Every finding on record at Lyonsview Health and Rehabilitation Center

Based on facility policy review, observation, and interview, the facility failed to maintain sanitary kitchen equipment in 1 of 1 kitchen observed. The facility's failure had the potential to affect 166 of 168 residents.The findings include: Review of the facility policy titled, Food Safety Requirements, dated 3/26/2025, revealed, .All equipment used in handling food shall be cleaned and sanitized, and handled in a manor [manner] to prevent contamination .Staff shall follow facility procedures for .cleaning fixed cooking equipment . During an observation on 5/17/2026 at 10:40 AM, with the Dietary Manager (DM) revealed a line of fixed kitchen cooking equipment which included a convection oven, tilt skillet, and a front oven. Each piece of equipment was observed in unclean and in unsanitary conditions as evidence by dried, dark brown food debris located on multiple surface areas of each piece of equipment. The debris appeared on the front and sides of the units. During an interview on 5/17/2026 at 10:48 AM, the DM confirmed the convection oven, tilt skillet, and front oven had dark, dried brown food debris present. The DM confirmed each piece needed .a cleaning . and was in an unsanitary condition.

Based on facility policy review, observation, and interview, the facility failed to ensure the facility's main dining room was open for resident use for 2 of 7 days of the week. The findings include: Review of the facility's policy titled, Resident Rights, dated 3/7/2023, revealed .All residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation or gender identity or expression .The resident has the right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility . During the initial tour of the facility on 5/17/2026, the activity calendar was observed to have in-room only dining for the weekends. During an interview on 5/19/2026 3:55 PM, Resident #77 stated .I would like to be able to eat in there with everybody else on the weekends. Some people want to bring their families and want to see everybody . During an interview on 5/19/2026 3:59 PM, Resident #58 .I would like the option to eat in the dining room on the weekends if I felt like it. I might not do it every weekend, but I'd like to be able to choose . During an interview on 5/19/2026 at 4:00 PM, Resident #130 stated .I would prefer if we could eat in the dining room on the weekends . During an interview on 5/19/2026 at 4:19 PM, Certified Nursing Assistant (CNA) E stated .The dining room isn't open on the weekends. I don't know why, but I've been here for a year and it's not been open on the weekends the whole time .The residents know though . During an interview on 5/19/2026 at 4:22 PM, CNA F stated .I work 3:00-11:00 PM, so I don't know if it's open for breakfast or lunch but it's not open on the weekends for dinner. We do try to tell the residents but some of them don't always understand, so we'll just redirect them . During an interview on 5/19/2026 at 4:29 PM, The Administrator confirmed the facility had gone to in-room dining during the last COVID outbreak in the facility (could not give date), and residents appeared to have had low turnout after the outbreak for meal service in the main dining room. The Administrator further confirmed the dining room was not open on the weekends for dining.

Based on job description review, employee file review, and interviews the facility failed to ensure the Dietary Manager completed accredited course work in dietetic training and certification.The findings include: Review of the Food Service Manager (Dietary Manager) job description, undated, revealed .The primary purpose of your position is to assist the Dietitian in planning, organizing, developing and directing the overall operation of the Food Service Department .Qualifications .a high school diploma .Graduate of an accredited course in dietetic training approved by the American Dietetic Association . Review of the employee file for the Dietary Manager (DM), revealed no certificate of completion of course work which would satisfy the job description requirement. Further review revealed The DM had been in his current role since 3/13/2018. During an interview on 5/17/2026 at 11:37 AM, the DM stated .I'm working on it [dietary certification] . when asked if he had completed the accredited course work for dietetic training and certification. During employee file review and interview on 5/19/2026 at 4:10 PM, the Human Resources (HR) representative confirmed the DM had not completed an accredited course in dietetic training and certification.

Based on facility policy review, medical record review, and interviews, the facility failed to maintain ongoing communication and collaboration with the dialysis facility and failed to document the status of the resident upon return to the facility for 1 resident (Resident #113) of 4 residents reviewed for Hemodialysis. The findings include:Review of the facility's policy titled, Hemodialysis, undated, revealed .The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with the professional standards of practice. This will include .ongoing assessment of the resident's condition and monitoring before and after dialysis treatments .ongoing assessment and oversight of the resident before during and after dialysis treatments .communication with the dialysis facility regarding dialysis care and services .the nurse will monitor and document the status of the resident's access site(s) upon return from the dialysis treatment to observe for bleeding and other complications .the administrator, nursing director .should review the facility's dialysis care and services on an ongoing basis including .communication .Review of the medical record revealed Resident #113 was admitted to the facility on [DATE] with diagnoses including Parkinsons Disease, End Stage Renal Disease with Dialysis, and Diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored a 4 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment.Review of a Physician's Order for Resident #113 dated 2/26/2026, revealed an order for in center dialysis on Mondays, Wednesdays, and Fridays. Review of the dialysis communication sheets for Resident #113 for the month of 4/2026 and 5/2026 revealed the dialysis center pre-weight, post- weight, dialysis start time, end time, fluid removed, meal/snack intake, catheter status and location, changes in condition, and vital signs had not been recorded on the dialysis communication form on 4/22/2026, 4/27/2026, 5/1/2026, and 5/6/2026. Further review revealed post dialysis information, catheter location status, catheter dressing, bleeding, general condition of resident, and vital signs had not been recorded on the dialysis communication form on 4/1/2026, 4/6/2026, 4/10/2026, 4/15/2026, 4/20/2026, 4/24/2026, 4/29/2026, 5/6/2026, and 5/13/2026. Review of Resident #133's medical record revealed the post dialysis information catheter, location status, catheter dressing, bleeding, general condition of resident, and vital signs had not been recorded on 4/1/2026, 4/6/2026, 4/10/2026, 4/15/2026, 4/20/2026, 4/24/2026, 4/29/2026, 5/6/2026, and 5/13/2026. During an interview on 5/19/2026 at 11:06 AM, Licensed Practical Nurse (LPN) A stated the residents dialysis site was monitored daily, prior to dialysis, and upon return. LPN A stated she documented vital signs in the electronic medical record and not on the dialysis communication sheets. During an interview and medical record review on 5/19/2026 at 1:59 PM, the Director of Nursing (DON) confirmed the nurse was to call the dialysis facility to obtain missing information regarding changes of condition, access site concerns, or physician order changes. The DON confirmed the resident was to be assessed prior to leaving and upon return to the facility. If the information was not provided on the form the nurse was to call the dialysis facility and obtain the pertinent information and document the information on the Dialysis Communication form. The DON further confirmed the forms were not filled out in entirety and the required information was not documented in the Electronic Medical Record (EMR). During an interview on 5/19/2026 at 2:06 PM, LPN A confirmed the forms were not filled out and stated she was not aware she needed to fill out the Dialysis Communication form after the resident returns from dialysis. LPN A stated she called the dialysis center for missing information and confirmed she does not document the information received on the form or in the electronic medical record.

Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual review, medical record review, and interview, the facility failed to complete quarterly assessments, using the Centers for Medicare & Medicaid Services-specified RAI process within the regulatory time frames for 1 resident (Resident #20) of 33 residents reviewed for MDS assessments.The findings include: Review of the MDS 3.0 RAI Manual version 20.1, dated 10/2025, revealed, .The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment .The MDS completion date for quarterly assessments must be no later than 14 days after the ARD [Assessment Reference Date] . Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Heart Disease, Diabetes Mellitus Type 2, and Old Myocardial Infarction. Review of the quarterly MDS assessment dated [DATE], revealed the assessment was completed on 5/18/2026 (the assessment was 49 days past due). During an interview on 5/19/2026 at 7:26 PM, the Registered Nurse (RN) MDS Coordinator stated quarterly MDS assessments were to be completed within 14 calendar days of the assessment reference date. The RN MDS Coordinator confirmed Resident #20's quarterly MDS assessment dated [DATE] was completed late.

Based on facility policy review, medical record review, facility documentation review, and interviews, the facility failed to ensure 1 of 8 (Resident #1) sampled residents reviewed for accident hazards received adequate supervision to prevent elopement (a situation where a resident leaves the premises or safe area without necessary supervision). On 12/10/2023, at approximately 10:50 PM, the facility staff observed Resident #1, a vulnerable and cognitively impaired resident with a history of wandering behaviors, outside the building next to a fence. The facility's failure to provide adequate supervision to Resident #1 resulted in Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) for Resident #1 and placed 4 other residents identified as having the potential for elopement at risk for Immediate Jeopardy. The Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) were notified of the Immediate Jeopardy on 7/24/2024 at 8:48 AM in the Administrator's office. The facility was cited Immediate Jeopardy at F-689 at a scope and severity of J which constitutes Substandard Quality of Care. The IJ began on 12/10/2023 and continued through 12/13/2023. The facility's corrective actions were completed on 12/13/2023. An acceptable Removal Plan/Allegation of Compliance for the past noncompliance, which removed the immediacy, was provided by the facility on 7/24/2024 and was validated on site. The IJ was cited as past noncompliance for F-689 and the facility is not required to submit a Plan of Correction. The findings include: Review of the undated facility policy titled, Elopement Response, revealed .Purpose: It is the intent of the facility to provide a safe and home-like environment for all residents and to provide adequate supervision .to prevent the possibility of elopement or unsafe wandering .Elopement: When a resident leaves the facility premises or a safe area without authorization .or supervision .Any staff member observing a resident attempting to leave the premises .shall attempt to re-direct the resident . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety Disorder, and Hypertension. Review of an Elopement Risk assessment dated [DATE] and reviewed on 10/24/2023, revealed Resident #1 was a moderate risk for elopement on the assessment .cognitively impaired with poor decision making skills .resident ambulate independently, with or without assistive device .resident verbally expressed the desire to go home .[box checked for the following] Resident is not at risk for elopement/wandering at this time .Summary of Review .Resident ambulates throughout the facility looking for bank, dept [department] store .She knows her room number .No exit seeking toward doors observed .Date 10/24/23 . Review of a care plan for Resident #1 dated 2/23/2023 showed .Elopement risk as evidenced by a history of wandering aimlessly, impaired safety awareness . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment which indicated moderate cognitive impairment, and no wandering behaviors were identified on the MDS. Review of a witness statement dated 12/10/2023, revealed Certified Nursing Assistant (CNA) A stated .just .got to 400 hall nurse [Registered Nurse, (RN) D] was .going outside .[RN D] came right back in saying [Resident #1] was outside. [RN D] .2nd shift CNAs and I went outside .escorted her back inside, when I came in I went to her room. Door was shut, opened door to find her window wide open and no screen .Let others [nurses] see it [see the window open] then closed the window .3rd shift CNA and I keep close watch to [Resident #1], assisted with getting an UA [urinalysis, a test of urine for checking for presence of bacteria] and skin assessment then helped [Resident #1] to bed . Review of a progress note for Resident #1 dated 12/11/2023 at 2:15 AM, revealed .At [10:50 PM] this nurse was informed that resident had climbed out of room window and was observed outside attempting to climb fence on facility property. Resident was assisted by staff inside facility. Resident observed AA/O [alert and oriented] to self .no c/o [complaints of] pain or discomfort. small abrasion .base of index finger. No other injuries observed at this time. When asked why resident climbed out window, resident stated 'I wanted to go home'. Resident stated 'I don't understand what I did wrong'. Nurse informed resident of risk for injury and staff responsibility for her care and safety. Resident observed at this time with sweater, shirt, pants, and tennis shoes on-appropriately dressed .Nurse [RN D] stated 'the resident was never left unattended, she opened the exterior door and yelled for the CNA's to assist her that a resident had gotten outside'. Staff assisted the resident back inside the facility via wheelchair and placed in hall next to resident's room. Nurse informed that the window was open. This Nurse [RN D] closed the window and had made .notification at [11:15 PM] to have maintenance come into facility to screw window shut .skin assessment obtained and documented .residents RP [responsible party] was notified . Review of a witness statement dated 12/11/2023, revealed CNA B stated .20 mins[minutes] before th [the] incident [Resident #1] was at the nurses station talking to us she went back to her room with her door shut as usual . Review of a witness statement dated 12/11/2023, revealed CNA C stated .was observing [Resident #1] come back in from outside I [CNA C] watched over [Resident #1] after she came to her room from being outside .my shift 11p [PM]- 7 AM . Review of a witness statement dated 12/11/2023, revealed RN D stated .[RN D] stepped off the unit 400 hall side door for some air. Observed resident [Resident #1] .outside standing at fence attempting to climb fence I held door open and did not leave .while I called for CNAs to come that a resident was outside .[Resident #1] had on appropriate clothing and sneakers .[Resident #1] was assisted back inside and to her room where it was observed that her window was standing open .has no obvious injury except for small abrasion .Right index finger . Review of the facility documentation for Resident #1 dated 12/11/2023, revealed .On 12/10/2023, Administrator was notified .that [Resident #1] was outside by the fence .nurse observed this and called .for help .Resident was escorted back into the building and checked. Increased monitoring was initiated .Resident was appropriately dressed in warm clothes. Resident room was checked for environmental safety and staff continues to monitor closely .Describe any changes in the resident's behavior .No changes . Review of a progress note for Resident #1 dated 12/11/2024 at 7:49 PM, revealed .resident continues to voice wanting to leave the facility DON .notified instructed to provide 1 on 1 care. CNA sitting in room at bedside resident laying in bed no distress noted . During a telephone interview on 7/23/2024 at 3:35 PM, CNA A stated the resident elopement happened as she showed up for her 11-7 shift on 12/10/2023, the nurse was going outside for fresh air and saw Resident #1 against the fence. Staff brought her in and found her door closed, window open and screen off laying outside the building. The CNA stated no one saw her leave the building through the window. The nurse who found her by the fence was RN D. The resident .was on 1 on 1 watch for 72 hours after that happened . During an interview on 7/24/2024 at 8:48 AM, the Administrator stated, immediately following the incident, rounds were done with other residents to make sure no other residents were affected and the resident had increased supervision. The Administrator stated 1:1 [1 on 1] supervision was initiated on 12/11/2023 at 7:00 PM after Resident #1's comments about wanting to go home were heard by staff. The Administrator stated that before 12/10/2023, there were no stop screws on any windows except the back 400 hall (secure unit), and the screws were put on all windows after the incident. The Administrator confirmed that Resident #1 eloped from the facility. During an interview on 7/24/2024 at 9:35 AM, CNA F stated she was working on 12/10/2023 and stated the nurse went to the outside door and stepped out and saw Resident #1 .holding on to the fence about to go over it . The CNA went outside and helped the resident inside with another staff member (RN D). The CNA stated she did not see the resident climb out the window as the resident's door was closed. The CNA stated she had never witnessed Resident #1 trying to get out a door or window, but the resident had asked to get out of doors before while wandering. The facility's corrective actions for the removal plan were issued to the state surveyors on 7/24/2024. The corrective action plan included the following: 1. How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. The facility held a Quality Assurance Performance Improvement meeting on 12/11/2023 during which the attendees found it necessary to ensure building windows were all secure, review the Elopement Response policy with staff, review the Abuse policy with staff, and review elopement protocol with staff. The Administrator, Director of Rehab Therapy, Admissions, Human Resources Director, and Business Office Manager were included in the meeting. 2. How the facility completed the action plan and identified and protected other residents having the potential to be affected by the same deficient practice. A head count was completed for all residents on 12/10/2023 by the DON and designees and elopement assessments completed on all residents on 12/12/2023, and the elopement assessments were ongoing and were used to update elopement books with current pictures of those residents to be kept at each nurses' station. Five residents were identified as elopement risk outside of the secured unit. Physician's orders, care plans and TASK [CNA communication] were updated on 12/11/2023 by MDS staff and included assessments completed on 12/12/2023 by medical and psychiatric nurse practitioners for Resident #1. All windows were checked and secured per regulations and completed on 12/11/2023 by the Maintenance Director and the Facility Manager. Ongoing door checks were initiated on 12/11/2023 by the Maintenance Director. Education was completed with current staff on 12/11/2023 by the Administrator and DON and will be ongoing for new staff. Education included Abuse and Elopement procedures and management. Continuing education was provided via telephone to include staff not available to attend in person and was completed on 12/13/2023. 3. What measures were put into place or systemic changes made to ensure the deficient practice will not reoccur. Elopement drills were completed on 12/11/2023 and will be ongoing. Elopement education is ongoing through monthly staff meetings, orientation, and in-services for employees. Ongoing window audits were initiated on 12/11/2023 by the Environmental Service Director to ensure secure windows for all residents. Monitoring will be completed by a designated monitor who performs daily rounds to check for window security. The Removal Plan was validated onsite by the surveyors on 7/24/2024 which included review of the facility documentation to show each step was completed and staff interviews to confirm the completed and ongoing actions. Interviews with 21 staff members confirmed staff had been educated on elopement and participated in elopement drills.

Based on facility policy review, medical record review, facility investigation documentation review, police report review, and interview, the facility failed to protect the residents' right to be free from physical abuse for 3 residents (Resident #2, Resident #4, and Resident #6) of 21 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, effective 8/2023, revealed .Purpose: To prohibit and prevent abuse, neglect, exploitation .and to ensure reporting of alleged violations . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Type 2 Diabetes Mellitus, and Major Depressive Disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored a 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was cognitively intact. Continued review revealed no behaviors were observed during the assessment period. Review of the comprehensive care plan for Resident #2 revised 9/28/2023, revealed .Resident tries to direct other residents without their approval .Resident to notify staff for assistance for other residents as needed instead of her trying to direct them . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnosis including Alzheimer's Disease, Encounter for Palliative Care, and Non-[NAME] Lymphoma. Continued review revealed the resident discharged to another facility on 11/9/2023. Review of a quarterly MDS assessment dated [DATE], revealed Resident #3 scored a 99 on the BIMS which indicated the resident was unable to complete the interview. Continued review revealed no behaviors were observed during the assessment period. Review of the comprehensive care plan for Resident #3 revised 9/28/2023, revealed .Provide doll to resident when agitated and redirect to room .Psy [psychiatric] services referral as needed . Review of the facility investigation dated 9/28/2023, revealed .[Resident #2] .was assisting another resident .[Resident #3] from another resident room .[Resident #3] made contact with [Resident #2's] face Resident #2 stated .it was a tap .[Resident #2] wanted nothing to be done regarding incident .Reeducated [Resident #3] to get staff for redirection of other residents . Review of a Police Report investigation dated 9/28/2023, revealed .on 9/28/2023 .officer .responded to Simple Assault .The complainant .is the director of the nursing home .stated that one resident had hit another resident .When went to speak with the suspect .was unable to get clear statement from her due to severely declined mental state .I then spoke with the victim .who stated she was trying to get .[suspect] back to correct room and .[suspect] hit her in the side of the face .stated it wasn't hard .she did not have any injuries from being hit . Review of a Skin Assessment for Resident #2 completed on 9/28/2023 revealed no injuries or new areas observed. Review of a Psychiatric Nurse Practitioner (NP) note for Resident #3 dated 9/29/2023, revealed .[Resident #3] is alert with confusion .co-managed by .hospice .[NP] asked to see [Resident #3] regarding altercation between another resident [Resident #2] .[Resident #3]does not have the mental capacity to answer questions about the the incident .does not appear to be in any distress .continues to be confused .no known triggers to behaviors or modifying factors .Recommendations .discontinue .[antipsychotic medication] . Review of a Psychiatric NP Note for Resident #2 dated 9/29/2023, revealed .[Resident #2] is pleasant and smiling .asked to see [Resident #2] regarding an incident where she [Resident #2] was smacked by another resident [Resident #3] .[Resident #2] states she likes to help take care of the other residents and feels like she can be helpful with redirection .we discussed boundaries and letting the staff take care of other residents .Recommendations: continue current treatment plan and medications . During an interview on 7/24/2024 at 12:51 PM, Licensed Practical Nurse (LPN) H stated she was standing there when incident happened on 9/28/2023, and she observed Resident #3 hit Resident #2 in the face. Continued interview revealed the LPN denied prior incidents between the two residents. Interview revealed the residents were immediately separated with neither resident having any injury. During an interview on 7/24/2024 at 1:02 PM, Resident #2 stated she was redirecting Resident #3 and she [Resident #2] smacked her .it didn't hurt . Continued interview revealed the resident stated no further incidents happened between the two residents. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Contractures, Hypertension, and Hypoglycemia. Continued review revealed the resident transferred to another facility she had resided at prior to admission on 3/13/2024. Review of an admission MDS assessment dated [DATE], revealed Resident #4 scored a 15 on the BIMS assessment which indicated resident was cognitively intact. Continued review revealed no behaviors were observed during the review. Review of the comprehensive care plan for Resident #4 revised 12/28/2023, revealed .allow resident the opportunity to identify own self needs .encourage the resident to participate in conversation .refer to Psy [psychiatric] PRN [as needed] . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Progressive Ophthalmoplegia, Type 2 Diabetes Mellitus, and Urinary Tract Infection. Review of an admission MDS assessment dated [DATE], revealed Resident #5 scored a 99 on the BIMS assessment indicating the resident was unable to complete the interview. Continued review revealed no behaviors were observed during the review. Review of the comprehensive care plan for Resident #5 revised 12/28/2023, revealed .resident to resident altercation .causative factors/ situations will be identified and avoided .redirect as needed .allow resident to express thoughts and feelings .send to ER [emergency room ] for psychiatric evaluation . Review of a Nursing Progress Note for Resident #5 dated 12/28/2023, revealed .[Resident #5]went into [Resident #4's] room and was squeezing and holding her leg and hitting roommate [Resident #4] . Review of the facility investigation dated 12/28/2023, revealed .[Resident #4] was struck and grabbed by roommate [Resident #5] .roommate and resident separated immediately .[Resident #5] was sent to hospital . Review of facility documentation dated 12/28/2023, revealed .Administrator notified police .two police officers came to building to interview residents [Resident #4 and Resident #5] they did not feel that they needed to do police report on this . Review of a Skin Assessment for Resident #4 completed on 12/28/2023, revealed no changes or bruising noted. Review of a Psychiatric NP Note for Resident #4 dated 12/28/2023, revealed .[Resident #4] lying in her bed .nursing observed another resident [Resident #5] pulling on her legs and tapping on her leg .[Resident #4] denies .injuries or areas in which resident touched her will continue to monitor for any latent effects of this incident. No injury noted, resident denies any pain or discomfort . Review of a Psychiatric NP Note for Resident #5 dated 12/28/2023, revealed .[Resident #5] has a history of vascular dementia .she was observed pulling on another resident's leg [Resident #4] trying to pull resident toward her .she denies any pain or discomfort or recollection of the above mentioned incident with the other resident .Resident has had increased behaviors .has been evaluated by the psychiatric nurse practitioner .without significant improvement in her behaviors, will ask that she be sent for geropsychiatric evaluation . During an interview on 7/24/2024 at 7:12 AM, the Social Services Director (SSD) stated she was aware of the resident-to-resident contact when Resident #5 struck and squeezed Resident #4. Continued interview revealed the SSD was not aware of any other incidents prior to Resident #4 discharge on 3/13/2024 . During an interview on 7/24/2024 at 9:15 AM, Resident #5 appeared frail and confused and unable to recall the incident [between Resident #4 and Resident #5] stating .everyone is treating her well . Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Anxiety Disorder, and Acute Respiratory Failure. Review of a quarterly MDS assessment dated [DATE], revealed Resident #6 scored a 15 on the BIMS assessment which indicated resident was cognitively intact. Continued review revealed no behaviors observed during the assessment period. Review of the comprehensive care plan for Resident #6 revised 12/17/2023, revealed .resident to resident altercation .causative factors/situation will be identified .allow resident to express thought and feelings .refer to mental health for evaluation . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Dementia and Behavioral Disturbances. Review of the admission MDS assessment dated [DATE], revealed Resident #7 scored a 3 on the BIMS assessment indicating severe cognitive impairment. Continued review revealed no behaviors observed during the assessment period. Review of the comprehensive care plan for Resident #7 revised 12/17/2023, revealed .resident to resident altercation .causative factor/ situations will be identified .redirect as needed .maintain calm environment .refer to mental health . Review of the facility investigation dated 12/17/2023, revealed .heard .[Resident #6] saying, get her [Resident #7]out of my room .[Resident #7] was hitting [Resident #6] on the arm. Resident #7 was immediately escorted back to her room. Review of facility documentation dated 12/17/2023, revealed .police were notified and came to building. They do not feel that an official police report needs to be made .there is no redness or bruising at all during full body assessment . Review of a Skin Assessment for Resident #6 completed 12/17/2023, revealed no injuries or new areas found . Review of a Psychiatric NP Note for Resident #6 dated 12/21/2023 revealed .[Resident #6] had an encounter with [Resident #7]. It was reported [Residnet #6] was hit by [Resident #7] .[Resident #6] feels safe and does not feel threatened when she sees the resident who was accused of hitting her .she said it was incredibly silly to bring a cop. She agreed to talk to the Police officer .as long as he had a sense of humor .she said it was not like she was punched or hurt . Review of a Psychiatric NP Note for Resident #7 dated 12/18/2023 revealed .[Resident #7] wandered into another residents room and lightly tapped the other resident [Resident #6] on the arm .she has no recollection .she is pleasantly confused .she is easily redirected .ordered a urinalysis, CBC [complete blood count], CMP [comprehensive metabolic panel] to rule out any type of metabolic disturbances that could cause these behaviors . During an interview on 7/24/2024 at 7:12 AM, the SSD stated Resident #6 and Resident #7 had no prior resident to resident altercations denied any lasting effects with either resident. Continued interview revealed the residents had no further altercations with Resident #7. Resident #7 had a planned discharge from the facility to home on 1/5/2024. During an interview on 7/24/2024 at 9:22 AM, Resident #6 stated everyone is good to her and when questioned about the past incident. The resident stated, .that was nothing but a light hit and overreaction . Continued interview revealed the resident was immediately removed from her room with no further incidents. During an interview on 7/24/2024 at 2:02 PM, the Administrator confirmed .if the facility investigation said it [physical contact] happened between the residents, when Resident #3 struck [Resident #2, when Resident #5 struck Resident #4, and when Resident #7 struck Resident #6] then it is true .

