion off unit, dressing, toilet use, and personal hygiene; was totally dependent with transferring, eating, and bathing; did not walk in his room; had functional limitation to one side of his leg and foot; other persons wheeled him for locomotion; used bed rails for mobility or transfers; was lifted mechanically; used a transfer aid (e.g., slide board, trapeze, cane, walker, brace); was incontinent of bowel and bladder; did not have pain symptoms; had swallowing problems; had a feeding tube, was on a therapeutic diet and received dietary supplements between meals; received 76% to 100% of total calories through [MEDICATION NAME] or tube feedings; used six different medication; received ostomy care and oxygen therapy; required reorientation-e.g.., cueing for mood, behavior, and/or cognitive loss; had abnormal lab values during the last 90 days (or since admission). A review of the Resident Assessment Protocol Review Report dated 08/17/10, revealed the following regarding Resident #4; possessed some decision-making abilities; was not in End Stage Disease (6 month or less to live); did not experience a decline in the resident's ability to express, understand or hear information; had the ability to call on past memory to assist in current problem solving situations; and had impaired communication. A review of the Comprehensive Care Plan revealed the following regarding Resident #4: "Date 08/17/10 Problem Advance Care Planning... Goal Resident will be informed of his/her right to complete advanced directives to direct his/her values and treatment goals known. Resident stated desires will be honored. Approach Resident/responsible party advised of ACP. Advanced directives of residents choice completed and placed on medical record under advanced directives tab (copy in financial records). Physician notified of residents desires and any needed physicians order obtained. Resident/responsible party will be informed of any changes in residents condition and benefits, risk and possible choices of treatments." "Date 08/17/10 Problem Resident Request Code Status of: Full code... Goal Status will be maintained over next 90 days. Approach 1) Inform staff of code status. 2) Monitor for decrease in change of condition - report to M.D. and responsible party. 3) Make sure that code status is signed by resident or responsible party, and in the active medical record." A review of the Advance Directives/Medical Treatment Decisions Acknowledgement of Receipt dated 08/17/10, revealed it was signed by the Responsible Party for Resident #4. It reflected the following information: "This is to acknowledge that I have been informed in writing in a language that I understand of my rights and all rules and regulation to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate and to issue advance directives to be followed should I become decisionally incapable. I understand it is my responsibility to provide to the facility copies of all pertinent documentation which verify advance directives formulated and/or issued by me for placement in my medical record." This Advance Directives/Medical Treatment Decisions Acknowledgement of Receipt Form further acknowledged receipt of a Medical Durable Power of Attorney and Financial Durable Power of Attorney. It did not reflect receipt of a Do-Not-Resuscitate Order/Form. A review of the clinical record for Resident #4 revealed the presence of an 8" x 11" sheet of green paper with the words "FULL CODE" printed on it. A review of the clinical record revealed a Texas Department of Health Standard Out-of-Hospital Do-Not-Resuscitate Order regarding Resident #4, which was signed by the agent under Medical Power of Attorney and witnessed by two individuals on 08/26/10. This agent was the same person, who signed the facility's Consent to Treatment and was reflected on Resident #4's Face Sheet as the Responsible Party and Emergency Notification Person. This copy did not contain the signature of a physician. On 09/23/10 at 9:45 a.m., the DON was interviewed regarding the code status of Resident #4. She was asked if she knew Resident #4's code status. She stated, "He is a full code." She was asked if it was the facility's practice/policy to determine the code status or update the code status of a resident, especially if the resident was admitted to Hospice Services. She stated, "I can't say that's the policy. The only thing I can do is go back." On 09/23/10 at 3:45 p.m. an interview was conducted with the Hospice Social Worker. At that time, the Social Worker provided the surveyor with a copy of the Texas Department of Health Standard Out-of-Hospital Do-Not-Resuscitate Order regarding Resident #4, which was signed by the agent under Medical Power of Attorney, witnessed by two individuals and signed by the Physician on 08/26/10. The Hospice Social Worker was asked what the time frame was for notifying the facility of a change in resident's code status. She stated, "We usually get the facility a copy of the DNR no later than one day after it is signed but this one must have fallen through the crack." After review of the Clinical Record for Resident #4, it was revealed the facility did not identify Resident #4 as having a DNR from 08/26/10 to 09/23/10 (28 days). 4) CMS form 672, dated 09/21/10, and signed by the DON reflected 15 residents were identified as being on a pain management program, the resident census was 105 and 52 residents with Advance Directives.

