Every finding on record at Landmark of Baton Rouge

Based on observations, record review, and interviews, the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles for 2 (Cart A and Cart B) of 3 medication carts reviewed. Review of the facility's policy titled Medication Storage with a revision date of 11/2017 revealed, the following, in part: Medication storage shall meet all applicable federal, state and local guidelines. On 02/23/2026 at 11:40 a.m., an observation was made of Cart B with S6LPN, which revealed fifteen loose and unlabeled pills on the bottom of the cart's drawers. On 02/23/2026 at 11:52 a.m., an interview was conducted with S6LPN. She stated the nurses should check the medication carts daily for loose medications. S6LPN confirmed the above pills were loose and unlabeled in the cart and should not have been. On 02/23/2026 at 12:07 p.m., an observation was made of Cart A with S7LPN, which revealed one loose and unlabeled pill on the bottom of the cart's drawer. On 02/23/2026 at 12:23 p.m., an interview was conducted with S7LPN. She stated the nurses should check the medication carts daily for loose medications. S7LPN confirmed the above pills were loose and unlabeled in the cart and should not have been. On 02/23/2026 at 2:15 p.m., an interview was conducted with S2DON. She stated she expected the nursing staff to perform medication cart checks on each shift, which included checking for any loose medications in the cart's drawers. She confirmed medications should not be loose and unlabeled in the cart.

Based on record reviews and interviews, the facility failed to ensure dietary services were provided in accordance with professional standards for food service safety for the 117 residents served a meal tray from the kitchen. The facility failed to ensure:Staff routinely performed temperature checks on the food served to residents; and Thawing of meat in the refrigerator, in a drip-proof container.1.Review of facility's Policy titled Sanitary Conditions of the food service department with a revision date of 05/2018 revealed the following, in part: Policy: Facilities and equipment used in the preparation and serving of food provided to residents are safe and sanitary. Review of the facility's policy titled, Monitoring temperatures of cooked foods, last reviewed 02/2022, revealed the following in part: Policy: The temperature of potentially hazardous cooked foods will be monitored to insure that the foods are not in the danger zone for more than 6 hours.Procedure: 2. The temperature of each potentially hazardous food will be taken at the following times. a.) when the cooking process is completed. 3. Cooking, holding and storage temperatures should be recorded on Food Temperature Monitoring Log. These logs should be maintained at least three months. Review of food temperature log binder, as of 02/23/2026 at 9:00 a.m., revealed missing food temperature logs on the following meal dates: 02/18/2026 - lunch, 02/19/2026 - breakfast and lunch, 02/21/2026 - dinner, and 02/22/2026 - dinner. On 02/23/2026 at 8:44 a.m., an interview was conducted with S3DPM. S3DPM confirmed the above food temperature logs were missing and should have been documented. On 02/23/2026 at 1:38 p.m., an interview was conducted with S4DM. S4DM confirmed the above food temperature logs were missing and should have been documented. 2.Review of the Weekly Cleaning Schedule revealed the refrigerators should be cleaned by the dishwashers as needed. On 02/23/2026 at 8:37 a.m., a tour was conducted of the facility kitchen with S3DPM. There were dark red meat drippings on the main refrigerator floor. On 02/23/2026 at 8:44 a.m., an interview was conducted with S3DPM. S3DPM confirmed the meat drippings should not be on the floor of the refrigerator. On 02/23/2026 at 1:37 p.m., a tour was conducted with S4DM. S4DM showed us the refrigerator and the dark red meat drippings were still on the floor. On 02/23/2026 at 1:38 p.m., an interview was conducted with S4DM. S4DM confirmed the meat drippings should not be on the floor of the refrigerator.

Based on observations and interviews, the facility failed to ensure resident's room were clean and maintained in a sanitary manner for 1 (#15) of 3 (#15, #23, and #34) sampled residents investigated for environment. The facility failed to ensure Resident #15's room was properly cleaned.A review of Resident #15's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Hemiplegia And Hemiparesis Following Cerebrovascular Disease Affecting Left Dominant Side, Dysphagia, Cognitive Communication Deficit and Aphasia On 02/24/2026 at 1:58 p.m., an observation was conducted of Resident #15's bathroom. Resident #15's bathroom was noted with the following: one foot in front of the commode was a clear wet liquid with a dried brown substance approximately 4 cm in length. Adjacent to the commode base was a large dried brown substance approximately, one foot in length and 6 inches in width. The paper towel dispenser was noted to be covered with a dry white substance. The wall next to the trim exiting the bathroom was noted to have two dry brown markings approximately 2-3 cm in length, and the light switch plate had 4 markings of a dried brown substance.On 02/25/2026 at 10:00 a.m., an observation was conducted of Resident #15's room. Surveyor entered Resident #15's room and noted wet floors. Resident #15 shook his head, indicating housekeeping had recently cleaned his room. Resident #15's bathroom was noted with the following: one foot in front of the commode was a clear wet liquid with a dried brown substance approximately 4 cm in length. Adjacent to the commode base was a large dried brown substance approximately, one foot in length and 6 inches in width. The paper towel dispenser was noted to be covered with a dry white substance. The wall next to the trim exiting the bathroom was noted to have two dry brown markings approximately 2-3 cm in length, and the light switch plate had 4 markings of a dried brown substance.On 02/25/2026 at 11:08 a.m., an interview was conducted with S10HK. She confirmed she had cleaned and sanitized Resident #15's room and bathroom this morning.On 02/25/2026 at 11:40 a.m., an observation and interview was conducted with S8AADM and S9HKS. They both confirmed the above observations in Resident #15's room and the bathroom. They both confirmed Resident #15's room and bathroom were not clean and sanitary.

Based on observations, interviews, and record reviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards of practice. The facility failed to ensure oxygen tubing was labeled for 1 (#14) of 26 residents reviewed in the final sample. Findings: Review of the facility's policy titled Infection Control Oxygen Equipment Cleaning, with a revision date of 03/18 revealed the following:Use disposable tubing, masks, and cannulas for patients receiving oxygen therapy.7. Tubing should be replaced every 7 days.10. When not in use, store the mask/cannula in a plastic bag clearly labeled with the resident's name and date. Review of Resident #14's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Pneumonia and Atrial Fibrillation.Review of Resident #14's admission MDS with an ARD of 02/05/2026 revealed Resident #14 had a BIMS of 11, which indicated moderate cognitive impairment. Review of Resident #14's current Physician Orders revealed the following, in part: -Ipratropium-Albuterol Inhalation Solution 0.5-2.5 MG/3ML. 1 vial inhale orally every 6 hours as needed for Dyspnea related to Pneumonia. On 02/23/2026 at 11:22 a.m., an observation was made of Resident #14's room. The tubing connected to Resident #14's nebulizer and the tubing connected to Resident #14's portable oxygen canister were not labeled. On 02/24/2026 at 8:33 a.m., an interview was conducted with S12LPN. S12LPN observed and confirmed the tubing connected to Resident #14's nebulizer and the tubing connected to Resident #14's portable oxygen canister were not labeled and should have been. On 02/24/2026 at 3:55 p.m., an interview was conducted with S2DON. S2DON confirmed all nebulizer and oxygen tubing should be labeled with the date it was changed.

Based on observations, interviews, and record review, the facility failed to provide pharmaceutical services, including services that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident. The facility failed to ensure a resident had a physician's order before being allowed to self-administer medication, including routine medication, for 1 (#51) of 26 residents reviewed in the final sample.Findings:Review of the facility's policy titled Self-Administration of Medication, with a revision date of 11/2017, revealed the following, in part:A resident will be allowed to self-administer medications only if:a) the attending physician writes or gives a verbal order that the resident may keep a medication at the bedside for the purpose of self-administration2.) All medications are kept in a locked cabinet or box in the resident's room.Review of Resident #51's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included Diabetes Mellitus Type 2 and Dermatitis.Review of Resident #51's Annual Minimum Data Set with an Assessment Reference Date of 11/28/2025 revealed a Brief Interview for Mental Status of 15, which indicated Resident #51 was cognitively intact.Review of Resident #51's current Physician's Orders revealed no evidence of a written order for self-administration of medication.On 02/23/2026 at 12:26 p.m., an observation was made of a bottle of generic Benadryl sitting on Resident #51's bedside table.On 02/24/2026 at 8:33 a.m., an interview was conducted with S12LPN. S12LPN stated residents should not have medications, including over the counter, kept at their bedside without a physician's order to self-administer. She further stated medications should be kept in a locked compartment in the resident's room if they were able to self-administer.On 02/24/2026 at 10:35 a.m., an observation was made of a bottle of Benadryl tablets on Resident #51's bedside table.On 02/24/2026 at 12:50 p.m., an observation and interview was conducted with S11LPN. S11LPN stated residents should have a doctor's order for self-administration of medications and medications should be kept in a locked compartment in the resident's room if they were able to self-administer. S11LPN observed the bottle of generic Benadryl on Resident #51's bedside table. She confirmed Resident #51 did not have an order to self-administer medications and should not have had medications in her room.On 02/24/2026 at 3:55 p.m., an interview was conducted with S2DON. S2DON stated a resident must have a Physician's Order to keep medication at their bedside to self-administer and medications had to be locked in a drawer/compartment. She confirmed Resident #51 did not have a self-administration order and should not have had medications in her room.

Based on record reviews and interviews, the facility failed to ensure it was free of significant medication errors for 1 (#126) of 11 residents reviewed for medication administration. Review of Resident #126's clinical record revealed he was admitted to the facility on [DATE] with a diagnosis of Sepsis due to Methicillin Resistant Staphylococcus Aureus (MRSA). Review of Resident #126's admission MDS with an ARD of 02/24/2026 revealed it was still in progress and the BIMS had not been completed. Review of Resident #126's Discharge Orders from a local hospital dated 02/19/2026 revealed the following antibiotic order:Daptomycin-Sodium Chloride Intravenous Solution. Inject 1000 mg into the vein in the morning for 19 days. Indication: Bacteria in the blood. Review of Resident #126's Physician Orders since admission revealed, in part: Start date 02/20/2026. Daptomycin-Sodium Chloride Intravenous (IV) Solution 1000-0.9 mg/ml. Review of Resident #126's MAR dated February 2026 revealed the following, in part:Daptomycin charted as administered on 02/20/2026 by S7LPN;Daptomycin charted as a 9 on 02/21/2026 and 02/22/2026 by S13LPN; Daptomycin charted as administered on 02/23/2026 by S7LPN; and Further review of the MAR revealed a 9 indicated Other, See Progress Notes. Review of Resident #126's Progress Notes dated February 2026 revealed the following, in part:02/21/2026 at 7:23 a.m. - Daptomycin-Sodium Chloride Intravenous Solution 1000-0.9 mg/ml. Medication not available. Signed, S13LPN; and02/22/2026 at 7:36 a.m. - Daptomycin-Sodium Chloride Intravenous Solution 1000-0.9 mg/ml. Medication not available. Signed, S13LPN. On 02/23/2026 at 9:24 a.m., an interview was conducted with Resident #126. He stated he acquired a post-operative surgical infection and was admitted to the facility for IV antibiotics on 02/19/2026. He stated he was supposed to receive the antibiotic every morning. He stated he did not receive the antibiotic over the weekend on 02/21/2026 and 02/22/2026. He stated he was told by S13LPN, she could not find the antibiotic. He stated he received the antibiotic on the morning of 02/20/2026 and this morning, so he did not understand why the nurse told him she could not find it over the weekend. On 02/25/2026 at 9:57 a.m., an interview and observation was conducted with S7LPN. She stated Resident #126 was admitted on [DATE] for IV antibiotic therapy. She stated he was oriented and could make his needs known. She stated she administered the first dose of the antibiotic on Friday 02/20/2026. She stated Resident #126's antibiotics were stored in Medication Room A's refrigerator. She stated when she administered the antibiotic on 02/20/2026, there were multiple doses in the refrigerator. She stated when she returned to work on Monday 02/23/2026, she was told Resident #126 did not receive his antibiotic over the weekend due to it not being available. She stated when she administered Resident #126's antibiotic on 02/23/2026, the antibiotics were still in the refrigerator. She confirmed the antibiotic should have been administered to Resident #126 on 02/21/2026 and 02/22/2026. At that time, an observation was made of the refrigerator in Medication Room A with S7LPN. There was a bag of Resident #126's Daptomycin antibiotics in the door of the refrigerator. The antibiotic label was observed with S7LPN, and she confirmed there was an issue date of 02/19/2026 on the pharmacy label. There were three antibiotics left in the bag. On 02/25/2026 at 10:25 a.m., an interview was conducted with S13LPN. She stated she was assigned to Resident #126 on 02/21/2026 and 02/22/2026. She stated Resident #126 had an antibiotic ordered once a day to be given in the morning. She stated she could not find Resident #126's Daptomycin to administer to him on 02/21/2026 and 02/22/2026. She stated over the weekend, the facility did not have pharmacy services to deliver medications. She stated she did not notify any other staff that she could not find Resident #126's antibiotic. She confirmed the antibiotic should have been given if it was available. On 02/25/2026 at 11:06 a.m., an interview was conducted with a local Pharmacist. He confirmed his pharmacy serviced the facility. He verified the pharmacy sent Resident #126's antibiotics to the facility on [DATE]. He confirmed seven antibiotic doses were sent to the facility on [DATE]. On 02/25/2026 at 11:57 a.m., an interview was conducted with S2DON. She verified the facility had pharmacy services on the weekend, and further stated there was also an on-call pharmacy service who delivered to the facility on weekends when needed. S2DON confirmed Resident #126 should have received his antibiotic on 02/21/2026 and 02/22/2026. She further stated the nurse should have notified other facility staff when she could not find Resident #126's antibiotic.

Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infections for 1 (#15) of 2 residents reviewed for having a feeding tube. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) when providing care to Resident #15, who was on Enhanced Barrier Precautions (EBP).A review of Resident #15's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included, gastrostomy status. A review of Resident #15's current Physician Orders revealed the following, in part: Order Start Date: 07/01/2024 Enhanced Barrier Precautions - gown and gloves to be worn during high contact resident care activities (device care - feeding tube). On 02/23/2026 at 1:15 p.m., an observation of the Enhanced Barrier Precautions sign posted on the outside of Resident #15's door revealed the following, in part: Providers and staff must wear gloves and a gown for high-contact resident care activities. Device care or use: feeding tube. On 02/23/2026 at 1:15 p.m., an observation was made of S5LPN administering a bolus tube feeding to Resident #15. S5LPN did not wear a gown while administering the bolus tube feeding. On 02/23/2026 at 1:21 p.m., an interview was conducted with S5LPN. She stated she did not have to wear a gown when administering Resident #15's bolus tube feeding. She stated Resident #15 was currently on enhanced barrier precautions. She stated she did not have to wear a gown while administering tube feeding. On 02/24/2026 at 12:21 p.m., an interview was conducted with S2DON. S2DON confirmed she expected all nurses to follow Enhanced Barrier Precautions which included wearing a gown and gloves when administering tube feeding.

Based on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (#1) of 3 sampled residents reviewed for witnessed falls. The facility failed to ensure nursing staff accurately documented Resident #1's witnessed fall. Findings: Review of the facility's policy dated 09/2025 and titled, Documentation, revealed the following, in part:1. Documentation shall be completed for residents on acute, observational, and incidental frequency Acute (Once per shift)Observational (Daily)Incidental (As needed)5. Whenever there is an update regarding a resident's behavior, condition, or other relevant information, it shall be documented in the resident's chart.9. It is the policy of this facility to maintain accurate medical records. Review of the facility's policy dated 09/2025 and titled, Accident/Incident Reports revealed the following, in part:7. Information regarding accidents/incidents that involve a resident will be recorded in the resident's medical record in the nurses' notes. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included, Cerebrovascular Disease, Hemiplegia and Hemiparesis following Cerebral Infraction affecting right dominant side. Review of Resident #1's Quarterly MDS with an ARD of 11/06/2025 revealed Resident #1 had a BIMS score of 3 which indicated she had a severe cognitive impairment. Further review revealed Resident #1 was dependent on staff assistance for the completion of ADL's. Review of the Resident #1's Care Plan, dated 11/06/2025 through 11/25/2025 revealed the following in part: Resident lifting Plan: Red-Stop-Total LiftResident ADL assistance: Dependent on staff for transfers from bed to chair, bed mobility position changes every two hours, side railsPotential for falls: Follow facility fall protocol Review of the facility's Incident/Accident Log dated 10/01/2025 through 11/24/2025 revealed Resident #1 had a witnessed fall on 11/14/2025. Review of Resident #1's nurses' notes dated 11/14/2025 revealed the following in part: 11/14/2025 at 6:04 p.m.: Resident #1 to be sent out for evaluation and treatment. RP present and notified. Entered by S2LPNR. 11/14/2025 at 7:18 p.m.: Resident #1 transported via emergency medical services to the emergency room of record for evaluation and treatment. Entered by S2LPNR. Further review of the nurses' notes revealed no entries by S2LPNR pertaining to the witnessed fall involving Resident #1 on 11/14/2025. An interview was conducted on 11/25/2025 at 2:30 p.m. with S2LPNR via telephone. S2LPNR stated she was responsible for Resident #1's care on the morning of 11/14/2025. She stated around 9:00 a.m., S3CNA yelled for assistance from Resident #1's room. S2LPNR stated when she entered the room, S3CNA was holding Resident #1 up on the edge of the bed. S2LPNR stated her and S3CNA lowered Resident #1 to the floor. S2LPNR stated S4CNA assisted them in returning Resident #1 back into bed using 3-persons to manually lift Resident #1. S2LPNR confirmed she did not report the incident to administration, S5FNP or Resident #1's RP. S2LPNR further confirmed she did not document the incident nor file an incident report because she did not believe the incident was a fall. An interview was conducted on 11/25/2025 at 2:40 p.m. with S1DON. S1DON stated on 11/14/2025 around 1:30 p.m. Resident #1's RP inquired about discoloration and bruising on the right side of Resident #1's body. She stated the incident was initially identified as an injury of unknown origin because no staff had reported an accident. S1DON stated Resident # 1 was immediately assessed and S5FNP notified around 2:30 p.m. On 11/17/2025 S1DON stated she became aware S3CNA and S2LPNR assisted Resident #1 to the floor on 11/14/2025 and called for additional assistance. S4CNA entered the room and assisted them return Resident#1 back to bed using 3-person lifting. S1DON stated guiding Resident #1 to the floor would be considered a fall. S1DON confirmed S2LPNR failed to document the incident in the nurses' notes and failed to complete an incident report and should have.

Based on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 3 (#5, #60 and #122) residents out of a total of 27 sampled residents. The facility failed to ensure: 1. Resident #5 was coded correctly for PASRR (Pre-admission Screening and Resident Review); 2. Resident #60 was coded correctly for pressure ulcers; and 3. Resident #122 was coded correctly for discharge. Findings: 1. Resident #5 Review of Resident #5's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #5's OBH-Level II Evaluation Summary & Determination Notice dated 07/17/2024 revealed under recommendations: The individual has a serious mental illness and nursing home admission was recommended. Review of Resident #5's most recent Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/17/2024 revealed Section A1500 PASRR: Is the resident currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, was coded as 0. No. On 02/25/2025 at 2:50 p.m. an interview was conducted with S3MDS. S3MDS stated she was responsible for completing resident's MDS assessments. She reviewed Resident #5's PASRR Level II dated 07/17/2024 indicating she had a serious mental illness. S3MDS reviewed Resident #5's Annual MDS with an ARD of 10/17/2024. S3MDS confirmed Resident #5 was not coded accurately for having a serious mental illness and should have been. On 02/26/2025 at 1:40 p.m., an interview was conducted with S2DON and S11CRP. They reviewed Resident #5's information listed above. She confirmed Resident #5 was not coded accurately for having a serious mental illness and should have been. 2. Resident #60 Review of Resident #60's Clinical Record revealed he was readmitted to the facility on [DATE] with diagnoses, which included the following, in part: pressure ulcer of sacral region unstageable. Review of Resident #60's most recent Quarterly MDS with an ARD of 02/07/2025 revealed Section M0210 Unhealed Pressure Ulcers/Injuries, and Section M0300 Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage A-G were blank. Review of Resident #60'a Physician Orders revealed the following in part: Reopened stage 4 pressure ulcer to sacrum; clean with wound cleanser, pat dry, apply santyl then calcium alginate and cover with a bandage daily until resolved, every day shift. Start date: 12/26/2024. On 02/25/2025 at 10:25 a.m., an interview was conducted with S8WCN. She confirmed Resident #60 had an unhealed stage 4 pressure ulcer to his sacrum. On 02/26/2025 at 8:55 a.m., an interview was conducted with S5MDS. S5MDS reviewed Resident #60's physician orders and confirmed Resident #60 had a stage 4 pressure ulcer to his sacrum that he had been receiving care for since 12/26/2024. S5MDS reviewed Resident #60's Quarterly MDS with an ARD of 02/07/2025 and confirmed Section M was blank, and not accurately coded for pressure ulcers and should have been. On 02/26/2025 at 12:45 p.m., an interview was conducted with S2DON. S2DON reviewed Resident #60's physician orders and confirmed he had a stage 4 pressure ulcer that was being treated since 12/26/2024. S2DON reviewed Resident #60's Quarterly MDS dated [DATE], and confirmed the resident was not accurately coded under section M for pressure ulcers and should have been. 3. Resident #122 Review of Resident #122's Clinical Record revealed she was admitted to the facility on [DATE] and left the facility without signing AMA on 12/14/2024. Review of Resident #122's Discharge MDS with an ARD of 12/14/2024 revealed Section A2105 Discharge Status: Short Term Acute Hospital. Review of Resident #122's 148 Discharge Form revealed the following, in part: Resident was discharged on [DATE] to her own home. On 02/26/2025 at 11:45 a.m., an interview was conducted with S4MDS. She reviewed the above documentation and confirmed Resident #122 should have been coded as having a discharge location for Home and not Short Term General Hospital. On 02/26/2025 at 1:40 p.m., an interview was conducted with S2DON and S11CRP. They reviewed Resident #122's information listed above. She confirmed Resident #122 was not coded accurately for discharge home, and should have been. 52121

Based on record review and interviews, the facility failed to ensure a resident with mental disorders had an accurate Pre-admission Screening for 1 (#118) of 5 (#5, #6, #10, #63, and #118) residents reviewed for Pre Admission Screening and Resident Review (PASRR). Findings: Review of Resident #118's Clinical Record revealed he was admitted to the facility on [DATE] with diagnosis, which included Bipolar Disorder. Review of Resident #118's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/13/2025, revealed the following: Review of Section A1500 - Identification Information revealed Resident #118 was not considered for a Level II PASRR for having a serious mental illness. Review of Section I - Active Diagnoses revealed Resident #118 had a triggered diagnosis of Bipolar Disorder listed. Review of Resident #118's Level I Pre-admission Screening and Resident Review completed by a social worker at a local hospital dated 01/31/2025, indicated Resident #118 did not presently have or at any point a mental disorder, which could have led to chronic disability. Review of Resident #118's preadmission records revealed a diagnosis of Bipolar Disorder. Review of Resident #118's Care Plan revealed the following: Focus: The Resident has Bipolar Disorder On 02/26/2025 at 11:36 a.m., an interview was conducted with Office of Behavioral Health spokesperson. She stated in the event of a Level I PASRR being inaccurately submitted the facility would be required to resubmit a resident review form to accurately reflect the residents' current diagnoses. She stated on 02/21/2025, a fax was sent to the facility requesting for additional documentation for Resident #118 with no response to date. On 02/26/2025 at 11:50 a.m., an interview was conducted with S12SSD. She stated she was responsible for submitting resident review forms for Level II evaluation. She reviewed the Level I PASRR and confirmed it was inaccurately coded to reflect Resident #118 diagnosis of Bipolar Disorder. She confirmed a resident review form had not been submitted to the Office of Behavioral Health and should have been. On 02/26/2025 at 1:37 p.m., an interview was conducted with S1ADM. He reviewed Resident #118 Level I PASRR and confirmed it was inaccurately coded to reflect diagnosis of Bipolar Disorder. He confirmed a resident review form should have been resubmitted for Level II evaluation and was not.

Based on observations, interviews, and record reviews, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (#55 and #60) of 2 (#55 and #60) residents observed with catheters. The facility failed to ensure: 1. Staff used proper hand hygiene and infection control techniques when providing catheter care for Resident #55; and 2. Resident #60's catheter bag remained off of the floor. Findings: Resident #55 Review of Resident #55's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included the following, in part: Urinary Tract Infection. On 02/26/2025 at 9:00 a.m., an observation was made of S9CNA performing catheter care for Resident #55. S9CNA applied gloves and then used one disposable cleansing wipe to wipe from the tip of the penis outward. S9CNA then turned the resident to his left side, and used a second wipe to remove stool from the resident's buttocks. S9CNA then emptied the resident's urine collection bag into a urinal, opened the bathroom door by touching the handle, and emptied the urinal into the toilet. S9CNA did not change gloves at any time between the above steps. On 02/26/2025 at 9:15 a.m., an interview was conducted with S9CNA. S9CNA stated she should have changed her gloves after wiping stool from Resident #55's buttocks, before emptying the catheter bag, and before touching the door handle to the bathroom and did not. On 02/26/2025 at 9:30 a.m., an interview was conducted with S2DON. She confirmed staff should have changed her gloves after wiping stool from Resident #55's buttocks, before emptying the catheter bag, and before touching the door handle to the bathroom and did not. 2. Resident #60 Review of Resident #60's Clinical Record revealed he was readmitted to the facility on [DATE] with diagnoses, which included the following, in part: Need for Assistance with Personal Care, Urinary Tract Infection, and Other Specified Disorders of Bladder. On 02/24/2025 at 10:30 a.m., an observation was made of Resident #60's suprapubic catheter bag on the floor. On 02/25/2025 at 10:31 a.m., an observation was made of Resident #60's suprapubic catheter bag on the floor. On 02/25/2025 at 10:38 a.m., an observation and interview was conducted with S8WCN. She confirmed Resident #60's catheter bag was lying on the floor and should not have been. On 02/26/2025 at 9:09 a.m., an observation was made of Resident #60's suprapubic catheter bag on the floor. On 02/26/2025 at 9:46 a.m., an observation and interview was conducted with S10CNA. She confirmed Resident #60's catheter bag was lying on the floor and should not have been. On 02/26/2025 at 12:45 p.m., an interview was conducted with S2DON. S2DON confirmed indwelling catheter bags should be kept off of the floor. 52121

Based on interviews and record reviews, the facility failed to promote and facilitate resident self-determination through support of resident choice for 1 (#2 and #R4) of 3 (#1, #2, and #R4) residents reviewed for resident rights. The facility failed to ensure: 1. Residents #2 and #R4 were able to choose the type of bath they received; and 2. Resident #R4 was able to choose when she wanted to get back in bed. Findings: Review of the facility's policy revised in January 2024 titled, Bathing revealed the following, in part: Processes: Inquire with the resident concerning bathing preferences (Ex - type of bathing: shower, bed bath, etc.) Resident #2 Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Cerebral Infarction, Unspecified Dementia, Aphasia Following Cerebral Infarction, and Flaccid Hemiplegia Affecting Right Dominant Side. Review of Resident #2's Quarterly MDS with an ARD of 12/27/2024 revealed a BIMS of 99, which indicated the BIMS assessment was unable to be completed. An interview was conducted with Resident #2's family member on 03/26/2024 at 9:09 a.m. She stated Resident #2 was supposed to receive a shower in the shower room by the facility on Tuesdays, Thursdays, and Saturdays. She stated facility staff would give Resident #2 a bed bath on her scheduled bath days instead of taking her to the shower room. An interview was conducted with S16CNA on 03/26/2024 at 2:34 p.m. She stated she was the only CNA assigned to the hall and did not have a whirlpool aide. She stated when she was by herself and did not have a whirlpool aide, she was unable to bring the residents to the shower room. She stated on Saturday, Resident #2 was supposed to go on the gurney to the shower room because that was what her family wanted. She stated she gave her a bed bath, which was against her family's wishes. She confirmed it was the residents' right to choose which type of bath they received. Resident #R4 Review of Resident #R4's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Bilateral Primary Osteoarthritis of Knee, Muscle Wasting and Atrophy, Age-Related Physical Debility, and Morbid Obesity. Review of Resident #R4's Quarterly MDS with an ARD of 02/15/2024 revealed a BIMS of 15, which indicated intact cognition. An interview was conducted with Resident #R4 on 03/25/2024 at 1:30 p.m. She stated she required a Hoyer Lift for transfers. She stated S14CNA told her last Wednesday she could get her up but she could not put her back to bed before the end of her shift at 6:00 p.m. because she had other things to complete. She stated she decided to stay in bed because she did not want to have to wait for the night shift to put her back to bed. She stated the last three months there had been a staffing shortage and she did not understand what was going on. She stated she had a care plan meeting, and it was decided for her to go to the shower room on Wednesdays and a bed bath Mondays and Fridays. She stated about one month ago she started getting only bed baths every Monday, Wednesday, and Friday related to staffing. She explained it took two CNAs to get her onto the shower gurney. She stated she wanted to go to the shower room at least once per week. An interview was conducted with S14CNA on 03/25/2024 at 2:05 p.m. She stated Resident #R4 was scheduled for baths on Mondays, Wednesdays, and Fridays. She stated the shower aide was supposed to give the bath but if there was not a shower aide, she was responsible. She stated Resident #R4 had to have two staff for the shower gurney. She stated when she was responsible for Resident #R4's bath, she gave her a bed bath instead of putting her on the shower gurney. She stated one day last week, Resident #R4 asked to get out of bed after lunch. She stated she explained to Resident #R4 she was able to get her up but she would have to go back to bed on the 6:00 p.m. shift because there were not enough staff. She stated Resident #R4 decided not to get up because she did not want to wait for the next shift to put her back to bed. An interview was conducted with S4CNAS on 03/26/2024 at 11:01 a.m. She stated when it was a resident's bath day, they should be offered to be brought to the shower room. She stated Resident #2 had scheduled baths by the facility every Tuesday, Thursday, and Saturday, and she should have been brought to the whirlpool room. She stated Resident #R4 should have been brought to the shower room every Wednesday. She confirmed the residents should be able to choose when to get out of bed, go back to bed, and the type of bath they wanted to receive. An interview was conducted with S2DON on 03/26/2024 at 4:33 p.m. She confirmed if there was not a shower aide, the CNA assigned to the resident should still bring the resident in the shower room if it was their choice. She confirmed residents had the right to choose when to get out of bed and when to go back to bed.