Based on facility policy review, electronic communication review, observation, and interview the facility failed to maintain an effective pest control program potentially affecting 144 residents. Deficiencies were cited resulting in an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Interim Administrator and Regional [NAME] President/Administrator (ADM #1) were notified of the Immediate Jeopardy for F812 and F925 on 4/4/2023 at 6:36 PM in the Administrator's office. The Regional [NAME] President/Administrator (ADM #1) was notified of the Immediate Jeopardy for F835 on 4/11/2023 at 10:55 AM in the Administrator's office. The Interim Administrator and Regional [NAME] President/Administrator (ADM #1) were notified of the Immediate Jeopardy for F837 on 4/12/2023 at 11:57 AM in the Administrator's office. The facility was cited Immediate Jeopardy at F812 (L), F835 (L), F837 (L), and F925 (L). The facility was cited F656 (G), F-684 (G), and F710 (G). The Immediate Jeopardy began on 4/3/2023 and was removed on 4/13/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 4/12/2023 at 5:37 PM, and the corrective actions were validated on-site by the surveyors on 4/13/2023. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's policy titled, Pest Control, revised 5/2008, showed .Our facility shall maintain an effective pest control program .This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .Pest control services are provided . Review of an email dated 11/4/2022 at 11:59 AM, titled request [previous pest control company name] payment from the facility Business Office Manager (BOM #1) revealed, .[name of previous pest control company] pest control called regarding balance of [$]3600.00 .They will not be back out to services [service] us without a payment first .Can we please get them paid . Review of an email dated 11/21/2022 at 11:16 AM, titled RE: request [previous pest control company name] payment from BOM #1 revealed, [name of previous pest control company] .called regarding payment again. They have stopped services and will be sending us to collections by the end of the month if they do not receive payment. They are looking for payment from July through October [2022] .Can we get them a payment of $3600.00 . Review of an email dated 3/31/2023 at 1:58 PM, titled [previous pest control company name] payment request from Business Office Manager (BOM #1) revealed, .Can we get payment as soon as possible? We owe them $1125.00. We really need the pest control service started back up before our annual survey . During an observation, interview and tour of the kitchen with the Dietary Manager (DM #1) on 4/3/2023 at 9:27 AM, the following was observed: 1. DM #1 confirmed florescent light fixtures showed multiple insects. 2. DM #1 confirmed a roach crawled up the wall behind the ice cream storage cooler. During an observation and interview on 4/3/2023 at 9:27 AM, DM#1 used a paper towel with a bare hand to kill a roach crawling on the wall behind the milk cooler. During an observation and interview in the kitchen, on 4/4/2023 at 9:30 AM, DM #1 and Registered Dietitian (RD) revealed the following: 1. RD #1 confirmed live roaches on the clean side of the dish table. 2. DM #1 confirmed live roaches inside one sleeve of the plate warmer 2 empty sleeves with thick dark buildup in the bottom, two sleeves full of plates ready to be used. During an observation on 4/4/2023 at 1:57 PM, on the 100 hallway revealed a live cockroach crawling on the forehead of Surveyor #1. Surveyor #3 removed and killed the cockroach. During an interview on 4/4/2023 at 3:10 PM, Pest Control Technician (PCT) #1 revealed .Previous vendor had rodent control program PCT #1 further revealed he found some roach communes in the kitchen in .cracks where the caulking is missing . The roach locations were in the dish room, the wall behind the freezer and the center serving line, where there is a curling cord and some roaches were trying to run in that. During an observation and interview in the kitchen, on 4/5/2023 at 8:28 AM, RD #1 confirmed the presence of live roaches in the plate warmer on clean plates (picture taken). During an observation and tour of the kitchen on 4/5/2023 at 8:43 AM, a roach was observed crawling up the wall, in the kitchen, near an ice scoop. The ice scoop was uncovered, positioned in an open holder, attached to the wall. During an observation and tour of the kitchen on 4/5/2023 at 8:45 AM, multiple live roaches were observed in the kitchen, behind the ice machine, milk cooler, reach in refrigerator, under the drink station table, and under the serving line. During an interview in the kitchen on 4/5/2023 at 8:50 AM, DM #1 revealed that he was not aware of the last time pest control came to the facility. During an interview in the dining area outside the kitchen on 4/5/2023 at 9:25 AM, Regional [NAME] President/Administrator of Record (ADM #1) revealed .usually the Maintenance Director or Dietary Manager would make us aware if they've not had these things [pest control services] . ADM #1 confirmed that the Corporate Office was responsible for bills to be paid. Bills were .recorded here [at the facility] and sent to the Corporate Office for payment there .Checks are cut centrally . During an interview on 4/5/2023 at 8:58 AM, the Maintenance Director (MA #1) stated, .We've always had an issue .[regarding pests] . MA #1 stated regarding the roaches in the kitchen, .It's .ongoing .I have seen them .I have seen them since November [2022] .It needs to be taken care of immediately . MA #1 confirmed the pest control had not been completed because of .lack of payment . by the facility. MA #1 stated .We've had a few Administrators .[Previous Administrator Name (ADM #2)] . had been advised of the pest control problem. MA #1 stated the interim administrator had been made aware of the pest control problem. MA #1 revealed he had seen roaches .in the past .randomly throughout the building . During an interview on 4/6/2023 at 8:36 AM, Licensed Practical Nurse (LPN) #6 revealed she had .seen roaches in resident's rooms and on the hallway .I've seen them [roaches] the whole two years . on the 100, 200, and 300 hallways. LPN #6 revealed that pest sightings had been reported through a maintenance book. During an interview and document review on 4/6/2023 at 8:43 AM, the Assistant Director of Nursing (ADON #1) provided copies of the maintenance book which revealed multiple reports of pest sightings in the facility since 2022. During an interview on 4/6/2023 at 9:10 AM, Physical Therapist (PT #1) revealed he had .seen a couple of roaches .those little bitty mice .in lounge . PT #1 revealed that the pests were reported to maintenance and .I told my boss . During an interview on 4/6/2023 at 1:30 PM, with Resident #26 and Resident #28's sitters revealed there was a roach in the floor of Resident #28's room, adjacent to the sink area, .about 2 weeks ago . During the interview, Resident #26 revealed there was a .rodent [mouse] . in her room several months ago. During an observation and tour of the kitchen on 4/10/2023 at 3:31 PM, showed live roaches behind the ice machine on the wall, the floor, front of the oven, and on the door frame. During an interview on 4/12/2023 at 9:12 AM, MA #1 revealed he observed the pest control logs there was presence of mice in the facility and the logs were reviewed in the daily morning meeting. MA #1 placed sticky pads throughout the inside and outside of the facility and revealed that the sticky pads had been checked every couple of days in which varied amounts of mice have been observed. During an observation in the Conference Room, on 4/12/2023 at 3:23 PM, Surveyor #2 found a roach crawling on her chest. During an interview on 4/13/2023 at 10:05 AM, Registered Nurse #2 confirmed there was not an effective pest control program at the facility. On 4/13/2023, Surveyors reviewed the education and sign in sheets which validated the corrective action plans onsite which was provided by the Regional [NAME] President/Administrator (ADM #1). Surveyors verified onsite the kitchen was closed for meal service from 4/3/2023-4/13/2023. Surveyors verified resident meals were obtained from an outside source from 4/3/2023-4/13/2023. Surveyors verified by review of cleaning logs that meal preparation and meal serving areas were being conducted three times daily in a sanitary manner. Surveyors observed dishes, utensils, pots, pans, meal prep items, surfaces, and equipment to ensure these were cleaned and sanitized three times daily after each meal. Surveyors verified the dishware was cleaned, sanitized, dried, and stored properly in airtight and waterproof containers. Surveyors interviewed dietary staff & cleaning logs to verify the kitchen was cleaned and sanitized at the end of each day. Surveyors interviewed the pest control technician and observed the kitchen to verify the treatment strategies were effective and the presence of dead and live pest were improving. Interview with the pest control technician, Regional [NAME] President/Administrator (ADM #1), Interim Administrator, and Registered Dietician showed they are consulting with the pest control service provider for treatment strategies. Surveyors verified on 4/13/2023 the kitchen was cleaned by the dietary manager, dietary staff, and other members of the facility's team. Surveyors observed all unsealed boxes of meal preparation items had been discarded. Observations showed a clean oven, stove, and door frame to the washroom. Noncompliance at F-925 continues at a scope and severity of F for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on job description review, facility documentation, observations, and interviews the facility failed to produce evidence of an effective governing body (GB), failed to manage its financial resources to ensure an effective pest control program was maintained for 144 residents in the facility. Deficiencies were cited resulting in an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Interim Administrator and Regional [NAME] President/Administrator (ADM #1) were notified of the Immediate Jeopardy for F812 and F925 on 4/4/2023 at 6:36 PM in the Administrator's office. The Regional [NAME] President/Administrator (ADM #1) was notified of the Immediate Jeopardy for F835 on 4/11/2023 at 10:55 AM in the Administrator's office. The Interim Administrator and Regional [NAME] President/Administrator (ADM #1) were notified of the Immediate Jeopardy for F837 on 4/12/2023 at 11:57 AM in the Administrator's office. The facility was cited Immediate Jeopardy at F812 (L), F835 (L), F837 (L), and F925 (L). The facility was cited F656 (G), F-684 (G), and F710 (G) . The Immediate Jeopardy began on 4/3/2023 and was removed on 4/13/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 4/12/2023 at 5:37 PM, and the corrective actions were validated on-site by the surveyors on 4/13/2023. The facility is required to submit a Plan of Correction. Findings include: Review of the facility's documentation, untitled and undated, of the Regional [NAME] President job responsibilities showed, .Regional Vice-President of Operations .work has purpose; the capacity to strengthen the financial stability .improve the quality of life of .patients .will act in the role of a trusted advisor .to identify improvement opportunities, share pertinent data and information, and be responsive to .needs .Lead Board Chair prep calls, content creation, Executive Director calls, and participate in Board Meetings .Follow up on .issues .The Regional [NAME] President is responsible for overall programs .in accordance with the policies, procedures and in compliance with state, local and federal guidelines. Direct day-to-day management oversight .which ensures the health, safety, and satisfaction of all residents, budgetary control .responsibilities include .Fiscal Management, Quality Assurance .Regulatory Compliance .Property and Plant Maintenance and Improvements .Conduct site visits on a regular and routine basis to assist Executive Directors and Department Supervisors with operating issues and to monitor the quality of all programs and departmental operations .Creating and adhering to the budget .Ensuring the quality of care and service delivered is of the highest level . Review of an email on 11/4/2022 at 11:59 AM, titled request [previous pest control company name] payment from the facility Business Office Manager (BOM #1) to Regional [NAME] President of Operations/Administrator (ADM) #1 revealed .[name of previous pest control company] pest control called regarding balance of [$]3600.00 .They will not be back out to services [service] us without a payment first .Can we please get them paid . Review of an email on 11/21/2022 at 11:16 AM, titled RE: request [previous pest control company name] payment from BOM # to Regional [NAME] President of Operations/Administrator (ADM) #1 revealed [name of previous pest control company] .called regarding payment again. They have stopped services and will be sending us to collections by the end of the month if they do not receive payment. They are looking for payment from July through October [2022] .Can we get them a payment of $3600.00 . Review of the Medical Director Agreement signed by Medical Director [MD] #1 showed . Physician [reference to Medical Director/Physician] shall guide, approve, and help oversee the development, implementation, and monitoring/evaluation of Facility's resident care policies and procedures in the following areas: .Admission policies and care practices that address the types of residents that may be admitted and retained based upon the ability of the Facility to provide the services and care to meet their needs .Mechanisms for communicating and resolving issues related to medical care . Physician shall be responsible for coordination of medical care in the Facility. Physician shall help the Facility obtain and maintain timely and appropriate medical care that supports the healthcare needs of the residents, is consistent with current standards of practice, and helps the Facility meet its regulatory requirements . Review of the Medical Director Agreement signed by MD #2 on 11/23/2022, showed, .Scope of Services: Medical Director shall provide overall medical leadership for .operations including the nursing facility .Medical Director shall provide medical direction and guidance .including participation in the .QI (quality improvement) meetings .This agreement shall be for a term of one (1) year from the effective date above the signature line . Further review revealed there was no mention of Medical Director #2's responsibilities limited to the skilled residents. Review of the Minutes of Board of Directors Meeting (Governing Body), dated 12/7/2022 revealed the meeting was held via video teleconference and the topics were fiscal in nature. The minutes did not reflect clinical or any other concerns other than revenue for the facility. Review of an email on 3/31/2023 at 1:58 PM, titled [previous pest control company name] payment request from BOM #1 to Regional [NAME] President of Operations/Administrator (ADM) #1 revealed .Can we get payment as soon as possible? We owe them $1125.00. We really need the pest control service started back up before our annual survey . During an interview on 4/11/2023 at 2:31 PM, MD #1 stated he had not been made aware of the members of the GB. During an interview on 4/12/2023 at 3:13 PM, Registered Nurse (RN) #2 stated the governing body consist of the Administrator, Regional [NAME] President and Senior Director of Clinical Operations. During an interview on 4/12/2023 at 3:33 PM, the Regional [NAME] President of Operations/ADM #1 confirmed she was a member of the GB and reported to the Chief Executive Officer (CEO) but was unable to readily identify all members of the governing body. She stated the governing body meets monthly to discuss Quality Indicators, staffing, financial operations, HR [Human Resources] updates, and business office updates. Regional [NAME] President of Operations/ADM #1 stated past due pest control bills or concerns with the facility acquiring two medical directors was not discussed in morning standup, QAPI or Governing Body meetings. Regional [NAME] President of Operations/ADM #1 was not sure if Governing Body was aware of past due pest control bills (this information is conflicting due to emails sent to Regional [NAME] President of Operations/ADM #1). Regional [NAME] President of Operations/ADM #1 stated the Chief Financial Officer, or designee is responsible for invoice and bill payment approval. She stated the GB had only discussed accounts receivable and further confirmed no other issues or concerns of the facility had been identified or discussed during their monthly meetings. 4/13/2023, Surveyors reviewed the education and sign in sheets which validated the corrective action plans onsite which was provided by the Regional [NAME] President/Administrator (ADM #1). Surveyors verified onsite the kitchen was closed for meal service from 4/3/2023-4/13/2023. Surveyors verified a new contract for pest control had been initiated on 4/5/2023. Interview with the he pest control technician showed pest control was provided on 4/4/2023, 4/5/2023, 4/6/2023 and 4/10/2023. Further interview with the pest control technician showed pest control services will be continued through the month of April. Interviews with licensed nurses showed 100% of staff had been educated on food borne illnesses and had been completed by 4/12/2023. The surveyors verified payment for pest control service had been issued to the pest control service one month in advance for the month of April and May to be sure no disruption of service. Surveyors verified in-service and education had been conducted by the Corporate Controller to the Interim Administrator, Regional [NAME] President/Administrator (ADM #1), and Business Office Manager (BOM). Interview with the Interim Administrator, Regional [NAME] President/Administrator (ADM #1), and BOM showed they were aware of the accounts payable process and steps to ensure payments to pest control services. Surveyors verified audits had been conducted by the administrator to determine the quality assurance efforts were in place. Noncompliance at F-837 continues at a scope and severity of F for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on review of the facility policy review, Administrator's job description, review of the facility's Medical Director Agreements, facility documentation review, and interview the facility's Administration failed to manage its resources and operating budget to maintain an effective pest control program after an invoice was not paid to the pest control company which resulted in an interruption in services from 11/30/2022 - 4/4/2023 and an outbreak of pest in the facility's kitchen. The facility's failure did not maintain the highest practicable physical, mental, and psychosocial wellbeing of the 144 residents residing in the facility. The Regional [NAME] President of Operations failed to address facility concerns. Deficiencies were cited resulting in an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Interim Administrator and Regional [NAME] President/Administrator (ADM #1) were notified of the Immediate Jeopardy for F812 and F925 on 4/4/2023 at 6:36 PM in the Administrator's office. The Regional [NAME] President/Administrator (ADM #1) was notified of the Immediate Jeopardy for F835 on 4/11/2023 at 10:55 AM in the Administrator's office. The Interim Administrator and Regional [NAME] President/Administrator (ADM #1) were notified of the Immediate Jeopardy for F837 on 4/12/2023 at 11:57 AM in the Administrator's office. The facility was cited Immediate Jeopardy at F812 (L), F835 (L), F837 (L), and F925 (L). The facility was cited F656 (G), F-684 (G), and F710 (G). The Immediate Jeopardy began on 4/3/2023 and was removed on 4/13/2023. An acceptable removal plan, which removed the immediacy of the jeopardy, was received 4/12/2023 at 5:37 PM, and the corrective actions were validated on-site by the surveyors on 4/13/2023. The facility is required to submit a Plan of Correction. The findings include: Review of the facility's policy titled, Pest Control, revised 5/2008, showed .Our facility shall maintain an effective pest control program .This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .Pest control services are provided . Review of the facility's Administrator job description, undated, and unsigned, showed .The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times .Safety and Sanitation .Ensure that the building and grounds are maintained in good repair .Ensure that the facility is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained to perform such duties/services .assure that the facility is maintained in a clean, safe and sanitary manner .Prepare an annual operating budget for approval by the governing board and allocate the resources to carry out programs and activities of the facility . Review of the facility's documentation, untitled and undated, of the Regional [NAME] President job responsibilities showed, .Regional Vice-President .work has purpose .improve the quality of life of .patients .will act in the role of a trusted advisor .to identify improvement opportunities .The Regional [NAME] President is responsible for overall programs .Direct day-to-day management oversight .which ensures the health, safety, and satisfaction of all residents .Ensuring the quality of care and service delivered is of the highest level . Review of an email on 11/4/2022 at 11:59 AM, titled request [previous pest control company name] payment from the facility Business Office Manager (BOM #1) to Regional [NAME] President of Operations/Administrator (ADM) #1 revealed .[name of previous pest control company] pest control called regarding balance of [$]3600.00 .They will not be back out to services [service] us without a payment first .Can we please get them paid . Review of an email on 11/21/2022 at 11:16 AM, titled RE: request [previous pest control company name] payment from BOM # to Regional [NAME] President of Operations/Administrator (ADM) #1 revealed [name of previous pest control company] .called regarding payment again. They have stopped services and will be sending us to collections by the end of the month if they do not receive payment. They are looking for payment from July through October [2022] .Can we get them a payment of $3600.00 . Review of an email on 3/31/2023 at 1:58 PM, titled [previous pest control company name] payment request from Business Office Manager (BOM #1) to Regional [NAME] President of Operations/Administrator (ADM) #1 revealed .Can we get payment as soon as possible? We owe them $1125.00. We really need the pest control service started back up before our annual survey . During an observation and interview on 4/3/2023 at 9:27 AM, Dietary Manager (DM) #1 used a paper towel with an ungloved hand to kill roach crawling on the wall in the kitchen and did not sanitize hands. During an observation and interview in the kitchen on 4/4/2023 at 9:30 AM, DM #1 and Registered Dietitian (RD) #1 confirmed live roaches were observed on the clean side of the dish table and in the dish room. During an observation and interview in the kitchen on 4/4/2023 at 9:30 AM, DM #1 confirmed live roaches were noted inside one sleeve of the plate warmer used to serve hot food to residents in the facility. During an interview on 4/4/2023 at 3:10 PM, Pest Control Technician (PCT)#1 revealed .Previous vendor had rodent control program PCT #1 confirmed roach communes in the .cracks where the caulking is missing . were noted in the kitchen and roaches were observed in the dish room, the wall behind the freezer and the center serving line, where there is a curling cord, and .some roaches were trying to run in that . During an observation and interview, in the kitchen on 4/5/2023 at 8:28 AM, RD #1 confirmed the presence of live roaches in the plate warmer. During an observation and tour of the kitchen on 4/5/2023 at 8:45 AM, multiple live roaches were observed in the kitchen, behind the ice machine, milk cooler, reach-in refrigerator, under the drink station table, and under the serving line. During an interview in the kitchen on 4/5/2023 at 8:50 AM, DM #1 revealed he was not aware when pest control serviced the facility. During an interview on 4/5/2023 at 8:58 AM, the Maintenance Director (MA #1) stated, .we've .had an issue .[regarding pests] .it's .ongoing .I have seen them .since November [2022] .It needs to be taken care of immediately . MA #1 confirmed the pest control had not been completed because of .lack of payment . by the facility. During an interview on 4/5/2023 at 9:25 AM, the Regional [NAME] President of Operations/ADM #1 confirmed the corporate office was responsible for bills to be paid. Bills were .recorded here [at the facility] and sent to the corporate office for payment .The Regional [NAME] President of Operations/ADM#1 had fiscal responsibility . During an interview and document review on 4/6/2023 at 8:43 AM, the Assistant Director of Nursing (ADON #1) provided copies of the maintenance book which revealed multiple reports of pest sightings in the facility since 2022. During an interview on 4/11/2023 at 2:31 PM, Medical Director [MD#1], confirmed he was not made aware of pest control concerns in the facility by the Administrator. During an interview on 4/12/2023 at 3:33 PM, the Regional [NAME] President of Operations/ADM#1 confirmed she had not consulted with another qualified clinician to address the administration concerns. On 4/13/2023, Surveyors reviewed the education and sign in sheets which validated the corrective action plans onsite which was provided by the Regional [NAME] President/Administrator (ADM #1). Surveyors verified onsite the kitchen was closed for meal service from 4/3/2023 - 4/13/2023. Surveyors verified a new contract for pest control had been initiated on 4/5/2023. Interview with the pest control technician showed pest control was provided on 4/4/2023, 4/5/2023, 4/6/2023 and 4/10/2023. Further interview with the pest control technician showed pest control services will be continued through the month of April. Interviews with licensed nurses showed 100% of staff had been educated on food borne illnesses and had been completed by 4/12/2023. The surveyors verified the Business Office Manager (BOM) provided the correct email address to the pest control services and the pest control provider provided the BOM with the pest control invoice. Surveyors verified in service and education had been conducted by the Corporate Controller to the Interim Administrator, Regional [NAME] President/Administrator (ADM #1) and Business Office Manager (BOM) on 4/11/2023. The Surveyors verified payment for pest control service had been issued to the pest control service one month in advance for the month of April and May to be sure no disruption of service. Interview with the Interim Administrator, Regional [NAME] President/Administrator (ADM #1), and BOM showed they were aware of the accounts payable process and steps to ensure payments to pest control services. Surveyors verified audits had been conducted by the administrator to determine the quality assurance efforts were in place. Noncompliance at F-835 continues at a scope and severity of F for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on review of the Centers for Disease Control (CDC) and Prevention and U.S. Department of Housing and [NAME] Development Healthy Housing Reference Manual, job description review, facility documentation review, facility policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions. The facility failed to maintain effective pest control in the kitchen as evidenced by the presence of live and dead roaches in the kitchen and food preparation areas which had the potential to affect all 144 residents in the facility. Deficiencies were cited resulting in an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Interim Administrator and Regional [NAME] President/Administrator (ADM#1) were notified of the Immediate Jeopardy for F812 and F925 on [DATE] at 6:36 PM in the Administrator's office. The Regional [NAME] President/Administrator (ADM#1) was notified of the Immediate Jeopardy for F835 on [DATE] at 10:55 AM in the Administrator's office. The Interim Administrator and Regional [NAME] President/Administrator (ADM#1) were notified of the Immediate Jeopardy for F837 on [DATE] at 11:57 AM in the Administrator's office. The facility was cited Immediate Jeopardy at F812 (L), F835 (L), F837 (L), and F925 (L). The facility was cited F656 (G), F-684 (G), and F710 (G). The Immediate Jeopardy began [DATE] and was removed [DATE]. An acceptable removal plan, which removed the immediacy of the jeopardy, was received [DATE] at 5:37 PM, and the corrective actions were validated on-site by the surveyors on [DATE]. The facility is required to submit a Plan of Correction. The findings include: Review of documentation titled, Centers for Disease Control and Prevention and U.S. Department of Housing and [NAME] Development. Healthy housing reference manual. Atlanta: US Department of Health and Human Services, dated 2006, showed .The existence of cockroaches, rats, and mice mean that they can also be vectors for significant problems that affect health and well-being. They are capable of transmitting diseases to humans .Disease Vectors and Pests .Integrated pest management (IPM) techniques are necessary to reduce the number of pests that threaten human health and property. This systems approach to the problem relies on more than one technique to reduce or eliminate pests. It can be visualized best as concentric rings of protection that reduce the need for the most risky and dangerous options of control and the potential for pests to evolve and develop. It typically involves using some or all of the following steps .monitoring, identifying, and determining the level of threat from pests .Daytime sightings may indicate potentially heavy infestations .German cockroach (Blattella germanica) . Four management strategies exist for controlling cockroaches. The first is prevention .The second strategy is sanitation. This denies cockroaches food, water, and shelter. These efforts include quickly cleaning food particles from shelving and floors; timely washing of dinnerware; and routine cleaning under refrigerators, stoves, furniture, and similar areas . The third strategy is trapping . The fourth strategy is chemical control .Rodent-associated diseases affecting humans include plague, murine typhus, leptospirosis, rickettsialpox, and rat-bite fever. The three primary rodents of concern to the homeowner are the Norway rat (Rattus norvegicus), roof rat (Rattus rattus), and the house mouse (Mus musculus). The term commensal is applied to these rodents, meaning they live at people's expense .The first of four basic strategies for controlling rodents is to eliminate food sources. To accomplish this, it is imperative .to do a goodjob of solid waste management. This requires proper storing, collecting, and disposing of refuse . Review of the facility's policy titled, Food-Related Garbage and Rubbish Disposal, revised ,d+[DATE], showed .Food-related garbage and rubbish shall be disposed of in accordance with current state laws regulating such matters .All garbage and rubbish containing food wastes shall be kept in containers .All garbage and rubbish containers shall be provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use .Garbage and rubbish containing food wastes will be stored in a manner that is inaccessible to vermin . Review of the facility's policy titled, Pest Control, revised ,d+[DATE], showed .Our facility shall maintain an effective pest control program .This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .Pest control services are provided . Review of the facility's policy, Sanitization, revised ,d+[DATE], showed .The food service area shall be maintained in a clean and sanitary manner .All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects .All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that my affect their use of proper cleaning .All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions .For fixed equipment or utensils that do not fit in the dishwashing machine, washing shall consist of the following steps .Equipment will be disassembled as necessary to allow access of the detergent/solution to all parts .Removable components will be scraped to remove food particle accumulation and washed according to manual or dishwashing procedures .Plasticware .that cannot be sanitized or are hazardous because of chips, cracks .shall be discarded. Damaged or broken equipment that cannot be repaired shall be discarded .Kitchen wastes that are not disposed of by mechanical means shall be kept in clean, leakproof, nonabsorbent, tightly closed containers .Kitchen .surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime .The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen .Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task . Review of the facility's policy titled, Food Receiving and Storage, revised [DATE], showed .Foods shall be received and stored in a manner that complies with safe food handling practices .Food services, or other designated staff, will maintain clean food storage areas at all times .Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean .Food in designated storage areas shall be kept of the floor . Review of the facility's documentation titled, Agreement to Provide Dietitian Consulting Services Between [name of provider company] and [name of the facility], dated [DATE], showed .Dietitian shall review Facility's food safety and sanitation procedures to assure quality food service .Dietitian shall provide written reports of work completed to the Facility Administrator as requested . Review of a Director of Food Services job description, undated, and unsigned by the Dietary Manager, showed .The primary purpose of your job description is to assist .directing the overall operation of the Food Services Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility .to assure that quality nutritional services are provided on a daily basis and that the Food Services Department is maintained in a clean, safe, and sanitary manner .Inspect food storage rooms .Review and assist in developing a plan of correction for food services .deficiencies noted during survey inspections .Ensure that food services service work areas are maintained in a clean and sanitary manner. Ensure that food storage rooms, preparation areas .are maintained in a clean, safe, and sanitary manner .Make weekly inspections of all food services functions to assure that quality control measures are continually maintained .Education .Be a graduate of an accredited course in dietetic training approved by the American Dietetic Association .Must have training in cost control, food management, diet therapy .Specific Requirements .Must be registered as a Food Service Director in this state .Must be knowledgeable of food services practices and procedures as well as the laws, regulations and guidelines governing food services functions in nursing care facilities .Must maintain the care and use of supplies, equipment .and maintain the appearance of food services service areas; must perform regular inspections of food services service areas for sanitation order, safety and proper performance of assigned duties . Review of an Administrator job description, undated, and unsigned, showed .The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations .to assure that the highest degree of quality care can be provided to our residents at all times .Safety and Sanitation .Ensure that the facility is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained to perform such duties/services .assure that the facility is maintained in a clean, safe and sanitary manner . Review of the facility's documentation, untitled and undated, of the Regional [NAME] President job responsibilities showed, .Regional Vice-President .work has purpose .improve the quality of life of .patients .will act in the role of a trusted advisor .to identify improvement opportunities .The Regional [NAME] President is responsible for overall programs .Direct day-to-day management oversight .which ensures the health, safety, and satisfaction of all residents .Ensuring the quality of care and service delivered is of the highest level . During an observation and tour of the kitchen with the Dietary Manager (DM #1) on [DATE] at 9:27 AM, the following was observed: 1. No trash can at the handwash sink. 2. The cover on eye wash sprayer was broken off and missing. 3. In the walk-in refrigerator, there were orange juices, apple juices, and prune juices which the DM #1 stated was left over from the prior day ([DATE]) but were incorrectly dated ([DATE]). This incorrect dating was confirmed by DM #1. 4. Macaroni and cheese stored unsealed with a torn cover in walk-in refrigerator. 5. Cheese slices stored uncovered in the walk-in refrigerator and confirmed by DM #1. DM #1 identified approximately 1 ,d+[DATE] pounds of uncovered cheese and discarded it. 6. Four (4) cooler bags stored in walk-in refrigerator next to other food items, which was confirmed by DM #1. DM #1 stated the cooler bags had been used by the Activities staff to transport food to the residents, and were stored on the top shelf in the refrigerator next to other food items. 7. The air vent over the food preparation area near wash sink was noted as rusted with peeling paint. DM #1 confirmed that the vent had been in this condition for a couple of months (exact time period unknown). 8. Food residue noted on the clean glassware. 9. A spoon and food debris was noted in the hand wash sink. 10. A dirty used glove was noted lying on the food prep area. 11. The florescent light fixtures were noted to have multiple dead insects. 12. Broken thermometer noted in the ice cream storage cooler. 13. An employee water bottle in the food preparation area. 14. DM #1 confirmed a roach crawled up the wall behind the ice cream storage cooler. 15. In the dry storage area, DM #1 confirmed a coffee cup contained a dried food substance. 16. In the dry storage area, DM#1 confirmed 2 jackets stored near thickened water and plastic cups. 17. DM #1 confirmed 7 of the 9 coolers were stored .dirty . 18. In the dry storage area, there was a serving dish and plastic bowls stored on the floor and the floor was noted with a black substance. DM #1 confirmed the condition of the floor was .unacceptable . 19. In dry storage area, 2 trays of wine glasses, 1 cardboard box of to-go boxes, on top shelf of shelving unit were not stored below the fire line. 20. In dry storage area, large amount of dust was noted on the vent and the sprinkler head. 21. In dry storage area, flour and corn meal bins were unsealed and open to air. 22. A cell phone left on top of the food warmer. 23. A jacket, eyeglasses, hammer, black backpack and a water bottle was observed in the food prep area. 24. 4 trays of Apple cobbler in serving bowls were left on a rack, uncovered and opened to air food prep area. 25. Refrigerator had an undated peanut butter and jelly sandwich. 26. 2 coffee carafes had missing lids open to air. 27. Observation showed a staff member pushed an uncovered bin loaded with multiple plastic bags of trash from the dining room through the kitchen prep area. 28. Trash was uncovered and overflowing onto the ground near a rolling cart at the back door of the kitchen. 29. DM #1 confirmed 3 spatulas with chips/broken pieces were noted in a clean utensil drawer. DM #1 further confirmed the broken pieces of spatula were consistent with mice or rat bites. 30. The oven door and control dials were noted with dark dried food debris and dead roaches behind the control dials. 31. 54 expired milk cartons in milk cooler. (50 whole milk cartons with expiration date of [DATE] and 4 fat free milk cartons with expiration dates of [DATE]). During an observation and interview on [DATE] at 9:27 AM, DM #1 was observed using a paper towel with an ungloved hand to kill roach crawling on the wall behind the milk cooler. Without performing hand hygiene, DM #1 proceeded to remove the thermometer from the reach in cooler and wipe the thermometer on his soiled shirt. DM #1 then replaced thermometer into reach in cooler. DM #1 was informed by the surveyor of the need to sanitize the thermometer after wiping it on his shirt. During an observation and interview in the kitchen on [DATE] at 9:30 AM, DM #1 and Registered Dietitian (RD #1) confirmed the following: 1. Dish room had orange/rusty areas around the ceiling on the trim, dried debris around the floor base. 2. RD #1 confirmed multiple live roaches were observed on the clean side of the dish table and in the dish room. 3. Kitchen table under flat top grill, equipment electric boxes on the back of stove and smoker, faucet handles with thick dark, greasy, and crumbly debris. 4. Behind the double oven on the floor was thick dark debris. 5. Juice machine spouts were noted with dried debris 6. 3 compartment sink #1 had pipes with dust and dried debris. 7. 3 compartment sink #2 drain was full with black flaky debris in water. 8. Dried food debris on the back of the steam table. 9. DM #1 confirmed live roaches were noted inside one sleeve of the plate warmer and contained thick dark buildup in the bottom of the warmer and contained clean plates ready for use. 10. Walk in cooler contained 2 bags of cereal unsealed, unlabeled, open to air, and partially used, ,d+[DATE]-gallon jugs ,d+[DATE] full each of mayonnaise open and undated. 11. Walk in freezer had 1 gallon bag ,d+[DATE] full of frozen diced chicken unlabeled and undated, a 2.5-pound bag of peppers/onions open, unlabeled, and undated. 12. Observation of the chemical room showed paper, debris, and thick dark marks on the floor. During an observation on the 100 hallway on [DATE] at 1:57 PM, a live cockroach was noted crawling on the forehead of Surveyor #1. Surveyor #3 removed the cockroach from the surveyor's forehead, and killed and disposed the cockroach. During an interview on [DATE] at 3:10 PM, Pest Control Technician (PCT)#1 revealed .Previous vendor had rodent control program PCT #1 confirmed roach communes in .cracks where the caulking is missing . were noted in the kitchen and roaches were observed in the dish room, the wall behind the freezer and the center serving line. During a facility kitchen tour on [DATE] at 8:13 AM, DM #1, RD #1, and Regional [NAME] President/Administrator (ADM#1) confirmed the following: 1. No hot water at the hand wash sink. 2. The cover on eye wash sprayer was broken off and missing. 3. Live and dead roaches observed in the kitchen. 4. Debris and dead and live roaches noted in the plate warmer. 5. Debris noted behind the equipment along the walls. 6. Disheveled paper and boxes next to two (2) gallon jugs of bleach stored on the floor. During an observation and interview, in the kitchen on [DATE] at 8:28 AM, RD #1 confirmed the presence of live roaches in the plate warmer (picture taken). During an observation and interview in the kitchen on [DATE] at 8:41 AM, DM #1 confirmed quarter baking pans were observed nested wet. DM #1 stated .yeah, that pan's wet . During an observation and tour of the kitchen on [DATE] at 8:43 AM, a roach was observed crawling up the wall, in the kitchen, near an ice scoop. The ice scoop was uncovered, positioned in an open holder, attached to the wall. During an observation and tour of the kitchen on [DATE] at 8:45 AM, multiple live roaches were observed in the kitchen, behind the ice machine, milk cooler, reach in refrigerator, under the drink station table, and under the serving line. During an interview in the kitchen on [DATE] at 8:50 AM, RD #1 revealed she was not aware until [DATE], of a pest control problem in the facility. During an interview in the kitchen on [DATE] at 8:50 AM, DM #1 revealed that he was not aware of the last time pest control came to service the facility. During an interview on [DATE] at 8:58 AM, the Maintenance Director (MA #1) stated, .We've always had an issue .[regarding pests .It's .ongoing .I have seen them .I have seen them since November [2022] .It needs to be taken care of immediately . MA #1 confirmed that the pest control had not been completed because of .lack of payment . by the facility. MA #1 stated .We've had a few Administrators .[Previous Administrator Name (ADM #2)] . had been advised of the pest control problem. MA #1 stated the interim administrator had been made aware of the pest control problem .in the last week or so . MA #1 revealed he had requested the replacement of the kitchen vents on [DATE] and the Corporate office had not sent the replacement vents until after .you guys [surveyors] walk in the door . MA #1 revealed he checked the water temperatures .Yes, we check them, supposed to do it weekly .but it's about every two weeks . MA #1 further stated the hot water was off at the hand washing sink in the kitchen because it was 160 degrees and that the mixing valves probably needed to be maintenanced. MA #1 revealed he had seen roaches .in the past .randomly throughout the building . MA #1 revealed .They're [kitchen staff] supposed to dump that [garbage] daily .I guess [they wait to dump it] when there is a male .some of that stuff . heavy . MA #1 revealed the kitchen staff were responsible to clean trash area. During an interview in the dining area outside the kitchen on [DATE] at 9:25 AM, Regional [NAME] President/Administrator (ADM#1) stated .usually the Maintenance Director or Dietary Manager would make us aware if they've not had these things [pest control services] . Regional [NAME] President/ADM #1 confirmed she had been the Administrator of Record for the facility since [DATE]. ADM #1 confirmed a pest control issue had not been identified by the facility. ADM #1 confirmed that the Corporate Office was responsible for bills to be paid. Bills were .recorded here [at the facility] and sent to the Corporate Office for payment there .Checks are cut centrally . Interview revealed the Regional VP had fiscal responsibility. During an interview on [DATE] at 8:36 AM, Licensed Practical Nurse (LPN) #6 revealed she had .seen roaches in resident's rooms and on the hallway .I've seen them [roaches] the whole two years . on the 100, 200, and 300 hallways. LPN #6 revealed that pest sightings had been reported through a maintenance book. During an interview and document review on [DATE] at 8:43 AM, the Assistant Director of Nursing (ADON #1) provided copies of the maintenance book which revealed multiple reports of pest sightings in the facility since 2022. During an interview on [DATE] at 9:10 AM, Physical Therapist (PT #1) revealed he had .seen a couple of roaches .those little bitty mice .in lounge . PT #1 revealed the pests were reported to maintenance and .I told my boss . During an interview on [DATE] at 1:30 PM, with Resident #26 and Resident #28's sitters revealed there was a roach on the floor of Resident #28's room, adjacent to the sink area .about 2 weeks ago . During the interview Resident #26 revealed there was a .rodent .[mouse] . in her room several months ago. During an observation and tour of the kitchen on [DATE] at 3:31 PM, showed the following: 1. A dark dried substance on the clean dish rack 2. A 5 gallon bucket ,d+[DATE] full of powdered thickener, stored in the dry storage area, open to air 3. Live roaches behind the ice machine on the wall and on the floor 4. A live roach on the floor in front of the oven and climbing up the door frame to the dish room. 5. A sleeve of disposable 8 ounce cups open to air on the prep table. 6. The steamer contained a dark murky water with brown and white foam floating on top of the water and the water had a foul odor. During an interview on [DATE] at 3:51 PM, DM #1 confirmed there was a dark, dried substance on the clean dish rack, the bucket of thickener was left open to air, live roaches in the kitchen, the sleeve of the disposable cups had been left open to air, and the steamer contained dirty water. DM #1 stated the steamer had only been used at breakfast to maintain pureed food temperature until the food was served and the steamer had not been cleaned. DM #1 confirmed the kitchen had been closed for service from [DATE] (the steamer was not to be used on [DATE]). During an interview on [DATE] at 9:12 AM, MA #1 revealed he observed on the pest control logs the presence of mice in the facility. MA #1 stated he placed sticky pads throughout the inside and outside of the facility and revealed the sticky pads had been checked every couple of days in with varied amounts of mice observed on pads. During an observation in the Conference Room, on [DATE] at 3:23 PM, Surveyor #2 found a live roach had crawled on her chest. On [DATE], Surveyors reviewed the education and sign in sheets which validated the corrective action plans onsite which was provided by the Regional [NAME] President/ADM #1 and Interim Administrator. Surveyors verified onsite the kitchen was closed for meal service from [DATE] - [DATE]. Surveyors verified resident meals were obtained from an outside source from [DATE] - [DATE]. Surveyors verified by review of cleaning logs that meal preparation and meal serving areas were being conducted three times daily in a sanitary manner. Surveyors observed dishes, utensils, pots, pans, meal prep items, surfaces, and equipment to ensure these were cleaned and sanitized three times daily after each meal. Surveyors verified the dishware was cleaned, sanitized, dried, and stored properly in airtight and waterproof containers. Surveyors interviewed dietary staff & cleaning logs to verify the kitchen was cleaned and sanitized at the end of each day. Surveyors interviewed the pest control technician and observed the kitchen to verify the treatment strategies were effective and the presence of dead and live pest were improving. Interview with the pest control technician, Regional [NAME] President/Administrator (ADM#1), Interim Administrator, and Registered Dietician showed they are consulting with the pest control service provider for treatment strategies. Surveyors verified on [DATE] the kitchen was cleaned by the dietary manager, dietary staff, and other members of the facility's team. Surveyors observed all unsealed boxes of meal preparation items had been discarded. Observations showed a clean oven, stove, and door frame to the washroom. Noncompliance at F-812 continues at a scope and severity of F for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on the facility policy review, medical record review and interview, the facility failed to ensure 1 resident's (Resident #583) medical care was supervised by a physician of 36 residents reviewed for physician services. The facility's failure to monitor Resident #583's medical status resulted in an elevated International Normalized Ratio (INR a test which measures how long it takes blood to clot) critical lab value which required the resident to be hospitalized , diagnosed with a GI (Gastrointestinal) bleed upon arrival to the hospital and required a blood transfusion, which resulted in Harm for Resident #583. The findings include: Review of the facility's policy, Anticoagulation-Clinical Protocol, dated 9/2012, revealed .Assessment and Recognition .The physician will identify individuals who are currently anticoagulated .Assess for evidence of effects related to the subtherapeutic or greater than therapeutic drug level related to that particular drug .In addition, the nurses shall assess and document/report the following .Current anticoagulant therapy .Recent labs, including therapeutic dose monitoring .Treatment/Management The physician will prescribe anticoagulation therapy .appropriately . Review of the facility's policy, Physician Services, dated 4/2013, revealed .Policy Interpretation and Implementation .The resident's attending physician participates in the resident's assessment and care planning, monitoring changes in resident's medical status, providing consultation or treatment when called by the facility, and overseeing a relevant plan of care for the resident .The physician will perform pertinent, timely medical assessments: prescribe an appropriate medical regimen: provide adequate, timely information about the resident's condition and medical needs . Resident #583 was admitted to the facility on [DATE] with diagnoses including Acute Embolism and Thrombosis of Unspecified Deep Vein of Right Lower Extremity, Stage 3 Chronic Kidney Disease, and Venous Insufficiency. Review of Resident #583's care plan dated 12/29/2022 revealed the resident was care planned for potential for bleeding secondary to anticoagulant therapy related to reoccurring deep vein thrombosis. Interventions in place included administer anticoagulant medication as ordered, monitor labs as ordered, notify physician of abnormal labs and document, monitor daily during care for signs/symptoms of bleeding and to notify the physician of abnormal findings. Review of a physician order dated 12/30/2022, revealed an order to check the resident's Prothrombin time (PT a test which measures how quickly the blood clots) and INR every Monday. Review of Resident #583's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had severe cognitive impairment. Review revealed the resident had received an anticoagulant during her last 7 days or since admission/entry or reentry into the facility. Review of a lab dated 1/9/2023 revealed Resident #583 had a PT of 30.5 (normal range 9.6-12.2)), and an INR of 2.81 (normal range 0.80-3.50). Review of a physician order dated 1/10/2023 revealed, .D/C [discontinue] warfarin 6 mg po daily start warfarin 5 mg on M [Monday] W [Wednesday] F [Friday], S [Saturday] S [Sunday] start warfarin 6 mg on T [Tuesday], T [Thursday] check PT INR Monday [1/16/2023] . Review of a lab dated 1/16/2023 revealed the facility had performed a PT/INR lab draw on Resident #583 on 1/16/2023. Review showed there was a coagulation defect (clotted blood specimen). Review revealed the PT/INR lab was not redrawn. Review of physician orders dated 1/16/2023-1/23/2023, showed the resident's PT/INR lab draw was not re-ordered by the physician. Review of orders revealed no documentation related to the missing results from the resident's PT/INR lab draw from 1/16/2023 or concerns related to the resident's PT/INR Review of lab results revealed a repeat PT/INR lab draw was not performed from 1/16/2023-1/23/2023. Review of a physician note dated 1/20/2023 at 9:36 PM, revealed Resident #583's Physician (Medical Director #2) had assessed the resident on 1/20/2023. Review revealed, .Chief complaint .Reason for visit .Acute visit to SNF .Patient seen due to staff stopping me in hallway due to her SOB . She [Resident #583] has been therapy[to therapy] and became dyspneic(short of breath) .upon checking her VS [vital signs] her T[temperature] was high at 100.1 .Due to her urinary frequency a ua [urine analysis (UA) test used to test a person's urine] was ordered .Her u/a from 1/20[1/20/2023] revealed .none[no] bacteria were seen . Review revealed Medical Director #2 had reviewed Resident #583's UA results on 1/20/2023. Review of MD #2's note revealed no documentation related to the missing results from the resident's PT/INR lab draw from 1/16/2023 or concerns related to the resident's PT/INR. Review of the MAR dated 1/2023 revealed the resident's scheduled doses of Warfarin had not been adjusted from 1/11/2023-1/22/2023, after PT/INR results were not obtained or reviewed by the physician. Review of a physician order dated 1/23/2023, revealed .PT/INR in AM .Fax me INR from 1/16/23 [2023] [13 days after the 1/9/2023 PT/INR results] . Review of a nursing note dated 1/24/2023 at 3:18 PM revealed, .Resident was showing s/s [signs/symptoms] of SOB [shortness of breath][ a symptom of a low hgb]during therapy .Upon examination resident O2 [oxygen saturation level] was 71% .started resident on oxygen 2 L[liters] .O2[oxygen saturation level] came up to 97% .[name of the resident's physician] stated she was stopping by and will exam resident herself upon arrival .When [name of physician] came she stated that she believed the resident was fine that she wasn't worried that anything was wrong with resident [Resident #583] .X-ray came back and showed resident had R [right] side PNA [Pneumonia], and labs came back and showed critical lab values .Son was notified and stated he wanted his mother sent out due to critical values .Awaiting ambulance services now . Review of a lab dated 1/24/2023 revealed the resident had a PT >90 (normal range 9.6-12.2) and an INR of >9 (normal range 0.80-3.50). Review of a physician order dated 1/24/2023 revealed, .Vitamin K [medication used to treat bleeding] 1 po [by mouth] now (5mg) .PT/INR in AM [1/25/2023] .D/C Coumadin .Indication-DX [diagnose] .critical INR/Blood work . Review of the physician order dated 1/24/2023 revealed, .Send to [name of hospital emergency room ] per son request . Review of a nursing note dated 1/24/2023 at 3:52 PM, revealed the resident was sent to the emergency room at 3:45 PM, by ambulance per the resident's son request. Review of Resident #583's Hospital History and Physical, dated 1/24/2023, revealed .Nursing home sent the patient for shortness of breath and low H &H [hemoglobin and hematocrit/ red blood cell measurements lab values] .I [hospital physician] did call and speak with her son who reported that she had not felt well for 3 or 4 days .She is also profoundly supratherapeutic [an amount of drug medication that was greater than the therapeutic concentration] on her INR .She has received Kcentra [a medication used for urgent reversal of adverse effects of Coumadin] .Tells me me that she [Resident #583] just feels rough. Review revealed .Patient [Resident #583] is quite ill in conjunction with her frailty her prognosis is poor . GI bleed .I suspect this is related to her having a supratherapeutic INR .Acute blood loss anemia .Patient is in the process of being transfused [blood transfusion] Hemorrhagic [spontaneous or near spontaneous bleeding caused by a defect in clotting mechanisms] disorder secondary to .anticoagulants therapy . Review revealed the resident had Hemorrhagic disorder due to circulating anticoagulants and had heme positive stool [blood in stool] and an INR greater than 12. The resident's Coumadin medication was held in the hospital. The resident had an Acute Blood Loss Anemia with blackish colored stool. The resident was diagnosed with COVID-19 and Acute Respiratory Failure in the hospital. Review of Resident 583's Hospital Discharge report, dated of 1/27/2023, revealed .Discharge diagnoses .Hemorrhagic disorder .Acute blood loss anemia .Acute respiratory Failure .Supratherapeutic INR .GI bleed . Review of a physician note dated 1/27/2023 revealed, .96 y/o [year old] .female readmitting from [name of the hospital] after a 1/24/2023 admission due to hemorrhagic disorder d/t [due to] circulating anticoagulants, Acute blood loss anemia, COVID-19 . During an interview on 4/4/2023 at 9:25 AM, revealed, Licensed Practical Nurse (LPN) #7 stated, .I called [name of the resident's Physician Medical Director #2] on morning [1/24/2023] patient [Resident #583] was not acting right .[name of Medical Director #2] she stated she was fine .When patient went to hospital, she tested positive for COVID and had a GI bleed .I called son [Resident #583's son] and told him she wasn't doing like self [1/24/2023] and told him [Resident #583's son] her critical labs .Patient was tired .She [Resident #583] had declined [in her physical health] . The LPN confirmed the resident's son requested the resident be sent to the hospital due to her critical lab values. During an interview on 4/5/2023 at 2:54 PM, Medical Director #1 confirmed Coumadin/Warfarin was a high-risk medication and residents on the medication could have adverse reactions. Medical Director #1 revealed only a few residents in the facility were on Coumadin/Warfarin due to the risks of adverse reactions and side effects of the medication. Medical Director #1 stated residents in the facility on Coumadin/Warfarin were to have their PT/INR levels reviewed and monitored by the physician weekly. Medical Director #1 confirmed the resident's Physician (Medical Director #2) failed to monitor, check, and review Resident #583's PT/INR for approximately 2 weeks. Medical Director #1 stated the resident had an INR of 9 (on 1/24/2023) which was a critical lab value. Medical Director #1 confirmed Medical Director #2 failed to ensure Resident #583's PT/INR lab was obtained [the week of 1/16/2023] and a PT/INR was not obtained until 1/23/2023 (14 days after the resident's lab was resulted on 1/9/2023). Medical Director #1 confirmed PT/INR labs were to be reviewed weekly by the physician to ensure adjustments were made to the resident's Coumadin/Warfarin drug regimen based on the resident's weekly PT/INR labs results. Medical Director #1 stated, .The patient [Resident #583] could have bleed out . Medical Director #1 confirmed Resident #583 had a high potential for harm when Resident #583's PT/INR lab was not redrawn on 1/16/2023 to ensure the resident was receiving a therapeutic dose of Warfarin/Coumadin. Medical Director #1 stated .You can easily have GI bleed and bleed out [blood loss to such a degree that the person bleeding dies] if medication [Coumadin] given and no lab [performed] to monitor PT/INR every week .High risk of severe outcome .If she fell , she [Resident #583] could bleed out easily . During an interview on 4/6/2023 at 11:02 AM, the Director of Nursing (DON] confirmed Resident #583 continued to received Warfarin/ Coumadin at the same dosage without having a lab with current PT/INR levels from 1/9/2023-1/23/2023. The DON revealed Medical Director #2 (Resident #583's Physician) was notified of the lab not being resulted on 1/16/2023 by the nurse. The DON confirmed Medical Director #2 failed to reorder a PT/INR for Resident #583 the week of 1/16/2023. The DON revealed the resident's nurse called the resident's son and informed him of the critical lab values on 1/24/2023 and the resident's son requested the resident be sent to the hospital for treatment. During an interview on 4/10/2023 at 2:44 PM, the DON confirmed Coumadin/Warfarin was a high-risk medication. The DON stated, .If not monitored [PT/INR labs] blood [a resident's] can get too thin and they can bleed to death or require a blood transfusion . The DON confirmed Resident #583 had a change in her medical status and required hospitalization . During an interview on 4/10/2023 at 3:14 PM, Nurse Practitioner (NP) #1 confirmed Resident #583 continued to receive the same dosage of Coumadin without a current PT/INR level. The NP #1 confirmed PT/INR were to be monitored and checked by the physician weekly to ensure residents were receiving the appropriate dose of Coumadin/Warfarin medication to prevent adverse side effects such as bleeding and a GI bleed. The NP revealed the Coumadin/Warfarin protocol was for the Physician to hold Resident #583's Monday's dose (1/16/2023) of Coumadin until a PT/INR was obtained to determine if the resident's Coumadin was at a therapeutic level. The NP #1 stated, . PT/INR levels are reviewed and drawn to ensure a resident's does not bleed out, have blood in their stool .That's a problem if someone gets Warfarin and has a GI bleed . NP #1 confirmed Resident #583 failed to receive appropriate Physician services to prevent harm to the resident [Resident #583] which caused the resident to be hospitalized . During an interview on 4/11/2023 at 10:17 AM, Resident #583's Physician (Medical Director #2) confirmed the resident had an INR of 9 on 1/24/2023 required hospitalization , was diagnosed with a GI Bleed, Anemia, required a blood transfusion, and had supratherapeutic INR which required urgent treatment with Kcentra to reverse the effects of her Coumadin/Warfarin medication she received at the facility. Medical Director #2 confirmed the resident's son had initiated the resident's transfer to the hospital for treatment after being made aware by the floor nurse of his mother's critical lab values. Medical Director #2 confirmed she was responsible for monitoring the resident's PT/INR and was responsible for regulating the resident's medication based on the resident's PT/INR results. Medical Director #2 confirmed the resident continued to receive the same dosage of Coumadin from 1/10/2023-1/23/2023 and the PT/INR's were not monitored by Medical Director #2. Medical Director #2 confirmed she was unaware the resident did not have a PT/INR from 1/16/2023-1/23/2023. During an interview on 4/11/2023 at 2:14 PM, Medical Director #1 confirmed the resident's Medical Director #2 failed to monitor and review Resident #583 PT/INR from 1/16/2023- 1/23/2023. Medical Director #1 confirmed STAT labs [laboratory tests and services that are needed immediately in order to manage medical emergencies] for Resident #583 were to be ordered when[Medical Director #2 noted the resident's PT/INR results were not available. The Medical Director #1 revealed the resident's INR was 9 (1/24/2023) and Resident #583 was not medically stable. The Medical Director #1 stated the resident required a higher level of care then the facility could provide, and the resident should have been sent out immediately to the hospital for treatment when Resident #583's PT/INR results were critical (Medical Director #2 was treating the resident at the facility for elevated INR and wrote an order to have INR drawn on 1/25/2023 after a critical lab value was resulted). Medical Director #1 stated Medical Director #2 was lucky the resident did not fall, or she could have had a serious bleed. The Medical Director #1 confirmed the resident sustained a GI bleed, required a blood transfusion, and required Kcentra to reverse the effects of Coumadin she received at the facility. Medical Director #1 confirmed Resident #583 did not receive effective physician supervision to prevent harm to Resident #583. During an interview on 4/12/2023 at 11:00 AM, NP #1 confirmed Resident #583 was harmed as a result of not having her PT/INR monitored weekly by the Medical Director #2. During an interview on 4/13/2023 at 10:45 AM, Medical Director #1 stated, .The professional standard is the Physician must follow up and ensure all labs are done, reviewed and collected . Medical Director #1 confirmed stat labs for Resident #583 were to be ordered when the physician noted the resident's PT/INR results were not available. Medical Director #1 revealed if labs are not resulted physicians were to re-order PT/INR labs. The Medical Director #1 confirmed the facility failed to provide physician services to meet professional standards which caused Resident #583 harm.