Based on observation, interview, and record review the facility failed to ensure one (Resident #4) of 21 sampled residents was provided care and services when he developed feelings of anger, frustration and depression. Resident #4 was admitted to the facility on [DATE]. During the six weeks in the facility, the resident's wife died and the resident experienced signs of anger, frustration, and depression, which had been on-going. Facility staff were aware of the resident's behaviors. The facility did not recognize and address the resident's needs until surveyor intervention. Orders were then received for an anti-depressant and a psychiatric evaluation. These failures could affect the facility's 105 residents, including Resident #4, and placed them all at risk for decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, which might or might not be recognized by the facility, but not acted upon to improve the resident's quality of life resulting in these behaviors becoming more inclusive and more oppressive for the resident. Findings included: On [DATE] at 11:10 a.m. during initial tour with LVN KK, Resident #4 was observed lying in bed with full siderails up. The resident was awake, but the room was dark without any lights on, and the window shades were pulled shut. LVN KK stated Resident #4's roommate had a " condition, " which required the light be off most of the time. On observation, Resident ' s face was dry and flaky. Facial hair presence indicated the resident was in need of a shave. A review of the face sheet dated [DATE], revealed Resident #4 was admitted to the facility on [DATE]. The Physician order [REDACTED]. A review of Resident #4 ' s admission MDS assessment dated [DATE] revealed Resident #4 was moderately impaired in cognitive skills for daily decision-making, had no indicators of depression, anxiety and sad mood, and had no behavior symptoms. The Initial Social Services Assessment and History dated [DATE] reflected Resident #4 did not exhibit verbal expressions of distress, anger, anxiety, sleep problems, depression, crying, sadness or repetitive statements. There were no other Social Services Notes located in the clinical record. On [DATE] at 3:00 p.m. Resident #4 was observed in his room. He was in bed, and the television was on. One of two light bulbs worked, but the pull cord was out of reach. A music player was observed on a bedside table, but it was out of reach. No assistive device for reaching items was present. At the time of the observation, Resident #4 asked that the overbed table be placed in his reach. At that time an interview was conducted with Resident #4. Resident #4 stated the facility did not provide him with the assistance he needed. He stated he waited 4 - 6 hours for his call light to be answered. He stated he needed assistance with turning and positioning in bed as well as assistance with oral care. He stated the facility did not provide those services. He further revealed the staff controlled his lighting. He had no way to turn the lights on or off. He stated although he wanted to, he was not gotten out of bed except for showers. In regard to his siderails, Resident #4 said he had not been asked if he wanted them or not. He appreciated one siderail to help him turn when the facility staff cleaned him. Resident #4 added the facility would not get him any grape juice, so his son brought it to him. Still, the staff sometimes refused to give it to him. Resident #4 stated, due to his medical condition, he could not walk and therefore participate in any activities. He stated, " I feel sad about my condition. That is why I don't do anything. " The resident then volunteered he had just lost his " ex wife " approximately a week ago, which was contributing to his sadness. The resident was queried about any intervention from the facility to help him with his feelings. He said neither the staff nor his doctor had talked with him about his feelings. On [DATE] at 9:45 a.m., 1:00 p.m., 1:46 p.m., 2:23 p.m., the following were observed regarding Resident #4: He was in bed with siderails in the upright position. He had not been shaved. The overbed table was out of reach; the pull cord for the overbed light was out of reach; the one bulb in the overbed light did not work; a music player was sitting on the bedside table out of the resident's reach. A reacher was not observed. During an interview on [DATE] at 6:10 p.m., LVN U was asked if about Resident #4's demeanor and if he had been feeling sad. The nurse stated, "His wife was here (facility). She died two weeks ago. So all of last week, he (Resident #4) was real depressed. He didn't want us to do anything. This is the first week he is coming around ...The son didn't want him (Resident #4) to know the wife was here. She (Resident #4's wife) took a turn for the worst and they (family) took her home to go (die). He (Resident #4) was really down, really, really sad about it." LVN U was then asked if Resident #4 verbalized his sadness to anyone or did he keep it to himself. She stated, "He was vocal about it. He verbalized it to me. He likes to talk." Review of Resident #4 ' s current care plans dated [DATE] revealed the resident ' s sad behavior or withdrawal was not identified or addressed. On [DATE] at 9:45 a.m., an