Every finding on record at Silsbee Oaks Health Care LLP

Based on record review and interview, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System within 14 days after a facility completes the resident's assessment for 3 of 3 residents reviewed for MDS transmission. (Resident #s #3, #87, and #98) The facility failed to complete and transmit a Discharge MDS assessment for Resident #3 within 14 days of completion.The facility failed to initiate and complete Discharge MDS assessments for Resident #s #87 and #98 within 14 days of discharge. These failures could place residents at risk of not having their assessment and care plan completed timely, which could result in denial of services and/or payment for services.Findings included:1. Record review of Resident #3's face sheet indicated [AGE] year-old-male admitted to the facility on [DATE] with diagnoses including acute respiratory failure and morbid obesity. Record review of Resident #3's MDS assessments indicated a Discharge assessment -return not anticipated dated 08/30/2025 had been completed but not transmitted to CMS as of 01/28/2026.2. Record review of Resident #87's face sheet indicated an [AGE] year-old-male admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and diabetes mellitus. Record review of a Transfer/Discharge report indicated Resident #87 was discharged from the facility on 09/29/2025 to a private home with home health services.Record review of the MDS tracking tab in Resident #87's electronic medical record indicated a Discharge MDS was due with an ARD of 9/29/2025. Record review of an MDS tab in Resident #87's electronic medical record indicated there had been no MDS Discharge assessment completed as of 01/28/2026. 3. Record review of Resident # 98's face sheet indicated an [AGE] year-old-female admitted to facility on 09/06/2025 with diagnoses including osteoporosis with fracture to left femur and muscle weakness. Record review of a Transfer/Discharge report indicated Resident #98 was discharged from the facility on 11/05/2025 to a private home with no home health services. Record review of the MDS tracking tab in Resident #98's electronic medical record indicated a Discharge MDS was due with an ARD of 11/05/2025. Record review of an MDS tab in Resident #98's electronic medical record indicated there had been no MDS Discharge assessment completed as of 01/28/2026.During an interview on 01/28/2026 at 10:50 a.m., the DON said the MDS coordinator was responsible for completing and transmitting MDS assessments. She said the role of MDS coordinator had been changed a few times in the last year most likely contributing to the MDS assessments not being completed nor transmitted as required. She said going forward she would be responsible for monitoring and ensuring timely completion and submissions. She said by not being completed, this could hold up billing and potentially cause issues with the former residents receiving services elsewhere. The DON said the discharge MDSs should be completed and transmitted within 14 days of discharge date . During an interview on 01/28/2026 at 11:30 a.m., the Administrator said she expects all MDS assessments to be completed and transmitted to CMS in a timely manner per the RAI guidelines. She said this failure could delay payments to the facility and for the future services of the residents already discharged from facility. Record review of the Assessment Frequency/Timeliness policy dated 06/21/2023 indicated the following: . The purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current RAI manual.6. An OBRA discharge assessment will be completed within 14 days of the discharge date .

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for essential equipment. The facility did not ensure the gas stove was in safe operating condition. This failure could place the residents at risk of a fire and not receiving their meals in a timely manner.Findings included: During an observation and interview on 01/26/26 at 9:30 a.m., DM turned on the burners on the stove. 2 of 10 burners (front left first burner and the back third burner) did not light using their pilot lights. The stove did not have an odor of escaping gas. DM said sometimes the 2 burners were slow to light but had been lighting and she turned the 2 burners off. She said she would clean the stove today maybe something boiled over this morning during breakfast, and she would have maintenance check the stove. During an observation and interview 01/26/26 at 11:33 a.m., the 2 burners were not being used during the cooking of the lunch meal. There was no odor of escaping gas in the kitchen. The pilot lights were lit on all 10 burners. The stove was clean and free of spills. The DM said we are not using those 2 burners. During an observation and interview 01/27/26 at 11:30 a.m., the 2 burners were not being used during the cooking of the lunch meal. There was no odor of escaping gas in the kitchen. The pilot lights were lit on all 10 burners. The stove was clean and free of spills. The DM said we are not using those 2 burners. During an interview on 01/28/26 at 10:00 a.m., the maintenance supervisor said the pilot lights on the stove are required to be cleaned at times and said she would check the stove today. She said if pilot lights do not light the burners, the stove would not be working properly and could allow gas to escape. During an interview on 01/28/26 at 11:00 a.m., the Administrator said her expectation was for the stove to light with the pilot light. She said the DM should report to her immediately if equipment in dietary was not working properly. She said the facility did not have a policy about equipment however the stove should work properly. She said the two burners were not being used until repaired. She said she would have the stove service company come to the facility and service the stove today. During an interview on 01/28/26 at 11:45 a.m., the Administrator said the stove service company checked the stove and replaced 2 pilot lights and the stove burners all worked. During an observation on 01/28/26 at 12:30 p.m., the 10 burners on the stove were lighting promptly when the DM turned the burners on. Record review of the Sanitation Policy dated 07/18/2025 indicated Policy: It is the policy of this facility as part of the departments of program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations. 5. Inspections will be conducted but not limited to the following areas. i. stove .

Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 2 of 12 residents (Resident #5 & #9) reviewed for advanced directives. The facility failed to ensure Resident #5 who was listed as DNR (Do Not Resuscitate) had valid Out-of-Hospital Do Not Resuscitate (OOH-DNR) form that was missing the doctor's medical identification number and did not have the POA's signature at the bottom of the document. The facility failed to ensure Resident #9 who was listed as DNR (Do Not Resuscitate) had valid Out-of-Hospital Do Not Resuscitate (OOH-DNR) form that was not missing required information and did not have Witness sign date or printed name. This failure could place residents at risk of not having their end-of-life wishes honored.Findings included: 1.Record Review of Resident # 5's face sheet, dated [DATE], indicated a [AGE] year-old female, originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included: multiply fractures of the pelvis (hip), osteoarthritis of the hip (deterioration of joints), and Alzheimer's disease (an umbrella term for a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking and behavior). Further review under the advance directive section the resident was listed as a DNR (Do Not Resuscitate). Record review of an admission MDS dated [DATE] indicated Resident #5 had adequate hearing, she had clear speech, she was always able to make herself understood, she was able to always understand others, and she had a BIMS of 10 indicating she was moderately impaired cognitively. Record Review of Resident #5's Care Plan dated [DATE], indicated: problem of MY CODE STATUS: DNR and an intervention of Obtain written DNR. Record Review of Resident #5's physician order dated [DATE] indicated: communication method Verbal, order status Active, description Do Not Resuscitate. Record Review of Resident #5's OOH-DNR dated [DATE] indicated: Under the Physician's Statement section, the physician's license number was blank. Under the All persons who have signed above must sign below, acknowledge that this document has been properly completed. The person's signature and POA's signature line was blank. During an observation and interview on [DATE] at 1:45 p.m. Resident # 5 was lying in her bed in her room. She said she was not on hospice and was a DNR and wanted to remain that way. Record review of Resident #9's face sheet, dated [DATE], indicated a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses that included: essential hypertension (high blood pressure), and unspecified dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking and behavior). Further review under the advance directive section the resident was listed as a DNR (Do Not Resuscitate). Record review of an admission MDS dated [DATE] indicated Resident #9 had adequate hearing, she had clear speech, she was able to sometimes make herself understood, she was able to usually understand others, and she had a BIMS score of 3, indicating severe impaired cognitive skills for daily decision making. Record review of Resident #9's Care Plan dated [DATE], indicated: problem of MY CODE STATUS: DNR and an intervention of Obtain written DNR. Record review of Resident #9's physician order dated [DATE] indicated: communication method prescriber written, order status Active, description Do Not Resuscitate. Record review of Resident #9's OOH-DNR record dated [DATE] indicated there was no date of when witness #1 signed and Witness #1 printed/typed name section was left blank. During an observation and interview on [DATE] at 1:30 p.m. Resident #9 was sitting in her wheelchair in her room. She said she was doing fine. She indicated she did not want anyone to do CPR on her. During an interview on [DATE] at 1:00 p.m., the SW said if a DNR form was not completed correctly with accurate dates and signatures, the DNR could be considered invalid. The SW said it was the social worker's responsibility to ensure the top portion of the DNR forms were completed accurately to include signatures and dates. The SW said she must had probably overlooked Resident #9 witness had not signed or dated the DNR, and for Resident #5 the physician's license number was blank and the POA's signature line was blank she said she must have not looked in detail like she should be. The SW said the nursing administration nurses are responsible for the bottom half of the DNR for completeness to include the doctor's information. The SW said she would check all the DNRs for proper completeness of signatures and dates. The SW said a resident's wishes may not have been followed if their advance directive was not completed. During an interview on [DATE] at 1:30 p.m. the DON said Advance Directives were reviewed by the admitting nurse and social worker to ensure accuracy. The DON said the SW fills out the top half of the DNR to include resident or POA signatures and witnesses' signatures. The DON said she or the ADON would make sure the bottom half of the DNR was complete to include the doctor's information. The DON said Advance Directives should be completed thoroughly to include dates that the document was witnessed sign and doctors' information. The DON verified there were no additional advance directives for Resident #9 or #5. The DON verified the current Advance Directives for Residents #9 and #5 were not completed. The DON said Resident #9's DNR #1 Witness did not have a date or signature, and Resident #5 the physician's license number was blank and the POA's signature line was blank. The DON said it was important for Advance Directives to be completed thoroughly to ensure the documents were legally binding. The DON said if an advance directive was not completed, the resident's wishes may not be honored. The DON said she would ensure the advance directives for Resident #9 and #5 was updated as soon as possible. During an interview on [DATE] at 2:00 p.m. the Administrator said if a DNR form was not completed correctly with accurate dates and signatures, the DNR would not be accepted. She said that in such a case, staff would be required to initiate CPR, which would go against the resident's expressed wishes. The Administrator said she believed it was the social worker's responsibility to ensure DNR forms top part was signed and complete and the nursing administration were responsible for making sure the doctor signed it and that the overall DNR was completed accurately and in accordance with requirements before it would be uploaded to the resident's medical record. Record review of a Do Not Resuscitate Order back page instructions read, .the OOH-DNR order Must be signed and dated by two competent adult witnesses .The form must be signed and dated by two witnesses except when executed by two physicians only.

Based on observation, interview, and record review, the facility failed to provide an environment that was free from accident hazards and provide assistive devices to each president to prevent avoidable accidents 1 of 6 residents (Resident #117), reviewed for accidents and hazards. The facility failed to ensure Resident #117 had fall mats in place bedside while she was in bed.These failures could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health. The findings included: Record review of Resident # 117's face sheet dated 01/28/2026 indicated an [AGE] year-old male admitted to the facility on [DATE]. Resident #117 had diagnoses of anxiety disorder (group of mental health conditions that cause fear, dread) and muscle weakness (refers to a reduced ability of one or more muscles to generate force). Record review of Resident #117's Quarterly MDS assessment dated [DATE] indicated she had a BIMS score of 9, which indicated moderate cognitive impairment. In section J1800- Any Falls Since Admission/Entry or Reentry or Prior Assessment indicated she had falls since admission. In Section V - Care Area Assessment (CAA) Summary indicated that falls were triggered, and a care planning decision was made. Record review of Resident #117's care plan dated 01/29/2026 indicated she had falls on 08/13/25,11/21/25,11/24/25,12/30/25, 01/19/26. The care plan had fall mats on floor bedside listed as an intervention. During an observation on 01/27/2026 at 11:15 a.m. Resident #117 had no fall mats in place when she was in bed. During an interview on 01/27/2026 at 12:00 p.m., LVN G said she was not aware that Resident #117's fall mat was not bedside nor in the room. She said the fall mat was there earlier but had to be cleaned. She said she was responsible for ensuring Resident #117's fall mat was bedside. She said she did not follow up to ensure the fall mat was returned to Resident #117's bedside after cleaning. She said the purpose for the fall mat was to cushion her fall if she ever fell from bed. She said all staff that enter the room should be aware if her floor mat was in place at her bedside. During an interview on 01/27/2026 at 12:15 p.m., the DON said Resident #117's should have had her fall mat bedside. She said it was in there earlier that day. She said she did not know where it was at that time. She said it was her expectation that all staff would ensure her fall mats all bedside while in bed due to Resident #117 being a high risk for falls. She said staff should communicate to the charge nurse or herself when fall mats are not bedside. She said the associated potential risk would be the resident falling with nothing to break her fall. She said she would reeducate all staff on the process as not using fall mats on high fall risk residents could lead to an injury. During an interview on 01/27/2026 at 1:00 p.m., the Administrator said all residents that require fall mats should have them. She said it was her expectation for all staff walking into Resident #117's room to be observative and ensure the fall mat was bedside. She said the associated potential risk was falls. Record review of the facility policy and procedure titled, Fall Prevention Program, dated 10/17/2023, indicated in part, . Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines:3. The nurse will indicate on the resident's fall risk and initiate interventions on the resident's level of fall risk.

Based on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 10 residents (Resident #90) reviewed for respiratory therapy. The facility failed to keep the oxygen concentrator filter clean for Resident #90. This failure could place residents at risk of receiving incorrect or inadequate oxygen support which could result in a decline in health. Findings include: Record review of Resident #90's face sheet dated 01/28/2026, indicated she was a [AGE] year-old female readmitted on [DATE] with a diagnosis of systolic and diastolic heart failure (condition in which the heart does not pump blood as well as it should). Record review of Resident #90's most recent admission MDS assessment dated [DATE] indicated she had a BIMS score of 10 which indicated moderately impaired cognition. The assessment indicated medical diagnoses of systolic and diastolic heart failure and no shortness of breath. The assessment did not indicate respiratory therapy during the lookback period. Record review of Resident #90's care plan with a target date of 05/13/2026 indicated she received oxygen therapy for ineffective gas exchange related to shortness of breath with interventions including provide oxygen as ordered. Record review of Resident #90's Physicians Order Summary dated 01/26/2026 indicated she was prescribed *oxygen at 2 liters per nasal canula (a thin flexible tube that delivers supplemental oxygen through your nose) every shift with a start date of 11/12/2026 and *Oxygen at 2 liters per nasal canula as needed for shortness of breath with a start date of 11/12/2025. *Oxygen concentrator filters cleaned every week on Sundays on the night shift with a start date of 11/16/2025. During an observation and interview on 01/26/2026 at 10:05 a.m., Resident #90 was lying in bed with oxygen per nasal canula set at 2 liters/minute to an oxygen concentrator with a black filter on the back soiled with a thick grayish/ white powdery substance. Resident #90 said the staff changed the oxygen tubing every Sunday but she was unsure if they cleaned the oxygen concentrator filter. During an observation and interview on 01/28/2026 at 8:00 a.m., Resident #90 was lying in bed with oxygen in use per nasal canula set at 2 liters/minute to an oxygen concentrator with a black filter on the back soiled with a thick grayish/ white powdery substance. Resident #90 said the staff change the oxygen tubing every Sunday, but she was unsure if they clean the oxygen concentrator filter. During an observation and interview on 01/28/2026 at 8:05 a.m., LVN D said she was providing care for Resident #90 this week Monday (01/26/2026) through today (01/28/2026). She said Resident #90's filter was soiled and she immediately cleaned it. She said the 10/6 shift nurses were responsible for cleaning the oxygen concentrator filters every Sunday night and the day and evening nurses were the back up to ensure all oxygen concentrator filters were cleaned. LVN D said Resident #90's oxygen concentrator filter was overlooked. She said the nurses were educated on cleaning oxygen concentrator filters. LVN D said the resident risk of a soiled oxygen concentrator filter was potential infection and decrease in delivery of oxygen through the oxygen concentrator. During an observation and interview on 01/28/2026 at 8:14 a.m., the SW said she was not sure who was responsible for ensuring oxygen concentrator filters were cleaned. She said she was a hall monitor for Resident #90's hall and did not notice Resident #90's oxygen concentrator filter was soiled. The SW said she was not in-serviced on cleaning oxygen concentrator filters, she was in-serviced to notify nursing if she found a soiled oxygen concentrator filters for them to clean it. The SW said the resident risk of a soiled oxygen concentrator filter was that the oxygen concentrator may not work properly. During an observation and interview on 01/28/2026 at 8:16 a.m., Activity Director E said the hall monitors were responsible for ensuring all oxygen concentrator's filters were cleaned weekly. She said she was the other hall monitor for Resident #90's hall. She said the nurses were the back up to ensure all oxygen concentrator filters were cleaned weekly and as needed. Activity Director E said she overlooked Resident #90's oxygen concentrator filter. She said she normally checks the oxygen concentrator filters, but she did not this week. She said she was in-serviced on notifying nursing if she found a soiled oxygen concentrator filter for them to clean it. The Activity director said the resident risk of a soiled oxygen concentrator filter was it could potentially make the resident sick or the oxygen concentrator did not work as well as it should. During an observation and interview on 01/28/2026 at 8:35 a.m., The DON said the 10/6 shift nurses were responsible for ensuring all oxygen concentrator filters were cleaned weekly on Sunday nights and as needed. She said Resident #90's oxygen concentrator filter was overlooked. The DON said the nurses working the halls were the backup and responsible for ensuring all oxygen concentrator filters were cleaned weekly and as needed. She said the staff were educated on ensuring all oxygen concentrator filters were cleaned weekly and as needed. The DON said the resident risk of an oxygen concentrator with a soiled filter was the potential of low oxygen intake. She said her expectation was oxygen concentrator filters were cleaned on schedule and if staff see a soiled filter to clean it. During an observation and interview on 01/28/2026 at 11:18 a.m., LVN F said she was the nurse that worked Sunday night (01/25/2026) and was responsible for cleaning Resident #90's oxygen concentrator filter. She said she overlooked it. LVN F said the day nurses were the back up to double check and ensure all oxygen concentrator filters were cleaned. She said she was in-serviced recently on ensuring oxygen concentrator filters were cleaned weekly. LVN F said the resident risk of an oxygen concentrator with a soiled filter was that the resident may potentially get sick from it. During an interview on 01/28/2026 at 11:27 a.m., the Administrator said the hall monitors were responsible for ensuring oxygen concentrators filters were cleaned and the nurses working the hall were the back up to double check the oxygen concentrators to ensure the oxygen concentrator filters were clean. She said Resident #90's oxygen concentrator filter was overlooked. The Administrator said the staff were in-serviced on ensuring oxygen concentrator filters were cleaned. She said the resident risk of an oxygen concentrator with a soiled filter was that the oxygen concentrator may potentially not be as effective. The Administrator said her expectation was all oxygen concentrators filters be monitored and cleaned routinely. Record review of a facility in-service dated 11/01/2025, titled, Concentrators/ Oxygen indicated, .Every Sunday night: change all oxygen tubing and humidifiers and date; check filters and clean or change Q Sunday and as needed . OXYGEN: Air filters. The air filter should be cleaned at least once a week. To clean, follow these steps: 1/ Remove the air filter, located on the back of the unit. Remove the oxygen outlet connector (if used). 2. Wash in a solution of warm water and soap. 3. Rise thoroughly with warm tap water and towel dry. The filter should be completely dry before reinstalling. Record Review of a facility policy dated 06/28/2023, titled, Oxygen Administration indicated, .OXYGEN: Air filters. The air filter should be cleaned at least once a week. To clean, follow these steps: 1/ Remove the air filter, located on the back of the unit. Remove the oxygen outlet connector (if used). 2. Wash in a solution of warm water and soap. 3. Rise thoroughly with warm tap water and towel dry. The filter should be completely dry before reinstalling.

Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 30 residents (Resident #10) observed for infection control. The facility failed to ensure CNA A and CNA B followed the EBP and infection control procedures for Resident #10 on 01/28/26. This failure could place the residents at risk of cross-contamination and the development of infection.Findings included: Record review of the admission record dated 01/28/26 indicated Resident #10 was [AGE] years old female admitted on [DATE] with diagnoses which included dementia and generalized muscle weakness. Record review of Resident #10's quarterly MDS assessment dated [DATE] indicated she required with assistance of 1-2 staff for incontinence care. The MDS indicated Resident #10 indicated she had memory problems with short term and long term. Resident #10 was always incontinent with Bladder and Bowels. Record review of Resident #10's care plan dated 12/05/25 indicated she had bladder incontinence. She had a history of UTI and was at risk for septicemia (a serious, life-threatening infection) with a goal of will be minimized/prevented via prompt recognition and treatment of symptoms of UTI through the review date. Resident #10's care plan indicated she required Enhanced Barrier Precautions related to gastric tube to minimize risk and exposure to infectious disease. Record review of Resident #10's physicians indicated EBP (enhanced barrier precautions) was initiated on 08/20/2025 related to her gastric tube and EBP was initiated on 12/11/2025 for her wound. During an observation on 01/28/26 at 9:20 a.m. CNA A and CNA B provided incontinent care for Resident #10. CNA A used wipes after wiping her front peri area and used more wipes on her coccyx area. CNA A removed her gloves and did not use hand sanitizer or wash her hands prior to putting on a clean pair of gloves. The CNAs completed care and CNA B walked down the hall and put the package of the wipes in the supply closet of wipes into the closet. During an interview on 01/28/26 at 9:45 a.m., CNA A said she should have washed her hands before she applied clean gloves. CNA A said we are to wash our hands to prevent spread of germs. CNA B said she should have placed the package of the wipes into Resident #10's drawer or night side table. The supplies that we bring in the room can only be used by that resident to prevent spread of germs. During an interview on 01/28/26 at 10:24 a.m., LVN C said hands were to be washed or sanitized after removing gloves and the wipes should have been left in the residents' night side table. He said washing hands and not sharing supplies can prevent the spread of germs. During an interview on 01/28/26 at 10:45 a.m., the DON said hands are to be sanitized before and after glove use. She said supplies should not be brought out of the room and used on other residents. Record review of Hand Hygiene policy dated 03/23/2021 indicated Policy: All staff will perform proper hand hygiene procedure to prevent the spread of infection to other personnel, residents, and visitors. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on observation, interview, and record review, the facility failed to provide or obtain from an outside source dental service to meet the needs of 1 of 29 residents reviewed for dental services. (Resident #132) The facility did not assist Resident #132, who had missing teeth and dental decay, with a dental service consult. This failure could place the residents at risk for not receiving care and services to maintain their highest practicable mental, physical, and psychosocial well-being. Findings included: Record review of an admission record dated 10/30/24 indicated Resident #132 admitted on [DATE] and was [AGE] years old with diagnoses of high blood pressure, diabetes (disease results in too much sugar in the blood), and peripheral vascular disease (chronic condition when blood vessels become block). Record review of an admission document dated 05/21/24 for Resident #132 indicated no concerns with his teeth. Record review of a quarterly MDS assessment dated [DATE] for Resident #132 did not indicate any problems with his oral health. His BIMS indicated he was cognitively intact. He required set up assistance of staff for oral care. Record review of the care plan dated 09/05/24 indicated Resident #132 was independent with his oral care and no mention of dental problems. During an observation and interview on 10/28/24 at 8:53 a.m., Resident #132 said he had not seen a dentist in a long time and needed an appointment. He opened his mouth and said, I am missing some teeth. There were some teeth on the lower jaw that were deteriorated. He denied being in pain or difficulty in chewing his food. During an interview on 10/29/24 at 10:00 a.m., the SW said she was responsible for making the appointments for the residents to see the dentist. She said Resident #132 had not complained to her and none of the nursing staff had reported he had a need for dental consult. She said they have a dentist to send residents too if they have dental issues. She said nurses normally let her know. She said Resident #132 had Medicaid so she would get him an appointment. During an interview on 10/29/24 at 10:55 a.m., the DON said Resident #132's teeth should have been assessed on admission and quarterly. She said we should have addressed that during care plan meetings. During an interview on 10/30/24 at 8:57 a.m., the DON said she had observed Resident #132's teeth after surveyor intervention and said the nurses should have referred him to the social worker for missing and deteriorated teeth. During an interview on 10/30/24 at 10:25 a.m., LVN C said she looked at the residents' teeth while making rounds. She said if the resident complained of issues or pain, she would refer them to the SW. She said Resident #132 performed his own oral care himself. LVN C said she had not seen any missing teeth or cavities but if he needed an appointment, she would tell the social worker. During an interview on 10/30/24 at 9:30 a.m., the Administrator said her expectations were for the residents to be referred to the dentist as needed. Record review of the policy dated 08/14/17 titled Dental Care indicated Resident assessed and assisted with dental care needs to help maintain their nutritional needs and promote oral hygiene. Residents will be assessed by nursing personnel for dental care needs at admission and as needed.Referrals for professional dental care needs will be facilitated by the facility according to resident'/ resident' representatives' preference.

Based on interview and record review, the facility failed to provide services as outlined by the comprehensive care plan, to meet professional standards of quality for consultation with the resident's physician when there was a significant change in the resident's condition or a need to alter treatment significantly for 1 (Resident #13) of 29 residents reviewed for following physician's orders. The facility failed to implement Resident #13's care plan when the blood pressure and/or heart rate was below prescribed parameters and did not notify the physician in October 2024. (10/07, 10/8, 10/15, 10/16, 10/21, 10/23, 10/25, 10/26, and 10/28). Th failure placed residents, who required blood pressure and heart rate monitoring, at risk for complications due to delayed physician intervention. Findings included: Record review of Resident #13's clinical record indicated she was admitted on [DATE], was [AGE] years old with diagnosis which included hypertension (high blood pressure). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #13 had a BIMS score of 08 which indicated cognition was moderately impaired. She had a diagnosis of hypertension. Review of Resident #13's care plan dated 07/02/24 indicated the resident had diagnosis of hypertension and was at risk for decreased cardiac output (a state in which your heart does not pump enough blood to supply your organs and tissues with adequate oxygen), activity intolerance from weakness, and ineffective coping. The interventions included administering anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (a sudden drop in blood pressure when you stand from a seated or prone position) and increased heart rate and effectiveness. Record review of physician orders dated October 2024 indicated Resident #13 was prescribed carvedilol 12.5 mg (used to lower blood pressure) twice daily for hypertension. Hold for blood pressure less than 110/60; and hold for heart rate below 60. Record review of the MAR dated October 1 - 29, 2024 indicated on the following dates at 8:00 a.m. and at 5:00 p.m., Resident #13's carvedilol 12.5 mg was held and there was no indication in the electronic clinical record the physician had been notified : 10/07/24 at 5:00 p.m., B/P (blood pressure) was 94/54, 10/08/24 at 8:00 a.m., B/P was not recorded but coded as held, 10/14/24 at 5:00 p.m., B/P was 100/56, 10/15/24 at 8:00 a.m., B/P was not recorded but coded as held, 10/16/24 at 8:00 a.m., B/P was not recorded but coded as held, 10/16/24 at 5:00 p.m., B/P was 116/56, 10/21/24 at 8:00 a.m., B/P was not recorded but coded as held, 10/23/24 at 5:00 p.m., B/P was 120/47, 10/25/24 at 5:00 p.m., B/P was 117/56, 10/26/24 at 8:00 a.m., B/P was 113/46, and 10/28/24 at 5:00 p.m., B/P was 113/56 and heart rate was 56. Record review of the nurse's notes for Resident #13 dated October 3 through October 29, 2024, gave no indication of notifying the physician of the blood pressure medication being held for 11 of 57 opportunities. During an interview on 10/30/24 at 9:00 a.m., MA B said she would obtain resident vital signs prior to blood pressure medication administration, and if medication were held due to being outside prescribed parameters, she would alert the charge nurse. MA B said the charge nurse would then assess residents and recheck their blood pressure with a manual cuff. During an interview and record review on 10/30/24 at 8:40 a.m., LVN A reviewed Resident #13's current electronic MAR and acknowledged the B/P medication was held on multiple occasions in October due to B/P being out of parameters prescribed by the physician. LVN A said the nurses were responsible for notifying the physician after B/P medication was held 3 times or more. She added the DON and ADON were responsible for ensuring the physician had been notified. Nurses were educated to notify physicians when medications were held. LVN A said Resident #13's had been overlooked and she would notify immediately. The risk was medication may not be therapeutic if physician not notified when held so adjustments may be made to dosages. During an interview and record review on 10/30/24 at 9:00 a.m., the DON said her expectations were for residents with prescribed parameters for administration of medications to have documentation of those vital signs. She added she will conduct weekly chart audits, and it was her responsibility to assure accuracy of resident's clinical records. She acknowledged Resident #13's October MAR indicated B/P medications were held on multiple occasions. She said the physicians or Nurse Practitioners visited facility weekly or bi-weekly and were made aware of any concerns with residents during their visits unless there was an emergency. During a joint interview on 10/30/24 at 12:00 p.m., the DON and ADON said they were responsible for ensuring the physician was notified when medications were being held. They were overlooked. They said they would in-service staff and start running a report in the electric medical record system weekly/monthly to ensure physician notification of any medication that was consistently held or refused. She said the risk was that the medication may not be therapeutic if the physician was not notified when held. Record review of the policy Specific Medication Administration Procedures dated August 2019 indicated . P. Notification of Physician/Prescriber: 2) Held medications for pulse, blood pressure, low or high blood sugar, or other abnormal test results, vital signs, resulting in medications being held.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents and supervision. The facility failed to provide adequate supervision after a resident expressed suicidal ideations (she wanted to die). The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 9/10/2023 and ended on 9/11/2023. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving appropriate supervision and interventions for suicidal thoughts and attempts which could lead to residents sustaining serious injury or harm. Findings include: Record review of an undated, face sheet indicated Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included dementia (loss of cognitive functioning), diabetes (chronic condition that affects the way the body processes blood sugar), stroke (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off ), difficulty speaking and swallowing due to a stroke, major depression, (medical illness that negatively affects how you feel, the way you think and how you act) and anxiety (persistent and excessive worry that interferes with daily activities). Record review of physician orders, dated 7/10/2023, indicated Resident #1 received psych services for evaluation and monitoring. The orders indicated she received Depakote 125 mg one time a day for mood disorder and Paroxetine 40 mg one time a day for depression and anxiety. Record review of an annual MDS, dated [DATE], indicated Resident #1 was usually understood and usually understood others. A BIMS score of 12, which indicated Resident #1 was moderately impaired cognitively. Resident #1 required limited to extensive assistance with most ADLs. Resident #1 had signs and symptoms of delirium to include disorganized thinking behaviors present. Record review of Resident #1's care plan, dated 12/01/2021, indicated Resident #1 was at risk for behavioral symptoms/suicidal ideation related to vocalized wanting to die when she was mad. The care plan interventions included to allow her time to answer questions and to verbalize feelings perceptions, and fears; consult with pastoral care, social services, or psych services; and when conflict arises, remove to a calm safe environment, and allow to vent/share feelings. Record review of a progress note dated 9/4/2023, from NP D from psychiatric services, indicated the resident was negative for suicidal ideations. Resident #1 was being seen 2-3 times a month by psych services for major depression disorder, insomnia, and medication monitoring. Record review of a progress note for Resident #1, dated 9/10/2023 at 10:10 p.m., LVN A indicated Resident #1 was sitting up in her wheelchair in her room. Resident #1 refused medications at 8:30 p.m. and was yelling at staff to leave her alone, she just wanted to die. LVN A tried to redirect the resident, but the resident continued to yell get out, just leave me alone. LVN A left Resident #1 alone in her room and when she came back to the room, the resident was not yelling. LVN A found Resident #1 with shoestrings tied around her neck. LVN A cut the shoestring off and asked the resident if she did that to kill herself and Resident #1 screamed out I sure did! Resident #1 was placed on 24-hour 1-on-1 monitoring, and the MD, RP, and DON were notified. A call was placed for EMS to transport the resident to the local hospital for evaluation and treatment. When EMS arrived, Resident #1 continued yelling, was aggressive and refused to cooperate with staff and EMS. EMS administered Haldol (antipsychotic medication) intramuscularly, but the medication was ineffective. While EMS transferred Resident #1 from her wheelchair to the stretcher, the resident was alert and yelling and hitting EMS as they exited the facility. The RP was notified. During a telephone interview on 9/13/2023 at 5:05 p.m., LVN A said she was the nurse on duty for Resident #1 the evening of 9/10/2023, the date the incident occurred. She said around 8:45 p.m. - 9:00 p.m. she checked Resident #1's fingerstick blood sugar level, but the resident became aggressive when she returned to give her the scheduled 9 p.m. medications. She said the resident started hollering, screaming, and cussing at her telling her to get the hell out, don't want to live/want to die. She said CNA B was in the room behind the privacy curtain providing care for Resident #1's roommate. LVN A said she left the room to get CNA C who could calm Resident #1 down and get her to take medications and/or allow staff to provide care. LVN A said as she was leaving the room, she told CNA B to keep an eye on Resident #1. LVN A said she returned to Resident #1's room with CNA C around 9:15 p.m. and found the resident had 2 shoestrings tied together around her neck tightly. She said the resident was combative (slapping the nurse's hands back), but she was able to release tension of the shoestrings from around the resident's neck. LVN A said she directed for CNA C to get scissors to cut the string. She said when CNA C returned to the room with the scissors from the nurses' station, she cut the shoestrings and removed them from the resident's neck. She said after cutting the string, there were red marks to the left side of Resident #1's neck. LVN A said she asked the resident if she did that to kill herself and the resident screamed out I sure did! She said Resident #1's MD, the DON, administrator, and RP were notified. She said Resident #1 was placed on 24-hour 1-on-1 monitoring at 9:30 p.m. until the ambulance arrived at 9:45 p.m. to transport her to the hospital for evaluation. She said when EMS arrived, the resident was combative and hollering out. LVN A said EMS administered Haldol to Resident #1, but it was ineffective as she continued yelling and hitting the EMS staff as they exited the facility. LVN A said she did not recall this resident ever being this aggressive and combative. LVN A said the resident had a history of episodes of hollering and fighting staff at times with episodes of crying saying she wanted to die. LVN A said when she was upset or had those behaviors, she usually would be calmed down by certain staff. During a telephone interview on 9/13/2023 at 5:27 p.m., CNA B said around 9 p.m. (on 09/10/23), she was in Resident #1's room providing care to the resident's roommate. She said she heard when Resident #1 was refusing her medications, yelling at the nurse to get the hell out, and saying she wanted to die. CNA B said LVN A told her to keep an eye on Resident #1 as she (the nurse) left the room for assistance. CNA B said she did not stay in the room with Resident #1 once she finished providing care to the roommate, she left the room. She said LVN A did not direct her to provide 1:1 care to Resident #1, and she was not assigned to provide care for Resident #1. CNA B said you could hear Resident #1 hollering and screaming from the hallway. During a telephone interview on 9/13/2023 at 5:35 p.m., CNA C said on 09/10/2023, she was assigned to care for Resident #1 and when she provided care for the resident around 7:30 p.m., the resident was not as talkative as usual but did not make any statements about wanting to die. CNA C said LVN A went to her and asked her to go to Resident #1's room to help calm her down so she would take her nighttime medications and get ready for bed. CNA C said her and LVN A walked into the resident's room around 9:15 p.m. She said LVN A asked the resident, What is that around your neck? She said when LVN A reached for the shoestrings around the resident's neck, she slapped at LVN A's hands. CNA C said LVN A told her to go get scissors from the nurses' station. She said when she returned to the resident's room with the scissors, LVN A was trying to release tension on the shoestrings. She said LVN A cut the shoestrings from around the resident's neck and asked the resident, Did you do that to kill yourself? CNA C said Resident #1 screamed out, I sure did! She said Resident #1 was placed on 1-on-1 supervision at that time. CNA C said it was a very scary incident and said she would never thought Resident #1 would have done anything like that. CNA C did not recall seeing any other staff in the room prior to them entering. Record review of Resident #1's hospital records, dated 9/11/2023, indicated she was transferred from the facility to the acute care hospital and later seen by the associated behavioral unit. During a telephone interview on 9/14/2023 at 12:19 p.m., NP D said he was a psych service NP and visited with Resident #1 two to three times a month for a year or more. He said he was seeing the resident for delusions, depression/sadness, sleep disturbances, and for management of psychotropic medications and side effects, and to monitor the effects of medications and for dose adjustments. He said he was surprised to hear the resident made suicidal ideations or expressed any desire or plan to commit suicide because she denied risk of self-harm during visits. NP D said Resident #1 could be moody at times and depending on her mood, she might not speak with anyone or allow anyone to assess her. NP D said the facility notified him of Resident #1's suicide attempt and her being sent out for evaluation. He said he would visit with her when she returned to the facility. NP D denied knowledge of the resident having occasional episodes of crying and hollering out and saying she wanted to die. Record review of progress note on 9/14/2023 at 12:30 p.m. indicated Resident #1 returned to facility on 9/13/2023 at 11:00 pm. During an observation and interview on 9/14/2023 at 1:30 p.m., Resident #1 was sitting up in her wheelchair in her room. She had slurred speech but was able to answer questions and made her needs known. Resident #1 answered questions, but when asked about the 09/10/2023 suicide attempt incident, she would not respond. Resident #1's room was clean, and no hazardous materials were noted (shoes with no shoestrings or elastic shoes with strings sewn in, no sharp objects). During an interview on 9/14/2023 at 3:00 p.m., the DON said Resident #1 had been a resident at the facility for several years and had a history of making statements about wanting to die when she was mad. The DON said she was aware of Resident #1 making the statements of wanting to die at times. She said the resident would do this at times when her family would leave after visiting or it seemed to happen when she was mad or seeking attention. The DON said the facility care planned those behaviors with interventions to include staff talking with her and see why she was upset or mad. She said usually the staff could resolve the issue and Resident #1's behavior. She said prior to Resident #1's suicide attempt, if a resident made a suicide threat or expressed they wanted to die, the expectations of staff's response to the resident depended on who the resident was and if this was a previously identified behavior. The DON said (on 09/11/2023) after Resident #1's suicide attempt, the facility implemented a new suicidal prevention policy to include if any resident expressed or voiced thoughts of suicide/wanting to die, the resident would not be left alone and 1-on-1 care would be provided until arrangements could be made for the resident to receive emergency psychiatric care or until the resident's physician determined when the resident was no longer a suicide risk. She said all staff prior to working their next shift were in-serviced on the new suicidal precautions and expectations. She said Resident #1's care plan was updated to include interventions of: provide counseling with psych services, keep family involved, provide one to one care if a resident expressed wanting to die and consult psych services, psych would continue to follow the resident and treat her for depression. She said when Resident #1 returned the facility on 09/13/23, the facility implemented every 15-minute observations for 72 hours following recent behavioral hospital stay for suicide attempt, provide calming atmosphere, engage resident in activities, provide care, and alert MD of any negative changes. The DON said her expectations were all residents with suicidal ideations were not to be left alone, and staff to monitor 1:1 until the resident was sent out for evaluation or when the resident received a psych emergency evaluation. The DON said no other residents in the facility have been identified as a suicide risk. Record review of an undated care plan dated indicated Resident #1 was placed on every 15 minute frequent monitoring by staff observations related to a recent behavioral hospital stay for a suicide atempt for the next 72 hours with a target date of 09/17/23. Record review of an undated care plan indicated Resident #1 had a psychosocial well-being problems, often making statements of wanting to die. The resident was sent out to the emergency roiagnom on [DATE] for an attempted suicide and returned to the facility on [DATE]. The interventions included: counseling would be provided with psych services, provide 1:1 care when resident was having episodes of stating she wanted to die and consult psych services, and psych would continue to follow residents and treat for depression. The target date was 11/05/23. Record review of the facility policy, implemented date of 9/11/2023, titled Suicide Prevention Policy: it is the policy of the facility to act quickly and appropriately if a resident expresses thoughts of suicide. Definitions: 'Suicide' is defined as a death from injury, poisoning or suffocation where there is evidence that the death was self-inflicted. 'Suicidal Ideation' is defined as self-reported thoughts about engaging in suicide-related behaviors .1. All staff members will immediately report any suicidal ideation to the resident's charge nurse and facility social worker .2. Immediately notify the resident's physician if the resident presents with suicidal ideation even if he or she isn't specific about a plan or intent .3. If applicable, notify the resident's responsible party of the resident's suicidal ideations and any orders received from the residence physician .4. The resident will not be left alone. One-on-one care will be provided until arrangements can be made for the resident to receive emergency psychiatric care, or until the residence physician determines that the risk of suicide is no longer present .5. Objectively and thoroughly document the resident's mood and behaviors, as well as all actions taken, in the medical record .6. If the resident requires inpatient psychiatric service state specific guidelines and requirements will be followed. Record review of in-service sign in sheet for new policy on Suicidal Prevention, dated 9/11/2023, indicated 69 staff members signed the in-service record which included LVN A, CNA B, and CNA C. During interviews on 9/13/2023 from 1:30 p.m. - 9/14/2023 4:30 p.m., 6 LVNs (2 from each shift- LVN A, LVN L, LVN I, LVN K, LVN G, LVN N), were able to identify suicidal expressions, all were knowledgeable of the new suicide policy implemented 09/11/2023, all were aware of the new expectations to not leave any resident who alone if suicidal expressions/ideations occurred, and said residents would need 1:1 care at that time, and to notify the DON/ADON and the Administrator immediately. During interviews on 9/13/2023 from 1:30 p.m. - 9/14/2023 4:30 p.m., 6 CNAs (2 from each shift- CNA B, CNA C, CNA M, CNA H, CNA E, CNA O, CNA P) were able to identify suicidal expressions, all were knowledgeable of the new suicide policy implemented 09/11/2023, all were aware of the new expectations to not leave any resident alone if suicidal expressions/ideations occurred, and said residents would need 1:1 care at that time, and to notify the charge nurse/DON/ADON and the Administrator immediately. During interviews on 9/13/2023 from 1:30 p.m. - 9/14/2023 4:30 p.m., 2 MAs (one from each shift- MA F and MA J) were able to identify suicidal expressions, both were knowledgeable of the new suicide policy implemented 09/11/2023, both were aware of the new expectations to not leave any resident who alone if suicidal expressions/ideations occurred, and said residents would need 1:1 care at that time, and to notify the charge nurse/DON/ADON and the Administrator immediately. Record review of in-service sign in sheet for new policy on Suicidal Prevention, dated 9/11/2023, indicated 69 staff members signed the in-service record which included LVN A, CNA B, and CNA C. Record review of a QAPI Committee Report, dated 9/11/2023 & 9/15/2023, indicated there was a meeting held on 9/11/2023and 9/15/2023 at 8:00 a.m. consisting of the Administrator, the assistant Administrator, the DON, the ADON, the AD, the wound care nurse, the MDS nurse, the social worker, the wound care nurse, the psych services NP, and the MD. The following interventions were put in place: New Policy: Suicide prevention In-service: Suicide Prevention Care planning for suicidal ideations and attempts The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 9/10/2023 and ended on 9/11/2023. The facility had corrected the noncompliance before the survey began.