Based on the facility policy review, medical record review, and interview, the facility failed to follow a physician's order to obtain a weekly lab for medication monitoring for 1 resident (Resident 583) of 30 residents reviewed for quality of care. Resident #583's lab specimen clotted rendering the specimen unusable, and a new specimen was not obtained. The facility's failure to ensure Resident #583's lab was obtained per the physician order resulted in an elevated International Normalized Ratio (INR a test which measures how long it takes blood to clot) critical lab value which required the resident to be hospitalized , diagnosed with a GI (Gastrointestinal) bleed upon arrival to the hospital, and required a blood transfusion, which resulted in Harm for Resident #583. The findings include: Review of the facility's policy, Anticoagulation-Clinical Protocol, dated 9/2012, revealed .Assessment and Recognition .The physician will identify individuals who are currently anticoagulated .Assess for evidence of effects related to the subtherapeutic or greater than therapeutic drug level related to that particular drug .In addition, the nurses shall assess and document/report the following .Recent labs, including therapeutic dose monitoring .Treatment/Management The physician will prescribe anticoagulation therapy .appropriately . Review of the facility's policy, Lab and Diagnostic Test Results-Clinical Protocol, dated 2012 revealed .Assessment and Recognition .the physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs .The staff will process test requisitions and arrange for tests .The laboratory, diagnostic .or other testing source will report test results to the facility .A nurse will review all results .The person who is to communicate results to a physician will review and be prepared to discuss the following .How test results might relate to the individual's current status, treatments, or medications .The nursing staff will then contact the physician .A physician will respond within an appropriate time frame, based on .the clinical significance of the information .Physician decisions .When responding to notification of test results, the physician and staff will discuss the implications of the test results for the resident, as well as subsequent actions . Review revealed Resident #583 was admitted to the facility on [DATE] with diagnoses including Acute Embolism and Thrombosis of Unspecified Deep Vein of Right Lower Extremity, Stage 3 Chronic Kidney Disease, and Venous Insufficiency. Review of Resident #583's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had severe cognitive impairment. Review revealed the resident had received an anticoagulant during her last 7 days or since admission/entry or reentry into the facility. Review of Resident #583's care plan dated 12/29/2022, revealed the resident was care planned for potential for bleeding secondary to anticoagulant therapy related to reoccurring deep vein thrombosis. Interventions in place included administer anticoagulant medication as ordered, monitor labs as ordered, notify physician of abnormal labs and document, monitor daily during care for signs/symptoms of bleeding and to notify the physician of abnormal findings. Review of a physician order dated 12/30/2022, revealed an order to check the resident's Prothrombin time (PT a test which measures how quickly the blood clots) and INR every Monday. Review of a lab dated 1/2/2023 revealed Resident #583 had a PT of 11.4 (normal range 9.6-12.2) and the resident's INR was 1.0 (normal range 0.80-3.50). Review of a physician order dated 1/4/2023, revealed .Give xtra [extra] 1mg [milligram] coumadin [Warfarin, the generic name for a blood thinner medication used to prevent blood clots] daily for a total of 6 mg warfarin daily po [by mouth] .check PT/INR Monday [1/9/2023] . Review of a lab dated 1/9/2023 revealed Resident #583 had a PT of 30.5 (high), and an INR of 2.81. Review of a physician order dated 1/10/2023 revealed, .D/C [discontinue] warfarin 6 mg po daily start warfarin 5 mg on M [Monday] W [Wednesday] F [Friday], S [Saturday] S [Sunday] start warfarin 6 mg on T [Tuesday], T [Thursday] check PT INR Monday [1/16/2023] . Review of a lab dated 1/16/2023 revealed the facility had performed a PT/INR lab draw on Resident #583 on 1/16/2023. Review showed there was a coagulation defect (blood specimen clotted). Review revealed the PT/INR labs was not redrawn from 1/10/2023-1/23/2023 after the coagulation defect. Review of a physician orders dated 1/10/2023-1/23/2023 showed the resident's PT/INR lab draw was not re-ordered. Review of orders revealed no documentation related to the missing results from the resident's PT/INR lab draw from 1/16/2023 or concerns related to the resident's PT/INR Review of the Medication Administration Records (MARS) dated 1/11/2023-1/22/2023 revealed the resident continued to receive Warfarin 5 mg on Monday, Wednesday, Friday, Saturday, and Sunday. Resident #583 received Warfarin 6 mg on Tuesday and Thursday. Review of a physician note dated 1/20/2023 at 9:36 PM, revealed Resident #583's Physician (Medical Director #2) had assessed the resident on 1/20/2023. Review revealed, .Chief complaint .Reason for visit .Acute visit to SNF .Patient seen due to staff stopping me in hallway due to her SOB [shortness of breath] . She [Resident #583] has been therapy [to therapy] and became dyspneic [short of breath] .upon checking her VS [vital signs] her T [temperature] was high at 100.1 .Due to her urinary frequency a ua [urine analysis (UA) test used to test a person's urine] was ordered .Her u/a from 1/20[1/20/2023] revealed .none[no] bacteria were seen . Review revealed Medical Director #2 had reviewed Resident #583's UA results on 1/20/2023. Review of Medical Director #2's note revealed the physician did not address the missing results from the resident's PT/INR lab draw from 1/16/2023 or concerns related to the resident's PT/INR. Review of the MAR dated 1/2023 revealed the resident's scheduled doses of Warfarin had not been adjusted from 1/11/2023-1/22/2023 after PT/INR results were not obtained for review by the physician. Review of a physician order dated 1/23/2023 revealed, . PT/INR in AM . Fax me INR from 1/16/23 [2023] [13 days after the 1/9/2023 PT/INR results] . Review of Resident #583's MAR revealed the resident's 5 mg and 6 mg dose Warfarin was held on 1/23/2023 with no specified reason given. Review of a nursing note dated 1/24/2023 at 3:18 PM revealed, .Resident was showing s/s [signs/symptoms] of SOB [shortness of breath] during therapy .Upon examination resident O2 [oxygen saturation level] was 71% . started resident on oxygen 2 L [liters] .O2 [oxygen saturation level] came up to 97% . [name of the resident's physician] stated she was stopping by and will exam resident herself upon arrival .When [name of physician] came she stated that she believed the resident was fine that she wasn't worried that anything was wrong with resident [Resident #583] .X-ray came back and showed resident had R [right] side PNA [Pneumonia], and labs came back and showed critical lab values .Son was notified and stated he wanted his mother sent out due to critical values .Awaiting ambulance services now . Review of a lab dated 1/24/2023 revealed the resident had a Prothrombin time >90 (normal range 9.6-12.2) and an INR of >9 (normal range 0.80-3.50). Review of a physician order dated 1/24/2023 revealed, .Vitamin K [medication used to manage and treat bleeding] 1 po [by mouth] now (5mg) .PT/INR in AM [1/25/2023] .D/C Coumadin .Indication-DX [diagnose] .critical INR/Blood work . Review of the physician order dated 1/24/2023, revealed .Send to [name of hospital emergency room ] per son request . Review of Resident #583's nursing note dated 1/24/2023 at 3:52 PM, revealed the resident was sent to the emergency room at 3:45 PM by ambulance per the resident's son request. Review of Resident #583's Hospital History and Physical, dated 1/24/2023, revealed .Nursing home sent the patient for shortness of breath and low H &H [hemoglobin and hematocrit/red blood cell count] .I [hospital physician] did call and speak with her son who reported that she had not felt well for 3 or 4 days .She is also profoundly supratherapeutic [an amount of drug medication that was greater than the therapeutic concentration] on her INR .She has received Kcentra [a medication used for urgent reversal of Coumadin effects) .Tells me that she [Resident #583] just feels rough. Review revealed, .Patient [Resident #583] is quite ill in conjunction with her frailty her prognosis is poor . GI bleed .I suspect this is related to her having a supratherapeutic INR .Acute blood loss anemia .Patient is in the process of being transfused [blood transfusion] Hemorrhagic [spontaneous or near spontaneous bleeding caused by a defect in clotting mechanisms] disorder secondary to .anticoagulants therapy . Review revealed the resident had Hemorrhagic disorder due to circulating anticoagulants and had heme positive stool [blood in stool] and an INR greater than 12. The resident's Coumadin medication was held in the hospital. The resident had an Acute Blood Loss Anemia with blackish colored stool. The resident was diagnosed with COVID-19 and Acute Respiratory Failure in the hospital. Review of Resident #583's Hospital discharge date of [DATE] revealed . Discharge diagnoses .Hemorrhagic disorder .Acute blood loss anemia .Acute respiratory Failure .Supratherapeutic INR .GI bleed . Review of a physician note dated 1/27/2023 revealed, .96 y/o [year old] .female readmitting from [name of the hospital] after a 1/24/2023 admission due to hemorrhagic disorder d/t [due to] circulating anticoagulants, Acute blood loss anemia, COVID-19 . During an interview on 4/4/2023 at 9:25 AM, Licensed Practical Nurse (LPN) #7 stated, .I called [name of the resident's Physician Medical Director #2] one morning [1/24/2023] patient [Resident #583] was not acting right .[name of Medical Director #2] she stated she was fine .When patient went to hospital, she tested positive for COVID and had a GI bleed .I called son [Resident #583's son] and told him she wasn't doing like self [1/24/2023] and told him her critical labs values .Patient was tired .She [Resident #583] had declined [in her physical health] . The LPN confirmed the resident's son requested the resident be sent to the hospital due to the resident's critical labs values. During an interview on 4/4/2023 at 2:10 PM, LPN #5 confirmed the nurses were responsible for checking and ensuring each lab draw was performed as ordered by the physician. The LPN stated, No one questioned the missed lab [Resident #583's resulted PT/INR] for 2 weeks . During an interview on 4/5/2023 at 2:54 PM, Medical Director #1 confirmed .I've been concern about quality of care . He stated Coumadin/Warfarin was a high-risk medication and residents on the medication could have adverse reactions. The Medical Director revealed only a few residents in the facility were on Coumadin/Warfarin due to the risks of adverse reactions and side effects of the medication. The Medical Director revealed residents in the facility on Coumadin/Warfarin were to have their PT/INR levels reviewed and monitored weekly. Medical Director #1 confirmed the facility failed to monitor, check, and review Resident #583's PT/INR for approximately 2 weeks. Medical Director #1 stated the resident had an INR of 9 (on 1/24/2023) which was a critical lab value. Medical Director #1 confirmed the facility failed to ensure Resident #583's PT/INR resulted lab was obtained [the week of 1/16/2023] [7 days after the resident's INR was resulted on 1/9/2023]. Medical Director #1 revealed PT/INR labs were to be reviewed weekly to ensure adjustments were made to the resident's Coumadin/Warfarin drug regimen based on their weekly PT/INR lab results. Medical Director #1 stated, .The patient [Resident #583] could have bleed out . Medical Director #1 confirmed Resident #583 had a high potential for harm when Resident #583's PT/INR lab value was not determined on 1/16/2023 to ensure the resident was receiving a therapeutic dose of Warfarin/ Coumadin. Medical Director #1 stated, .You can easily have GI bleed and bleed out if medication [Coumadin] given and no lab [performed] to monitor INR/PT every week .High risk of severe outcome .If she fell , she [Resident #583] could bleed out easily . Medical Director #1 confirmed Resident #583 was harmed. During an interview on 4/6/2023 at 11:02 AM, the DON confirmed the process for obtaining resident labs were the following: The physician wrote an order for a lab to be performed. The nurse on duty responsible for the resident or the Unit Nurse Manger then placed the order for the lab in the computer. The night shift nurse then printed the lab requisition for the lab scheduled to be drawn the next morning/or on day shift. The resident's nurse then placed the lab requisition in the lab book located at the nurse's station. The outside lab personnel retrieve the lab book the day of the lab draw. The lab personnel review the requisition. The lab personnel perform the lab draw and collected the lab specimen. The lab personnel then signed their name on the form in the lab book next to the resident's name to confirm a lab draw had been performed. The DON confirmed Resident #583 continued to received Warfarin/ Coumadin at the same dosage without having a lab with current PT/INR levels from 1/9/2023-1/23/2023. The DON confirmed the facility was aware the lab was not resulted on 1/16/2023 and confirmed the facility failed to reorder and obtain a PT/INR on Resident #583 the week of 1/16/2023. The DON confirmed Resident #583's Warfarin/Coumadin medication was not readjusted after 1/10/2023-1/22/2023. The DON revealed the resident's nurse called the resident's son and informed him of the critical lab values and the resident's son initiated and requested the resident be sent to the hospital for treatment. During an interview on 4/10/2023 at 7:50 AM, LPN #11 stated the nurses were responsible for printing resident lab results from the computer located at the nursing station. The LPN stated the resident's assigned nurse would then place the results of the lab in the resident's physician's lab book for review by the physician. The LPN stated if labs were ordered STAT or were not resulted the resident's physician would either be verbally informed in person of the results, telephoned, or faxed the results. The LPN stated the resident's Physician would then order the lab to be redrawn or discontinue the lab. The Nurse stated, . [Medical Director #2] wants it [lab results] called or faxed .If not resulted Nurse calls the doctor and get an order to redraw labs . During an interview on 4/10/2023 at 2:44 PM, the DON stated, .The Unit Managers [Nurse Managers] ensure labs are done .and doctors are informed of the lab results daily . The DON confirmed Resident #583's PT/INR lab was drawn by an outside lab service on 1/16/2023. The DON stated the Unit Manger notified the Medical Director on 1/16/2023 the resident's PT/INR was not resulted. The DON stated she was present at the nursing station when the Unit Manager informed Medical Director #2 Resident #583's PT/INR labs were not resulted from 1/16/2023. The DON confirmed Medical Director #2 did not give the Unit Manger a verbal order to reorder the resident's PT/INR lab. The DON stated the Medical Director #2 had the resident's chart in her hand and was to write an order for the lab to be redrawn. The DON confirmed Coumadin/Warfarin was a high-risk medication. The DON confirmed the resident's INR was 9 on 1/24/2023. The DON stated, .If not monitored [PT/INR labs] blood [a resident's] can get too thin and they can bleed to death or require a blood transfusion . The DON confirmed Resident #583 had a change in her medical status and required hospitalization . During an interview on 4/10/2023 at 3:14 PM, Nurse Practitioner (NP) #1 stated residents who are ordered and receiving Coumadin/Warfarin were to have their PT/INR labs drawn at least weekly and have their labs reviewed by the NP/Physician weekly to ensure residents receive appropriate therapeutic dosages of Coumadin. The NP #1 confirmed PT/INR levels are reviewed and drawn to ensure a resident does not bleed out. The NP #1 stated an adverse effect of Warfarin was a GI Bleed or any bleeding. The NP #1 stated, .That's a problem if someone gets Warfarin and has a GI bleed . During an interview on 4/11/2023 at 10:17 AM, Medical Director #2 stated, .If labs not drawn they [nurse] call me tell me to reorder the lab .I don't recall if any staff asked me to reorder [Resident #583's labs [PT/INR when not resulted on 1/16/2023] .My expectation is for staff .to redraw the labs the next day . Medical Director #2 confirmed Resident #583 continued to receive the same dosage of Coumadin/Warfarin without a current PT/INR the week of 1/16/2023. Medical Director #2 confirmed the Resident #583's transfer to hospital was initiated by the resident's son on 1/24/2023. Medical Director #2 confirmed the resident had an INR of 9 on 1/24/2023 required hospitalization , was diagnosed with a GI bleed, Anemia, a supratherapeutic INR which required urgent treatment with Kcentra to reverse the effects of her Coumadin/Warfarin medication she received at the facility and required a blood transfusion. Medical Director #2 stated she was responsible for providing quality of care to the Resident #583. During an interview on 4/11/2023 at 2:14 PM, Medical Director #1 stated .The resident [Resident #583} failed to receive appropriate quality of care and treatment at the facility to prevent harm . During an interview on 4/11/2023 at 3:45 PM, LPN #8 stated, .She [Resident #583] continued to receive medications [Coumadin] that's a big No No .she did not receive proper care . During an interview on 4/11/2023 at 4:00 PM, LPN #10 revealed the resident had to receive a higher level of care because of elevated INR. The LPN stated, If too high your blood too thin and you can bleed out [blood loss to such a degree the person bleeding dies] .and can require blood .It would be hard to stop bleeding . LPN #10 stated, .The patient [Resident #583] did not get quality care . During an interview on 4/12/2023 at 11:00 AM, .Nurse Practitioner #2 confirmed the resident's lab values were not obtained and monitored weekly by the facility. The Nurse Practitioner stated, .Not keeping up with PT/INR can cause harm .The resident (Resident #583) didn't get good quality of care .That caused her harm . During an interview on 4/12/2023 at 12:01 PM, the LPN #8 stated, .The Doctor was going to leave the patient in house [at the nursing home] the son was the one who wanted the resident sent to the hospital . The LPN revealed the resident's PT/INR was not drawn 1/17/2023-1/23/2023 and the resident's PT/INR was not monitored. The LPN stated, .I can say she [Resident #583] did not get good quality care . During an interview on 4/13/2023 at 10:45 AM, Medical Director #1 revealed the professional standard was for all labs ordered to be collected, reviewed and followed up by the facility. Medical Director #1 confirmed STAT labs [laboratory tests and services that are needed immediately in order to manage medical emergencies] for Resident #583 should have been ordered when it was noted the Resident #583's PT/INR results were not available [1/9/2023-1/23/2023]. Medical Director #1 revealed if PT/INR labs are not resulted they should be re-ordered. The Medical Director confirmed the facility failed to provide quality of care to Resident #583 which resulted in harm to Resident #583.

Based on the facility policy review, medical record review and interview, the facility failed to develop and implement care plans for 2 Residents (Residents #583 and #102) of 36 residents reviewed for care plans. The facility failure to implement Resident #583's care plan resulted in the resident having a critical lab value, the resident was transferred to the hospital and diagnosed with a GI (Gastrointestinal Bleed), Anemia, and required a blood transfusion which resulted in Harm for Resident #583. The facility failed to develop and implement an individualized and person-centered care plan related to activities for 1 non-English speaking resident (Resident #102) of 2 non-English speaking residents reviewed. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, showed .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care planning process will .Facilitate resident and/or representative involvement .Include an assessment of the resident's strengths and needs; and Incorporate the resident's personal and cultural preferences in developing the goals of care .The comprehensive, person-centered care plan will .Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Incorporate identified problem areas; Reflect treatment goals, timetables and objectives in measurable outcomes; .Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the residents' problem areas and their causes, and relevant clinical decision making . Review of the facility's policy titled, Activity Programs, revised 8/2006, showed Individualized and group activities are provided that .Reflect .choices and rights of the resident .Reflect the cultural and religious interests, hobbies, life experiences, and personal preferences of the residents . Review of the medical record revealed Resident #583 was admitted to the facility on [DATE] with diagnoses including Acute Embolism and Thrombosis of Unspecified Deep Vein of Right Lower Extremity, Stage 3 Chronic Kidney Disease, and Venous Insufficiency. Review of Resident #583's care plan dated 12/29/2022, revealed the resident was care planned for potential bleeding secondary to anticoagulant therapy related to reoccurring deep vein thrombosis. Interventions in place included administer anticoagulant medication as ordered, monitor labs as ordered, notify physician of abnormal labs and document, monitor daily during care for signs/symptoms of bleeding and to notify the physician of abnormal findings. Review of the physician order dated 12/30/2022, revealed an order to check the resident's Prothrombin Time (PT a test that measures how quickly the blood clots) and International Normalized Ratio (INR a test that measures how long it takes blood to clot) every Monday. Review of a lab dated 1/2/2023 revealed Resident #583 had a PT of 11.4 (normal range 9.6-12.2) and the resident's INR was 1.0 (normal range 0.80-3.50). Review of a physician order dated 1/4/2023, revealed .Give xtra [extra] 1 mg [milligram] coumadin [warfarin][the generic name for a blood thinner medication used to prevent blood clots] daily for a total of 6 mg warfarin daily po [by mouth] .check PT/INR Monday [1/9/2023] . Review of Resident #583's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident had severe cognitive impairment. The resident had received an anticoagulant during her last 7 days or since admission/entry or reentry into the facility. Review of a lab dated 1/9/2023, revealed Resident #583 had a Prothrombin time of 30.5 (high), and an INR of 2.81. Review of Resident #583's Physician order dated 1/10/2023 revealed, .D/C [discontinue] warfarin 6 mg po daily start warfarin 5 mg on M [Monday] W[Wednesday] F [Friday], S [Saturday] S [Sunday] start warfarin 6 mg on T [Tuesday], T [Thursday] check PT INR Monday [1/16/2023] . Review of a lab dated 1/16/2023, revealed the facility had performed a PT/INR lab draw on Resident #583 on 1/16/2023. Review showed there was a coagulation defect (blood specimen clotted). Review revealed the PT/INR lab was not redrawn after the coagulation defect. Review of physician orders dated 1/10/2023-1/23/2023, showed the resident's PT/INR lab draw was not re-ordered. Review of orders revealed no documentation related to the missing results from the resident's PT/INR lab draw from 1/16/2023 or concerns related to the resident's PT/INR. Review of the Medication Administration Records (MARS) dated 1/11/2023-1/22/2023, revealed Resident #583 continued to receive Warfarin 5 mg on Monday, Wednesday, Friday, Saturday, and Sunday. Resident #583 received Warfarin 6 mg on Tuesday and Thursday. Review of a physician note dated 1/20/2023, electronically signed at 9:36 PM, revealed Resident #583's Physician (Medical Director #2) had assessed the resident on 1/20/2023. Review revealed, .Chief complaint .Reason for visit .Acute visit to SNF .Patient seen due to staff stopping me in hallway due to her SOB [shortness of breath][symptom of low Hgb] .She [Resident #583] has been [in] therapy and became dyspneic [short of breath] .upon checking her VS [vital signs] her T [temperature] was high at 100.1 .Due to her urinary frequency a ua [urine analysis (UA) test used to test a person's urine] was ordered .Her u/a from 1/20[1/20/2023] revealed .none bacteria were seen . Review revealed no documentation related to the missing results from the resident's PT/INR lab draw from 1/16/2023 or concerns related to the resident's PT/INR. Review of a physician order dated 1/23/2023 revealed, . PT/INR in AM [morning] . Fax me INR from 1/16/23 [2023, approximately 13 days since resulted PT/INR lab levels reviewed by the Medical Director #2] . Review of a lab dated 1/24/2023, revealed the resident had a Prothrombin time >90 (normal range 9.6-12.2) and an INR of >9 (normal range 0.80-3.50). Review revealed this was a critical lab and the resident's INR was elevated. Review of the MAR dated 1/23/2023, revealed Resident # 583's Coumadin doses were held on 1/23/2023 and 1/24/2023. Review of a physician order dated 1/24/2023 revealed, .INR [lab] on M [Monday], W [Wednesday], F [Friday] while on antibiotic .DX [diagnosis] Right lung PNA [Pneumonia] . Review of a physician order dated 1/24/2023, revealed .1) Vitamin K [medication used to manage and treat bleeding] 1 po [by mouth] now (5mg) 2) PT/INR in AM [the physician ordered another lab draw to be performed the next day 1/25/2023 in the facility] 3) D/C Coumadin .Indication-DX [diagnose] critical INR/Blood work [last resulted PT/INR performed 1/09/2023] . Review of the physician order dated 1/24/2023 revealed, .Send to [name of hospital emergency room ] per son request . Review of Resident #583's Hospital History and Physical, dated 1/24/2023, revealed .Nursing home sent the patient for shortness of breath and low H &H [hemoglobin and hematocrit/red blood cell count] .I [hospital physician] did call and speak with her son who reported that she had not felt well for 3 or 4 days .She is also profoundly supratherapeutic [an amount of drug/medication that was greater than the therapeutic concentration]on her INR .She has received Kcentra [a medication use for urgent reversal of acquired coagulation factor deficiency induced by Coumadin/Warfarin] .Tells [Resident #583] me that she just feels rough Review revealed the resident had Hemorrhagic disorder [spontaneous or near spontaneous bleeding caused by a defect in the clotting mechanisms] due to circulating anticoagulants[in her bloodstream] and had heme positive stool [blood in stool] and an INR greater than 12. The resident's Coumadin medication was held. The resident had Acute Blood Loss Anemia with blackish colored stool. She was diagnosed with COVID and Acute Respiratory Failure. Review revealed, .Patient [Resident #583] is quite ill in conjunction with her frailty her prognosis is poor .GI bleed .I suspect this is related to her having a supratherapeutic INR .Acute blood loss anemia .Patient is in the process of being transfused [blood transfusion] Hemorrhagic disorder secondary to extrinsic [administering of anticoagulant medication] anticoagulants therapy . Review of Resident #583's Hospital discharge date d 1/27/2023 revealed . Discharge diagnoses .Hemorrhagic disorder .Acute blood loss anemia .COVID 19 .Acute respiratory Failure .Supratherapeutic INR .GI bleed . Review of discharge medication list showed the resident was not discharged from the hospital with an order for Coumadin/Warfarin. Review of a nursing note dated 1/27/2023 at 4:43 PM, revealed the resident returned to the nursing home following her hospitalization . During an interview on 4/11/2023 at 10:17 AM, Resident #583's Physician (Medical Director #2) stated the care plan informed the staff on how to care for residents in the facility. The Medical Director confirmed the resident had no PT/INR labs with results from 1/10/2023-1/23/2023 and the facility failed to monitor Resident #583's labs. Medical Director #2 revealed the resident's PT/INR lab was drawn on 1/24/2023 and was a critical lab value. Resident #583 required hospitalization , was diagnosed with a GI bleed, Anemia and required a blood transfusion, the resident had a supratherapeutic INR and required treatment with Kcentra [a medication use for urgent reversal of acquired coagulation factor deficiency induced by warfarin]. The Medical Director confirmed Resident #583's care plan was not followed and the resident's labs were not monitored by the facility the week of 1/16/2023. Medical Director #2 stated .The missed labs contributed to the resident being harmed . During an interview on 4/11/2023 at 2:14 PM, Medical Director #1 confirmed the facility failed to follow the resident's care plan to monitor the residents PT/INR and caused harm for Resident #583. During an interview on 4/11/2023 at 3:45 PM, Licensed Practical Nurse (LPN #8) revealed Resident #583's care plan was accurate. The LPN revealed the care plan was used as a guide for the CNAs, Nurses, and Physicians to implement interventions for resident care. The LPN confirmed Resident #583's care plan was not followed by staff and the resident's lab were not monitored by the facility. Resident #102 was admitted to the facility on [DATE] with diagnoses including Dysphagia, Unspecified Dementia with Other Behavioral Disturbance, End Stage Renal Disease, Chronic Congestive Heart Failure, Acute Respiratory Failure, Diabetes Mellitus, Polyneuropathy and Depression. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. The MDS showed the resident's activities of choosing clothes to wear, bedtime, being around animals/pets, keeping up with the news, doing things with groups of people, doing favorite activities, and going outside when there was good weather was somewhat important to the resident, and the activity of listening to music was very important. Review of a comprehensive care plan dated 9/20/2022, revised on 9/29/2022, and 4/4/2023, revealed Resident #102 was at risk for cognitive deficit related to the diagnosis of Dementia and had a communication barrier related to .Vietnamese as .first language . with interventions including .Contact RP [responsible party] via phone to translate, if needed. The care plan showed to post an activity calendar in the resident's room, encourage the resident to do activities in his own way, and provide the resident with in room activities. The resident enjoyed watching television and listening to Vietnamese music .[Resident #102] will be offered 1:1 visits and be invited to OOR [out of room] activities .had decreased mobility . and required assistance of staff with activities of daily living (ADLs) . The care plan showed there was no specific person-centered activities related to the resident's language, religious and cultural preference. During an observation on 4/3/2023 at 5:14 PM, Resident #102 was asleep in bed. Observation of the resident's room showed the television was playing on an English-speaking program and an activities calendar printed in English was posted on the resident's wall. Continued observation showed no activities of the Vietnamese language available in the resident's room. During an observation and interview on 4/4/2023 at 3:48 PM, Resident #102 was awake, laying in bed. Attempts to interview Resident #102 were unsuccessful due to the resident's inability to communicate in English. Continued observation showed the television program on in the resident's room was in the English language. During an interview on 4/6/2023 at 11:52 AM, the Activities Director revealed she was responsible for completing the activities portion of the care plan. The Activities Director confirmed Resident #102 had limited person-centered activities on the care plan and stated .I wish I could do 100% more . The Activities Director further stated Vietnamese television programs or videos had not been provided to the resident and the activities calendar had only been provided in the English language. The Activities Director confirmed the activity care plan did not meet the needs of Resident #102. 39794

Based on facility policy review and interview the facility failed to ensure Medical Director duties were coordinated to clearly delineate responsibilities of the facility's Medical Directors. The facility's failure to implement and coordinate resident care created an environment which impaired the nursing staff to effectively provide patient care and services which had the potential to affect all 144 residents in the facility. The findings include: Review of the Medical Director Agreement signed by Medical Director #1 showed . Physician [reference to Medical Director/Physician] shall guide, approve, and help oversee the development, implementation, and monitoring/evaluation of Facility's resident care policies and procedures in the following areas: .Admission policies and care practices that address the types of residents that may be admitted and retained based upon the ability of the Facility to provide the services and care to meet their needs .Mechanisms for communicating and resolving issues related to medical care . Physician shall be responsible for coordination of medical care in the Facility. Physician shall help the Facility obtain and maintain timely and appropriate medical care that supports the healthcare needs of the residents, is consistent with current standards of practice, and helps the Facility meet its regulatory requirements . Review of the Medical Director Agreement signed by Medical Director #2 on 11/23/2022, showed .Scope of Services: Medical Director shall provide overall medical leadership for .operations including the nursing facility .Medical Director shall provide medical direction and guidance .including participation in the .QI (quality improvement) meetings .This agreement shall be for a term of one (1) year from the effective date above the signature line . Further review revealed there was no mention of Medical Director #2's responsibilities limited to the skilled residents. During an interview on 4/11/2023 at 2:14 PM, Medical Dierector #1 (MD #1) stated .with 2 medical directors it causes conflict .definitely . it would impede the nursing home [resident care] . During an interview on 4/11/2023 at 2:31 PM, MD#1 stated after his most recent contract was signed, then he was told by the facility MD #2 would reside over the skilled residents and he (MD#1) would be over the rest (remainder of the residents). MD #1 stated that he understood he was not to contact (MD#2) regarding residents and that his care for residents was separate from (MD#2). MD #1 stated he was to consider (MD#2) as an equal provider and that no one was over one another. MD #1 revealed his contract with the facility stated he should have control of resident care but stated he was not allowed to have total control. MD #1 stated he feels this lack of total control causes confusion with the nursing staff and unequivocally impedes nurses' abilities to streamline resident care. MD #1 stated .I can't do my job if I don't know what's going on . MD #1 stated the Regional [NAME] President of Operations/ADM #1 told him not to communicate with (MD#2) and stated there is not a system in place at this facility to address resident care issues or failures as the medical director. MD #1 confirmed he told the Chief Executive Officer (CEO) care concerns needed to be handled with MD #2 and the facility could not continue to operate with two medical directors. The CEO advised MD #1 he (CEO) would .look into things .however nothing has changed here . During an interview on 4/12/2023 at 3:13 PM, Registered Nurse (RN) #2 stated staff have told her MD #2 was unapproachable and nurses were confused on which medical director to report resident health concerns to on a daily basis. During an interview on 4/12/2023 at 3:33 PM, the Regional [NAME] President of Operations/ADM #1 stated she remembered getting an email from a clinical staff member regarding clinical care practices and negative interactions with MD #2 but, .cannot remember details . ADM #1 stated she could not address the clinical concerns and confirmed she had not consulted with any qualified clinical counterpart to MD#2 for assistance in addressing the issues presented. The Regional [NAME] President of Operations/ADM #1 stated she talked to MD #2 about interpersonal interactions with the nursing staff. The Regional [NAME] President of Operations/ADM #1 stated the MD #1 was told that he would be sharing medical director roles with MD#2. The Regional [NAME] President of Operations/ADM #1 confirmed MD #2 was to have control over skilled residents and the MD #1 who was appointed in 2018, would have control over the remaining residents. Regional [NAME] President of Operations/ADM #1 stated .if nurses have concerns with the medical provider, they can contact the [facility's] compliance line . Regional [NAME] President of Operations/ADM #1 verified she is part of the governing body. Regional [NAME] President of Operations/ADM #1 stated the governing body meets monthly to discuss Quality Indicators, staffing, financial operations, HR [Human Resources] updates, and business office updates. Regional [NAME] President of Operations/ADM #1 stated past due pest control bills or concerns with the facility acquiring two medical directors was not discussed in morning standup, QAPI or Governing Body meetings. Regional [NAME] President of Operations/ADM #1 was not sure if Governing Body was aware of past due pest control bills.