47500 Based on interviews and record reviews, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good hygiene for 2 (#R4, and #R5) of 5 (#1, #2, #3, #R4, and #R5) residents reviewed for ADLs. The facility failed to ensure: 1. Residents #R4 and #R5 received baths as scheduled; and 2. Resident #R4 was provided incontinence care timely after calling for assistance. 1. Resident #R4 Review of Resident #R4's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included Muscle Wasting and Atrophy, Age-Related Physical Debility, and Morbid Obesity. Review of Resident #R4's Quarterly MDS with an ARD of 02/15/2024 revealed, in part, she had a BIMS of 15, which indicated intact cognition. Further review of the MDS revealed she was dependent on staff for showers/baths. Review of Resident #R4's current Care Plan revealed the following, in part: Problem: Self-care deficit; and Requires assistance with meeting ADLs and maintaining hygiene. Review of Resident #R4's Bath Documentation dated 03/21/2024 through 03/25/2024 revealed no documentation she received a bath. An interview was conducted with Resident #R4 on 03/25/2024 at 1:30 p.m. She stated she had not received a bath since Wednesday of last week. She stated she should have received a bath this past Friday because her bath days were Monday, Wednesday, and Friday. An interview was conducted with S11CNA on 03/25/2024 at 3:25 p.m. She confirmed she was assigned to Resident #R4 on Friday, 03/22/2024, from 6:00 a.m. to 6:00 p.m. She stated Resident #R4's scheduled bath days were Mondays, Wednesdays, and Fridays. She stated she was unsure if she or the shower aide were responsible for Resident #R4's bath on Friday. She confirmed she did not bathe Resident #R4 on 03/22/2024. An interview was conducted with S4CNAS on 03/26/2024 at 11:01 a.m. She stated Resident #R4's shower days were Mondays, Wednesdays, and Fridays. She stated she and S11CNA were responsible for Resident #R4's bath on 03/22/2024. She confirmed she did not give Resident #R4 a bath on 03/22/2024. An interview was conducted with S9CNA on 03/25/2024 at 1:19 p.m. She stated she was assigned to Hall B. She stated sometimes she had a shower aide for the hall and sometimes she did not. She stated when there was a shower aide, the shower aid was not always able to complete all baths and she was responsible for the incomplete baths. She stated sometimes she would be unable to complete the baths and they would not get done. She stated she would try to complete the bath the following day, but that did not always happen. Resident #R5 Review of Resident #R5's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Muscle Weakness, Cognitive Communication Deficit, and Paroxysmal Atrial Fibrillation. Review of Resident #R5's Quarterly MDS with an ARD of 02/01/2024 revealed, Resident #R5 had a BIMS of 7, which indicated severe cognitive impairment. Further review revealed he was dependent on staff for showers/baths. The facility failed to provide evidence of bath documentation for Resident #R5's bath on 03/23/2024. An interview was conducted with Resident #R5 on 03/26/2024 at 10:15 a.m. He stated he had not had a bath in 5 days and wants to get in the whirlpool. An interview was conducted with S6CNA on 03/26/2024 at 3:41 p.m. She stated Resident #R5's bath days were Tuesday, Thursday, and Saturday. She confirmed on 03/23/2024 she did not bathe Resident #R5 and should have since it was his bath day. An interview was conducted with S2DON on 03/26/2024 at 4:30 p.m. She confirmed residents should receive their baths on the scheduled bath day. 2. Resident #R4 Review of Resident #R4's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included Muscle Wasting and Atrophy, Age-Related Physical Debility, and Morbid Obesity. Review of Resident #R4's Quarterly MDS with an ARD of 02/15/2024 revealed she had a BIMS of 15, which indicated intact cognition. Further review of the MDS revealed she was dependent on staff for toileting hygiene. Review of Resident #R4's current Care Plan revealed the following, in part: Problem: Incontinent of bowel and bladder Interventions: Peri-care after each incontinent episode. An interview was conducted with Resident #R4 on 03/25/2024 at 1:30 p.m. She stated this past Friday night, on 03/22/2024, her call light was on for two hours before she received assistance with incontinence care after having a bowel movement. She stated during the time her call light was on, she called the facility phone from her cell phone five times. She showed surveyor her call log, which revealed she made calls to the facility on [DATE] at 6:15 p.m., 6:20 p.m., 6:51 p.m., 8:08 p.m., and 8:09 p.m. She stated she initiated her call light at 6:10 p.m. and it was answered at 8:15 p.m. She stated S7WC answered the phone and verified the call light had been going off for two hours. An interview was conducted with S7WC on 03/25/2024 at 3:10 p.m. He stated he was the ward clerk from 2:00 p.m. to 10:00 p.m. on Friday, 03/22/2024. He confirmed, on the evening of 03/22/2024, Resident #R4 initiated her call light and called the facility phone five times asking to be cleaned up after having a bowel movement. He confirmed Resident #R4 waited two hours to be changed after initiating her call light. An interview was conducted with S8CNA on 03/26/2024 at 2:53 p.m. She confirmed she was assigned to Resident #R4 on 03/22/2024 from 6:00 p.m. to 6:00 a.m. She stated toward the beginning of her shift, she was notified by S7WC Resident #R4 had her light on and needed to be changed. She stated she was on another hall and had to finish her rounds before going to assist Resident #R4. She stated she was unaware the call light had been on for two hours. A telephone interview was conducted with S12LPN on 03/26/2024 at 3:53 p.m. She confirmed she was assigned to Resident #R4 on Friday night, 03/22/2024. She stated she was unaware Resident #R4 had initiated her call light to be changed. She stated a call light being on 2 hours was excessive. An interview was conducted with S3ADON on 03/26/2024 at 4:01 p.m. She stated a reasonable call light response time was twenty minutes. She confirmed two hours for a resident to wait to be changed was an extended period of time. An interview was conducted with S2DON on 03/26/2024 at 4:33 p.m. She stated a reasonable call light response time was twenty minutes. She stated a two hour call light wait time was an extended amount of time. She stated Resident #R4 should not have had to wait two hours for incontinence care.

47500 Based on record review, interviews, and observations, the facility failed to have sufficient certified nursing assistant staff to provide direct care and related services to maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 4 (#1, #2, #R4 and #R5) of 6 (#1, #2, #3, #R4, #R5, and #R6) residents reviewed for staffing. Findings: Review of the facility's PBJ Staffing Data Report for Fiscal Year 2024 Quarter 1 (October 1 - December 31), with a run date of 03/22/2024 revealed the facility had a 1-star staffing rating. Review of the facility's CNA Staffing Assignment Sheet dated 03/22/2024 revealed, in part, from 6:00 a.m. to 6:00 p.m. 1 CNA was assigned to Hall A, 1 CNA was assigned to Hall B, and 1 CNA was assigned to Hall C; 1 CNA was assigned to the shower room for Hall A and Hall B; and from 6:00 p.m. to 6:00 a.m. 1 CNA was assigned to Hall A and the odd numbered rooms of Hall B and 1 CNA was assigned to Hall C and the even numbered rooms of Hall B. Review of the facility's CNA Staffing Assignment Sheet dated 03/23/2024 revealed, in part, from 6:00 a.m. to 6:00 p.m. 1 CNA was assigned to each Hall A, Hall B, and Hall C; and from 6:00 p.m. to 6:00 a.m. 1 CNA was assigned to Hall A, 1 CNA was assigned to Hall B, and 1 CNA was assigned to Hall C. Further review revealed, on 03/23/2024, from 6:00 a.m. to 6:00 p.m. there was no shower aide assigned to Hall A, Hall B, and Hall C. Review of the facility's CNA Staffing Assignment Sheet dated 03/24/2024 revealed, in part, from 6:00 a.m. to 6:00 p.m., 1 CNA was assigned to Hall A, 1 CNA was assigned to Hall B, and 1 CNA was assigned to Hall C; and from 6:00 p.m. to 6:00 a.m. 1 CNA was assigned to Hall A, 1 CNA was assigned to Hall B, and 1 CNA was assigned to Hall C. Review of the facility's CNA Staffing Assignment Sheet dated 03/25/2024 revealed, in part, from 6:00 a.m. to 6:00 p.m. 1 CNA was assigned to each Hall A, Hall B, and Hall C; and from 6:00 p.m. to 6:00 a.m. 1 CNA was assigned to each Hall A, Hall B, and Hall C. Resident #1 Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnoses which included Muscle Weakness, and Unspecified Atrial Fibrillation. Review of Resident #1's MDS with an ARD of 01/30/2024 revealed Resident #1 had a BIMS score of 9, which indicated she had moderate cognitive impairment. Further review revealed she was always incontinent of bowel and bladder and required partial/moderate assistance with eating and was dependent with shower/bath. On 03/26/2024 at 10:54 a.m., an interview was conducted with Resident #1's RP. She stated she visited every other day in the afternoon from 2:00 p.m. until after dinner to feed Resident #1. She stated if Resident #1 was not fed she would not eat. She stated hospice bathes Resident #1 every other day and the facility does not bathe Resident #1 on the other days. She stated Resident #1 would prefer a whirlpool bath on the opposite days of her hospice bed bath. Resident #2 Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Cerebral Infarction, Unspecified Dementia, Aphasia Following Cerebral Infarction, and Flaccid Hemiplegia Affecting Right Dominant Side. Review of Resident #2's Quarterly MDS with an ARD of 12/27/2023 revealed she had a BIMS score of 99, which indicated she was unable to complete a BIMS assessment. Further review revealed she was dependent on staff for toileting and bathing. On 03/26/2024 at 9:09 a.m., an interview was conducted with Resident #2's family member. She stated Resident #2 was supposed to receive a shower in the shower room by the facility on Tuesdays, Thursdays, and Saturdays. She stated the facility staff would give Resident #2 a bed bath on her scheduled bath days instead of taking her to the shower room or she would not get a bath at all. On 03/26/2024 at 2:34 p.m., an interview was conducted with S16CNA. She confirmed she was assigned to Resident #2 from 6:00 a.m. to 6:00 p.m. on 03/22/2024, 03/23/2024, and 03/24/2024. She stated on 03/23/2024, Resident #2 was unable to shower in the shower room because there were not enough staff to get Resident #2 on the shower gurney. Resident #R4 Review of Resident #R4's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Bilateral Primary Osteoarthritis of Knee, Muscle Wasting and Atrophy, Age-Related Physical Debility, and Morbid Obesity. Review of Resident #R4's Quarterly MDS with an ARD of 02/15/2024 revealed she had a BIMS of 15, which indicated she was cognitively intact. Further review of the MDS revealed she was dependent on staff for toileting hygiene and bathing. On 03/25/2024 at 1:30 p.m., an interview was conducted with Resident #R4. She stated she required a Hoyer Lift for transfers. She stated, on 03/20/2024, S14CNA told her S14CNA could get her up, but she could not put Resident #R4 back to bed before the end of her shift at 6:00 p.m. because she had other tasks to complete. She stated she decided to stay in bed because she did not want to have to wait for the night shift to put her back to bed. She stated, on the night of 03/22/2024, her call light was on for two hours before she received assistance with incontinence care after having a bowel movement. She stated she initiated her call light at 6:10 p.m. and it was answered at 8:15 p.m. She stated being left soiled in feces for two hours made her feel anxious, helpless, and frustrated. She stated in the last three months, she had been missing baths due to short staffing. On 03/25/2024 at 3:10 p.m., an interview was conducted with S7WC. He stated he was the ward clerk from 2:00 p.m. to 10:00 p.m. on 03/22/2024. He confirmed, on the evening of 03/22/2024, Resident #R4 initiated her call light asking to be cleaned up after having a bowel movement. He confirmed Resident #R4 waited two hours to be changed after initiating her call light. He stated there were only two CNAs for Hall A, Hall B, and Hall C on 03/22/2024 from 6:00 p.m. to 6:00 a.m. On 03/26/2024 at 2:53 p.m., an interview was conducted with S8CNA. She confirmed she was assigned to Resident #R4 on 03/22/2024 from 6:00 p.m. to 6:00 a.m. She stated toward the beginning of her shift, she was notified by S7WC Resident #R4 had her light on and needed to be changed. She stated she was on another hall and had to finish her rounds before going to assist Resident #R4. She stated she was unable to provide timely care to the residents that night because there was not enough staff. On 03/25/2024 at 2:05 p.m., an interview was conducted with S14CNA. She stated she regularly was assigned to Resident #R4, and Resident #R4 was scheduled for baths on Mondays, Wednesdays, and Fridays. She stated the shower aide was supposed to give the bath but if there was not a shower aide, she was responsible. She stated Resident #R4 required the gurney for baths, which required assistance of two staff members. She stated when there was not a shower aide, she would have to give Resident #R4 a bed bath because of staffing. She stated Resident #R4 required a Hoyer lift for transfers. She stated one day last week, Resident #R4 asked to get out of bed after lunch. She stated she told her she was able to get her up but she would have to go back to bed on the 6:00 p.m. shift because of the amount of tasks there were for her to complete between 4:00 p.m. and 6:00 p.m. when the next shift arrived. She stated Resident #R4 decided not to get up that day because she did not want to wait for the next shift to put her back to bed. Resident #R5 Review of Resident #R5's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Muscle Weakness, Cognitive Communication Deficit, and Paroxysmal Atrial Fibrillation. Review of Resident #R5's MDS with an ARD of 02/01/2024 revealed, he was always incontinent of bowel and bladder and was dependent with toileting hygiene and bathing. On 03/26/2024 at 10:15 a.m., an interview was conducted with Resident #R5. He stated he had not had a bath in 5 days and wanted to get in the whirlpool tub. On 03/25/2024 at 9:05 a.m., an interview was conducted with S9CNA. She stated she was responsible for all the residents on Hall B, which was 16 residents. She stated she had trouble completing her tasks for all the residents. She stated residents have missed baths. She stated she had 6 residents who required total feeding assistance, and she would often have to let the oncoming shift know who had not eaten yet for the oncoming staff to complete the task. On 03/25/2024 at 1:19 p.m., an interview was conducted with S9CNA. She stated there was sometimes an assigned shower aide for Hall A, Hall B, and Hall C. She stated when there was one shower aide for Halls A, B, and C, the shower aide was not able to complete all baths, and she would be responsible for the baths the shower aide was unable to complete. She stated that would cause her to have to rush to feed residents and rush to give a bath. She stated sometimes the bath did not happen that day, and she would try to get it done the following day. She stated sometimes she was unable to complete the bath following day as well. She stated she was assigned to more total care residents than independent. She stated she had reported the staffing concerns to S4CNAS. On 03/25/2024 at 10:20 a.m., an interview was conducted with S10CNA. She stated she was responsible for Hall C. She stated most days, residents would wait up to an hour to be changed. On 03/25/2024 at 2:05 p.m., an interview was conducted with S14CNA. She stated she was assigned to Hall A, which currently housed 19 residents. She stated she almost always was assigned to the hall by herself. She stated there were also days when she was on the hall by herself and there was not a shower aide. She stated she completed the tasks she could. She stated when there was no shower aide, she provided bed baths for the scheduled baths. She stated it was impossible to do rounds every two hours on all of her residents. She stated she was unable to complete her charting with the current amount of workload and staff. She stated there were 13 residents who were incontinent or who required assistance to the bathroom on her hall. She stated there were 3 residents on the hall that had to be fed. She stated there were 4 residents who utilized a stand-up lift or Hoyer lift, which required two staff members. She stated sometimes the residents who required two staff members for transfers and assistance had to wait a while to get up because she could not find another staff or they were busy. She stated she reported to S4CNAS multiple times there was not enough staff to complete all of her tasks. On 03/25/2024 at 3:10 p.m., an interview was conducted with S7WC. He stated when the facility was short staffed, the call lights would go off for thirty minutes to an hour. He stated on 03/22/2024 , a CNA called in and was not replaced so residents had to wait a long time for their call light to be answered. On 03/26/2024 at 9:32 a.m., an interview was conducted with S15CNA. She stated there was supposed to be two shower aides to split Hall A, Hall B, and Hall C, a split hall CNA then 1 CNA for Hall A, 1 CNA for Hall B, and 1 CNA for Hall C. She stated there had not been a split hall CNA so the hall CNAs were assigned to the whole hall independently, and they were unable to complete their tasks timely. She stated the residents were not being checked and changed every two hours. On 03/26/20124 at 2:34 p.m., an interview was conducted with S16CNA. She confirmed she was assigned to Hall B from 6:00 a.m. to 6:00 p.m. on 03/22/2024, 03/23/2024, and 03/24/2024 . She stated she was the only CNA assigned to Hall B, and she did not have a shower aide. She stated when she was by herself and did not have a shower aide, she was unable to bring the residents to the shower room. On 03/26/2024 at 3:41 p.m., an interview was conducted with S6CNA. She stated when there was no shower aide, residents did not get a bath because it was impossible to perform baths and make rounds every two hours. She stated residents have waited longer than two hours between rounds for incontinence care. She stated there was no shower aide on Saturday, 03/23/2024, and she could not complete all the baths scheduled on 03/23/2024 on Hall C and make rounds to assist residents with ADL tasks. She stated Resident #R5's bath days were Tuesday, Thursday, and Saturday. She confirmed on 03/23/2024 she did not bathe Resident #R5 and should have since it was his bath day. On 03/26/2024 at 1:14 p.m., an interview was conducted with S4CNAS. She stated there was not enough CNAs scheduled to care for the residents on Hall A, Hall B, and Hall C. She stated today there was 53 total residents. She stated they should have had 4 CNAs working the floor on Hall A, Hall B, and Hall C, which was one CNA per hall and one split CNA. She stated today, Hall A, Hall B, and Hall C each had 1 CNA which was not enough to care for all the residents. She stated most of the dependent residents resided on Halls A, B, and C. She stated it was not staffed with enough CNAs on day shift. She stated when there were no shower aides, the hall CNAs were responsible for baths and sometimes had to perform bed baths instead of showers to be able to get it completed. She stated some of the CNAs had communicated with her they did not have enough time to complete their tasks, such as baths and documentation. She stated she lost 4 CNAs in the last 2 weeks due to the workload. She stated S2DON was aware of the CNA staffing concerns. On 03/26/2024 at 4:30 p.m., an interview was conducted with S2DON. She confirmed there was no shower aide on 03/23/2024. She also confirmed there was 1 CNA assigned to Hall A, 1 CNA assigned to Hall B, and 1 CNA assigned to Hall C on 03/22/2024, 03/23/2024, and 03/24/2024 from 6:00 a.m. to 6:00 p.m. and there should have been 4 CNAs. She confirmed on 03/22/2024 from 6:00 p.m. to 6:00 a.m. 1 CNA was assigned to Hall A and the odd numbered rooms of Hall B and 1 CNA was assigned to Hall C and the even numbered rooms of Hall B; and there should have been 3 CNAs from 6:00 p.m. to 6:00 a.m.

Based on observation, interviews, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents during a Hoyer Lift transfer for 1 (#R6) of 3 (#2, #R4, and #R6) residents reviewed who required a Hoyer Lift for transfers. Findings: Review of Resident #R6's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. Review of Resident #R6's Admission MDS with an ARD of 01/21/2024 revealed he had a BIMS of 99, which indicated the BIMS could not be completed. Review of Resident #R6's Lifting Plan revealed STOP - total lift. Further review of the lifting plan revealed a question and answer for staff, which stated, If lift is needed, how many staff are to be in attendance? Two. An observation was made of S13CNA entering Resident #R6's room with a Hoyer lift on 03/25/2024 at 9:53 a.m. S13CNA exited the room with the Hoyer lift at 10:01 a.m. An interview was conducted with S13CNA on 03/25/2024 at 10:01 a.m. She confirmed she assisted Resident #R6 out of bed into his wheelchair with the use of the Hoyer Lift independently. She stated there should always be two staff members when transferring a resident with the Hoyer lift. An observation was made of Resident #R6 on 03/25/2024 at 10:06 a.m. He was seated at the foot of his bed in his wheelchair with the lift pad under him. An interview was conducted with S4CNAS on 03/25/2024 at 2:38 p.m. She stated all Hoyer lift transfers required assistance of two staff members to prevent accidents, and it was never acceptable to have one staff member present while utilizing a Hoyer lift. An interview was conducted with S2DON on 03/26/2024 at 4:33 p.m. She reviewed Resident #R6's Clinical Record and confirmed he required assistance of two staff members for Hoyer lift transfers. She confirmed two staff members should have been present for Resident #R6's Hoyer lift transfer.

Based on record review and interviews, the facility failed to implement a comprehensive person-centered care plan for 1 (#35) of 25 residents reviewed in the final sample. The facility failed to ensure specialty consult appointments were scheduled as ordered by the physician. Findings: A review of Resident #35's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included, in part; UTI, Retention of Urine, and Chronic Kidney Disease. A review of Resident #35's most recent MDS, with an ARD of 01/17/2023, indicated resident had a BIMS of 15, which indicated resident was cognitively intact. A review of Resident #35's Physician Orders revealed, in part, the following orders: 05/22/2023 - Schedule f/u appointment with resident's Urologist; and 08/02/2023 - Schedule f/u appointment with resident's Nephrologist. A review of Resident #35's current Care Plan revealed, in part, the following: Problem: Alteration in Elimination Pattern. Approach: Refer to Urology per Physician Orders. A review of the facility's 2023 and 2024 Appointment Book revealed, in part, the following: No documentation of an appointment scheduled for Resident #35 with Nephrology; and One appointment scheduled for Resident #35 on 06/13/2023 at 2:45 p.m. with Urology. An interview was conducted on 01/22/2024 at 4:10 p.m. with Resident #35. She stated she had not seen any specialty providers over the past year and never refused to attend any outside appointments or consults. An interview was conducted on 01/22/2024 at 3:25 p.m. with S8WC. She reviewed the facility's 2023 and 2024 Appointment Book. She confirmed Resident #35 did not have any appointments scheduled with Nephrology and had one appointment scheduled with Urology on 06/13/2023. She stated she did not attend the Urology appointment due to being sent to the hospital for an unrelated issue. She confirmed the missed Urology appointment was not rescheduled. An interview was conducted on 01/22/2024 at 1:55 p.m. with the Scheduling Department of Resident #35's Urology Clinic. She confirmed the only appointment Resident #35 was scheduled for was on 06/13/2023, but she did not show up. She confirmed the appointment was not rescheduled. An interview was conducted on 01/22/2023 at 2:05 p.m. with the Scheduling Department of Resident #35's Nephrology Clinic. She confirmed Resident #35 had not been scheduled for an appointment with their office in over three years. An interview was conducted on 01/23/2024 at 9:30 a.m. with S7NP. She confirmed Resident #35 had a physician's order written on 05/22/2023 to consult Urology and an order written on 08/02/2023 to consult Nephrology. She confirmed she would have expected the appointments to be scheduled and if an appointment was missed, she would expect the appointment to be rescheduled. She confirmed if an order was written for a resident to receive a specialty provider consult, she would expect the facility to ensure it was done as ordered. An interview was conducted on 01/22/2023 at 2:13 p.m. with S1DON. She confirmed Resident #35 had a physician's order written on 05/22/2023 to consult Urology. She confirmed Resident #35 did not attend her scheduled Urology appointment on 06/13/2023, and the appointment was not rescheduled but should have been. She confirmed Resident #35 had a physician's order written on 08/02/2023 to consult Nephrology and the appointment was not scheduled but should have been. She confirmed she would expect staff to follow all physician's orders.

Based on record reviews, observations, and interviews, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals, to meet the needs of each resident. The facility failed to ensure the correct medication was prepared prior to medication administration for 1 (#22) of 5 (#22, #23, #34, #69, and #319) residents observed during medication administration. Findings: Review of Resident #22's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included Type 2 Diabetes Mellitus. Review of Resident #22's current Physician Orders revealed the following, in part: Humalog 100 unit/mL Kwik pen before meals and bedtime administer SQ per sliding scale 201-250 - 4 units Levemir Flextouch 100 unit/mL inject 20 units subcutaneously twice a day at 5:00 a.m. and 8:00 p.m. An observation was made of medication administration for Resident #22 on 01/18/2024 at 11:39 a.m. with S2LPN. S2LPN obtained a blood glucose level from Resident #22, which read 238 mg/dL. S2LPN then reviewed Resident #22's Humalog Insulin order and sliding scale. S2LPN removed Resident #22's Levemir 100 unit/mL insulin pen from her medication cart and dialed up 4 units. S2LPN did not review the insulin pen label to verify the insulin she obtained from the medication drawer was the insulin ordered. S2LPN walked into Resident #22's room to administer the insulin. Prior to administration, an interview was conducted with S2LPN. S2LPN stated she was unsure if she had the correct insulin and returned to her medication cart. S2LPN then reviewed Resident #22's insulin medication order on the MAR and confirmed she prepared and was going to administer Levemir instead of the ordered Humalog. S2LPN confirmed if surveyor had not intervened, she would have administered 4 units of Levemir to Resident #22 instead of the ordered 4 units of Humalog per sliding scale. S2LPN confirmed she did not check the medication label prior to going to administer the insulin to Resident #22 and should have. An interview was conducted with S1DON on 01/18/2024 at 1:56 p.m. She was made aware of the above observations. She confirmed the nurse should always compare the medication label to the current Physician Order prior to preparing the medication for administration. An interview was conducted with S5NP on 01/23/2024 at 9:15 a.m. She confirmed Resident #22 was Diabetic and received Humalog before meals and bedtime per sliding scale. She confirmed Levemir was a long acting insulin and Humalog was a rapid acting insulin, and the two medications could not be interchanged. She stated nurses should always verify the medication matched the Physician Order prior to preparing and administering medication.