Based on interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, complete and accurately documented medical records for each resident, for 1 of 27 residents (Resident #5) reviewed for accurate records. The facility failed to document Resident #5's baths for 08/01/23 - 08/29/23. This failure could place residents at risk for inaccurate and missing documentation in their records. Findings included: Record review of a face sheet dated 08/30/23 indicated Resident #5 admitted to the facility on [DATE] and was [AGE] years old with diagnoses including a seizure disorder and hemiplegia (paralysis of one side of the body). Record review of the MDS dated [DATE] indicated Resident #5 had no speech, was unable to express ideas and wants, and he rarely/never understood. The resident's cognitive skills for daily decision making were severely impaired and he required one staff member for grooming and personal hygiene. Record review of the care plan dated 08/29/23 indicated Resident #5 had a deficit with ADL self-care performance and he was totally dependent on staff for ADLs. It indicated for personal hygiene: He was dependent on (1) staff for personal hygiene and oral care; provide my care and notify nurse of any changes in my abilities. The CNA bathing/showering care plan indicated: He was dependent on (1-2) staff to provide bath/shower and as necessary. Record review of the August 2023 aide flowsheet in the electronic medical record indicated no documented evidence Resident #5 did not received his baths from 08/01/23 - 08/29/23. During an interview on 08/29/23 at 9:30 a.m., the DON said Resident #5's August 2023 ADL flowsheet with the bath record was incomplete and said the 2 p.m. - 10 p.m. aide did not chart the baths for him. The DON said she knew the bath had been given because she saw the CNA C perform the bath last week. She said the CNA C was the only CNA that bathed Resident #5 and should have charted the bath was given. The DON said the staff could look at the clinical record and ensure baths werewas given as required. The DON said Resident #5 should have been charted at least three times weekly for his bath. During an interview on 08/29/23 at 3:00 p.m., CNA C said she had given Resident #5 his bath every day she worked on the 2-10 shift Monday-Friday but did not chart the baths as being given during the month of August 2023. She said there was not a place for charting his baths and did not report to the nurse or the DON that she was unable to chart Resident #5's bath. During an interview on 08/30/23 at 7:45 a.m., the DON said she and the nurses were responsible for making sure the aide flowsheets were correct and completed. She said Resident #5 bath was put in the computer on night shift, but he received the bath on 2-10 and was given by CNA C. During an interview on 8/30/23 at 7:55 a.m., the a dministrator said she expected the clinical electronic medical records to be correct and completed when the residents received their baths. She said they had given training on completing aide flowsheets and medical records in June 2023. Record review of the undated policy and procedure titled electronic charting and electronic signatures revealed . will maintain residents' charts through electronic charting using the .with only minimal paper charting. The direct care staff will enter their documentation . b. The staff member will complete their documentation as required

Based on observation, interview, and record review, the facility failed to ensure residents, who were unable to carry out activities of daily living, received the necessary services to maintain good grooming, and personal hygiene for 1 of 28 residents reviewed for ADL care. (Resident #15) The facility did not shave Resident #15's upper lip and chin hairs. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of psycho-social well-being. Findings included: Record review of physician's orders dated August 2023 indicated Resident #15 was admitted to the facility on [DATE], was an [AGE] year old female, and had diagnoses of anxiety, muscle weakness and macular degeneration. Record review of the most recent MDS dated [DATE] indicated Resident #15 was alert and, oriented with a BIMS of 13 (score of 13 to 15 indicates the resident is cognitively intact) and required extensive assistance of one person for personal hygiene. Record review of a care plan updated 06/11/23 indicated Resident #15 had ADLs and preferences that needed staff attention, understanding, and possible assistance for her deficits. The care plan indicated the resident required extensive assistance with ADL care needs. The goal was to maintain the resident's dignity and needs. There was no care plan to indicate the resident resisted care or refused care. During observation and interview on 08/28/23 at 8:52 a.m., revealed Resident #15 was lying in bed. The resident had multiple hairs on her upper lip and chin approximately 3/4 inch in length. She said the facility staff usually shaved her but had not shaved her recently. She said she wanted to keep the facial hair shaved. She denied concerns related to dignity. During observation and interview on 08/28/23 at 12:15 p.m., revealed Resident #15 had multiple hairs to upper lip and chin approximately 3/4 inch in length. During observation and interview on 08/29/23 at 12:26 p.m., revealed Resident #15 had long hairs to her upper lip approximately 3/4 inch in length. HerThe chin had been shaved. The resident said one of the staff shaved her chin but did not shave her upper lip. She said she wanted her upper lip shaved but did not feel it was a dignity issue. CNA A entered the resident's room. She said Resident #15 did have multiple long hairs on herthe upper lip. She said the resident sometimes told them she didn't want to be shaved. The resident said she always wanted to keep her facial hair shaved. The CNA said it was her responsibility to keep the resident's facial hair shaved. She said it could be a dignity concern if the resident's facial hair was not shaved. During an interview on 08/29/23 at 2:38 p.m., LVN B said it was the direct care staff's responsibility to ensure the residents received the necessary ADL care. She said Resident #15's daughter family member usually shaved her. She said it was ultimately the facility's responsibility to ensure the resident's facial hair was shaved. She said the department heads were supposed to monitor the halls and report to the charge nurse if the residents needed to be shaved. She said the possible negative outcome of the resident's facial hair not being shaved would be they might feel negative about their appearance. During an interview on 08/29/23 at 2:34 p.m., the Accounts Payable person said she was the Hall 100 monitor for the month of August 2023. She said she did observation rounds every morning to check oxygen, nebulizers, hazards and to check resident's care needs. She said she did not notice Resident #15 had facial hair because usually the resident was sleeping 9 times out of 10 when she did her rounds and she did not want to be bothered, so she left her alone. She said it was her responsibility to report Resident #15's facial hair to the charge nurse, but she had not. She said the possible negative outcome of the resident not being shaved could be she would feel bad about herself. She said knowing the resident, the resident did not care if she was shaved. During an interview on 08/29/23 at 3:23 p.m., the a dministrator said her expectations were for the staff to keep the residents shaved. She said even if Resident #15's family shaved the resident at times,; it was the staff's responsibility to ensure Resident #15 was shaved. She said the residents not being shaved could be a dignity concern. Record review of an Activities of Daily Living Policy dated 06/28/2003 indicated: . Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and, personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to, in accordance with State and Federal laws, provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 1 of 1 storage area located in the DON's office of drugs for destruction reviewed for drug storage. The facility failed to ensure controlled drugs for destruction were stored in a separately locked, permanently affixed compartment for storage until destroyed. This failure could place residents at risk for possible drug diversion. The findings included: During observation and interview on 08/30/23 at 9:16 a.m., revealed the DON opened a cabinet drawer in her office using her key. She said the drawer contained all the discontinued drugs intended for destruction at the facility. Inside the drawer was a secured/affixed lock box that was closed and locked and lying across the bottom of the drawer were medication cards holding medications and control medication count sheets. Included in the medications lying in the bottom of the drawer outside the secured lock box were the following controlled medications: -Hydrocodone-Acetaminophen 5-325mg card and count sheet - 45 tablets -Acetaminophen-Codeine #3 card and count sheet - 28 tablets -Alprazolam 0.25mg card and count sheet - 27 tablets -Hydrocodone-Acetaminophen 5-325mg card and count sheet - 20 tablets The DON said all drugs for destruction should be kept under a double lock system with the drawer locked and all drugs secured into the lock box inside the drawer. She said she, the pharmacist, and the ADON planned to destroy the drugs on 08/29/23, but she got called away. She said she did not place all medications back into the affixed/secure box before she locked the drawer. She said the possible negative outcome of not keeping controlled medications under a double lock system could be drug diversion. During an interview on 08/30/23 at 9:32 a.m., the ADON said she shared the office with the DON where drugs for destruction were secured, but she did not have a key to the drawer or the lock box. She said only the DON had a key. The ADON confirmed that she, the pharmacist, and the DON had planned to destroy the medications on 08/29/23 but were interrupted and they did not destroy the drugs. During an interview on 08/30/23 at 10:10 a.m., the Pharmacist said he was at the facility on 08/29/23 and was about to destroy discontinued medications with the DON and ADON when the DON was called away. He said he saw the DON put the medications into the drawer without locking them all in the lock box. He said they did not complete the drug destruction and the medications were left in the drawer without being secured into the lock box. He said the possible negative outcome of medications not being stored/locked properly could be drug diversion. Record review of the facility's policy and procedure dated 06/28/23 and titled, Destruction of Unused Drugs indicated the following: All unused, unwanted, and non-returnable medications should be removed from their storage area and secured until destroyed.