interview was conducted with the DON. She was asked the effects of an almost constant, dark, room would have on Resident #4. She stated, "He doesn't like to get out." On [DATE] at 11:20 a.m. 2:45 p.m., the following were observed regarding Resident #4: was observed lying in bed with full S/R in the up position; the over bed table was observed to be out of reach of the Resident #4; the pull cord for the over bed light was out of reach for Resident #4 to use without staff assistance; the one bulb was not working in the over bed light; a music player was sitting on the bedside table, out of the resident's reach. A reacher was not observed present. On [DATE] at 2:45 p.m. Resident #4 was interviewed. When asked if he wanted to get out of bed, he answered, "Yes. I would like to get up in the wheel chair, sit in the rooms, wheel myself outside, but I've let myself get so weak." He added, "This is so boring (just staying in the room)." At 3:45 p.m. on [DATE] an interview was conducted with the Hospice Social Worker. She was asked to describe Resident #4 ' s mental status. The Hospice Social Worker stated she had seen Resident #4 " mad. " She stated, "He gets mad when he can't watch his TV. He gets mad cause the roommates TV is loud." She added, "He was worried about his kids." The Hospice Social Worker was asked if she was aware if Resident #4 psychosocial needs had been assessed and addressed. She stated, "There hasn't been a social worker (at the facility) for the last few weeks." She was asked if anyone had communicated to her Resident #4 voiced feelings of sadness regarding his physical condition and the death of his wife. The Hospice Social Worker stated, "No one communicated that to me." She added, "He has said on occasion the staff don't give him drinks." She was then asked when the last time she saw/visited with him. The Hospice Social Worker said, " I saw him last week. " On [DATE] at 6:00 p.m. and on [DATE] at 9:30 a.m., the following were observed regarding Resident #4: He was in bed with full siderails in the upright position. The overbed table was out of reach of Resident #4; the pull cord for the over bed light was out of reach for Resident #4; the one bulb was not working in the over bed light; a music player was sitting on the bedside table out of the resident's reach. A reacher was not observed present. At 12:10 p.m. on [DATE], an interview was conducted with a family member of Resident #4. He stated, "He (Resident #4) had depression for a long time. It first started when he lost his job. He had a good job. He never got treatment. He ' s been depressed since that (time). " On [DATE] At 2:05 p.m., an interview was conducted with the AD. She was asked to identify the activities she provided for Resident #1. She stated, "I go into his room and turn his music on." She added that she "talks" to Resident #4 but he refuses to come out of his room. Physician ' s Telephone Orders dated [DATE] reflected, " Referral to be evaluated by Dr. ____, Psychiatrist. Start [MEDICATION NAME] (antidepressant) 10 milligram tablet via [DEVICE] q (every) day." Updates to Resident #4 ' s Care Plan dated [DATE] reflected: Problem Resident has signs of Depression Goal Resident will have fewer or no episodes of Depression and will voice positive feelings about self over next 90 days. Will not have S/E from [MEDICATION NAME]. Approach 1) Encourage resident to be an active participant in decision-making. 2) Encourage resident to be involved in activities of choice and preference. 3) Provide care in a warm and caring manner. 4) Give meds per order - monitor labs - report abnormals to M.D. 5) Provide Psych Consult per order 6) Allow resident to verbalize feelings. 7) Staff will encourage resident to sit up in w/c at least 3Xweekly. Allow choice of days. " The Resident Census and Condition of Residents (Form CMS 672) signed and dated on [DATE] by the DON reflected a facility census of 105.

Based on observation, interview and record review, it was determined the facility failed to provide adequate supervision and/or safe transfers to prevent resident injury for two (Residents #12 and #19) of 21 sampled residents. 1. Resident #19 was assessed at High Risk for falls and required the extensive assistance of two persons for transfers. The resident experienced an unwitnessed fall from her bed and fractured her hip. No fall prevention measures had been implemented. 2. Resident #12 was assessed as requiring two persons for transfer assistance. CNA E attempted to transfer the resident alone after the resident requested additional assistance. The resident fell to the floor and sustained a fracture of her left, lower leg. These failures could affect the facility's 96 residents, who required assistance with transfers, including Residents #12 and #19, and placed them at risk for falls, fractures, abrasions, bruises, pain and mental anguish. 3. Resident #16 almost fell from his motorized wheelchair when he hit a pothole in the outside walkway/pathway, which was accessible to residents. There were three loose pieces of concrete and potholes in the outside walkways of the facility. This failure could affect the 10 residents, who were independently ambulatory, including Resident #16, and placed them at risk for accidents causing falls, injury, pain and suffering. 