Based on record review, observations, and interviews, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 2 (Cart A and Cart B) of 3 (Cart A, Cart B, and Cart C) medication carts observed. The facility failed to ensure: 1. Insulin pens were labeled with the date opened and 2. Insulin pens were discarded 28 days after the date opened. Findings: Review of the facility's policy titled, Medication Storage revealed the following, in part: Storage, supplies, and equipment necessary for appropriate temperatures and conditions per the manufacturer's specifications. Review of the Levemir (Insulin Detemir) Flex Pen Manufacturer Insert revealed the following, in part: 16.2 Storage: Store at room temperature for up to 42 days once opened Review of the Lantus (Insulin Glargine) Solostar Manufacturer Insert revealed the following, in part: 16.2 Storage: Store at room temperature for 28 days once opened Review of the NovoLog Flexpen's Manufacturer Insert revealed the following, in part: Storage Conditions: Store at room temperature for up to 28 days Review of the Humalog (Insulin Lispro) Kwikpen's Manufacturer's Insert revealed the following, in part: Storage: Store pens at room temperature for up to 28 days Cart A: Resident #37 Review of Resident #37's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included Type 2 Diabetes Mellitus. Review of Resident #37's current Physician Orders revealed the following, in part: Insulin Glargine 100 unit/mL pen administer 18 units SQ at night daily Insulin Lispro 100 unit/mL pen SQ per sliding scale. Accuchecks before meals and at bedtime. Resident #65 Review of Resident #65's Clinical record revealed she was admitted to the facility on [DATE] and had diagnoses which included Type 2 Diabetes Mellitus. Review of Resident #65's current Physician Orders revealed the following, in part: Novolog 100 unit/mL flexpen SQ per sliding scale. Accucheck before meals and bedtime. Resident #80 Review of Resident #80's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses which included Type 2 Diabetes Mellitus. Review of Resident #80's current Physician orders revealed the following, in part: Levemir Flexpen 100 unit/mL solution give 10 units SQ at bedtime An observation was made of Cart A on 01/17/2024 at 2:05 p.m. with S3LPN who confirmed the below observation: Resident #37 - Insulin Glargine insulin pen was open, in use, and not dated to indicate when the insulin pen was opened. Resident #37 - Insulin Lispro insulin pen was open, in use, and labelled with an open date of 12/09/2023. Resident #65 - Novolog insulin pen was open, in use, and labelled with an open date of 12/01/2023. Resident #80 - Levemir insulin pen was open, in use, and not dated to indicate when the insulin pen was opened. An interview was conducted with S3LPN following the above observation. S3LPN stated insulin pens should have been labeled with the open date and discarded 28 days after opening and they were not. Cart B: Resident #7 Review of Resident #7's Clinical Record revealed she was admitted on [DATE] and had diagnoses which included Type 2 Diabetes Mellitus. Review of Resident #7's current Physician Orders revealed the following, in part: Lantus Solostar 100 unit/mL inject 10 units SQ at morning Lantus Solostar 100 unit/mL inject 10 units SQ at bedtime Humalog 100unit/mL SQ per sliding scale. Accuchecks 3 x daily. Resident #20 Review of Resident #20's Clinical record revealed he was admitted to the facility on [DATE] and had diagnoses which included Type 2 Diabetes Mellitus. Review of Resident #20's current Physician Order revealed the following, in part: Humalog 100 unit/mL flexpen SQ accucheck before meals and at bedtime per sliding scale Resident #31 Review of Resident #31's Clinical record revealed she was admitted to the facility on [DATE] and had diagnoses which included Type 2 Diabetes Mellitus. Review of Resident #31's current Physician Orders revealed the following, in part: Novolog 100 units/mL flexpen SQ twice a day before meals Lantus Solostar U-100 insulin 100 unit/mL (3mL) inject 20 units SQ twice daily Resident #36 Review of Resident #36's Clinical record revealed she was admitted to the facility on [DATE] and had diagnoses which included Type 2 Diabetes Mellitus. Review of Resident #36's current Physician orders revealed the following, in part: Novolog 100 unit/mL flexpen SQ twice daily per sliding scale Resident #110 Review of Resident #110's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included Type 2 Diabetes Mellitus. Review of Resident #110's current Physician Orders revealed the following, in part: Lantus Solostar 100 unit/mL give 10 units SQ daily An observation was made of Cart B on 01/17/2024 at 2:13 p.m. with S4LPN who confirmed the below observation: Resident #7 - Humalog insulin pen was open, in use, and labelled with an open date of 12/01/2023. Resident #7 - Lantus insulin pen was open, in use, and not dated to indicate when the insulin pen was opened. Resident #20 - Humalog insulin pen was open, in use, and not dated to indicate when the insulin pen was opened. Resident #31 - Novolog insulin pen was open, in use, and labelled with an open date of 12/01/2023. Resident #31 - Lantus insulin pen was open, in use, and not dated to indicate when the insulin pen was opened. Resident #36 - Novolog insulin pen was open, in use, and not dated to indicate when the insulin pen was opened. Resident #110 - Lantus insulin pen was open, in use, and not dated to indicate when the insulin pen was opened. An interview was conducted with S4LPN on 01/17/2024 at 2:25 p.m. She stated insulin pens should have been labeled with the open date and discarded 28 days after opening and they were not. An interview was conducted with S1DON on 01/18/2024 at 1:56 p.m. She stated insulin pens should be labeled with the open date and discarded 28 days after opening.

Based on record reviews, observations, and interviews, the facility failed to ensure an infection prevention and control program was maintained to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure nursing staff sanitized insulin pen stoppers prior to attaching an insulin pen needle for 2 (#22 and #34) of 3 (#22, #23, and #34) residents reviewed for insulin administration. Findings: Review of the facility's policy titled, Injections revealed the following, in part: Preparation: 5. Prepare syringe as follows. f. If medication is in a vial. i. Remove protective cap. ii. Wipe the rubber stopper with an alcohol pad and allow surface to dry. Review of the Humalog Kwikpen Manufacturer's Insert revealed the following, in part: Preparing your Pen: Step 1: Pull the Pen Cap straight off. Wipe the Rubber Seal with an alcohol swab. Step 2: Check the liquid in the pen Step 3: Select a new needle. Step 4: Push the capped Needle straight onto the Pen and twist the Needle on until it is tight. Resident #22 Review of Resident #22's current Physician Orders revealed, in part, an order for Humalog 100 unit/mL Kwik pen before meals and bedtime SQ per sliding scale. An observation was made of S2LPN administering Resident #22's Humalog insulin on 01/18/2024 at 11:39 a.m. S2LPN removed Resident #22's Humalog insulin pen cap and attached the insulin pen needle without sanitizing the insulin pen stopper. S2LPN administered Resident #22's insulin. Resident #34 Review of Resident #34's current Physician Orders revealed, in part, an order for Humalog 100 unit/mL Kwik pen before meals and bedtime SQ per sliding scale. An observation was made of S2LPN administering Resident #34's Humalog insulin on 01/18/2024 at 11:33 a.m. S2LPN removed Resident #34's Humalog insulin pen cap and attached the insulin pen needle without sanitizing the insulin pen stopper. S2LPN administered Resident #34's insulin. An interview was conducted with S2LPN on 01/18/2024 at 11:43 a.m. She confirmed she did not sanitize Resident #22 and #34's insulin pen stoppers prior to applying the insulin pen needles. S2LPN stated she was unaware the insulin pen stopper had to be sanitized prior to applying the needle. An interview was conducted with S1DON on 01/18/2024 at 1:56 p.m. She confirmed all insulin pen stoppers should have been sanitized prior to applying the insulin pen needle.

Based on interviews and record review, the facility failed to ensure each resident was given the appropriate treatment and services to maintain his or her ability to carry out activities of daily living for 1 (#1) of 5 (#1, #2, #3, #4, and #5) residents reviewed for ADLs. The facility failed to ensure Resident #1 was provided toileting when requested. Findings: Review of the facility's policy titled, Toileting Residents revealed the following, in part: Purpose: Residents are toileted safely on a routine basis in a timely manner according to their individualized plan of care. Review of the facility's policy titled, Call Light/Bell: revealed the following, in part: Procedure: 2. All applicable staff are responsible to answer a call light within a reasonable time. 4. Ascertain the resident's needs and requests 5. Respond to the requests. If the item is not available or you are unable to assist, explain to the resident and notify the charge nurse for further instructions. Review of Resident #1's Clinical Record revealed an admitted [DATE] and diagnoses, which included Cerebral Infarction due to Unspecified Occlusion or Stenosis of Left Posterior Cerebral Artery, Other transient Cerebral Ischemic Attacks, Other Lack of Coordination, Hemiplegia Following Cerebral Infarction Affecting Left Nondominant Side, Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side, Dysphagia - Oropharyngeal Phase, and Generalized Muscle Weakness. Review of Resident #1's Quarterly MDS with an ARD of 07/12/2023 revealed a BIMS of 3, which indicated she was severely cognitively impaired. Further review of the MDS revealed she required extensive assistance of one person for toileting and was occasionally incontinent of bowel and bladder. Review of the Grievance/Complaint Report for Resident #1 dated 06/24/2023 revealed the following, in part: Name of person making complaint: Resident #1's family member Explanation/Nature of Complaint: 1. Family stated they put on resident #1's call light at 5:30 p.m., and they waited 15 minutes and someone came with the resident's tray, turned off the call light, and stated they would come back when they finished passing out trays. Resident #1's family stated nobody had come back by 6:05 p.m., so they put on the call light and went to the nurses' station for help. Summary of pertinent findings or conclusions: 1. The nurses stated the CNA had already clocked out and gone home. An interview was conducted with S4CNA on 09/12/2023 at 6:14 p.m. She stated Resident #1 was continent and required assistance for toileting. She stated she recalled an incident, on 06/24/2023, when Resident #1's call light was initiated around supper time. S4CNA stated when she walked in the room with Resident #1's supper tray, she addressed the call light. She stated Resident #1's sons were in the room, and one of her sons requested for Resident #1 to be transferred to the bathroom and put in bed. She stated the request was during meal time so she told Resident #1 and her sons she had to finish with the meal then would assist Resident #1, and she turned off the call light. She confirmed she did not report to another staff member Resident #1 needed to go to the bathroom. She stated when the meal was over, she did not return to assist Resident #1 and left the facility. She stated she should have gone back to assist Resident #1 once the meal trays were picked up and she did not. An interview was conducted with S3LPN on 09/13/2023 at 9:09 a.m. She stated Resident #1 required one person assistance for toileting, and she was mostly continent. She stated Resident #1 utilized her call light to summon staff for toileting. She stated she remembered a time when S4CNA went into Resident #1's room and turned the call light off and told her she would come back to assist her, however, she never returned. She stated her and another CNA assisted Resident #1 when the family made her aware Resident #1 was not assisted by S4CNA. She stated S4CNA left the facility without assisting Resident #1. An interview was conducted with S2DON on 09/13/2023 at 2:43 p.m. She stated a staff member should be present to answer call lights and assist residents during meal time. She stated nurses could assist residents with toileting during meal time. She stated Resident #1 could have been transferred to the bathroom by another staff member. An interview was conducted with S1ADM on 09/13/2023 at 2:59 p.m. She stated the recalled the incident with Resident #1 and S4CNA turning her call light off and not assisting the resident. He stated he expected S4CNA would have answered Resident #1's light and left the call light on until the task was performed. He stated he would have expected S4CNA assist Resident #1 to the bathroom as soon as all the meal trays were passed out. He confirmed Resident #1 was continent and could have been assisted to the bathroom at that time.

Based on record reviews, observations, and interviews, the facility failed to ensure an effective pain management regime was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the goals and preferences for 1 (#18) of 4 (#2, #18, #59, #71) sampled residents by failing to ensure: 1.) Nursing staff monitored the effectiveness of Resident #18's scheduled pain medication. 2.) Nursing staff implemented interventions when Resident #18's pain was unrelieved by measures already prescribed; and 3.) Nursing staff identify the underlying cause and seek appropriate treatment when Resident #18 began declining in Activities of Daily Living (ADLs) due to pain. The deficient practice resulted in an immediate jeopardy situation for Resident #18, a cognitively impaired resident, on 01/11/2022 after she returned to the facility from a local hospital for evaluation of a fall. S10LPN administered a dose of [MEDICATION(S)] 5-325 mg for pain on 01/11/2022 at 11:10 a.m. S10LPN failed to evaluate the effectiveness of the medication. Resident #18's unrelieved pain resulted in a physical decline in the residents ability to feed herself, propel within the facility, transfer herself, toilet herself, and participate in usual activities. On 01/14/2022, Resident #18 underwent an x-ray, which revealed an acute fracture of the left humeral head/left humeral neck. Facility staff confirmed the injury resulted from the fall on 01/10/2022. S1ADM was notified of the Immediate Jeopardy on 01/14/2022 at 5:45 p.m. The Immediate Jeopardy was removed on 01/18/2022 at 11:40 a.m. when the facility submitted an acceptable Plan of Removal. Through observations, interviews and record reviews, the surveyors confirmed the following had been implemented prior to exit. The Immediate Jeopardy Plan of Removal included: 1. Corrective action for Resident #18 found to have been affected by the alleged deficient practice: a. The facility has continued to assess for verbal and nonverbal indicators of pain. Routine [MEDICATION(S)] & PRN medications remain ordered for breakthrough pain. The nurse will evaluate the effectiveness of PRN pain medication by assessing verbal and nonverbal indicators one hour after PRN administration. Any unrelieved pain will be communicated to the physician. Facility's documentation system was updated to require every 4 hour pain evaluation for resident #18 in effort to evaluate the effectiveness of scheduled and PRN pain medication. b. Regional Supervisor contacted Hospice provider who agreed to come more frequently to assess resident #18. 2. All facility residents who have the potential to be affected by the cited deficient practice. a. On 01/14/2022, residents who have had incidents with injury over the past week were assessed by the Nursing Interdisciplinary Team for unrelieved pain. 7 out of 7 reported no unrelieved pain. Completed 01/14/2022. The Nursing Interdisciplinary Team has established a plan to perform a Pain evaluation on every resident upon admission, significant change, and quarterly to further evaluate effectiveness of Scheduled and PRN pain medication. The plan in place will be evaluated monthly until substantial compliance is achieved and monthly for an additional two months by the facility QA committee. b. Beginning 01/15/2022, the facility has continued to assess for verbal and nonverbal indicators of pain for all facility residents. A process has been put in place whereby the nurse will evaluate the effectiveness of PRN pain medication by assessing verbal and nonverbal indicators one hour after PRN administration. Beginning 01/14/2022, the Nursing Interdisciplinary Team began performing a pain evaluation on every facility resident to evaluate effectiveness of Scheduled and PRN which was completed on 01/17/2022. A process has been put in place whereby the Nursing Interdisciplinary Team will perform a Pain evaluation on every resident upon admission, significant change, and quarterly to further evaluate effectiveness of Scheduled and PRN pain medication plan in place. The plan in place will be evaluated monthly until substantial compliance is achieved and monthly for an additional two months by the facility QA committee. c. On 01/17/2022, all remaining facility residents were evaluated by the Nursing Interdisciplinary Team for current pain level with a focus on non-verbal signs and symptoms of pain. One resident complained of a headache and received PRN medication as ordered. All remaining residents had no verbal or nonverbal indicators of pain. Completed 01/17/2022. The Nursing Interdisciplinary Team will perform a Pain evaluation on every resident upon admit/readmit, significant change, and quarterly to further evaluate effectiveness of Scheduled and PRN pain medication plan in place. This plan will be evaluated monthly until substantial compliance is achieved and monthly for an additional two months by the facility QA committee. 3. Measures implemented to an effort to eliminate the recurrence of the cited deficiency are as follows: a. On 01/14/2022, the facility had an immediate QA with the Medical Director to review the plan for correction. Completed 01/14/2022. b. On 01/14/2022 the Medical Director performed a verbal and nonverbal assessment of pain with the DON on Resident #18 and was satisfied with the DONs assessment skills and deemed her competent to perform and train other staff on assessing verbal and nonverbal pain through direct observation. The DON immediately began in-servicing nursing staff present and all others will be in-serviced prior to beginning their next shift on assessing and reporting verbalize pain or non-verbal signs and symptoms of pain. The licensed nurses have been instructed to provide pain medication as needed, evaluate the effectiveness of PRN pain medication by assessing verbal and nonverbal indicators one hour after PRN administration. All licensed nurses were in-serviced on contacting the attending physician to alert them of unrelieved pain and inquire if a new order is warranted. A request will be made of the physician to schedule the pain medication as opposed to PRN. All nursing staff, including agency staff, will be required to receive in-servicing as stated above prior to beginning their next shift. Estimated completion date 01/17/2022. c. The facility will monitor staff competency by administration of a post training test. Estimated completion date 01/17/2022. The plan in place will be evaluated monthly until substantial compliance is achieved and monthly for an additional two months by the facility QA committee. d. The DON will randomly assess residents three times per week through direct observation to monitor that pain is being appropriately addressed. Estimated completion date will be ongoing until compliance achieved. e. The Nursing Interdisciplinary Team will perform a Pain evaluation on every resident upon admission, significant change, and quarterly to further evaluate effectiveness. f. Beginning 01/14/2022, the Nursing Interdisciplinary Team began performing a pain evaluation on every facility resident to evaluate effectiveness of Scheduled and PRN pain medications, which was completed on 01/17/2022. A process has been put in place whereby the Nursing Interdisciplinary Team will perform a Pain evaluation on every resident upon admission, significant change, and quarterly to further evaluate effectiveness of Scheduled and PRN pain medication plan in place. The plan in place will be evaluated monthly until substantial compliance is achieved and monthly for an additional two months by the facility QA committee. The deficient practice continued at a potential for more than minimal harm for the other 99 residents in the facility who were at risk for being in pain and not having their pain managed. Findings: Review of the facility's policy titled Pain Screen and Management revealed, in part: All residents who experience routine pain receive a comprehensive pain screening and a treatment plan until acceptable level of relief is achieved. All residents had the right to treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] The resident's statements are the most valid measurement of pain. Non-communicative residents are assessed by observation of nonverbal behavior. A pain screening is completed minimally at admission/readmission. 1. All residents who receive routine pain medication will have a pain screening completed by a licensed nurse. 2. A pain scale is used whereby the resident describes his/her pain and amount of pain relief. 3. A plan for pain and symptom management is developed based upon the collected data in collaboration with the appropriate interdisciplinary care team members, which includes the resident and family as needed. 4. Acute onset of pain: a. A pain screen is completed when a resident has a new onset of pain, a new type of pain, new pain medication or treatment, or when a resident has not experienced an acceptable level of pain relief. b. New or changed medication orders are transcribed per facility standard of practice and a clinical note is documented. c. When documenting regarding pain the following elements should be addressed: date and time of onset, location of pain, character, severity (use pain scale), alleviation factors (what makes it better), exacerbation factors (what makes it worse), treatments and medications, and responses. d. When the resident is medicated with prescribed medication or treated as ordered, documentation of medication or treatment is done on the MAR or the TAR. e. Documentation, using the pain scale, of a new type of pain, a pain medication and/or treatment change, is done every shift until the pain is managed effectively. f. Documentation includes location of pain, medication given and its effect using the pain scale plus any concerns about side effects. Review of the clinical record for Resident #18 revealed she was admitted to the facility on [DATE] with diagnosis, which included [CONDITION(S)] with [CONDITION(S)], Hypertensive [CONDITION(S)] with Heart Failure, Shortness of Breath, Alzheimer's Disease, Major Depressive Disorder, Anxiety Disorder, [CONDITION(S)], Unsteadiness on Feet, Need for Assistance with Personal Care, Cognitive Communication Deficit, Age-related [CONDITION(S)], Chronic Obstructive Pulmonary Disease, Moderate Protein Calorie Malnutrition, and Pain. Further review revealed Resident #18 was admitted to Hospice on 10/07/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's quarterly MDS with an ARD of 01/06/2022 revealed a BIMS of 4, which indicated she was severely cognitively impaired. Resident #18's speech clarity was clear with distinct intelligible words and she was able to make herself understood. She was able to respond adequately to simple, direct communication. She did not wear a hearing aid. Resident #18 required limited assistance of one person for transfers, locomotion, dressing, toileting, personal hygiene, and eating. Review of the Care Plan with problem onset dated 11/27/2019 revealed, in part: Resident is at risk for pain with approaches including: Administer medications as ordered; notify MD of any unrelieved pain; reposition for comfort as needed; observe onset, location, severity, and duration of pain; and observe effectiveness of med. Review of the nurse's note dated 01/10/2022 at 11:48 p.m. revealed around 10:50 p.m. notified by CNA that Resident #18 had fallen. The resident was noted on the floor lying on her left side next to the wheelchair. After assessing Resident #18, a cut was noted above the resident's left eye. Resident #18 has no recollection of how the fall occurred. The resident complained of pain to the left arm. Spoke with on call staff, S6NP, and received the okay to send the resident out to emergency room for further evaluation. Notified EMS for transfer. Spoke with Resident #18's daughter and made her aware of the fall and the transfer to ER for further evaluation. Safely transferred the resident back to bed and CNA cleaned her in prep for transfer. Resident #18's daughter called again and asked to speak to the resident. I went into the room and called the daughter from the resident's phone. After EMS left with Resident #18, her daughter then called back and said, She's in much worse condition than you led me to believe and her arm is hurting her! Will report fall to oncoming nurse and any update I receive about resident's condition during the shift. Signed by: S19LPN A review of the emergency room notes for Resident #18 from the local hospital, dated 01/11/2022 at 12:05 a.m., revealed the following: Triage nurse note: left eye laceration and left shoulder pain/swelling HPI note: right arm pain, fall Free text summary: patient presents to the ED with right arm pain and small facial lacerations after an unwitnessed fall at the nursing home. Patient does not remember the fall, she has a history of dementia. Patient states her right arm hurts and her back hurts. ROS: Extremities: There is tenderness to palpation of the left shoulder. There is swelling and mild bruising noted to the shoulder. Patient has decreased ROM of this shoulder due to pain. Patient has abrasions and mild swelling to the left knee. X-ray, humerus, right: impression: no significant radiographic abnormality of the right humerus. Progress note at 4:45 a.m.: patient continues to complain of pain to her left humerus. Her x-rays without dislocation or fracture. Patient to be placed in an arm sling for comfort. discharged , stable at 4:45 a.m. with Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurses note dated 01/11/2022 at 1:10 p.m. revealed Resident #18 returned from the hospital with no new orders and in stable condition. The resident complained of pain to the left arm. Sling noted in place. New order given per hospice for [MEDICATION(S)] 0.5 mL, give by mouth now and for [MEDICATION(S)] 5-325 mg, give by mouth three times daily due to complaint of pain. Signed by: S10LPN Review of the clinical record for Resident #18 revealed no pain screening was completed upon readmission from the hospital on 01/11/2022. Further review, revealed no evidence Resident #18's pain was being assessed before and after pain medication was administered to determine the effectiveness, and the location of the resident's pain. Review of Resident #18's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 11/27/2021, [MEDICATION(S)] 5-325 mg 1 tablet by mouth every 6 hours as needed for pain 01/11/2022, [MEDICATION(S)] 5-325 mg 1 tablet by mouth three times a day for pain 01/11/2022, [MEDICATION(S)] 10 mg/mL syringe give 0.5 mL now for pain A review of the MAR for November 2021, December 2021 and January 2022 revealed Resident #18 had not received PRN [MEDICATION(S)] 5-325 mg for pain as ordered by the MD in either November or December 2021. Further review revealed only one dose was administered on January 11, 2022 at 11:10 a.m. On 01/13/2022 at 9:20 a.m., an observation was made of Resident #18. The resident was in bed with her eyes closed. Her breakfast was untouched. The left arm was swollen and bruised below the shoulder to the elbow, and on top of the arm. Resident #18 had a facial expression noted to be in a grimace with her lips in a frown and brow furrowed. Resident #18 was breathing heavily. On 01/13/2022 at 9:40 a.m., an observation was made of Resident #18. The resident's breakfast was still not eaten. The resident's left arm was swollen and bruised below the shoulder to the elbow, and on top of the arm. Resident #18's eyes were closed. Her facial expression was noted to be in a grimace with her lips in a frown and brow furrowed. On 01/13/2022 at 9:46 a.m., an interview was conducted with S22CNA. She said she worked the day shift with Resident #18 today. She said Resident #18 was normally able to feed herself, but she confirmed she had not fed herself breakfast today. She said Resident #18 had a fall on 01/10/2022 and hurt her left arm. She said the resident had been complaining of pain today to her left arm. She said she reported the pain to the nurse. S22CNA said it was difficult to provide care to Resident #18 since the fall because of the pain in her left arm. On 01/14/2022 at 8:59 a.m., an interview was conducted with Resident #18. The resident said she was in pain and touched her left arm with her right hand to indicate where the pain was. She said it hurt to move her left arm. Resident #18 slowly and reluctantly picked up her left arm. Resident #18 moaned aloud when she moved the arm. Resident #18's face tightened into a deep frown, she grimaced during the observation, and her body flinched and muscles tightened. Resident #18 had difficulty verbalizing her pain numerically or verbally describing the pain due to her cognitive impairment. On 01/14/2022 at 9:02 a.m., an interview was conducted with S12LPN. She said she worked the day shift with Resident #18 this week. She said since 01/10/2022 Resident #18 had complained of pain in her left arm. She said she gave the resident scheduled [MEDICATION(S)], but the pain was unrelieved. She denied contacting the physician or the hospice nurse to report unrelieved pain after administration of the scheduled [MEDICATION(S)]. She denied administering the resident's PRN [MEDICATION(S)] between scheduled doses to help with pain relief. She confirmed Resident #18 was experiencing unrelieved pain to her left arm since falling on 01/10/2022. On 01/14/2022 at 9:04 a.m., an interview was conducted with S2DON. She said Resident #18 had a fall on 01/10/2022, which resulted in bruising to her left arm. She said the resident was sent to the emergency room for evaluation and the x-rays came back negative for injury. She confirmed she had not reviewed Resident #18's discharge hospital records from 01/10/2022. S2DON reviewed the hospital records and confirmed Resident #18's right arm had been x-rayed instead of the left. She verified the wrong arm had been x-rayed by the hospital. She confirmed the facility did not identify until now that Resident #18's left arm was not x-rayed on 1/10/2022. She confirmed she had not observed the resident since prior to her fall on 01/10/2022. She confirmed no one had notified her of Resident #18 having unrelieved pain since her return from the emergency room . She stated she was not aware Resident #18 was declining in her ability to complete and participate in activities of daily living. On 01/14/2022 at 9:12 a.m., an interview was conducted with S23CNA. She said she normally worked the day shift with Resident #18. She said Resident #18 had complained of left arm pain since falling on 01/10/2022. She said the pain made it difficult to provide care because the resident did not want her left arm moved. She said Resident #18 was unable to move her left arm so she had to move it for her during care. She confirmed each time she attempted to move Resident #18's arm the resident felt pain and stopped her from providing care. On 01/14/2022 at 11:30 a.m., an interview was conducted with the Hospice RN. She said the facility did not notify hospice when Resident #18 fell on [DATE] or that she was sent to the local emergency room . She said she was at the facility to see Resident #18 for a routine visit on Tuesday, 01/11/2022, at approximately 11:00 a.m. She said she could hear Resident #18 hollering out in pain from the hallway. She said when she entered Resident #18's room she observed the resident to have her left arm in a sling and bruising. She said the facility nurse told her there were no discharge papers from the hospital. She said the facility nurse was not able to give her a full picture of what happened and was only able to tell her the resident fell . She said Resident #18 told her she was in pain from her left arm. She said she asked the facility nurse if Resident #18 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she reviewed the residents MAR and realized she did have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she changed the resident's [MEDICATION(S)] 5-325 mg from PRN every 6 hours to scheduled three times a day. She also added in a one time dose of [MEDICATION(S)] to try and relieve Resident #18's pain. She explained she changed the pain medication to scheduled after review of the MAR, because Resident #18 had dementia and she was not sure the resident would ask for the pain medication and she wanted to ensure she received it. She confirmed she did not discontinue the order for PRN [MEDICATION(S)] 5-325 mg and the resident could receive it if the scheduled medication was not effective. She stated she had not seen Resident #18 since the visit on 01/11/2022 and the facility had not contacted hospice since then either. On 01/14/2022 at 11:58 a.m., an interview was conducted onsite with Resident #18's daughter. She said her mother fell on the night of Monday, 01/10/2022. She said the facility sent her mother to the hospital and she had an x-ray of the left arm, which was negative for a fracture. She said even though there was no fracture her mother continued to be in severe pain. She said prior to the fall on 01/10/2022, her mother stayed in her wheelchair most of the day and was able to propel herself within the facility. She said her mother would get up, dress herself, and go out to talk with her friends. She said her mother would usually sit in the dining room for meals and was able to feed herself. She said her mother could go the bathroom as well. She said her mother would call her every night and they would talk on the phone. She said since the fall her mother was no longer calling her at night, getting up in her wheelchair, going to the bathroom, going to the dining room, or able to independently feed herself. She said she had become incontinent. Resident #18's daughter confirmed since the fall on 01/10/2022 her mother had declined. She also confirmed Resident #18 had been in severe pain that did not seem to be relieved since she returned to the facility on [DATE]. On 01/14/2022 at 12:21 p.m., an interview was conducted with S10LPN. She said she worked the day shift with Resident #18 regularly. She said Resident #18 fell in the facility on 01/10/2022 and was sent to the emergency room for evaluation. She said Resident #18 returned to the facility on [DATE], during her shift, and she was assigned to care for her. She said upon assessing Resident #18, she indicated her left arm hurt and it was in a sling. She said the left arm was not bruised at the time, but the resident was guarding the left arm and holding it with it the right hand. She said the hospice nurse was already in the facility when the resident returned from the hospital, and ordered a one-time dose of [MEDICATION(S)] and scheduled [MEDICATION(S)] three times a day for pain. She said there was a major change in Resident #18 after the fall. She said, prior to the fall on 01/10/2022, Resident #18 would sit in the dining room with her friend for meals and feed herself. She stated since the fall, the resident had been unable to feed herself and was not getting out of bed. She confirmed Resident #18 had notable pain to her left arm and increased confusion since returning from the hospital on 01/11/2022. She said she did not report Resident #18's left arm pain to anyone and just gave the scheduled pain medication. She confirmed Resident #18's pain was not relieved by the scheduled [MEDICATION(S)] and she did not administer an as needed dose to assist with pain relief. On 01/14/2022 at 1:40 p.m., an observation was made of Resident #18 up in her wheelchair. She by exhibiting frowning and facial grimacing. An interview was conducted at this time with Resident #18 and she said she was in pain and her left arm hurt. Resident #18's face tightened into a grimace and she moaned aloud when she attempted to lift the left arm. Resident #18 had difficulty verbalizing her pain numerically or verbally describing the pain at this time due to her impaired cognitive ability. On 01/14/2022 at 3:36 p.m., an interview was conducted with S30LPN. She said she worked the evening shift with Resident #18 regularly. She said Resident #18's daughter called her on the evening of 01/11/2022 because of the pain her mother was having and she felt the facility was not doing enough to get the resident out of pain. She said she gave Resident #18 scheduled pain medication and thought it helped her to rest a little, but it did not relieve the pain. She said she never reached out to the MD, NP, or the hospice nurse to tell them Resident #18 was experiencing unrelieved pain and not her normal self. She said before the fall, the resident would get out of bed, go to the bathroom, and she was independent. She said after the fall, the resident was staying in bed and constantly in pain. On 01/14/2022 at 4:00 p.m., an interview was conducted with S2DON. She said an x-ray was completed on Resident #18's left arm today and the x-ray results revealed a fracture to the left arm. Review of x-ray performed in the facility on 01/14/2022 and electronically signed at 12:16 p.m., revealed the following: Clinical indications: pain Impression: acute fracture left humeral head/left humeral neck at least 2 cm impaction/displacement. Overlying soft tissue swelling. Osteoarthritic change. No dislocation. On 01/14/2022 at 5:53 p.m., an observation was made of Resident #18. She was seated in a wheelchair. She exhibited frowning and facial grimacing. An interview was conducted at this time with Resident #18 and she said her left arm hurt. The resident's face tightened into a grimace with slight movement. Resident #18 began to move her left arm in a slow and guarded manner. She held her breath as she moved the left arm. The resident's whole body tightening and flinching with the small movement. Resident #18 had difficulty verbalizing her pain numerically or describing the pain due to her impaired cognitive ability. On 01/14/2022 at 6:40 p.m., an observation was made of Resident #18. She was in her recliner in her room. She exhibited frowning and facial grimacing. An interview was conducted with Resident #18 with two surveyors present. When asked if her arm hurt the Resident moved her right arm with no issues and denied pain. When asked if her left arm hurt the Resident attempted to move the left arm and stated it hurt too bad to move it. She stated she had not received any pain medication recently. Resident #18's face tightened into a grimace, brows furrowed, and she frowned during the interview. Her whole body tightened and she held her breath as she attempted to move her left arm. Resident #18 had difficulty verbalizing her pain numerically or describing the pain due to her impaired cognitive ability. On 01/14/2022 at 6:45 p.m., an interview was conducted with S1ADM. He said S2DON assessed Resident #18, along with himself at the bedside, on 01/14/2022. He said they determined Resident #18 was not in any pain. He stated the facility determined Resident #18 was able to use the call bell to notify the nurse if she was in pain. On 01/14/2022 at 8:13 p.m., an observation was made of Resident #18. She was in the bed lying supine at a 45-degree angle. Her arm was observed to be resting in a sling with the fabric cinched together near the elbow revealing bruising and swelling to the left arm. An interview was then conducted with Resident #18 with two surveyors present. Resident #18 said she was in constant pain. She said she did not know what to do and just prayed that the Lord would help her with the pain and give her strength to get through it. Resident #18 was unable to recall she had fallen and was unable to verbalize how her left arm was injured. Resident #18 was unable to communicate that she could or would use the call light if she needed the nurse or had pain. Throughout the interview, Resident #18 was observed to tightly close her eyes, frown, breathe deeply, [NAME] her brows, stop talking mid-sentence, and grimace. She consistently wiggled her lower body in the bed, but each time she moved she would grimace and her body would flinch again. Resident #18 was unable to rate her pain numerically or describe the pain due to her impaired cognitive ability. On 01/18/2022 at 12:18 p.m., an interview was conducted with S31CNA. She said she worked with Resident #18 on the day shift. She said Resident #18 was going down. She said the resident used to assist her while she provided care and talk to her. She said the resident no longer does that. She said the resident could not feed herself anymore and she was incontinent. She said the resident was not like that prior to her fall on 01/10/2022.