Based on facility policy review, medical record review, observation, and interview, the facility failed to develop and implement an individualized and activities program to meet the needs for 1 non-English speaking resident (Resident #102) of 2 non-English speaking residents reviewed for activities. The findings include: Review of the facility's policy titled, Activity Programs, revised 8/2006, showed Activity programs designed to meet the needs of each resident are available on a daily basis .Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs .Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs .Our activity programs consist of individual and small and large group activities that are designed to meet the needs and interests of each resident and include, as a minimum .Activities that stimulate the cardiovascular system and assist with range of motion, such as exercise, movement to music, wheelchair basketball/volleyball .are offered five to seven times per week .Intellectual activities that are mentally stimulating, such as current events, trivia, word games, book reviews, educational movies .are provided five to seven times per week .Spiritual programming is scheduled to meet the religious needs of the residents .Creative and expressive activities .are available on a regular basis to meet the needs of residents .Social activities are scheduled to increase self esteem, to stimulate interest and friendships, and to provide fun and enjoyment .Scheduled activities are posted on the resident bulletin board schedules are also provided individually to residents who cannot access the bulletin board .Individualized and group activities are provided that .Reflect the schedules, choices and rights of the residents .are offered at hours convenient to the residents, including evenings, holidays and weekends .Reflect the cultural and religious interests, hobbies, life experiences, and personal preferences of the residents . Resident #102 was admitted to the facility on [DATE] with diagnoses including Dysphagia, Unspecified Dementia with Other Behavioral Disturbance, End Stage Renal Disease, Chronic Congestive Heart Failure, Acute Respiratory Failure, Diabetes Mellitus, Polyneuropathy, and Depression. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. The MDS showed the resident's activities of choosing clothes to wear, bedtime, being around animals/pets, keeping up with the news, doing things with groups of people, doing favorite activities, and going outside when there was good weather was somewhat important to the resident, and the activity of listening to music was very important. Review of a comprehensive care plan dated 9/20/2022, revised on 9/29/2022, and 4/4/2023, revealed Resident #102 was at risk for cognitive deficit related to the diagnosis of Dementia and had a communication barrier. The resident .was born in Vietnam with Vietnamese as his first language . The care plan showed to post an activity calendar in the resident's room, encourage the resident to do activities in his own way, and provide the resident with in room activities. The resident enjoyed watching television and listening to Vietnamese music .[Resident #102] will be offered 1:1 visits and be invited to OOR [out of room] activities .had decreased mobility . and required assistance of staff with activities of daily living (ADLs) The care plan showed there was no specific person-centered activities related to the resident's language, religious or cultural preference. Review of the resident's individual daily activity record dated 1/1/2023-1/31/2023, showed Resident #102 participated in the radio/television activity (provided in the English language) all 31 days. The resident's individual daily activity record showed the resident participated in the activity of music/CDs (compact discs) for 10 of the 10 days offered. Review of a nurse practitioner (NP) progress note dated 2/27/2023, showed Resident #102 was alert and oriented to self, place, time, and situation and followed commands. Review of the resident's individual daily activity record dated 2/1/2023-2/28/2023, showed Resident #102 participated for 28 days when radio/television (provided in the English language) and the telephone/facetime activity was provided. The resident's individual daily activity record showed the resident participated in the activity of music/CDs 12 of the 12 offered days. Review of a physician's progress note dated 3/27/2023, showed Resident #102 was alert and oriented to self, place, time, and situation. Review of the resident's individual daily activity record dated 3/1/2023-3/31/2023, showed Resident #102 participated in 1 of the 1 offered dry for the coffee, food/snacks, and movie activity (provided in English language). The resident's individual daily activity record showed the resident participated in 31 of 31 days of the activity of radio/television (provided in the English language) and 31 of 31 days of the telephone/face time activity. The resident's individual daily activity record showed the resident participated in 9 of the 9 offered days of the activity of music/CDs and verbal discussions held by the activities staff were conducted on 9 of the 10 offered days. All other activities were blank. During observations on 4/3/2023 at 5:14 PM, Resident #102 was lying in bed asleep. The television was playing on an English-speaking program and an activities calendar printed in English was posted on the resident's wall. Continued observation showed no activities of the Vietnamese language and culture were available in the resident's room. During observations on on 4/5/2023 at 11:00 AM, Resident #102 was lying in bed asleep. The television was playing on an English-speaking program and an activities calendar printed in English was posted on the resident's wall. Continued observation showed no activities of the Vietnamese language and culture were available in the resident's room. During a telephone interview on 4/5/2023 at 5:40 PM, Resident #102's daughter confirmed Resident #102 expressed his basic needs through the paper she created in the resident's room. The resident's daughter stated the facility staff .call me all the time . and stated the facility had not provided translation services for the resident. Resident #102's daughter stated the resident loved Vietnamese music and the facility only provided the activity 2-3 days per week. The resident's daughter also stated she was not aware of any other Vietnamese activities that were provided to the resident. During observations on 4/6/2023 at 11:45 AM, Resident #102 was lying in bed asleep. The television was playing on an English-speaking program and an activities calendar printed in English was posted on the resident's wall. Continued observation showed no activities of the Vietnamese language and culture were available in the resident's room. During an interview on 4/6/2023 at 11:52 AM, the Activities Director revealed communication with Resident #102 occurred with a translation application on her cell phone. The Activities Director stated the Vietnamese music activity had been provided to the resident .2 to 3 times a week .usually .like 20 minutes .[or by a tablet electronic device] for an hour . at times. The Activities Director stated the resident and the resident's family stated Resident #102 enjoyed music .whenever I've talked to him, he says he likes his music . The Activities Director confirmed Resident #102 had limited person-centered activities and stated .I wish I could do 100% more . The Activities Director further stated Vietnamese television programs or videos were not available and had not been provided to the resident, the activities calendar had only been provided in the English language, and other than the music provided 2-3 days per week, no other Vietnamese cultural or language activities had been provided. The Activities Director further stated, the facility had a pet therapy program and was not aware if Resident #102 had been offered or participated in the activity. The Activities Director confirmed the activity care plan did not meet the needs of Resident #102.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide interpretation services or an effective communication service for 1 non-English speaking resident (Resident #102) of 2 non-English speaking residents reviewed. The findings include: Review of the facility's policy titled, Translation and/or Interpretation, revised 5/2017, showed .This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility .the types of language access services provided by this facility shall be determined by the following factors .The size .of the eligible LEP population served by the facility .The frequency with which the particular LEP population is in contact with the facility .The nature and/or importance of the information or service that needs to be conveyed .The point of contact regarding facility's language access program is the Director of Social Services .All LEP persons will be informed of their rights to obtain competent oral translation services free of charge .Non-vital: information includes .Dietary .menus .and activity services .Competent oral translation of vital information .and non-vital information shall be provided in a timely manner and at no cost to the resident through the following means A staff interpreter who is trained and competent in the skill of interpreting .Contracted interpreter service .Voluntary community interpreters who are trained and competent in the skill of interpreting .Telephone interpretation service .Interpretation devices, translation applications or on line services .Family members and friends may be relied upon to provide interpretation services for the resident .It is understood that providing meaningful access to services provided by this facility requires also that the LEP residents needs and questions are accurately communicated to the staff . Resident #102 was admitted to the facility on [DATE] with diagnoses including Dysphagia, Unspecified Dementia with Other Behavioral Disturbance, End Stage Renal Disease, Chronic Congestive Heart Failure, Acute Respiratory Failure, Diabetes Mellitus, Polyneuropathy, and Depression. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #102 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. The MDS showed the resident required extensive 1 staff assistance for bed mobility, and was totally dependent on 1 staff for transfers, locomotion on and off the unit, toileting, and hygiene. Review of a comprehensive care plan dated 9/20/2022, revised on 9/29/2022 and 4/4/2023, revealed Resident #102 was at risk for cognitive deficit related to the diagnosis of Dementia and had a communication barrier related to .Vietnamese as .first language . with interventions including .Contact RP [responsible party] via phone to translate, if needed . Review of a Nurse Practitioner (NP) progress note dated 2/27/2023 showed Resident #102 was alert and oriented to self, place, time, and situation and followed commands. Review of a physician's progress note dated 3/27/2023 showed Resident #102 was alert and oriented to self, place, time, and situation. During an observation on 4/3/2023 at 5:14 PM, Resident #102 was asleep in bed. Observation of the resident's room showed a communication paper provided by the resident's family which included .Drink .Hunger .Hot .Cold .Pain .Sleepy .Up (out of bed) .Down (to bed) . Continued observation showed the resident's daughter's phone number was posted on the resident's bulletin board to aid with translation. During an interview on 4/4/2023 at 3:41 PM, the Director of Nursing (DON) confirmed Resident #102 had limited English communication, the family had posted a paper with words the resident used to communicate his basic needs, and communication could also occur with Resident #102 using an application on a cellular (cell) telephone (phone). During an observation in Resident #102's room and interview on 4/4/2023 at 3:48 PM, Licensed Practical Nurse (LPN) #9 stated she used the communication paper in the resident's room or called the resident's daughter to aid with translation. The LPN stated she was not aware of the facility having a translation service if the resident's daughter was unable to be reached. During an observation and interview with LPN #9, in Resident #102's room, on 4/4/2023 at 3:48 PM, Resident #102 was awake, laying on his bed. Attempts to interview Resident #102 was unsuccessful due to the resident's inability to communicate in English. Continued observation showed the television program on in the resident's room was in English. During an observation and interview, on 4/4/2023 at 4:08 PM, Resident Aide (RA) #1 stated there was a communication paper on the resident's board to help with basic needs, or at times the staff could call the Resident's daughter on the phone to help translate. RA #1 stated she could use Google App [Application] to help with translation, if needed. Observation of the Google App with RA #1 showed she was unable to demonstrate use of the application for translation. During an observation and interview on 4/4/2023 at 4:18 PM, Certified Nursing Assistant (CNA) #2 stated she communicated with Resident #102 with a paper that hung on the resident's wall. The CNA stated she did not have conversations with the resident and used the paper or body language to help determine the resident's needs. The CNA stated she had Google translator if she had her cell phone to aid with communication. Observation with CNA #2 of the Google translator on the CNA's cell phone, showed she was unable to demonstrate use of the application for translation. During an observation and interview on 4/5/2023 at 2:04 PM, Licensed Practical Nurse (LPN) #6 stated she used .Google Translate . on her phone to communicate with Resident #102. LPN #6 stated the facility did not have a translation service to aid in communication with the resident. LPN #6 stated she was not aware if the facility had any Vietnamese reading materials, activities, or items for the resident's use. Observation of the Google Translate application on the LPN's cell phone and on the resident's cell phone, with LPN #6, showed the LPN was unable to demonstrate use of the translation application on either phone. During a telephone interview on 4/5/2023 at 5:40 PM, Resident #102's daughter confirmed Resident #102 expressed his basic needs through the paper she created in the resident's room. The resident's daughter stated the facility staff .call me all the time . and stated the facility had not provided an alternate means of translation services for the resident. Resident #102's daughter stated the resident loved Vietnamese music and the facility only provided the activity 2-3 days per week. The resident's daughter also stated she was not aware of any other activities in Vietnamese provided in to the resident. During an interview on 4/6/2023, at 9:01 AM, the Social Services Director stated she had conducted assessments of the resident previously and had not used a translation service to conduct the assessments. During an interview on 4/6/2023 at 9:25 AM, the Interim Administrator confirmed the facility did not have translator/translation agreement .I don't believe we have one . During an observation and interview on 4/6/2023 at 11:52 AM, the Activities Director revealed communication between her, and Resident #102 usually occurred with a translation application on a cell phone. The Activities Director stated she had not provided Vietnamese language movies, books, or other activities for Resident #102. The Activity Director confirmed the activity calendar in Resident #102's room was in the English language and she had not thought to try to provide in the Vietnamese language. The Activities Director stated the daily scheduled activities had not been discussed in the Vietnamese language to the resident. Observation of a translation application on the Activity Director's cell phone, with the Activities Director, showed it took multiple attempts and more than 10 minutes to demonstrate how the translation service worked. The Activities Director stated she was not aware any further translation services available at the facility.

Based on facility policy review, facility investigation review, medical record review, observation and interview, the facility failed to protect 2 Residents (#56 and #17) from physical abuse of 30 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse Prevention/Reporting Policy and Procedure, dated 2018, showed .Residents must not be subjected to abuse by anyone, including, but not limited to employees, other residents .Abuse is defined as willful infliction of injury . Resident #56 was admitted to the facility 10/1/2021, with diagnoses including Vascular Dementia without Behavioral Disturbance, Hypertension, Type II Diabetes Mellitus, Major Depressive Disorder and Chronic Kidney Disease. Review of Resident #56's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had severe cognitive impairment, a short and long term memory problem, and displayed inattention and disorganized thinking during the assessment. Resident #56 required extensive assistance of 1 staff member for bed mobility, transfer and activities of daily living. The resident required supervision of 1 staff for locomotion on the unit. The resident received anti-anxiety and anti-depressant medications for the past 7 day look back period. Resident #332 was admitted to the facility on [DATE], with diagnoses including: COVID-19, Encephalopathy, Unspecified Intellectual Disabilities, Adjustment Disorder, Cognitive Communication Deficit and Chronic Obstructive Pulmonary Disease. Review of Resident #332's comprehensive care plan dated 9/9/2022, showed .Bx [Hx-history] of physical aggression towards another resident. Resident became physically aggressive towards staff on 9/8/2022 and 2/12/2023. SW to follow up with resident x 3 days dt [due to] altercation .Resident has no awareness of personal space .Resident will not display any physical aggression thru [through] next review . Review of Resident #332's quarterly MDS assessment dated [DATE], showed the resident had moderate cognitive impairment. The resident felt down, tired and bad about herself for 2-6 days, and no behaviors were documented. Resident required limited assistance of 1 staff member for bed mobility, transfer, and activities of daily living. The resident received anti-anxiety medication for the past 7 day look back period. Review of facility documentation, untitled, and undated showed .Female resident [Resident #332] was sitting in the hallway outside of her room. Another female resident [Resident #56] approached her and attempted to touch some of the resident's [Resident #332] personal items .Staff reported that the resident [Resident #332] struck the other female resident [Resident #56] on the upper arm .the residents were separated . Review of facility documentation, untitled, and undated, showed .On 2/12/2023 at approximately 2:45 PM, this writer was walking down the hallway .observed [Resident #332's name] raise hand and strike [Resident #56] on the right shoulder .Residents were separated . During an interview on 4/5/2023 at 10:27 AM, Licensed Practical Nurse (LPN) #2 confirmed both residents were in the hallway, near the nurses station .[Resident #332's name] raised her hand and slapped [Resident #56's name] .I saw it .I couldn't get there fast enough . LPN #2 stated both residents were separated and assessed with no injury. During an interview on 4/5/2023 at 2:20 PM, Social Worker (SW) #1 stated .[Resident #56 name] was a nurturing person, but did not have spatial boundaries, she would get in other people's space . SW #1 described the resident to resident altercation as .[Resident #56 name] was messing with her [Resident #332] stuff and got a little whack from that . During an interview on 4/6/2023 at 9:17 AM, Registered Nurse (RN) #2 confirmed she was aware of the resident to resident altercation. RN #2 stated the facility substantiated the allegation of resident to resident abuse had occurred. Resident #12 was admitted to the facility on [DATE], with diagnoses including Hypertension, Vascular Dementia without Behaviors, Type II Diabetes, Depression, and Anxiety Disorder. Review of Resident #12's comprehensive care plan dated 12/1/2022, showed .resident will maintain stable mood and have improved behaviors in the next 90 days .Interventions approach in a calm manner .Offer activities of interest .Monitor behaviors .Administer medications as ordered .Monitor for side effects of medications . Review of the facility's investigation documentation dated 3/16/2023, showed Certified Nursing Assistant (CNA) #1 stated .female resident [Resident#56] stopped in front of the male resident [Resident #12] and was adjusting her socks and shoes .CNA #1 observed the male resident strike the female resident on the face and knocked off her glasses Did not see the female resident make any contact to the male resident . CNA #1 stated .the 2 residents were separated, and she took the female resident back to her home unit. No injuries noted to either resident . Review of a nurse progress note dated 3/16/2023 5:03 AM, .resident [Resident #56] was brought to the unit with broken glasses, and this nurse was told she was hit in the face by another resident [Resident #12] on another hall. During an interview on 4/6/2023 at 8:45 AM, LPN #1 revealed resident (Resident #56) had come out of her room on to hallway. The altercation occurred when the resident was sitting in wheelchair, in the hallway taking her shoes off. The man (Resident #12) was sitting beside her, and he stated he thought she was going to touch his feet, he struck her in the face knocking her reading glasses off of her face. No injuries were observed to the residents upon assessment. Both residents were separated immediately. During an interview on 4/6/2023 at 10:30 AM, the Regional [NAME] President/Administrator (ADM) #1 confirmed the altercation between Resident #12 and Resident #56 had occurred. Resident #17 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Chronic Pain Syndrome, Major Depressive Disorder, Panic Disorder, Diabetes, Bipolar Disorder, Schizophrenia, and Dementia with Behavior Disturbance. Review of Resident #17's admission MDS assessment dated [DATE], showed a BIMS score of 14 which indicated cognitively intact, verbal behavior symptoms and rejection of care exhibited 1 to 3 days, required supervision for bed mobility, transfer, dressing, personal hygiene, bathing and ambulation. Resident #282 was admitted to the facility on [DATE], with diagnoses including Anxiety Disorder, Alzheimer's Disease, and Dementia without Behavior Disturbance. Review of Resident #282's admission MDS assessment dated [DATE], showed a BIMS score of 1, which indicated had severe cognitive impairment, required limited assistance of 1 staff member for bed mobility, supervision, oversight to walk in room, extensive assistance of 1staff member for dressing, total dependence for toilet use and personal hygiene. Review of Resident #282's nurse progress note dated 4/2/2023 3:19 PM, showed .noted to be wandering around facility without assistance, wandering to different resident rooms and noted to have increased anxiety noted. prn [as needed] [name of anti-anxiety medication] administered and noted to be effective . Review of Resident #17's nurse progress note dated 4/3/2023, showed .RESIDENT STATED SHE WOKE UP AROUND 130P [1:30 pm] TO HER ROOMMATE [Resident #282] TOUCHING HER FACE. AND WHEN SHE OPENED HER EYES, HER ROOMMATE THROUGH THE PAPER BACK BOOK SHE HAD IN HAND AND HIT RESIDENT IN THE HEAD. RESIDENT STATED SHE WASN'T HURT. and thank GOD IT WAS A PAPER BACK BOOK. Review of Resident #282's nurse progress note dated 4/3/2023 at 5:44 PM, showed .At 1:30 pm CNA reported that Resident's roommate reported that resident came into room and put her hand on her face the (roommates face) and made noise in an angry tone. Roommate states I must have went back to sleep for a second I woke up and she had her arm raised. She had a book in her hand and threw it at me Review of a social worker progress note for Resident #17 dated 4/3/2023 at 7:18 PM, showed .Sw [Social Worker] spoke with resident regarding incident with another resident. Resident reports her being asleep and waking up to her roommate having her hand on her face. Then when resident opened her eyes, her roommate had a book in her hand and threw a paperback book at resident hitting her in the head . During an observation and interview on 4/4/2023 at 3:17 PM, Resident #17 stated she liked her new room on the 200 hallway because she doesn't have a roommate. When asked if she recalled an issue with her previous roommate, she stated there was nothing between her and her roommate. During an interview on 4/5/2023 at 2:00 PM, Housekeeper #2 stated she witnessed the incident between Resident #282 and Resident #17 in the resident's room. She stated Resident #282 stood up and pulled the resident's curtain back. She stated she heard Resident #17 say .What are you doing . Housekeeper #2 stated she saw Resident #282 poking Resident #17 in the head with her finger. She stated Resident #17 got out of bed and Resident #282 hit Resident #17 on the head with one of Resident #17's books. She stated she called for help and CNA #3 came in the resident's room. The residents were standing facing each other and the residents were separated. Resident #17 was moved to a different room on a different hallway. Resident #282 was escorted to the nurse's station for observation. During an interview on 4/11/2023 at 4:10 PM, Regional [NAME] President/Administrator (ADM #1) stated she was involved in the investigation of the resident altercation between Resident # 282 and #17 which had occurred. She stated the facility did not consider altercation as abuse. The Interim Administrator stated the facility was aware Resident #282 struck Resident #17 with a book, but there was no psychological harm to the resident, so the facility .did not substantiate abuse . 40639 Surveyor: [NAME]-[NAME], [NAME] 35200

Based on facility policy review, medical record review, resident fund review, and interview the facility failed to issue resident refunds within 30 days of the resident's discharge for 14 residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #14) of 16 residents reviewed. Review of a facility policy titled Resident Refund Policy, dated 3/20/2017, showed .ensure that all resident accounts are reconciled and maintained according to federal and state regulations . Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE]. Review of Resident #1's Acccounts Receivable (A/R) Refund form dated 1/31/2022, showed .Total Amount of refund: $4,294.68 . Review of Resident #1's account activity conducted on 6/28/2022, showed a refund had not been issued. (198 days after discharge). Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged from the facility on 1/4/2022. Review of Resident #2's A/R Refund form dated 1/31/2022, showed .Total Amount of refund: $1,540.00 . Review of Resident #2's account activity conducted on 6/28/2022, showed a refund had not been issued. (175 days after discharge). Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE]. Review of Resident #3's A/R Refund form dated 3/31/2022, showed .Total Amount of refund: $380.00 . Review of Resident #3's account activity conducted on 6/28/2022, showed a refund had not been issued (134 days after discharge). Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE]. Review of Resident #4's A/R Refund form dated 1/31/2022, showed .Total Amount of refund: $320.00 . Review of Resident #4's account activity conducted on 6/28/2022, showed a refund had not been issued (179 days after discharge). Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE]. Review of Resident #5's A/R Refund form dated 3/31/2022, showed .Total Amount of refund: $100.00 . Review of Resident #5's account activity conducted on 6/28/2022, showed a refund had not been issued (186 days after discharge). Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE]. Review of Resident #6's A/R Refund form dated 5/31/2022, showed .Total Amount of refund: $389.00 . Review of Resident #6's account activity conducted on 6/28/2022, showed a refund had not been issued (137 days after discharge). Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE]. Review of Resident #7's A/R Refund form dated 5/31/2022, showed .Total Amount of refund: $6,380.00 . Review of Resident #7's account activity conducted on 6/28/2022, showed a refund had not been issued (56 days after discharge). Resident #8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE]. Review of Resident #8's A/R Refund form dated 3/31/2022, showed .Total Amount of refund: $411.94 . Review of Resident #8's account activity conducted on 6/28/2022, showed a refund had not been issued (165 days after discharge). Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE]. Review of Resident #9's A/R Refund form dated 1/31/2022, showed .Total Amount of refund: $66.00 . Review of Resident #9's account activity conducted on 6/28/2022, showed a refund had not been issued (167 days after discharge). Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE]. Review of Resident #10's A/R Refund form dated 3/31/2022, showed .Total Amount of refund: $5.26 . Review of Resident #10's account activity conducted on 6/28/2022, showed a refund had not been issued (150 days after discharge). Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE]. Review of Resident #11's A/R Refund form dated 2/24/2022, showed .Total Amount of refund: $2,611.20 . Review of Resident #11's account activity conducted on 6/28/2022, showed a refund had not been issued (133 days after discharge). Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE]. Review of Resident #12's A/R Refund form dated 3/31/2022, showed .Total Amount of refund: $870.00 . Review of Resident #12's account activity conducted on 6/28/2022, showed a refund was issued on 6/2/2022 (128 days after discharge). Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE]. Review of Resident #13's A/R Refund form dated 5/31/2022, showed .Total Amount of refund: $1,200.00 . Review of Resident #13's account activity conducted on 6/28/2022, showed a refund was issued on 6/8/2022 (43 days after discharge). Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE]. Review of Resident #14's A/R Refund form dated 1/31/2022, showed .Total Amount of Refund: $2,280.00 . Review of Resident #14's account activity conducted on 6/28/2022, showed a refund was issued on 4/19/2022 (145 days after discharge). During an interview on 6/28/2022 at 12:01 PM, the Business Office Manager (BOM) confirmed Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, and Resident #11 had been discharged from the facility greater than 30 days ago, a refund form had been submitted for processing, and no refund check had been issued. The BOM confirmed the refunds for Resident #12, Resident #13, and Resident #14 were issued greater than 30 days after the resident's discharge. During an interview on 6/28/2022 at 3:30 PM, the Administrator confirmed the facility was required to issue a resident refund within 30 days after the day of discharge. He confirmed the discharge of Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11 had been more than 30 days, and a refund check had not been issued. The Administrator confirmed the refunds for Resident #12, Resident #13, and Resident #14 were issued greater than 30 days past their discharge date .

Based on facility policy review, medical record review, review of facility documentation, and interview, the facility failed to ensure 2 residents (#55 and #53) remained free from abuse of 14 residents reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse Prevention/Reporting Policy and Procedure dated 8/15/2017 showed .Every resident has the right to be free from abuse, neglect, misappropriation .exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint .Residents must not be subjected to abuse by anyone, including, but not limited to .other residents . Medical record review showed Resident #55 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review showed Resident #77 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Medical record review of Resident #77's care plan dated 3/11/2019 showed the resident was care planned for .behavior problem: Hx [history] of delusions, physical and verbal aggression toward staff . Continued review revealed interventions to observe and redirect inappropriate behaviors as needed. Medical record review of a Significant Change Minimum Data Set (MDS) dated [DATE] for Resident #77 showed the resident scored a 5 on the Brief Interview for Mental Status (BIMS) indicating the resident was severely cognitively impaired. Continued review revealed the resident required supervision and set-up help for transfers and locomotion on the unit and was assessed as having behavior problems which interfered with participation in activities and behavior which intruded on the privacy of others. Record review showed the Social Services yearly assessment dated [DATE] included, .[Resident #77] is a long term care resident .alert and pleasant during visit. Brief Interview of Mental Status score of 5 - Severe impairment .Cognitive decline reported and observed .more confused .times when she asked staff if she lives here and unable to find her room or the bathroom .Neurocognitive Impairment/Neurocognitive D/O [disorder] .dx [diagnosis] of Depression, Generalized Anxiety Disorder, [CONDITION(S)], and Pseudobulbar Affect secondary to Dementia .followed by Psych services . Review of a facility Post-Incident Actions dated 3/25/2021 showed .CNA [Certified Nursing Assistant] informed nurse that [Resident #77] slapped another resident [Resident #55] in the face . Review of the facility's Follow-up Report for Resident #55 dated 3/26/2021 - 3/30/2021, showed .Incident Type: Resident to Resident .No injuries noted . Review showed daily assessments done by the Memory Care nursing staff and the Director of Nursing (DON). On 3/26/2021 the assessment included .This resident has no recall. No skin issues .Will continue to observe . Review of Resident #77's Quarterly MDS dated [DATE], showed she had a BIMS of 4 indicating the resident was severely cognitively impaired, required extensive assistance of one person for transfer and for locomotion with her wheelchair. Further review showed the resident was documented as having delusions and physical and verbal behavior symptoms directed towards others 1 to 3 days during the assessment period. Review of Resident #77's nursing notes revealed on 5/24/2021 the resident was transferred to Memory Care (the secured unit) for exit seeking behavior and wandering. Review of a nursing note dated 5/25/202, showed Resident #77, while seated in a wheelchair, approached Memory Care unit CNA #1 while the CNA was assisting another resident (Resident #55) back into her wheelchair. Resident #77, also in a wheelchair, proceeded to hit Resident #55 on the buttocks as Resident #55 sat down in her wheelchair. Resident #77 then slapped Resident #55 on the right side of her face. Further review of the nursing notes showed Resident #77 was transferred to the hospital for evaluation for gero-psych placement. Continued review of the nursing notes showed Resident #77 was readmitted to the facility's Memory Care unit on 5/28/2021. Medical record review showed Resident #53 was admitted to the facility's Memory Care unit on 5/14/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's documentation, dated 5/18/2021, showed on 5/17/2021 .resident to resident abuse .[Resident #77] became upset and smacked Resident #53. Investigation initiated .neither resident received any injury and both could not recall the incident .Resident #77 was admitted to a behavioral facility on 5/20/2021 for further evaluation and treatment . Telephone interview on 6/30/2021 at 8:00 AM, with CNA #2, on 6/30/2021, at 8:00 AM, confirmed she was present when Resident #77, seated in the hall in her wheelchair, reached out and hit Resident #53 on the thigh 3 times as he walked around Resident #77. Continued interview confirmed the CNA immediately separated the residents and notified the nurse in charge. During a telephone interview on 6/30/2021 at 9:00 AM, with Licensed Practical Nurse (LPN) #1, in charge of the Memory Care unit, on 6/30/2021 at 9:00 AM, confirmed her assessment of Resident #53, after the incident on 5/17/2021, showed no injury from the incident and no recall of the incident. The LPN stated .she [Resident #77] had been acting out for months . During an interview on 6/30/2021 at 2:15 PM, with the Administrator, the Administrator confirmed the incidents with Resident #77 were resident to resident abuse.

Based on review of facility policies, medical record review, review of the facility's investigation, interview, and observation, the facility failed to prevent neglect for 1 resident (#7) of 6 residents reviewed for neglect, of 8 residents reviewed. The facility's failure to prevent neglect resulted in a delay in receiving services and treatment after a fall with fractures, with Resident #7 experiencing intense pain, and placing Resident #7 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The facility was cited F600 at a scope and severity of J which constitutes Substandard Quality of Care (SQC). The Immediate Jeopardy (IJ) was effective [DATE] and is ongoing. The findings include: Review of the facility's policy titled Change in a Resident's Condition or Status dated [DATE] revealed .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician and the resident's representative when there has been .d. A significant change in the resident's physical/emotional/mental condition; that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications . Review of the facility's policy titled Abuse Prevention/Reporting Policy and Procedure dated (YEAR) revealed .7. Neglect: the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 2 staff for bed mobility (how resident moves to and from lying position, turns side to side). Review of the facility's incident report dated [DATE] at 6:45 AM, revealed Resident #7 .was noted to slide off air mattress on to the floor during a bed change .no injury noted . Review of the facility's investigation revealed a written statement completed by Certified Nursing Assistant (CNA) #8 dated [DATE], which stated .I was in the middle of changing patient sheets, when patient rolled over. She slid out of the bed and landed on her knees and fell toward her left side . Medical record review of the Medication Administration Record [REDACTED]. Continued review revealed Resident #7 was prescribed [MEDICATION NAME]-APAP 7XXX,[DATE] milligrams (mg) every 4 hours as needed (PRN) for pain on [DATE]; [MEDICATION NAME] 50 mg every 12 hours for pain on [DATE]; and [MEDICATION NAME] 12 mcg (micrograms)/HR (per hour) patch every 72 hours for pain on [DATE] prior to the fall. Medical record review of the (MONTH) MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] at 11:00 AM, revealed the resident complained of bilateral hip and left shoulder pain and x-rays of the hips and shoulder were ordered. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of the radiology report for the bilateral hips and left shoulder x-rays dated [DATE] revealed no fracture or dislocation. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] at 12:10 PM, revealed the resident still had complaints of pain related to the fall and pain medications were given as ordered. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] at 12:30 PM revealed Resident #7's bilateral knees were swollen and bruised. Further review revealed .on Dr.'s (physician) board for today (indicating the resident was to be seen by the physician or Nurse Practitioner) . Further medical record review revealed no documentation the resident was seen by the physician or Nurse Practitioner (NP) on [DATE]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] at 2:30 AM, revealed the resident woke up at night complaining of pain in the legs and knees and pain medication was given. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of a physician's telephone order dated [DATE] at 1:30 PM, revealed an order for [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of the radiology report dated [DATE] revealed .Impacted right knee fracture involving the distal femoral metaphysis .Impacted fracture (left) involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Old internally fixated proximal tibial fracture . Medical record review of the radiology report and nursing notes dated [DATE] revealed the x-ray results was reported to the Director of Nursing (DON). Further review revealed no documentation the physician or NP were notified of the bilateral fractures. Further review revealed the nurse scheduled an appointment for Resident #7 to be seen by an orthopedic physician on [DATE]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] revealed Resident #7's bilateral knees remained bruised. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review revealed the first documentation the resident was seen by a physician following the fall on [DATE] was on [DATE] when the resident was sent to the orthopedic physician's office. Medical record review of the History and Physical completed by the orthopedic physician dated [DATE] revealed Resident #7 was complaining of pain only in her knees and legs, but it was quite significant. Continued review revealed both knees were swollen and deformed with some flexion. Resident #7 had some mild ecchymosis (bruising) around the knees. Further review revealed Resident #7 had significant osteoporotic appearing bone with significant arthritis and previous tibial hardware in both legs. The resident had bilateral distal femur fractures. The resident was admitted to the hospital because of the severity of the knee fractures. Medical record review of the hospital Death Summary completed by the orthopedic surgeon dated [DATE] revealed Resident #7 .sustained bilateral distal femur fractures. She was in extreme pain at the time of admission .She was normally non ambulatory however the fractures were extremely painful and they were repaired for palliative reasons .Palliative Care was consulted to discuss goals of care with the patient's family due to her severe debility and multiple comorbidities . The resident expired [DATE]. Telephone interview with the NP on [DATE] at 9:25 AM, revealed she remembered Resident #7 had a fall. The NP stated she gave the order for x-ray of both knees on [DATE] because the resident was still hurting. Telephone interview with CNA #8 on [DATE] at 10:55 AM revealed she was making her last round around 6:45 AM on [DATE] and went into Resident #7's room to change the resident. CNA #8 stated when she turned Resident #7 over to change the sheet, the resident fell to the floor and landed on her knees. CNA #8 stated she screamed for help, the nurse came in to assess the resident, and they put the resident back to bed. CNA #8 stated the resident grabbed her knees after she fell . Interview with Registered Nurse (RN) #2 on [DATE] at 11:30 AM, at a location outside the facility, revealed when she came in to work on [DATE] for the 7:00 AM to 7:00 PM shift, she was told Resident #7 rolled out of bed and had fallen to the floor. RN #2 stated she assessed the resident who complained of pain in the left shoulder and left hip, so she texted the Director of Nursing (DON) at 9:30 AM, and was given verbal permission to get x-rays of the shoulder and bilateral hips. RN #2 stated the resident was in pain and would scream when moved or turned. Further interview with RN #2 revealed when she worked Sunday [DATE], the resident was still complaining of pain. RN #2 further stated she knew the resident was in pain. Continued interview with RN #2 revealed she did not work [DATE], [DATE], and [DATE]. On [DATE], when she returned to work, the resident still had not been seen by either the doctor or the Nurse Practitioner (NP), but the NP was at the nurses' station, so she asked if she could get x-rays of the knees for Resident #7. The nurse stated when she got the x-ray report on [DATE] she scheduled an appointment with an orthopedic surgeon for [DATE]. Further interview with RN #2 confirmed the NP had not been made aware of the resident's complaints of knee pain prior to [DATE]. Telephone interview with RN #4 on [DATE] at 1:00 PM, revealed the resident was alert with confusion at times. RN #4 stated Resident #7 was not a complainer and usually would not volunteer to tell you she was hurting. RN #4 stated on [DATE] the resident was in so much pain, the CNAs reported the resident would scream when she was turned. RN #4 stated she then went in to talk with Resident #7, who stated her knees hurt badly. RN #4 stated both knees were swollen and black and blue. RN #4 stated on [DATE] there was a sign posted at the nurses' station to go to the supervisor before calling the physician, so she went to the Assistant Director of Nursing (ADON). The RN told the ADON the resident was in severe pain and the ADON asked .from what . RN #4 replied, .probably from the fall she had . According to RN #4, the ADON stated they had performed x-rays and they were all negative. RN #4 informed the ADON, .no, we have not x-rayed the knees . The ADON replied it was too late to call the physician and to place the resident on the Dr.'s Board (place to notify the physician or NP residents who need to be seen on next visit) for the resident to be seen the next day. RN #4 stated on [DATE], she saw the physician and the NP in the facility, but they never came to the floor to see Resident #7. RN #4 revealed when she spoke to the ADON on [DATE], she reminded her Resident #7 needed to be seen. The ADON replied the physician and NP were not seeing residents that day. RN #4 stated she did not work on [DATE], [DATE], and [DATE]. RN #4 confirmed the resident was not seen by the physician or NP on [DATE] or [DATE] when she was on duty and she had reported to the ADON the resident needed to be seen. RN #4 further confirmed Resident #7 was never a good eater, but was not eating as much since the accident, and the resident was in pain. RN #4 further confirmed she administered the resident pain medication as much as possible to keep her comfortable. Interview with the Restorative Aide on [DATE] at 9:50 AM, in the Resting Lounge, revealed she had worked with Resident #7 multiple times doing Range of Motion (ROM). The Restorative Aide stated after the fall on [DATE], the resident didn't want her to do ROM on her legs at all. The Restorative Aide stated the resident told her she had a fall and was in .so much pain . The Restorative Aide further stated the resident was also moaning, and her complaint of pain was different from her normal baseline and .enough to get my attention . Interview with CNA #4 on [DATE] at 10:50 AM, in the Resting Lounge, revealed Resident #7 was never really one to complain of pain but would close her eyes and crunch up her face when in pain. CNA #4 stated before the fall when she would turn the resident, she would complain of pain and may complain more on rainy or cold days. After the fall, the resident was in a lot of pain all the time. CNA #4 stated when she turned the resident, she would scream out in pain and complained her knees were hurting. The CNA stated the resident's knees were swollen and bruised. CNA #4 stated she was working [DATE], and it was either [DATE] or [DATE], when she first noticed the bruising and swelling of both knees of Resident #7 and notified the nurse. When asked if the resident's complaints of pain were different after the fall, the CNA replied .absolutely . CNA #4 stated the resident was screaming with intense pain, especially on turning. CNA #4 stated the nurses told the CNAs nursing had been instructed to put it on the doctor's board and the resident's condition could wait until the physician came. CNA #4 stated she felt the nurses on the floor and the CNAs did everything they could do, but she .laid there several days in pain . Telephone interview with the former DON (who was DON at the time of the incident) on [DATE] at 10:15 AM, revealed he did not remember anything about the incident. The DON confirmed several days after the fall, when he was told the resident was complaining of knee pain and the nurses had seen bruising, he told the nurse to obtain x-rays of the knees and an orthopedic appointment. During observation and interview with RN #4 on [DATE] at 12:10 PM, in the Resting Lounge, the nurse presented a piece of paper, which she stated she had taken down from the nurses' station, .Staff are never to call Dr. (Medical Director) or his NP until contact has been made with the on-call Nurse Mgr. (manager). If you have questions about this see (DON) or (ADON). The sign had the DON's name typed at the bottom. RN #4 also presented a copy of the physician board sheet which revealed a notation dated [DATE] for Resident #7 XXX,[DATE] S/P (status [REDACTED]. Continued interview with RN #4 revealed the nurses were to call management before calling the physician. When asked when the sign was taken down from the nurses' station, the nurse replied when they found out they were being sued. RN #4 confirmed she saw a big change in Resident #7after the fall where she didn't eat as well and she didn't want to be changed by the CNAs. Interview with the Regional Quality Specialist on [DATE] at 3:20 PM, in the Resting Lounge, revealed, when asked what she would have expected the nursing staff to do when the resident continued to complain of pain, and especially knee pain, the Regional Quality Specialist replied .would have expected a call placed to provider . Telephone interview with the attending physician (medical doctor) on [DATE] at 3:45 PM revealed, when asked what he would have expected the nursing staff to do for any change in resident status including increased pain or swelling and bruising of both knees, the physician stated he would have expected to be called regarding these changes. The physician further confirmed he did not remember the facility calling him for any changes to Resident #7. Interview with CNA #17 on [DATE] at 4:00 PM, in the upper 400 hall shower room, revealed when she took care of Resident #7, she observed the knees swollen and the resident stated she had fallen out of bed. The CNA informed RN #4 the resident's knees were swollen and painful on turning. The CNA stated RN #4 said she had been told to put it on the doctor's board. CNA #17 confirmed both knees were swollen and the resident complained of a lot of pain on [DATE]. The CNA stated she asked nursing again on [DATE] about the resident being seen by the physician and was told the doctor had still not seen the resident. Interview with CNA #18 on [DATE] at 4:15 PM, in the upper 400 hall shower room, revealed Resident #7's legs and knees were swollen and she .screamed . when turned and would say .Oh Please, Please, Please . during ADL (activities of daily living) care. The CNA further stated she asked staff everyday if anything had been done for the resident, such as an x-ray, and was told no. Interview with RN #2 on [DATE] at 5:45 PM, at the 400 hall nurses' station, revealed when she left work on [DATE] the results of the x-rays of the bilateral knees for Resident #7 had not returned. RN #2 stated when she came in on [DATE], she read the x-ray results and was in contact with the DON per text messaging. RN #2 stated she received a text from the DON, ortho (orthopedic physician) appointment ? When the RN was asked who gave the order for Resident #7 to go to the orthopedic physician's office, the nurse replied the DON. The RN stated she then started calling around to orthopedics and many did not want to see the resident due to the resident's previous surgery and hardware in her leg. The RN stated she talked to the resident, who could not remember the name of the orthopedic she had previously seen. RN #2 stated she kept calling and finally got in touch with the orthopedic who had done the previous surgery and made an appointment for Monday,[DATE]. When RN #2 was asked if she had given the resident or the Power of Attorney (POA) the option of going to the hospital or waiting to go to the orthopedic surgeon, the RN replied she did not but didn't know if anyone else had. When RN #2 was asked how Resident #7 was from [DATE] until the doctor appointment on [DATE], the RN replied the same. RN #2 stated they kept the resident comfortable with the [MEDICATION NAME], and [MEDICATION NAME] the resident had been prescribed prior to the accident on [DATE]. Telephone interview with the Medical Director, who was the resident's attending physician, on [DATE] at 5:59 PM, revealed, when asked did he know about the bilateral fractures of Resident #7, he replied .this is the first I've heard right now . When asked if he would have expected to be notified, the physician replied all fractures should be called to the physician or the person on call. When asked what would be his plan of care, the physician replied he would ask the resident and/or family if they wanted to go to the hospital, go to the physician, or did they need to be seen now. Telephone interview with the NP on [DATE] at 9:11 PM, revealed the NP had reviewed her notes for Resident #7 and found no notation of being notified of the results of the bilateral knee x-rays. Interview with the Administrator on [DATE] at 9:00 AM, in the Administrator's Office, revealed during review of nursing notes for [DATE] and [DATE], the Administrator did not see the physician or NP had been notified of the results of the bilateral knee x-rays. When asked when she became aware of the fall and fractures related to Resident #7, the Administrator replied when Adult Protective Services came in (MONTH) of (YEAR). Continued interview with the Administrator confirmed when asked if the documentation showed the physician or the NP had been made aware of the results of the bilateral knee x-rays the Administrator shook her head back and forth and stated .no .