4. The medicine cabinet in one (300 Hall) of eight shower rooms was unlocked and accessible to residents. Razors and other toiletries were stored in the cabinet. This failure could affect the facility's ten residents, who were independently ambulatory, allowing them access to hazardous items, which could result in injury, pain and suffering. Findings included: 1) Initial tour on 09/21/10 at 10:15 a.m. with ADON F revealed Resident #19 was admitted to the hospital "about three weeks ago" for a fracture of her "femur." Resident #19 was found beside her bed with bed sheets tangled around her legs at the time of the fracture. ADON F revealed Resident #19 did not walk, was transferred using a gait belt with assistance of one staff member, was non-interviewable, required total assistance with ADLs, was incontinent of bowel and bladder, and required assistance in eating her pureed food. Resident #19's current MDS assessment (Significant Change in Status) dated 08/17/10 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #19 was severely impaired for cognitive skills for daily decision making. Resident #19 required extensive assistance from two plus staff members with transfers, locomotion on the unit, dressing, toilet use, and personal hygiene. Resident #19's primary mode of locomotion was by a wheelchair, pushed by a staff member. The MDS reflected Resident #19 had experienced a fall in the past 30 days, but did not have a hip fracture in the past 180 days. Review of Resident #19's History and Physical dated 08/03/10 and completed by the NP when she was readmitted from a hospitalization revealed, "Pt has multiple complex medical conditions including status [REDACTED]." Review of Resident #19's RESIDENT TRANSFER EVALUATION dated 09/03/10 revealed the resident had a total score of nine, which placed her in "Category 3: (score 9-14) Caregiver performs 50% of the task or greater. Equipment: Mechanical Lift (Total Body/Sling or Stand Assist as appropriate)...." Review of Resident #19's Comprehensive care plan dated 09/03/10 revealed the facility identified the resident's risk for falls and revealed, "...Res. continues to be at risk for falls but has become more alert and is able to stand with assist X 2 to transfer...." Review of Resident #19's INCIDENT/ACCIDENT REPORT dated 09/12/10 at 5:30 p.m. revealed the resident was "found sitting on the floor by her bed with bed sheet wrapped around her legs - unattended. Assisted back into her bed - able to bear wt on L (left) leg, but not on R (right) leg - R leg pulled up as if contractured (sic) - c/o pain to R femur area. Able to MAE (move all extremities) ... C/o (complaint of) pain to R femur area...." Review of LVN A's written statement dated 09/12/10 and attached to the Incident/Accident Report revealed, "Was called to pt's (Resident #19's) room to find her sitting on the floor by her bed with bed sheet wrapped around her legs. Assisted per 2 (people) back to bed. Unable to bear wt on her R leg - looks pulled up as if contractured (sic) - c/o pain to R femur area when asked 3 different times. Xrays (sic) of R hip & R femur ordered." Interview on 09/22/10 at 1:00 p.m. with LVN A revealed she worked on the 6:00 a.m. to 6:00 p.m. shift on 09/12/10. MA D called her to Resident #19's room on 09/12/10. She observed Resident #19 on the floor with the bed sheets wrapped around her legs. Resident #19 could not bear weight on her right leg, but could on her left leg. Resident #19 pointed at her right leg when asked if she was in pain, and said, "Yes." Resident #19 then contradicted herself and said, "No." LVN A said Resident #19 had Dementia. LVN A then stated, "I didn't know what she was feeling." LVN A stated Resident #19's right leg was "bent at the knee," but after the resident was transferred to her bed it "looked normal." LVN A thought the incident occurred around 5:30 p.m., but she said MA D thought it was earlier. LVN A revealed she didn't look at the clock. LVN A revealed she called for an x-ray on Resident #19's right lower extremity. When LVN A was queried as to the decision to not send the resident to the emergency room , and she stated she needed to do "finger sticks and insulins," because it was almost dinner time for the residents. Resident #19 "settled down" after she was transferred to her bed. When LVN A was asked what type of emergency would prompt her to send a resident to the emergency room , she stated, "Respiratory arrest, cardiac arrest and an open fracture. With a closed fracture you don't know if it's broken so I wouldn't send them out until after an x-ray confirmed it." When LVN A was asked what kind of complications could result from a hip fracture, she stated, "fat embolism, nerve damage, vascular compromise and impaired circulation." When asked how a resident's leg might look if their hip was fractured, she stated, "It could have external rotation, maybe shorter, can't bear weight and complain of pain." LVN A stated she reported the incident to RN C at the end of shift report (at approximately 6:00 p.m.). Review of Resident #19's Physician's Telephone Orders dated 09/12/10 at 4:35 p.m. revealed, "X-ray R leg R/O (rule out) fx (fracture)." Review of Resident #19's NURSING DAILY SKILLED SUMMARY dated 09/12/10 at 5:30 p.m. revealed, "Resident found sitting on the floor by her bed, bed sheet wrapped around her legs. Assisted back to bed unable to bear wt on R leg - R leg is contractured (sic). Neuro is WNL (within normal limits). Able to bear wt (weight) on L leg and moves extremities... 