Based on record review and interviews, the facility failed to ensure the resident had the right to be free from neglect for 1(#71) of 5(#2, #18, #59, #64, #71) residents reviewed for accidents. Facility staff neglected to provide needed care and services to Resident #71 after a fall with injury by failing to: 1. Obtain and implement treatment orders timely; 2. Administer additional pain medication as ordered after the initial dose of pain mediation was ineffective; 3. Communicate unrelieved pain to the physician; and 4. Provide incontinent care to Resident #71 who continually requested to be cleaned. This deficient practice resulted in an actual harm for Resident #71 on 12/20/2021 after the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #71 continued to have unrelieved pain after she received one dose of [MEDICATION(S)] 50mg po at 8:00 a.m. She reported pain to S10LPN and S21CNA throughout the day but did not receive additional pain medication. S10LPN acknowledged she failed to follow up with Resident #71's physician until 11:27 a.m. regarding the residents continued pain and for an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . S10LPN further acknowledged she received an x-ray order from the physician on 12/20/2021 at 11:43 a.m. but the order was not called to the local imagining company until 1:58 p.m. Resident #71 cried in pain throughout the day and continued to ask to be cleaned after she urinated on herself. Resident #71 said, That was the worse pain I have experienced in my life and that she felt humiliated when she had to sit in her own urine for 8 hours. She said she asked to go to the hospital multiple times during the day. Resident #71 continued to have unrelieved pain and sat in her own urine in her recliner until 3:00 p.m. when her daughter requested she be transferred to a local hospital. On 12/20/2021 at 3:47 p.m. Resident #71 was transferred to a local hospital where x-ray results confirmed Resident #71 suffered from an acute traumatic comminuted fracture involving the proximal left femur. Findings: Review of the medical record for Resident #71 revealed the resident was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was readmitted to the facility after a hospitalization on [DATE] with diagnoses, which included Fracture of Unspecified Part of Neck of Left Femur and Subsequent Encounter for Closed Fracture with Routine Healing. Review of the most recent MDS for Resident #71 with an ARD of 09/29/2021 revealed the resident had a BIMS of 12, which indicated the resident had moderately impaired cognition. Further review revealed the residents functional status was supervision/set up help only for transfers, walking in room and corridor, locomotion on and off the unit, dressing and personal hygiene. Resident #71 was occasionally incontinent of urine and always incontinent of bowel. Review of the investigative report for Resident #71 dated 12/20/2021 at 8:00 a.m. revealed the following, in part; Narrative of incident and description of injuries: S10LPN was summoned to Resident #71's room per S21CNA. The resident was noted lying on the floor on her left side in front of closet in her room. The resident complained of pain to left leg and left hip. A call was made to her doctor for an x-ray to left leg and hip. Awaiting call back. Action taken: Assisted off the floor, assessment, and increase supervision. Resident Incident Follow up: hospitalized . Review of the Fax Form for Non-Emergency Communication dated 12/20/2021 revealed the facility faxed the form to Resident #71's physician at 11:27 a.m., which was indicated by the time 11:27 a.m. on top of the form. Further review revealed: Nurse Communication: Concerns and assessment: Resident had a fall this morning. The resident complained of left side pain to left hip and leg. Please give ok to do x-ray. Signed S10LPN. Review of the Fax Form for Non-Emergency Communication dated 12/20/2021 revealed the facility received a return fax at 11:43 a.m. from Resident #71's physician's office. Further review revealed: Physician Communication: Ok for x-ray left hip and left leg. Signed S3NP. Review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 50mg take 1 tablet by mouth every 6 hours as needed for pain- Start Date: 10/19/2020. Review of the Narcotics Record log for Resident #71 revealed the following: [MEDICATION(S)] 50mg po given on 12/20/2021 at 8:00 a.m. by S10LPN. Further review revealed Resident #71 had not received pain medication prior to the fall on 12/20/2021. Review of the nurse's notes for Resident #71 revealed the following, in part; 12/20/2021 at 11:02 a.m., Summoned to room per S21CNA. Resident #71 noted lying on the floor on her left side in front of closet in her room. The resident stated she was getting her clothes for the Christmas party when she fell . The resident complained of pain to her left leg and left hip. A call was made to Resident #71's physician regarding residents complaining of pain. Requested an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] 50mg 1 tablet given due to pain. Signed S10LPN. 12/20/2021 at 12:57 p.m., new order noted per S3NP- ok to x-ray left hip and leg. Signed S10LPN. 12/20/2021 at 3:18 p.m., new order noted to send resident to ER for evaluation and treatment. Signed S10LPN. 12/20/2021 at 3:47 p.m., ambulance here at present time. Daughter at resident's side. Resident in route to local hospital. Signed S10LPN. 12/20/2021 at 3:53 p.m., X-ray cancelled due to resident going to emergency room . Signed S10LPN. Review of the Emergency Department physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] 12/20/2021 at 4:49 p.m., [AGE] year-old female presents to the Emergency Department via Emergency Medical Services from her nursing home with left leg pain after a syncopal episode around 8:00 a.m. this morning. She was unable to ambulate after fall. Appears well but in pain. Left leg appears shortened and externally rotated. Hip x-ray shows acute traumatic comminuted fracture involving proximal left femur with femoral neck displacement. Pain controlled with [MEDICATION(S)] and [MEDICATION(S)]. Review of the Radiology results of Resident #71's left hip and pelvis x-ray obtained on 12/20/2021 revealed the following: Acute traumatic comminuted fracture involving the proximal left femur. The fracture is through the femoral neck with displacement. An interview was conducted on 01/12/2022 at 3:45 p.m. with Resident #71's daughter. She said on 12/20/2021 at 8:00 a.m. she was notified by S10LPN that her mother had a fall while attempting to get clothes from her closet. She said S10LPN and S21CNA assisted her mother in her recliner after the fall. She said when she arrived at the facility at 3:00 p.m. she found her mother to be experiencing excruciating pain. She said her mother had been in her recliner since 8:00 a.m. that morning. She said she could not move her leg and had urinated on herself. She said her mother told her she was embarrassed because she had to sit in her own urine for 8 hours. She said she received pain medication only one time after the fall at 8:00 a.m. She said when she arrived at the facility; the portable x-ray had not been completed. She said the staff could not move Resident #71 because of the pain she was experiencing from her left leg and hip. She said facility did not provide timely care and she demanded her mother be transported the hospital without the x-ray. An interview was conducted on 01/12/2022 at 4:00 p.m. with Resident #71. The resident was observed to be alert and oriented during the interview. She said on 12/20/2021 she had a misstep and fell on the floor in her room. She said S10LPN and S21CNA assisted her off of the floor and into her recliner after the fall at 8:00 a.m. She said she immediately began to feel pain and was unable to move her body because the pain would increase. She said S10LPN and S21CNA were in and out of her room throughout the day and each time she told the staff she was having excruciating pain to her left leg and left hip. She said S10LPN administered one dose of pain medication the entire 8 hours. She said, That was the worse pain I have experienced in my life. She said she told S10LPN several times to send her to the hospital instead of waiting for the x-ray, but the S10LPN told her she could not send her without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she urinated on herself and the staff refused to clean her because of the pain and fear of further injury. She tearfully said, I felt humiliated when I had to sit in my own urine for 8 hours. She said she stayed in the recliner all day until her daughter came. She said, My daughter came to the facility at 3:00 p.m. and demanded for me to be transferred to the hospital. She said she was later diagnosed with a left hip fracture. An interview was conducted on 01/13/2022 at 11:15 a.m. with S21CNA. She said she provided care to Resident #71. She said Resident #71 needed minimal assistance with ADL's. She said Resident #71 could make her needs known. She said she was working on 12/20/2021 when Resident #71 fell on the floor in her room. She said she was delivering breakfast trays and found Resident #71 on the floor. She said Resident #71 was crying and complaining of left hip and left leg pain. She said she called S10LPN to Resident #71's room. She said she and S10LPN assisted Resident #71 to her recliner. She said Resident #71 was grimacing, crying, and reporting pain to her left leg and hip. She said the resident continued to complain of pain to the left hip and left leg throughout the day while sitting in the recliner. She said Resident #71 remained in the recliner until she went to the hospital around 3:00 p.m. She said she reported to S10LPN each time Resident #71 complained of pain. She said when she made rounds at 10:00 a.m. Resident #71 told her she had urinated on herself and wanted to be changed. She said S10LPN told her not to move Resident #71 until an x- ray had been done. She said throughout the day Resident #71 continued to complain of pain to her left hip/left leg and requested to be cleaned. She said Resident #71 cried on and off most of the day requesting to go to the hospital. An interview was conducted on 01/13/2022 at 12:00 p.m. with the local imagining company technician. He reviewed the company's call log and verified he received a phone call from the facility staff on 12/20/2021 at 1:58 p.m. for an x-ray of the left hip and femur for Resident #71. He said he received another phone call from the facility staff at 3:48 p.m. to cancel the x-ray for Resident #71. He confirmed the facility had not contacted the local imaging company prior to 1:58 p.m. on 12/20/2021 to schedule an x-ray for Resident #71. An interview was conducted on 01/13/2022 at 1:00 p.m. with S10LPN. She said she provided care to Resident #71. She said Resident #71 needed minimal assistance with ADL's. She said Resident #71 could make her needs known. She confirmed Resident #71 had a fall in her room on 12/20/2021 at 8:00 a.m. She said S21CNA reported finding Resident #71 on the floor in her room. S10LPN said she assessed Resident #71 and assisted her to the recliner with the help of S21CNA. She said Resident #71 complained of pain to her left leg and left hip when they moved her to the recliner. She said she administered an as needed dose of [MEDICATION(S)] 50mg po to Resident #71 at 8:00 a.m. She said she called Resident #71's physician and left a message with the answering service but was unsure of the time. She said Resident #71 continued to complain of pain throughout the day. She said Resident #71 urinated in her underwear shortly after falling and continued to request to be cleaned throughout the day. She said she instructed S21CNA not to move the resident and clean her until the x-ray had been done. S10LPN reviewed Resident #71's medical record and verified she requested an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #71's daughter came to the facility at 3:00 p.m. and requested she be transferred to the hospital immediately. S10LPN said she should have followed up on obtaining the x-ray instead of waiting for Resident #71's physician's office to call her with an order. She said she should not have waited until 11:27 a.m. to make another attempt to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed Resident #71 complained of pain to her left leg and left hip throughout the day. She said she did not notify Resident #71's doctor to inform him she continued to have pain after administering [MEDICATION(S)] 50mg po at 8:00 a.m. She further said she did not give Resident #71 additional [MEDICATION(S)] 50mg to relieve the pain she had voiced throughout the day. She confirmed Resident #71 urinated on herself shortly after the fall and repeatedly asked to be cleaned during the day. She said she should have followed up to ensure the x-ray was ordered immediately, notified Resident #71's physician of continued pain and administered additional pain medication. She said, I should have transferred Resident #71 to the hospital after she fell . She confirmed Resident #71 had requested to go to the hospital during the day but she told her she needed an order from the physician before transferring her to the Emergency Department. An interview was conducted on 01/13/2022 at 2:10 p.m. with S2DON. She said she was aware Resident #71 had a fall in the facility on 12/20/2021 that resulted in a left hip fracture. She said she was unaware there was a delay in obtaining an x-ray of Resident #71's left hip/ left leg or that she had complained of left hip pain throughout the day. After reviewing Resident #71's medical record, she verified the resident fell at 8:00 a.m. on 12/20/2021. She confirmed Resident #71 received [MEDICATION(S)] 50mg po at 8:00 a.m. She also confirmed Resident #71's physician was notified via fax at 11:27 a.m. She said S10LPN should have followed up sooner with Resident #71's physician to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the physician should have also been notified when Resident #71 continued to experience pain after receiving pain medication. She reviewed Resident #71's MAR and confirmed S10LPN could have administered another dose of prn pain medication while waiting for the local imagining company to come to the facility. She said she was unaware Resident #71 had experienced humiliation because she had urinated on herself. She said S10LPN should have informed her of Resident #71's fall, the delay in obtaining an x-ray and that the resident had experienced pain throughout the day.

Based on interviews and record reviews, the facility failed to ensure a resident's environment remained as remained as free of accident hazards as possible for 1 (#2) of 5 (#1, #2, #3, #4, #5) residents reviewed for transfers. The facility failed to ensure staff transferred Resident (#2) with 2 staff present as identified in the plan of care. This resulted in an actual harm on 06/12/18 when S3CNA neglected to follow the resident's plan of care and transferred Resident #2 from her wheelchair to the bed without another staff member present which resulted in the resident sustaining a fracture to the left humerus (long bone in the arm that runs from the shoulder to the elbow). The resident was sent out to the emergency department on 06/12/18 for evaluation and treatment of [REDACTED]. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility policy titled Lifting Policy revealed the following: . Procedures: . Staff will follow the documented lifting protocol deemed appropriate for each resident as noted on their ADL information. This information is documented in the resident's chart on the ADL sheets and via a color coded sticker system. This information should be referred to prior to lifting/transferring or assisting each resident. This documentation will also include which sling type and sling size is appropriate for each resident. Plan of Care for lifting will be developed for each resident in need of a mechanical lift and followed per all staff. *Exception: Although the mechanical lift, if indicated by screening, is the preferred method of transfer it is recognized it may not always be possible due to certain circumstances. Circumstances to included emergencies, residents care needs, mechanical failure, and some areas in which mechanical lifts do not fit. In these circumstances it would be acceptable to transfer a resident manually with the assistance of one (1) or more staff as indicated on the most recent nurse data collection or lift transfer assistance screening and care plan. This information will be communicated to the CNAs per the ADL information . Dots to identify type of lift will be color coded as follows: Green-no assistance with lifting required-independent for lifting Blue-no mechanical lift required- hold hand or assist X 1 Yellow-Stand-n-Lift- 1 or more-person transfer Red-Total Lift- 1 or more-person transfer This information will be posted in a designated area and on Resident's ADL documentation by writing the color red, green, blue or yellow with the transfer instructions. The appropriate color dot will be placed at the head of the bed. A large red dot will be placed on the total lift and a yellow dot on the stand-n-lift Review of the clinical record for Resident #2 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan for Resident #2 revealed the resident required a total assist with 2 person present for transfers. Review of the Nurses Notes for Resident #2 revealed the following: 6/12/18 9:57 p.m.- At 7:20 p.m. S3CNA reported to this nurse that she attempted to transfer resident on her own. During transfer S3CNA stated that she heard a popping sound. When entering bedroom, Resident #2's son was at bed side and stated he was present when incident occurred. Upon assessment, resident stated that her left shoulder was hurting. Area assessed and appeared to be slightly lower than the right shoulder. When touched resident grimaced and complained of pain. Spoke to on call Nurse Practitioner at 7:45 p.m. and received order to obtain stat x-ray of left shoulder and clavicle. Local X-ray imaging company arrived at 8:30 p.m. Reports were received at 9:00 p.m. stating there was an acute appearing fracture to the left humeral neck. Called on-call Nurse Practitioner with results and was given order to send resident to emergency room for evaluation and treatment. Resident #2 and son both made aware. Report called to nurse at receiving hospital at 9:45 p.m. Resident left facility at 9:50 p.m. on stretcher via ambulance to be transported to hospital. Review of the hospital record for Resident #2 revealed the following: Date of Service: 6/12/18 Nurses Triage Narrative: Patient transfer from nursing home for left humerus fracture Chief Complaint: left shoulder pain Text Summary: Patient is a [AGE] year-old African-American female with PMH [MEDICAL CONDITION] residual deficits currently in nursing home who present to the Emergency Department for evaluation of left humerus fracture. She was being transferred from her wheelchair to her bed by nursing home staff when she injured her left shoulder. An x-ray was performed which showed a left humerus fracture. Resident was given a sling and recommended to follow up with orthopedist and to receive Tylenol for pain. An interview was conducted with S1Administrator on 6/21/18 at 12:24 p.m. He stated they were made aware of the incident with Resident #2 on 6/12/18 and suspended the S3CNA when the fracture came back which was that evening. He stated that the investigation was opened the following day on 6/13/18 and S3CNA was terminated on 6/18/18. He stated S3CNA did not work with any other residents while they conducted their investigation. He stated when they called in S3CNA to question her about the incident, she confirmed she was aware the resident should have been transferred with 2 staff with a total lift. She further verified she transferred the resident incorrectly by herself and she should have gone and ask for help. S2DON was also present during this interview. Both S1Administrator and S2DON both confirmed S3CNA admitted to transferring Resident #2 incorrectly. They further confirmed there were no other incidents that had occurred since Resident #2 was transferred incorrectly. The facility has implemented the following actions to correct the deficient practice on 6/12/18: 1. Resident #2 was sent out to the emergency roiagnom on [DATE] immediately upon the discovery of the fracture for evaluation and treatment. The resident's arm was placed in a sling, instructed to follow-up with her Orthopedic Physician and to have Tylenol as needed to Pain. The resident was discharged that same day back to the facility. 2. S3CNA was immediately suspended 6/12/18 pending investigation and did not work with any other residents after this incident. When S3CNA was called in to provide her statement, the facility confirmed with S3CNA that she did transfer the resident incorrectly and was terminated on 6/18/18. 3. A complete facility assessment was done immediately on 6/13/18 on each resident residing in the facility by the Assessment Nurses to determine if resident's transfer statuses were accurate. Care plans were updated to reflect resident's that had a change in transfer status if deemed necessary during this assessment. All Dots above the resident's beds were observed to ensure they reflected the resident's accurate transfer status and in place above the resident's bed. 4. A full staff in-service was conducted on 6/14/18 and 6/17/18 to educate staff on the Transfer Policy and the Dot System informing the staff on the transfer status of each resident on whether they were Green, Blue, Yellow or Red, what the colors meant, and if the residents required 1 Staff or 2 Staff present per facility Policy, what each resident's transfer status was, reporting if residents refuse mechanical lifts for appropriate intervention, education and care planning. All new Nursing Staff will be provided transfer/lift training upon hire. 5. DON/Designee to monitor direct observations of 5 resident transfers 5x a week for 2 weeks, 3x a week for 2 weeks and weekly thereafter for 3 months to ensure staff adherence to and knowledge of facility staff policy. Monitoring to be completed on all shifts and observed on different transfers. Monitoring initiated on 6/14/18. 6. Results of direct observations of were to be assessed weekly by QA Committee for 4 weeks and then monthly thereafter until compliance achieved on 7/13/18.