Based on medical record review, facility investigation review, and interview, the facility failed to implement a comprehensive care plan for 1 resident (#7) of 6 residents reviewed for accidents and incidents, of 8 sampled residents. The facility's failure to implement the care plan interventions resulted in impacted fractures of both lower extremities and placed Resident #7 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Immediate Jeopardy (IJ) was effective 11/11/17 and is ongoing. The findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 2 staff for bed mobility (how resident moves to and from lying position, turns side to side). Medical record review of Resident #7's care plan, reviewed and updated 9/1/17, revealed for the problem of self-care deficit related to bedbound status, the resident's approach included .Bed mobility extensive assist of two . Medical record review of the Interdisciplinary Care Plan (used by the Certified Nurse Assistants (CNAs)), not dated, revealed Resident #7 was a two person assist for bed mobility. Review of the facility's incident report dated 11/11/17 at 6:45 AM revealed Resident #7 .was noted to slide off air mattress on to the floor during a bed change. Resident did not strike her head. Head to toe assessment performed, no injury noted .Two CNAs will be needed to turn resident on air mattress to prevent further falls . Review of the resident's care plan and assessment revealed the resident required a two person assist for bed mobility prior to the accident on 11/11/17. Review of the facility's investigation revealed a written statement completed by CNA #8 dated 11/11/17, which stated .I was in the middle of changing patient sheets, when patient rolled over. She slid out of the bed and landed on her knees and fell toward her left side and did not hit her head . Medical record review of nursing notes dated 11/11/17 revealed the resident complained of pain in the hips and left shoulder and x-rays of the bilateral hips and left shoulder were ordered. Medical record review of the radiology report dated 11/11/17 revealed .Minimal to moderate [MEDICAL CONDITION] changes to the right hip .Moderate to severe [MEDICAL CONDITION] changes of the left hip . No fracture, dislocation, [MEDICAL CONDITION] changes or destructive [MEDICAL CONDITION] of the left shoulder were present. Medical record review of the resident's care plan revealed on 11/13/17 .noodles to bed . had been added as an intervention for at risk for falls due to decrease in mobility. Medical record review of a physician's telephone order dated 11/16/17 at 1:30 PM revealed an order for [REDACTED]. Medical record review of the radiology report dated 11/16/17 revealed .Impacted right knee fracture involving the distal femoral metaphysis .Impacted fracture (left) involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Old internally fixated proximal tibial fracture . Interview with the Administrator on 7/10/18 at 9:00 AM, in the Conference Room, revealed Resident #7 did have a fall in (MONTH) of (YEAR) when a CNA turned the resident in the bed and the resident fell to the floor. Continued interview with the Administrator revealed the resident should have been turned by 2 staff members. When asked if the resident was care planned for 2 staff members the Administrator stated yes. Telephone interview with CNA #8 on 7/10/18 at 10:55 AM revealed she was making her last round around 6:45 AM on 11/11/17 when she went into Resident #7's room. The CNA stated when she went to change the resident she noticed something on her sheet, so she decided she would change the sheet. CNA #8 stated the resident had always grabbed the hand rail to hold when she turned but for some reason she did not get a grip on the hand rail. The CNA stated when she turned Resident #7 over to change the sheet, the resident fell to the floor and landed on her knees. CNA #8 stated she screamed for help and the nurse came in to assess the resident and then they put the resident back to bed. CNA #8 stated the resident grabbed her knees after she fell . When CNA #8 was asked had she been turning Resident #7 by herself, the CNA responded she had always turned the resident by herself. When CNA #8 was asked how did she know if a resident was a 1 person or a 2 person assist for bed mobility or transfer, the CNA stated .by word of mouth .asked other CNAs . Interview with Registered Nurse (RN) #3 on 7/10/18 at 12:05 PM, in the Conference Room, revealed each nurses' station had a CNA binder book which had the Interdisciplinary Care Plans for the CNAs to follow and included assistance needed for Activities of Daily Living (ADL). Interviews with 16 CNAs on 7/10/18 and 7/11/18 revealed all but 2 (CNA #8 and #11) knew about the CNA binders at each nurses' station. Interview with CNA #11 on 7/10/18 at 5:18 PM, at the 300 Hall nurses' station, revealed when asked about the CNA binder, he replied .never used it . Telephone interview with the former Director of Nursing (DON) on 7/11/18 at 10:15 AM, revealed when he was asked if he was aware Resident #7 was care planned for a 2 person assist during bed mobility, he replied no, she was a 2 person assist only for transfer from bed to chair. The DON stated he did remember implementing a practice change to deflate the air mattress before doing care and turning. Interview with the Regional Quality Specialist on 7/11/18 at 3:20 PM, in the Resting Lounge, revealed when the Regional Quality Specialist was asked what she would have expected when a CNA stated she was not aware of the CNA Care Guides, which documented assistance needed for ADLs, the Regional Quality Specialist replied .would have expected all CNAs would have been in-serviced on the Care Guides . Refer to F-689

Based review of facility's policies, review of Rules and Regulations of Registered Nurses, review of Tennessee Code Annotated, medical record review, facility investigation review, interview, and observation, the facility failed to assure the services provided met professional standards of quality and acceptable standards of clinical practice for 1 resident (#7), of 8 residents reviewed. The facility's failure to ensure care was provided within professional scope of practice resulted in Resident #7 sustaining bilateral fractures, nursing staff ordering interventions without consulting with physician services, and placed Resident #7 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, impairment or death to a resident). The Immediate Jeopardy (IJ) was effective 11/11/17 and is ongoing. The findings include: Review of the facility's policy titled Change in a Resident's Condition or Status dated 12/28/16 revealed .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician .when there has been .d. A significant change in the resident's physical/emotional/mental condition; that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications .2. A significant change of condition is a decline or improvement in the resident's status . Review of the Tennessee Rules and Regulations of Registered Nurses Chapter 1000-01 revised June, (YEAR) revealed .3 .(a) Responsibility .Registered nurses are liable if they perform delegated functions they are not prepared to handle by education and experience and for which supervision is not provided. In any patient care situation, the registered nurse should perform only those acts for which each has been prepared and has demonstrated ability to perform, bearing in mind the individual's personal responsibility under the law . Review of the Tennessee Code Annotated 63-7-103 Practice of professional nursing and professional nursing defined revealed .(F) .(b) Notwithstanding subsection (a), the practice of professional nursing does not include acts of medical [DIAGNOSES REDACTED]. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of the facility's investigation revealed a written statement completed by Certified Nursing Assistant (CNA) #8 dated 11/11/17, which stated .I was in the middle of changing patient sheets, when patient rolled over. She slid out of the bed and landed on her knees and fell toward her left side and did not hit her head . Medical record review of nurse's notes dated 11/11/17 at 11:00 AM, revealed the resident complained of bilateral hip and left shoulder pain and x-rays had been ordered. Medical record review of a telephone order dated 11/11/17, at 10:45 AM, revealed .Bilateral hips & (and) L (left) shoulder x-ray .fall .VORB (verbal order read back) (name of the former Director of Nursing) Continued review of the order revealed the order was a verbal order written by a Registered Nurse (RN) and given by the former Director of Nursing (DON). Medical record review of the radiology report for the hips and left shoulder dated 11/11/17 revealed no fracture or dislocation of left shoulder or hips was present. Medical record review of nurse's notes dated 11/14/17 at 12:30 PM, revealed the resident's bilateral knees were swollen and bruised. Further review revealed .on Dr.'s (physician) Board (meaning the resident was on the list to be seen by the physician) for today . Medical record review of a physician's telephone order dated 11/16/17 at 1:30 PM, revealed a verbal order for x-ray of bilateral knees given by the Nurse Practitioner (NP). Medical record review of the radiology report dated 11/16/17 revealed .Impacted right knee fracture involving the distal femoral metaphysis .Impacted fracture (left) involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Old internally fixated proximal tibial fracture . Medical record review of a nursing progress note dated 11/16/17 revealed the DON was notified of the results of the x-ray on 11/16/17 at 9:10 PM. Continued review of the nursing progress note and the radiology report revealed no documentation the physician or NP had been notified. Medical record review of a nurse's note dated 11/17/17 revealed .spoke to resident's sister .to notify her of resident's orthopedic appt (appointment) . Medical record review revealed there was no documentation of an order for [REDACTED].>Telephone interview with the Nurse Practitioner (NP) on 7/10/18 at 9:25 AM, confirmed she gave the order for the x-ray of the knees on 11/16/17 because the resident was still in pain. Interview with RN #2 on 7/10/18 at 11:30 AM, at a location outside the facility, revealed when she came to work on 11/11/17 for the 7:00 AM to 7:00 PM shift, she was told Resident #7 rolled out of bed and had fallen to the floor. RN #2 stated she assessed the resident who complained of pain in the left shoulder and left hip, so she texted the DON at 9:30 AM and was given verbal permission by the DON to order x-rays of the shoulder and bilateral hips. Continued interview with RN #2 revealed when she returned to work on 11/16/17 the resident still had not been seen by the Nurse Practitioner (NP) or the physician, but the NP was at the nurses' station, so she asked if she could get x-rays of the knees of Resident #7. Telephone interview with RN #4 on 7/10/18 at 1:00 PM, revealed on 11/13/17 and 11/14/17 there was a sign posted at the nurses' station to notify the supervisor before calling the physician or NP, so she reported to the Assistant Director of Nursing (ADON) Resident #7 was having knee pain and x-rays of the knees had not been done. The ADON instructed RN #4 to place the resident on the Dr.'s Board. RN #4 confirmed Resident #7 was not seen by the physician or the NP on 11/13/17 or 11/14/17. Telephone interview with the former DON (who was DON at time of the incident) on 7/11/18 at 10:15 AM, revealed he didn't remember anything about the incident. The DON confirmed several days after the fall, when he was made aware the resident was having a lot of pain and swelling and bruising of both knees, he instructed the nurses to get x-rays and an orthopedic appointment. Observation and interview with RN #4 on 7/11/18 at 12:10 PM, in the Resting Lounge, revealed she presented a sign she stated she took down from the nurses station which read .Staff are never to call Dr. (Medical Director) or his NP until contact has been made with the on-call Nurse Mgr. (manager). If you have questions about this see (DON) or (ADON). The DON's name was typed on the bottom. Continued interview with RN #4 revealed the nurses were to call management first. Interview with the Regional Quality Specialist on 7/11/18 at 3:20 PM, in the Resting Lounge, revealed she was in the building at least monthly 2-3 days at a time. When asked if she had ever seen the sign regarding not to call the physician or NP, the Regional Quality Specialist stated she had not seen it and the DON (who was ADON at time of incident) had told her there was no sign. When asked what she would have expected the nursing staff to do when the resident continued to complain of pain, and especially knee pain, the Regional Quality Specialist replied .would have expected a call placed to the provider . Interview with RN #2 on 7/13/18 at 5:45 PM, at the 400 hall nurses' station, revealed when she left work on 11/16/17, the results of the x-rays of the bilateral knees for Resident #7 had not returned. RN #2 stated when she returned to work on 11/17/18 she read the x-ray results and was in contact with the DON per text messaging. RN #2 stated she received a text from the DON regarding .ortho (orthopedic physician) appointment? . When the RN was asked who gave the order for Resident #7 to go to the orthopedic's office, the nurse replied the DON. Telephone interview with the Medical Director, attending physician, on 7/13/18 at 5:59 PM, revealed when asked did he know about the bilateral fractures of Resident #7, he replied .this is the first I've heard right now . Interview with the Administrator on 7/13/18 at 6:05 PM, at the 400 hall nurses' station, revealed when shown the nurses' notes of 11/16/17, of the results of the x-rays and the physician was not noted as being notified, and on 11/17/17 when the staff made an appointment with an orthopedic surgeon without a physician's orders [REDACTED].(DON) is not a Doctor .

Based on medical record review, facility investigation review, and interview, the facility failed to prevent an avoidable accident for 1 resident (#7) of 6 residents reviewed for accidents, of 8 sampled residents. The facility's failure to prevent an avoidable accident resulted in a fall, in which Resident #7 sustained bilateral impacted knee fractures, and placed Resident #7 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The facility was cited F689 at a scope and severity of J, which constitutes Substandard Quality of Care (SQC). The Immediate Jeopardy (IJ) was effective [DATE] and is ongoing. The findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 2 staff for bed mobility (how resident moves to and from lying position, turns side to side). Medical record review of the Fall Risk Evaluation dated [DATE] revealed Resident #7 scored 16 (score of 10 or higher placed the resident at risk for falls). Medical record review of Resident #7's care plan reviewed and updated [DATE], revealed for the problem of self-care deficit, related to bedbound status, the resident's approach included .Bed mobility extensive assist of two . Medical record review of the Interdisciplinary Progress Notes dated [DATE] revealed Resident #7 required extensive assist of two persons for bed mobility. Medical record review of the Interdisciplinary Care Plan (used by the Certified Nursing Assistants), not dated, revealed Resident #7 was a two person assist for bed mobility. Review of the facility's incident report dated [DATE] at 6:45 AM, revealed Resident #7 .was noted to slide off air mattress on to the floor during a bed change. Resident did not strike her head. Head to toe assessment performed, no injury noted .Sister .Dr (physician) .notified. Two CNAs (Certified Nursing Assistants) will be needed to turn resident on air mattress to prevent further falls . Continued review revealed the resident was care planned and assessed as a 2 staff assist for bed mobility prior to the accident. Review of the facility's investigation revealed a written statement completed by CNA #8 dated [DATE], which stated .I was in the middle of changing patient sheets, when patient rolled over. She slid out of the bed and landed on her knees and fell toward her left side and did not hit her head . Medical record review of nurse's notes dated [DATE] at 11:00 AM, revealed the resident complained of bilateral hip and left shoulder pain and x-rays were ordered. Medical record review of the radiology report dated [DATE] revealed .Minimal to moderate [MEDICAL CONDITION] changes to the right hip .Moderate to severe [MEDICAL CONDITION] changes of the left hip . No fracture or dislocation of the left shoulder was present. Medical record review of the Fall Risk Evaluation dated [DATE] revealed Resident #7 scored 18 (score of 10 or higher placed the resident at risk for falls). Review of the 5 WHYs worksheet (a worksheet used to ask 5 why questions to determine the root cause of a problem and implement interventions to prevent recurrence) revealed the worksheet was incomplete for the resident's accident. Further review revealed Define the problem: Resident slid out of bed . Further review revealed 5 boxes on the worksheet under why is it happening? with an area to answer why it happened, followed by why is that? and then a space to continue answering until the root cause was found. Further review revealed only 1 of the 5 why boxes was completed with, Air mattress unstable on edge of bed and then an arrow drawn to the side stating, use two CNAs to change or reposition resident, an intervention that was already to be done. Medical record review of nurse's notes dated [DATE] at 12:10 PM, revealed the resident still had complaints of pain related to the fall. Medical record review of the Interdisciplinary Progress Notes dated [DATE] revealed, IDT (Interdisciplinary Team) clinical post fall [DATE], slide from air mattress during care. 0 (no) injurys (injuries) .foam noodles added to bed . Medical record review of the resident's care plan revealed on [DATE] .noodles to bed . had been added as an intervention for at risk for falls due to decrease in mobility. Medical record review of nurse's notes dated [DATE] at 12:30 PM, revealed Resident #7's bilateral knees were swollen and bruised. Further review revealed .on Dr.'s (physician) Board for today (indicating the resident was to be seen by the physician or Nurse Practitioner) . Medical record review of a physician's telephone order dated [DATE] at 1:30 PM, revealed an order for [REDACTED]. Medical record review of the radiology report dated [DATE] revealed .Impacted right knee fracture involving the distal femoral metaphysis .Impacted fracture (left) involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Old internally fixated proximal tibial fracture . Continued review revealed the Director of Nursing (DON) was notified of the results of the x-ray on [DATE] at 9:10 PM, and the family was notified of the results at 9:20 PM. Medical record review of nurse's notes dated [DATE] revealed the bilateral knees remained bruised. Medical record review of the office History and Physical completed by the orthopedic physician dated [DATE] revealed Resident #7 was complaining of pain only in her knees and legs, but it was quite significant. Continued review revealed both knees were swollen and deformed with some flexion. Resident #7 had some mild ecchymosis (bruising) around the knees. Further review revealed Resident #7 had significant osteoporotic appearing bone with significant arthritis and previous tibial hardware in both legs. The resident had bilateral distal femur fractures. The resident was admitted to the hospital due to the severity of the knee fractures. Medical record review of the hospital Death Summary dated [DATE], revealed Resident #7 .sustained bilateral distal femur fractures. She was in extreme pain at the time of admission and was initially admitted .She was normally non ambulatory however the fractures were extremely painful and they were repaired for palliative reasons .Palliative Care was consulted to discuss goals of care with the patient's family due to her severe debility and multiple comorbidities . The resident expired [DATE]. Interview with the Administrator on [DATE], at 9:00 AM, in the Conference Room, confirmed Resident #7 had a fall in (MONTH) (YEAR). Continued interview with the Administrator revealed when asked if the resident was assisted by 1 or 2 people, the Administrator stated only one. When asked how many staff members were to assist the resident the Administrator replied .2 . Telephone interview with the Nurse Practitioner (NP) on [DATE] at 9:25 AM, revealed she remembered Resident #7 had a fall. The NP stated she gave the order for the x-ray of the knees on [DATE] because the resident was still hurting. Telephone interview with CNA #8 on [DATE] at 10:55 AM, revealed she was making her last round around 6:45 AM on [DATE], and went to change Resident #7 when she noticed something on her sheet, so she decided she would change the sheet. CNA #8 stated the resident had always grabbed the hand rail to hold onto when she turned, but for some reason she did not get a grip on the hand rail. CNA #8 stated when she turned Resident #7 over to change the sheet, the resident fell to the floor and landed on her knees. CNA #8 stated she screamed for help and the nurse came in to assess the resident and then the staff put the resident back to bed. CNA #8 stated the resident was .shaking really bad and I couldn't even get her vital signs . CNA #8 stated the resident grabbed her knees after she fell . When CNA #8 was asked had she been turning Resident #7 by herself, the CNA responded she had always turned the resident by herself. When CNA #8 was asked how did she know if a resident was a 1 person or a 2 person assist for bed mobility or transfer, the CNA stated .by word of mouth .asked other CNAs . Interview with Registered Nurse (RN) #3 on [DATE] at 12:05 PM, in the Conference Room, revealed each nurses' station had a CNA binder book which had the Interdisciplinary Care Plans for the CNAs to follow, and included assistance needed for Activities of Daily Living (ADL). Interviews with 16 CNAs on [DATE] and [DATE] revealed all but 2 (CNA #8 and #11) knew about the CNA binders at each nurses' station and where to find the information needed for resident care. Interview with CNA #11 on [DATE] at 5:18 PM, at the 300 hall nurses' station, revealed he didn't use the care guides and didn't know anything about them. Interview with RN #2 on [DATE] at 11:30 AM, at a location outside the facility, revealed when she came to work on [DATE] for the 7:00 AM to 7:00 PM shift, she was informed Resident #7 rolled out of bed and had fallen to the floor. RN #2 stated she assessed the resident who complained of pain in the left shoulder and left hip, and obtained x-rays of the shoulder and hips. RN #2 stated the resident was in pain and would scream when moved or turned. Further interview with RN #2 revealed when she worked Sunday [DATE], the resident was still complaining of pain. Further interview with RN #2 confirmed the NP had not been made aware of the resident's complaints of knee pain until [DATE], when an order to obtain x-rays of the bilateral knees was given by the NP. Telephone interview with RN #4 on [DATE] at 1:00 PM, revealed the resident was alert with confusion at times. RN #4 stated on [DATE] the CNAs reported the resident would scream when she was turned. RN #4 stated she went in to talk with Resident #7 who stated her knees hurt her badly. RN #4 confirmed the resident was not seen by the physician or NP on [DATE] or [DATE]. Interview with CNA #4 on [DATE] at 10:50 AM, in the Resting Lounge, revealed when she turned the resident she would scream out in pain in her knees. The resident's knees were swollen and bruised. When she was working [DATE] and it was either [DATE] or [DATE] when she notified the nurse of the swelling and bruising of both knees of Resident #7. Telephone interview with the former DON (who was DON at time of the incident) on [DATE] at 10:15 AM, revealed he didn't remember anything about the incident. When asked if he was aware the resident was care planned for a 2 person assist during bed mobility, he replied she was a 2 person assist only for transfer from bed to chair. The former DON stated he did remember they implemented a practice change to deflate the air mattress before doing care and turning residents. Interview with the Regional Quality Specialist on [DATE] at 3:20 PM, in the Resting Lounge, revealed she was in the building at least monthly ,[DATE] days at a time. The duties of the Regional Quality Specialist included survey readiness, compliance, review of policies and procedures, and performance improvement plans. When asked when she became aware of the accident of [DATE], the Regional Quality Specialist stated on Monday [DATE] when she came into the facility. When the Regional Quality Specialist was asked what she would have expected when a CNA stated she was not aware of the CNA Care Guides which documented assistance needed for ADLs, the Regional Quality Specialist replied .would have expected all CNAs would have been in-serviced on the Care Guides . Interview with CNA #17 on [DATE] at 4:00 PM, in the upper 400 hall shower room, revealed when she took care of Resident #7 she observed the knees swollen and the resident told the CNA she had fallen out of bed. CNA #17 reported to RN #4 about the knees being swollen and pain on turning and was informed the RN had been instructed to add the resident to the doctor's board by the ADON. CNA #17 confirmed both knees were swollen and the resident complained of a lot of pain on [DATE]. Interview with CNA #18 on [DATE] at 4:15 PM, in the upper 400 hall shower room, revealed Resident #7's legs and knees were swollen and she .screamed . when turned and would say .Oh Please, Please, Please . begging during changing. The CNA further stated she asked nursing everyday if anything had been done for the resident, such as an x-ray and was told no. Interview with the Administrator on [DATE] at 8:10 AM, in the Resting Lounge, revealed the facility discussed falls during the morning meetings and reviewed the 24 hour reports. The facility conducted a Risk Management meeting weekly where they went through all falls for the week. The Administrator stated their process .now . during the risk meeting was to look at interventions to see if the intervention was appropriate, pulling each chart, reviewing the nursing notes and trying to do a better and thorough job. The Administrator confirmed they were not doing this in-depth meeting at the time of Resident #7's accident. The Administrator confirmed if they had been doing the type of risk meeting they were doing now, including reading the nurses notes, they would have been aware of the accident. They would have included a teachable moment for the CNA regarding use of the Care Guides and provided more staff education. The Administrator further stated she could not say at the time of the incident that they read the accident reports out loud or discussed the interventions during the meetings but .We do now . When asked when they started doing the new process regarding incident reports the Administrator stated it was after [DATE] when the previous DON left. Telephone interview with the Medical Director on [DATE] at 5:59 PM, revealed, when asked did he know about the bilateral fractures of Resident #7, he replied .this is the first I've heard right now . The MD confirmed all fractures should be called to the physician or the person on call. Interview with the Administrator on [DATE] at 9:00 AM, in the Administrator' Office, confirmed she became aware of the fall and fractures for Resident #7 when Adult Protective Services (APS) came in (MONTH) of (YEAR). The Administrator confirmed the incident resulting in bilateral fractures involving Resident #7 was not discussed for implementation of a corrective action plan.

Based on medical record review, facility investigation review, observation, and interviews, the governing body failed to ensure implemention of policies regarding the management and operation of the facility. The governing body's failure placed 1 resident (#7) of 6 residents of 8 residents reviewed for accidents and incidents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Immediate Jeopardy (IJ) was effective [DATE] and is ongoing. The findings include: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident required extensive assist of 2 staff for bed mobility which include turning from side to side. Medical record review of the care plan updated [DATE] revealed Resident #7 required extensive assistance of 2 for bed mobility. During the survey conducted [DATE] - [DATE], investigation revealed on [DATE] at 6:45 AM, Resident #7 was turned in bed by 1 Certified Nursing Assistant (CNA), instead of 2 CNAs as required, and the resident fell to the floor, landing on her knees. The nurse gave the resident Tylenol for knee pain. X-rays were completed on [DATE] of bilateral hips and left shoulder. The results of the x-rays were negative. Resident #7 continued to complain of pain, especially on turning. Interview with Registered Nurse (RN) #4 on [DATE] revealed on [DATE] Resident #7 was in so much pain the CNAs reported the resident would scream when she was turned. RN #4 assessed Resident #7 and found both knees to be swollen and bruised. According to RN #4 on [DATE] a sign was posted at the nurses station to call the supervisor before calling the physician or the Nurse Practitioner (NP), so RN #4 reported to the Assistant Director of Nursing (ADON) who instructed the nurse to place a note on the Dr's Board (list for physician or NP know the residents needed to be seen the next visit). The physician and the NP were in the facility on [DATE] but did not see Resident #7. Resident #7 continued to have pain on turning from [DATE] until on [DATE], when RN #2 approached the NP, who was at the nursing station and bilateral knee x-rays were ordered. Results of the bilateral knee x-rays revealed bilateral knee fracture involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee). Neither the physician nor the NP were notified of the results of the bilateral knee x-rays. The Director of Nursing (DON) instructed RN #2 by text messaging to make an orthopedic physician's appointment without a physician's orders [REDACTED]. Resident #7 expired on [DATE]. Interview with the Regional Quality Specialist on [DATE] revealed she was in the facility monthly at least ,[DATE] days at a time. Continued interview with the Regional Quality Specialist revealed her duties while in the facility included survey readiness, compliance of policies and procedures, system breakdown, and performance improvement plans. Further interview revealed the Regional Quality Specialist was unaware of the sign hanging at the nurses' station not to call the physician or NP before calling the nursing supervisor. Continued interview revealed the Regional Quality Specialist was to be notified of all fractures but was unaware of the fractures to Resident #7 until [DATE]. When the Regional Quality Specialist was asked what she would have expected the nursing staff to do when the resident continued to complain of pain and especially with the knees swollen and bruised, the Regional Quality Specialist replied she .would have expected a call placed to the provider . When the Regional Quality Specialist was asked what she would have expected when a CNA stated she was not aware of the CNA Care Guides which documented assistance needed for Activities of Daily Living, the Regional Quality Specialist replied .would have expected all CNAs would have been in-serviced on the Care Guides .

Based on medical record review, facility investigation review, interview, and observation, the facility failed to ensure pain management was provided to 1 resident (#7) of 6 residents reviewed for accidents, after a fall which resulted in bilateral impacted knee fractures. The facility's failure to identify the cause of pain and provide interventions placed Resident #7 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The facility was cited F697 at a scope and severity of J, which constitutes Substandard Quality of Care (SQC). The Immediate Jeopardy (IJ) was effective [DATE] and is ongoing. The findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Rheumatology Consultation dated [DATE] revealed .has symptoms of chronic widespread pain. She is exquisitely sensitive to any sort of palpation of her extremities, particularly her lower extremities .would put her under pain amplificatio[DIAGNOSES REDACTED] . Medical record review of the Medication Administration Record [REDACTED]. Medical record review of psychiatric recommendations and progress notes dated [DATE] revealed Resident #7 complained of pain as a 10 (extreme pain) on a scale of 1 to 10. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Medical record review of Resident #7's MAR for (MONTH) (YEAR) revealed the resident had a pain assessment completed every shift (7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM) and the resident's pain was 0 every day until [DATE], after the resident was diagnosed with [REDACTED]. Review of the facility's incident report dated [DATE] at 6:45 AM, revealed Resident #7 .was noted to slide off air mattress on to the floor during a bed change. Review of the facility's investigation revealed a written statement completed by Certified Nursing Assistant (CNA) #8 dated [DATE], which stated .I was in the middle of changing patient sheets, when patient rolled over. She slid out of the bed and landed on her knees . Medical record review of the MAR indicated [REDACTED]. Medical record review of the (MONTH) MAR indicated [REDACTED]. Medical record review of Resident #7's (MONTH) (YEAR) MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] at 11:00 AM, revealed the resident complained of bilateral hip and left shoulder pain and x-rays were ordered. Medical record review of the radiology report dated [DATE] revealed no fracture or dislocation of the shoulder or hips was present. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] at 12:10 PM, revealed Resident #7 still had complaints of pain related to the fall. Continued review revealed pain medication was given as ordered. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of nurse's notes dated [DATE] at 12:30 PM, revealed Resident #7's bilateral knees were swollen and bruised. Further review revealed .on Dr.'s (physician) Board for today (indicating the resident needed to be seen by the physician or the Nurse Practitioner) . Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of the (MONTH) MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of a physician's telephone order dated [DATE] at 1:30 PM, revealed an order for [REDACTED]. Medical record review of the radiology report dated [DATE] revealed .Impacted right knee fracture involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Impacted fracture (left) involving the distal femoral metaphysis .Old internally fixated proximal tibial fracture . Continued review revealed the Director of Nursing (DON) was notified of the results of the x-ray on [DATE] at 9:10 PM. Review of the radiology report and nursing notes revealed no documentation the physician was notified. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of Resident #7's MAR indicated [REDACTED]. Medical record review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Medical record review of the office History and Physical completed by the orthopedic physician dated [DATE] revealed Resident #7 was complaining of pain only in her knees and legs, but it was quite significant. The resident had bilateral distal femur fractures. The resident was admitted to the hospital due to the severity of the knee fractures. Medical record review of the hospital Death Summary dated [DATE], revealed Resident #7 .sustained bilateral distal femur fractures. She was in extreme pain at the time of admission and was initially admitted .the fractures were extremely painful and they were repaired for palliative reasons .Palliative Care was consulted to discuss goals of care with the patient's family due to her severe debility and multiple comorbidities . The resident expired [DATE]. Telephone interview with the Nurse Practitioner (NP) on [DATE] at 9:25 AM, revealed she remembered she gave the order for the x-ray of the knees on [DATE] because the resident was still having pain. Telephone interview with CNA #8 on [DATE] at 10:55 AM, revealed she was making her last round around 6:45 AM on [DATE], and went in to change the resident's bed sheet. CNA #8 stated when she turned Resident #7 over to change the sheet, the resident fell to the floor and landed on her knees. CNA #8 stated she screamed for help and the nurse came in to assess the resident and then they put the resident back to bed. CNA #8 stated the resident was .shaking really bad and I couldn't even get her vital signs . CNA #8 stated the resident grabbed her knees after she fell . Interview with Registered Nurse (RN) #2 on [DATE] at 11:30 AM, at a location outside the facility, revealed when she came in [DATE] (for the 7:00 AM to 7:00 PM shift) she was told Resident #7 rolled out of bed and had fallen to the floor. RN #2 stated she assessed the resident in the resident's room who complained of pain in the left shoulder and left hip. RN #2 stated the resident was in pain and would scream when moved or turned. Further interview with RN #2 revealed when she worked Sunday [DATE], the resident was still complaining of pain and she gave the resident pain medication to try to keep her comfortable. RN #2 further stated she knew Resident #7 was in pain. Continued interview with RN #2 revealed she was not working [DATE], [DATE], and [DATE]. RN #2 stated on [DATE] when she returned to work the resident still had not been seen by the Nurse Practitioner or the physician, but stated the NP was at the nurses' station so she asked if she could get x-rays of the knees of Resident #7. The nurse further revealed when she read the report on [DATE] from the bilateral knee x-rays she scheduled an appointment with an orthopedic surgeon for [DATE]. Further interview with RN #2 confirmed the NP had not been made aware of the resident's complaints of knee pain until [DATE]. Telephone interview with RN #4 on [DATE] at 1:00 PM, revealed the resident was alert with confusion at times. RN #4 stated Resident #7 was not a complainer and usually would not volunteer to tell you she was hurting. RN #4 stated on [DATE] the resident was in so much pain the CNAs reported the resident would scream when she was turned. RN #4 stated she went in to talk with Resident #7 who stated her knees hurt her badly. RN #4 stated both knees were swollen and black and blue. RN #4 stated at this time there was a sign posted at the nurse's station to notify the supervisor before calling the physician or NP so she went to the Assistant Director of Nursing (ADON) and reported the resident was in severe pain. RN #4 stated the ADON said they had done x-rays and they were all negative. RN #4 then replied .no, we have not x-rayed the knees . The ADON replied it was too late to call the physician and just place it on the Dr.'s Board (which is used to list residents who need to be seen by the physician or NP on the next visit) for the resident to be seen the next day. RN #4 stated on [DATE] she saw the physician and the NP in the facility but they never came to the floor to see Resident #7 and when she reminded the ADON Resident #7 needed to be seen, the ADON replied to her the physician and NP were not seeing residents that day. RN #4 confirmed the resident was not seen by the physician or NP on [DATE] or [DATE] when she was on duty. RN #4 further revealed Resident #4 was never a good eater, but after the incident the resident was not eating as much and the resident was in a lot of pain. RN #4 further confirmed she administered the resident pain medications that had been previously prescribed as much as possible to keep her comfortable. Interview with the Restorative Aide on [DATE] at 9:50 AM, in the Resting Lounge, revealed she had worked with Resident #7 multiple times doing Range of Motion (ROM). The Restorative Aide stated after the fall on [DATE] the resident didn't want her to do ROM on her legs at all because of the pain. The Restorative Aide stated the resident told her she had a fall and was in .so much pain . The Restorative Aide further stated the resident was also moaning and her complaint of pain was different from her normal baseline and .enough to get my attention . Interview with CNA #4 on [DATE] at 10:50 AM, in the Resting Lounge, revealed Resident #7 was never really one to complain of pain but would close her eyes and crunch up her face. CNA #4 stated before the fall when she would turn the resident, the resident would complain of pain, and maybe even more on rainy or cold days. But after the fall, the resident was in a lot of pain all the time. CNA #4 stated when she turned the resident, she would scream out in pain in her knees. The resident's knees were swollen and bruised. When asked if the complaint of pain was different after the fall the CNA replied .absolutely . CNA #4 stated the resident was screaming with intense pain especially on turning. CNA #4 stated the nurses told the CNAs they had been instructed to put the resident on the doctor's board and the pain could wait until the physician came. CNA #4 stated she felt the nurses on the floor and the CNAs did everything they could do but the lady .laid there several days in pain . Telephone interview with the former DON (who was DON at time of the accident) on [DATE] at 10:15 AM, confirmed he was notified several days after the fall the resident was having a lot of pain. During observation and interview with RN #4 on [DATE] at 12:10 PM, in the Resting Lounge, RN #4 presented a copy of the physician board sheet which revealed a notation dated [DATE] for Resident #7 XXX,[DATE] S/P (status [REDACTED]. RN #4 confirmed she saw a big change in Resident #4 after the fall where she didn't eat as well and she didn't want to be changed because of the pain. Interview with the Regional Quality Specialist on [DATE] at 3:20 PM, in the Resting Lounge, revealed she was in the building at least monthly ,[DATE] days at a time. When asked what she would have expected the nursing staff to do when the resident continued to complain of pain the Regional Quality Specialist replied .would have expected a call placed to the provider . Telephone interview with the attending physician (Medical Doctor) on [DATE] at 3:45 PM, revealed when asked what he would have expected the nursing staff to do for any increased pain, the MD stated he would expect to be called for any changes. The MD further confirmed he did not remember the facility calling him for any changes to Resident #7. Interview with CNA #17 on [DATE] at 4:00 PM, in the upper 400 hall shower room, revealed when she took care of Resident #7 she observed the knees swollen and the resident told the CNA she had fallen out of bed. CNA #17 reported to RN #4 about the resident's pain on turning and was informed the RN had been instructed to put it on the doctor's board by the ADON. CNA #17 confirmed the resident complained of a lot of pain on [DATE]. CNA #17 asked nursing again on [DATE] and was told the doctor had still not seen the resident. Interview with CNA #18 on [DATE] at 4:15 PM, in the upper 400 hall shower room, revealed Resident #7's legs and knees were swollen and she .screamed . when turned and would say .Oh Please, Please, Please . begging during changing. The CNA further stated she asked nursing everyday if anything had been done for the resident, and was told no. Interview with RN #2 on [DATE] at 5:45 PM, at the 400 hall nurses' station, revealed when she left on [DATE] the results of the x-rays of the bilateral knees for Resident #7 had not returned. She returned to work on [DATE], read the x-ray results, was in contact with the DON per text messaging, and an appointment was made for [DATE]. When RN #2 was asked how Resident #7 was during [DATE] until the doctor appointment on [DATE], the RN replied the same. RN #2 stated they (nursing) kept the resident comfortable with the [MEDICATION NAME], and [MEDICATION NAME] the resident was prescribed prior to the fall. In summary, Resident #7 experienced an avoidable accident on [DATE]. From [DATE] until [DATE] Resident #7 experienced significant increase in pain from her baseline level. On [DATE] an x-ray was completed on the bilateral knees indicating bilateral knee fractures. Resident #7 was not seen by a physician at the facility from [DATE] through [DATE], when she was sent out to see an orthopedic physician, and the facility failed to provide interventions to address the cause of newly increased pain, bilateral leg fractures from a fall on [DATE]. Resident #7 was admitted to the hospital from the orthopedic physician's office for repair of the fractures and palliative care. The resident expired on [DATE].

Based on medical record review, review a facility incident report, interview, and observation, the facility failed to obtain an order by the physician or Nurse Practitioner (NP) prior to obtaining x-rays and failed to promptly notify the ordering physician or NP the results of the x-rays, for 1 resident (#7) of 8 sampled residents. Failure to obtain a physician's orders [REDACTED].#7 experiencing pain, and placed Resident #7 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Immediate Jeopardy (IJ) was effective 11/11/17 and is ongoing. The findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's incident report dated 11/11/17 at 6:45 AM, revealed Resident #7 .was noted to slide off air mattress on to the floor during a bed change .no injury noted . Medical record review of nurse's notes dated 11/11/17 at 11:00 AM, revealed the resident complained of bilateral hip and left shoulder pain and x-rays had been ordered. Medical record review of a telephone order dated 11/11/17, at 10:45 AM, revealed Bilateral hips & (and) L (left) shoulder x-ray .fall .VORB (verbal order read back) (name of the Director of Nursing). Continued review of the order revealed the order was a verbal order written by a Registered Nurse and given by the Director of Nursing (DON). Further review revealed the order was signed by the Nurse Practitioner (NP) on 11/16/17. Medical record review of the radiology report for the shoulder and hip x-rays dated 11/11/17 revealed no fracture or dislocation. Medical record review of a physician's telephone order dated 11/16/17 at 1:30 PM, revealed a verbal order from the NP for x-ray of bilateral knees. Medical record review of the radiology report dated 11/16/17 revealed .Impacted right knee fracture involving the distal femoral metaphysis .Impacted fracture (left) involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Old internally fixated proximal tibial fracture . Medical record review of a nursing progress note dated 11/16/17 revealed the DON was notified of the results of the x-ray on 11/16/17 at 9:10 PM, and the family was notified of the results at 9:20 PM. Further review of the radiology report and nursing notes revealed no documentation the physician or NP were notified of the results of the radiology report indicating the resident had fractures. Telephone interview with the Nurse Practitioner (NP) on 7/10/18 at 9:25 AM, revealed she remembered giving the order for the x-ray of the knees on 11/16/17 because the resident was still hurting. Interview with RN #2 on 7/10/18 at 11:30 AM, at a location outside the facility, revealed when she came to work 11/11/17 for the 7:00 AM to 7:00 PM shift she was told Resident #7 rolled out of bed and had fallen to the floor. RN #2 stated she assessed the resident who complained of pain in the left shoulder and left hip, so she texted the DON at 9:30 AM and was given verbal permission to obtain x-rays of the shoulder and bilateral hips from the DON. Continued interview with RN #2 revealed she was not working 11/13/17, 11/14/17, and 11/15/17. RN #2 stated on 11/16/17, when she returned to work, the resident still had not been seen by the NP or the physician, but the NP was at the nurses' station so she asked the NP if she could get x-rays of the knees of Resident #7. Telephone interview with the former DON (who was DON at time of the incident) on 7/11/18 at 10:15 AM, revealed he did remember several days after the fall, when he was made aware the resident was having a lot of pain and her knees were swollen and bruised, he instructed the nurses to get x-rays. Observation and interview with RN #4 on 7/11/18 at 12:10 PM, in the Resting Lounge, revealed she presented a sign she stated she took down from the nurses station which read .Staff are never to call Dr. (Medical Doctor) or his NP until contact has been made with the on-call Nurse Mgr. (manager). If you have questions about this see (DON) or (ADON). The DON's name was typed on the bottom. Continued interview with RN #4 revealed the nurses were to call management first. Telephone interview with the attending physician on 7/11/18 at 3:45 PM, revealed he did not remember the facility calling him for any changes to Resident #7 or for any further orders. Interview with RN #2 on 7/13/18 at 5:45 PM, at the 400 hall nurses' station, revealed when she left work on 11/16/17, the results of the x-rays of the bilateral knees for Resident #7 had not returned. RN #2 stated when she returned to work on 11/17/18, she read the x-ray results and was in contact with the DON per text messaging. Further interview revealed she did not contact the physician or the NP with the results. Telephone interview with the Medical Director, who was the resident's attending physician, on 7/13/18 at 5:59 PM, revealed when asked did he know about the bilateral fractures of Resident #7 he replied .this is the first I've heard right now . When asked if he would have expected to be notified, the physician replied all fractures should be called to the physician or the person on call. Interview with the Administrator on 7/13/18 at 6:05 PM, at the 400 hall nurses' station, revealed when shown the nurses' notes dated 11/16/17, with the results of the knee x-rays, the Administrator confirmed the physician was not noted as being notified. Telephone interview with the NP on 7/13/18 at 9:11 PM, revealed the NP had researched her notes related to Resident #7 and found no notation of being notified of the results of bilateral knee x-rays. Interview with the Administrator on 7/14/18 at 9:00 AM, in the Administrator's Office, confirmed during review of nursing notes for 11/16/17 and 11/17/17, the Administrator did not see any documentation the physician or NP had been notified of the results of the bilateral knee x-rays. The Administrator replied .don't see anything .