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 of 10 residents (Resident #1) reviewed for treatment and services. The facility did not consult with the physician or provide interventions when Resident #1 fell and hit her head and began vomiting approximately 3 hours after the fall on [DATE]. The resident was on anticoagulant therapy and was admitted to the hospital with a diagnosis of intracranial bleed on [DATE]. Resident #1 was admitted to Hospice services and died on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] The IJ template was provided to the facility on [DATE] at 5:35 p.m. While the IJ was removed on [DATE] at 1:54 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving care as required and that could cause, or likely continue to cause, serious injury, harm, impairment or death. Findings included: Record review of physician orders dated [DATE] indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), neuropathy (damage to the nerves located outside of the brain and spinal cord), difficulty walking, cognitive communication deficit (difficulty with thinking and how someone uses language), lack of coordination (uncoordinated movement), and muscle wasting and atrophy (decrease in size and wasting of muscle tissue). Record of physician order dated [DATE] indicated Resident #1 was prescribed Eliquis (used to prevent serious blood clots from forming due to a certain irregular heartbeat) 2.5 mg BID related to chronic atrial fibrillation (longstanding chaotic and irregular atrial arrhythmia). Record review of an MDS dated [DATE] indicated Resident #1 was able to make herself understood, sometimes understands others, had severe impaired cognitive skills, was not able to focus and had disorganized thinking. She had behaviors daily that included physical and verbal directed at others. She required extensive physical assist for most ADLS. Resident #1 required limited physical assist for walking. She was not stable during walking but was able to stabilize without staff assist. She utilized a walker for mobility. She was incontinent off bladder and bowel. Record review of a care plan dated [DATE] indicated Resident #1 was at risk for falls related to confusion, deconditioning, gait/balance problems, incontinence, poor communication/comprehension, and unawareness of safety needs. Interventions included anticipate needs, provide prompt assistance, IDT to review fall risk every 90 days and after each fall, notify MD/family of falls, and frequent rounds. Record review of care plan dated [DATE] indicated Resident #1 was on anticoagulant therapy Eliquis (blood thinner) related to her disease process. Interventions included daily skin inspection and report abnormalities to the nurse, take precautions to avoid falls, and monitor/document/report to MD PRN signs and symptoms of anticoagulant complications: .nausea, vomiting, . Record review of a fall assessment dated [DATE] indicated Resident #1 was a moderate risk for falls due to recent fall and multiple falls within last three months. She was unable to come to a standing position independently, had loss of balance while standing, required hands on assist to move from place to place, and used an assistive device. Conditions that could increase risk for falls included cardiovascular diagnosis, unsteady gait pattern, joint pain/arthritis, impaired hearing, impaired vision, anxiety/agitation, and chronic condition which makes resident unstable. Record review of incident and accident report dated [DATE] 2:00 p.m., completed by LVN A, indicated she was called to Resident #1's room by CNA B. Resident #1 was lying on the floor, on her left side with her head resting on the leg of the bedside table. A small laceration was present on the left side of her forehead, above the eyebrow. Pressure was applied, the area was cleansed and steri strips were applied. There were no other injuries present. Resident #1 had full range of motion in all extremities. She was assisted to the bed and neuro checks were initiated. BP was ,d+[DATE], pulse was 112, RR was 22 even and labored, and hand grasp was equal bilaterally. Pain level was assessed at a 7. Resident #1 was alert and normally ambulatory without assist. The report also indicated DON was notified at 2:27 p.m., the physician was notified at 2:28 p.m., and the RP was notified at 2:29 p.m. Record review of undated neuro check for Resident #1 indicated: from 2:00 PM to 3:30 PM the neuro checks indicated the resident had equal grip strength. 2:00 p.m. alert, pupil equal and reactive, equal hand grasps, moves all extremities, no pain response-completed by LVN A. 3:30 p.m. alert, pupils equal and reactive, unable to follow commands for hand grasps or move extremities, no pain response completed by LVN A 5:00 p.m. alert, pupils equal and reactive, unable to follow commands for hand grasps or move extremities, no pain response, vomit X1 completed by LVN A 6:00 p.m. alert, pupils equal and reactive, unable to follow commands for hand grasps or move extremities, no pain response completed by LVN A 10:00 p.m. alert, pupils equal and reactive, unable to follow commands for hand grasps or move extremities, no pain response completed by LVN C 2:00 a.m. drowsy, eye (see note), unable to follow commands for hand grasps or move extremities, no pain response completed by LVN C Note: 3:00 a.m. right eye dilated Record review of a nurse note dated [DATE] at 3:30 p.m., completed by LVN A, indicated continued neuro check related to fall. Resident #1 was resting with both eyes closed, unable to follow commands related to hearing impairment but opened her eyes when LVN A tapped her hand. Laceration above left eye remains covered in steri strips and appeared slightly swollen and light purple in color. The RP and MD notified. Record review of a nurse note dated [DATE] at 5:00 p.m., completed by LVN A, indicated Resident #1 vomited after dinner. Record review of a nurse note dated [DATE] at 5:01 p.m., completed by LVN A indicated the RP was notified of Resident #1's vomiting and the RP told the nurse she would come and check on the resident in the morning. The MD was notified. Record review of a nurse note dated [DATE] at 3:30 a.m., completed by LVN C, indicated she checked on Resident #1 and Resident #1 had vomited and was not very responsive. Her left pupil was not responsive. Resident #1 was sent to the hospital for further evaluation. LVN C contacted the RP. Resident #1 was transferred out of the facility at 4:01 by EMS. LVN C notified the MD and the ADON. Record review of hospital records dated [DATE] at 4:36 a.m. indicated Resident #1's CT indicated a 6.8 cm acute intraparenchymal (a bleed that occurs within the brain parenchyma, the functional tissue in the brain) hematoma (pool of mostly clotted blood that forms in an organ, tissue, or body space) in the left frontal cerebrum (front-most part of your brain), with moderate surrounding vasogenic brain edema (cerebral edema in which the blood brain barrier (BBB) is disrupted). There was a small intraventricular (bleeding inside or around the ventricles) hemorrhage in the left lateral ventricle, third ventricle, and fourth ventricle. There was a small acute subdural (bleeding in the area between the brain and the skull) hematoma in the right frontal temporal (behind the temple area on each side of the head, and the lobe extends backward along the side of the brain to a point just behind the ears) region. There was a small acute subdural hematoma in the left temporal region/middle cranial fossa (a butterfly-shaped depression of the skull base, which is narrow in the middle and wider laterally). There was a small acute subarachnoid hemorrhage in the left temporal sulci (bleeding in the space that surrounds the brain). There was a resultant mass effect with regional sulcal effacement, effacement of the left lateral ventricle, and 1.3 cm midline shift, left to right. Impression: 1. Multifocal acute intracranial hemorrhage including intraparenchymal, subdural, subarachnoid, and intraventricular hemorrhage. 2. Mass effect with midline shift, left to right (when the midline of the brain shifts, it indicates a significant increase in pressure in the brain. A midline brain shift is considered a medical emergency). Record review of a nurse note dated [DATE] at 3:45 p.m., completed by ADON E, indicated Resident #1 was readmitted to the facility. Resident #1 had no facial grimacing, purple bruising noted to left orbital with small laceration. Resident #1's pupils were unreactive and sluggish. She was unable to respond to verbal stimuli. Resident #1 was admitted to hospice care and remained a DNR. Record review of Resident #1's clinical chart, including physician orders, nurse progress notes, and care plans, indicated there was no written documentation Resident #1 was not to be sent out to hospital for acute illnesses/injuries. During an observation on [DATE] at 2:00 p.m., Resident #1 was lying in bed. She was not responsive to verbal stimuli. She had a bruised area around her left eye with steri-strips on the laceration above her left eyebrow. Record review of a nurse note dated [DATE] at 6:45 a.m., completed by ADON E, indicated Resident #1 had no VS or pulse. Hospice and family notified of change of condition. Record review of a nurse note dated [DATE] at 7:00 a.m., completed by ADON E, indicated RN was present at Resident #1's bedside and she was pronounced deceased . During an interview on [DATE] at 2:45 p.m., the DON said Resident #1 was found with her head resting on the leg of the bedside table. She said the roommate called for help. She said the roommate heard the fall but did not see the fall. She said Resident #1 sustained a brain bleed. She said Resident #1 was ambulatory but at times was unsteady and would use a wheelchair. She said Resident #1 did have a history of falls. She said interventions included a low bed and call light in reach. She said Resident #1 was alert but not oriented. She said she was not aware of a change of condition until the middle of the night on [DATE]. She said neuro checks were in progress at the time. During an interview on [DATE] at 9:14 a.m., CNA B said on [DATE] she assisted Resident #1 to the middle of the bed She said it was approximately 1:45 p.m. She said she talked to NA G and continued with other resident care. She said she looked over approximately 15 minutes later and saw staff in Resident #1's room. She said she was asked to bring the medication cart to the room. She said Resident #1's roommate indicated Resident #1 hit her head on the corner of the bedside table. She said she fed Resident #1 supper that evening. She only ate ,d+[DATE] of her salad and fruit cup. She said Resident #1 refused her milk. She said she was changing another resident when she was told Resident #1 had vomited. CNA B said Resident #1 seemed off. She said Resident #1 was usually aggressive when she was changed her and she was not aggressive when she cleaned up the vomit and changed her clothes. She said Resident #1 did not scream like usual and kept her arms close to her. She said the nurse even said she was acting different. She said LVN H checked Resident #1's eyes and said they were equal and reactive. She said Resident #1 went to sleep after she was cleaned up. She said Resident #1 usually slept a lot throughout the day. She said Resident #1's eye area turned purple and was swelling. She said the nurses said her vital signs were normal. During an interview on [DATE] at 12:09 p.m., LVN A said she was called to Resident #1's room by CNA B. She said Resident #1 was lying on the floor, on her left side with her head resting on the leg of the bedside table. She said there was small laceration on the left side of her forehead, above the eyebrow. She said the bleeding was stopped and RN F applied steri strips. She said Resident #1 had full ROM of all extremities and neuro checks were initiated. She said Resident #1 was usually alert and could ambulatory without staff assist. During an interview on [DATE] at 1:07 p.m., LVN C said Resident #1 was resistive and would not move her extremities on command. She said she thought her left eye was not reactive after the vomiting incident on [DATE] at 5:00 p.m. She said a second nurse (LVN H) assessed her and said both pupils were reactive. She said Resident #1 was not resistive at 3:00 a.m. and she had vomited a second time. She said she called for a second nurse (LVN H) who was more familiar with her. She was re-assessed and was not alert. She was limp. She said an ambulance was called. She said Resident #1 had a twitch or a shake on her left shoulder. LVN C said she left the doctor a message. She said Resident #1 was transferred to the hospital for evaluation. During an interview on [DATE] a 1:57 p.m. RN F said LVN A was supposed to notify the physician of Resident #1's fall and head injury. She said a message qualified as notification and should be documented in the nurse note. She said the doctor would call back after he received a message. She said Resident #1 had a laceration above her left eye. She said the bleeding was stopped and she cleaned the wound and applied the steri-strip. She said Resident #1 appeared to be her normal. She said Resident #1's family had just left and barley made it down the road. She said Resident #1 was placed back in bed and the bleeding completely stopped. She said any change of condition should be reported to the doctor. She said she knew LVN A had called and left a message for MD I but did not know if the physician had responded. During an interview on [DATE] at 2:10 p.m., the DON said the protocols for resident fall included neuro checks, assessment for pain and injury, and notifications of MD and RP. She said MD notification was a fax or call. She said leaving a message for the MD depended on level of urgency for a change of condition. She did not say the nurses had to speak with the physician. She said she was called after Resident #1 vomited and was told the vital signs were normal. She said the only change noted was Resident #1 was not combative. She said Resident #1 had a history of resting but would respond to tactile stimulation. She said Resident #1 would open her eyes and look and then close her eyes and go back to sleep. Physician notification during office hours would be calling the physician's office number. Physician notification after hours included calling his mobile number directly and via fax. The DON said she could not say Resident #1 should have been sent out to the hospital because she had dementia and was not able to follow commands which was probably her baseline. She said delay of sending a resident to hospital for evaluation and treatment could result in worsening condition and death. During an interview on [DATE] at 2:17 p.m., NA G said she had just arrived at work and Resident #1's roommate said Resident #1 needed help. She said she found Resident #1 on the floor and she was bleeding from her head. She said the nurses came in the room, got her up from the floor, stopped the bleeding and patched up her head. She said Resident #1 was checked on every 15 minutes. During an interview on [DATE] at 2:46 p.m., LVN H said LVN A asked her to check Resident #1's pupils. She said Resident #1 was in a recliner and she was being changed. She said she Resident #1's pupils were normal. She said the physician was contacted via his cell phone. She said he was usually contacted via text. She said sometimes he responded and sometimes did not. She said if Resident #1 was acting out of her normal she would have sent her to the hospital if she did not reach the physician. She said delay of sending a resident to hospital for evaluation and treatment could result in worse condition and death. During an interview on [DATE] at 5:09 p.m., LVN A said Resident #1 vomited right after dinner on [DATE]. She said the family indicated they had given her candy prior to leaving which probably made stomach upset. She said Resident #1's vital signs were fine. She said her pupils were reactive and her baseline was confused. She said Resident #1 continued to fight during wound care so that was how she knew Resident #1 had a strong grip. She said it was typical for Resident #1 to fight during care. She said Resident #1 was hard of hearing but would open her eyes to touch. She said Resident #1 was cleaned up. She said she did notify the doctor. She said she did not speak to the doctor directly but left him (MD I) a message. She said on the weekend the doctor did not usually respond back to messages. During an interview on [DATE] at 1:56 p.m., RN F said she was not aware Resident #1 was on Eliquis. She said she would have sent Resident #1 out to the hospital at the time of the fall for evaluation if she had known. She said she did not check Resident #1's medications. She said Resident #1's head laceration stopped bleeding. She said she would have checked the medications if the bleeding had not stopped. She said delay of sending a resident to hospital for evaluation and treatment could result in worsening condition and death. During an interview on [DATE] at 1:53 p.m., LVN A said she was not aware Resident #1 was on the anticoagulant Eliquis. She said she probably would have sent Resident #1 to the hospital if she was aware. She said she was not aware because the medication aides give the medications and she did not review the medications or check for blood thinners. She said delay of sending a resident to hospital for evaluation and treatment could result in worsening condition and death. During an interview on [DATE] at 10:48 a.m., the DON said LVN A did not specify Resident #1 was on Eliquis. She said she did not look at Resident #1's chart. She said residents on blood thinners were monitored on MARS. She said if she had been informed of the Eliquis, she would have notified the doctor and then called the doctor if he did not respond to a text or voicemail. She said Resident #1 was a DNR so the facility went by the RP's wishes to not send Resident #1 to the hospital. She said if a resident was full code they would be sent to the hospital regardless of directives. She said the RP was informed and updated of Resident #1's status until she was sent out on [DATE]. She said she was aware vomiting was a sign of a head injury and Eliquis increased the chances of a severe head injury/brain bleed and injury. She said as of [DATE] all residents with head injuries would be sent out if the physician did not respond immediately. She said it was part to the POR and would be included in the new staff training. During an interview on [DATE] at 12:06 p.m., Resident #1's family member said she was aware Resident #1 was on a blood thinner, Eliquis. She said the facility did not specifically tell her Resident #1 was at increased risk of brain injury or brain bleeding. She said she was made aware of the fall and head laceration. She said she told the facility she would check in on Resident #1 in the morning, following the fall. She said she was notified of the change of condition and that the facility was transferring Resident #1 to the hospital for evaluation. She said she told the facility to do what they thought was best for Resident #1. During an interview on [DATE] at 12:40 p.m., MD I said the facility nursing staff had his direct number to call and text. He said they were to call him for all falls and injuries. He said when in doubt the facility should send the resident to the hospital for evaluation. He said if the staff were not able to get in touch with him they should send out the resident to the hospital. When asked if he was notified by the facility of Resident #1's fall and injury on [DATE] and if he was aware she was on Eliquis, MD I would only say the facility followed the family wishes and he was aware of the family wishes for Resident #1. Record review of Eliquis (https://www.eliquis.bmscustomerconnect.com/) accessed [DATE] indicated possible serious side effects included bleeding. Record review of https://premierneurologycenter.com/blog/blood-thinners-head-injuries-what-you-need-to-know/#:~:text=%3D%3EIf%20you%20are%20taking%20a,seek%20medical%20attention%20right%20away accessed on [DATE] indicated blood thinners are medications that help prevent blood clots from forming, however they can increase the risk of delayed intracranial hemorrhage after a head injury. If you experience a bump, blow, or jolt to the head, it is important to seek medical attention right away. Even if you do not feel any symptoms after the injury, it is still important to be evaluated by a doctor. Record review of the facility's Head Injury policy dated 2020 indicated: It is the policy of the facility to report potential head injuries to the physician and implement interventions to prevent further injury. Policy Explanation and Compliance Gridlines: 1. Assess resident following a known, suspect, or verbalized head injury. The assessment shall include, at a minimum: a. vital signs. B. General condition and appearance. Neurological evaluation for changes in i. Physical functioning ii. Behavior iii. Cognition iv. Level of consciousness v. Dizziness vi. Nausea vii. Irritability viii. Slurred speech o slow to answer questions d. Evaluation of he, eyes, ears, and nose for significant changes of vision, hearing, smell, or bleeding. E. Any injuries to head, neck, eyes, or face including lacerations, abrasions, or bruising. F. Pain assessment. 2. Call 911/EMS and attempt to stabilize the resident's condition if respiratory distress or a hemorrhaging wound occurs. 3. Notify the physician and follow orders for care. a. Provide information from physical assessment. b. Describe how the injury occurred and how the situation has been managed so far. c. Report any recent medication changes or use of antiplatelet/anticoagulant medications. 4. Perform neuro checks as indicated or as specified by the physician. 5. Limit activity and/or implement seizure precautions following the injury as specified by the physician. 6. Continue monitoring for 72 hours following the incident or until the resident is asymptomatic for a period of time specified by the physician. 7. Notify t family and document all assessments, actions, and notifications. Record review of the facility's Notification of Changes Policy dated 2022 indicated: The purpose of this policy is to ensure the facility informs residents, consults with the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is change requiring notification. Circumstances requiring notification include: 1. Accidents a. Resulting in injury. B. Potential to require physician intervention. An Immediate Jeopardy (IJ) situation was identified on [DATE]. The IJ template was provided to the Administrator on [DATE] at 5:35 p.m. While the IJ was removed on [DATE] at 1:54 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. The facility's POR dated [DATE] indicated: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: [DATE] @ 11:00 PM) The DON or designee notified the facility Medical Director of the incident. Nursing supervisors/designees completed physical assessments on all residents to identify any changes in condition and notification was made to the physician of any noted changes. The DON and/or designee provided in-service and education to LVN A related to notification of physician, and complete documentation to include physician response. No need for any emergency treatment identified with completion of resident physical assessments. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: [DATE] @ 4:30 PM). 1. All licensed nurses were educated by the DON/designee on change of condition and physician notification regulations, complete documentation to include physician response, anticoagulant policy, and adverse consequences, head injury policy including neuro checks as well as facility policy and procedure. 2. When a change in condition is suspected, Staff will utilize STOP AND WATCH as an assessment tool and SBAR as a communication transfer tool. Licensed nursing staff will continue to monitor anticoagulant use and adverse effects through Nursing MAR and has been added to SBAR to include anticoagulant use. For any non-emergent situations, utilize SBAR and send to MD I fax number at (fax number). Alternate fax number: (fax number). The nurse is to note on 24-hour report awaiting return call or return communication from MD. If there is no response within 24 hours, notify supervisor. For any emergent situations, such as but not limited to a serious, unexpected and potentially dangerous situation requiring immediate action (acute chest pain, sudden change in mental status, unrelenting pain, shortness of breath, head injury, etc.) MD is to be notified by cell phone at (cell phone) If MD is unable to be notified, per standing orders, send resident to ER immediately with RP notification. After the plan of care has been completed, fill out SBAR and fax to MD. Attach confirmation sheet to SBAR and place in DON/ADON box. Nurse aides were educated by DON/designee on change of condition regulations to promote their situational understanding and facilitate communication with licensed nurses. Nurse Staff members were not permitted to work a shift until education was completed. New hires (licensed nurses and nurse aides) will be educated on change of condition and physician notification regulations, including but not limited to life threatening conditions, clinical complications, need to alter treatment, accidents resulting in injury, adverse consequences as well as facility policy and procedure, accordingly in orientation by human resources/designee. The DON implemented a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) with a focus on: QUALITY OF CARE to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered plan, and the residents' choices. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review physical assessments of all residents were completed. Changes of condition were noted and the physician was notified and reply pending for 2 of 4 residents, 1 resident was sent out to hospital for assessment and returned with no new orders, and 1 resident had new orders implemented. Record review of LVN A's in-service and education related to physician notification and completion of documentation was completed on [DATE] and [DATE]. Record review of licensed nurse training and check off list indicated all nurses received training on change of condition and physician notification regulations, completing documentation to include physician response, anticoagulant policy, and adverse consequences, head injury policy including neuro checks as well as facility policy and procedure. Training included to notify the physician via phone call and document in the electronic records. If there was no response the nursing staff would notify the DON. If there was no immediate response from the physician nursing staff would send the resident to the hospital. Record review of 3 residents' MARs indicted anticoagulants were monitored as required. During interviews on [DATE] from 9:00 a.m. through 1:45 p.m., the DON, ADON, 1 RN, 10 LVNs who worked all shifts indicated they would continue to monitor anticoagulant use and adverse effects through the MAR, for a suspected change in condition they would utilize STOP AND WATCH as an assessment tool and SBAR as a communication transfer tool. They said any non-emergent situations, they would utilize SBAR and send to MD. They were able to give examples of non-emergent situations. They would note in the 24-hour report if they were waiting return call or return communication from MD. If there is no response within 24 hours, notify supervisor. For any emergent situations, such as but not limited to a serious, unexpected and potentially dangerous situation requiring immediate action (acute chest pain, sudden change in mental status, unrelenting pain, shortness of breath, head injury, etc.) they would notify the MD is to be notified by cell phone. If MD is unable to be notified, per standing orders, send resident to ER immediately with RP notification. They indicated after the plan of care has been completed, they would fill out SBAR and fax to MD and then attach confirmation sheet to SBAR and place in DON/ADON box. Record review of staff training dated [DATE] indicated all nursing staff from all shifts received a group text advising them of the updated training. Nursing staff signed the training record as they came on shift. Nursing staff would continue to sign the training record as they were scheduled and before working any shifts. Record review of new hire packets indicated education included change of condition and physician notification regulations, as well as facility policy and procedure, accordingly in orientation by human resources/designee. There were no new hires in training as of [DATE]. Record review of in-service dated [DATE] indicated nurse aides were educated by the DON/designee on change of condition regulations to promote their situational understanding and facilitate communication with licensed nurses. During interviews on [DATE] from 9:00 a.m. through 1:45 p.m., interviews with 5 CNAs who worked all shifts indicated they would immediately advise the charge nurse of resident change of condition. During an interview on [DATE] at 11:37 a.m., the DON said she sent a mass text to all nursing staff and they initialed acknowledgment of changes and corrections to facility policy and protocol. She said all staff would sign the in-service as they came into works shifts and prior to taking the floor. She was able to indicate what emergent conditions were. She said standing physician orders related to physician notification and emergent conditions incorporated into the facility policy, were posted at the nurse station, and incorporated into the new hire training. During an interview on [DATE] at 12:53 p.m., the Administrator said during emergent situations all residents would be sent out to the ER via EMS for evaluation. She said the 24-hour reports were reviewed daily in morning meeting by the DON or designee (Administrator or ADON). She said the RN on duty would review the weekend 24-hour reports and report significant events to the DON and the administrator immediately. She [NAME] [TRUNCATED]