6:15 p (p.m.) X-ray ordered for R hip and R femur..." NP H was notified and ordered Ultram (pain medication)... 8:30 p X-ray done with nurse assisting technician to position pt. Nurse explained to x-ray tech that resident has contracture to R leg. Pt did not show any signs of pain... 10:15 p x-ray returned for more pictures, stated that she did not get enough for viewing. Nurse assisted x-ray technician to position pt. for x-ray. Pt asleep throughout positioning. Neuro checks WNL..." The notes reflected the nurse instructed the RCS (Resident Care Specialist - CNA) to be "careful during pericare and call for assistance with turning pt. 3:30 am (a.m.) x-ray results called into nurse...." RN C faxed the x-ray results to NP H. Review of Resident #19's Physician's Telephone Order dated 09/12/10 at 6:30 p.m. revealed an order for [REDACTED]. One to two tablets were to be given every six hours whenever necessary for pain. Review of Resident #19's x-ray report with a date of service 09/12/10 and faxed to the facility on [DATE] at 12:18 a.m. revealed, "...RIGHT HIP UNILATERAL: There is a right intertrochanteric fracture with modest displacement. Mild callous formation is seen. The joint shows no dislocation. Pubic rami are intact. Osteoporosis is present ... RIGHT FEMUR: The femur shows osteoporosis. There is a right intertrochanteric fracture with modest displacement. Mild callous formation is seen. The joint shows no dislocation. Pubic rami are intact. The remainder of the femur is intact...." Interview on 09/22/10 at 1:15 p.m. with RN C stated she worked the 6:00 p.m. (09/12/10) to 6:00 a.m. (09/13/10) shift. RN C said Resident #19 did not appear to be in pain when she assessed her. RN C revealed she received a verbal report from the local x-ray company at approximately 3:30 a.m., and at that time she learned the x-ray report had been faxed to the facility earlier that morning. RN C stated she did not call NP H with the x-ray report; instead she faxed the x-ray report to NP H. RN C said she should have called NP H stating, "I don't know why I didn't." RN C revealed when she gave report at approximately 6:00 a.m. 09/13/10 to LVN B, LVN B made the decision to send Resident #19 to the emergency room . Interview on 09/24/10 at 10:00 a.m. with RN C revealed she did not send Resident #19 to the emergency room after receiving the x-ray report reflecting a fracture because she was waiting on NP H to call back with orders. When RN C was asked what complications could occur as a result of a hip fracture, she replied, "Bleeding, blood clots and long term disability." RN C stated the x-ray report didn't sound "that urgent." RN C stated she was very busy that night and had sent another resident to the emergency room . RN C stated, "I took on too much. It will never happen again." Interview with X-Ray CSR from the local x-ray company on 09/24/10 at 9:40 a.m. revealed the call for an x-ray for Resident #19 came in on 09/12/10 at 4:48 p.m. and was listed as a "normal case." The x-ray technician was dispatched "five minutes later." X-ray reports were on auto-fax, and were faxed to a facility immediately after receiving the report. A verbal report was given by phone afterwards to confirm receipt of the faxed report. Resident #19's verbal report was given at 2:00 a.m. on 09/13/10 to RN C. The local x-ray company had used the auto-fax for the "last three months." Interview with LVN B on 09/23/10 at 12:25 p.m. revealed she worked the 6:00 a.m. to 6:00 p.m. shift on 09/13/10. When she received report from RN C regarding Resident #19, and learned the resident had a hip fracture, she decided to send her to the emergency room . Resident #19 was sent to a local emergency room at approximately 7:00 a.m. LVN B stated she looked at the x-ray report, and thought, "Why is she still here?" Interview with ADON F on 09/23/10 at 2:40 p.m. revealed she learned Resident #19 had a right hip fracture from LVN B on the morning of 09/13/10. ADON F stated she did not know why Resident #19 was not sent to the emergency room immediately. ADON F stated, "I would have sent her out when the resident couldn't bear weight. I still don't understand why she wasn't sent out. I would have sent her out without a physician's orders [REDACTED]." Interview with a local Hospital Social Worker on 09/22/10 at 2:15 p.m. revealed Resident #19 was checked into the emergency roiagnom on [DATE] at 8:30 a.m. Resident #19 had right hip surgery with an open reduction with internal fixation on 09/17/10. Interview with the DON on 09/22/10 at 4:50 p.m. regarding Resident #19's fall revealed, "The nurse should call the physician and see what he wants to do." The DON was queried about possible complications of a hip fracture. She stated, "Pain, deformities, they could throw a clot and eventually die if it goes to the lung or organs." The DON revealed LVN A "did an assessment and did order x-rays." The DON stated, "I don't want to say the nurse did anything wrong." When asked how she could ensure delay in treatment and notification of changes would not be repeated with another resident, the DON stated, "When things happen, I talk to them (staff) about what we need to do. As their leader I give recommendations. I didn't document the