Based on facility policy review, facility investigation review, interview, and observation, the Administrator failed to ensure facility policies were implemented, physicians were notified timely of changes in condition, and residents were free from neglect, avoidable accidents, and pain. The Administrator's failure resulted in a resident having an avoidable accident and a delay in receiving services and treatment after a fall with fractures, with Resident #7 experiencing intense pain, and placing Resident #7 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Immediate Jeopardy (IJ) was effective [DATE] and is ongoing. The findings include: Review of the facility's policy Change in a Resident's Condition or Status dated [DATE] revealed .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician and the resident's representative when there has been .d. A significant change in the resident's physical/emotional/mental condition; that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications .2. A significant change of condition is a decline or improvement in the resident's status . Review of the facility's policy titled Abuse Prevention/Reporting Policy and Procedure dated (YEAR) revealed .7. Neglect: the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 2 staff for bed mobility (how resident moves to and from lying position, turns side to side) Review of the facility's incident report and investigation dated [DATE] at 6:45 AM, revealed Certified Nursing Assistant (CNA) #8 was changing Resident #7's bed linen without assistance of a second staff person, and Resident #7 fell in the floor landing on her knees. Medical record review of the resident's nursing notes and Medication Administration Record [REDACTED]. Further review revealed the physician nor Nurse Practitioner (NP) was notified of the resident having pain, bruising or swelling in her knees and was not assessed at any time after the fall by the physician or NP. Medical record review of a physician's telephone order dated [DATE] at 1:30 PM, revealed an order for [REDACTED]. Medical record review of the radiology report dated [DATE] revealed .Impacted right knee fracture involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Impacted fracture (left) involving the distal femoral metaphysis .Old internally fixated proximal tibial fracture . Medical record review of nursing notes, radiology reports, and physician's orders revealed the Director of Nursing (DON) was notified of the results of the x-ray on [DATE] at 9:10 PM, and the family was notified of the results at 9:20 PM, but there was no documentation the physician or NP was notified of the results. Further review revealed Registered Nurse (RN) arranged an appointment with an orthopedic physician for [DATE] and there was no physician's order for the orthopedic consult. Medical record review of the nursing notes and MAR for [DATE] through [DATE] revealed the resident continued to experience pain, swelling, and bruising in her knees and legs. Further review revealed no documentation the physician or NP was notified of the pain or results of the x-rays, and no documentation the resident was assessed by the physician or NP. Medical record review of the office History and Physical completed by the orthopedic physician dated [DATE] revealed Resident #7 was complaining of pain only in her knees and legs, but it is quite significant. Continued review revealed both knees were swollen and deformed with some flexion. Resident #7 had some mild ecchymosis (bruising) around the knees. The resident had bilateral distal femur fractures. The resident was admitted to the hospital due to the severity of the knee fractures. Medical record review of the hospital Death Summary by the orthopedic surgeon dated [DATE] revealed Resident #7 .sustained bilateral distal femur fractures. She was in extreme pain at the time of admission and was initially admitted .She was normally non ambulatory however the fractures were extremely painful and they were repaired for palliative reasons .Palliative Care was consulted to discuss goals of care with the patient's family due to her severe debility and multiple comorbidities . The resident expired [DATE]. Interviews with CNA #8, RN #2, RN #4, CNA #4 during investigation [DATE] - [DATE] revealed the resident continued to complain of severe pain and staff reported the resident's condition to the DON and Assistant Director of Nursing (ADON), who failed to ensure the physician or NP was notified of the resident's condition and assessed the resident. Staff interviews revealed the physician and NP were not notified of the resident's pain or results of the x-rays indicating the resident had bilateral fractures, and the physician and NP did not assess the resident. Telephone interview with the former DON (who was DON at time of the incident) on [DATE] at 10:15 AM, revealed he didn't remember anything about Resident #7's accident. Continued interview with the DON revealed he did remember several days after Resident #7's fall when he was made aware the resident was having a lot of pain. Observation and interview with RN #4 on [DATE] at 12:10 PM, in the Resting Lounge, revealed she presented a sign she stated she took down from the nurses station which read .Staff are never to call Dr. (Medical Director) or his NP until contact has been made with the on-call Nurse Mgr. (manager). If you have questions about this see (DON) or (ADON). The DON's name was typed on the bottom. RN #4 also presented a copy of the physician board sheet which revealed a notation dated [DATE] for Resident #7 XXX,[DATE] S/P (status [REDACTED]. Continued interview with RN #4 revealed the nurses were to call management first. Telephone interview with the attending physician on [DATE] at 3:45 PM, revealed when asked what he would have expected the nursing staff to do for any change in resident status including increased pain or swelling and bruising of both knees, the physician stated he would expect to be called for any changes. The MD further confirmed he did not remember the facility calling him for any changes to Resident #7. Interview with the Administrator on [DATE] at 8:10 AM, in the Resting Lounge, revealed she had not seen the sign hanging at the nursing station to call the nurse supervisor before calling the physician or NP. Telephone interview with the Medical Director, who was the resident's attending physician, on [DATE] at 5:59 PM, revealed when asked when did he know about the bilateral fractures of Resident #7, he replied .this is the first I've heard right now . When asked if he would have expected to be notified, the physician replied all fractures should be called to the physician or the person on call. Interview with the Administrator on [DATE] at 9:00 AM, in the Administrator' Office, confirmed during observation of nursing notes for [DATE] and [DATE] the Administrator did not see any documentation the physician or NP had been notified of the results of the bilateral knee x-rays. The Administrator replied .don't see anything . When asked when she became aware of the fall and fractures related to Resident #7, the Administrator replied when Adult Protective Services (APS) came in (MONTH) of (YEAR). The Administrator stated she didn't remember if she was present or not at the facility for the morning meeting when the fall should have been discussed, but at the time of the fall they were not reading the incidents out loud and the assumption was the DON was looking at all nursing notes of residents with falls. Continued interview with the Administrator confirmed, when asked if the documentation showed the physician or the NP had been made aware of the results of the bilateral knee x-rays, the Administrator shook her head back and forth and said .no . Further interview with the Administrator revealed QA meetings were conducted on [DATE] and [DATE] at which time only number of incidents and location of the incidents were presented. Continued interview revealed no fractures were reported during these meetings.

Based on facility policy review, review of facility investigation, review of Quality Assurance and Performance Improvement (QAPI) meeting documentation, and interview, the QAPI committee failed to identify and correct quality deficiencies resulting in an avoidable accident where Resident #7 rolled out of bed during care and received bilateral leg fractures that were not identified for 5 days and the resident was not assessed and treated by a physician for another 4 days after x-ray results. The QAPI's failure placed 1 resident (#7) of residents reviewed in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Immediate Jeopardy (IJ) was effective on [DATE] and is ongoing. The findings include: Review of the facility's policy titled Abuse Prevention/Reporting Policy and Procedure dated (YEAR) revealed .7. Neglect: the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress . Review of the facility's policy titled Change in a Resident's Condition or Status dated [DATE] revealed .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician and the resident's representative when there has been .d. A significant change in the resident's physical/emotional/mental condition; that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications .2. A significant change of condition is a decline or improvement in the resident's status . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 2 staff for bed mobility (how resident moves to and from lying position, turns side to side). Review of the facility's incident report dated [DATE] at 6:45 AM, revealed Resident #7 .was noted to slide off air mattress on to the floor during a bed change .Two Certified Nursing Assistants (CNAs) will be needed to turn resident on air mattress to prevent further falls . Further review revealed Resident #7 required 2 person assist with bed mobility prior to the incident. Review of the facility's investigation revealed a written statement completed by CNA #8 dated [DATE], which stated .I was in the middle of changing patient sheets, when patient rolled over. She slid out of the bed and landed on her knees and fell toward her left side and did not hit her head . Medical record review of a physician's telephone order dated [DATE] at 1:30 PM, revealed an order for [REDACTED]. Medical record review of the radiology report dated [DATE] revealed .Impacted right knee fracture involving the distal femoral metaphysis .Impacted fracture (left) involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Old internally fixated proximal tibial fracture . Medical record review of the office History and Physical completed by the orthopedic physician dated [DATE] revealed Resident #7 was complaining of pain only in her knees and legs, but it was quite significant. Continued review revealed both knees were swollen and deformed with some flexion. Resident #7 had some mild ecchymosis (bruising) around the knees. The resident had bilateral distal femur fractures and was admitted to the hospital due to the severity of the knee fractures. Medical record review of the hospital Death Summary dated [DATE] revealed Resident #7 .sustained bilateral distal femur fractures. She was in extreme pain at the time of admission and was initially admitted .She was normally non ambulatory however the fractures were extremely painful and they were repaired for palliative reasons .Palliative Care was consulted to discuss goals of care with the patient's family due to her severe debility and multiple comorbidities . The resident expired [DATE]. Interview with the Administrator on [DATE] at 8:10 AM, in the Resting Lounge, revealed the facility conducted Quality Assurance meetings monthly with the Administrator, Director of Nursing (DON), Staff Development Coordinator, Medical Director, Dietary Manager, Social Services, Activities, Infection Control Director, Rehab Director, Human Resources, Medical Records Director, Registered Dietician, MDS Coordinator, Maintenance Director, a CNA, a Nurse, Respiratory Therapist, Wound Care Nurse, and Pharmacy Consultant (at least quarterly). The Administrator stated they go through each department, investigations, customer satisfaction, family satisfaction, revised policies, discharges, falls, and trends. The Administrator stated they discussed falls during the morning meetings and reviewed the 24 hour reports. The facility conducted a Risk Management meeting weekly where they go through all falls for the week. The Administrator stated .now . during the risk meeting they were looking at interventions to see if the intervention was appropriate, pulling each chart, reviewing the nursing notes, and trying to do a better and through job. The Administrator stated they were not doing this in-depth meeting when the previous DON was at the facility at the time of Resident #7's fall. The Administrator confirmed if they had been doing the type of risk meeting they were doing now, including reading the nurses notes, they would have been aware of the accident and the days following the accident, including the resident's continued complaints of pain with the swelling and bruising of both knees. Further interview with the Administrator confirmed if they had been doing the new process at the time of the incident they would have also included a teachable moment for the CNA regarding use of the Care Guides and provided more staff education. The Administrator further stated she was not sure at the time if they read the incident reports out loud or discussed the interventions during the meetings but .We do now . When asked when the new process for reviewing incidents started the Administrator replied after [DATE] when the prior DON left. The Administrator stated we review verbally now, including nursing notes for days after an incident, but the previous DON did not see the value in doing this process. Telephone interview with the Medical Director on [DATE] at 5:59 PM, revealed when asked did he know about the bilateral fractures of Resident #7, he replied .this is the first I've heard right now . Interview with the Administrator on [DATE] at 9:00 AM, in the Administrator's Office, revealed when asked when she became aware of the fall and fractures related to Resident #7, the Administrator replied when Adult Protective Services came in (MONTH) of (YEAR). The Administrator stated she didn't remember if she was present or not at the facility for the morning meeting when the fall should have been discussed, but at the time of the fall they were not reading the incidents out loud, and the assumption was the DON was looking at all nursing notes of residents with falls. Continued interview revealed the facility conducted QA meetings on [DATE] and [DATE], at which time only numbers and locations of accidents and incidents was presented. Further interview confirmed no fractures were reported to the committee at either committee meeting and the facility had not made any type of systemic correction or performance improvement related to the events involving Resident #7 on [DATE].

Based on facility policy review, medical record review, facility investigation review, interview, and observation, the facility failed to immediately notify the resident's physician when there was a significant change in the resident's physical, mental and psychosocial status for 1 resident (#7) of 6 residents reviewed for accidents and incidents, of 8 sampled residents. The facility's failure to immediately inform the physician or Nurse Practitioner (NP) of a significant change in the resident's pain intensity and the resident's physical condition (swollen and bruised bilateral knees and resulting fractures) placed Resident #7 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The Immediate Jeopardy (IJ) was effective [DATE] and is ongoing. The findings include: Review of the facility's policy titled Change in a Resident's Condition or Status dated [DATE] revealed .1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician and the resident's representative when there has been .d. A significant change in the resident's physical/emotional/mental condition; that is a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications .2. A significant change of condition is a decline or improvement in the resident's status . Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was coded 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review revealed the resident required extensive assistance of 2 staff for bed mobility (how resident moves to and from lying position, turns side to side). Medical record review of the resident's Medication Administration Record (MAR) and nursing notes for (MONTH) (YEAR) revealed Resident #7 was to have a pain assessment every shift (7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM), and had an order for [REDACTED]. Further review of the MAR and nursing notes revealed the resident rated her pain as 0 daily and did not require any of the as needed [MEDICATION NAME] until [DATE], after she was diagnosed with [REDACTED]. Review of the facility's incident report dated [DATE] at 6:45 AM, revealed Resident #7 .was noted to slide off air mattress on to the floor during a bed change. Head to toe assessment performed, no injury noted .Sister .Dr (physician) .notified. Review of the facility's investigation revealed a written statement completed by Certified Nursing Assistant (CNA) #8 dated [DATE], which stated .I was in the middle of changing patient sheets, when patient rolled over. She slid out of the bed and landed on her knees and fell toward her left side and did not hit her head . Medical record review of Resident #7's MAR revealed on [DATE] the resident's pain was 6 out of 10 (with 10 being the most severe pain) on the 7:00 AM to 7:00 PM shift and was administered [MEDICATION NAME] 7.5 mg at 8:00 AM. Medical record review of a telephone order dated [DATE] at 10:45 AM, revealed .Bilateral hips & (and) L (left) shoulder x-ray .fall .VORB (verbal order read back) (name of the former Director of Nursing) . Continued review of the order revealed the order was a verbal order written by a Registered Nurse (RN) and received from the former Director of Nursing (DON). Further review revealed the order was signed by the Nurse Practitioner (NP) on [DATE]. Medical record review of nurse's notes dated [DATE] at 11:00 AM, revealed the resident complained of bilateral hip and left shoulder pain and x-rays were ordered. Medical record review of the radiology report dated [DATE] revealed no fracture or dislocation of the shoulder or hips was present. Medical record review of the nursing notes and the resident's MAR from [DATE] - [DATE] revealed the resident complained of pain daily that was rated between 5 and 7 on a scale of ,[DATE], with 10 being the worse pain and [MEDICATION NAME] 7.5 mg was given. Further review revealed no documentation the physician or NP was notified of the resident's increased pain or increased need for pain medication. Medical record review of nurse's notes dated [DATE] at 12:30 PM, revealed Resident #7's bilateral knees were swollen and bruised. Further review revealed .on Dr.'s (physician) Board for today (indicating the resident needed to be seen by the physician or the NP) . Medical record review of the resident's MAR and nursing notes for [DATE] and [DATE] revealed the resident continued to rate her pain at 6 out of 10, with [MEDICATION NAME] 7.5 mg administered for pain. Further review revealed no documentation the physician or NP was notified of the resident's increased pain, increased need for pain medication, or of the swollen and bruised knees. Medical record review of a physician's telephone order dated [DATE] at 1:30 PM, revealed a verbal order for x-ray of bilateral knees was written by an RN, verbally given by the NP. Medical record review of the radiology report dated [DATE] revealed .Impacted right knee fracture involving the distal femoral metaphysis .Impacted fracture (left) involving the distal femoral metaphysis (fracture in the area where the long bone femur of the upper leg meets the knee) .Old internally fixated proximal tibial fracture . Continued review of the report revealed documentation the DON and a family member of the resident were notified of the results of the x-ray on [DATE] at 9:10 PM and 9:20 PM. Medical record review of a nursing note dated [DATE], with no time, revealed, Called results to (former DON) and sister .Re: (regarding) knee film . Further medical record review revealed no documentation the physician or NP were notified the resident had fractures in both legs. Medical record review of the resident's MAR and nursing notes from [DATE] through [DATE] revealed the resident continued to have pain daily, rated at ,[DATE] on a ,[DATE] scale, and was given [MEDICATION NAME] 7.5 mg. Further review revealed no documentation the NP or physician was notified of the resident's increased pain, increased need for pain medication, bruising or swelling in the knees, or the x-ray results indicating the resident had bilateral fractures. Medical record review of the office visit History and Physical completed by the orthopedic physician dated [DATE] revealed Resident #7 was complaining of pain only in her knees and legs, but it was quite significant. Continued review revealed both knees were swollen and deformed with some flexion. Resident #7 had some mild ecchymosis (bruising) around the knees. The resident had bilateral distal femur fractures. The resident was admitted to the hospital due to the severity of the knee fractures. Medical record review of the hospital Death Summary completed by the orthopedic surgeon dated [DATE], revealed Resident #7 .sustained bilateral distal femur fractures. She was in extreme pain at the time of admission .the fractures were extremely painful and they were repaired for palliative reasons .Palliative Care was consulted to discuss goals of care with the patient's family due to her severe debility and multiple comorbidities . The resident expired [DATE]. Telephone interview with the NP on [DATE] at 9:25 AM, revealed she remembered she gave the order for the x-ray on [DATE] because the resident was still having pain. Telephone interview with CNA #8 on [DATE] at 10:55 AM, revealed she was making her last round around 6:45 AM on [DATE], and went in to change the resident's bed sheet. CNA #8 stated when she turned Resident #7 over to change the sheet, the resident fell to the floor and landed on her knees. CNA #8 stated she screamed for help and the nurse came in to assess the resident and then the staff put the resident back to bed. CNA #8 stated the resident grabbed her knees after she fell . Interview with RN #2 on [DATE] at 11:30 AM, at a location outside the facility, revealed when she came in [DATE] for the 7:00 AM to 7:00 PM shift, she was informed Resident #7 rolled out of bed and had fallen to the floor. RN #2 stated she assessed the resident who complained of pain in the left shoulder and left hip. RN #2 stated the resident was in pain and would scream when moved or turned. Further interview with RN #2 revealed when she worked Sunday [DATE], the resident was still complaining of pain and she gave the resident pain medication to try to keep her comfortable. Continued interview with RN #2 revealed she was not working [DATE], [DATE], and [DATE]. RN #2 stated on [DATE] when she returned to work, the resident still had not been seen by the Nurse Practitioner or the physician, but stated the NP was at the nurses' station so she asked if she could get x-rays of the knees of Resident #7. Further interview with RN #2 confirmed the NP had not been made aware of the resident's complaints of knee pain until [DATE]. Telephone interview with RN #4 on [DATE] at 1:00 PM, revealed the resident was alert with confusion at times. RN #4 stated on [DATE] the resident was in so much pain the CNAs reported the resident would scream when she was turned. RN #4 stated she went in to talk with Resident #7 who stated her knees hurt her badly. RN #4 stated both knees were swollen and black and blue. RN #4 stated at this time there was a sign posted at the nurse's station to notify the supervisor before calling the physician or NP so she went to the Assistant Director of Nursing (ADON) and reported the resident was in severe pain. RN #4 stated the ADON said they had done x-rays and they were all negative. RN #4 then replied .no, we have not x-rayed the knees . The ADON replied it was too late to call the physician and just place it on the Dr.'s Board (used to list residents who need to be seen by the physician or NP on the next visit) for the resident to be seen the next day. RN #4 stated on [DATE] she saw the physician and the NP in the facility but they never came to the floor to see Resident #7 and when she reminded the ADON Resident #7 needed to be seen, the ADON replied to her the physician and NP were not seeing residents that day. RN #4 confirmed the resident was not seen by the physician or NP on [DATE] or [DATE] when she was on duty. Interview with CNA #4 on [DATE] at 10:50 AM, in the Resting Lounge, revealed after the fall the resident was in a lot of pain all the time. CNA #4 stated when she turned the resident, she would scream out in pain in her knees. The resident's knees were swollen and bruised. When asked if the complaint of pain was different after the fall the CNA replied .absolutely . CNA #4 stated the nurses told the CNAs they had been instructed to put the resident on the doctor's board and the resident could wait until the physician came. Interview with the DON (who was the ADON at the time of the incident) on [DATE] at 11:00 AM, in the Resting Lounge, revealed she could not remember the nurses saying anything to her about the resident having swollen or bruised knees, and if they had told her, she would have told them to call the physician or NP. During observation and interview with RN #4 on [DATE] at 12:10 PM, in the Resting Lounge, the nurse presented a piece of paper, which she stated she had taken down from the nurses' station, .Staff are never to call Dr. (Medical Doctor) or his NP until contact has been made with the on-call Nurse Mgr. (manager). If you have questions about this see (DON) or (ADON). The sign had the DON's name at the bottom. RN #4 also presented a copy of the physician board sheet which revealed a notation dated [DATE] for Resident #7 XXX,[DATE] S/P (status [REDACTED]. Continued interview with RN #4 revealed the nurses were to call management before calling the physician. When asked when the sign was taken down from the nurses' station, the nurse replied when they found out they were being sued. Interview with the Regional Quality Specialist (RQS) on [DATE] at 3:20 PM, in the Resting Lounge, revealed, when asked what she would have expected the nursing staff to do when the resident continued to complain of pain, the Regional Quality Specialist replied .would have expected a call placed to the provider . Telephone interview with the resident's physician on [DATE] at 3:45 PM, revealed when asked what he would have expected the nursing staff to do for any change in resident status including increased pain, the physician stated he would expect to be called for any changes. The physician further confirmed he did not remember the facility calling him for any changes to Resident #7. Interview with CNA #17 on [DATE] at 4:00 PM, in the upper 400 hall shower room, revealed when she took care of Resident #7 she observed the knees swollen and the resident told the CNA she had fallen out of bed. CNA #17 reported to RN #4 the resident's pain on turning and was informed the RN had been instructed to put it on the doctor's board by the ADON. CNA #17 asked nursing again on [DATE] and was told the doctor had still not seen the resident. Interview with RN #2 on [DATE] at 5:45 PM, at the 400 hall nurses' station, revealed when she left on [DATE] the results of the x-rays of the bilateral knees for Resident #7 had not returned. She returned to work on [DATE], read the x-ray results, and was in contact with the DON per text messaging. Further interview confirmed she did not call the physician or NP with the results of the x-rays. Telephone interview with the Medical Director, who was the resident's attending physician, on [DATE] at 5:59 PM, revealed, when asked when he became aware of the bilateral fractures of Resident #7, he replied .this is the first I've heard right now . When asked if he would expect the physician to be notified, the Medical Director replied all fractures should be called to the physician or the person on call. Telephone interview with the NP on [DATE] at 6:20 PM, revealed she could not remember clearly if she was notified of the results of the bilateral knee x-rays and replied .I'm sorry I don't . The NP stated when she got home she would look at her notes and see if she had any notations of notification of the results. Telephone interview with the NP on [DATE] at 9:11 PM, revealed the NP had reviewed her notes for Resident #7 and found no notation of being notified of the results of the bilateral knee x-rays. Interview with the Administrator on [DATE] at 9:00 AM, in the Administrator's Office, revealed during review of nursing notes for [DATE] and [DATE], the Administrator confirmed she did not see documentation the physician or NP had been notified of the results of the bilateral knee x-rays. When asked when she became aware of the fall and fractures related to Resident #7, the Administrator replied when Adult Protective Services came in (MONTH) of (YEAR).

Based on review of facility policy, medical record review and interview, the facility failed to develop a care plan for pressure ulcers for 1 resident (#135) of 3 residents reviewed for pressure ulcers, of 32 residents reviewed, resulting in Harm to the resident. The findings included: Review of the facility policy Pressure Ulcers/Skin Breakdown-Clinical Protocol revised February 2014 revealed . modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions . Medical record review revealed Resident #135 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 8/12/16 revealed the resident had a potential for alteration in skin integrity due to decreased mobility and incontinence. Medical record review of the Skin Inspection report dated 9/10/16 revealed the resident's skin was not intact. Medical record review of the nurse's notes dated 9/10/16 revealed the physician ordered daily treatment for [REDACTED].apply skin prep peri wound cover with [MEDICATION NAME] . Continued review of the nurse's note revealed Care plan reviewed . Medical record review revealed the care plan was not updated or revised with the new problem of the pressure ulcer and any corresponding interventions. Medical record review of the physician progress notes [REDACTED].It was noted as stage 3 by the initial evaluation by nursing staff .a stage 3 sacral decubitus ulcer that measures about 3.1 x 1.3 x 0.3 cm (centimeters) depth heavy necrotic slough devitalized tissue . that definitely needs to be debrided (surgical removal of dead tissue) today . Continued review of the Physician's Progress Note revealed the surgical procedure was completed; the assessment and Plan: 1 .he (Resident #135) will have orders for off-loading pressure, evaluate mattress for improved pressure relief. Also, we will start with twice daily dressing changes . Medical record review revealed the care plan was not revised following the debridement of the pressure ulcer to reflect any planned interventions. Interview with the Director of Nursing on 10/06/16 at 9:54 AM in the conference room confirmed the facility failed to revise the Care Plan for Resident #135 after the development of a pressure ulcer.

Based on review of the Enforcement History, and interview the facility Administrator failed to ensure compliance was maintained with federal regulation F314 for 1 of 1 previous complaint surveys. The facility's failure resulted in harm for 1 resident (#135) of 3 residents reviewed. The findings included: Review of the Provider History Profile revealed the facility was cited for F314 at a G level on a complaint survey on 5/25/16. Interview with the Administrator on 10/6/16 at 10:50 AM in the Administrator's office confirmed the Quality Assurance Performance Improvement Committee failed to follow up on the implementation and execution of the Plan of Correction for F314 cited on 5/25/16. Continued interview confirmed that the facility's audit of 5 residents' skin assessments was not acceptable to ensure compliance with the regulation. Refer to F314, F280.

Based on review of facility policy, medical record review, observation and interview, the facility failed to provide treatment and services to prevent development of a pressure ulcer, promote healing and prevent worsening of a pressure ulcer for 1 resident (#135) of 3 residents reviewed for pressure ulcers, of 32 residents reviewed, resulting in harm to the resident. The findings included: Review of the facility policy Pressure Ulcer Risk Assessment revised 2010 revealed .Pressure ulcers are usually formed when a resident remains in the same position for extended period of time causing increased pressure to a decrease of circulation (blood flow) that area, which destroys tissue .If pressure ulcers are not treated when discovered they quickly get larger .Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently . Review of the facility policy Pressure Ulcers/Skin Breakdown-Clinical Protocol revised 2014 .the nurse shall describe and document/report the following: .full assessment of pressure sore including location, stage, length width and depth, presence of exudate or necrotic tissue on a weekly basis or as ordered . Medical record review revealed Resident #135 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Braden Scale for Predicting Pressure Sore Risk dated 7/31/16 revealed Resident #135 was at risk for a pressure ulcer. Medical record review of the History and Physical dated 8/1/16 revealed .There are no observable decubiti . Medical record review of the Subsequent Patient Visit Progress Note dated 8/3/16 revealed the appearance of a previous decubitus. Medical record review of the Care Plan dated 8/12/16 revealed the resident had a potential for alteration in skin integrity due to decreased mobility and incontinence. Continued review of the care plan revealed the resident was care planned for a head to toe skin assessment weekly, was incontinent of bowel and bladder, was an extensive two person assist with bed mobility and transfers, required a pressure relief mattress, and the staff were to reposition the resident prn (as needed). Medical record review of the Treatment Record dated 8/1/16-8/31/16 revealed no documentation of a weekly skin assessment for 8/6/16, and 8/20/16. Medical record review of the Weekly Skin Integrity Review revealed no skin assessments for 14 days ( 8/13/16-8/27/16). On 8/27/16 the assessment documented redness to the resident's coccyx. There was no skin integrity review for another 13 days (8/27/16-9/10/16). Further review revealed on 9/10/16 the resident had an open area on the buttock, with no assessment of location, staging, or measurements. Medical record review of the Skin Inspection report dated 9/10/16 revealed the resident's skin was not intact. Medical record review of the Physician Telephone Order dated 9/10/16 revealed .Cleanse coccyx . wound cleanser, pat dry .with gauze, apply santyl (ointment) to slough using a cotton tipped applicator .apply skin prep to periwound cover with [MEDICATION NAME] (adhesive dressing) change, q (every) day and PRN (as needed) until resolved . Medical record review of Resident #135's care plan revealed it was not updated/revised with any new interventions to address the pressure ulcer. Medical record review of the Progress Note dated 9/16/16 revealed .It was noted as stage 3 by the initial evaluation by nursing staff .a stage 3 sacral decubitus ulcer that measures about 3.1 x 1.3 x 0.3 cm depth heavy necrotic slough devitalized tissue . that definitely needs to be debrided (surgical removal of dead tissue) today . Continued review of the Physician's Progress Note revealed the surgical procedure was completed; the assessment and Plan: 1 .he (Resident #135) will have orders for off-loading pressure, evaluate mattress for improved pressure relief. Also, we will start with twice daily dressing changes . Medical record review revealed the care plan was not revised following the debridement of the pressure ulcer to reflect any planned interventions. Medical record review of a Wound assessment dated [DATE] revealed .Unstageable due to slough and eschar . Medical record review of the Weekly Summary dated 9/23/16 revealed .Ulcers .None . Observation with the wound care nurse on 10/05/16 at 7:43 AM in the resident's room revealed Resident #135 sacral pressure ulcer. Further observation of the resident's sacral pressure ulcer revealed as described by the wound care nurse an open area to coccyx 1.0 x 0.5 x 0.4 cm. with slough on the inside and [DIAGNOSES REDACTED] (redness) noted around the surrounding tissue. Interview with the Wound Care Nurse on 10/04/16 at 3:36 PM in the 200 hall nursing station confirmed Resident #135 was scheduled for another debridement of his sacral wound on 10/7/16. Interview with the Medical Director on 10/05/16 at 9:22 AM in the conference room confirmed would expect skin assessments to be performed and documented weekly. Interview with the Director of Nursing (DON) on 10/05/16 at 9:52 AM in the conference room confirmed the resident developed the pressure ulcer in the facility, he would expect skin assessments to be done weekly and he was unaware when the pressure ulcer was identified. Interview with Nurse Practitioner (NP) #2 on 10/05/2016 at 10:58 AM in the conference room revealed NP #2 examined the resident on 8/3/16 and Resident #135 had a previous healed wound to coccyx. Continued interview confirmed the resident's skin (where the previous healed wound was) was fragile and the resident did not have a pressure ulcer on 8/3/16. Further interview confirmed . I would expect a nurse would do a weekly skin assessments especially for his fragile coccyx skin area . Interview with the Assistant Director of Nursing on 10/05/2016 at 1:25 PM in the conference room confirmed . I expect wounds (pressure ulcers) to be assessed weekly . Interview with the DON on 10/6/16 at 8:22 AM in the conference room confirmed the facility failed to describe, document and report the full assessment of the pressure ulcer and had no documentation of treatments provided to the pressure ulcer on the resident's coccyx; the facility failed to update the care plan with new approaches or interventions; the resident developed a stage 3 pressure ulcer which required debridement. Refer to F 280

Based on review of facility policy, medical record review, observation, and interview, the facility failed to provide effective interventions for the prevention of falls for 1 (#3) resident, of 3 residents reviewed for falls, of 17 residents reviewed, resulting in Harm to the resident. The findings included: Review of Falls and Fall Risk, Management Guidelines dated 12/13/14 revealed, based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk factors to try to prevent the resident from falling and to try to minimize complications from falling. Interventions should be individualized, according to the resident's needs. If falling recurs despite initial interventions, the interdisciplinary team will implement additional or different interventions, or indicate why the current approach remains relevant. Resident #3 was admitted on [DATE] and [DIAGNOSES REDACTED]. Medical record review of the care plan initiated on 2/23/15 for at risk for falls due to shuffling gait, listed these interventions: bed in lowest position, call light in reach, encourage the resident to ask for assistance with ADLs, and remind the resident to use the walker/wheelchair when in the hallway. Medical record review of the Fall Risk Evaluation dated 6/30/15 revealed the resident scored 19, with a score of ten or more placing the resident at a risk for falls. The eight Fall Risk Evaluations completed from 8/19/15 to 5/19/16 assessed the resident at a risk for falls. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment, required extensive assistance with bed mobility transfers, walking, locomotion, dressing, toilet use, and personal hygiene. The resident was not steady but able to stabilize without staff assistance with moving from a seated to standing position, walking and surface to surface transfers; and not steady and only able to stabilize with staff assistance with turning around and moving on and off the toilet. The resident used a walker and a wheelchair, was frequently incontinent of urine and continent of bowel. The resident had two or more no injury falls since the previous assessment and received no therapy or restorative services. Medical record review revealed the resident had a fall on 10/9/15 at 9:11 AM. Staff found the resident lying on the floor between the beds and between the headboard and wall. Glasses were on and an indention was noted into the forehead. Staff sent the resident to the emergency room . The Resident Transfer Form dated 10/9/15 documented the resident was sent to the emergency room for evaluation of head trauma. There were no medical interventions and no documentation of additional falls interventions put in place. Medical record review revealed the resident had a fall on 10/12/15 at 9:00 PM. Staff found the resident lying prone on the floor between the beds and the resident received a one centimeter laceration to the right eye. The resident was sent to the emergency room and the laceration was superglued. Medical record review revealed no documentation of any falls interventions put in place. Medical record review revealed the resident had a fall on 1/8/16 at 7:05 PM. Staff found the resident lying on left hip on the floor next to the bed. Staff instructed the resident (who was cognitively impaired) to use the call light before attempting to transfer by self, and no other falls interventions were put in place. Medical record review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 10, moderately cognitively impaired. The resident displayed inattention and disorganized thinking that fluctuated and displayed no behaviors. The resident required extensive assistance with bed mobility, transfers, ambulation, locomotion, dressing, toilet use, personal hygiene, and bathing. The resident was not steady but able to stabilize without staff assistance when moving from a seated to standing position, walking, and surface to surface transfers, and was not steady and only able to stabilize with staff assistance with turning around and moving on and off the unit. The resident utilized a walker and a wheelchair. The resident was always incontinent of bladder and always continent of bowel. The resident has had one non injury fall since the last assessment and did not receive therapy or restorative services. Medical record review of the care plan interventions dated 2/18/16 revealed interventions for history of falls due to shuffling gait: bed in lowest position, call light in reach, encourage the resident to ask for assistance with ADLs, remind resident to use walker/wheelchair when in hallway, not compliant with asking for assistance. Medical record review revealed the resident had a fall on 3/31/16 at 11:30 PM. Staff found the resident on the floor with an approximate one inch laceration to the chin. The resident was sent to the emergency room for a deep laceration and stitches were received. Staff instructed the resident (who was cognitively impaired) to call when needs help. Medical record review of the resident's care plan revealed it was updated for the 3/31/16 fall to include, .educated to use call light when transitioning to a different position . Observation on 5/24/16 at 1:28 PM, revealed the resident laid in bed with head at the foot of the bed and feet at the top of the bed. Observation on 5/24/16 at 2:15 PM, revealed the resident sat in a wheelchair in their room trying to put on shoes. Interview with direct care staff D on 5/25/16 at 3:05 PM, revealed the resident walked on their own, was a little unstable, and sometimes used a walker, but also had a wheelchair. This staff also stated the resident will use the call light when they needed something. Interview with licensed nurse B on 5/25/16 at 5:35 PM, revealed the resident was alert and oriented and does what he/she wants to. The facility failed to provide effective interventions for the prevention of falls for a cognitively impaired resident who required extensive assistance with activities of daily living and had emergency room visits resulting in glue and stitches.

Based on medical record review and interview, the facility failed to provide necessary treatment and services to promote healing and prevent worsening of pressure ulcers for one resident (#9) of 3 residents reviewed for pressure ulcers, of 17 sampled residents, resulting in Harm to Resident #9. The findings included: Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) with an assessment date of 11/28/15 revealed the resident had a Brief Interview for Mental Status (BIMS) of 3 (severely impaired cognition) with no behaviors present during the assessment period. The resident was totally dependent on staff for all levels of activities of daily living (ADLs) and the resident had function limitation in range of motion of upper and lower extremity. Medical record review of the facility's admission assessment and interim care plan dated 11/4/15 revealed the resident was a high risk for skin breakdown. On admission the resident was identified as having red area with broken skin on the coccyx, left ankle with a red scab area, and left lateral foot with a dark purple area. Medical record review of the care plan developed 11/4/15 with a revision date of 2/17/16 revealed the resident had impaired skin integrity with skin tear on sacrum, and a dark area on the left lateral foot. Interventions included administer treatment as ordered, monitor wounds for healing progress, or lack and notify MD/NP (physician or nurse practitioner) as needed, and weekly skin assessments. Medical record review revealed the resident was sent to the hospital, with the pressure areas, and was discharged from the hospital in December 2015, after receiving treatment for [REDACTED]. The resident was in the hospital for several days and was assessed as having a stage II sacral ulcer while in the hospital and at discharge. Medical record review of a skin assessment dated [DATE] revealed the resident scored 12 indicating the resident was a high risk for pressure ulcers. Medical record review of the wound care nursing notes and weekly skin assessments from December 2015 to February 2016 revealed the resident's sacral stage II ulcer was slowly healing. Medical record review of the physician reconciliation orders for February 2016 revealed the resident's wound treatment protocol included cleanse wound with normal saline or wound cleaner and cover with Alginate silver. Medical record review of a nurses' note dated 2/20/16 for 7 PM - 7AM, revealed the treatment for [REDACTED]. Further medical record review revealed no documentation regarding the area of the wound or whether the wound was healed. Medical record review revealed no further documentation for wound care after 2/20/16. Medical record review of the Weekly Skin Integrity Review dated 2/25/16, revealed the resident was assessed with [REDACTED]. Further review revealed the skin review stated if there was an open area, proceed to appropriate skin condition record. Medical record review revealed the skin condition record was not in the chart and there was no documentation of the stage or characteristics of the wound. Medical record review revealed no further documentation regarding the presence of a wound on the sacral area, the condition of the resident's skin after the Weekly Skin Integrity Review note dated 2/25/16, and no documentation of wound care treatments being performed. Medical record review of nurses' notes dated 3/3/16 at 10:00 AM, revealed the resident was assessed as having altered mental status, respiratory distress, and an elevated temperature. The resident was started on [MEDICATION NAME] (antidiuretic), [MEDICATION NAME] (antibiotic), and [MEDICATION NAME] (steroid), with orders for a chest x-ray, and a new urinary catheter was inserted. Further review revealed the resident was later transferred to the emergency room . Medical record review of the emergency room records dated 3/3/16 revealed the resident was admitted to the hospital with [REDACTED]. Further review of the emergency room records revealed the stage III decubitus ulcer, which was noted to be present on admission to the emergency room , was a potential source for the [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON) on 5/26/16 at 1:30 PM, revealed the wound nurse was responsible for doing weekly wound assessments on residents with pressure ulcers and writing a summary note in the nursing notes. Medical record review of the hospital discharge note dated 12/23/15, with the DON, confirmed the resident was discharged from the hospital with a stage II decubitus ulcer. The DON reviewed the resident's weekly skin inspection review sheets dated 2/25/16 and confirmed the skin inspection review sheet identified the resident had an open area on the sacrum. Further interview confirmed the sheet did not identify the stage of the wound. The DON confirmed the next skin inspection review was dated 3/3/16, when the resident was in the hospital. Medical record review and interview with the DON confirmed there was no documentation of wound assessments or wound care being completed after the treatment was discontinued on 2/20/16. Interview with the Wound Care Nurse on 5/26/16 at 4:00 PM, revealed the nurse was new to the position and was not in the wound care position during the months of January and February 2016. The Wound Care Nurse confirmed the resident was admitted to the facility with a pressure ulcer and was receiving treatment for [REDACTED]. Further medical record review and interview confirmed the Wound Care Nurse could not explain the lack of documentation in the nurses' notes and weekly skin inspections during this period of time (from 2/20/16) since she was not performing wound care duties during that time. Medical record review and interview with the Wound Care Nurse confirmed, according to the hospital record dated 3/3/16, the resident was admitted to hospital with a Stage III sacral ulcer. Interview with the Wound Care Nurse on 5/26/16 at 7:00 PM, confirmed the facility was unable to produce any documentation regarding the status of Resident #9's skin and wounds from the time the treatments were discontinued on 2/20/16, until the resident's discharge to the emergency roiagnom on [DATE]. The Wound Care Nurse confirmed the former wound care nurse was terminated for failure to complete wound care treatments according to the physicians' orders.