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician when there was an accident which resulted in injury and required physician intervention for 1 of 10 residents (Resident #1) reviewed for change of condition. Resident #1 was on an anticoagulant therapy and the facility did not: *consult with the physician when Resident #1 fell and hit her head sustaining a laceration to her head on [DATE] at 2:00 p.m. *consult with the physician when Resident #1 began vomiting at approximately 5:00 p.m. On [DATE] at 3:30 a.m., Resident #1 was found to be unresponsive with nonreactive pupils and was transferred to an acute care hospital with a diagnosis of intracranial hemorrhage and died on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE]. The IJ template was provided to the Administrator on [DATE] at 5:35 p.m. While the IJ was removed on [DATE] at 1:54 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving immediate corrective actions necessary for their health and that could cause, or likely continue to cause, serious injury, harm, impairment or death. Findings included: Record review of physician orders dated [DATE] indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), irregular heartbeat, neuropathy (damage to the nerves located outside of the brain and spinal cord), difficulty walking, cognitive communication deficit (difficulty with thinking and how someone uses language), lack of coordination (uncoordinated movement), and muscle wasting and atrophy (decrease in size and wasting of muscle tissue). Record of physician order dated [DATE] indicated Resident #1 was prescribed Eliquis (used to prevent serious blood clots from forming due to a certain irregular heartbeat) 2.5 mg BID related to chronic atrial fibrillation (longstanding chaotic and irregular atrial arrhythmia). Record review of an MDS dated [DATE] indicated Resident #1 was able to make herself understood, sometimes understands others, had severe impaired cognitive skills, was not able to focus and had disorganized thinking. She had behaviors daily that included physical and verbal behaviors directed at others. She required extensive physical assist for most ADLS. Resident #1 required limited physical assist for walking. She was not stable during walking but was able to stabilize without staff assist. She utilized a walker for mobility. She was incontinent off bladder and bowel. Record review of a care plan dated [DATE] indicated Resident #1 was at risk for falls related to confusion, deconditioning, gait/balance problems, incontinence, poor communication/comprehension, and unawareness of safety needs. Interventions included anticipate needs, provide prompt assistance, IDT to review fall risk every 90 days and after each fall, notify MD/family of falls, and frequent rounds. Record review of a care plan dated [DATE] indicated Resident #1 was on anticoagulant therapy Eliquis (blood thinner) related to her disease process. Interventions included daily skin inspection and report abnormalities to the nurse, take precautions to avoid falls, and monitor/document/report to MD PRN signs and symptoms of anticoagulant complications: .nausea, vomiting, . Record review of a fall assessment dated [DATE] indicated Resident #1 was a moderate risk for falls due to recent fall and multiple falls within last three months. She was unable to come to a standing position independently, had loss of balance while standing, required hands on assist to move from place to place, and used an assistive device. Conditions that could increase risk for falls included cardiovascular diagnosis, unsteady gait pattern, joint pain/arthritis, impaired hearing, impaired vision, anxiety/agitation, and chronic condition which makes resident unstable. Record review of incident and accident report dated [DATE] 2:00 p.m., completed by LVN A, indicated she was called to Resident #1's room by CNA B. Resident #1 was lying on the floor, on her left side with her head resting on the leg of the bedside table. A small laceration was present on the left side of her forehead, above the eyebrow. Pressure was applied, the area was cleansed and steri strips (thin adhesive bandages) were applied. There were no other injuries present. Resident #1 had full range of motion in all extremities. She was assisted to the bed and neuro checks were initiated. BP was ,d+[DATE], pulse was 112, RR was 22 even and labored, and hand grasp was equal bilaterally. Pain level was assessed at a 7. Resident #1 was alert and normally ambulatory without assist. The report also indicated DON was notified at 2:27 p.m., the physician was notified at 2:28 p.m., and the RP was notified at 2:29 p.m. Record review of undated neuro check for Resident #1 indicated: from 2:00 PM to 3:30 PM the neuro checks indicated the resident had equal grip strength. 2:00 p.m. alert, pupil equal and reactive, equal hand grasps, moves all extremities, no pain response-completed by LVN A. 3:30 p.m. alert, pupils equal and reactive, unable to follow commands for hand grasps or move extremities, no pain response completed by LVN A. 5:00 p.m. alert, pupils equal and reactive, unable to follow commands for hand grasps or move extremities, no pain response, vomit X1 completed by LVN A 6:00 p.m. alert, pupils equal and reactive, unable to follow commands for hand grasps or move extremities, no pain response completed by LVN A. 10:00 p.m. alert, pupils equal and reactive, unable to follow commands for hand grasps or move extremities, no pain response completed by LVN C. 2:00 a.m. drowsy, eye (see note), unable to follow commands for hand grasps or move extremities, no pain response completed by LVN C Note: 3:00 a.m. right eye dilated Record review of a nurse note dated [DATE] at 3:30 p.m., completed by LVN A, indicated continued neuro check related to fall. Resident #1 was resting with both eyes closed, unable to follow commands related to hearing impairment but opened her eyes when LVN A tapped her hand. Laceration above left eye remained covered in steri strips and appeared slightly swollen and light purple in color. The RP and MD notified. Record review of a nurse note dated [DATE] at 5:00 p.m., completed by LVN A, indicated Resident #1 vomited after dinner. Record review of a nurse note dated [DATE] at 5:01 p.m., completed by LVN A indicated the RP was notified of Resident #1's vomiting and the RP told the nurse she would come and check on the resident in the morning. The MD was notified. Record review of a nurse note dated [DATE] at 3:30 a.m., completed by LVN C, indicated she checked on Resident #1 and Resident #1 had vomited and was not very responsive. Her left pupil was not responsive. Resident #1 was sent to the hospital for further evaluation. LVN C contacted the RP. Resident #1 was transferred out of the facility at 4:01 a.m. by EMS. LVN C notified the MD and the ADON. Record review of hospital records dated [DATE] at 4:36 a.m. indicated Resident #1's CT indicated a 6.8 cm acute intraparenchymal (a bleed that occurs within the brain parenchyma, the functional tissue in the brain) hematoma (pool of mostly clotted blood that forms in an organ, tissue, or body space) in the left frontal cerebrum (front-most part of your brain), with moderate surrounding vasogenic brain edema (cerebral edema in which the blood brain barrier (BBB) is disrupted). There was a small intraventricular (bleeding inside or around the ventricles) hemorrhage in the left lateral ventricle, third ventricle, and fourth ventricle. There was a small acute subdural (bleeding in the area between the brain and the skull) hematoma in the right frontal temporal (behind the temple area on each side of the head, and the lobe extends backward along the side of the brain to a point just behind the ears) region. There was a small acute subdural hematoma in the left temporal region/middle cranial fossa (a butterfly-shaped depression of the skull base, which is narrow in the middle and wider laterally). There was a small acute subarachnoid hemorrhage in the left temporal sulci (bleeding in the space that surrounds the brain). There was a resultant mass effect with regional sulcal effacement, effacement of the left lateral ventricle, and 1.3 cm midline shift, left to right. Impression: 1. Multifocal acute intracranial hemorrhage including intraparenchymal, subdural, subarachnoid, and intraventricular hemorrhage. 2. Mass effect with midline shift, left to right (when the midline of the brain shifts, it indicates a significant increase in pressure in the brain. A midline brain shift is considered a medical emergency). Record review of a nurse note dated [DATE] at 3:45 p.m., completed by ADON E, indicated Resident #1 was readmitted to the facility. Resident #1 had no facial grimacing, purple bruising noted to left orbital with small laceration. Resident #1's pupils were unreactive and sluggish. She was unable to respond to verbal stimuli. Resident #1 was admitted to hospice care and remained a DNR. During an observation on [DATE] at 2:00 p.m., Resident #1 was lying in bed. She was not responsive to verbal stimuli. She had a bruised area around her left eye with steri-strips on the laceration above her left eyebrow. Record review of a nurse note dated [DATE] at 6:45 a.m., completed by ADON E, indicated Resident #1 had no VS or pulse. Hospice and family notified of change of condition. Record review of a nurse note dated [DATE] at 7:00 a.m., completed by ADON E, indicated RN was present at Resident #1's bedside and she was pronounced deceased . During an interview on [DATE] at 2:45 p.m., the DON said Resident #1 was found with her head resting on the leg of the bedside table. She said the roommate called for help. She said the roommate heard the fall but did not see the fall. She said Resident #1 sustained a brain bleed. She said Resident #1 was ambulatory but at times was unsteady and would use a wheelchair. She said Resident #1 did have a history of falls. She said Resident #1 was alert but not oriented. She said there was no change of condition until the middle of the night on [DATE]. She said neuro checks were in progress at the time. During an interview on [DATE] at 9:14 a.m., CNA B said on [DATE] she assisted Resident #1 to the middle of the bed. She said it was approximately 1:45 p.m. She said she talked to NA G and continued with other resident care. She said she looked over approximately 15 minutes later and saw staff in Resident #1's room. She said she was asked to bring the medication cart to the room. She said Resident #1's roommate indicated Resident #1 hit her head on the corner of the bedside table. She said she fed Resident #1 supper that evening. She only ate ,d+[DATE] of her salad and fruit cup. She said Resident #1 refused her milk. She said she was changing another resident when she was told Resident #1 had vomited. CNA B said Resident #1 seemed off. She said Resident #1 was usually aggressive when she changed her and she was not aggressive when she cleaned up the vomit and changed her clothes. She said Resident #1 did not scream like usual and kept her arms close to her. She said the nurse even said she was acting different. She said LVN H checked Resident #1's eyes and said they were equal and reactive. She said Resident #1 went to sleep after she was cleaned up. She said Resident #1 usually slept a lot throughout the day. She said Resident #1's eye area turned purple and was swelling. She said the nurses said her vital signs were normal. During an interview on [DATE] at 12:09 p.m., LVN A said she was called to Resident #1's room by CNA B. She said Resident #1 was lying on the floor, on her left side with her head resting on the leg of the bedside table. She said there was small laceration on the left side of her forehead, above the eyebrow. She said the bleeding was stopped and RN F applied steri strips. She said Resident #1 had full ROM of all extremities and neuro checks were initiated. She said Resident #1 was usually alert and could ambulate without staff assist. She did not did not speak and consult with the the physician after the fall or the vomiting During an interview on [DATE] at 1:07 p.m., LVN C said Resident #1 was resistive and would not move her extremities on command after the fall. She said she thought her left eye was not reactive after the vomiting incident. She said Resident #1 was not resistive at 3:00 a.m. and she had vomited a second time. She said she called for a second nurse (LVN H) who was more familiar with her. She was re-assessed and was not alert. She was limp. She said an ambulance was called. She said Resident #1 had a twitch or a shake on her left shoulder. LVN C said she left the doctor a message before Resident #1 was transferred to the hospital on [DATE]. She said Resident #1 was transferred to the hospital for evaluation. During an interview on [DATE] a 1:57 p.m. RN F said LVN A was supposed to notify the physician of Resident #1's fall and head injury. She said a message qualified as notification and should be documented in the nurse note. She said the doctor would call back after he received a message. She said Resident #1 had a laceration above her left eye. She said the bleeding was stopped and she cleaned the wound and applied the steri-strip. She said Resident #1 appeared to be her normal. She said Resident #1's family had just left and barely made it down the road. She said Resident #1 was placed back in bed and the bleeding completely stopped. She said any change of condition should be reported to the doctor. During an interview on [DATE] at 2:10 p.m., the DON said the protocols for resident fall included neuro checks, assessment for pain and injury, and notifications of MD and RP. She said MD notification was a fax or call. She said leaving a message for the MD depended on level of urgency for a change of condition. She said she was called after Resident #1 vomited and was told the vital signs were normal. She said the only change noted was Resident #1 was not combative. She said Resident #1 had a history of resting but would respond to tactile stimulation. She said Resident #1 would open her eyes and look and then close her eyes and go back to sleep. Physician notification during office hours would be calling the physician's office number. Physician notification after hours included calling his mobile number directly and via fax. The DON said she could not say Resident #1 should have been sent out to the hospital because she had dementia and was not able to follow commands which was probably her baseline. She said delay of sending a resident to hospital for evaluation and treatment could result in worsening condition and death. During an interview on [DATE] at 2:17 p.m., NA G said she had just arrived at work and Resident #1's roommate said Resident #1 needed help on [DATE]. She said she found Resident #1 on the floor and she was bleeding from her head. She said the nurses came in the room, got her up from the floor, stopped the bleeding and patched up her head. She said Resident #1 was checked on every 15 minutes. During an interview on [DATE] at 2:46 p.m., LVN H said LVN A asked her to check Resident #1's pupils. She said Resident #1 was in a recliner and she was being changed. She said she Resident #1's pupils were normal. She said MD I was contacted via his cell phone by LVN A. She did not know if LVN A spoke with MD I. She said he was usually contacted via text. She said sometimes he responded and sometimes did not. She said if Resident #1 was acting out of her normal she would have sent her to the hospital if she did not reach the physician. She said delay of sending a resident to hospital for evaluation and treatment could result in worse condition and death. During an interview on [DATE] at 5:09 p.m., LVN A said Resident #1 vomited right after dinner [DATE]. She said the family indicated they had given her candy prior to leaving which probably made her stomach upset. She said Resident #1's vital signs were fine. She said her pupils were reactive and her baseline was confused. She said Resident #1 continued to fight during wound care so that was how she knew Resident #1 had a strong grip. She said it was typical for Resident #1 to fight during care. She said Resident #1 was hard of hearing but would open her eyes to touch. She said Resident #1 was cleaned up. She said she did notify MD I (who is also the medical director) on [DATE]. She said she did not speak to the doctor directly but left him a message. She said on the weekend the doctor did not usually respond back to messages. During an interview on [DATE] at 10:48 a.m., the DON said LVN A did not specify Resident #1 was on Eliquis. She said if she had been informed of the Eliquis, she would have notified the doctor and then called the doctor if he did not respond to a text or voicemail. She said Resident #1 was a DNR so the facility went by the RP's wishes to not send Resident #1 to the hospital. She said if a resident was full code they would be sent to the hospital regardless of directives. She said the RP was informed and updated of Resident #1's status until she was sent out on [DATE]. She said she was aware vomiting was a sign of a head injury and Eliquis increased the chances of a severe head injury/brain bleed and injury. She said delay of sending a resident to hospital for evaluation and treatment could result in worsening condition and death. During an interview on [DATE] at 1:53 p.m., LVN A said she was not ware Resident #1 was on the anticoagulant Eliquis. She said she probably would have sent Resident #1 to the hospital at the time of the fall had she been aware. She said she was not aware because the medication aides gave medications and she did not review the medications or check for blood thinners. She said delay of sending a resident to hospital for evaluation and treatment could result in worsening condition and death. During an interview on [DATE] at 1:56 p.m., RN F said she was not aware Resident #1 was on Eliquis. She said she would have sent Resident #1 out to the hospital at the time of the fall for evaluation if she had known. She said she did not check Resident #1's medications. She said Resident #1's head laceration stopped bleeding. She said she would have checked the medications if the bleeding had not stopped. She said delay of sending a resident to hospital for evaluation and treatment could result in worsening condition and death. During an interview on [DATE] at 12:06 p.m., Resident #1's family member said she was aware Resident #1 was on a blood thinner, Eliquis. She said the facility did not specifically tell her Resident #1 was at increased risk of brain injury or brain bleeding. She said she was made aware of the fall and head laceration. She said she told the facility she would check in on Resident #1 in the morning, following the fall. She said she was notified of the change of condition and that the facility was transferring Resident #1 to the hospital for evaluation. She said she told the facility to do what they thought was best for Resident #1. During an interview on [DATE] at 12:40 p.m., MD I said the facility had his direct number to call and text. He said they were to call him for all falls and injuries. He said when in doubt the facility should send the resident to the hospital for evaluation. He said if the staff were not able to get in touch with him, they should send out the resident to the hospital. When asked if he was notified by the facility of Resident #1's fall and injury on [DATE], MD I would only say the facility followed the family wishes and he was aware of the family wishes for Resident #1. Record review of Eliquis (https://www.eliquis.bmscustomerconnect.com/) accessed [DATE] indicated possible serious side effects included bleeding. Record review of https://premierneurologycenter.com/blog/blood-thinners-head-injuries-what-you-need-to-know/#:~:text=%3D%3EIf%20you%20are%20taking%20a,seek%20medical%20attention%20right%20away accessed on [DATE] indicated blood thinners are medications that help prevent blood clots from forming, however they can increase the risk of delayed intracranial hemorrhage after a head injury. If you experience a bump, blow, or jolt to the head, it is important to seek medical attention right away. Even if you do not feel any symptoms after the injury, it is still important to be evaluated by a doctor. Record review of the facility's Head Injury policy dated 2020 indicated: It is the policy of the facility to report potential head injuries to the physician and implement interventions to prevent further injury. Policy Explanation and Compliance Gridlines: 1. Assess resident following a known, suspect, or verbalized head injury. The assessment shall include, at a minimum: a. vital signs. B. General condition and appearance. Neurological evaluation for changes in i. Physical functioning ii. Behavior iii. Cognition iv. Level of consciousness v. Dizziness vi. Nausea vii. Irritability viii. Slurred speech o slow to answer questions d. Evaluation of he, eyes, ears, and nose for significant changes of vision, hearing, smell, or bleeding. E. Any injuries to head, neck, eyes, or face including lacerations, abrasions, or bruising. F. Pain assessment. 2. Call 911/EMS and attempt to stabilize the resident's condition if respiratory distress or a hemorrhaging wound occurs. 3. Notify the physician and follow orders for care. a. Provide information from physical assessment. b. Describe how the injury occurred and how the situation has been managed so far. c. Report any recent medication changes or use of antiplatelet/anticoagulant medications. 4. Perform neuro checks as indicated or as specified by the physician. 5. Limit activity and/or implement seizure precautions following the injury as specified by the physician. 6. Continue monitoring for 72 hours following the incident or until the resident is asymptomatic for a period of time specified by the physician. 7. Notify t family and document all assessments, actions, and notifications. Record review of the facility's Notification of Changes Policy dated 2022 indicated: The purpose of this policy is to ensure the facility informs residents, consults with the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is change requiring notification. Circumstances requiring notification include: 1. Accidents a. Resulting in injury. B. Potential to require physician intervention. An Immediate Jeopardy (IJ) situation was identified on [DATE]. The IJ template was provided to the Administrator on [DATE] at 5:35 p.m. While the IJ was removed on [DATE] at 1:54 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. The facility's POR dated [DATE] indicated: Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: [DATE] @11:00 PM) The DON or designee notified the facility Medical Director of the incident. Nursing supervisors/designees completed physical assessments on all residents to identify any changes in condition and notification was made to the physician of any noted changes. The DON and/or designee provided in-service and education to LVN A related to notification of physician, and complete documentation to include physician response. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: [DATE] @ 4:30 PM). All licensed nurses were educated by the DON/designee on change of condition and physician notification regulations, complete documentation to include physician response, anticoagulant policy, and adverse consequences, head injury policy including neuro checks as well as facility policy and procedure. Licensed nursing staff will continue to monitor anticoagulant use and adverse effects through Nursing MAR and has been added to SBAR to include anticoagulant use. When a change in condition is suspected, Staff will utilize STOP AND WATCH as an assessment tool and SBAR as a communication transfer tool. For any non-emergent situations, utilize SBAR and send to MD I [NAME] fax number at (fax number). Alternate fax number: (alternate fax number). The nurse is to note a 24-hour report awaiting return call or return communication from MD. If there is no response within 24 hours, notify supervisor. For any emergent situations, such as but not limited to a serious, unexpected and potentially dangerous situation requiring immediate action (acute chest pain, sudden change in mental status, unrelenting pain, shortness of breath, head injury, etc.) MD is to be notified by cell phone at (cell phone). If MD is unable to be notified, per standing orders, send resident to ER immediately with RP notification. After the plan of care has been completed, fill out SBAR and fax to MD. Attach confirmation sheet to SBAR and place in DON/ADON box. Nurse aides were educated by the DON/designee on change of condition regulations to promote their situational understanding and facilitate communication with licensed nurses. Nurse Staff members were not permitted to work a shift until education was completed. New hires (licensed nurses and nurse aides) will be educated on change of condition and physician notification regulations, as well as facility policy and procedure, accordingly in orientation by human resources/designee. The DON implemented a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) with a focus on PHYSICIAN NOTIFICATION OF SIGNIFICANT CHANGES. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review physical assessments of all residents were completed. Changes of condition were noted and the physician was notified and reply pending for 2 of 4 residents, 1 resident was sent out to hospital for assessment and returned with no new orders, and 1 resident had new orders implemented. Record review of LVN A's in-service and education related to physician notification and completion of documentation was completed on [DATE] and [DATE]. Record review of licensed nurse training and check off list indicated all nurses received training on change of condition and physician notification regulations, completing documentation to include physician response, anticoagulant policy, and adverse consequences, head injury policy including neuro checks as well as facility policy and procedure. Training included to notify the physician via phone call and document in the electronic records. If there was no response the nursing staff would notify the DON. If there was no immediate response from the physician nursing staff would send the resident to the hospital. During interviews on [DATE] from 9:00 a.m. through 1:45 p.m., the DON, ADON, 1 RN, 10 LVNs who worked all shifts indicated they would continue to monitor anticoagulant use and adverse effects through the MAR, for a suspected change in condition they would utilize STOP AND WATCH as an assessment tool and SBAR as a communication transfer tool. They said any non-emergent situations, they would utilize SBAR and send to MD. They were able to give examples of non-emergent situations. They would note in the 24-hour report if they were waiting return call or return communication from MD. If there is no response within 24 hours, notify supervisor. For any emergent situations, such as but not limited to a serious, unexpected and potentially dangerous situation requiring immediate action (acute chest pain, sudden change in mental status, unrelenting pain, shortness of breath, head injury, etc.) they would notify the MD is to be notified by cell phone. If MD is unable to be notified, per standing orders, send resident to ER immediately with RP notification. They indicated after the plan of care has been completed, they would fill out SBAR and fax to MD and then attach confirmation sheet to SBAR and place in DON/ADON box. Record review of staff training dated [DATE] indicated all nursing staff from all shifts received a group text advising them of the updated training. Nursing staff signed the training record as they came on shift. Nursing staff would continue to sign the training record as they were scheduled and before working any shifts. Record review of new hire packets indicated education included change of condition and physician notification regulations, as well as facility policy and procedure, accordingly in orientation by human resources/designee. There were no new hires in training as of [DATE]. Record review of in-service dated [DATE] indicated nurse aides were educated by the DON/designee on change of condition regulations to promote their situational understanding and facilitate communication with licensed nurses. During interviews on [DATE] from 9:00 a.m. through 1:45 p.m., interviews with 5 CNAs who worked all shifts indicated they would immediately advise the charge nurse of resident change of condition. During an interview on [DATE] at 11:37 a.m., the DON said she sent a mass text to all nursing staff and they initialed acknowledgment of changes and corrections to facility policy and protocol. She said all staff would sign the in-service as they came into works shifts and prior to taking the floor. She was able to indicate what emergent conditions were. She said standing physician orders related to physician notification and emergent conditions incorporated into the facility policy, were posted at the nurse station, and incorporated into the new hire training. During an interview on [DATE] at 12:53 p.m., the Administrator said during emergent situations all residents would be sent out to the ER via EMS for evaluation. She said the 24-hour reports were reviewed daily in morning meeting by the DON or designee (Administrator or ADON). She said the RN on duty would review the weekend 24-hour reports and report significant events to the DON and the administrator immediately. She said all nursing staff would receive training on the policy changes prior to working their next scheduled shifts. She said the new policy changes would continue until all staff were trained. She said the new policy addendums were added to the new hire packets. An Immediate Jeopardy (IJ) situation was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:35 p.m. While the IJ was removed on [DATE] at 1:54 p.m., the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 residents (Resident #1) reviewed for privacy. CNA A did not close Resident #1's privacy curtain while providing incontinent care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings include: Record review of Resident #1's face sheet, dated 9/28/2022, revealed an admitted [DATE] and with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 2, which indicated severe cognitive impairment. Resident #1 required limited to extensive assistance with all activities of daily living and was always incontinent of bladder and bowel. Record review of Resident #1's care plan for bladder incontinence with a target date of 12/11/2022 indicated Resident #1 used disposable briefs. During an observation on 9/27/22 at 7:13 a.m., CNA A did not close the privacy curtain when she provided incontinent care to Resident #1. Resident #1's roommate was in her bed at the time. During an interview on 9/27/22 at 11:16 a.m., the DON said privacy must be provided during nursing care and Resident #1's privacy curtains should have been closed. During an interview on 9/29/22 at 12:05 p.m., CNA A said she should have closed the privacy curtain when she provided care to Resident #1. She said she had been a CNA since 2020 and had been trained on providing privacy during care. Record review of the facility's Promoting/Maintaining Resident Dignity policy, implemented and reviewed on 3/23/2021, indicated, .12. Maintain resident privacy. Record review of the facility's Perineal Care policy, revised on 3/21/21 indicated Perineal care refers to the care of the external genitalia and the anal area . 5. Provide privacy by pulling privacy curtain or closing room door if a private room.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 staff reviewed for infection control. (CNA A) CNA A did not wash or sanitize her hands prior to or after performing incontinent care for Resident #1. CNA A did not change gloves after performing incontinent care and prior to dressing and transferring Resident #1 to the wheelchair. This failure could place residents at risk of exposure to communicable diseases and infections. Findings included: Record review of Resident #1's face sheet, dated 9/28/2022, revealed an admitted [DATE] and with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 2, which indicated severe cognitive impairment. Resident #1 required limited to extensive assistance with all activities of daily living and was always incontinent of bladder and bowel. Record review of Resident #1's care plan for bladder incontinence with a target date of 12/11/2022 indicated Resident #1 used disposable briefs. During an observation on 9/27/2022 at 7:13 a.m., CNA A was in Resident # 1's room to provide incontinent care. CNA A did not wash her hands prior to putting gloves on her hands. She opened the brief on Resident #1 and removed wipes from the package and wiped both inner thighs in perineal area wiping from top to bottom and front to back. She then placed the wipes in the trash. CNA A placed a clean brief and dressed Resident #1 without changing her gloves or washing or sanitizing her hands. During an interview on 9/27/22 at 11:16 a.m., the DON said she expected staff to change their gloves between dirty and clean and to either wash or sanitize their hands prior to and after care.