conversations." The DON said RN C "should have called the doctor when she got the x-ray report. You can't depend on a fax especially at three in the morning. You have to call the doctor." Untitled and undated notes signed by the DON regarding Resident #19's fractured right hip were provided to the surveyors to review. The notes reflected, "...After staff interviews it was determined that the fall was not caused by staff or negligence. It was identified that staff in-service needed to be given for a clear picture on what items needed to be called to nurse management and/or Administrator. Also, that the staff members involved needed additional training on incidents ie when to notify physician, supervisor, process for x-ray results, etc. This in-service was completed on Wednesday, September 15 (2010)." Interview on 09/22/10 at 1:30 p.m. with LVN M revealed when the surveyor asked LVN M if a fractured hip was an emergency she replied, "Of course." LVN M stated , with a hip fracture, there could be internal bleeding and the resident could go into shock. LVN M revealed a resident with a hip fracture would complain of pain, may have rotation of the leg, and the leg could appear shorter. If a hip fracture was suspected, LVN M would send the resident to the emergency room even if there was not an x-ray. Review of Resident #19's INCIDENT/ACCIDENT INVESTIGATION FOLLOW-UP from 09/12/10 revealed: "...PAST INTERVENTIONS ATTEMPTED... falling star program, bed chair alarm, low bed position. RECOMMENDATIONS/NEW INTERVENTIONS Will re-evaluate resident when she returns from hosp...." An undated note included reflected, "...After interviewing the staff there were no signs of neglect. The resident was properly positioned in bed and the bed in proper position. The resident had hardly any muscle mass and has dx of osteoporosis, which exposed her to higher risk for injury." Review of an Attendance Form for "Fall Intervention" dated 09/15/10 listed a total of two employees, LVN A and MA D, in attendance. The form reflected, "Inservice Regarding falls. Assessment of Res (resident) that has fallen is first. If Resident is not standing as she usually does or it is noticed that she is not bearing weight on one foot, verbalizing pain or facial grimacing after/before phy. (physician) notified this Resident can and should be sent to the hospital. This is a Nursing Assessment." On 09/28/10 the facility provided DISCIPLINARY ACTION RECORDs on LVN A and RN C to the surveyor by fax, regarding Resident #19. Review of LVN A's DISCIPLINARY ACTION RECORD dated 09/26/10, 14 days after Resident #19 had an un-witnessed fall, revealed, "...On 9/12/10 Charge Nurse during her 6A-6P shift had a Resident fall out of bed. (Resident #19) was assessed by charge nurse and according to I/A report when Res. was assisted to a standing position she said 'ouch' and would not bear wt on one leg. Charge nurse did not follow policy by using Resources available to her when she was not able to reach the Nurse Practitioner. Charge Nurse wrote order for x-ray but did not specify STAT. Also did not notify Nurse Manager on Duty, DON or Administrator. Employee Statement: To be completed by employee. In the past, I was informed not to call 'on call' personnel. Didn't think to notify mgr (manager) on duty, DON, or administrator @ this time; just 'sailing my ship.' The nurse practitioner had told us to 'use your head, use your common sense, you're a nurse with a license' When calling her in the past; I was just using my head & common sense. Corrective Action: To be completed by Supervisor. Be specific, include goals and timetable for follow-up. Charge Nurse will set up time for education with SDC no later than Tue 9/28/10...." Review of RN C's DISCIPLINARY ACTION RECORD dated 9/26/10, 14 days after Resident #19 had an un-witnessed fall resulting in a hip fracture, revealed "...Charge Nurse did not follow policy with notification to manager on duty, DON or Administrator Regarding the Res. fall. Even after (local x-ray company) called the results to the Charge Nurse no attempt was made to get the Res. to the hospital... Corrective Action: To be completed by Supervisor... Employee will set up time with SDC by 9-28-10 for education...." 2) Initial tour on 09/21/10 at 10:20 p.m. with ADON F revealed Resident #12 required transfers with a mechanical lift, did not walk, was incontinent of bowel and bladder, was alert and oriented to person, place and time; and had a fall approximately a month ago which resulted in a left tibia (lower leg) fracture. When ADON F was asked if Resident #12 had behaviors, she said, "She cries, looks for sympathy and has a pity thing." Resident #12 was observed with a fracture boot on her left lower leg. Resident #12's facility face sheet dated 09/24/10 reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #12's admission MDS assessment dated [DATE] revealed the resident was independent for cognitive skills for daily decision-making and required extensive assistance from two plus staff members for bed mobility, transfers, toilet use, and personal hygiene. Resident #12's mode of locomotion was by wheelchair pushed by another person. Resident #12's ADL self-performance had deteriorated, and the resident was receiving Physical and Occupational Therapies. Review of Resident #12's COMPREHENSIVE PLAN of CARE for ADL Functions dated 