Based on interviews and record reviews, the facility failed to ensure the resident had the right to be free from neglect for 1 (#3) of 5 (#1,#2, #3, #4, #5) residents reviewed. The facility failed to correctly transfer Resident (#3) using a total lift for transfers. This resulted in an actual harm on 11/22/17 when S4CNA neglected to follow the resident's plan of care and transferred Resident #3 from a Geri-chair to the bed without another staff member present and without using a total lift which resulted in the resident sustaining a fracture to the left hip. The resident was sent out to the hospital on [DATE] and underwent a left hip resection orthroplasty and right distal femur closed reduction and placement of knee immobilizer on 11/25/17. Findings: Review of the medical record for Resident #3 revealed the resident was admitted to the facility 11/22/13 and had [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set) for Resident #3 with an ARD (Assessment Reference Date) of 12/5/17 revealed that resident had a BIMS (Brief Interview for Mental Status) of 0 which indicated the resident was severely impaired for cognition. Further review revealed the resident was totally dependent with two persons' extensive staff assistance for transfers. Review of the Care Plan Smart Chart I for Resident #3 under approaches revealed LFT- Lift Status-RED-STOP-Total Lift Required. Review of the Nurses Notes for Resident #3 revealed the following: 11/22/17, 2:00 p.m.- 10:00 p.m.- S4CNA (Certified Nurse Assistant) reported to S5LPN (Licensed Practical Nurse) that she transferred Resident #3 from wheelchair to the bed and heard a pop sound. The resident had an elevated blood pressure and non-verbal symptoms of pain that she could not verbalize. Hospice was notified and recommended [MEDICATION NAME] (for pain) and [MEDICATION NAME] (for elevated blood pressure) to be given. One hour later the resident was sleeping with no complaints of pain and Hospice instructed S8LPN to call back for any more problems. 11/23/17, 6:00 a.m. - 2:00 p.m. - S4LPN noted Resident #3 would scream and grimace in pain with touching or moving her legs. She notified the on call NP (Nurse Practitioner), obtained an order for [REDACTED]. 11/23/17, 2:00 p.m. to 10:00 p.m.- S8LPN noted the X-ray results came back positive for a left [MEDICAL CONDITION]. She notified the on call NP and received an order to send the resident to the emergency room for evaluation and treatment. Resident left by Emergency Transport at approximately 8:40 p.m. Review of an Investigative Report for Resident #3 on 11/23/17 revealed the following: 11/22/17 at approximately 4:15pm, S4CNA reported that she was dressing resident, resident was struggling, S4CNA heard a cracking sound from resident's back, resident was laid down by S4CNA and S4CNA reported to nurse. Immediate actions taken: Assessed resident, called and reported to hospice, administered pain medication as ordered by Hospice 24 hour follow up: Resident has no visible injuries noted, but does report pain all over. Resident cries out in pain when lower extremities moved. 11/23/17 X-ray ordered to bilateral hip, pain medication administered. Review of an X-ray with 2 views of bilateral hips obtained on 11/23/17 revealed the following: 1. an acute left intertrochanteric femoral fracture with moderate displacement with Varus angulation. Review of the hospital records for Resident #3 revealed the following: Hospital stay from 11/23/17 through 11/28/17 - Resident #3 arrived at the emergency department on 11/23/17 at 8:35 p.m. with a chief complaint of a hip injury. An X-ray taken of her left hip revealed a traumatic left femoral neck intertrochanteric fracture is seen. On 11/25/17, resident underwent [REDACTED]. Review of S4CNA's written statement obtained on 12/7/17 revealed the following: I, S4CNA, upon ambulation reclined Resident #3's Geri-chair all the way back, lowered her bed to meet even with the chair and airplaned Resident#3 in the bed once she was positioned, I began to change her into her gown. She resisted and leaned back so, I then placed my hand near the base of her neck and leaned her forward suddenly I heard a loud pop. I immediately went and told the nurse on duty. The nurse then followed the proper protocol. - Signed S4CNA On 1/23/2018 at 11:03 a.m., an interview with S11CNA was conducted. She said she worked with Resident #3 off and on for several months. She said the resident was a total lift with 2 people at all times. She said she was aware of incident with the transfer and the resident had fallen when a CNA dropped her. She said this is what she heard but she did not know that by firsthand knowledge. She said when she saw Resident #3 the next morning for breakfast sitting in her Geri-chair after the incident she seemed to be in pain because she was crying. She said she saw the resident cry out in pain upon being touched. She said the staff could not touch the Resident #3 without her crying out in pain. On 1/23/2018 at 11:24 a.m. an interview was conducted with S12CNA. She said Resident #3's functional status was total care with a red dot for a total lift. She said the resident was able to communicate her needs to her but it would take a little time and patience to get it out of her. She said she worked with Resident #3 on 11/22/17 before the incident occurred that afternoon. She said she left the resident sitting up in her Geri-chair when her shift ended. She said when she came back the next morning on 11/23/17, the resident's facial expression was one of pain. She said the resident told her she fell and she told S9LPN that something wasn't right but did not mention the reported fall. She said she told S2DON and S9LPN that they needed to find out what was wrong. She said on 11/23/17, several people were in Resident #3's room doing a body audit on her. Resident #3 said nothing hurt her up on her shoulders, her arms, chest, and abdomen but when the nurse touched her legs, the resident would cry out. On 1/23/2018 at 12:00 p.m. an interview was conducted with S9LPN. She stated she worked with Resident #3 from (MONTH) of (YEAR) until she passed away. She said Resident #3 did have an incident in November. She stated on 11/23/17, it had been reported to her that on the afternoon shift 11/22/17, S4CNA was working with the resident and heard a crack. She said it had been reported S4CNA had put Resident #3 in the bed and heard the crack. She said she went in to assess Resident #3. She stated she would barely touch the resident's leg and the resident moaned. She said she definitely knew something was wrong when she saw her. She said she called hospice that morning and they instructed her to call the NP (Nurse Practitioner) and get an X-ray and give her a dose of [MEDICATION NAME] (for pain). On 1/23/18 at 3:11 p.m., a phone interview was held with S5LPN. She said S4CNA came to her and reported that the resident was struggling against her when she was changing the resident's clothes in bed when she heard a crack. S5LPN said S4CNA was in a panic when she reported this and the way she spoke and acted were very nervous. She reported she did not witness S4CNA transfer the resident. She said Resident #3 was already in bed when she went to assess her and found her face flushed with an elevated blood pressure and no issues with injury when she performed a body audit and ROM checks. She said Resident #3 did seem to be in pain. She said she notified the S2DON and told him about the incident and he instructed her to notify hospice. She said it was at this time that she wanted to do an incident report because it was the first time she had experienced something like this and S2DON instructed her to just notify hospice. She said she notified hospice nurse of the incident and was instructed to give the [MEDICATION NAME] and [MEDICATION NAME] and someone would come out and assess her. On 1/24/18 at 9:29 a.m., an interview was conducted with S10CNA. She said Resident #3 was total care and needed total assistance with everything in her activities. She said she did not work with the resident on 11/22/17 but S4CNA did that evening. She stated she saw S4CNA running out of the room after changing Resident#3's gown and hearing a pop. She said S4CNA seemed nervous and seeming not to know what to do. On 1/24/18 at 10:15 a.m., a phone interview was conducted with S2DON. He said on 11/22/17, S5LPN came into his office to report an incident. She said S4CNA reported when she was working with Resident #3, she heard the resident's back crack. He instructed S5LPN to notify the resident's Hospice company. He said he did not go in and assess the resident that day or interview any staff. He said on 11/23/17, he did go in and look at the resident and she was in obvious pain, crying out and grimacing when touched. He said he instructed S4LPN to give ordered [MEDICATION NAME] and to call Hospice. He said an X-ray was ordered but because of the holiday, the technician came out later than normal. He stated when the results came back, he was gone for the day. He said S3ADON called him later to notify him of the [MEDICAL CONDITION] once the x-ray report came back. He said at this time, he contacted S4CNA. He said upon his investigation and interviewing his staff, he found there were no other occurrences to attribute the Resident #3's injuries. He said after interviewing S4CNA on several occasions, S4CNA eventually admitted to transferring Resident #3 by herself without the lift. On 1/24/18 at 11:20 a.m., an interview was conducted with S1Admin. He said he was made aware of the incident with Resident #3 on 11/23/17 when the X-ray revealed she had a [MEDICAL CONDITION]. He stated he could not remember who told him but they reported S4CNA had been working with the resident, sat her up, and heard a crack. He said after the X-ray revealed a [MEDICAL CONDITION], they sent the resident to the hospital. He said they were notified by Resident #3's family that while at the hospital, the physician had found a fracture with her right leg. He said on an interview with himself, S2DON and S10CNASup, S4CNA confessed she had transferred Resident #3 to her bed improperly. S4CNA reported in this meeting that she transferred Resident #3 on 11/22/17 by airplaning the resident. S4CNA explained airplaning by leveling the Geri chair with the bed and then described moving the upper part of the resident's body in bed then the lower part. S4CNA reported it was after she had Resident #3 in the bed, that she heard the pop. S1Admin verified that Resident #3 was a total lift and S4CNA transferred the resident improperly.

Based on interviews and record review, the facility failed to implement a comprehensive person-centered care plan for 1 (#3) of 5 (#1, #2, #3, #4, #5) residents reviewed that required assistance with transfers. The facility failed to implement a care plan to meet the resident's nursing needs by failing to transfer Resident #3 utilizing a total lift with the assistance of 2 staff members from a Geri-Chair to the bed. This resulted in an actual harm when S4CNA transferred Resident #3 on 11/22/17 from a Geri-Chair to the bed without another staff member present and without using a total lift. An X-ray was obtained on 11/23/17 after observations of the resident being in pain which resulted in the discovery of the resident having a left [MEDICAL CONDITION]. The resident was sent out to the hospital on the same day (11/23/17) and later underwent a left hip resection orthroplasty and right distal femur closed reduction and placement of knee immobilizer on 11/25/17. Findings: Review of the medical record for Resident #3 revealed the resident was admitted to the facility 11/22/13 and had [DIAGNOSES REDACTED]. Review of the most recent MDS (Minimum Data Set) for Resident #3 with an ARD (Assessment Reference Date) of 12/5/17 revealed that resident had a BIMS (Brief Interview for Mental Status) of 0 which indicated the resident was severely impaired for cognition. Further review revealed the resident was totally dependent with extensive staff assistance with two persons for transfers. Review of the Care Plan Smart Chart I for Resident #3 under approaches revealed LFT- Lift Status-RED-STOP-Total Lift Required. Review of an OTIS (Online incident tracking system) discovered on 9/26/17 revealed the resident was found to have a bruise under her right arm and right breast an unknown origin that was unsubstantiated abuse. An x-ray was ordered out of an abundance of caution and was found to have a fracture of her right 6th rib. The facility did an assessment of the resident's lift status and she was moved from a no mechanical lift Blue (Hold Hand or Staff Assistance x1 with Transfers) to a total lift Red (Mechanical Lift- with 1 or More Staff Assistance with Transfers). Review of the Nurses Notes for Resident #3 revealed the following: 11/22/17, 2:00 p.m.- 10:00 p.m.- S4CNA (Certified Nurse Assistant) reported to S5LPN (Licensed Practical Nurse) that she transferred Resident #3 from wheelchair to the bed and heard a pop sound. The resident had an elevated blood pressure and non-verbal symptoms of pain that she could not verbalize. Hospice was notified and recommended [MEDICATION NAME] (for pain) and [MEDICATION NAME] (for elevated blood pressure) to be given. One hour later the resident was sleeping with no complaints of pain and Hospice instructed S8LPN to call back for any more problems. 11/23/17, 6:00 a.m. - 2:00 p.m. - S4LPN noted Resident #3 would scream and grimace in pain with touching or moving her legs. She notified the on call NP (Nurse Practitioner), obtained an order for [REDACTED]. 11/23/17, 2:00 p.m. to 10:00 p.m.- S8LPN noted the X-ray results came back positive for a left [MEDICAL CONDITION]. She notified the on call NP and received an order to send the resident to the emergency room for evaluation and treatment. Resident left by Emergency Transport at approximately 8:40 p.m. Review of an X-ray with 2 views of bilateral hips obtained on 11/23/17 for Resident #3 revealed the following: 1. an acute left intertrochanteric femoral fracture with moderate displacement with Varus angulation. Review of the hospital records for Resident #3 revealed the following: Hospital stay from 11/23/17 through 11/28/17 - Resident #3 arrived at the emergency department on 11/23/17 at 8:35 p.m. with a chief complaint of a hip injury. An X-ray taken of her left hip revealed a traumatic left femoral neck intertrochanteric fracture is seen. On 11/25/17, resident underwent [REDACTED]. On 1/23/2018 at 11:03 a.m., an interview with S11CNA was conducted. She said she worked with Resident #3 off and on for several months. She said the resident was a total lift with 2 people at all times. She said she was aware of incident with the transfer with resident that the resident had fallen and a CNA had dropped her. She said this is what she heard but she did not know that by firsthand knowledge. She said when she saw Resident #3 the next morning for breakfast sitting in her Geri-chair after the incident she seemed to be in pain because she was crying. She said she saw the resident cry out in pain upon being touched. She said the staff could not touch the Resident #3 without her crying out in pain. On 1/23/2018 at 11:24 a.m. an interview was conducted with S12CNA. She said Resident #3's functional status was total care with a red dot for a total lift. She said when she came back the next morning on 11/23/17, the resident's facial expression was one of pain. On 1/24/18 at 9:29 a.m., an interview was conducted with S10CNA. She said Resident #3 was total care and needed total assistance with everything in her activities. She said she did not work with the resident on 11/22/17 but S4CNA did that evening. She stated she saw S4CNA running out of the room after changing Resident#3's gown and hearing a pop. On 1/24/18 at 10:15 a.m., a phone interview was conducted with S2DON. She said S4CNA reported when she was working with Resident #3, she heard the resident's back crack. He said he was later informed the resident had a fractured left hip on 11/23/17. He stated she was sent to the hospital that same day. He said after interviewing S4CNA on several occasions, S4CNA eventually admitted to transferring Resident #3 by herself without the lift. On 1/24/18 at 11:20 a.m., an interview was conducted with S1Admin. He said on an interview with himself, S2DON and S10CNASup, S4CNA confessed she had transferred Resident #3 to her bed improperly. S4CNA reported in this meeting that she transferred Resident #3 on 11/22/17 by airplaning the resident. She explained airplaning by leveling the Geri chair out with the bed and then described moving the upper part of the resident's body in bed then the lower part. S4CNA reported it was after she had Resident #3 in the bed that she heard the pop. S1Admin verified that Resident #3 was a total lift and S4CNA transferred the resident improperly.

Based on observations, interviews and record reviews, the facility failed to ensure the resident was free from accident hazards for 1 (#36) of 3 (#36, #56, #114) residents reviewed for accidents. The facility failed to: 1. Provide a safe environment for Resident #36 by recreating the same accident hazard after she returned from the hospital due to entrapment of her right arm in the side rail on her bed by replacing the same type of side rail back on her; 2. Develop and initiate interventions to prevent future entrapment of Resident #36 in the side rail of her bed; and 3. Assess Resident #36 ' s safe use of and need for side rails. There were 122 residents who resided in the facility who used side rails that had the potential to be affected by this deficient practice out of a total resident population of 126 as identified by S1ADM. This resulted in an Immediate Jeopardy situation for Resident #36 on 08/06/15 at 9:20 PM when she returned from the hospital after having her right arm entrapped in the ½ upper side rail of the bed which required the fire department to use the Jaws of Life to cut the side rail to free the resident ' s arm. The Jaws of Life is a trademark name defined by Dictionary.com, as a heavy-duty tool that can cut through metal or pry apart sections of it: used especially to free people trapped in wrecked vehicles. Resident #36 was an [AGE] year old who had left sided paralysis and was confirmed by Occupational Therapy as not being able to use side rails for physical functioning and identified as a fall risk by the facility. On 08/06/15 Resident #36 ' s right arm became entrapped in the right upper ½ side rail of her bed, she experienced pain that required narcotic administration, and required the fire department to cut the side rail to free the resident ' s limb from being entrapped in the side rail. The resident was sent to the hospital for evaluation and upon her return, she was placed back in the bed with identical ½ side rails as the one she became entrapped. The side rails were left in place at the request of S1ADM and remained in place while the resident was in bed. The facility did not have a system in place to assess the resident ' s safe use of and need for side rails and did not put interventions in place to prevent the resident from becoming entrapped again. S1ADM was notified of the Immediate Jeopardy situation on 08/26/15 at 3:30 PM. The Immediate Jeopardy remained in effect for Resident #36 until 8/27/15 at 3:00 PM when an acceptable plan of removal was provided. The plan included the following: Resident #36 was assessed for the use of side rails using an updated assessment tool. Resident #36 had her right side rail removed, a wing mattress put into place, and the left side rail secured to immobilize utilization. Other residents who were identified as being at risk were assessed. The facility implemented a new side rail utilization tool to be completed on all residents to establish a base line. An emergency Quality Assurance (QA) meeting with the Medical Director was held and a QA tool was implemented. Staff in-servicing was initiated and will continue until all licensed nursing staff and certified nursing assistants have been properly educated. Residents assessed as not requiring a side rail had it properly secured to avoid utilization. Incident/accident logs will be reviewed daily to ensure no negative outcomes related to the use of side rails and or proper implementation for corrective measures to avoid further occurrences. In-servicing of all licensed nurses and nursing assistants will be done every shift prior to providing resident care on the newly implemented protocol. The facility will implement QA tools to review targeted residents no less than 4 times a week on alternating shifts to include nights and weekends, the use of side rails will be reviewed by the interdisciplinary team on admission, quarterly, annually and after any significant change assessment and after any documented incident or accident related to side rail use. Staff failure to implement the proposed protocol will receive progressive discipline up to and including termination. The deficient practice remains at a level 2, potential for more than minimal harm, for the residents in the facility who continue to use side rails. Findings: A copy of the facility ' s policy and procedure on side rails was requested from S2DON. A copy of a policy titled Restraints with a latest revision of 04/15 was provided. Review of the policy revealed residents must be screened for use of approved restraints to meet their particular needs. Bedrail usage should also be reviewed. If necessary, use side rail covers or bolsters to prevent the resident ' s body from going under or through side rails if side rails are used. Review of the clinical record for Resident #36 revealed an admission date of [DATE]. Further review revealed [DIAGNOSES REDACTED]. Review of Resident #36 ' s Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/14/15 revealed a Brief Interview for Mental Status (BIMS) score of 2 coding the resident as severely cogitatively impaired. Review of the same MDS revealed the resident was 2 person extensive assist for bed mobility and had upper and lower extremity limitation in range of motion on one side. Review of the care plan for Resident #36 revealed the resident was at risk for falls related to [DIAGNOSES REDACTED] and had psychotic behavior as evidenced by hallucinations and delusions. Further review revealed a problem onset of 08/17/15 of discomfort and weakness to right upper extremity due to trauma related to recent fall. Resident #36 was coded with a fall risk score of 15 (high risk for falls) on the Nurse Data Collection and Screening form dated 07/14/15. Review of the Nurses Notes and an incident report for Resident #36, dated 08/06/15, revealed that on 08/06/15 at 4:40 PM S8LPN was summonsed to Resident #36 ' s room. The nurse observed the resident sitting on the floor with her right arm hooked in her bed rail . S8LPN attempted to move the resident ' s arm but it was difficult to move and the resident complained of pain when her arm was touched. An ambulance was called and the resident remained on the floor in the position she was found in until the ambulance arrived. The Nurses Notes further revealed that at 4:50 PM the ambulance arrived and the ambulance personnel attempted to try and remove the resident ' s arm from the bed rail and were unable to because it was hard to remove and the resident complained of pain. The fire department was called for assistance. S4Maintenance was also called to assist by unscrewing the bed rail from the bed but this was unsuccessful in getting the resident ' s arm out of the bed rail. The fire department arrived and used the Jaws of Life to cut the bed rail to free the resident ' s extremity from entrapment in the side rail. The ambulance personnel placed an Intravenous Catheter (IV) in the Resident ' s left hand and administered the resident Fentanyl (a narcotic pain medication) IV due to the resident complaining of pain. The resident was then transferred to the hospital for an evaluation. At 9:20 PM on 08/06/15, Resident #36 returned to the facility from the hospital. Documentation on the Resident Incident Follow-up for the incident on 08/06/15 revealed the resident was attempting to go to the restroom and fell on the floor and her arm became entrapped in the bed rail. Additional follow-ups were listed on the form as bed alarm was put in place on the resident ' s bed. The follow-up was signed by S2DON. Review of the Nurses Notes from 08/07/15 to 08/09/15 revealed documentation of the resident having a bruise to her right arm and complaining of pain to right arm. Review of the Ambulance Company ' s Pre-hospital Care Report Summary, dated 08/06/15, revealed ambulance personnel arrived at the facility on 08/06/15 at 4:39 PM. The Narrative History Text section revealed Resident #36 stated she slid out of bed and her arm got caught in the bed rail. The resident ' s arm was pinned in the bedrail and the ambulance personnel were unable to remove her arm. The fire department was contacted and cut the bed rail with Jaws of Life to remove Resident #36 ' s arm from being entrapped in the bed rail. Fentanyl 25 mg (micrograms) was given IV to the resident at 5:33 PM by the ambulance personnel. During an observation on 08/24/15 at 10:00 AM, Resident #36 was lying in bed with ½ upper side rails raised on both sides of her bed. The resident was asked to move her left arm. She stated she was not able to. Her left hand was observed to have a splint device in place. Each upper side rail was partitioned into 4 parts by cross bars Further observations were made of Resident #36 on 08/25/15 at 10:00 AM, and again on 08/26/15 at 8:30 AM and 2:45 PM. The resident was lying in bed with the ½ upper side rails raised on both sides of her bed during each observation. During the observation on 8/26/15 at 2:45 PM the resident ' s right leg was hanging off the right side of the bed. In an interview on 08/26/15 at 08:30 AM, Resident #36 stated she slid out of the bed one day when trying to get up to go to the bathroom and her right arm got caught in the side rail of the bed. She further stated the emergency people had to cut the bed rail to get her arm out of the bed. She said her arm hurt really bad . During an interview on 08/26/15 at 8:33 AM, S3CNA stated she cared for Resident #36 and the resident required 2 person total assist for bed mobility and was a fall risk. She also stated the resident would see things like snakes in her room and would talk out of her head . S3CNA explained she was working the day the resident slid out of the bed while trying to get up to go to the bathroom. She further explained when she entered Resident #36 ' s room she observed the resident sitting on the floor with her right arm, from her elbow to her wrist, entrapped in the upper right side rail of the bed. She explained S8LPN was in the room with the resident and when the LPN (licensed practical nurse) attempted to remove her arm from the side rail, the resident complained of pain. She said S1ADM was in the resident ' s room during the incident and requested the maintenance director to remove the side rail from the bed in an attempt to free the resident ' s arm. S3CNA stated the resident continued to complain of pain and required use of the fire department to free her right arm from the bed rail. She reported the resident was taken to the hospital and returned the same night during her shift and was placed back in the same bed in which a new side rail, identical to the one she had been entrapped, had been put on the bed. S3CNA demonstrated on a similar side rail how the resident ' s arm was wedged between the cross bars of the side rail. An interview was held on 08/26/2015 9:05 AM with S4Maintenance. He explained that on 08/06/15 he responded to a call from S1ADM asking him to bring his screw driver and come quick to Resident #36 ' s room. He further explained upon his arrival to the resident ' s room ambulance personnel and facility staff was in the room and Resident #36 was on the floor with her right arm entrapped in the right upper ½ side rail of the bed. S4Maintenance stated the Administrator asked him to remove the side rail from the bed with the resident ' s arm still entrapped in it. He said he unscrewed the rail from the bed but did not remove it because the ambulance company decided it was not a good idea . He said during the time he was in the resident ' s room the fire department arrived and a decision was made by them and the supervisor of the ambulance company to use the Jaws of Life to cut the bed rail to release the resident ' s arm. Once the resident was taken to the hospital he was instructed by S1ADM to either replace the bed with one that had 2 upper ½ rails or to replace the side rail that had been cut so that when the resident returned from the hospital there would be 2 upper ½ side rails on the bed for use while the resident was in bed. He stated he removed the damaged side rail from Resident #36 ' s bed and replaced it with another side rail that was identical to the one that the resident became entrapped. He demonstrated using the same type of side rail how the resident ' s right arm was wedged in the cross bars of the rail. He confirmed this side rail was currently in use on Resident #36 ' s bed. In an interview on 08/26/15 at 10:03 AM, S5RN stated she and S2DON were responsible for putting interventions into place following a resident fall or incident in the facility to prevent reoccurrence. She stated she was in the facility and had observed Resident #36 ' s right arm entrapped in the right upper side rail of her bed. She said the resident was complaining of pain in that arm when staff attempted to remove her arm from the rail. She further explained S2DON was not in the facility at the time of the incident but S1ADM was in the room during the removal of the resident ' s arm from the bedrail. She stated on the day following the incident she observed the resident ' s bed which had the side rail replaced with one identical to the one she was entrapped. She confirmed the side rails on the resident ' s bed were still in use. The Registered Nurse said she and S1ADM decided to add a bed alarm as an intervention for falls after Resident #36 became entrapped in the bed rail. S5RN was asked if the intervention of a bed alarm would prevent the resident from becoming entrapped in the bed rail again. She stated the alarm would not prevent entrapment of the resident ' s body or limbs in the side rail. On 08/26/15 at 10:30 AM an interview was held with S2DON. She confirmed on 08/06/15 at 4:40 PM Resident #36 became entrapped in her ½ upper side rail on the right side of the bed and required the fire department to use the Jaws of Life to remove the resident ' s arm from the side rail. She revealed she was responsible for investigation of accidents during that time. She stated she spoke with S1ADM and they decided a bed alarm should be placed on the Resident ' s bed as an intervention to prevent reoccurrence. S2DON said the bedrails were on the resident ' s bed for safety , were used by the resident for grabbing and kept her from falling out of the bed. She stated if the resident was out of the bed and on the floor the alarm would alert someone so they could get to her to see what was going on . S2DON was asked what interventions were put into place to prevent future entrapment of the resident in the side rail and she stated she personally thought the bed alarm would be enough and that she did not feel the bed rail was a hazard. The DON was asked if the bed alarm would prevent the resident from becoming entrapped in the bed rail again and she stated no. She was asked if supervision of the resident was increased, in-services or education related to entrapment was provided to staff, or monitoring was put into place to prevent reoccurrence following the resident ' s entrapment in the side rail and she stated no. During an interview on 08/26/15 at 11:15 a.m., S1ADM confirmed Resident #36 ' s limb was entrapped in the right side rail of her bed on 08/06/15 at 4:40 PM. He confirmed he had S4Maintenance notified to remove the side rail on the bed while the resident was entrapped and that the fire department had to use the Jaws of Life to cut the rail so the resident ' s arm could be released. He also confirmed that after the resident left for the hospital he instructed S4Maintenance to replace the side rail that was cut with an identical side rail so that upon her return form the hospital the resident would have 2 functioning upper side rails for safety. He was asked what his role was in putting interventions in place to prevent the resident from becoming entrapped in the side rail again upon her return from the hospital. S1ADM stated a mattress pad alarm was placed on the resident ' s bed and the new side rail were the interventions he had put into place. He was asked if increased supervision was put into place, staff were educated or a program had been put into place and he responded not that he was aware of. He was asked if any other interventions were put into place to prevent reoccurrence of entrapment of the resident in the side rails besides replacing the side rail and a bed alarm and he stated not that he was aware of. An interview was held on 08/26/15 at 11:37 AM with S6COTA. She stated she was familiar with Resident #36 and provided her with Occupational Therapy Services (OT). S6COTA revealed the resident had OT services from 01/21/15 to 02/12/15 and then again from 08/19/15 to current. She was asked if the resident could use her ½ upper side rails for bed mobility or position changes. S6COTA stated the resident had paralysis of her left arm, hand and leg and could not use them at all. She further stated the resident did not have enough upper body strength in her right arm/hand to grasp the side rails, pull herself up in bed or to turn herself. She stated the side rails did not benefit the resident for physical functioning in any way because she was unable to use them. A follow up interview was held on 08/26/15 at 12:19 PM with S5RN. She stated the facility did not assess residents for the use of side rails. She stated residents did not need to be assessed for the use of side rails because they were used for safety and to prevent residents from falling out of bed. On 08/26/15 at 1:38 PM an interview was held with S7OT. She stated she evaluated Resident #36 on 01/21/15 and again on 08/19/15 for OT services. S7OT stated the resident had left sided paralysis of her upper and lower extremities, could not move them, and was dependent on staff for activities of daily living. She also stated during both of the assessments she performed, Resident #36 could not use the side rails for mobility, positioning of herself nor could she grab the side rail with her right hand. She stated currently the resident had difficulty holding a coffee cup or even a pen in her right hand. The Occupational Therapist state she had never evaluated resident ' s in the facility for the safe use of side rails. She stated the side rails would be an assistive device for the resident to use while rolling, turning or sitting up on the edge of the bed with trunk control. She stated Resident #36 was not capable of performing any of these tasks and would not benefit from the use of bed rails for physical functioning. An interview was held on 08/26/15 at 3:56 PM. withS8LPN. She confirmed she was working on 08/06/15 when Resident #36 ' s right arm became entrapped in the upper side rail of the bed. She said when she entered the room she found the resident sitting on the floor with her right arm in the side rail saying she thought she broke something . S8LPN said she thought the resident had broken something in her arm too because her hand was white in color. She stated she tried to remove the resident ' s arm out of the side rail but her fingers were stuck and the resident complained of pain. S8LPN reported that the side rail was cut by the fire department and the resident was sent to the hospital for evaluation. Upon the resident ' s return she was placed back in the bed with the cut side rail having been replaced with an identical one. She said a side rail was used for the resident so she would not fall out of the bed. She confirmed the resident had continued to have ½ upper side rails raised on her bed since her return from the hospital. She stated the resident was too weak to use the side rails for mobility. During an interview on 08/27/15 at 9:18 AM, S11NP identified herself as the nurse practitioner for the resident ' s primary care physician. She stated she had not ordered Resident #36 ' s side rails for medical symptoms. S11NP stated it was standard in the facility to use the side rails for resident ' s with dementia to keep them from falling out of the bed.