Based on observation, interview and record review, the facility failed to ensure an effective infection prevention and control program to prevent the development and transmission of communicable diseases was implemented by the facility for 1 of 5 units (Hall 5 COVID unit/secure unit) reviewed for infection control. The facility cohorted (a group of people treated as a group, who share the same characteristic) COVID ([coronavirus disease] an acute respiratory illness caused by a coronavirus, capable of producing severe symptoms) positive residents and COVID negative residents in the resident rooms together. This failure placed the residents at risk of contracting the infectious disease. Findings included: During observation on 09/16/22 at 9:15 a.m., there was a sign on the outside entrance door indicating the facility had COVID positive residents in the building. During the entrance conference interview on 09/16/22 at 9:20 a.m. with the Administrator and DON, the DON said there was a CNA that tested positive, and the facility had a sporadic outbreak ever since. She stated all positives were on the secure unit (Hall 5) and they were contained to the secure unit. She said due to the residents' wandering and for their safety, the negative residents were kept on the unit with the positive residents. When asked if the COVID positive residents were contained on one part of the hall, she said they were not. She said due to their behaviors it was not possible to keep them in their rooms or on a specific hall. She added they had previously tried to isolate them before, and they tore down the barriers. Record review of the COVID positive unit resident roster dated 09/19/22 indicated the following: *Resident #1, who was positive, resided in room [ROOM NUMBER] with resident #2, who was positive; *Resident #3, who was positive, resided in room [ROOM NUMBER] with Resident #4, who was positive; *Resident #5, who was positive, resided in room [ROOM NUMBER]. She did not have a roommate; Resident #6 was not found on the COVID positive unit roster; Resident #7, who was COVID positive, resided in room [ROOM NUMBER] with Resident #8, who was positive; Resident #9, who was COVID positive, resided in room [ROOM NUMBER] with Resident #10, who was positive; Resident #11, who was positive, resided in room [ROOM NUMBER] with Resident #12, who was COVID positive *Resident #13, who was negative, resided in room [ROOM NUMBER] with Resident #14, who was COVID positive; *Resident #15, who was negative, resided in room [ROOM NUMBER] with Resident #16 who was COVID positive; *Resident #17, who was negative, resided in room [ROOM NUMBER] with Resident #18, who was COVID positive; *Resident #19, who was negative, resided in room [ROOM NUMBER] with Resident #20, who was COVID positive; and *Resident #21, who was negative, resided in room [ROOM NUMBER] with Resident #22, who was COVID positive. Record review of a face sheet indicated Resident #1, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was diagnosed with COVID 19 on 9/16/22. Record review of a face sheet indicated Resident #2, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a nurse note dated 09/09/22 indicated Resident #2 tested positive for COVID. Record review of a face sheet indicated Resident #3, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was diagnosed with COVID on 09/16/22. Record review of a face sheet indicated Resident #4, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was diagnosed with COVD on 09/09/22. Record review of a face sheet indicated Resident #5, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was diagnosed with COVID on 09/08/22. Record review of a face sheet indicated Resident #6, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The face sheet did not indicate when the resident was diagnosed with COVID. Record review of Resident #6's nurse notes indicated on 09/09/22 the resident tested positive for COVID. The resident was sent out to the hospital on 9/9/22 and did not return to the facility. Record review of a face sheet indicated Resident #7, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was diagnosed with COVID on 09/12/22. Record review of a face sheet indicated Resident #8, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a face sheet indicated Resident #9, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The face sheet did not indicate when the resident tested positive for COVID. Record review of a nurse note dated 09/12/22 indicated Resident #9 tested positive for COVID. Record review of a face sheet indicated Resident #10, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The face sheet did not indicate when the resident was diagnosed with COVID. Record review of a nurse note dated 09/19/22 indicated Resident #10 tested positive for COVID. Record review of a face sheet indicated Resident #11, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was diagnosed with COVID on 9/16/22. Record review of a face sheet indicated Resident #12, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was diagnosed with COVID on 9/16/22. Record review of a face sheet indicated Resident #13, admitted [DATE], was years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a COVID test results sheet indicated Resident #13 tested negative for COVID on 09/12/22. Record review of a face sheet indicated Resident #14, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a face sheet indicated Resident #15, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a COVID test results sheet indicated Resident #15 tested negative for COVID on 09/12/22. Record review of a face sheet indicated Resident #16, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a face sheet indicated Resident #17, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the COVID testing sheets indicated Resident #17 tested negative for COVID on 09/12/22. Record review of a face sheet indicated Resident #18, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was diagnosed with COVID on 09/09/22. Record review of a face sheet indicated Resident #19, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a COVID testing sheet indicated Resident #17 tested negative for COVID on 09/12/22. Record review of a face sheet indicated Resident #20, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was diagnosed with COVID on 09/16/22. Record review of a face sheet indicated Resident #21, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a COVID testing sheet indicated Resident #21 tested negative for COVID on 09/12/22. Record review of a face sheet indicated Resident #22, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident tested positive for COVID on 09/12/22. During an interview and record review of the COVID unit resident roster on 09/19/22 at 2:00 p.m., the ICP said the COVID negative residents were placed in the rooms with the COVID positive residents. She said it was not possible to keep the COVID positive and negative residents separated due to their behaviors, and she had consulted with the epidemiologist regarding the residents being on the secure/COVID unit and having dementia. She said residents were tested with signs/symptoms, and/or with exposure and then again 7 days later. She said a resident tested positive 009/16/22, so all of the residents were re-tested today (09/19/22) and she had one more positive resident. She said the epidemiologist said since the residents all had dementia and the facility was limited on staff, they could place the COVID unit as the isolation unit and keep the COVID negative residents with the COVID positive. She said the residents had communal dining and they were taken out for fresh air daily. She said she monitored infection control precautions with facetime on her cell phone and the cameras the facility had in the common areas on the locked unit. She said the residents on Hall 5 had dementia and they wandered, they would go in each other's rooms and get in each other's beds; they had tried before to put up barriers and they would tear them down. She said they did have positives and negatives cohorted together in resident rooms, but it was because they were already exposed once their roommate became positive. She said the residents had very minor symptoms, if any. She said the residents were exposed and we knew COVID would have to run its course on the secure unit, but they had it contained to the secure unit. During an interview on 09/19/22 at 2:10 p.m., the epidemiologist for the county said she had discussed Hall 5 (secure/COVID unit) with the facility for quite a while. She said when the concerns were first brought to her, she reached out to the state HAI (health associated infections) epidemiologist, and we decided to wave the risks of setting up a warm and hot unit on the locked unit due to the residents having dementia. She said they had come to the decision there was nowhere to move the COVID negative residents for their safety. When asked what her expectations were regarding cohorting COVID negative residents with COVID positive residents in the same room, she said the residents should be separated according to what was recommended by the state agency. She said the staff should ensure social distancing and keep residents separated during mealtimes or have staggered dining times. During observations on the secure/COVID unit on 09/19/22 at 2:28 p.m., the resident room name plates on each of the rooms indicated the following: *Resident #1 and Resident #2 resided in room [ROOM NUMBER]; *Resident #3 and Resident #4 resided in room [ROOM NUMBER]; *Resident #5 resided in room [ROOM NUMBER]; *Resident #6's name was not found on the name plates; *Resident #7 and Resident #8 resided in room [ROOM NUMBER]; *Resident #9 and Resident #10 resided in room [ROOM NUMBER]; *Resident #11 and Resident #12 resided in room [ROOM NUMBER]; *Resident #13 and Resident #14 resided in room [ROOM NUMBER]; *Resident #15 and Resident #16 resided in room [ROOM NUMBER]; *Resident #17 and Resident #18 resided in room [ROOM NUMBER]; *Resident #19 and Resident #20 resided in room [ROOM NUMBER]; and *Resident #21 and Resident #22 resided in room [ROOM NUMBER]. During an interview and record review on 09/19/22 at 2:37 p.m., LVN A, charge nurse on the COVID unit, said to prevent the spread of COVID on the unit, the COVID positive residents were isolated as much as possible. She said they kept the COVID positive and COVID negative residents separated while in the common areas and at mealtimes. She said their census on the unit was 33 and they had 17 positive residents. When asked if the COVID negative residents were placed in the room with COVID positive residents, she said yes, they were placed in the rooms together. She said residents had regularly tested positive since the outbreak. She said the facility had cohorted the positive and negative residents in rooms on the unit since the outbreak started on 09/06/22. She said the negative outcome could be the COVID negative residents become positive. She said most of the residents had mild symptoms. LVN A reviewed the COVID unit resident roster with surveyor and said the above observations of COVID positive and negative residents in the same resident rooms together was correct. During observations on the locked unit/COVID unit on 09/19/22 at 2:40 p.m., the residents were socially distanced, and staff were redirecting the residents as needed. There were no COVID positive and negative residents in close distance of each other. Record review of the facility daily COVID report dated 09/20/22 indicated the following: *Resident #1, room [ROOM NUMBER]A, tested positive for COVID on 09/6/22 and roommate Resident #2, room [ROOM NUMBER]B, tested positive for COVID on 09/09/22; *Resident #3, room [ROOM NUMBER]A, tested positive for COVID on 09/06/22 and roommate Resident #4, room [ROOM NUMBER]B, tested positive for COVID on 09/09/22; *Resident #5, room [ROOM NUMBER]B, tested positive for COVID on 09/9/8/22 and roommate Resident #6, room [ROOM NUMBER]A, tested positive for COVID on 09/09/22; *Resident #7, room [ROOM NUMBER]B, tested positive for COVID on 09/12/22 and roommate Resident #8, room [ROOM NUMBER]A, tested positive for COVID on 09/16/22; *Resident #9, room [ROOM NUMBER]B, tested positive for COVID on 09/12/22 and roommate Resident #10, room [ROOM NUMBER]A, tested positive for COVID on 09/19/22; and *Resident #11, room [ROOM NUMBER]A, tested positive for COVID on 09/12/22 and roommate Resident #12, room [ROOM NUMBER]B tested positive for COVID on 09/16/22. During an interview on 09/20/22 at 8:55 a.m., after surveyor intervention, the ICP said the facility had intervened on the concern related to cohorting of COVID residents and moved all of the COVID positive residents in with the other COVID positive residents and moved the COVID negative residents into rooms with other COVID negative residents yesterday evening (09/19/22). She said she had spoken with the Medical Director yesterday and he agreed that due to the residents having dementia on the unit, it would be difficult to keep them separated. She said he felt like they were doing the best job possible with the type of residents they had on hall 500. During an interview on 09/20/22 at 9:40 a.m., the Medical Director said, ideally, you would separate positive from negative but the unit was unique. He said if you started moving those residents around, it would confuse them more. He said the residents wandered and it was difficult to keep them separated. He said he knew the facility was doing their best to keep them separated. When asked what his expectations were regarding cohorting COVID positive residents in the same room with COVID negative residents, he said We will do whatever you want us to do. During an interview on 09/20/22 at 10:50 a.m., the DON said Resident #6 did reside in the room with Resident #5, who was positive. She said Resident #5 tested positive on 09/08/22 and had symptoms of sinus drainage and Resident #6 tested positive on 09/09/22. She said Resident #5 was sent out to the hospital on 09/09/22 due to a choking incident and did not return, but it was not related to symptoms of COVID. She said she did understand cohorting the COVID positive residents in the room with the COVID negative residents had caused the number of COVID positive residents to increase. During an interview on 09/20/22 at 1:20 p.m., LVN C said on 09/19/22 the COVID positive residents and the COVID negative residents were placed in the rooms together. She said she received report that the COVID positive residents were moved in with the other positive resident and the negative residents were moved in together yesterday evening on 09/19/22. She said the negative outcome of not separating the positive residents from the negative residents would be the negative residents could get COVID. She said most of the residents had very mild symptoms (i.e., runny nose, dry cough etc). She said Resident #6 was cohorted with resident #5 and Resident #5 was diagnosed with COVID on 09/08/22. She said on 09/09/22, Resident #6 tested positive and was transferred to the hospital due to a choking incident, but it was not related to signs/symptoms of COVID. During an interview on 09/20/22 at 1:40 p.m., CNA D said the facility did have COVID positive and negative residents in the same room together but moved them yesterday. She said the COVID positive and COVID negative residents resided in the rooms together since the beginning of the outbreak. She was unable to say when the outbreak started. She said the possible negative outcome would be the positive residents would give it to the negative residents. During an interview on 09/21/22 at 3:30 p.m., the DON said her expectations regarding cohorting residents that are positive and negative in the same room were for the staff to follow policy and physician orders. She said the ICP was responsible for monitoring the COVID unit. She said the negative outcome would be sinus like symptoms. She said she did not feel like cohorting the residents contributed to the spread of COVID in the facility because of the disease process of the Alzheimer's residents on the unit and their wandering behaviors. Record review of the Covid-19 Response for Nursing Facilities, version 4.3, updated on 06/27/2022 revealed the following: .Isolation - Once a case of COVID-19 is identified in the NF, immediate action must be taken to isolate the resident who is positive for COVID-19 away from other residents .page 18 .Isolate residents with positive cases according to CDC Guidance . Accessed on 09/21/2022 Record review of the World Health Organization: Coronavirus disease (COVID-19) is an infectious disease caused by the [CONDITION(S)]-CoV-2 virus. Most people infected with the virus will experience mild to moderate respiratory illness and recover without requiring special treatment. However, some will become seriously ill and require medical attention. Older people and those with underlying medical conditions like cardiovascular disease, diabetes, chronic respiratory disease, or cancer are more likely to develop serious illness. Anyone can get sick with COVID-19 and become seriously ill or die at any age. The best way to prevent and slow down transmission is to be well informed about the disease and how the virus spreads .and follow local guidance. The virus can spread from an infected person's mouth or nose in small liquid particles when they cough, sneeze, speak, sing, or breathe. These particles range from larger respiratory droplets to smaller aerosols. It is important . self-isolate until you recover if you feel unwell. Accessed on 09/21/22. (https://www.who.int/health-topics/coronavirus#tab=tab_1) Record review of the COVID-19 Virus Pandemic Policy dated 06/17/22 indicated . Residents positive and confirmed with COVID 19 infection will be placed in HOT Zone in private room if possible, or cohorted with one other COVID 19 positive resident for care by dedicated (if possible) staff designated to the HOT zone. Revision 01/28/2021- Hall 5 secured unit for dementia care. When positive residents cannot be moved to the designated Hall 4 COVID unit due to their dementia, wandering, or behaviors it will become necessary to designate Hall 5 as a COVID Unit with same procedures as Hall 4 as residents on Hall 5 are very interactive, social, and most likely exposed if a positive is identified on the dementia care hall.