06/16/10 revealed, "Transfers: ext (extensive) X 2 Assist: Hoyer (mechanical lift)...." Interview on 09/21/10 at 12:25 p.m. with Resident #12 revealed she was a retired Registered Nurse. When Resident #12 was asked by the surveyor how she fractured her left lower leg, she said on the day of the incident, she told CNA E she needed to use the bed side commode. Resident #12 revealed she asked CNA E to get some help before transferring her from her chair to the bedside commode, but CNA E ignored her request. CNA E placed the gait belt around Resident #12's waist, and instead of holding onto the gait belt at the resident's sides, she grasped the gait belt with both hands in front of the resident. Resident #12 revealed since she was an RN, she knew CNA E was supposed to place her hands on the gait belt on each side of her waist. Resident #12 revealed CNA E assisted her into a standing position, and when the resident became unsteady, CNA E panicked and jerked her in an upward motion, but then dropped her onto the floor. She stated she landed in a sitting position with her left leg folded under her. Resident #12 stated she was able to remove her left leg from underneath her. Resident #12 added she was screaming, and CNA E and "someone else" came into the room and tried to "shush me." Resident #12 stated she told them CNA E dropped her. Resident #12 stated she did not think CNA E intentionally dropped her. Resident #12 said she no longer wanted any staff members except PT G to transfer her. Review of a written statement from PT G attached to the Incident/Accident Report dated 08/23/10 revealed, "PT called to pt's room to assist with floor transfer per pt request. Upon entering, PT saw pt in long-sitting on floor in front of bedside commode. Pt states 'they dropped me.' Pt in distress with yelling and moaning...." Review of ADON F's written statement attached to the Incident/Accident Report dated 08/23/10 revealed, "When I entered (Resident #12's) room to see how she was and what happened, she said the girl had the gait belt around me and she was very strong and lifted her off her feet and when she came down her legs were like wet noodles and the girl sat her on the floor. She said she was in a sitting position and moved her leg from under her. She started saying, 'Make sure you tell them exactly what happened'...." Review of Resident #12's PHYSICIAN's TELEPHONE ORDERS dated 08/23/10 at 11:35 a.m. revealed an order for [REDACTED]. Review of Resident #12's x-ray result dated 08/23/10 at 1:49 p.m. revealed, "...LEFT KNEE: There is a fracture involving left proximal fibula with no displacement. The joint shows no dislocation. There is no joint effusion. Osteoporosis is present. IMPRESSION: Acute left proximal fibula fracture as described above. LEFT TIBIA/FIBULA: There is a fracture involving the proximal fibula with no displacement. The knee and ankle joints are intact in alignment. Osteoporosis is present. IMPRESSION: Acute left lower leg fracture as described ...." Interview with LVN M on 09/22/10 at 1:30 p.m. revealed on the morning of 08/23/10 she heard Resident #12 screaming. LVN M entered Resident #12's room and found her on the floor in a sitting position with her legs out in front of her. Resident #12 told LVN M her leg had been under her. Resident #12 stated CNA E dropped her. Resident #12 complained that her left leg hurt. The resident would not allow anyone to transfer her to her bed except for PT G. PT G and another staff member used a mechanical lift to transfer the resident to her bed. (LVN M did not identify the other staff member.) LVN M called and reported the incident to the resident's physician and obtained an order for [REDACTED]. LVN M revealed an x-ray report was faxed first to the facility, and later a verbal report of the x-ray was given over the phone from the local x-ray company. Each nurse's station had a fax machine where an x-ray report could be faxed. Interview with PT G on 09/22/10 at 2:10 p.m. revealed he entered Resident #12's room on 08/23/10 to assist the resident with a transfer. Resident #12 was sitting on the floor with her legs in front of her. He stated the resident was tearful and complained that her legs hurt her. Resident #12 told PT G when she fell , her leg folded under her. Resident #12 said, "They dropped me. They dropped me." PT G stated the resident told CNA E it was not her fault. PT G and another staff member, who was no longer at the facility, assisted in transferring Resident #12 into her bed with a mechanical lift. PT G revealed Resident #12 was fearful. He stated, "Now she won't let anyone transfer her but me." PT G revealed the resident was walking with him approximately 100 feet with stand by assistance before the fall. PT G was asked how many staff members were required to assist Resident #12 with gait belt transfers prior to the fall. He replied, "Probably one CNA, but if having a bad day, she would need two staff to assist." Interview with CNA E on 09/22/10 at 2:45 p.m. revealed she worked on a PRN (as needed) basis. On 08/23/10 Resident #12 requested help in transferring from her chair to the bed side commode. CNA E revealed she placed the gait belt around Resident #12's waist, held onto both sides of the gait belt, counted to three and Resident #12 pushed up from her chair. Resident #12 "held onto her walker" but began to