F-490 Administration Based on observations, interview and record reviews, the facility failed to have an effective administration that used it resources effectively and efficiently to maintain the highest practicable physical well-being of each resident. The facility failed to: 1. Put interventions into place to ensure the prevention of reoccurrence of the entrapment of residents with side rails on the bed; 2. Have a system in place for the assessment of the need for and the safe use of side rails for all residents: 3. Identify residents at risk of becoming entrapped in side rails; and 4. Have a policy/procedure in place for the use of side rails. There were 122 residents who resided in the facility who used side rails that had the potential to be affected by this deficient practice out of a total resident population of 126 as identified by S1ADM. This resulted in an Immediate Jeopardy situation for Resident #36 on 08/06/15 at 9:20 PM when she returned from the hospital after having her right arm entrapped in the ½ upper side rail of the bed which required the fire department to use the Jaws of Life to cut the side rail to free the resident ' s arm. The Jaws of Life is a trademark name defined by Dictionary.com, as a heavy-duty tool that can cut through metal or pry apart sections of it: used especially to free people trapped in wrecked vehicles. Resident #36 was an [AGE] year old who had left sided paralysis and was confirmed by Occupational Therapy as not being able to use side rails for physical functioning and identified as a fall risk by the facility. On 08/06/15 Resident #36 ' s right arm became entrapped in the right upper ½ side rail of her bed, she experienced pain that required narcotic administration, and required the fire department to cut the side rail to free the resident ' s limb from being entrapped in the side rail. The resident was sent to the hospital for evaluation and upon her return, she was placed back in the bed with identical ½ side rails as the one she became entrapped. The side rails were left in place at the request of S1ADM and remained in place while the resident was in bed. The facility did not have a system in place to assess the resident ' s safe use of and need for side rails and did not put interventions in place to prevent the resident from becoming entrapped again. S1ADM was notified of the Immediate Jeopardy situation on 08/26/15 at 3:30 PM. The Immediate Jeopardy remained in effect for Resident #36 until 8/27/15 at 3:00 PM when an acceptable plan of removal was provided. The plan included the following: Resident #36 was assessed for the use of side rails using an updated assessment tool. Resident #36 had her right side rail removed, a wing mattress put into place, and the left side rail secured to immobilize utilization. Other residents who were identified as being at risk were assessed. The facility implemented a new side rail utilization tool to be completed on all residents to establish a base line. An emergency Quality Assurance (QA) meeting with the Medical Director was held and a QA tool was implemented. Staff in-servicing was initiated and will continue until all licensed nursing staff and certified nursing assistants have been properly educated. Residents assessed as not requiring a side rail had it properly secured to avoid utilization. Incident/accident logs will be reviewed daily. In-servicing of all licensed nurses and nursing assistants will be done every shift prior to providing resident care on the newly implemented protocol. The facility will implement QA tools to review targeted residents no less than 4 times a week, the use of side rails will be reviewed by the interdisciplinary team on admission, quarterly, annually and after any significant change assessment and after any documented incident or accident related to side rail use. The deficient practice remains at a level 2, potential for more than minimal harm, for the residents in the facility who continue to use side rails. Findings: Cross reference Tag F-323 A copy of the facility ' s policy and procedure on side rails was requested from S2DON. A copy of a policy titled Restraints , with a latest revision of 04/15, was provided. Review of the policy revealed residents must be screened for use of approved restraints to meet their particular needs. Bedrail usage should also be reviewed. If necessary, use side rail covers or bolsters to prevent the resident ' s body from going under or through side rails if side rails are used. Review of the clinical record for Resident #36 revealed an admission date of [DATE]. Further review revealed [DIAGNOSES REDACTED]. Review of Resident #36 ' s Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/14/15 revealed a Brief Interview for Mental Status (BIMS) score of 2 coding the resident as severely cogitatively impaired. Review of the same MDS revealed the resident was 2 person extensive assist for bed mobility and had upper and lower extremity limitation in range of motion on one side. Review of the care plan for Resident #36 revealed the resident was at risk for falls related to [MEDICAL CONDITION] and had psychotic behavior as evidenced by hallucinations and delusions. Further review revealed a problem onset of 08/17/15 of discomfort and weakness to right upper extremity due to trauma related to recent fall. Resident #36 was coded with a fall risk score of 15 (high risk for falls) on the Nurse Data Collection and Screening form dated 07/14/15. Review of the Nurses Notes and an incident report for Resident #36, dated 08/06/15, revealed that on 08/06/15 at 4:40 PM S8LPN was summonsed to Resident #36 ' s room. The nurse observed the resident sitting on the floor with her right arm hooked in her bed rail . S8LPN attempted to move the resident ' s arm but it was difficult to move and the resident complained of pain when her arm was touched. An ambulance was called and the resident remained on the floor in the position she was found in until the ambulance arrived. The Nurses Notes further revealed that at 4:50 PM the ambulance arrived and the ambulance personnel attempted to try and remove the resident ' s arm from the bed rail and were unable to because it was hard to remove and the resident complained of pain. The fire department was called for assistance. S4Maintenance was also called to assist by unscrewing the bed rail from the bed but this was unsuccessful in getting the resident ' s arm out of the bed rail. The fire department arrived and used the Jaws of Life to cut the bed rail to free the resident ' s extremity from entrapment in the side rail. The ambulance personnel placed an Intravenous Catheter (IV) in the Resident ' s left hand and administered the resident [MEDICATION NAME] (a narcotic pain medication) IV due to the resident complaining of pain. The resident was then transferred to the hospital for an evaluation. At 9:20 PM on 08/06/15, Resident #36 returned to the facility from the hospital. Documentation on the Resident Incident Follow-up for the incident on 08/06/15 revealed the resident was attempting to go to the restroom and fell on the floor and her arm became entrapped in the bed rail. Additional follow-ups were listed on the form as bed alarm was put in place on the resident ' s bed. The follow-up was signed by S2DON. Review of the Ambulance Company ' s Pre-hospital Care Report Summary, dated 08/06/15, revealed ambulance personnel arrived at the facility on 08/06/15 at 4:39 PM. The Narrative History Text section revealed Resident #36 stated she slid out of bed and her arm got caught in the bed rail. The resident ' s arm was pinned in the bedrail and the ambulance personnel were unable to remove her arm. The fire department was contacted and cut the bed rail with Jaws of Life to remove Resident #36 ' s arm from being entrapped in the bed rail. [MEDICATION NAME] 25 mg (micrograms) was given IV to the resident at 5:33 PM by the ambulance personnel. During an observation on 08/24/15 at 10:00 AM, Resident #36 was lying in bed with ½ upper side rails raised on both sides of her bed. The resident was asked to move her left arm. She stated she was not able to. Her left hand was observed to have a splint device in place. Each upper side rail was partitioned into 4 parts by cross bars Further observations were made of Resident #36 on 08/25/15 at 10:00 AM, and again on 08/26/15 at 8:30 AM and 2:45 PM. The resident was lying in bed with the ½ upper side rails raised on both sides of her bed during each observation. During the observation on 8/26/15 at 2:45 PM the resident ' s right leg was hanging off the right side of the bed. In an interview on 08/26/15 at 08:30 AM, Resident #36 stated she slid out of the bed one day when trying to get up to go to the bathroom and her right arm got caught in the side rail of the bed. She further stated the emergency people had to cut the bed rail to get her arm out of the bed. She said her arm hurt really bad . An interview was held on 08/26/2015 9:05 AM with S4Maintenance. He explained that on 08/06/15 he responded to a call from S1ADM asking him to bring his screw driver and come quick to Resident #36 ' s room. He further explained upon his arrival to the resident ' s room ambulance personnel and facility staff was in the room and Resident #36 was on the floor with her right arm entrapped in the right upper ½ side rail of the bed. S4Maintenance stated the Administrator asked him to remove the side rail from the bed with the resident ' s arm still entrapped in it. He said he unscrewed the rail from the bed but did not remove it because the ambulance company decided it was not a good idea . He said during the time he was in the resident ' s room the fire department arrived and a decision was made by them and the supervisor of the ambulance company to use the Jaws of Life to cut the bed rail to release the resident ' s arm. Once the resident was taken to the hospital he was instructed by S1ADM to either replace the bed with one that had 2 upper ½ rails or to replace the side rail that had been cut so that when the resident returned from the hospital there would be 2 upper ½ side rails on the bed for use while the resident was in bed. He stated he removed the damaged side rail from Resident #36 ' s bed and replaced it with another side rail that was identical to the one that the resident became entrapped. He demonstrated using the same type of side rail how the resident ' s right arm was wedged in the cross bars of the rail. He confirmed this side rail was currently in use on Resident #36 ' s bed. On 08/26/15 at 10:30 AM an interview was held with S2DON. She confirmed on 08/06/15 at 4:40 PM Resident #36 became entrapped in her ½ upper side rail on the right side of the bed and required the fire department to use the Jaws of Life to remove the resident ' s arm from the side rail. She revealed she was responsible for investigation of accidents during that time. She stated she spoke with S1ADM and they decided a bed alarm should be placed on the Resident ' s bed as an intervention to prevent reoccurrence. S2DON said the bedrails were on the resident ' s bed for safety , were used by the resident for grabbing and kept her from falling out of the bed. She stated if the resident was out of the bed and on the floor the alarm would alert someone so they could get to her to see what was going on . S2DON was asked what interventions were put into place to prevent future entrapment of the resident in the side rail and she stated she personally thought the bed alarm would be enough and that she did not feel the bed rail was a hazard. The DON was asked if the bed alarm would prevent the resident from becoming entrapped in the bed rail again and she stated no. She was asked if supervision of the resident was increased, in-services or education related to entrapment was provided to staff, or monitoring was put into place to prevent reoccurrence following the resident ' s entrapment in the side rail and she stated no. During an interview on 08/26/15 at 11:15 a.m., S1ADM confirmed Resident #36 ' s limb was entrapped in the right side rail of her bed on 08/06/15 at 4:40 PM. He confirmed he had S4Maintenance notified to remove the side rail on the bed while the resident was entrapped and that the fire department had to use the Jaws of Life to cut the rail so the resident ' s arm could be released. He also confirmed that after the resident left for the hospital he instructed S4Maintenance to replace the side rail that was cut with an identical side rail so that upon her return form the hospital the resident would have 2 functioning upper side rails for safety. He was asked what his role was in putting interventions in place to prevent the resident from becoming entrapped in the side rail again upon her return from the hospital. S1ADM stated a mattress pad alarm was placed on the resident ' s bed and the new side rail were the interventions he had put into place. He was asked if increased supervision was put into place, staff were educated or a program had been put into place to prevent reoccurrence and he responded not that he was aware of. He was asked if any other interventions were put into place to prevent reoccurrence of entrapment of the resident in the side rails and he stated not that he was aware of. An interview was held on 08/26/15 at 12:19 PM with S5RN. She stated the facility did not assess residents for the use of side rails. She stated residents did not need to be assessed for the use of side rails because they were used for safety and to prevent residents from falling out of bed. On 08/26/15 at 1:38 PM an interview was held with S7OT. She stated she evaluated Resident #36 on 01/21/15 and again on 08/19/15 for OT services. S7OT stated the resident had left sided paralysis of her upper and lower extremities, could not move them, and was dependent on staff for activities of daily living. She also stated during both of the assessments she performed, Resident #36 could not use the side rails for mobility, positioning of herself nor could she grab the side rail with her right hand. She stated currently the resident had difficulty holding a coffee cup or even a pen in her right hand. The Occupational Therapist state she had never evaluated resident ' s in the facility for the safe use of side rails. She stated the side rails would be an assistive device for the resident to use while rolling, turning or sitting up on the edge of the bed with trunk control. She stated Resident #36 was not capable of performing any of these tasks and would not benefit from the use of bed rails for physical functioning.

Based on observation, interviews and clinical record review, the facility failed to ensure the resident was free from neglect for 1 (#156) of 1 (#156) residents reviewed for neglect from a Stage II sample of 37 residents. The facility failed to: 1. ensure qualified medical personnel immediately assessed Resident #156 for possible physical injuries following a fall in his wheelchair while being transported in the van on 6/18/12 that resulted in the resident's head hitting the lift in the van, causing his head to bleed. 2. ensure Resident #156's wheelchair was properly secured in the transportation van on 6/18/12 to prevent the wheelchair from rolling backwards and forwards and falling over while the van was moving. 3. ensure the transportation van driver was trained to correctly secure resident wheelchairs in the transportation van prior to moving the vehicle to prevent the wheelchair from falling over. (#156) 4. ensure the transportation van driver immediately implemented the facility's policy and procedure regarding vehicle safety/emergency issues when Resident #156 fell over backwards in his wheelchair on 6/18/12 while the van was moving causing the resident to hit his head on the lift and his head to bleed.. 5. ensure the transportation van driver immediately notified her supervisor for directions/instructions on how to proceed when a resident fell over backwards in his wheelchair (#156) while riding in the transportation van. 6. ensure facility nursing staff immediately reported the accident to the facility Administrator upon notification of the accident. (#156) Resident #156 was placed in Immediate Jeopardy on 6/18/12 at approximately 11:45 a.m. while riding in the transportation van when the resident fell over backwards in his wheelchair 0.3 to 0.4 of a mile from the facility. The van driver pulled the vehicle over and observed that resident #156 had hit his head on the lift and his head was bleeding. The transportation van driver did not immediately notify her supervisor at the facility of the incident at that time. The van driver did not call 911 for assistance. The transportation driver drove the van back to the facility with the resident on the floor of the vehicle still in his overturned wheelchair. Upon arrival back at the facility, the transportation van driver failed to immediately notify the Administrator of the incident involving the wheelchair. The facility staff that was aware of the situation failed to immediately report the incident to the Administrator so that an investigation could be initiated. Another resident was placed half way on the lift, prior to surveyor intervention, while the Administrator and DON were present. The 82 residents (1, 2,4-8, 13-16, 18, 19, 20, 23, 25, 26, 28, 29, 30, 33, 34, 36, 44, 46-48, 50-53, 55, 58, 59, 64, 66, 70, 71, 73, 76, 79, 81-84, 88, 90, 91, 93, 94, 98, 99, 101, 103, 105-107, 110, 111, 115, 117, 120, 122, 125-128, 132, 134-136, 139, 141, 143-147, 152, 154, 156, 021) who used wheelchairs and were transported by the facility van were also placed in an Immediate Jeopardy situation. The Administrator was informed of the Immediate Jeopardy on 6/18/12 at 4:30 p.m. The Immediate Jeopardy was lifted on 6/19/2012 at 4:30 p.m. when a Plan of Removal was accepted. The Plan of Removal included having the van inspected for problems related to the securing of residents in the van with lap and shoulder belts, 4 point retractable tie downs for all passenger seats and wheelchairs; in-service of all staff members who drove the transportation van with return demonstration of use of the wheelchair tie downs, seat belts, and harness straps. The facility also in-serviced the staff on who to report emergency/safety issues to and the different types of emergency or safety issues, and how to handle medical emergencies and emergency issues while on the van during transportation. The Administrator/designee will quiz the van driver and other staff members that were eligible to drive the van on what to do in emergency or safety issues that might arise, who to notify. Quality Assurance measures were put into place to ensure compliance with the Plan of Removal. The deficient practice continued at a pattern of potential for more than minimal harm for the residents in wheelchairs who used the facility van for transportation. Findings: Review of the Abuse/Neglect Reporting Policy dated with a revision date of 7/11 revealed in part: Neglect: a failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. 3. In the event of any evidence involving mistreatment, exploitation, neglect or abuse, or other crime, including injuries of an unknown source, an occurrence will be reported immediately to the Administrator of the facility ... .... 4. The facility will thoroughly investigate all alleged violations under the direct supervision of the Administrator. The facility will take all necessary steps to prevent further potential abuse while the investigation is in progress. Any employee of the facility suspected of abuse or neglect will be suspended pending investigation until such time as the facility investigation is complete. Review of the facility policy for Company Owned Vehicle, dated March, 2011 revealed in part: Seatbelts- The driver and all passengers in the company/facility vehicle must be safely restrained by buckled seat belts, wheelchair floor tie downs and wheelchair harness type seatbelts at all times the vehicle is in use. A qualified individual shall assist patients/residents/clients with seatbelts and wheelchair tie downs and belts, and is responsible for ensuring that all person(s) in the vehicle are safely seat belted and remain safely seat belted until the vehicle reaches its assigned destination. Cell Phone Use- Unless it is an emergency situation, and a cell phone call is absolutely necessary while operating a vehicle on company/facility business, the driver should stop the vehicle in a safe area prior to making or answering the call. A cellular phone is provided for the van driver's use for emergencies only and when necessary, should be used in accordance with the company/facility policy as set forth above. Vehicle Safety/Emergency Issues- Any time there is an emergency or safety issue, the driver of the company and/or facility owned vehicle must: Stop the vehicle in a safe and appropriate place, and Call his/her immediate supervisor for directions/instructions on how to proceed Complete an incident report immediately on their return to the facility. Medical Emergency- Any time there is an emergency or safety issue, the driver of the company/facility owned vehicle must: Call 911 Call his/her immediate supervisor for directions/instructions on how to proceed Complete an incident report immediately on their return to the facility. An observation was made on 6/18/12 at 11:55 a.m. while at the Nurse's Station conducting staff interviews. S17CNA (Transportation) rushed into the building and told S16LPN that she was returning to the facility with Resident #156. She stated she came off the interstate onto A------. She said when she got on the service road his wheelchair flipped over backwards and he hit his head on the lift. She said his head was bleeding. S16LPN, S8SocialServices, S17CNA (Transportation), and 2 other aides went to the van. At 12:05 p.m., S16LPN returned to the facility and said Resident #156 was all right. She said he had a laceration to the back of his head. She said he was in the wheelchair on the floor of the van with his legs bent up a little. She said the hooks were in place on the wheelchair. An observation at 12:06 p.m. on 6/18/12 revealed the resident was rolled into the facility by S17CNA and to his room. He was sitting with his buttocks toward the front edge of the chair cushion. He was leading against the back of the chair at an angle. Resident #156 was talking to the staff. During an interview at 12:20 p.m. on 6/18/12 with S17CNA (Transportation), she revealed she worked as transportation at the facility for 7 years. She said the resident leaned back in his chair all the time. She said that she was coming off the interstate and he fell over backwards. She said that she pulled the van over at the storage facility on the service road, 0.4 mile from the facility, and went to the back of the van to see about the resident. She said that the resident was still in his wheelchair, lying with the back of the wheelchair on the floor of the van and the hooks were still in place on the wheelchair. She said that his head was bleeding, but he was talking to her. She said that she knew she couldn't get him up by herself and she drove on to the facility with him still lying on the floor in his wheelchair. She said that she told the nurse and S13ADON when she got back to the facility. She said that she had gone and asked the Administrator how the hooks worked and after he told her how they worked, she said "good, that's how I did it." When asked if she told him what had happened, she said no she told the nurse. She said she was supposed to report to the nurse. She was asked to bring the van around to demonstrate what happened. She said she guessed she had time; she had to take another resident for an appointment at B--------- B---. An observation of the van's lift, at 12:25 p.m., revealed fresh blood on the floor of the lift. An observation of the van with the lift door closed revealed a portion of the lift did not lay flat, but sat up at an angle when the door was closed. S17CNA said, at the time of the observation, she put 6 hooks on his wheelchair. She said she put 2 on the back, 2 on the middle and 2 on the front. She demonstrated that to release the hook she would release a lever that was behind a metal cover. She said to tighten the hook on the wheelchair; she would turn a round knob (clockwise) which made a ratcheting noise. She said she heard that noise when his chair went over. She said that the knob could not be turned to release the hook; it could only be released with the lever. S17CNA was asked to get S1Administrator and ask him to come to the van. When S1Administrator arrived, he said he had not been told of the incident until S17CNA came to get him. He said PT had also come to the office, at that same time, to tell him about the incident. He said an investigation had not been started. An observation was made of the S17CNA (Transportation) rolling a resident in a wheelchair toward the van. They were about half way down the sidewalk. The resident's husband and the S2DirectorOfNursing were walking out with them. S17CNA approached the van lift with the resident. An observation was made of the S17CNA (Transportation) with the resident partially on the lift. At this point, S1Administrator, who had his back to the lift, was asked to ask the aide not to put the resident on the lift or in the van. He told the aide 3 times to go get the other van. At 12:50 p.m. on 6/18/12, Resident #156 was observed sitting in his room in his wheelchair. The back of chair was noted at his mid back. He was leaning back against the back at an angle with his buttocks close to the front of the seat cushion. He had a prosthetic left leg in place which rested on the foot rest. His right leg was on the floor with a cloth boot on it. He stated he was nauseated and had a head ache. The treatment nurse was present and said that he had an abrasion type injury to the back of his head. He had an elongated abrasion/hematoma down the center of his skull (2 inches long x 1 1/2 inches wide). He said that the wheelchair had been secured in the van with the hooks. During an interview at 1:30 p.m. on 6/18/12 with S1Administrator and S2DON, the Administrator stated S17CNA didn't tell him about the incident, but did ask him about how the hooks in the van worked. He was not sure of the time she asked him this. He said that a little while later PT and S17CNA came to his office telling him about the incident. He said that he didn't know what time that was, but it was at the time he was asked to come out to the van. He said that he in-serviced the transportation aide quarterly on the van. He said the in-service consisted of going over the van check list with the driver. He said that he did not cover what to do and who to report to if an incident happened away from the facility in the van. He said that the driver reported to the nurse if an incident occurred. He said that there was no policy for incidents that happened away from the facility or safety related to the van. At 1:45 p.m. on 6/18/12 an interview with S22CNA who had assisted the staff with the resident when he returned to the facility. She said the resident was lying on the floor beside his chair. She said the hooks weren't on the chair, but S17CNA could have removed them before she saw it. She said he was able to stand up with help and she helped put him in his wheelchair. At 1:50 p.m. on 6/18/12 an interview with S25CNA revealed she was called out to the van while she was assisting in the dining room. She said Resident #156 was observed still sitting in his wheelchair in the van, lying on his back with the wheels up in the air. She said the straps were still attached to the chair. She helped the staff pick him up and noticed his head was bleeding. She said he was alert and oriented and said he was all right. At 1:50 p.m. on 6/18/12 Resident #156 stated he stayed in his chair when he fell over and didn't fall out of his chair. He again said that his chair was secured with hooks, but he didn't know how many were used. He said his chair was rolling back and forth some during the transportation while the hooks were on his chair, prior to the wheelchair falling over. An interview was held with S13ADON on 6/18/12 at 1:55 p.m. She explained that she had been the ADON since April 2, 2012. She said that S17CNA, the van driver, stopped her that morning and told her that Resident #156 fell in the van this morning. She could not remember what time she told her about the occurrence. She said she asked her if she reported it to the nurse. S17CNA told her that the nurse was assessing him. S13ADON said that she also asked if he was ok, and S17CNA told her that he was ok. S17CNA told her that his chair flipped back and he had a small scrape on the back of his head. S17CNA told S13ADON that Resident #156 was talking and said that he was ok. She said that she did not tell S17CNA anything else. She said that she was not aware of this ever happening since she had been working at the facility. She said that she did not know who did the training on securing wheelchair in the vans. She said when an occurrence of this nature occurs, the S17CNA was to notify the nurse immediately and stay with the resident until the nurse arrived. S13ADON said that she did not report the incident to the DON or Administrator. An interview was held with S16LPN on 6/18/12 at 1:58 p.m. She said she was aware that Resident #156 had been taken in the van to a physician's appointment. She said that S17CNA (transportation) came in the door and told her that Resident #156 had fallen in the van. She went out to the van and observed the resident in his wheelchair lying on his back. She immediately called two other CNAs to assist with the resident. She said when she assessed the resident when he was in the van, the straps to the wheelchair had already been unfastened. She said she did not report the incident to Administration because she thought if it happened outside the facility, she didn't have to report it. During an interview at 2:05 p.m. on 6/18/12, S8SocialServices revealed he knew the wheelchair tipped over. He said he saw S17CNA undoing the hooks when he went to the van. He said he was not sure if the resident was in his chair, but his legs were bent a little bit. He said he didn't get too close to the resident, but observed from the front of the van. On 6/18/12 at 5:00 p.m., an observation of the parking lots for both the storage facility and the generator facility revealed the driver had to go up on a curb to enter the parking lots and down off of the curb to exit the parking lots. To enter the parking lot of the Nursing Home the driver also had to go up on a curb. On 6/19/12 at 4:30 p.m. a second interview was conducted with S17CNA. During this interview she said the accident happened in a curve of the service road by the generator place, 0.3 miles from the facility. She said that she pulled into the generator business parking lot and ran to the back of the bus and checked Resident #156. She said his head was bleeding. She said she then drove to the facility with the resident on the floor of the van. She said she did not have a cell phone with her. She said she had a facility cell phone to use, but she had left the phone at the facility charging because it was new. She said she didn't go to her car to get her cell phone. She also stated that she was on the van alone with the resident. During this interview, she said she used 4 straps and they were pulled tight. She said she put 2 on the front and 2 on the back on the metal bar of the wheelchair. She said she told the resident's S16LPN and the S13ADON about the incident. She said she told S1Administrator when she went to get him to come to the van as requested. She said when she went to get the other van to transport the next resident, the lift would not work. She said she transported residents to their doctor's appointments 3-5 days a week. She further stated that she was bringing the other resident to the van to demonstrate how to secure a wheelchair in the van. She acknowledged she did not tell us she was doing this as a demonstration. She verified she had not been inserviced by S1Administrator regarding the policy and procedure for Company/Facility Owned Vehicle until 6/19/12. S17CNA also verified she transported another resident on 6/18/12 to an appointment after the incident with Resident #156. She said she used the van of a sister facility and got the resident to her appointment on time. On 6/20/12 at 4:35 p.m., during an interview with S1Administrator, it was revealed there had not been another accident with a resident and the van since he had been working at the facility. He said he was employed at the facility since 2009. An interview was held with S1Administrator on 6/19/12 at 5:00 p.m. He verified that the S17CNA had come to his office on 6/18/12 twice. The first time she asked him about the wheelchair straps on the van. She described to him how she used them, and he verified to her that was the correct way. He verified again that the S17CNA did not tell him about the accident until she came to him the second time requesting that he come and look at the van with the surveyors. He stated the incident should have been reported to him by the staff immediately. A review of Resident #156's clinical record revealed the resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A review of Resident #156's MDS (Minimum Data Set), dated with an Assessment Reference Date of 6/08/12, revealed his BIMS (Brief Interview for Mental Status) score was 15. The MDS also revealed the resident needed extensive assistance with all ADLs (Activities of Daily Living). Section G0300 Balance during Transitions and Walking revealed the resident was not steady, but only able to stabilize with staff assistance in moving from seated to standing position, walking, moving on and off toilet and surface-to-surface transfer. Resident #156 was assessed for fall risk on 5/26/12, 6/1/12, and 6/7/12. The resident scored 17 for the 3 fall risk assessments. A score of 7 or greater indicated a High Risk for Falls. Each Fall Risk Screening had documentation the resident had fallen in the last 6 months. His cognitive status was marked as intact. He was marked as immobile and needed extensive/total assistance with transfer ability. He was coded as non-weight bearing and as using brace, wheelchair, walker, cane, etc. Review of Resident #156's Care Plan revealed he was care planned for falls. The goal for falls was to decrease the risk for falls through environment and physical management. One of the approaches was maintain resident environment free of clutter and safety hazards. Review of Departmental Notes revealed a Nurse's Note dated 6/18/12 that revealed the resident returned to the facility per wheelchair per transportation van. The note said the transportation van driver came in the facility and said when she made a turn the patient turned over in the wheelchair backwards. The nurse documented she went on the van and saw the resident on his back, still in the wheelchair with the wheelchair turned over backwards, his legs in place on the wheelchair from the straps that are supposed to prevent the chair from moving while transporting the patient. The note stated he said he was having head pain. The note also contained documentation that area on the back of his head was red, about 2 inches long and 1 ? inches wide. The note documented it was an abrasion with minimal amount of bleeding. The Nurse's Note continued that the resident went to the emergency room at 2:45 p.m. A Nurse's Note timed at 4:30 p.m. revealed a nurse in the emergency room called the facility and reported the resident had a CT scan of the head. Review of the Hospital Transition Record dated 6/18/12 revealed the chief complaint was a fall. The primary [DIAGNOSES REDACTED]. Review of a document provided by K------ A -------- V---, dated 6/18/12, revealed all seat belts on passenger seats were checked and in good working order. All wheelchair 4 point retractable tie downs were checked and in good working order. All lap and shoulder belts for wheelchairs were checked and in good working order. Review of the Company Owned Vehicle Driver Inservice Checklist revealed the areas covered in quarterly in-service were as follows: 1. Vehicle controls which included: Headlight, Turn indicators, Location and use of hazard signals, windshield wipers, horn seat adjustments/location of controls, audio and temperature controls, door operation and locking, and fasten/unfasten seatbelts and wheelchair tie downs and shoulder harness straps. 2. Driving the vehicle which included: Forward motion-general operation and maneuverability, appropriate braking, stopping and moving again, appropriate vehicle size allowance and speed when making 90 degree turn. Backward motion -general operation and maneuverability while moving backward. Non motion- appropriately parking the vehicle in both perpendicular and parallel parking situations. 3. Patient/passenger safety & special equipment included: safely and adequately assisting a patient/passenger into and out of the vehicle; properly securing a patient/passenger in the vehicle with seatbelts; the proper and safe operation of the wheelchair lift; properly securing of a wheelchair in the vehicle; and properly securing the wheelchair occupant with safety and/or shoulder harness belts. The Company Owned Vehicle Driver Inservice Checklist was dated 4/25/12 and signed by S1Administrator and S17CNA.