Based on medical record review and interview, the facility failed to provide treatment and services for pressure ulcers per the care plan for one resident (#9) of 3 residents reviewed for pressure ulcers, of 17 sampled residents, resulting in Harm to Resident #9. The findings included: Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) with an assessment date of 11/28/15 revealed the resident had a Brief Interview for Mental Status (BIMS) of 3 (severely impaired cognition) with no behaviors present during the assessment period. The resident was totally dependent on staff for all levels of activities of daily living (ADLs) and the resident had function limitation in range of motion of upper and lower extremity. Medical record review of the facility's admission assessment and interim care plan dated 11/4/15 revealed the resident was a high risk for skin breakdown. On admission the resident was identified as having red area with broken skin on the coccyx, left ankle with a red scab area, and left lateral foot with a dark purple area. Medical record review of the care plan developed 11/4/15 with a revision date of 2/17/16 revealed the resident had impaired skin integrity with skin tear on sacrum, and a dark area on the left lateral foot. The resident had potential for increased skin impairment due to incontinence and decreased mobility. Interventions included the following: administer treatment as ordered, monitor wounds for healing progress, or lack and notify MD/NP (physician or nurse practitioner) as needed. Report onset signs/symptoms of infection (odor, redness, drainage) to MD/NP. Weekly skin assessments. Check for incontinence every 2 hours and more often if needed. Turn and reposition every two (2) hours when in bed; when in Geri-chair provide total assistance to relieve pressure by boosting, shifting weight, and use cushion in Geri-chair. Bunny boots while in bed. Medical record review revealed the resident was sent to the hospital, with the pressure areas, and was discharged from the hospital in December 2015, after receiving treatment for [REDACTED]. The resident was in the hospital for several days and was assessed as having a stage II sacral ulcer while in the hospital and at discharge. Medical record review of the wound care nursing notes and weekly skin assessments from December 2015 to February 2016 revealed the resident's sacral stage II ulcer was slowly healing. Medical record review of the physician reconciliation orders for February 2016 revealed the resident's wound treatment protocol included cleanse wound with normal saline or wound cleaner and cover with Alginate silver. Medical record review of a nurses' note dated 2/20/16 at 7p-7a revealed the treatment for [REDACTED]. Medical record review of the Weekly Skin Integrity Review dated 2/25/16, revealed the resident was assessed with [REDACTED]. Further review revealed the skin review stated if there was an open area, proceed to appropriate skin condition record. Medical record review revealed the skin condition record was not in the chart and there was no documentation of the stage or characteristics of the wound and no documentation of wound treatment. Medical record review revealed no further documentation regarding the presence of a wound on the sacral area or the condition of the resident's skin after the Weekly Skin Integrity Review note dated 2/25/16. Medical record review of nurses' notes dated 3/3/16 at 10:00 AM, revealed the resident was assessed as having altered mental status, respiratory distress, and an elevated temperature. Further review revealed the resident was transferred to the emergency room . Medical record review of the emergency room records dated 3/3/16 revealed the resident was admitted to the hospital with [REDACTED]. Further review of the emergency room records revealed the stage III decubitus ulcer, which was noted to be present on admission to the emergency room , was a potential source for the [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON) on 5/26/16 at 1:30 PM, revealed the wound nurse was responsible for doing weekly wound assessments on residents with pressure ulcers and writing a summary note in the nursing notes. The DON reviewed the resident's weekly skin inspection review sheets dated 2/25/16 and confirmed the skin inspection review sheet identified the resident had an open area on the sacrum. Further interview confirmed the sheet did not identify the stage of the wound. The DON confirmed the next skin inspection review was dated 3/3/16, when the resident was in the hospital. Medical record review and interview with the DON confirmed there was no documentation of wound care being completed after the treatment was discontinued on 2/20/16. Interview with the Wound Care Nurse on 5/26/16 at 4:00 PM and at 7:00 PM, confirmed the nurse was new to the position and was not in the wound care position during the months of January and February 2016. The nurse confirmed the facility was unable to produce any documentation the care plan was followed and the wounds were monitored for healing, skin assessments were done, and wound treatments were provided between the time the wound treatment was discontinued on 2/20/16, until the resident's discharge to the emergency roiagnom on [DATE]. Refer to F-314

Based on medical record review, review of hospital records, review of personnel files, and interviews, the facility failed to ensure the proper use of a mechanical lift including use of the sling, locking and spreading the legs of the lift, and assist of two person at all times resulting in a fall for two residents (#7, #9,) of four residents reviewed for fall. The facility's failure to ensure the proper use of a mechanical lift and two person assist resulted in a left lower extremity muscle tear (HARM) for Resident #7. The findings included: Resident #7 was admitted to the facility on [DATE], with a readmitted [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Plan of Care dated January 2014 revealed the resident at risk for falls and "...assist x (times) 1-2 with all transfers and ambulation." Medical record review of the quarterly Minimal Data Set (MDS) dated [DATE], revealed the resident scored fifteen (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further medical record review revealed Resident #7 required total assistance of two persons for transfers. Medical record review of the Weekly Wound Evals (evaluations) dated June 25, 2014, revealed left calf "...improvement noted 0.6 cm (centimeters) x 0.4 cm moist and 100% (percent) red..." Medical record review of the Clinical Record dated June 28, 2014, at 10:20 a.m., revealed "Called to room by CNA (Certified Nursing Assistant)...resident noted lying on back in floor...head next to the bed, CNA reports fall occurred during transfer with (mechanical) lift from bed to chair when lift "tipped over" during transfer, pt (patient) c/o (complained of) head and neck pain, laceration to LLE (left lower extremity) with pressure dressing applied due to bleeding..." Medical record review of a hospital History and Physical dated July 1, 2014, revealed "Impression: 1. Left lower extremity muscle tear...sutures placed...significant bleeding was noted...2. Hypotension - believe this is related to acute blood loss anemia, hypovolemic state and potential early hypovolemic shock. Aggressive fluid resuscitation...3. Coagulopathy...will reverse with fresh frozen plasma and reassess..." Medical record review of the Wound Care report dated July 28, 2014, revealed "...left lower extremity 4 cm x 3.8 cm 100% red and second area 18 cm x 11 cm 100% red..." Interview with CNA #6 on October 20, 2014, at 8:10 a.m., in the In-Service Education Room, revealed "...had sling under resident in the chair...chair at foot and when pulled lift around...resident up in the air, legs on lift were open...when pulled back and turned to the right the whole lift tilted...resident fell to the floor..." Review of the personnel file for CNA #6, revealed CNA #6 was in-serviced on hire, May 7, 2014, regarding how to properly use the lift and demonstrate the technique back to the trainer. Further review revealed the in-service included the use of the sling, locking and spreading the legs out of the lift, prior to proceeding to lift the resident and two CNAs are required at all times. Interview with the Director of Nursing on October 21, 2014, at 9:40 a.m., in the In-Service Education Room confirmed transfer using the mechanical lift was a two person assist and the lift on June 28, 2014, was attempted with the assist of one CNA, the MDS was coded for a two person assist, and the resident sustained [REDACTED].#7 resulting in sutures, left lower extremity hematoma that necessitated debridement for acute onset [DIAGNOSES REDACTED], fresh frozen plasma and a hospital stay from June 28, 2014, until July 25, 2014. Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Interim Plan of Care, dated October 6, 2014, revealed the resident was assessed to be at risk for falls and planned interventions including: "(mechanical) lift x 2 staff with transfers as needed..." Medical record review of the admission MDS dated [DATE], revealed Resident #9 scored a fifteen (cognitively intact) on the Brief Interview for Mental Status. Further review revealed the resident required extensive assistance of two for transfer. Review of a facility investigation dated October 15, 2014, at 5:45 p.m., revealed, "Type of incident investigation: Fall...How many assists were used: 2...Pt was being transferred to bed from geri-chair, during transfer legs of lift were closed causing lift to tilt over in result pt slid off of bed and onto floor...Pt sent to (hospital) to eval (evaluate) and tx (treat), sent back with no new orders..." Review of the personnel files for CNA #14 revealed the CNA was in-serviced on hire, June 16, 2014, related to the proper use of the lift and demonstrated the technique to trainer. Further review revealed the in-service included the use of the sling, locking and spreading the legs out of the lift, prior to proceeding to lift the resident. Interview with CNA #14 on October 21, 2014, at 2:55 p.m., in the In-Service Education Room revealed Resident #9 was to be transferred from the chair to the bed with the use of the mechanical lift and two staff members. Further interview revealed CNA #14 was operating the mechanical lift and "...didn't close the legs of the lift but made it smaller...and the lift tilted to the bed...bed started to move...resident slid to the floor..." Continued interview with CNA #14 confirmed, "...I made a mistake." C/O #

Based on review of Guidance for Industry and FDA (Food and Drug Administration) March 2006, facility policy review, medical record review, review of facility investigation, observation and interview, the facility failed to assess side rails as a restraint; failed to ensure side rails did not pose a risk of entrapment or injury from falls; and failed to reduce or eliminate side rail restraints for five residents (#15, #17, #18, #20 and #47) with incidents and/or injuries involving side rails; failed to complete a pre-restraint assessment prior to placing one resident (#17) in a seat-belt restraint; and failed to assess side rails as a restraint for twenty-eight (#2, #4, #7, #14, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43 and #44) residents without identified incidents related to side rails for thirty-three of eighty-nine residents reviewed who were identified by the facility as having two full side rails in use. The facility's failure to follow a systematic process of assessing for appropriate use of the restraint and failure to reduce or eliminate side rail restraints placed residents #15, #17, #18, #20, #47, #2, #4, #7, #14, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43 and #44 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death). The Administrator and the Director of Nursing were informed of the Immediate Jeopardy on February 22, 2013 at 10:10 a.m. in the Administrator's office. F221 resulted in Substandard Quality of Care The findings included: Review of Guidance for Industry and FDA (Food and Drug Administration) updated May 16, 2011 revealed "...Hospital Bed system Dimensional and Assessment guidance to Reduce Entrapment...suggest that facilities...determine the level of risk for entrapment and take steps to mitigate the risk...The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movements...FDA recommends that healthcare facilities conduct a risk-benefit analysis to ensure that steps taken to mitigate the risk of entrapment do not create different, unintended risks or reduce clinical benefits available to patients..." Review of the facility restraint policy (undated) revealed "...It will be the policy of (facility) that restraints will not be used unless necessary to provide safety and prevent injury to residents...Residents who must be restrained will be evaluated by the falls team and the least restrictive means as possible will be used. Falls team will monitor every 6 months for the use of less restrictive measures and will do restraint reduction as appropriate...Restraint means are listed below to rate which is considered more or less restrictive: (A) is the most restrictive...a. Limb restraints (wrist)...b. Gerichair and/or Gerichair with tabletop...c. Full lap restraint...d. Velcro Self Release restraint...e. Self release with built in alarm...f. Hand Mittens..." Review of the facility's policy for assessment for the need of application of restraints dated December 29, 2005 revealed "Restraints may be used when the following fall risk assessment and prerestraining assessment criteria are met. The use of restraints is necessary to promote the resident's highest practicable physical, mental and psychosocial well being. The restraint assessment is completed to ensure that the least restrictive device is used and a physician's orders [REDACTED]. After completion of assessment, nurse or occupational/physical therapist will implement and apply recommended restraint..." Review of the facility's policy for restraint reduction (undated) "Goal: To reduce or remove residents from the use of restrictive devices. Residents who require restraints should be placed in the least restrictive device that will prevent harm to self or others. The following devices are listed from least to most restrictive:...Hand mittens...Abdominal binder...Lap pillow...Soft Velcro belt (for wheelchairs or G-chair without tabletop)...Soft wheelchair belt restraint...Geri-chair with tabletop...Soft Velcro bed restraint...Posey vest restraints...Before placing a resident in a restraint:...Establish need/reason for restraint...Determine if a restraint has been used before for this resident...Document behavior and reason you feel resident requires restraint..." Resident #15 was admitted to the facility on [DATE] from a rehabilitation facility following rehab for a Fractured Pelvis, Fractured Left Hip with [MEDICAL CONDITION] Hemiarthroplasty (hip replacement) and Fractured Left Elbow with Open Reduction Internal Fixation. Other admission [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident scored 12/15 (moderately impaired cognition) on the Brief Interview for Mental Status (BIMS); required extensive assistance with bed mobility and transfer; was not ambulatory; required assistance with surface-to-surface transfer; had a urinary catheter and was incontinent of bowel; and had a fall with major injury ([MEDICAL CONDITION]) since admission. Medical record review of an admission nursing assessment dated [DATE] revealed the resident scored 14 on the falls risk assessment (10 or greater=high risk) and had "...full bed rails on all open sides of bed..." Medical record review revealed a side rail assessment had not been completed to ensure the safe and appropriate use of the rails and to determine if the side rails were a restraining device. Medical record review of physician's admission orders ...high fall risk..." Review of a facility investigation dated October 30, 2012 revealed the resident crawled to the foot of the bed with the full side rails in a raised position; tried to stand and ambulate and fell on the right side. The resident complained of right groin pain and was transferred to the emergency room . Review of the hospital history and physical dated October 30, 2012 revealed "...recent treatment of [REDACTED]. show a displaced right femoral neck fracture..." Review of an operative report dated November 2, 2012 revealed "...Right femoral neck [MEDICAL CONDITION] hemiarthroplasty of the right hip..." Review of a hospital physician's orders [REDACTED]. Observation in the resident's room on February 4, 2013 at 7:30 a.m. revealed the resident lying in bed with full bilateral side rails in the raised position. Observation in the resident's room on February 12, 2013 at 7:20 a.m. revealed the resident lying in bed with full bilateral side rails in the raised position. Observation and interview on February 20, 2013 at 11:38 a.m. in the resident's room revealed the resident in a reclined geri-chair. Interview revealed the resident had recall of the year, the month and the time. Interview revealed "I didn't necessarily want both side rails up. It's harder to get over them." Interview on February 22, 2013 at 9:50 a.m. in the Director of Nursing's (DON) office with Licensed Practical Nurse (LPN) #2 who was on duty at the time of the fall on October 30, 2012 confirmed the resident crawled to the foot of the bed; fell on the floor at the foot of the bed; and complained of right groin pain after the fall. Continued interview revealed the resident reported at the time of the fall "...wanted to get out of bed..." The LPN stated "Those rails were there and (resident) just kept moving..." Continued interview revealed the LPN had "no specific recall" if full rails were in use at the time of the fall; however, the LPN stated "...would have had full rails if...crawled to the foot of the bed..." Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed the resident scored 0/15 (severe cognitive impairment) on the BIMS; had inattention and disorganized thinking; had both physical and verbal behaviors directed toward self and others which placed the resident at risk for physical illness or injury and significantly interfered with the resident's care; rejected care; required extensive assistance with bed mobility, transfers and activities of daily living; required staff assistance with moving from seated to standing position, walking, turning around, moving on and off toilet and for surface-to-surface transfer; was incontinent of bowel and bladder; had a fall with no injury since admission to the facility; and had side rails as a restraint. Medical record review of a nurse's note dated January 22, 2013 revealed "...(Up) in w/c (wheelchair)...Alert (with) confusion...Multiple attempts to ambulate (without) assist (assistance). New order noted for self release lap belt..." Medical record review of a nurse's note dated January 22, 2013 at 11:00 p.m. revealed "...very agitated et (and) resistant to care this shift...Alert...confusion...Kept taking off self-release lap belt...Yelling screaming et hitting staff. Hit nurse in face (with) fist...New order for [MEDICATION NAME]" Medical record review of a nurse's note dated January 23, 2013 revealed "...Multiple attempts to ambulate (without) assist. Self release lap belt applied...unaware of safety needs..." Medical record review of a nurse's note dated January 25, 2013 at 2:20 p.m. revealed "Resident in...room...and secured in w/c (with) a self-release lap belt...found (with) legs stretched out and buttocks on leg rest where pt (patient) had slid out of w/c...No adverse effects found...placed in bed..." Review of the facility investigation dated January 25, 2013 revealed "...slid from w/c seat to foot rests on w/c...being kept from hitting floor by srb (self-release belt) which caught resident under....arms..." Observation on January 28, 2013 at 2:00 p.m. in the 200 unit hallway revealed Registered Nurse (RN) #2 yelled "Somebody help me. She's sliding." Observation revealed resident #17 in a wheelchair with a self-release lap belt in place and revealed the resident had slid down in the wheelchair with the lap belt in place. Observation revealed two staff members assisted RN #2 to reposition the resident upright in the wheelchair with the self-release lap belt in place. Observation revealed RN #2 started wheeling the resident down the hallway approximately 15 feet. Observation revealed the resident slid down in the wheelchair again with the lap belt in place. Two staff again assisted RN #2 to reposition the resident upright in the wheelchair with the self-release lap belt still in place. Observation on January 28, 2013 at 3:50 p.m. revealed the resident in a reclined geri-chair near the nurses' station on the 200 unit with a safety alarm in place. Interview on January 28, 2013 at 3:55 p.m. at the 200 unit nurses' station with RN #3 (identified by LPN #1/MDS as being responsible for pre-restraint assessments on the 200 unit) confirmed a pre-restraint assessment was not completed because the RN had no knowledge the resident had a self-release seat belt. Interview on January 28, 2013 at 4:00 p.m. at the 200 unit nurses' station with LPN #4 confirmed LPN #4 applied the self-release seat belt to the resident on January 22, 2013 and confirmed LPN #4 did not complete a pre-restraint assessment prior to applying the seat belt. Continued interview confirmed the LPN had no knowledge if the resident could remove the self-release seat belt on command or at will. Medical record review of a falls team meeting progress note dated January 29, 2013 revealed "On 1/25/13 and 1/28/13 res (resident) observed sliding off w/c under self released seat belt & (and) sitting on foot rests...sustained no injuries...tends to lay down/scoot down in w/c...recom (recommend) to use a G-chair (Geri-chair)...legs elevated..." Medical record review of a nurse's note dated January 29, 2013 revealed "Resident noted to climb out of G-chair/on side & (and) slid to floor...landing on buttocks...Resident assisted to stand...placed in G-Chair...assisted to nsg (nursing) station for direct observation of staff..." Medical record review of a nurse's note dated January 30, 2013 revealed "...Continuously tries to exit chair & bed..." Observation on February 4, 2013 at 7:30 a.m. revealed the resident in bed with full side rails in the raised position. Medical record review of a falls team meeting dated February 4, 2013 revealed "1/29/13 at 4:30 pm...resident...in G-chair reclined & alarm placed in chair...had climbed from side of G-chair and sat on floor on buttocks...sustained no apparent injuries...observed in therapy (with) no attempts to get up unassisted...recom to cont. (continue) G-chair & sensor alarm..." Observation on February 5, 2013 at 10:00 a.m. in the resident's room revealed the resident was in bed with both full side rails in the raised position. Continued obervation revealed the resident had both legs dangling over one of the full side rails. Observation revealed the resident's hands were positioned on the top rail and the resident was attempting to raise the body over the rail. Observation and interview on February 5, 2013 at 10:01 a.m. revealed LPN #4 entered the resident's room and confirmed the resident had both legs over the raised side rail and both hands on the top rail attempting to raise the body over the rail. Observation revealed LPN #4 repositioned the resident in the bed. Observation and interview on February 5, 2013 at 10:05 a.m. revealed Certified Nursing Assistant (CNA) #1 entered the room and confirmed CNA #1 had previously observed the resident place both legs through the bars on the raised side rail. Observation and interview with LPN #4 on February 5, 2013 at 10:07 a.m. revealed the resident placed both legs through the bars of the raised side rail; grabbed the top rail with both hands; pulled on the rail with the hands; and attempted to stand. Observation revealed LPN #4 intervened and repositioned the resident in the bed. Observation revealed the resident attempted to exit the foot of the bed. Interview with LPN #4 at the time of the observations confirmed the full side rails in the raised position were a safety hazard for the resident. Interview on February 5, 2013 at 10:20 a.m. in the resident's room with RN #2 confirmed the side rails were a hazard for the resident. RN #2 stated "I'm afraid (resident) is going to get hurt." Interview on February 5, 2013 at 10:21 a.m. in the resident's room with RN #4/Supervisor revealed "I'm afraid (resident) is going to break a leg" and confirmed RN #4/Supervisor had witnessed the resident with the legs through the raised side rails on prior occasions. Continued interview with both RN #2 and RN #4 confirmed the resident was at risk for serious injury with the full side rails in the raised position. Observation on February 5, 2013 at 11:25 a.m. in the resident's room revealed a low bed in place with fall mats folded against the bed. Observation revealed the resident was in a geri-chair with a safety sensor alarm in place. Observation on February 5, 2013 at 12:10 p.m. on the 200 unit revealed the resident in a Geri-chair in the hallway. Observation revealed the sensor alarm was not connected to the operational device on the alarm. Observation and interview on February 5, 2013 at 2:13 p.m. on the 200 unit with Physical Therapist #1 confirmed the resident was in the Geri-chair and the alarm cord was not attached to the sensor unit on the alarm. Observation and interview on February 5, 2013 at 3:25 p.m. revealed a sensor alarmed sounded in the hallway on the 200 unit. Observation revealed CNA #2 was assisting resident #17 to the resident's room. Interview with CNA #2 confirmed the resident "slid down to the end of the Geri-chair and was getting ready to stand" when CNA #2 "got to (resident)." Interview on February 12, 2013 at 9:00 a.m. in room [ROOM NUMBER] with the DON revealed the resident had been discharged to an inpatient psychiatric facility because the DON "did not feel the facility was capable of caring" for the resident. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored 5/15 on the BIMS (severely impaired cognition); had physical and verbal behaviors directed toward others; had [MEDICAL CONDITION]; rejected care; required limited assistance with bed mobility; required assistance with moving from seated to standing position, walking, turning around, moving on and off the toilet and surface-to-surface transfers; was frequently incontinent of bladder; and had a trunk restraint. Resident #18 was identified by the facility as having full side rails raised when in bed. Medical record review revealed no evidence the resident had been assessed prior to February 8, 2013 (after the surveyor requested an assessment) for the safe use of side rails and had not been assessed to determine if full side rails were a restraint device. Continued review of the assessment dated [DATE] revealed "Full SR (side rails) provides sense of security..." Observation on February 12, 2013 at 7:48 a.m. in the resident's room revealed the resident was lying in bed with full side rails in the raised position. Observation revealed the resident lying on the right side against the far rail with the left hand on the rail. The resident stated "Hey, I need help to get up." Interview on February 12, 2013 at 3:30 p.m. in room [ROOM NUMBER] with LPN #3/QI (Quality Improvement) confirmed the resident had not been assessed prior to February 8, 2013 for the safe use of side rails and still had not been assessed for the use of side rails as a restraint. Observation on February 22, 2013 at 7:20 a.m. in the resident's room revealed the resident lying in a near fetal position against the far full side rail in the raised position with the left hand pulling on the rail. The resident stated "I need to get up. My knees will probably give way if I try to get up. Do you know a man's name anywhere so he could pull me up and out of here? If I could just get my knees up over this bar I can walk. If I can lift this bar down...you push that little green thing right there and push it down. I'm afraid to put too much weight on my knees. It'll make them worse." Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual MDS dated [DATE] revealed the resident had short and long-term memory problems; rejected care; required extensive assistance with bed mobility and transfer; required extensive assistance or was totally dependent on staff for all activities of daily living; had impairment of range of motion in both upper and lower extremities; and was incontinent of bowel and bladder. Medical record review of the fall risk assessment dated [DATE] and November 20, 2012 revealed the resident scored 19 (10 or greater=high risk). Observation on January 29, 2013 at 2:52 p.m. and on February 4, 2013 at 7:30 a.m. in the resident's room revealed the resident lying in bed with both full side rails in the raised position. Observation on February 5, 2013 at 12:05 p.m. in the resident's room revealed the resident was lying in bed with both full side rails in the raised position. Observation revealed the resident's right leg was dangling over the far side rail. Observation and interview on February 5, 2013 at 12:07 p.m. in the resident's room with CNA #3 confirmed the right leg was over the side rail and confirmed CNA #3 had witnessed the resident with the leg over the side rail on previous occasions. Medical record review revealed no assessment of side rails as a potential restraint was completed until February 8, 2013 after the surveyor requested the side rail assessment for resident #20 as well as all residents with full side rails. Medical record review of the side rail assessment dated [DATE] by LPN #3/Quality Improvement (Q.I.) revealed "...Resident tries to climb out of bed frequently...full rails..." Observation on February 12, 2013 at 7:30 a.m. in the resident's room revealed the resident lying in bed with both full side rails in the raised position. Interview on February 21, 2013 at 3:00 p.m. in the DON's office with the DON confirmed the side rail assessment completed on February 8, 2013 was inaccurate and full side rails were not appropriate for the resident. Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed the resident scored 14/15 on the BIMS (no impairment of cognitive skills); required extensive assistance with bed mobility; required assistance with moving from seated to standing position, walking, moving on and off the toilet and surface-to-surface transfer; was incontinent of bowel and bladder; and had no restraint. Medical record review of a nurse's note dated January 7, 2013 revealed the resident "...was trying to get out of bed et (and) abraded Rt (right) shin on siderail..." Review of the facility investigation revealed side rails were up and "...resident was climbing out of bed...hit Rt shin on siderail-Abrasion...(no) open areas...Bed alarm on bed..." Observation on February 4, 2013 at 7:30 a.m. revealed the resident lying in bed with full side rails in the raised position. Medical record review revealed no assessment of side rails as a potential restraint was completed until February 8, 2013 after the surveyor requested the side rail assessment for resident #47 as well as all residents with full side rails. Interview on February 12, 2013 at 3:30 p.m. in room [ROOM NUMBER] with LPN #3/QI confirmed the resident had not been assessed prior to February 8, 2013 for the safe use of side rails and still had not been assessed for the use of side rails as a restraint. Telephone interview on February 22, 2013 at 10:17 a.m. with CNA #2 who reported the injury from the resident's attempt to climb out of the bed on January 7, 2013 confirmed both full side rails were in the raised position at the time of the injury and confirmed the resident was "...trying to get up to use the bathroom...trying to lift her leg to come over the rail...made a place on...leg...purple bubble like comes up when they hit something." Continued interview confirmed full side rails remained up all the time after the incident. "We just told (resident) not to get up anymore...to call us and we'd give...bedpan..." Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident had short and long-term memory problems with severe cognitive impairment; was totally dependent on staff for all activities of daily living (ADL); had limitation in range of motion in an upper and lower extremity; was incontinent of bowel and had an indwelling urinary catheter; and had no restraint in place. Observation on February 4, 2013 at 7:30 a.m. and on February 12, 2013 at 7:20 a.m. in the resident's room revealed the resident in bed with both full side rails in the raised position. Medical record review on February 4, 2013 revealed no evidence the resident had been assessed to determine if side rails were a restraining device or for the safe and appropriate use of full raised side rails on the bed. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident had short and long-term memory problems with moderately impaired cognitive skills; was totally dependent on staff for all ADL; had limitation in range of motion in an upper and lower extremity; and was incontinent of bowel and bladder. Observation and interview on January 28, 2013 at 8:30 a.m. in the resident's room revealed the resident lying in bed with both full side rails in the raised position. Continued observations revealed the resident's legs were across one of the side rails. Continued observation revealed the head was resting against the opposite side rail. Observation on February 4, 2013 at 7:32 a.m. and on February 12, 2013 at 7:20 a.m. in the resident's room revealed the resident in bed with both full side rails in the raised position. Medical record review on February 4, 2013 revealed no evidence the resident had been assessed to determine if side rails were a restraining device or for the safe and appropriate use of full raised side rails on the bed. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a significant change MDS dated [DATE] revealed the resident scored 12/15 (moderately impaired cognitive skills) on the Brief Interview for Mental Status (BIMS); required extensive assistance with bed mobility and transfers; was totally dependent on staff for all other ADL; had no limitation in range of motion; and was incontinent of bowel and had an indwelling urinary catheter. Observation on February 4, 2013 at 7:34 a.m. in the resident's room revealed the resident lying in bed with both full side rails in the raised position. Medical record review on February 4, 2013 revealed no evidence the resident had been assessed to determine if side rails were a restraining device or for the safe and appropriate use of full raised side rails on the bed. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored 8/15 (moderately impaired cognitive skills) on the BIMS; required extensive assistance of staff with all ADL; and was incontinent of bowel and bladder. Observation on February 4, 2013 at 7:35 a.m. in the resident's room revealed the resident lying in bed with both full side rails in the raised position. Medical record review on February 4, 2013 revealed no evidence the resident had been assessed to determine if side rails were a restraining device or for the safe and appropriate use of full raised side rails on the bed. Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident had short and long-term memory problems and severely impaired decision-making skills; had inattention; had behavioral symptoms not directed toward others; rejected care; was totally dependent on staff for ADL; had limitation in range of motion in all extremities; was incontinent of bowel and bladder; and had bed rails as a restraint. Observation on January 29, 2013 at 3:17 p.m. in the resident's room revealed the resident lying in bed with Oxygen (O2) at 2.5 liters per minute per nasal cannula. Continued observation revealed both full side rails were in the raised position. Observation on February 4, 2013 at 7:41 a.m. revealed the resident in bed with full side rails in the raised position. Medical record review on February 4, 2013 revealed a side rail assessment had not been completed to determine if side rails were a restraining device or the safe and appropriate use of the rails. Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the annual MDS dated [DATE] revealed the resident had short and long-term memory problems and severe impairment of decision-making skills; had physical behavioral symptoms directed toward others; rejected care; was totally dependent on staff for all ADL; had limitation in range of motion in the upper and lower extremities; and was incontinent of bowel and bladder. Observation on January 29, 2013 at 3:13 p.m. in the resident's room revealed the resident lying in bed with both full side rails in the raised position. Observation on February 4, 2013 at 7:43 a.m. revealed the resident in bed with full side rails in the raised position. Medical record review on February 4, 2013 revealed a side rail assessment had not been completed to determine if side rails were a restraining device or to ensure the safe and appropriate use of the rails. Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE] revealed the resident scored 3/15 (severe cognitive impairment) on the BIMS; required extensive to total assistance with all ADL; was incontinent of bowel and bladder. Observation on February 4, 2013 at 7:44 a.m. revealed the resident in bed with full side rails in the raised position. Medical record review on February 4, 2013 revealed a side rail assessment had not been completed to determine if side rails were a restraining device or to ensure the safe and appropriate use of the rails. Resident #24 was admitted to the facility on [DATE]

Based on medical record review, review of facility investigation, observation and interview, the facility failed to assess the appropriate use of full side rails to prevent accidents and ensure side rails did not pose a risk of injury for three residents (#15, #17 and #47); failed to apply appropriate safety devices after falls for one resident (#17); and failed to ensure adequately trained staff performed a safe transfer for one resident (#45) resulting in an avoidable fall with head injury of fifty residents reviewed. The facility's failure to follow a systematic process of assessing for the safe and appropriate use of side rails placed residents #15, #17, #45 and #47 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death.) The facility's failure to ensure adequately trained staff transfered resident #47 resulted in harm for the resident. The Administrator and the Director of Nursing were informed of the Immediate Jeopardy on February 22, 2013 in the Administrator's office. F323 resulted in Substandard Quality of Care The findings included: Resident #15 was admitted to the facility on [DATE] from a rehabilitation facility following rehab for a Fractured Pelvis and Fractured Left Hip with Bipolar Hemiarthroplasty (hip replacement) and Fractured Left Elbow with Open Reduction Internal Fixation. Other admission [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident scored 12/15 (moderately impaired cognition) on the Brief Interview for Mental Status (BIMS); required extensive assistance with bed mobility and transfer; was not ambulatory; required assistance with surface-to-surface transfer; had a urinary catheter and was incontinent of bowel; and had a fall with major injury (Hip Fracture) since admission. Medical record review of an admission nursing assessment dated [DATE] revealed the resident scored 14 on the falls risk assessment (10 or greater=high risk) and had "...full bed rails on all open sides of bed..." Medical record review revealed a side rail assessment had not been completed to ensure safe and appropriate use of the side rails. Medical record review of physician's admission orders ...high fall risk..." Review of a facility investigation dated October 30, 2012 revealed the resident crawled to the foot of the bed with the full side rails in a raised position; tried to stand and ambulate and fell on the right side. The resident complained of right groin pain and was transferred to the emergency room . Review of the hospital history and physical dated October 30, 2012 revealed "...recent treatment of [REDACTED]. show a displaced right femoral neck fracture..." Review of an operative report dated November 2, 2012 revealed "...Right femoral neck fracture...Bipolar hemiarthroplasty of the right hip..." Review of a hospital physician's orders [REDACTED]. Observation in the resident's room on February 4, 2013 at 7:30 a.m. revealed the resident lying in bed with full bilateral side rails in the raised position. Observation in the resident's room on February 12, 2013 at 7:20 a.m. revealed the resident lying in bed with full bilateral side rails in the raised position. Observation and interview on February 20, 2013 at 11:38 a.m. in the resident's room revealed the resident in a reclined geri-chair. Interview revealed the resident had recall of the year, the month and the time. Interview revealed "I didn't necessarily want both side rails up. It's harder to get over them." Interview on February 22, 2013 at 9:50 a.m. in the Director of Nursing's (DON) office with Licensed Practical Nurse (LPN) #2 who was on duty at the time of the fall on October 30, 2012 confirmed the resident crawled to the foot of the bed; fell on the floor at the foot of the bed; and complained of right groin pain after the fall. Continued interview revealed the resident reported at the time of the fall "...wanted to get out of bed..." The LPN stated "Those rails were there and (resident) just kept moving..." Continued interview revealed the LPN had "no specific recall" if full rails were in use at the time of the fall; however the LPN stated "...would have had full rails if...crawled to the foot of the bed..." Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed the resident scored 0/15 (severe cognitive impairment) on the BIMS; had inattention and disorganized thinking; had both physical and verbal behaviors directed toward self and others which placed the resident at risk for physical illness or injury and significantly interfered with the resident's care; rejected care; required extensive assistance with bed mobility, transfers and activities of daily living; required staff assistance with moving from seated to standing position, walking, turning around, moving on and off toilet and for surface-to-surface transfer; was incontinent of bowel and bladder; had a fall with no injury since admission to the facility; and had side rails as a restraint. Medical record review of a nurse's note dated January 22, 2013 revealed "...(Up) in w/c (wheelchair)...Alert (with) confusion...Multiple attempts to ambulate (without) assist (assistance). New order noted for self release lap belt..." Medical record review of a nurse's note dated January 22, 2013 at 11:00 p.m. revealed "...very agitated et (and) resistant to care this shift...Alert...confusion...Kept taking off self-release lap belt...Yelling screaming et hitting staff. Hit nurse in face (with) fist...New order for Ativan..." Medical record review of a nurse's note dated January 23, 2013 revealed "...Multiple attempts to ambulate (without) assist. Self release lap belt applied...unaware of safety needs..." Medical record review of a nurse's note dated January 25, 2013 at 2:20 p.m. revealed "Resident in...room...and secured in w/c (with) a self-release lap belt...found (with) legs stretched out and buttocks on leg rest where pt (patient) had slid out of w/c...No adverse effects found...placed in bed..." Review of the facility investigation dated January 25, 2013 revealed "...slid from w/c seat to foot rests on w/c...being kept from hitting floor by srb (self-release belt) which caught resident under....arms..." Observation on January 28, 2013 at 2:00 p.m. in the 200 unit hallway revealed Registered Nurses (RN) #2 yelled "Somebody help me. She's sliding." Observation revealed resident #17 in a wheelchair with a self-release lap belt in place and revealed the resident had slid down in the wheelchair with the lap belt in place. Observation revealed two staff members assisted RN #2 to reposition the resident upright in the wheelchair with the self-release lap belt in place. Observation revealed RN #2 started wheeling the resident down the hallway approximately 15 feet. Observation revealed the resident slid down in the wheelchair again with the lap belt in place. Two staff again assisted RN #2 to reposition the resident upright in the wheelchair with the self-release lap belt still in place. Observation on January 28, 2013 at 3:50 p.m. revealed the resident in a reclined geri-chair near the nurses' station on the 200 unit with a safety alarm in place. Interview on January 28, 2013 at 3:55 p.m. at the 200 unit nurses' station with RN #3 (identified by LPN #1/MDS as being responsible for pre-restraint assessments on the 200 unit) confirmed a pre-restraint assessment had not been completed because the RN had no knowledge the resident had a self-release seat belt. Interview on January 28, 2013 at 4:00 p.m. at the 200 unit nurses' station with LPN #4 confirmed LPN #4 applied the self-release seat belt to the resident on January 22, 2013 and did not complete a pre-restraint assessment prior to applying the seat belt. Continued interview confirmed the LPN had no knowledge if the resident could remove the self-release seat belt on command or at will. Medical record review of a falls team meeting progress note dated January 29, 2013 revealed "On 1/25/13 and 1/28/13 res (resident) observed sliding off w/c under self released seat belt & sitting on foot rests...sustained no injuries...tends to lay down/scoot down in w/c...recom (recommend) to use a G-chair (with) legs elevated..." Medical record review of a nurse's note dated January 29, 2013 revealed "Resident noted to climb out of G-chair/on side & (and) slid to floor...landing on buttocks...Resident assisted to stand...placed in G-Chair...assisted to nsg (nursing) station for direct observation of staff..." Medical record review of a nurse's note dated January 30, 2013 revealed "...Continuously tries to exit chair & bed..." Observation on February 4, 2013 at 7:30 a.m. revealed the resident in bed with full side rails in the raised position. Medical record review of a falls team meeting dated February 4, 2013 revealed "1/29/13 at 4:30 pm...resident...in G-chair reclined & alarm placed in chair...had climbed from side of G-chair and sat on floor on buttocks...sustained no apparent injuries...observed in therapy (with) no attempts to get up unassisted...recom to cont. (continue) G-chair & sensor alarm..." Observation on February 5, 2013 at 10:00 a.m. in the resident's room revealed the resident was in bed with both full side rails in the raised position. Continued observation revealed the resident had both legs dangling over one of the side rails. Observation revealed the resident's hands were positioned on the top rail and the resident was attempting to raise the body over the rail. Observation and interview on February 5, 2013 at 10:01 a.m. revealed LPN #4 entered the resident's room and confirmed the resident had both legs over the raised side rail and both hands on the top rail attempting to raise the body over the rail. Observation revealed LPN #4 repositioned the resident in the bed. Observation and interview on February 5, 2013 at 10:05 a.m. revealed Certified Nursing Assistant (CNA) #1 entered the room and confirmed CNA #1 had previously observed the resident placed both legs through the bars on the raised side rail. Observation and interview with LPN #4 on February 5, 2013 at 10:07 a.m. revealed the resident placed both legs through the bars of the raised side rail; grabbed the top rail with both hands; pulled on the rail with the hands; and attempted to stand. Observation revealed LPN #4 intervened and repositioned the resident in the bed. Observation revealed the resident attempted to exit the foot of the bed. Interview with LPN #4 at the time of the observations confirmed the full side rails in the raised position were a safety hazard for the resident. Interview on February 5, 2013 at 10:20 a.m. in the resident's room with RN #2 confirmed the side rails were a hazard for the resident. RN #2 stated "I'm afraid (resident) is going to get hurt." Interview on February 5, 2013 at 10:21 a.m. in the resident's room with RN #4/Supervisor revealed "I'm afraid (resident) is going to break a leg" and confirmed RN #4/Supervisor had witnessed the resident with the legs through the raised side rails on prior occasions. Continued interview with both RN #2 and RN #4 confirmed the resident was at risk for serious injury with the full side rails in the raised position. Observation on February 5, 2013 at 11:25 a.m. in the resident's room revealed a low bed in place with fall mats folded against the bed. Observation revealed the resident was in a geri-chair with a safety sensor alarm in place. Observation on February 5, 2013 at 12:10 p.m. on the 200 unit revealed the resident in a Geri-chair in the hallway. Observation revealed the sensor alarm was not connected to the operational device on the alarm. Observation and interview on February 5, 2013 at 2:13 p.m. on the 200 unit with Physical Therapist #1 confirmed the resident was in the Geri-chair and the alarm cord was not cnnected to the sensor unit on the alarm. Observation and interview on February 5, 2013 at 3:25 p.m. revealed a sensor alarmed sounded in the hallway on the 200 unit. Observation revealed CNA #2 was assisting resident #17 to the resident's room. Interview with CNA #2 confirmed the resident "slid down to the end of the Geri-chair and was getting ready to stand" when CNA #2 "got to (resident)." Interview on February 12, 2013 at 9:00 a.m. in room 204 with the DON revealed the resident had been discharged to an inpatient psychiatric facility because the DON "did not feel the facility was capable of caring" for the resident. Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission MDS dated [DATE] revealed the resident scored 14/15 on the BIMS (no impairment of cognitive skills); required extensive assistance with bed mobility; required assistance with moving from seated to standing position, walking, moving on and off the toilet and surface-to-surface transfer; was incontinent of bowel and bladder; and had no restraint. Medical record review of a nurse's note dated January 7, 2013 revealed the resident "...was trying to get out of bed et (and) abraded Rt (right) shin on siderail..." Review of the facility investigation revealed side rails were up and "...resident was climbing out of bed...hit Rt shin on siderail-Abrasion...(no) open areas...Bed alarm on bed..." Observation on February 4, 2013 at 7:30 a.m. revealed the resident lying in bed with full side rails in the raised position. Medical record review revealed no assessment for the safe and appropriate use of side rails. Interview on February 12, 2013 at 3:30 p.m. in room 204 with LPN #3/QI (Quality Improvement) confirmed the resident had not been assessed prior to February 8, 2013 for the safe and appropriate use of side rails. Telephone interview on February 22, 2013 at 10:17 a.m. with CNA #2 who reported the injury from the resident's attempt to climb out of the bed on January 7, 2013 confirmed both full side rails were in the raised position at the time of the injury and confirmed the resident was "...trying to get up to use the bathroom...trying to lift her leg to come over the rail...made a place on...leg...purple bubble like comes up when they hit something." Continued interview confirmed full side rails remained up all the time after the incident. We just told (resident) not to get up anymore...to call us and we'd give...bedpan..." Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the nursing kardex dated September 6, 2012 revealed the resident was at hight risk for falls and required one or two staff for transfer to the wheelchair. Medical record review of the MDS dated [DATE] revealed the resident scored 6/15 (severe cognitive impairment) on the BIMS; required extensive assistance with all activities of daily living (ADL); required assistance with moving from seated to standing position, walking and surface-to-surface transfers; was incontinent of bowel and bladder; had a history of [REDACTED]. Medical record review of fall risk assessments dated September 6, 2012 and December 12, 2012 revealed the resident was at high risk for falls. Medical record review of the MDS dated [DATE] revealed the resident scored 6/15 on the BIMS; required extensive assistance with all activities of daily living (ADL); had not been assisted with moving from seated to standing position and walking; and continued to require assistance with surface-to-surface transfers. Medical record review of a physician's progress note dated October 4, 2012 revealed "Program change...Peaked in therapy...PT (Physical Therapy) eval (evaluation)-must have assist of 2 people for all activities...now CMO (comfort measures only). Medical record review of a physician's progress note dated February 1, 2013 revealed "Nursing reports tremors increasing...NAD (no acute distress), tremor..." Medical record review of a nurse's note dated February 4, 2013 revealed "...Tremors to both arms increasing. Increased assistance needed with feeding and fluid intake..." Medical record review of a nurse's note dated February 7, 2013 revealed "Res. (Resident) observed lying in the floor. CNAs recently transferred...from bed to Broda chair...has laceration to front of forehead and two skin tear on...(right) forearm...M.D. (Medical Doctor) notified...res going to...ER (emergency room ). Review of the ER record dated February 7, 2013 revealed "...There is a deep injury but basically clean abrasion located over the right side of forehead...No active bleeding noted...Exam of the right side of forehead revealed 3 inch cut...steri strips in place...There is a superficial and clean abrasion located over the upper lip...Combined there are 2 discrete areas where wounds were surgically treated...Explored to the base of the wound, with no visible foreign material seen...Skin closed with 9 sutures...Brain imaging study shows: Nothing acute...History of present illness...patient fell from chair height, hitting head, while being transferred...at (nursing home)...estimated that the patient fell approximately 2 feet...Has contractures...is nonambulatory...chronic contractures present...exhibits a fine resting Parkinsonian tremor...family states that (resident) is acting differently at this time. Side effects of concussion and delayed bleed were explained and discussed in detail..." The resident returned to the facility on [DATE] at 9:20 p.m. Medical record review of a progress note for the falls team meeting dated February 8, 2013 revealed "...Res (Resident) was up in Broda chair, CNA's raised back of chair up to weigh...went forward & (and) hit...forehead on sink and fell to floor...sustained laceration to...forehead and two skin tears to...forearm...received sutures to forehead laceration...recom. (recommend) to wt (weigh) resident on the bed (with) Hoyer lift (with) scale built in..." Interview on February 13, 2013 at 1:40 p.m. in room 204 with CNA #5 (employed since January 15, 2013) confirmed CNA #5 and CNA #6 were instructed by the nurse to weigh resident #45 in the Broda chair. Continued interview confirmed the resident's arms and legs were contracted. Continued interview revealed CNA #5 and #6 were positioned on each side of the resident during the transfer from the bed to the upright Broda chair. Continued interview revealed after the resident was placed in the upright Broda chair, CNA #6 "...was straightening the bed..." and CNA #5 "was behind the chair using the lever to recline the chair when (resident) fell forward." Continued interview confirmed CNA #5 was "not aware" the resident was a high fall risk and CNA #5 did not receive a report on the resident prior to the transfer. Interview on February 13, 2013 at 2:45 p.m. in room 204 with LPN #6 who was on duty on February 7, 2013 at the time of the fall revealed the LPN was a "float" nurse and did not regularly work the 200 unit where the resident was located. LPN #6 stated "With assistance to transfer of 2, (resident) could sit in Broda chair." Continued interview with LPN #6 revealed "...would assume (resident) was a fall risk...because...needed assistance..." Interview on February 13, 2013 at 3:10 p.m. in room 204 with CNA #6 confirmed the resident was transferred from the bed to the upright Broda chair. CNA #6 stated "(CNA) #5 was trying to recline the chair back...I was straightening the bed and turning off the bed alarm...contracted and had shakes at arms...whole body was shaking mostly during transfer. While I was at the bed and (CNA #5) was reclining...chair (resident) went forward and fell out of the chair. As fall was happening it looked like...may have hit the corner of the wall at the sink and then kind of slid down the wall." Continued interview with CNA #6 confirmed the CNA had only taken care of the resident "one other time." Interview on February 14, 2013 at 10:15 in room 204 with LPN #7, who had knowledge of the resident and was regularly assigned to the 300 unit where the resident resided, confirmed on February 7, 2013 the resident "was shaking a little bit more than usual that day." LPN #7 reported being told by LPN #3/QI to have the resident weighed on February 7, 2013. Continued interview revealed CNA #6 had been employed 2-3 weeks but had worked the 300 unit only one week. LPN #7 stated "...obviously some lack of supervision" with neither of the CNAs in front of the resident while the other CNA was "...doing something else in the room and not in front" of the resident. Continued interview confirmed CNA #6 "should not have left to turn the alarm off until (resident) was in a reclined state" and "(CNA #5) should not have left (resident) to lean the chair back without (CNA #6) with (resident)." Continued interview confirmed "During training" of the two CNAs, the resident was bed confined and the two CNAs had never transferred the resident prior to February 7, 2013. Continued interview confirmed the CNAs were "not trained adequately to transfer" the resident. Interview on February 14, 2013 at 1:50 p.m. in room 204 with LPN #8 confirmed the resident required two staff for transfers and confirmed the resident was "jerking more as...declined...and that week could not feed (self) and was also declining mentally." Interview on February 22, 2013 at 10:10 a.m. in the Administrator's office with the DON revealed the DON had instructed the Registered Nurse (RN) supervisors "to not schedule two new employees on the same end of the unit...two could be on the same hall but not on the same end of the hall." The Immediate Jeopardy was effective October 30, 2012 through March 12, 2013. An acceptable Allegation of Compliance, which removed the Immediate Jeopardy was received and corrective actions were validated by the surveyor through medical record review, review of inservice training records and interview. The surveyor verified the Allegation of Compliance through: 1. Reviewing thirty-two medical records which revealed all residents, who had been observed with both side rails in the raised position, had been reassessed to determine if the side rails were a restraint device and posed a risk for entrapment or injury. 2. Reviewing inservice/training records and the nursing roster to ensure nursing staff had been or would be educated on the facility's newly implemented policies and forms including the new, comprehensive Restraint Use policy, policy for the Use of Side Rails, policy for Falls Assessment and Review, Decision Tree to aid staff in identification of the least restrictive restraint device, Restraint Flow Sheet, Fall Risk Evaluation, Falls Investigation Worksheet, Accident/Incident Report, Evaluation for Use of Side Rails and Consent for Use of Side Rails. 3. Interviewing the DON to ensure 100% of the nurses/CNAs had been inserviced and nurses/CNAs who had not completed the inservice training would be removed from the schedule. The DON reported two nurses and four CNAs failed to attend the mandatory inservices scheduled for March 9 and March 10, 2013 and the six employees had been removed from the working schedule. The DON confirmed the staff would be required to attend the inservice before being placed back on the work schedule. The DON reported ten stations were set up for the inservice and all staff were required to go to each station and sign they understood the training which was presented. The ten stations included training and return demonstration by each staff in attendance on using the Hoyer lift, the sit-to-stand lift, weighing bed-confined residents without having to transfer the resident to a weight chair and newly implemented restraint, side rail, fall risk and post fall assessments and policies and procedure. 4. Reviewing the manual which had been placed in the four nurses' stations which included the newly implemented policies, procedures and forms and labeled "Communication Book." 5. Conducting interviews with nurses representing all shifts to determine the staff's understanding of the newly implemented policies, procedures and forms related to restraint use, falls and the use of side rails; to determine staff's knowledge of the manual and the contents of the manual which had been placed in all nurses' stations; and to determine staff's understanding of their responsibility in conducting assessments and documenting appropriately for each resident. Conducting interviews with CNAs to ensure training was provided as reported on use of lifts, weights and safe transfers. 6. Reviewing inservice/training records to ensure Certified Nursing Assistants (CNA) had been trained on the newly implemented side rail policies, safe transfer of residents requiring assistance and supervision, different methods available for weighing bed-confined residents, and methods to determine care requirements and changes in condition for each resident to whom the CNAs are assigned. 7. Conducting interviews with CNAs to determine the staff's understanding of the newly implemented side rail policies, safe transfer of residents requiring assistance and supervision, different methods available for weighing bed-confined residents, use of lifts and methods to determine care requirements and changes in condition for each resident to whom the CNAs are assigned. 8. Observing residents to ensure the facility had removed full side rails after assessing residents and determining full side rails posed a safety hazard and observing residents in restraining devices to ensure the least restrictive device was in use. Observing residents to ensure appropriate residents had been placed in low beds with fall mats; to determine if bolsters or winged mattresses were in place for some residents; and to ensure safety alarms were in place. Non-compliance continues at a "E" level for monitoring corrective actions. The facility is required to submit a plan of correction. C/O #