fall. CNA E said at that time she "eased" the resident down into a "squatting position." CNA E stated the resident began to "yell at that time." Interview on 09/22/10 at 4:50 p.m. with the DON revealed she and ADON F talked with Resident #12 after the incident, because PT G had told them Resident #12 said she was dropped. The DON stated, "She (Resident #12) didn't mention she was dropped." Referring to the conversation with Resident #12, the DON stated, "I didn't write it down." Review of Resident #12's NURSING DAILY SKILLED SUMMARY forms revealed Resident #12 required "limited assistance" with transfers on 06/20/10, 07/11/10, and 08/13/10, 08/14/10 and 08/20/10. Resident #12 required extensive assistance with transfers on 06/21/10, 06/30/10, 07/01/10, 07/12/10, 07/26/10, 07/28/10, 08/08/10, 08/21/10, 08/22/10, and 08/23/10. Interview with LVN M on 09/23/10 at 12:30 p.m. revealed Resident #12 "fluctuates" from day-to-day on the amount of assistance required for transfers. On some days, Resident #12 required "limited assistance" with a one-person, gait belt transfer, and other days she required "extensive assistance" with two-person transfers. LVN M stated, "She (Resident #12) doesn't stay the same; she's weaker some days more than others." Interview with the Administrator and the DON on 09/23/10 at 2:00 p.m. revealed, based on Resident #12's latest Care Plan and Cardex, Resident #12 required one person assistance with gait belt transfers prior to her fall. When queried about Resident #12's MDS assessment reflecting the resident required extensive assistance with two staff members for transfers, the DON replied, "Well, that's how you have to code an MDS. If the resident falls one time you have to code it that way." The Administrator and the DON were informed PT G and LVN M stated prior to the Resident #12's fall, some days the resident required limited assistance with one person gait belt transfers, and other days she required extensive assistance with two person gait belt transfers. The Administrator and the DON were asked how the staff knew if Resident #12 was having a good or a bad day? The Administer and DON did not answer. 3) Review of Perry and Potter's Clinical Nursing Skills & Techniques, Fifth Edition, Copyright 2004, chapter 27, Body Mechanics, Transfer, and Positioning, pages 808 and 810 revealed, " ...Expected outcome following completion of procedure: ... Client transfers without injury ... Rationale ... Proper techniques avoid injury ... Transfer belt is grasped at client's side to provide movement of client at center of gravity ...." Review of the facility's current Gait Belt Use policy dated 2/2010 revealed, "...If, during the course of care, it becomes necessary to provide lift/transfer assistance in a manner other than that specified in the resident's plain of care, the caregiver will contact his/her supervisor prior to the lift/transfer ...." 4) On 09/24/10 at approximately 10:15 a.m., observations of the outside environment of the facility revealed: A) Three loose pieces of concrete and a hole in the pavement at the bottom of the wheelchair ramp leading into the alcove between Room 237 and the laundry. B) A pothole in the pavement where the asphalt joined the cement at the northeast curve of the driveway. C) A large pothole on the east side of the pavement where the asphalt joined the cement at the curve in the driveway. There was a smaller pothole at the other end of the curve on the west side of the building. At that time, Resident #16 was observed by the surveyor riding around the drive in his motorized wheelchair. Resident #16's motorized wheelchair almost ran into the small pothole on the west side of the curve, causing him to almost tip over in his motorized wheelchair and land on the ground. 5) On 09/24/10 at approximately 12:30 p.m., the surveyor observed the following in the un-locked shower room across from the nurse's station for Hall 300: A) Both doors for the locked wall cabinet in the back right corner of the shower room were unlocked. The keys were in the lock. A sign on the cabinet door reflected "Must remain locked and closed at all times." B) A small blue plastic caddy containing five, un-used, disposable, blue plastic safety razors was located on the first shelf of the same unlocked wall cabinet. There were multiple empty plastic shampoo bottles, body wash bottles and disposable razor bags lying on the shelf around the caddy. C) A white plastic basket was fastened to the wall across from the shower stalls, which contained the a red, plastic, biohazard box, which had no lid. The red plastic biohazard box was approximately one-third full of used disposable blue plastic safety razors. 6) The DON provided a list of eight residents, who received in-house fractures from March 2010 through 09/24/10. The facility's CMS form 672 (Resident Census and Conditions of Residents) dated 09/21/10 and signed by the DON reflected 96 residents required assistance from staff with transfers and ten residents were independently ambulatory. The facility identified 10 residents who were independently ambulatory as reflected on the Resident Census and Condition of Residents signed and dated by the DON on 09/21/10. On 10/05/10 at 4:00 p.m., during a telephone interview, the Administrator identified 23 residents, whose medications were stored in Medication Cart #1.