Based on interviews, observations and clinical record review the facility failed to implement policies and procedures for training employees and for the prevention of occurrences of neglect for 1 (#156) of 3 (#36, #40, #156) residents reviewed for accidents from a total Stage II sample of 37 residents. The facility failed to: 1. ensure qualified medical personnel immediately assessed Resident #156 for possible physical injuries following a fall in his wheelchair while being transported in the van on 6/18/12 that resulted in the resident's head hitting the lift in the van, causing his head to bleed. 2. ensure Resident #156's wheelchair was properly secured in the transportation van on 6/18/12 to prevent the wheelchair from rolling backwards and forwards and falling over while the van was moving. 3. ensure the transportation van driver was trained to correctly secure resident wheelchairs in the transportation van prior to moving the vehicle to prevent the wheelchair from falling over. (#156) 4. ensure the transportation van driver immediately implemented the facility's policy and procedure regarding vehicle safety/emergency issues when Resident #156 fell over backwards in his wheelchair on 6/18/12 while the van was moving causing the resident to hit his head on the lift and his head to bleed. 5. ensure the transportation van driver immediately notified her supervisor for directions/instructions on how to proceed when a resident fell over backwards in his wheelchair (#156) while riding in the transportation van. 6. ensure facility nursing staff immediately reported the accident to the facility Administrator upon notification of the accident. (#156) 7. ensure facility staff were trained regarding the facility's policy and procedure regarding vehicle safety/emergency issues. Resident #156 was placed in Immediate Jeopardy on 6/18/12 at approximately 11:45 a.m. while riding in the transportation van when the resident fell over backwards in his wheelchair 0.3 to 0.4 of a mile from the facility. The van driver pulled the vehicle over and observed that resident #156 had hit his head on the lift and his head was bleeding. The transportation van driver did not immediately notify her supervisor at the facility of the incident at that time. The van driver did not call 911 for assistance. The transportation driver drove the van back to the facility with the resident on the floor of the vehicle still in his overturned wheelchair. Upon arrival back at the facility, the transportation van driver failed to immediately notify the Administrator of the incident involving the wheelchair. The facility staff that was aware of the situation failed to immediately report the incident to the Administrator so that an investigation could be initiated. Another resident was placed half way on the lift, prior to surveyor intervention, while the Administrator and DON were present. The 82 residents (1, 2,4-8, 13-16, 18, 19, 20, 23, 25, 26, 28, 29, 30, 33, 34, 36, 44, 46-48, 50-53, 55, 58, 59, 64, 66, 70, 71, 73, 76, 79, 81-84, 88, 90, 91, 93, 94, 98, 99, 101, 103, 105-107, 110, 111, 115, 117, 120, 122, 125-128, 132, 134-136, 139, 141, 143-147, 152, 154, 156, 021) who used wheelchairs and were transported by the facility van were also placed in an Immediate Jeopardy situation. The Administrator was informed of the Immediate Jeopardy on 6/18/12 at 4:30 p.m. The Immediate Jeopardy was lifted on 6/19/2012 at 4:30 p.m. when a Plan of Removal was accepted. The Plan of Removal included having the van inspected for problems related to the securing of residents in the van with lap and shoulder belts, 4 point retractable tie downs for all passenger seats and wheelchairs; in-service of all staff members who drive the transportation van with return demonstration of use of the wheelchair tie downs, seat belts, and harness straps. The facility also in-serviced the staff on who to report emergency/safety issues to and the different types of emergency or safety issues, and how to handle medical emergencies and emergency issues while on the van during transportation. The Administrator/designee will quiz the van driver and other staff members that were eligible to drive the van on what to do in emergency or safety issues that might arise, who to notify. Quality Assurance measures were put into place to ensure compliance with the Plan of Removal. The deficient practice continued at a pattern of potential for more than minimal harm for the residents in wheelchairs who used the facility van for transportation. Findings: Review of the facility policy for Company Owned Vehicle, dated March, 2011 revealed in part: Seatbelts- The driver and all passengers in the company/facility vehicle must be safely restrained by buckled seat belts, wheelchair floor tie downs and wheelchair harness type seatbelts at all times the vehicle is in use. A qualified individual shall assist patients/residents/clients with seatbelts and wheelchair tie downs and belts, and is responsible for ensuring that all person(s) in the vehicle are safely seat belted and remain safely seat belted until the vehicle reaches its assigned destination. Cell Phone Use- Unless it is an emergency situation, and a cell phone call is absolutely necessary while operating a vehicle on company/facility business, the driver should stop the vehicle in a safe area prior to making or answering the call. A cellular phone is provided for the van driver's use for emergencies only and when necessary, should be used in accordance with the company/facility policy as set forth above. Vehicle Safety/Emergency Issues- Any time there is an emergency or safety issue, the driver of the company and/or facility owned vehicle must: Stop the vehicle in a safe and appropriate place, and Call his/her immediate supervisor for directions/instructions on how to proceed Complete an incident report immediately on their return to the facility. Medical Emergency- Any time there is an emergency or safety issue, the driver of the company/facility owned vehicle must: Call 911 Call his/her immediate supervisor for directions/instructions on how to proceed Complete an incident report immediately on their return to the facility. An observation was made on 6/18/12 at 11:55 a.m. while at the Nurse's Station conducting staff interviews. S17CNA (Transportation) rushed into the building and told S16LPN that she was returning to the facility with Resident #156. She stated she came off the interstate onto A------. She said when she got on the service road his wheelchair flipped over backwards and he hit his head on the lift. She said his head was bleeding. S16LPN, S8SocialServices, S17CNA (Transportation), and 2 other aides went to the van. At 12:05 p.m., S16LPN returned to the facility and said Resident #156 was all right. She said he had a laceration to the back of his head. She said he was in the wheelchair on the floor of the van with his legs bent up a little. She said the hooks were in place on the wheelchair. An observation at 12:06 p.m. on 6/18/12 revealed the resident was rolled into facility and to his room by S17CNA. He was sitting with his buttocks toward the front edge of the chair cushion. He was leading against the back of the chair at an angle. Resident #156 was talking to the staff. During an interview at 12:20 p.m. on 6/18/12 with S17CNA (Transportation), she revealed she worked as transportation at the facility for 7 years. She said the resident leaned back in his chair all the time. She said that she was coming off the interstate and he fell over backwards. She said that she pulled the van over at the storage facility on the service road, 0.4 mile from the facility, and went to the back of the van to see about the resident. She said that the resident was still in his wheelchair, lying with the back of the wheelchair on the floor of the van and the hooks were still in place on the wheelchair. She said that his head was bleeding, but he was talking to her. She said that she knew she couldn't get him up by herself and she drove on to the facility with him still lying on the floor in his wheelchair. She said that she told the S16LPN and S13ADON when she got back to the facility. She said that she had gone and asked the Administrator how the hooks worked and after he told her how they worked, she said "good, that's how I did it." When asked if she told him what had happened, she said no she told the nurse. She said she was supposed to report to the nurse. She was asked to bring the van around to demonstrate what happened. She said she guessed she had time; she had to take another resident for an appointment at B--------- B---. An observation of the van's lift, at 12:25 p.m., revealed fresh blood on the floor of the lift. An observation of the van with the lift door closed revealed a portion of the lift did not lay flat, but sat up at an angle when the door was closed. S17CNA said, at the time of the observation, she put 6 hooks on his wheelchair. She said she put 2 on the back, 2 on the middle and 2 on the front. She demonstrated that to release the hook she would release a lever that was behind a metal cover. She said to tighten the hook on the wheelchair; she would turn a round knob (clockwise) which made a ratcheting noise. She said she heard that noise when his chair went over. She said that the knob could not be turned to release the hook; it could only be released with the lever. S17CNA was asked to get S1Administrator and ask him to come to the van. When S1Administrator arrived, he said he had not been told of the incident until S17CNA came to get him. He said PT had also come to the office, at that same time, to tell him about the incident. He said an investigation had not been started. An observation was made of the S17CNA (Transportation) rolling a resident in a wheelchair toward the van. They were about half way down the sidewalk. The resident's husband and the S2DirectorOfNursing were walking out with them. She approached the van lift with the resident. An observation was made of the S17CNA (Transportation) with the resident partially on the lift. At this point, S1Administrator, who had his back to the lift, was asked to ask the aide not to put the resident on the lift or in the van. He told the aide 3 times to go get the other van. At 12:50 p.m. on 6/18/12, Resident #156 was observed sitting in his room in his wheelchair. The back of chair was noted at his mid back. He was leaning back against the back at an angle with his buttocks close to the front of the seat cushion. He had a prosthetic left leg in place which rested on the foot rest. His right leg was on the floor with a cloth boot on it. He stated he was nauseated and had a head ache. The treatment nurse was present and said that he had an abrasion type injury to the back of his head. He had an elongated abrasion/hematoma down the center of his skull (2 inches long x 1 1/2 inches wide). He said that the wheelchair was secured in the van with the hooks. During an interview at 1:30 p.m. on 6/18/12 with S1Administrator and S2DON, the Administrator stated S17CNA didn't tell him about the incident, but did ask him about how the hooks in the van worked. He was not sure of the time she asked him this. He said that a little while later PT and S17CNA came to his office telling him about the incident. He said that he didn't know what time that was, but it was at the time he was asked to come out to the van. He said that he in-serviced the transportation aide quarterly on the van. He said the in-service consisted of going over the van check list with the driver. He said that he did not cover what to do and who to report to if an incident happened away from the facility in the van. He said that the driver reported to the nurse if an incident occurred. He said that there was no policy for incidents that happened away from the facility or safety related to the van. At 1:50 p.m. on 6/18/12 an interview with S22CNA revealed she went out to the van. She said the resident was lying on the floor beside his chair. She said the hooks weren't on the chair, but S17CNA could have removed them before she saw it. She said he was able to stand up with help and she helped put him in his wheelchair. At 1:50 p.m. on 6/18/12 Resident #156 said he stayed in his chair when he fell over and didn't fall out of his chair. He again said that his chair was secured with hooks, but he didn't know how many were used. He said his chair was rolling back and forth some during the transportation while the hooks were on his chair, prior to the wheelchair falling over. An interview was held with S13ADON on 6/18/12 at 1:55 p.m. She explained that she had been the ADON since April 2, 2012. She said that S17CNA, the van driver, stopped her that morning and told her that Resident #156 fell in the van that morning. She could not remember what time she told her about the occurrence. She said she asked her if she reported it to the nurse. S17CNA told her that the nurse was assessing him. S13ADON said that she also asked if he was ok, and S17CNA told her that he was ok. S17CNA told her that his chair flipped back and he had a small scrape on the back of his head. S17CNA told S13ADON that Resident #156 was talking and said that he was ok. She said that she did not tell S17CNA anything else. She said that she was not aware of this ever happening since she had been working at the facility. She said that she did not know who did the training on securing wheelchair in the vans. She said when an occurrence of this nature occurs, the S17CNA was to notify the nurse immediately and stay with the resident until the nurse arrived. S13ADON said that she did not report the incident to the DON or Administrator. An interview was held with S16LPN on 6/18/12 at 1:58 p.m. She said she was aware that Resident #156 had been taken in the van to a physician's appointment. She said that S17CNA (transportation) came in the door and told her that Resident #156 had fallen in the van. She went out to the van and observed the resident in his wheelchair lying on his back. She immediately called two other CNAs to assist with the resident. She said when she assessed the resident when he was in the van, the straps to the wheelchair had already been unfastened. She said she did not report the incident to Administration because she thought if it happened outside the facility, she didn't have to report it. During an interview at 2:05 p.m. on 6/18/12, S8SocialServices revealed he knew the wheelchair tipped over. He said he saw S17CNA undoing the hooks when he went to the van. He said he was not sure if the resident was in his chair, but his legs were bent a little bit. He said he didn't get to close too the resident, but observed from the front of the van. On 6/18/12 at 5:00 p.m., an observation of the parking lots for both the storage facility and the generator facility revealed the driver had to go up on a curb to enter the parking lot and down off of the curb to exit the parking lots. To enter the parking lot of the Nursing Home the driver also had to go up on a curb. On 6/19/12 at 4:30 p.m. a second interview was conducted with S17CNA. During this interview she said the accident happened in a curve of the service road by the generator place, 0.3 miles from the facility. She said that she pulled into the generator business parking lot and ran to the back of the bus and checked Resident #156. She said his head was bleeding. She said she then drove to the facility with the resident on the floor of the van. She said she did not have a cell phone with her. She said she had a facility cell phone to use, but she had left the phone at the facility charging because it was new. She said she didn't go to her car to get her cell phone. She also stated that she was on the van alone with the resident. During this interview, she said she used 4 straps and they were pulled tight. She said she put 2 on the front and 2 on the back on the metal bar of the wheelchair. She said she told the S16LPN and the S13ADON about the incident. She said she told S1Administrator when she went to get him to come to the van as requested. She said when she went to get the other van to transport the next resident, the lift would not work. She said she transported residents to their doctor's appointments 3-5 days a week. She further stated that she was bringing the other resident to the van to demonstrate how to secure a wheelchair in the van. She acknowledged she did not tell us she was doing this as a demonstration. She verified she had not been inserviced by S1Administrator regarding the policy and procedure for Company/Facility Owned Vehicle until 6/19/12. S17CNA also verified she transported another resident on 6/18/12 to an appointment after the incident with Resident #156. She said she used the van of a sister facility and got the resident to her appointment on time. On 6/20/12 at 4:35 p.m., during an interview with S1Administrator, it was revealed there had not been another accident with a resident and the van since he had been working at the facility. He said he was employed at the facility since 2009. An interview was held with S1Administrator on 6/19/12 at 5:00 p.m. He verified that S17CNA had come to his office on 6/18/12 twice. The first time she asked him about the wheelchair straps on the van. She described to him how she used them, and he verified to her that was the correct way. He verified again that the S17CNA did not tell him about the accident until she came to him the second time requesting that he come and look at the van with the surveyors. He stated the incident should have been reported to him by the staff immediately after it happened. A review of Resident #156's clinical record revealed the resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A review of Resident #156's MDS (Minimum Data Set), dated with an Assessment Reference Date of 6/08/12, revealed his BIMS (Brief Interview for Mental Status) score was 15. The MDS also revealed the resident needed extensive assistance with all ADLS. Section G0300 Balance during Transitions and Walking revealed the resident was not steady, but only able to stabilize with staff assistance in moving from seated to standing position, walking, moving on and off toilet and surface-to-surface transfer. Resident #156 was assessed for fall risk on 5/26/12, 6/1/12, and 6/7/12. The resident scored 17 for the 3 fall risk assessments. A score of 7 or greater indicated a High Risk for Falls. Each Fall Risk Screening had documentation the resident had fallen in the last 6 months. His cognitive status was marked as intact. He was marked as immobile and needed extensive/total assistance with transfer ability. He was coded as non-weight bearing and as using brace, wheelchair, walker, cane, etc. Review of Resident #156's Care Plan revealed he was care planned for falls. The goal for falls was to decrease the risk for falls through environment and physical management. One of the approaches was maintain resident environment free of clutter and safety hazards. Review of Departmental Notes revealed a Nurse's Note dated 6/18/12 that revealed the resident returned to the facility per wheelchair per transportation van. The note said the transportation van driver came in the facility and said when she made a turn the patient turned over in the wheelchair backwards. The nurse documented she went on the van and saw the resident on his back, still in the wheelchair with the wheelchair turned over backwards, his legs in place on the wheelchair from the straps that are supposed to prevent the chair from moving while transporting the patient. The note stated he said he was having head pain. The note also contained documentation that area on the back of his head was red, about 2 inches long and 1? inches wide. The note documented it was an abrasion with minimal amount of bleeding. The Nurse's Note continued that the resident went to the emergency room at 2:45 p.m. A Nurse's Note timed at 4:30 p.m. revealed a nurse in the emergency room called the facility and reported the resident had a CT scan of the head. Review of the Hospital Transition Record dated 6/18/12 revealed the chief complaint was a fall. The primary [DIAGNOSES REDACTED]. Review of a document provided by K------ A -------- V---, dated 6/18/12, revealed all seat belts on passenger seats were checked and in good working order. All wheelchair 4 point retractable tie downs were checked and in good working order. All lap and shoulder belts for wheelchairs were checked and in good working order. Review of the Company Owned Vehicle Driver Inservice Checklist revealed the areas covered in quarterly in-service were as follows: 1. Vehicle controls which included: Headlight, Turn indicators, Location and use of hazard signals, windshield wipers, horn seat adjustments/location of controls, audio and temperature controls, door operation and locking, and fasten/unfasten seatbelts and wheelchair tie downs and shoulder harness straps. 2. Driving the vehicle which included: Forward motion-general operation and maneuverability, appropriate braking, stopping and moving again, appropriate vehicle size allowance and speed when making 90 degree turn. Backward motion -general operation and maneuverability while moving backward. Non motion- appropriately parking the vehicle in both perpendicular and parallel parking situations. 3. Patient/passenger safety & special equipment included: safely and adequately assisting a patient/passenger into and out of the vehicle; properly securing a patient/passenger in the vehicle with seatbelts; the proper and safe operation of the wheelchair lift; properly securing of a wheelchair in the vehicle; and properly securing the wheelchair occupant with safety and/or shoulder harness belts. The Company Owned Vehicle Driver Inservice Checklist was dated 4/25/12 and signed by S1Administrator and S17CNA.