Based on medical record review, facility policy review, review of literature of pacemaker devices, review of facility documents, and interview, the facility failed to be administered in a manner to protect residents from abuse, ensure abuse does not reoccur, and to ensure services rendered were according to physician orders [REDACTED]. The facility's failure caused or was likely to cause serious harm, injury, impairment or death to resident #5. The Administrator, Director of Nursing, and Unit Manager were informed of the Immediate Jeopardy in the office of the Administrator on March 5, 2012, at 2:15 p.m. The findings included: Interview in the Activity Therapy room with the Medical Director, who was the resident's attending physician, on February 29, 2012, at 11:30 a.m., revealed the Medical Director had no knowledge of the allegation of LPN #1 placing a magnet on the chest of resident #5 on October 27, 2011 until February 13, 2012 when the TBI completed a phone interview with the Medical Director. Interview with the Director of Nursing (DON) in the Activity Therapy room on March 5, 2012, at 10:10 a.m., confirmed the alleged perpetrator Licensed Practical Nurse (LPN #1) was not immediately suspended on January 13, 2012 while the faciltiy conducted an investigation into the allegation of abuse of LPN #1 placing a magnet on the chest of resident #5 who had an implanted cardiac pacemaker while resident #5 was alive. Continued interview confirmed LPN #1 was not suspended until January 16, 2012. Review of the facility Time and Attendance Records for February 2012 revealed LPN #1 worked on February 24, 27, and 28, 2012 (for a total of 3 days). Continued interview confirmed LPN #1 was allowed to return to the facility on [DATE] to work in the facility for non-resident care duties and was not terminated until February 28, 2012. Continued interview revealed the facility had not completed a full investigation until March 1, 2012. Interview on March 5, 2012, at 3:30 p.m., in the Administrator's office with the Administrator confirmed the facility failed to immediately suspend the accused perpetrator; failed to complete a timely investigation of abuse that had been reported on January 16, 2012; failed to ensure a policy for pacemakers; and failed to report the allegation of abuse made on January 16, 2012 to the State. Refer to F-223 Refer to F-226 Refer to F-309 The Immediate Jeopardy was effective from January 16, 2012 through March 2, 2012. A written Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received on March 6, 2012 and corrective actions were validated as having been completed on March 2, 2012 through review of the facility documents and staff interviews conducted on-site on March 6, 2012. The verification of the allegation of compliance was confirmed by: 1.) Reviewing the facility's revised policy for Abuse Prevention/Reporting Investigation to include more comprehensive information related to identification, preventing occurrences, reporting, investigating, protecting, and procedures. 2.) Reviewing the facility's new policy and inservice records for Pacemaker Checks procedure. 3.) Reviewing the facility's new policy and inservice records for the new Pacemaker/Defibrillator procedure. 4.) Conducted interviews with CNA's and LPN's on all units, Housekeeping staff on all units, and Activity staff to ensure all had received inservices on Abuse Prevention/Reporting investigation and were able to identify types of abuse and when and how to report. Reviewing of the facility's inservice records on abuse, dated March 1 -2, 2012, to ensure all staff were inserviced prior to returning to work. Review of the facilty plan for staff to be inserviced on abuse prior to returning to work if staff had not attended the abuse inservices. 5.) Reviewed an additional six medical records for residents with pacemakers. 6.) Reviewed an additional six medical records for residents on Comfort Only Care. 7.) Reviewed an additional three medical records of incidents of suspected abuse reported since March 2, 2012 to ensure the facility was following the procedures for reporting and investigating. Non-Compliance continues at a "D" level for monitoring corrective actions. The facility is required to submit a plan of correction. C/O #

Based on medical record review, facility policy review, review of literature on pacemaker devices, review of facility documents, and interview, the facility failed to ensure a staff member followed physician orders for services rendered. A Licensed Practical Nurse (LPN) placed a magnet on the chest of one resident (#5), who had an implanted cardiac pacemaker. The facility's failure to ensure staff adhered to physician orders caused or was likely to cause serious harm, injury, impairment, or death to one resident (#5) of sixteen residents reviewed. The Administrator, Director of Nursing, and Unit Manager were informed of the Immediate Jeopardy in the office of the Administrator on [DATE], at 2:15 p.m. The findings included: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated [DATE], revealed the resident was rarely able to understand others; was sometimes able to make self understood; had short and long term memory deficits; had severely impaired decision making skills; required two person assistance for bed mobility and transfers; was non-ambulatory; required two person assistance for all activities of daily living; and was incontinent of bowel and bladder. Medical record review of the results from the cardiac pacemaker monitoring company, dated [DATE] and [DATE], revealed "...Pacemaker: Medtronic, Inc. VERSA VEDR01 (specific type of device implanted)...Implant date: February 5, 2010...Diagnosis: [REDACTED].." Medical record review of the recapitulation Physician Orders, dated [DATE] - 31, 2011, revealed the resident was initially ordered to be a "DNR" (Do Not Resuscitate) on [DATE] and the order was to be continued. Medical record review of the Medication Administration Record, [REDACTED]. Medical record review of the Physician's Order, dated [DATE], no time noted, revealed "...have POA (Power of Attorney) sign Advance Directive (POST - Physician's Order for Scope of Treatment) for CMO (Comfort Measures Only)..." Medical record review of the Physician's Order, dated [DATE], no time noted, revealed "...Make pt (patient) CMO DNR...no labs, no x-rays, no IV's (intravenous fluids), no antibiotics, no TF (tube feeding)..." Medical record review of the Plan of Care, updated [DATE], revealed no documentation of identification of or interventions to be implemented for the care of the resident related to the resident's Cardiac Pacemaker, Do Not Resuscitate order, or the Comfort Care only order. Medical record review of the Clinical Record Nurse's Notes revealed the following sequential notes: [DATE], at 2:30 a.m. - "...resting comfortable..."; [DATE], at 4:00 a.m. - "...resting...periods of apnea (not breathing for brief periods)...comfortable..."; [DATE], 3:00 p.m. to 11:00 p.m. (shift) - "...resting quietly...periods of apnea noted..."; [DATE], at 2:30 a.m. - "...resting...periods of apnea noted..."; [DATE], at 1:40 p.m. - "Resident c/ (with) no respirations or pulse. Pronounced death"; [DATE], 7:00 a.m. to 3:00 p.m. (shift) - "Deactived (questionable spelling) Pacemaker " signed by Licensed Practical Nurse (LPN) #1; [DATE], at 2:00 p.m. - "(named) funeral home here to transport body to funeral home." Review of facility Incident Report for Resident #5, dated [DATE], no time noted, signed by the Assistant Administrator, revealed "...CNA (Certified Nursing Assistant) #1 entered nursing office had several complaints about LPN #1. Questioning why a magnet was placed on Resident #5's chest on the day (resident #5) died ...noted CNA #1 did not work on the day of (resident #5's) death [DATE]...(CNA #1) discussed all complaints with (named) Administrator and (named) DON (Director of Nursing)..." Review of facility Incident Report for Resident #5, dated February 13, 2012, at 1:00 p.m., signed by the Director of Nursing, revealed " (named) TBI (Tennessee Bureau of Investigation) at facility...investigating the death of (resident #5). Requested (resident #5's) entire medical record and access to any staff requested. Request honored...Administrator present..." Interview by phone with CNA #2 on February 29, 2012, at 8:25 p.m., confirmed on [DATE], around lunchtime, CNA #2 was cleaning resident #5 along with CNA #3 and #4 and observed "a doughnut shaped red plastic covered" device on the chest of resident #5. Continued interview confirmed the resident was alive and breathing at the time. Continued interview revealed CNA #2 asked LPN #1 what the device was and was told to "leave it alone". Continued interview confirmed the CNA had never seen the device before. Continued interview revealed the CNA was talking about the observation sometime around Christmas and was told by CNA #1 that the device was a magnet and was not to be used on a dying pacemaker patient. CNA #1 reported the incident to Administration on [DATE]. Interview by phone with CNA #3 on [DATE], at 10:10 a.m., confirmed CNA #3 was helping clean resident #5 on [DATE] and observed what looked like "a roll of red and white tape on the left side of the chest" of resident #5. Continued interview confirmed the resident was breathing at the time. Continued interview confirmed when LPN #1 was asked about the device the LPN told CNA #3 "It's a magnet. Leave it alone". Continued interview confirmed CNA #3 stated sometime around Christmas 2011 CNA #1 overheard CNA #3 talking about the incident and told CNA #3 a magnet was not to be used with a pacemaker. Interview by phone with CNA #4 on [DATE], at 10:40 a.m., confirmed CNA #4 was helping clean resident #5 on [DATE], around 10:00 a.m., and observed what "looked like a rolled up white tape on the left side of the chest" of resident #5. Continued interview revealed the resident was breathing. Continued interview confirmed the device was in contact with the skin of the resident and visible between the collarbone and breast area. Interview by phone with the Assistant Administrator on [DATE], at 3:30 p.m., and review of an undated written statement, dated as received by the facility on [DATE] and signed by the Assistant Administrator of [DATE], regarding the Assistant Administrator presence for the events of [DATE] and February 13, 2012, confirmed the Assistant Administrator was not informed of the exact nature of the incident reported on [DATE]; but was present while TBI interviewed LPN #1 on February 13, 2012. Continued interview revealed LPN #1 informed TBI about placing a magnet on resident #5's chest to deactivate the pacemaker when resident #5 was still living. Interview in the Activity Therapy room with the Medical Director, who was the resident's attending physician, on February 29, 2012, at 11:30 a.m., revealed the Medical Director had no knowledge of the allegation of LPN #1 placing a magnet on the chest of resident #5 on [DATE] until February 13, 2012 when the TBI completed a phone interview with the Medical Director. Continued interview confirmed no Physician's order was written to utilize a magnet on resident #5 for any reason other than pacemaker monitoring as directed by the company performing the readings on the specified dates by the company. Continued interview confirmed there was no reason for a magnet to be in the room or on the chest of any resident with a pacemaker. Interview on [DATE], at 3:30 p.m., in the Administrator's office with the Administrator confirmed LPN #1 placed a magnet on the chest of resident #5 who had a pacemaker and was alive at the time the magnet was placed on the resident's chest on [DATE]; and the facility had not developed and implemented policies for Cardiac Pacemakers or Comfort Measures Only prior to [DATE]. The Immediate Jeopardy was effective from [DATE] through [DATE]. A written Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received on [DATE] and corrective actions were validated as having been completed on [DATE] through review of the facility documents and staff interviews conducted on-site on [DATE]. The verification of the allegation of compliance was confirmed by: 1.) Reviewing the facility's revised policy for Abuse Prevention/Reporting Investigation to include more comprehensive information related to identification, preventing occurrences, reporting, investigating, protecting, and procedures. 2.) Reviewing the facility's new policy and inservice records for Pacemaker Checks procedure. 3.) Reviewing the facility's new policy and inservice records for the new Pacemaker/Defibrillator procedure. 4.) Conducted interviews with CNA's and LPN's on all units, Housekeeping staff on all units, and Activity staff to ensure all had received inservices on Abuse Prevention/Reporting investigation and were able to identify types of abuse and when and how to report. Reviewing of the facility's inservice records on abuse, dated [DATE] -2, 2012, to ensure all staff were inserviced prior to returning to work. Review of the facilty plan for staff to be inserviced on abuse prior to returning to work if staff had not attended the abuse inservices. 5.) Reviewed an additional six medical records for residents with pacemakers. 6.) Reviewed an additional six medical records for residents on Comfort Only Care. 7.) Reviewed an additional three medical records of incidents of suspected abuse reported since [DATE] to ensure the facility was following the procedures for reporting and investigating. Non-Compliance continues at a "D" level for monitoring corrective actions. The facility is required to submit a plan of correction. C/O #

Based on medical record review, review of literature of pacemaker devices, facility policy review, review of facility documents, and interview, the facility failed to ensure timely and completion of an allegation of abuse investigation; failed to immediately suspend the alleged perpetrator of abuse; and failed to notify the State in a timely manner of an allegation of abuse for one resident (#5) of sixteen residents reviewed. The facility's failure caused or was likely to cause serious harm, injury, impairment or death to resident #5 as a result of the facility failure to ensure a timely and complete investigation of an allegation of abuse; failed to immediately suspend the alleged perpetrator of abuse; and failed to notify the State in a timely manner of an allegation of abuse for resident (#5). The Administrator, Director of Nursing, and Unit Manager were informed of the Immediate Jeopardy in the office of the Administrator on [DATE], at 2:15 p.m. The findings included: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated [DATE], revealed the resident was rarely able to understand others; was sometimes able to make self understood; had short and long term memory deficits; had severely impaired decision making skills; required two person assistance for bed mobility and transfers; was non-ambulatory; required two person assistance for all activities of daily living; and was incontinent of bowel and bladder. Medical record review of the results from the cardiac pacemaker monitoring company, dated [DATE] and [DATE], revealed "...Pacemaker: Medtronic, Inc. VERSA VEDR01 (specific type of device implanted)...Implant date: February 5, 2010...Diagnosis: [REDACTED].." Medical record review of the recapitulation Physician Orders, dated [DATE] - 31, 2011, revealed the resident was initially ordered to be a "DNR" (Do Not Resuscitate) on [DATE] and the order was to be continued. Medical record review of the Medication Administration Record, [REDACTED]. Medical record review of the Physician's Order, dated [DATE], no time noted, revealed "...have POA (Power of Attorney) sign Advance Directive (POST - Physician's Order for Scope of Treatment) for CMO (Comfort Measures Only)..." Medical record review of the Physician's Order, dated [DATE], no time noted, revealed "...Make pt (patient) CMO DNR...no labs, no x-rays, no IV's (intravenous fluids), no antibiotics, no TF (tube feeding)..." Medical record review of the Clinical Record Nurse's Notes revealed the following sequential notes: [DATE], at 2:30 a.m. - "...resting comfortable..."; [DATE], at 4:00 a.m. - "...resting...periods of apnea (not breathing for brief periods)...comfortable..."; [DATE], 3:00 p.m. to 11:00 p.m. (shift) - "...resting quietly...periods of apnea noted..."; [DATE], at 2:30 a.m. - "...resting...periods of apnea noted..."; [DATE], at 1:40 p.m. - "Resident c/ (with) no respirations or pulse. Pronounced death"; [DATE], 7:00 a.m. to 3:00 p.m. (shift) - "Deactived (questionable spelling) Pacemaker " signed by Licensed Practical Nurse (LPN) #1; [DATE], at 2:00 p.m. - "(named) funeral home here to transport body to funeral home." Review of facility Incident Report for Resident #5, dated [DATE], no time noted, signed by the Assistant Administrator, revealed "...CNA (Certified Nursing Assistant) #1 entered nursing office had several complaints about LPN #1. Questioning why a magnet was placed on Resident #5's chest on the day (resident #5) died ...noted CNA #1 did not work on the day of (resident #5's) death [DATE]...(CNA #1) discussed all complaints with (named) Administrator and (named) DON (Director of Nursing)..." Review of facility Incident Report for Resident #5, dated February 13, 2012, at 1:00 p.m., signed by the Director of Nursing, revealed " (named) TBI (Tennessee Bureau of Investigation) at facility...investigating the death of (resident #5). Requested (resident #5's) entire medical record and access to any staff requested. Request honored...Administrator present..." Interview by phone with CNA #2 on February 29, 2012, at 8:25 p.m., confirmed on [DATE], around lunchtime, CNA #2 was cleaning resident #5 along with CNA #3 and #4 and observed "a doughnut shaped red plastic covered" device on the chest of resident #5. Continued interview confirmed the resident was alive and breathing at the time. Continued interview revealed CNA #2 asked LPN #1 what the device was and was told to "leave it alone". Continued interview confirmed the CNA had never seen the device before. Continued interview revealed the CNA was talking about the observation sometime around Christmas and was told by CNA #1 that the device was a magnet and was not to be used on a dying pacemaker patient. CNA #1 reported the incident to Administration on [DATE]. Interview by phone with CNA #3 on [DATE], at 10:10 a.m., confirmed CNA #3 was helping clean resident #5 on [DATE] and observed what looked like "a roll of red and white tape on the left side of the chest" of resident #5. Continued interview confirmed the resident was breathing at the time. Continued interview confirmed when LPN #1 was asked about the device the LPN told CNA #3 "It's a magnet. Leave it alone". Continued interview confirmed CNA #3 stated sometime around Christmas 2011 CNA #1 overheard CNA #3 talking about the incident and told CNA #3 a magnet was not to be used with a pacemaker. Interview by phone with CNA #4 on [DATE], at 10:40 a.m., confirmed CNA #4 was helping clean resident #5 on [DATE], around 10:00 a.m., and observed what "looked like a rolled up white tape on the left side of the chest" of resident #5. Continued interview revealed the resident was breathing. Continued interview confirmed the device was in contact with the skin of the resident and visible between the collarbone and breast area. Interview by phone with the Assistant Administrator on [DATE], at 3:30 p.m., and review of an undated written statement, dated as received by the facility on [DATE] and signed by the Assistant Administrator of [DATE], regarding the Assistant Administrator presence for the events of [DATE] and February 13, 2012, confirmed the Assistant Administrator was not informed of the exact nature of the incident reported on [DATE]; but was present while TBI interviewed LPN #1 on February 13, 2012. Continued interview revealed LPN #1 informed to TBI about placing a magnet on resident #5's chest to deactivate the pacemaker when resident #5 was still living. Review of the facility policy Abuse Policy, dated [DATE], revealed "...Residents must not be subjected to abuse by anyone...Abuse means willful infliction of injury...Policy is to develop and implement procedures to prevent abuse...components...training...investigation, protection, reporting...protect the resident and the complainant...immediately respond...report by phone to the State of Tennessee within twenty-four hours, followed by a written report within forty-eight hours..." Review of the facility policy Incident/Accident Documentation and investigating, dated [DATE], revealed "...all resident incidents...immediately investigated...document on an incident report...Incident team:...meet daily to review all incidents/accidents..." Review of the facility policy Reporting Accident/Incidents, no date, Document all findings on an incident report...report to oncoming shifts (and) the resident's responsible party..." Interview in the Activity Therapy room with the Administrator on February 28, 2012, at 9:45 a.m., confirmed the policy did not contain the necessary information to ensure all the needed elements the facility staff were to follow. Continued interview confirmed the policy lacked directions to immediately suspend the accused until an investigation had been completed. Review of literature on magnets and pacemakers by Medscape, dated [DATE], revealed: "...Magnet Inhibition: In most devices, placing a magnet over a permanent pacemaker temporarily "reprograms" the pacer into asynchronous (to cease to cause to operate at the same rate) mode. It does not turn the pacemaker off. Each pacemaker type has a unique asynchronous rate for beginning-of-life (BOL), elective replacement indicator (ERI), and end-of-life (EOL). Therefore, if the device company parameters are known, application of a magnet can determine if the pacer's battery needs to be replaced. Further interrogation or manipulating of the device should be performed by an individual skilled in the technique ...Although many different branded pacemaker/ICD (internal cardiac defibrillator) magnets are available, emergency physicians should be aware that in general any pacemaker/ICD magnet can be used to inhibit the device..." Interview in the Activity Therapy room with the Medical Director, who was the resident's attending physician, on February 29, 2012, at 11:30 a.m., revealed the Medical Director had no knowledge of the allegation of LPN #1 placing a magnet on the chest of resident #5 on [DATE] until February 13, 2012 when the TBI completed a phone interview with the Medical Director. Continued interview confirmed no Physician's order was written to utilize a magnet on resident #5 for any reason other than pacemaker monitoring as directed by the company performing the readings on the specified dates by the company. Continued interview confirmed there was no reason for a magnet to be in the room or on the chest of any resident with a pacemaker. Review of the facility Time and Attendance Record for LPN #1 for [DATE] through [DATE], revealed LPN #1 worked [DATE] through February 28, 2012, without suspension, for a total of 26 days. Interview with the DON in the Activity Therapy room on [DATE], at 10:10 a.m., confirmed LPN #1 was not immediately suspended on [DATE] while the facility conducted an investigation into the allegation of abuse by LPN #1. Continued interview confirmed LPN #1 was not suspended until February 16, 2012. Review of the facility Time and Attendance Records for February 2012 revealed the LPN worked on February 24, 27, and 28, 2012 (for a total of 3 days). Continued interview confirmed LPN #1 was allowed to return to the facility on [DATE] to work in the facility on non-resident care duties; LPN #1 was not terminated until February 28, 2012; and the facility had not completed it's investigation until [DATE]. Interview on [DATE], at 3:30 p.m., in the Administrator's office with the Administrator confirmed the facility failed to immediately suspend the accused perpetrator; failed to complete a timely investigation of abuse that had been reported on [DATE]; failed to ensure a policy for pacemakers; and failed to report the allegation of abuse made on [DATE] to the State. The Immediate Jeopardy was effective from [DATE] through [DATE]. A written Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received on [DATE] and corrective actions were validated as having been completed on [DATE] through review of the facility documents and staff interviews conducted on-site on [DATE]. The verification of the allegation of compliance was confirmed by: 1.) Reviewing the facility's revised policy for Abuse Prevention/Reporting Investigation to include more comprehensive information related to identification, preventing occurrences, reporting, investigating, protecting, and procedures. 2.) Reviewing the facility's new policy and inservice records for Pacemaker Checks procedure. 3.) Reviewing the facility's new policy and inservice records for the new Pacemaker/Defibrillator procedure. 4.) Conducted interviews with CNA's and LPN's on all units, Housekeeping staff on all units, and Activity staff to ensure all had received inservices on Abuse Prevention/Reporting investigation and were able to identify types of abuse and when and how to report. Reviewing of the facility's inservice records on abuse, dated [DATE] -2, 2012, to ensure all staff were inserviced prior to returning to work. Review of the facilty plan for staff to be inserviced on abuse prior to returning to work if staff had not attended the abuse inservices. 5.) Reviewed an additional six medical records for residents with pacemakers. 6.) Reviewed an additional six medical records for residents on Comfort Only Care. 7.) Reviewed an additional three medical records of incidents of suspected abuse reported since [DATE] to ensure the facility was following the procedures for reporting and investigating. Non-Compliance continues at a "D" level for monitoring corrective actions. The facility is required to submit a plan of correction. C/O #

Based on medical record review, facility policy review, review of literature on pacemaker devices, review of facility documents, and interview, the facility failed to ensure one resident (#5) of sixteen residents reviewed was protected from abuse. The facility's failure caused or was likely to cause serious harm, injury, impairment, or death to resident #5 as a result of Licensed Practical Nurse (LPN) #1 placing a magnet on the chest of resident #5 who had an implanted cardiac pacemaker while resident #5 was alive. The placing of the magnet could inhibit the pacemaker from functioning increasing the likelihood of death for resident #5. The Administrator, Director of Nursing, and Unit Manager were informed of the Immediate Jeopardy in the office of the Administrator on [DATE], at 2:15 p.m. The findings included: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set, dated dated [DATE], revealed the resident was rarely able to understand others; was sometimes able to make self understood; had short and long term memory deficits; had severely impaired decision making skills; required two person assistance for bed mobility and transfers; was non-ambulatory; required two person assistance for all activities of daily living; and was incontinent of bowel and bladder. Medical record review of the results from the cardiac pacemaker monitoring company, dated [DATE] and [DATE], revealed "...Pacemaker: Medtronic, Inc. VERSA VEDR01 (specific type of device implanted)...Implant date: February 5, 2010...Diagnosis: [REDACTED].." Medical record review of the recapitulation Physician Orders, dated [DATE] - 31, 2011, revealed the resident was initially ordered to be a "DNR" (Do Not Resuscitate) on [DATE] and the order was to be continued. Medical record review of the Medication Administration Record, [REDACTED]. Medical record review of the Physician's Order, dated [DATE], no time noted, revealed "...have POA (Power of Attorney) sign Advance Directive (POST - Physician's Order for Scope of Treatment) for CMO (Comfort Measures Only)..." Medical record review of the Physician's Order, dated [DATE], no time noted, revealed "...Make pt (patient) CMO DNR...no labs, no x-rays, no IV's (intravenous fluids), no antibiotics, no TF (tube feeding)..." Medical record review of the Clinical Record Nurse's Notes revealed the following sequential notes: [DATE], at 2:30 a.m. - "...resting comfortable..."; [DATE], at 4:00 a.m. - "...resting...periods of apnea (not breathing for brief periods)...comfortable..."; [DATE], 3:00 p.m. to 11:00 p.m. (shift) - "...resting quietly...periods of apnea noted..."; [DATE], at 2:30 a.m. - "...resting...periods of apnea noted..."; [DATE], at 1:40 p.m. - "Resident c/ (with) no respirations or pulse. Pronounced death"; [DATE], 7:00 a.m. to 3:00 p.m. (shift) - "Deactived (questionable spelling) Pacemaker " signed by Licensed Practical Nurse (LPN) #1; [DATE], at 2:00 p.m. - "(named) funeral home here to transport body to funeral home." Review of facility Incident Report for Resident #5, dated [DATE], no time noted, signed by the Assistant Administrator, revealed "...CNA (Certified Nursing Assistant) #1 entered nursing office had several complaints about LPN #1. Questioning why a magnet was placed on Resident #5's chest on the day (resident #5) died ...noted CNA #1 did not work on the day of (resident #5's) death [DATE]...(CNA #1) discussed all complaints with (named) Administrator and (named) DON (Director of Nursing)..." Review of facility Incident Report for Resident #5, dated February 13, 2012, at 1:00 p.m., signed by the Director of Nursing, revealed " (named) TBI (Tennessee Bureau of Investigation) at facility...investigating the death of (resident #5). Requested (resident #5's) entire medical record and access to any staff requested. Request honored...Administrator present..." Interview by phone with CNA #2 on February 29, 2012, at 8:25 p.m., confirmed on [DATE], around lunchtime, CNA #2 was cleaning resident #5 along with CNA #3 and #4 and observed "a doughnut shaped red plastic covered" device on the chest of resident #5. Continued interview confirmed the resident was alive and breathing at the time. Continued interview revealed CNA #2 asked LPN #1 what the device was and was told to "leave it alone". Continued interview confirmed the CNA had never seen the device before. Continued interview revealed the CNA was talking about the observation sometime around Christmas and was told by CNA #1 that the device was a magnet and was not to be used on a dying pacemaker patient. CNA #1 reported the incident to Administration on [DATE]. Interview by phone with CNA #3 on [DATE], at 10:10 a.m., confirmed CNA #3 was helping clean resident #5 on [DATE] and observed what looked like "a roll of red and white tape on the left side of the chest" of resident #5. Continued interview confirmed the resident was breathing at the time. Continued interview confirmed when LPN #1 was asked about the device the LPN told CNA #3 "It's a magnet. Leave it alone". Continued interview confirmed CNA #3 stated sometime around Christmas 2011 CNA #1 overheard CNA #3 talking about the incident and told CNA #3 a magnet was not to be used with a pacemaker. Interview by phone with CNA #4 on [DATE], at 10:40 a.m., confirmed CNA #4 was helping clean resident #5 on [DATE], around 10:00 a.m., and observed what "looked like a rolled up white tape on the left side of the chest" of resident #5. Continued interview revealed the resident was breathing. Continued interview confirmed the device was in contact with the skin of the resident and visible between the collarbone and breast area. Interview by phone with the Assistant Administrator on [DATE], at 3:30 p.m., and review of an undated written statement, dated as received by the facility on [DATE] and signed by the Assistant Administrator of [DATE], regarding the Assistant Administrator presence for the events of [DATE] and February 13, 2012, confirmed the Assistant Administrator was not informed of the exact nature of the incident reported on [DATE]; but was present while TBI interviewed LPN #1 on February 13, 2012. Continued interview revealed LPN #1 informed TBI about placing a magnet on resident #5's chest to deactivate the pacemaker when resident #5 was still living. Review of the facility policy Abuse Policy, dated [DATE], revealed "...Residents must not be subjected to abuse by anyone...Abuse means willful infliction of injury..." Review of literature on magnets and pacemakers by Medscape, dated [DATE], revealed: "...Magnet Inhibition: In most devices, placing a magnet over a permanent pacemaker temporarily "reprograms" the pacer into asynchronous (to cease to cause to operate at the same rate) mode. It does not turn the pacemaker off. Each pacemaker type has a unique asynchronous rate for beginning-of-life (BOL), elective replacement indicator (ERI), and end-of-life (EOL). Therefore, if the device company parameters are known, application of a magnet can determine if the pacer's battery needs to be replaced. Further interrogation or manipulating of the device should be performed by an individual skilled in the technique ...Although many different branded pacemaker/ICD (internal cardiac defibrillator) magnets are available, emergency physicians should be aware that in general any pacemaker/ICD magnet can be used to inhibit the device..." Interview in the Activity Therapy room with the Medical Director, who was the resident's attending physician, on February 29, 2012, at 11:30 a.m., revealed the Medical Director had no knowledge of the allegation of LPN #1 placing a magnet on the chest of resident #5 on [DATE] until February 13, 2012 when the TBI completed a phone interview with the Medical Director. Continued interview confirmed no Physician's order was written to utilize a magnet on resident #5 for any reason other than pacemaker monitoring as directed by the company performing the readings on the specified dates by the company. Continued interview confirmed there was no reason for a magnet to be in the room or on the chest of any resident with a pacemaker. Interview on [DATE], at 3:30 p.m., in the Administrator's office with the Administrator confirmed LPN #1 placed a magnet on the chest of resident #5 who had a pacemaker and was alive at the time the magnet was placed on the resident's chest on [DATE]. The Immediate Jeopardy was effective from [DATE] through [DATE]. A written Acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received on [DATE] and corrective actions were validated as having been completed on [DATE] through review of the facility documents and staff interviews conducted on-site on [DATE]. The verification of the allegation of compliance was confirmed by: 1.) Reviewing the facility's revised policy for Abuse Prevention/Reporting Investigation to include more comprehensive information related to identification, preventing occurrences, reporting, investigating, protecting, and procedures. 2.) Reviewing the facility's new policy and inservice records for Pacemaker Checks procedure. 3.) Reviewing the facility's new policy and inservice records for the new Pacemaker/Defibrillator procedure. 4.) Conducted interviews with CNA's and LPN's on all units, Housekeeping staff on all units, and Activity staff to ensure all had received inservices on Abuse Prevention/Reporting investigation and were able to identify types of abuse and when and how to report. Reviewing of the facility's inservice records on abuse, dated [DATE] -2, 2012, to ensure all staff were inserviced prior to returning to work. Review of the facilty plan for staff to be inserviced on abuse prior to returning to work if staff had not attended the abuse inservices. 5.) Reviewed an additional six medical records for residents with pacemakers. 6.) Reviewed an additional six medical records for residents on Comfort Only Care. 7.) Reviewed an additional three medical records of incidents of suspected abuse reported since [DATE] to ensure the facility was following the procedures for reporting and investigating. Non-Compliance continues at a "D" level for monitoring corrective actions. The facility is required to submit a plan of correction. C/O #