Based on observation, interviews and clinical record review the facility failed to ensure the resident's environment remained as free of accident hazards as possible; and failed to ensure the resident received adequate supervision and assistance devices to prevent accidents for 1 (#156) of 3 (#36, #40, #156) residents reviewed for accidents from a Stage II sample of 37 residents. The facility failed to ensure: 1. qualified medical personnel immediately assessed Resident #156 for possible physical injuries following a fall in his wheelchair while being transported in the van on 6/18/12 that resulted in the resident's head hitting the lift in the van, causing his head to bleed. 2. Resident #156's the wheelchair was properly secured in the transportation van on 06/18/12 to prevent the wheelchair from rolling backwards and forwards and falling over while the van was moving. 3. the transportation van driver was trained to correctly secure resident wheelchairs in the transportation van prior to moving the vehicle to prevent the wheelchair from falling over. (#156) 4. the transportation driver immediately implemented the facility's policy and procedure regarding vehicle safety/emergency issues when Resident #156 fell over backwards in his wheelchair on 6/18/12 while the van was moving causing the resident to hit his head on the lift and his head to bleed.. 5. the transportation van driver had a means to communicate with the facility when an emergency occurred on 6/18/12 involving Resident #156's wheelchair tipping over while the van was moving. 6. transportation van driver immediately notified her supervisor for directions/instructions on how to proceed when a resident fell over backwards in his wheelchair (#156) while riding in the transportation van. 7. facility nursing staff immediately reported the accident to the facility Administrator upon notification of the accident (#156). Resident #156 was placed in Immediate Jeopardy on 6/18/12 at approximately 11:45 a.m. while riding in the transportation van when the resident fell over backwards in his wheelchair 0.3 to 0.4 of a mile from the facility. The van driver pulled the vehicle over and observed that resident #156 had hit his head on the lift and his head was bleeding. The transportation van driver did not immediately notify her supervisor at the facility of the incident at that time. The van driver did not call 911 for assistance. The transportation driver drove the van back to the facility with the resident on the floor of the vehicle still in his overturned wheelchair. Upon arrival back at the facility, the transportation van driver failed to immediately notify the Administrator of the incident involving the wheelchair. The facility staff, that was aware of the situation, failed to immediately report the incident to the Administrator so that an investigation could be started. Another resident was placed half way on the lift, prior to surveyor intervention, while the Administrator and DON were present. The 82 residents (1, 2,4-8, 13-16, 18, 19, 20, 23, 25, 26, 28, 29, 30, 33, 34, 36, 44, 46-48, 50-53, 55, 58, 59, 64, 66, 70, 71, 73, 76, 79, 81-84, 88, 90, 91, 93, 94, 98, 99, 101, 103, 105-107, 110, 111, 115, 117, 120, 122, 125-128, 132, 134-136, 139, 141, 143-147, 152, 154, 156, 021) who used wheelchairs and were transported by the facility van were also placed in an Immediate Jeopardy situation. The Administrator was informed of the Immediate Jeopardy on 6/18/12 at 4:30 p.m. The Immediate Jeopardy was lifted on 6/19/2012 at 4:30 p.m. when a Plan of Removal was accepted. The Plan of Removal included having the van inspected for problems related to the securing of residents in the van with lap and shoulder belts, 4 point retractable tie downs for all passenger seats and wheelchairs; in-service of all staff members who drive the transportation van with return demonstration of use of the wheelchair tie downs, seat belts, and harness straps. The facility also in-serviced the staff on who to report emergency/safety issues to and the different types of emergency or safety issues, and how to handle medical emergencies and emergency issues while on the van during transportation. The Administrator/designee will quiz the van driver and other staff members that are eligible to drive the van on what to do in emergency or safety issues that might arise, who to notify. Quality Assurance measures were put into place to ensure compliance with the Plan of Removal. The deficient practice continued at a pattern of potential for more than minimal harm for the residents in wheelchairs who used the facility van for transportation. Findings: Review of the facility policy for Company Owned Vehicle, dated March, 2011 revealed in part: Seatbelts- The driver and all passengers in the company/facility vehicle must be safely restrained by buckled seat belts, wheelchair floor tie downs and wheelchair harness type seatbelts at all times the vehicle is in use. A qualified individual shall assist patients/residents/clients with seatbelts and wheelchair tie downs and belts, and is responsible for ensuring that all person(s) in the vehicle are safely seat belted and remain safely seat belted until the vehicle reaches its assigned destination. Cell Phone Use- Unless it is an emergency situation, and a cell phone call is absolutely necessary while operating a vehicle on company/facility business, the driver should stop the vehicle in a safe area prior to making or answering the call. A cellular phone is provided for the van driver's use for emergencies only and when necessary, should be used in accordance with the company/facility policy as set forth above. Vehicle Safety/Emergency Issues- Any time there is an emergency or safety issue, the driver of the company and/or facility owned vehicle must: Stop the vehicle in a safe and appropriate place, and Call his/her immediate supervisor for directions/instructions on how to proceed Complete an incident report immediately on their return to the facility. Medical Emergency- Any time there is an emergency or safety issue, the driver of the company/facility owned vehicle must: Call 911 Call his/her immediate supervisor for directions/instructions on how to proceed Complete an incident report immediately on their return to the facility. An observation was made on 6/18/12 at 11:55 a.m. while at the Nurse's Station conducting staff interviews. S17CNA (Transportation) rushed into the building and told S16LPN that she was returning to the facility with Resident #156. She stated she came off the interstate onto A------. She said when she got on the service road his wheelchair flipped over backwards and he hit his head on the lift. She said his head was bleeding. S16LPN, S8SocialServices, S17CNA (Transportation), and 2 other aides went to the van. At 12:05 p.m., S16LPN returned to the facility and said Resident #156 was all right. She said he had a laceration to the back of his head. She said he was in the wheelchair on the floor of the van with his legs bent up a little. She said the hooks were in place on the wheelchair. An observation at 12:06 p.m. on 6/18/12 revealed the resident was rolled into facility and to his room by S17CNA. He was sitting with his buttocks toward the front edge of the chair cushion. He was leading against the back of the chair at an angle. Resident #156 was talking to the staff. During an interview at 12:20 p.m. on 6/18/12 with S17CNA (Transportation), she revealed she worked as transportation at the facility for 7 years. She said the resident leaned back in his chair all the time. She said that she was coming off the interstate and he fell over backwards. She said that she pulled the van over at the storage facility on the service road, 0.4 mile from the facility, and went to the back of the van to see about the resident. She said that the resident was still in his wheelchair, lying with the back of the wheelchair on the floor of the van and the hooks were still in place on the wheelchair. She said that his head was bleeding, but he was talking to her. She said that she knew she couldn't get him up by herself and she drove on to the facility with him still lying on the floor in his wheelchair. She said that she told the S16LPN and S13ADON when she got back to the facility. She said that she had gone and asked the Administrator how the hooks worked and after he told her how they worked, she said "good, that's how I did it." When asked if she told him what had happened, she said no she told the nurse. She said she was supposed to report to the nurse. She was asked to bring the van around to demonstrate what happened. She said she guessed she had time; she had to take another resident for an appointment at B--------- B---. An observation of the van's lift, at 12:25 p.m., revealed fresh blood on the floor of the lift. An observation of the van with the lift door closed revealed a portion of the lift did not lay flat, but sat up at an angle when the door was closed. S17CNA said, at the time of the observation, she put 6 hooks on his wheelchair. She said 2 on the back, 2 on the middle and 2 on the front. She demonstrated that to release the hook she would release a lever that was behind a metal cover. She said to tighten the hook on the wheelchair; she would turn a round knob (clockwise) which made a ratcheting noise. She said she heard that noise when his chair went over. She said that the knob could not be turned to release the hook; it could only be released with the lever. S17CNA was asked to get S1Administrator and ask him to come to the van. When S1Administrator arrived, he said he had not been told of the incident until S17CNA came to get him. He said PT had also come to the office, at that same time, to tell him about the incident. He said an investigation had not been started. An observation was made of the S17CNA (Transportation) rolling a resident ( 021) in a wheelchair toward the van. They were about half way down the sidewalk. The resident's husband and the S2DirectorOfNursing were walking out with them. She approached the van lift with the resident. An observation was made of the S17CNA (Transportation) with the resident partially on the lift. At this point, S1Administrator, who had his back to the lift, was asked to ask the aide not to put the resident on the lift or in the van. He told the aide 3 times to go get the other van. At 12:25 p.m. on 6/18/12, Resident #156 was observed sitting in his room in his wheelchair. The back of chair was noted at his mid back. He was leaning back against the back at an angle with his buttocks close to the front of the seat cushion. He had a prosthetic left leg in place which rested on the foot rest. His right leg was on the floor with a cloth boot on it. He stated he was nauseated and had a head ache. The treatment nurse was present and said that he had an abrasion type injury to the back of his head. He had an elongated abrasion/hematoma down the center of his skull (2 inches long x 11/2 inches wide). He said that the wheelchair was secured in the van with the hooks. During an interview at 1:30 p.m. on 6/18/12 with S1Administrator and S2DON, the Administrator stated S17CNA didn't tell him about the incident, but did ask him about how the hooks in the van worked. He was not sure of the time she asked him this. He said that a little while later PT and S17CNA came to his office telling him about the incident. He said that he didn't know what time that was, but it was at the time he was asked to come out to the van. He said that he in-serviced the transportation aide quarterly on the van. He said the in-service consisted of going over the van check list with the driver. He said that he did not cover what to do and who to report to if an incident happened away from the facility in the van. He said that the driver reported to the nurse if an incident occurred. He said that there was no policy for incidents that happened away from the facility or safety related to the van. At 1:45 p.m. on 6/18/12 an interview with S22CNA revealed she went out to the van. She said the resident was lying on the floor beside his chair. She said the hooks weren't on the chair, but S17CNA could have removed them before she saw it. She said he was able to stand up with help and she helped put him in his wheelchair. At 1:48 p.m. on 6/18/12 an interview with S25CNA revealed she was called out to the van while she was assisting in the dining room. She said Resident #156 was observed still sitting in his wheelchair in the van, lying on his back with the wheels up in the air. She said the straps were still attached to the chair. She helped the staff pick him up and noticed his head was bleeding. She said he was alert and oriented and said he was all right. At 1:50 p.m. on 6/18/12 Resident #156 stated he stayed in his chair when he fell over and didn't fall out of his chair. He again said that his chair was secured with hooks, but he didn't know how many were used. He said his chair was rolling back and forth some during the transportation while the hooks were on his chair, prior to the wheelchair falling over. An interview was held with S13ADON on 6/18/12 at 1:55 p.m. She explained that she had been the ADON since April 2, 2012. She said that S17CNA, the van driver, stopped her this morning and told her that Resident #156 fell in the van this morning. She could not remember what time she told her about the occurrence. She said she asked her if she reported it to the nurse. S17CNA told her that the nurse was assessing him. S13ADON said that she also asked if he was ok, and S17CNA told her that he was ok. S17CNA told her that his chair flipped back and he had a small scrape on the back of his head. S17CNA told S13ADON that Resident #156 was talking and said that he was ok. She said that she did not tell S17CNA anything else. She said that she was not aware of this ever happening since she had been working at the facility. She said that she did not know who did the training on securing wheelchair in the vans. She said when an occurrence of this nature occurs, the S17CNA was to notify the nurse immediately and stay with the resident until the nurse arrived. S13ADON said that she did not report the incident to the DON or Administrator. An interview was held with S16LPN on 6/18/12 at 1:58 p.m. She said she was aware that Resident #156 had been taken in the van to a physician's appointment. She said that S17CNA (transportation) came in the door and told her that Resident #156 had fallen in the van. She went out to the van and observed the resident in his wheelchair lying on his back. She immediately called two other CNAs to assist with the resident. She said when she assessed the resident when he was in the van, the straps to the wheelchair had already been unfastened. She said she did not report the incident to Administration because she thought if it happened outside the facility, she didn't have to report it. During an interview at 2:05 p.m. on 6/18/12, S8SocialServices revealed he knew the wheelchair tipped over. He said he saw S17CNA undoing the hooks when he went to the van. He said he was not sure if the resident was in his chair, but his legs were bent a little bit. He said he didn't get to close too the resident, but observed from the front of the van. On 6/18/12 at 5:00 p.m., an observation of the parking lots for both the storage facility and the generator facility revealed the driver had to go up on a curb to enter the parking lots and down off of the curb to exit the parking lots. To enter the parking lot of the Nursing Home the driver also had to go up on a curb. On 6/19/12 at 4:30 p.m. a second interview was conducted with S17CNA. During this interview she said the accident happened in a curve of the service road by the generator place, 0.3 miles from the facility. She said that she pulled into the generator business parking lot and ran to the back of the bus and checked Resident #156. She said his head was bleeding. She said she then drove to the facility with the resident on the floor of the van. She said she did not have a cell phone with her. She said she had a facility cell phone to use, but she had left the phone at the facility charging because it was new. She said she didn't go to her car to get her cell phone. She also stated that she was on the van alone with the resident. During this interview, she said she used 4 straps and they were pulled tight. She said she put 2 on the front and 2 on the back on the metal bar of the wheelchair. She said she told the S16LPN and the S13ADON about the incident. She said she told S1Administrator when she went to get him to come to the van as requested. She said when she went to get the other van to transport the next resident, the lift would not work. She said she transported residents to their doctor's appointments 3-5 days a week. She further stated that she was bringing the other resident to the van to demonstrate how to secure a wheelchair in the van. She acknowledged she did not tell us she was doing this as a demonstration. She verified she had not been inserviced by S1Administrator regarding the policy and procedure for Company/Facility Owned Vehicle until 6/19/12. S17CNA also verified she transported another resident on 6/18/12 to an appointment after the incident with Resident #156. She said she used the van of a sister facility and got the resident to her appointment on time. On 6/20/12 at 4:35 p.m., during an interview with S1Administrator, it was revealed there had not been another accident with a resident and the van since he had been working at the facility. He said he was employed at the facility since 2009. An interview was held with S1Administrator on 6/19/12 at 5:00 p.m. He verified that the S17CNA had come to his office on 6/18/12 twice. The first time she asked him about the wheelchair straps on the van. She described to him how she used them, and he verified to her that was the correct way. He verified again that the S17CNA did not tell him about the accident until she came to him the second time requesting that he come and look at the van with the surveyors. A review of Resident #156's clinical record revealed the resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A review of Resident #156's MDS (Minimum Data Set), dated with an Assessment Reference Date of 6/08/12, revealed his BIMS (Brief Interview for Mental Status) score was 15. The MDS also revealed the resident needed extensive assistance with all ADLs (Activities of Daily Living). Section G0300 Balance during Transitions and Walking revealed the resident was not steady, but only able to stabilize with staff assistance in moving from seated to standing position, walking, moving on and off toilet and surface-to-surface transfer. Resident #156 was assessed for fall risk on 5/26/12, 6/1/12, and 6/7/12. The resident scored 17 for the 3 fall risk assessments. A score of 7 or greater indicated a High Risk for Falls. Each Fall Risk Screening had documentation the resident had fallen in the last 6 months. His cognitive status was marked as intact. He was marked as immobile and needed extensive/total assistance with transfer ability. He was coded as non-weight bearing and as using brace, wheelchair, walker, cane, etc. Review of Resident #156's Care Plan revealed he was care planned for falls. The goal for falls was to decrease the risk for falls through environment and physical management. One of the approaches was maintain resident environment free of clutter and safety hazards. Review of Departmental Notes revealed a Nurse's Note dated 6/18/12 that revealed the resident returned to the facility per wheelchair per transportation van. The note said the transportation van driver came in the facility and said when she made a turn the patient turned over in the wheelchair backwards. The nurse documented she went on the van and saw the resident on his back, still in the wheelchair with the wheelchair turned over backwards, his legs in place on the wheelchair from the straps that are supposed to prevent the chair from moving while transporting the patient. The note stated he said he was having head pain. The note also contained documentation that area on the back of his head was red, about 2 inches long and 1? inches wide. The note documented it was an abrasion with minimal amount of bleeding. The Nurse's Note continued that the resident went to the emergency room at 2:45 p.m. A Nurse's Note timed at 4:30 p.m. revealed a nurse in the emergency room called the facility and reported the resident had a CT scan of the head. Review of the Hospital Transition Record dated 6/18/12 revealed the chief complaint was a fall. The primary [DIAGNOSES REDACTED]. Review of a document provided by K------ A -------- V---, dated 6/18/12, revealed all seat belts on passenger seats were checked and in good working order. All wheelchair 4 point retractable tie downs were checked and in good working order. All lap and shoulder belts for wheelchairs were checked and in good working order. Review of the Company Owned Vehicle Driver Inservice Checklist revealed the areas covered in quarterly in-service were as follows: 1. Vehicle controls which included: Headlight, Turn indicators, Location and use of hazard signals, windshield wipers, horn seat adjustments/location of controls, audio and temperature controls, door operation and locking, and fasten/unfasten seatbelts and wheelchair tie downs and shoulder harness straps. 2. Driving the vehicle which included: Forward motion-general operation and maneuverability, appropriate braking, stopping and moving again, appropriate vehicle size allowance and speed when making 90 degree turn. Backward motion -general operation and maneuverability while moving backward. Non motion- appropriately parking the vehicle in both perpendicular and parallel parking situations. 3. Patient/passenger safety & special equipment included: safely and adequately assisting a patient/passenger into and out of the vehicle; properly securing a patient/passenger in the vehicle with seatbelts; the proper and safe operation of the wheelchair lift; properly securing of a wheelchair in the vehicle; and properly securing the wheelchair occupant with safety and/or shoulder harness belts. The Company Owned Vehicle Driver Inservice Checklist was dated 4/25/12 and had been signed by S1Administrator and S17CNA.

Based on observation, interviews and clinical record review the facility failed to ensure the facility was administered in a manner that ensured the highest practicable physical well-being was maintained for 1 (#156) of 1 (#156) residents sustaining a fall with injury in the facility van during transportation back to the facility from a Stage II sample of 37 residents. The Administration failed to ensure: 1. the wheelchair was properly secured in the transportation van to prevent the wheelchair from rolling backwards and forward during transportation on 6/18/12 and falling over backwards while the van was moving (#156). 2. the transportation van driver and the facility nursing staff immediately notified the Administrator of the accident. (#156) 3. the transportation van driver had a cell phone with her on the transportation van to call the facility's Administration immediately for directions/instructions on how to proceed when a resident fell over backwards in his wheelchair (#156) while riding in the transportation van causing the resident to hit his head on the lift and his head to bleed. 4. transportation van driver immediately implemented facility policy and procedure regarding vehicle safety/emergency issues when Resident #156 fell over backwards in his wheelchair on 6/18/12 while the van was moving causing the resident to hit his head on the lift and his head to bleed. 5. have a system of monitoring in place to ensure staff were knowledgeable regarding what procedure to follow in the event an accident occurred while driving the transportation van. 6. have a system in place to ensure transportation van drivers were knowledgeable regarding correct procedure of securing wheelchairs in the van to prevent the wheelchair from falling over. (#156) 7. qualified medical personnel immediately assessed Resident #156 for possible physical injuries following a fall in his wheelchair while being transported in the van on 6/18/12 that resulted in the resident's head hitting the lift in the van, causing his head to bleed. Resident #156 was placed in Immediate Jeopardy on 6/18/12 at approximately 11:45 a.m. while riding in the transportation van when the resident fell over backwards in his wheelchair 0.3 to 0.4 of a mile from the facility. The van driver pulled the vehicle over and observed that resident #156 had hit his head on the lift and his head was bleeding. The transportation van driver did not immediately notify her supervisor at the facility of the incident at that time. The van driver did not call 911 for assistance. The transportation driver drove the van back to the facility with the resident on the floor of the vehicle still in his overturned wheelchair. Upon arrival back at the facility, the transportation van driver failed to immediately notify the Administrator of the incident involving the wheelchair. The facility staff that was aware of the situation failed to immediately report the incident to the Administrator so that an investigation could be started. Another resident was placed half way on the lift, prior to surveyor intervention, while the Administrator and DON were present. The 82 residents (1, 2,4-8, 13-16, 18, 19, 20, 23, 25, 26, 28, 29, 30, 33, 34, 36, 44, 46-48, 50-53, 55, 58, 59, 64, 66, 70, 71, 73, 76, 79, 81-84, 88, 90, 91, 93, 94, 98, 99, 101, 103, 105-107, 110, 111, 115, 117, 120, 122, 125-128, 132, 134-136, 139, 141, 143-147, 152, 154, 156, 021) who used wheelchairs and were transported by the facility van were also placed in an Immediate Jeopardy situation. The Administrator was informed of the Immediate Jeopardy on 6/18/12 at 4:30 p.m. The Immediate Jeopardy was lifted on 6/19/2012 at 4:30 p.m. when a Plan of Removal was accepted. The Plan of Removal included having the van inspected for problems related to the securing of residents in the van with lap and shoulder belts, 4 point retractable tie downs for all passenger seats and wheelchairs; in-service of all staff members who drive the transportation van with return demonstration of use of the wheelchair tie downs, seat belts, and harness straps. The facility also in-serviced the staff on who to report emergency/safety issues to and the different types of emergency or safety issues, and how to handle medical emergencies and emergency issues while on the van during transportation. The Administrator/designee will quiz the van driver and other staff members that are eligible to drive the van on what to do in emergency or safety issues that might arise, who to notify. Quality Assurance measures were put into place to ensure compliance with the Plan of Removal. The deficient practice continued at a pattern of potential for more than minimal harm for the residents in wheelchairs who used the facility van for transportation. Findings: Review of the facility policy for Company Owned Vehicle, dated March, 2011 revealed in part: Seatbelts- The driver and all passengers in the company/facility vehicle must be safely restrained by buckled seat belts, wheelchair floor tie downs and wheelchair harness type seatbelts at all times the vehicle is in use. A qualified individual shall assist patients/residents/clients with seatbelts and wheelchair tie downs and belts, and is responsible for ensuring that all person(s) in the vehicle are safely seat belted and remain safely seat belted until the vehicle reaches its assigned destination. Cell Phone Use- Unless it is an emergency situation, and a cell phone call is absolutely necessary while operating a vehicle on company/facility business, the driver should stop the vehicle in a safe area prior to making or answering the call. A cellular phone is provided for the van driver's use for emergencies only and when necessary, should be used in accordance with the company/facility policy as set forth above. Vehicle Safety/Emergency Issues- Any time there is an emergency or safety issue, the driver of the company and/or facility owned vehicle must: Stop the vehicle in a safe and appropriate place, and Call his/her immediate supervisor for directions/instructions on how to proceed Complete an incident report immediately on their return to the facility. Medical Emergency- Any time there is an emergency or safety issue, the driver of the company/facility owned vehicle must: Call 911 Call his/her immediate supervisor for directions/instructions on how to proceed Complete an incident report immediately on their return to the facility. An observation was made on 6/18/12 at 11:55 a.m. while at the Nurse's Station conducting staff interviews. S17CNA (Transportation) rushed into the building and told S16LPN that she was returning to the facility with Resident #156. She stated she came off the interstate onto A------. She said when she got on the service road his wheelchair flipped over backwards and he hit his head on the lift. She said his head was bleeding. S16LPN, S8SocialServices, S17CNA (Transportation), and 2 other aides went to the van. At 12:05 p.m., S16LPN returned to the facility and said Resident #156 was all right. She said he had a laceration to the back of his head. She said he was in the wheelchair on the floor of the van with his legs bent up a little. She said the hooks were in place on the wheelchair. An observation at 12:06 p.m. on 6/18/12 revealed the resident was rolled into facility and to his room by S17CNA. He was sitting with his buttocks toward the front edge of the chair cushion. He was leading against the back of the chair at an angle. Resident #156 was talking to the staff. During an interview at 12:20 p.m. on 6/18/12 with S17CNA (Transportation), she revealed she worked as transportation at the facility for 7 years. She said the resident leaned back in his chair all the time. She said that she was coming off the interstate and he fell over backwards. She said that she pulled the van over at the storage facility on the service road, 0.4 mile from the facility, and went to the back of the van to see about the resident. She said that the resident was still in his wheelchair, lying with the back of the wheelchair on the floor of the van and the hooks were still in place on the wheelchair. She said that his head was bleeding, but he was talking to her. She said that she knew she couldn't get him up by herself and she drove on to the facility with him still lying on the floor in his wheelchair. She said that she told the S16LPN and S13ADON when she got back to the facility. She said that she had gone and asked the Administrator how the hooks worked and after he told her how they worked, she said "good, that's how I did it." When asked if she told him what had happened, she said no she told the nurse. She said she was supposed to report to the nurse. She was asked to bring the van around to demonstrate what happened. She said she guessed she had time; she had to take another resident for an appointment at B--------- B---. An observation of the van's lift, at 12:25 p.m., revealed fresh blood on the floor of the lift. An observation of the van with the lift door closed revealed a portion of the lift did not lay flat, but sat up at an angle when the door was closed. S17CNA said, at the time of the observation, she put 6 hooks on his wheelchair. She said she put 2 on the back, 2 on the middle and 2 on the front of the wheelchair. She demonstrated that to release the hook she would release a lever that was behind a metal cover. She said to tighten the hook on the wheelchair; she would turn a round knob (clockwise) which made a ratcheting noise. She said she heard that noise when his chair went over. She said that the knob could not be turned to release the hook; it could only be released with the lever. S17CNA was asked to get S1Administrator and ask him to come to the van. When S1Administrator arrived, he said he had not been told of the incident until S17CNA came to get him. He said PT had also come to the office, at that same time, to tell him about the incident. He said an investigation had not been started. An observation was made of the S17CNA (Transportation) rolling a resident (# 021) in a wheelchair toward the van. They were about half way down the sidewalk. The resident's husband and the S2DirectorOfNursing were walking out with them. She approached the van lift with the resident. An observation was made of the S17CNA (Transportation) with the resident partially on the lift. At this point, S1Administrator, who had his back to the lift, was asked to ask the aide not to put the resident on the lift or in the van. He told the aide 3 times to go get the other van. At 12:50 p.m. on 6/18/12, Resident #156 was observed sitting in his room in his wheelchair. The back of chair was noted at his mid back. He was leaning back against the back at an angle with his buttocks close to the front of the seat cushion. He had a prosthetic left leg in place which rested on the foot rest. His right leg was on the floor with a cloth boot on it. He stated he was nauseated and had a head ache. The treatment nurse was present and said that he had an abrasion type injury to the back of his head. He had an elongated abrasion/hematoma down the center of his skull (2 inches long x 1 1/2 inches wide). He said that the wheelchair was secured in the van with the hooks. During an interview at 1:30 p.m. on 6/18/12 with S1Administrator and S2DON, the Administrator stated S17CNA didn't tell him about the incident, but did ask him about how the hooks in the van worked. He was not sure of the time she asked him this. He said that a little while later PT and S17CNA came to his office telling him about the incident. He said that he didn't know what time that was, but it was at the time he was asked to come out to the van. He said that he in-serviced the transportation aide quarterly on the van. He said the in-service consisted of going over the van check list with the driver. He said that he did not cover what to do and who to report to if an incident happened away from the facility in the van. He said that the driver reported to the nurse if an incident occurred. He said that there was no policy for incidents that happened away from the facility or safety related to the van. At 1:45 p.m. on 6/18/12 an interview with S22CNA revealed she went out to the van. She said the resident was lying on the floor beside his chair. She said the hooks weren't on the chair, but S17CNA could have removed them before she saw it. She said he was able to stand up with help and she helped put him in his wheelchair. At 1:50 p.m. on 6/18/12 an interview with S25CNA revealed she was called out to the van while she was assisting in the dining room. She said Resident #156 was observed still sitting in his wheelchair in the van, lying on his back with the wheels up in the air. She said the straps were still attached to the chair. She helped the staff pick him up and noticed his head was bleeding. She said he was alert and oriented and said he was all right. At 1:50 p.m. on 6/18/12 Resident #156 said he stayed in his chair when he fell over and didn't fall out of his chair. He again said that his chair was secured with hooks, but he didn't know how many were used. He said his chair was rolling back and forth some during the transportation while the hooks were on his chair, prior to the wheelchair falling over. An interview was held with S13ADON on 6/18/12 at 1:55 p.m. She explained that she had been the ADON since April 2, 2012. She said that S17CNA, the van driver, stopped her that morning and told her that Resident #156 fell in the van this morning. She could not remember what time she told her about the occurrence. She said she asked her if she reported it to the nurse. S17CNA told her that the nurse was assessing him. S13ADON said that she also asked if he was ok, and S17CNA told her that he was ok. S17CNA told her that his chair flipped back and he had a small scrape on the back of his head. S17CNA told S13ADON that Resident #156 was talking and said that he was ok. She said that she did not tell S17CNA anything else. She said that she was not aware of this ever happening since she had been working at the facility. She said that she did not know who did the training on securing wheelchair in the vans. She said when an occurrence of this nature occurs, the S17CNA was to notify the nurse immediately and stay with the resident until the nurse arrived. S13ADON said that she did not report the incident to the DON or Administrator. An interview was held with S16LPN on 6/18/12 at 1:58 p.m. She said she was aware that Resident #156 had been taken in the van to a physician's appointment. She said that S17CNA (transportation) came in the door and told her that Resident #156 had fallen in the van. She went out to the van and observed the resident in his wheelchair lying on his back. She immediately called two other CNAs to assist with the resident. She said when she assessed the resident when he was in the van, the straps to the wheelchair had already been unfastened. She said she did not report the incident to Administration because she thought if it happened outside the facility, she didn't have to report it. During an interview at 2:05 p.m. on 6/18/12, S8SocialServices revealed he knew the wheelchair tipped over. He said he saw S17CNA undoing the hooks when he went to the van. He said he was not sure if the resident was in his chair, but his legs were bent a little bit. He said he didn't get too close to the resident, but observed from the front of the van. On 6/18/12 at 5:00 p.m., an observation of the parking lots for both the storage facility and the generator facility revealed the driver had to go up on a curb to enter the parking lots and down off of the curb to exit the parking lots. To enter the parking lot of the Nursing Home the driver also had to go up on a curb. On 6/19/12 at 4:30 p.m. a second interview was conducted with S17CNA. During this interview she said the accident happened in a curve of the service road by the generator place, 0.3 miles from the facility. She said that she pulled into the generator business parking lot and ran to the back of the bus and checked Resident #156. She said his head was bleeding. She said she then drove to the facility with the resident on the floor of the van. She said she did not have a cell phone with her. She said she had a facility cell phone to use, but she had left the phone at the facility charging because it was new. She said she didn't go to her car to get her cell phone. She also stated that she was on the van alone with the resident. During this interview, she said she used 4 straps and they were pulled tight. She said she put 2 on the front and 2 on the back on the metal bar of the wheelchair. She said she told the S16LPN and the S13ADON about the incident. She said she told S1Administrator when she went to get him to come to the van as requested. She said when she went to get the other van to transport the next resident, the lift would not work. She said she transported residents to their doctor's appointments 3-5 days a week. She further stated that she was bringing the other resident to the van to demonstrate how to secure a wheelchair in the van. She acknowledged she did not tell us she was doing this as a demonstration. She verified she had not been inserviced by S1Administrator regarding the policy and procedure for Company/Facility Owned Vehicle until 6/19/12. S17CNA also verified she transported another resident on 6/18/12 to an appointment after the incident with Resident #156. She said she used the van of a sister facility and got the resident to her appointment on time. On 6/20/12 at 4:35 p.m., during an interview with S1Administrator, it was revealed there had not been another accident with a resident and the van since he had been working at the facility. He said he was employed at the facility since 2009. An interview was held with S1Administrator on 6/19/12 at 5:00 p.m. He verified that the S17CNA had come to his office on 6/18/12 twice. The first time she asked him about the wheelchair straps on the van. She described to him how she used them, and he verified to her that was the correct way. He verified again that the S17CNA did not tell him about the accident until she came to him the second time requesting that he come and look at the van with the surveyors. The Administrator stated the staff should have notified him immediately after the incident happened. A review of Resident #156's clinical record revealed the resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A review of Resident #156's MDS (Minimum Data Set), dated with an Assessment Reference Date of 6/08/12, revealed his BIMS (Brief Interview for Mental Status) score was 15. The MDS also revealed the resident needed extensive assistance with all ADLS. Section G0300 Balance during Transitions and Walking revealed the resident was not steady, but only able to stabilize with staff assistance in moving from seated to standing position, walking, moving on and off toilet and surface-to-surface transfer. Resident #156 was assessed for fall risk on 5/26/12, 6/1/12, and 6/7/12. The resident scored 17 for the 3 fall risk assessments. A score of 7 or greater indicated a High Risk for Falls. Each Fall Risk Screening had documentation the resident had fallen in the last 6 months. His cognitive status was marked as intact. He was marked as immobile and needed extensive/total assistance with transfer ability. He was coded as non-weight bearing and as using brace, wheelchair, walker, cane, etc. Review of Resident #156's Care Plan revealed he was care planned for falls. The goal for falls was to decrease the risk for falls through environment and physical management. One of the approaches was maintain resident environment free of clutter and safety hazards. Review of Departmental Notes revealed a Nurse's Note dated 6/18/12 that revealed the resident returned to the facility per wheelchair per transportation van. The note said the transportation van driver came in the facility and said when she made a turn the patient turned over in the wheelchair backwards. The nurse documented she went on the van and saw the resident on his back, still in the wheelchair with the wheelchair turned over backwards, his legs in place on the wheelchair from the straps that are supposed to prevent the chair from moving while transporting the patient. The note stated he said he was having head pain. The note also contained documentation that area on the back of his head was red, about 2 inches long and 1 ? inches wide. The note documented it was an abrasion with minimal amount of bleeding. The Nurse's Note continued that the resident went to the emergency room at 2:45 p.m. A Nurse's Note timed at 4:30 p.m. revealed a nurse in the emergency room called the facility and reported the resident had a CT scan of the head. Review of the Hospital Transition Record dated 6/18/12 revealed the chief complaint was a fall. The primary [DIAGNOSES REDACTED]. Review of a document provided by K------ A -------- V---, dated 6/18/12, revealed all seat belts on passenger seats were checked and in good working order. All wheelchair 4 point retractable tie downs were checked and in good working order. All lap and shoulder belts for wheelchairs were checked and in good working order. Review of the Company Owned Vehicle Driver Inservice Checklist revealed the areas covered in quarterly in-service were as follows: 1. Vehicle controls which included: Headlight, Turn indicators, Location and use of hazard signals, windshield wipers, horn seat adjustments/location of controls, audio and temperature controls, door operation and locking, and fasten/unfasten seatbelts and wheelchair tie downs and shoulder harness straps. 2. Driving the vehicle which included: Forward motion-general operation and maneuverability, appropriate braking, stopping and moving again, appropriate vehicle size allowance and speed when making 90 degree turn. Backward motion -general operation and maneuverability while moving backward. Non motion- appropriately parking the vehicle in both perpendicular and parallel parking situations. 3. Patient/passenger safety & special equipment included: safely and adequately assisting a patient/passenger into and out of the vehicle; properly securing a patient/passenger in the vehicle with seatbelts; the proper and safe operation of the wheelchair lift; properly securing of a wheelchair in the vehicle; and properly securing the wheelchair occupant with safety and/or shoulder harness belts. The Company Owned Vehicle Driver Inservice Checklist was dated 4/25/12 and signed by S1Administrator and S17CNA.