Based on observation, interview and record review, the facility failed to ensure respiratory care was provided according to professional standards for 1 of 29 residents reviewed for respiratory care and services. (Resident #15) Resident #15's, oxygen concentrator machine tubing had not been changed in 2 weeks and was dated [DATE]. This failure could place residents who required respiratory care at risk of not receiving proper care and treatment, infection and decreased quality of life. Findings included: Record review of Resident #15's face sheet dated [DATE] revealed, a [AGE] year-old admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on [DATE] at 8:40 a.m., Resident #15 was awake and alert, in bed, with the head of bed elevated and with no oxygen being administered. Resident #15 had an oxygen concentrator machine with attached tubing and pre-filled humidification bottle at his bedside. Resident #15 said he used the oxygen machine at night to help him breath and could not remember the last time the tubing or bottle was changed. The oxygen concentrator machine tubing was not dated and the pre-filled humidification bottle was dated [DATE]. Record review of Resident #15's Quarterly MDS dated [DATE] revealed, resident sometimes understands others and was sometime understood by others and had a BIMS score of 9 indicated moderately impaired cognition. Record review of Resident #15's Care Plan Dated [DATE] revealed, .has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .difficulty breathing. Record review of Resident #15's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] @ 2L/min per N/C PRN SOB as needed for SOB/Wheezing start dated [DATE]. During an observation and interview on [DATE] at 2:15 p.m., Resident #15 was not in the room. Resident #15 had an oxygen concentrator machine with attached tubing and pre-filled humidification bottle at his bedside. LVN G said Resident #15 used oxygen at night sometimes for shortness of breath and not changing the tubing weekly could increase the resident's risk to get a respiratory infection. LVN G said the tubing had no date on it and pre-filled humidification bottle was dated [DATE]. LVN G pulled out her phone from her pocket said Resident #15's tubing and bottle should have been changes at least 2 times already on the [DATE] and [DATE] because it's changed weekly on Sundays. LVN G said tubing and bottle changes were done on the night shift or day shift if not done. LVN G stated she had been trained on oxygen administration to include dating the tubing or humidification bottle when last changed. During an interview on [DATE] at 3:45 p.m., the DON said she was responsible for monitoring the nurses changed out expired or not dated oxygen equipment weekly and did so by randomly checking rooms of residents on oxygen. DON said if the tubing or pre-filled humidification bottle is not changed every 7 days it puts the resident at risk for infection and become ill. The DON said they did not have a specific policy for tubing or masks changes and said the nurses were to change tubing and humidification bottles every week on Sundays at 10p-6p shift. The DON further said nurses are trained on oxygen administration upon hire, annually and as the need arise. The DON said Resident #15's Oxygen tubing and pre-filled humidification should have been changed last on [DATE]. Record Review of facility undated policy titled Oxygen Administration revealed in part: Basic Responsibility: Licensed Nurses . 7. Care and Use of Prefilled disposable Humidifiers: . i. Label humidifier with date and time opened. Change humidifier and tubing per facility policy .12. At regular intervals, check and clean oxygen equipment , masks, tubing and cannulas .General Documentation Guidelines . humidifiers should be labeled with the date and time changed .

Based on interview and record review, the facility failed to ensure a timely and specific notice was given to the residents when the facility determined the residents no longer qualified for Medicare Part A skilled services for 2 of 3 residents (Resident #s 15 and 114) reviewed for beneficiary notice. The facility did not ensure Resident #15 and Resident #114 were given a skilled nursing facility Advanced Beneficiary Notice in a timely manner when they were discharged from Medicare Part A skilled services at the facility. This failure could place the residents who were discharged from Medicare Part A services at risk of not having knowledge of changes to services in a timely manner to allow the resident or their representative the option of appealing the denial of services. Findings included: Record review of a face sheet dated 06/29/22 indicated Resident #15, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a face sheet dated 06/29/22 indicated Resident #114, admitted [DATE], was [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #15's Notice of Medicare Non-coverage (NOMNC) was completed with verbal confirmation of Resident #15's representative on 05/04/22. The effective date coverage of your current Medicare skilled services will end was 05/5/22. Record review of Resident #114's Notice of Medicare Non-coverage (NOMNC) was signed by the resident's representative on 06/08/22. The effective date coverage of your current Medicare skilled services will end was 06/08/22. During an interview on 06/29/22 at 3:25 p.m., MDS nurse A said she was responsible for notifying residents of Medicare Part A services ending. She said she did not know she had to give the residents a 48-to-72-hour notification prior to Medicare services ending until the Medicare specialist informed her on 06/15/22 she had to notify the resident 48 to 72 hours before services ended. She said the prior MDS nurse was responsible for training her and did not take the time to train her properly before she left. She said the negative outcome of not giving the residents timely notification of Medicare services ending was they would not have time to appeal the denial. She said she did not give resident #15 or Resident #114 a timely notice. She said she did not have a signed Advanced Beneficiary Notice (ABN) for either resident. During an interview on 06/29/22 at 3:39 p.m., the facility coordinator said the residents should have a 48-to-72-hour notice of Medicare benefits ending. She said if the residents were not notified timely, they would not be able to appeal the Medicare denial. She said MDS nurse A should have completed an ABN for each resident. During an interview on 06/29/22 at 3:43 p.m., the DON said she expected the residents to be notified of Medicare benefits ending as according to policy. She said the negative outcome would be the residents would not be given time to appeal the discontinuation of Medicare benefits if they wanted to. She said the ABNs should be completed. Record review of the Advanced Beneficiary Notice policy dated 2022 indicated: . The facility must convey to the resident or the resident's representative about Medicare benefits in a timely manner as directed by CMS guidelines.

Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source are reported immediately or not later than 24 hours for 1 of 29 residents (Resident #120) reviewed for reporting. The facility failed to report Resident #120's injury of unknown origin to the state agency after she was found on the floor and her x-ray showed a subacute (injury phase that usually begins four days or so after the event) right greater trochanteric (right hip) avulsion fracture (chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone) and was unable to explain how the fracture happened or how she fell on the floor. This failure could place residents at risk for abuse and neglect. Findings included: Record review of Resident #120's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #120's quarterly MDS dated [DATE] revealed a BIMS score of 3 out 15 indicating severely impaired cognition. Further review of the MDS revealed she required extensive assistance with two people for bed mobility, transfers, dressing, and personal hygiene. The MDS indicated Resident #120 had 2 falls with no injury and 1 fall with major injury since admission. Record review of Resident #120's undated care plan revealed she was at risk for falls related to deconditioning, confusion, gait/balance problems, incontinence, unaware of safety needs, history of falls and at risk of major injury due to disease process. Care plan indicated Resident #120 fell on [DATE], 5/18/22, and 5/27/22. The care plan interventions were: anticipate and meet her needs, make sure her call light was within reach, encourage her to use call light and to provide prompt response to all request for assistance, check on her frequently in bed, complete comfort rounds every 2 hours, educate resident about safety reminders and what to do if a fall occurs, encourage resident to participate in activities, make sure she is wearing proper footwear, IDT team to review fall risk every 90 days, notify MD and family of falls, and pain medications will be evaluated by MD, psychotic medications will be evaluated by psych services, physical therapy evaluate and treat as ordered, and scoop mattress on bed for edge awareness and pressure relief. Further review of Resident #102's undated care plan revealed she had [CONDITION(S)]/osteopenia. The care plan listed interventions of, give analgesic PRN for pain. I may complain of pain, stiffness or weakness. Document complaints. Give medications as ordered. Monitor/document for side effects and effectiveness. Encourage intake of dairy products, cereals [MEDICATION(S)] with calcium and Vitamin D. Encourage physical activity and daily ambulation. Use assistive device if necessary. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Record review of Resident 102's progress notes dated 5/16/22 at 2:11AM written by LVN K revealed, Resident observed sliding out of wheelchair to floor in hallway. Resident states, I fell down. Resident assessed for injury. No injury noted. Assisted resident back up and back into wheelchair. Record review of Resident #102's progress notes dated 5/16/22 at 2:05PM written by the Social Worker revealed in part, .admitted from another nursing facility for long term care. She is alert but has trouble with temporal orientation and memory recall. She had difficulty hearing, but her vision is adequate, and her speech is clear . Her primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Social worker will continue to monitor . Record review of Resident #102's progress notes dated 5/18/22 at 4:44AM written by LVN K revealed, Resident resting well in bed this shift. No adverse effects noted from sliding out of wheelchair. Denies pain or discomfort. Bed in lowest position with fall mat in place. Call light within reach. Record review of Resident #102's incident report dated 5/18/22 at 11:44AM written by LVN J revealed, This nurse called to residents' room by CNA's due to resident being on the floor. When entering, resident was sitting on the floor. Resident fell off of recliner onto floor. Resident blood pressure 133/76, pulse 92, O2 96%. Resident assisted back into recliner. X-ray ordered for right hip to rule out injury. Resident complaints of pain 4/10 in location. Awaiting x-ray to be done. Md, DON and RP notified. Further review of the incident report revealed there was no injuries observed at time of incident and post incident. Review of the incident report revealed the area of report to document mental status was not completed. The predisposing physiological factors listed were: confused, incontinent, recent changes in condition, gait imbalance, impaired memory, recent changes in medications/new, and sedated. The report also indicated there was no witnesses to the incident. Record review of Resident #102's progress notes dated 5/18/22 at 2:05PM written by LVN J revealed, This nurse called to residents room by CNA's due to resident being on the floor. When entering, resident was sitting on the floor. Resident fell off of recliner onto floor. Resident blood pressure 133/76, pulse 92, O2 96%. Resident assisted back into recliner. X-ray ordered for right hip to rule out injury. Resident complaints of pain 4/10 in location. Awaiting x-ray to be done. Md, DON and RP notified. Record review of Resident #102's right hip x-ray (including pelvis) dated 5/18/22 revealed an impression of, 1. Bones are osteoporotic. 2. The bilateral hip [CONDITION(S)] is visualized. 3. The subacute right greater trochanteric avulsion fracture is visualized. Further review of the results revealed they were electronically signed on 5/18/22 at 7:50PM. Review of the facility copy of the x-ray results revealed a fax confirmation at the top of the page which noted, received 5/18/22 at 7:51PM with facility name listed next to date and time received. Further review of the facility paper copy of the results revealed, Faxed at 9:00PM 5/18. Record review of Resident #102's progress notes dated 5/19/22 at 8:20AM written by LVN J revealed, x-ray results show right hip fracture, sent to MD. MD ordered for resident to be sent to ER. RP notified. Resident picked up by ambulance at 8:10. All vital signs within normal limits. Resident going to hospital. RP to meet there. Resident had no complaints of pain when leaving. Record review of Resident #102's progress notes dated 5/19/22 at 3:57PM written by DON revealed, Hospital notified this nurse of resident being sent back to facility. No new order. Acute fracture to right hip is inoperable. Family is at bedside and aware of situation. EMS called for pick up at hospital. EMS ETA for pick up is 5:15PM. Record review of Resident #102's progress notes dated 5/19/22 at 6:56PM written by RN C revealed, Resident returned from hospital at 5:45PM via EMS stretcher. EMS transferred resident to bed. Resident has AMS. Resident receive dinner tray from the dining room. She received a [MEDICATION(S)] from the hospital at 7:40. Bed is locked in lowest position call light in reach, fall mat on floor next to bed. Interview and observations on 6/27/22 at 9:43AM, Resident #102 was lying in bed with a scoop mattress in place, her bed was low and there was a fall mat next to her bed. Resident said she was fine and was doing okay. Resident spoke clearly but was very confused and began to say roommate who was sitting in recliner was moved with her from somewhere. Resident began to talk in circles about being somewhere and did not know where she was or who brought her here. Resident #102 said someone brought her here yesterday and did not say why and had not told her anything. Interview on 6/28/22 at 9:00AM, LVN J said Resident #102 was very confused but aware at the same time. LVN J said on 5/18/22 she worked the morning shift (6am - 2pm) with Resident #102 and said she was found on the floor in front of her recliner. LVN J said Resident #102 was not able to explain how she got on the floor but said looking at the scene it was obvious she fell from the recliner because she last saw the resident in the recliner with her legs up and when she found her on the floor the bottom of the recliner legs were pointing down. LVN J said she asked Resident #102 if she fell from the recliner, and she was able to reply yes. LVN J was assessed, and she had no complaints of pain during her assessment while she was on the floor. LVN J said when Resident #1 was being assisted back into the recliner she expressed some pain in her right hip. An x-ray was ordered to check her right hip for injury. LVN J said when she left for her shift the x-ray had not been completed. LVN J denied Resident #102 having any more complaints of pain before she left for her shift. LVN J said she returned to work the next morning on 5/19/22 and saw the x-ray results had come in and showed Resident #102 had a hip fracture. LVN J said she notified the physician via phone that morning when she saw the results and he ordered Resident #102 to be sent to the ER. LVN J said she did not see in documentation or get report of the physician being previously notified of the x-ray results. Interview on 6/29/22 at 9:52AM, the Facility Coordinator the facility did not think Resident #102's incident with fracture was reportable because the resident agreed she fell but could not explain how she fell due to her cognitive status. The Facility Coordinator said given how the room looked and where the resident was found on the floor, they were able to determine she fell out of her recliner. Interview on 6/29/22 at 11:00AM, RN B said Resident #102 x-ray was completed and her shift and results were received on her shift by her. RN B said Resident #102 x-ray showed her hip bone was fractured but after looking into the results they indicated the fracture was subacute which meant the fracture had not just happened. RN B said she consulted a coworker/ another nurse, and they agreed the results meant the fracture did not just happen. RN B said Resident #102 received routine pain medications, so she had no complaints of pain during her shift. RN B said Resident #102 was confused so she could not remember she had fallen but could say she was in pain if she was asked. Interview on 6/29/22 at 4:39PM, the Administrator said she did not think Resident #102's incident with injury was reportable because Resident #102 was able to say she fell . The Administrator stated she talks with Resident #102 all the time and though she was confused she had lucid moments. The Administrator stated when Resident #102 admitted to the facility she was on a lot of medications and was much more confused and sedated than she is now which could indicate why her BIMS score was low. The Administrator said they were able to determine she had fallen from recliner even though the incident was unwitnessed, and resident was noted to be severely cognitive impaired. The Administrator said the facility has no problem with submitting self-reports to the state agency, but the situation was not a self-report to them (facility administration) for injury of unknow origin or neglect. Record review of the facility Resident Safety Regarding Abuse, Neglect, or Misappropriation of Resident Property (revised 8/17/2020) revealed in part, . Reporting - the facility will report to THHS within 24 hours as required, and will report allegation of abuse of incidents of serious injury within 2 hours . a. Abuse Coordinator and/or Administrator will report alleged violations to Texas HHS, and to other agencies as required, and will take corrective action as identified through investigation. b. Other types of injuries such as bruises, skin tears, abrasion will considered injury of unknown source and reportable if no one saw the incident or the resident cannot state the source, AND the injury is suspicious in nature because of the extent of the injury, the location of the injury, or a pattern or trend is noted .

Based on observation, interview and record review, the facility failed to provide adequate supervision and assistance to prevent accidents for 1 of 5 residents reviewed for accidents. (Resident #3) The facility did not secure Resident #3 in the shower chair to prevent falling. Resident #3 fell out of the shower chair and sustained a laceration to her head, requiring 3 staples. This failure could place 63 residents who required staff assistance with bathing at risk for injury. Findings included: The computerized admission record accessed on 09/26/17 indicated Resident #3 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 had clear speech, usually understood others and usually made herself understood by others. She had moderately impaired cognitive skills for daily decision making and required supervision. Resident #3 demonstrated no physical aggression towards others and had not exhibited the behavior of rejecting care. Resident #3 was totally dependent upon staff for assistance with bathing. A care plan dated 03/22/14 addressed Resident #3's risk for falling due to decreased strength and endurance with a listed intervention to not leave the resident unattended on a gurney or the shower chair. A care plan dated 09/10/15 addressed Resident #3's ADL deficits, and indicated she required two staff members for all transfers and one for bathing. A nursing progress note dated 08/26/17 at 2:38 p.m. indicated Resident #3 was in the shower room lying on her right side with a laceration to the right side of her forehead, a skin tear to her right elbow, right forearm and left forearm. This note indicated Resident #3 was transferred to the ER and received 3 staples to the laceration on her forehead. During an observation on 09/26/17 at 5:00 p.m., Resident #3 was in bed with oxygen in place. She had a bruise to her right hand and right arm. Resident #3 did not respond to questions. During an interview on 09/28/17 at 2:28 p.m., CNA R said he was assisting Resident #3 in the shower when he realized her socks were still on. CNA R said he knelt down on one knee in front of Resident #3 to remove her socks. He said as he removed the last sock, Resident #3 leaned forward in an attempt to hit him because she did not want her socks taken off. CNA R said, I turned away to put the socks in the dirty linen around the corner and she fell out of the shower chair. I saw her start to lean but I thought the seatbelt was on so I didn't worry about it but she kept leaning and fell . CNA R said the nurse assessed Resident #3 and sent her to the ER. He said he thought the other CNA who assisted with the transfer put the seat belt on and he did not check to ensure it was in place before starting the shower. During an interview on 09/26/17 at 5:26 p.m., the assistant administrator said she was the abuse coordinator. She said CNA R was taking off Resident #3's socks in the shower. The assistant administrator said CNA R just forgot to use the seatbelt. She said it was Resident #3's movement in the chair that caused her to fall. The assistant administrator said CNA R was in-serviced on proper use of the shower chair and verbally reprimanded following this incident. During an interview on 09/26/17 at 5:29 p.m., LVN M said even before Resident #3 fell on [DATE], she required two staff to assist her with showers most of the time. During an interview on 09/28/17 at 2:45 p.m., LVN T said she assessed Resident #3 and found bruises to her right arm, right side of her torso and her right knee. LVN T said there were skin tears on Resident #3's right hand, right elbow and right knee, and she was bleeding from a laceration to her head. She said she wrapped Resident #3's head to stop the bleeding while another nurse called EMS. She said Resident #3 returned from the ER that same day with 3 staples in her forehead. LVN T said CNA R failed to ensure Resident #3 was secured with the safety belt. A Resident Safety Policy: Bathing with Shower Chair dated 01/05/17 indicated .staff persons will secure resident in shower chair with latch or snap belt to help prevent falls .2. Snap or latch safety belt around resident's waist checking for appropriate fit . The CMS 672 dated 09/26/17 indicated 63 residents required one to two person assistance with bathing.

Based on observation, interview and record review the facility failed to ensure residents were free from physical restraints which were not required to treat medical symptoms or utilized as a replacement for staff supervision for 8 of 23 residents reviewed for restraint use. (Resident #s 6, 15, 17, 18, 8, 14, 20, and 36) Resident #6 did not have medical justification for a soft belt restraint. Resident #6 had a soft belt restraint to prevent him from getting out of his wheelchair. There was no evidence that other less restrictive devices were attempted. Resident #15 did not have medical justification for a soft belt restraint or side rails. She was unable to self-release the restraint. Resident #15 had a soft belt restraint in use while in her wheelchair. She was able to pull the soft belt restraint over her chest and shoulders. Resident #15 had side rails in use. She was able to crawl around the side rails to get out of bed. There was no evidence that other less restrictive devices were attempted. Residents #17,and 18 did not have medical justification for a soft belt restraint and could not self-release the restraint. The residents had soft belt restraints in use while they were in their wheelchairs. The soft belt restraint were around the residents' rib cages and tied in the back of their wheelchairs. There was no evidence that other less restrictive devices were attempted. Resident #14 did not have medical justification for a soft belt restraint and could not self-release the restraint. The resident had a soft belt restraint in use that was double tied in the back of her wheelchair. Resident #14 had side rails due to attempts to get out of bed and dementia. There was no evidence that other less restrictive devices were attempted. Resident #8 did not have medical justification for a soft belt restraint or side rails. The resident was unable to self-release the restraint. Resident #8 had side rails while in bed for safety. There was no evidence that other less restrictive devices were attempted. Resident #20 did not have medical justification or assessment for side rails. The resident was unable to lower the side rails and required extensive assistance for bed mobility. Resident #20 had full side rails in use. There was no evidence that other less restrictive devices were attempted. Resident #36 did not have medical justification for a soft belt restraint or side rails. The resident was unable to self-release the restraint. Resident #36 had full side rails in use. There was no evidence that other less restrictive devices were attempted. An Immediate Jeopardy situation was identified on 08/07/13. The Immediate Jeopardy was removed on 08/08/13. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to ensure all in-service training was completed and evaluate the effectiveness of its corrective systems. This failure could place the 15 residents with soft belt restraints and the 33 residents with side rails at risk of unnecessary restriction of movement, lack of staff supervision, and injury or death. Findings included: 1. A Medication Review Report (physician order) dated 08/01/13 (electronically monitored) indicated Resident #6, a [AGE] year old male admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated the resident was to have a soft belt restraint for safety to prevent him from standing while he is up in his wheelchair. An MDS dated [DATE] indicated Resident #6's cognitive status as modified independence-some difficulty in new situations. The assessment indicated the resident needed the extensive assistance of one person for transfers and that trunk restraints were used daily. A nursing progress note dated 05/28/13 at 12:11 p.m. indicated Resident #6 was found by a CNA in his room, on the floor, with the wheelchair flipped over on him with his soft belt restraint in place. An incident report dated 05/28/13 at 12:11 p.m. indicated Resident #6 was found by a CNA in his room with the wheelchair flipped over. A Comprehensive Care Plan dated 05/29/13 (received 08/06/13) indicated Resident #6 had a need for a soft belt restraint in his wheelchair due to progressing dementia and the resident did not understand that he was not supposed to stand without assistance. This care plan indicated the resident was a danger to himself. The care plans for Resident #6 dated May, June, July, and August 2013 indicated the soft belt restraint was used while the resident was up in his wheelchair for his safety. A nursing progress note dated 06/13/13 at 4:15 p.m., indicated Resident #6 had an unwitnessed fall out of his chair trying to get into bed and that he was halfway in wheelchair with one knee on the ground. The documentation did not reflect whether the soft belt restraint was in place. An incident report dated 06/13/13 at 3:30 p.m., indicated Resident #6 fell out of his chair trying to get into bed. The resident was still halfway in the wheelchair, but one knee hit the ground. An incident report dated 07/08/13 at 1:02 p.m. indicated Resident #6 had an un-witnessed fall. The resident was found sitting on the floor in his room. The report indicated the resident slipped out of his wheel chair under his soft belt restraint. The report was signed by the administrator and DON. A nursing progress note dated 07/25/2013 at 3:20 p.m. indicated Resident #6 had an unwitnessed fall and was found sitting on the floor in front of his wheelchair next to his bed. The resident said he wanted to get into his bed. The documentation did not reflect whether the soft belt restraint was in place. A Pre-Restraining assessment dated [DATE] indicated Resident #6 had a recommendation for side rails and a soft belt restraint while in the wheelchair. The assessment had no medical justification for the side rails and soft belt restraint. A nursing progress note dated 07/30/13 at 5:12 p.m. indicated Resident #6 had an unwitnessed fall and was found lying on the floor in his room facing upwards. The documentation did not reflect whether the soft belt restraint was in place. During an observation and interview on 08/05/13 at 10:35 a.m., Resident #6 was in a wheelchair with a soft belt restraint around his waist. The belt was tied behind the resident's wheelchair, crisscrossed in the back, and tied to the legs of the wheelchair, out of his reach. LVN J said the resident removed the soft belt restraint before and they had to reposition the ties behind the wheelchair to keep him from reaching the tie and releasing it. She said the soft belt restraint was to keep him in his wheelchair to keep him from falling. During observations on the following dates and times, Resident #6 was in his wheelchair with the soft belt restraint crisscrossed behind his wheelchair and tied to the wheelchair legs out of his reach: *08/05/13 at 11:55 a.m., *08/05/13 at 3:30 p.m., *08/06/13 at 11:58 a.m. *08/06/13 at 12:30 p.m., and *08/07/13 at 9:20 a.m. During an interview on 08/07/13 at 9:10 a.m., CNA M said Resident #6 wiggles out from under his soft belt restraint and slides to the floor. CNA M said she passed by his room once and found the resident halfway between the wheelchair and the floor with the soft belt restraint across the top of his chest. During an interview on 08/07/13 at 9:20 a.m., LVN J indicated Resident #6 wiggles and leans forward to get out of his soft belt restraint. The nurse said the resident had been found with the soft belt restraint around his chest while he was sitting on his wheelchair foot pedal. During an interview on 08/07/13 at 9:25 a.m., CNAs F and X indicated Resident #6 wiggles until he is able to get out of his soft belt restraint that was on the wheelchair. CNA F said Resident #6 had been found on the floor and in the bed after he got out of his wheelchair while the soft belt restraint was attached. CNA X said Resident #6 was found in his room with his arms raised and caught up in the soft belt restraint. Both CNAs said they had found the resident on the floor out from under his soft belt restraint at least a dozen times or more. During an interview on 08/07/13 at 10:15 a.m., the DON said she was aware that Resident #6 was able to get loose from the soft belt retraint, but she did not know how. The DON said she was aware that the soft belt restraints were being tied and placed out of the reach of the residents. The DON said if a resident kept getting out of their restraint, then there was a need to do try something else. The DON did not identify measures that were put into place to ensure the safety of Resident #6. During an observation on 08/07/13 at 9:30 a.m., Resident #6 was slipping his arm under the soft belt restraint, wiggling to the edge of his wheelchair, and attempting to pull the soft belt restraint over his head to get out of the wheelchair. During an interview on 08/07/13 at 12:30 p.m., the administrator said she did not see how the soft belt restraints were a problem. She said the staff frequently monitored Resident #6. The current (undated) Restraint Policy indicated, "The use of restraints in the aging population impairs the quality of life, produces immobility and all of the associated complication, which contribute to and expedite mental and physical deterioration. Therefore, the medical staffs who practice at this facility have determined that no restraints will be used on any resident of this facility". The current (undated) Policy and Procedure for Restraint Assessment, Reduction, and Consent indicated "Side rails are considered as a restraint if used as a minimal restraint for resident safety or as to treat a medical condition i.e. [MEDICAL CONDITION] disorder or involuntary movements". The current (undated) Restraint Policy indicated, "The use of restraints in the aging population impairs the quality of life, produces immobility and all of the associated complication, which contribute to and expedite mental and physical deterioration. Therefore, the medical staffs who practice at this facility have determined that no restraints will be used on any resident of this facility". Soft belt restraint manufacturer, JT Posey, Application Instruction Sheet, 2006, Warnings indicated, " ...After applying a restrictive product, always monitor to make sure the patient is not able to slide down, or fall off the chair seat ...If their body weight becomes suspended off the chair ... chest compression and suffocation could result ... Discontinue use immediately if the patient is able to slide forward or down underneath the device ... " Application instructions: chair indicated, " Put the belt over the patient's lap ...Bring the straps over the hips ...Secure them ... with a quick-release tie or buckle. 2. A Medication Review Report (physician order) dated 08/01/13 indicated Resident #15, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. These orders indicated the resident was to have side rails on both sides of the bed for mobility and a soft belt restraint while in her wheelchair. A Pre-Restraining Assessment signed 08/05/13 indicated Resident #15 was unsteady on her feet, loses balance, and has a history of falls. The recommendations for a soft belt restraint indicated frequent re-direction and reminders to use the call light for help were alternatives to restraints used. The recommendations note indicated the resident required a soft belt restraint while in her wheelchair because she would not stay seated due to her confusion. The assessment had no medical justification for the side rails and soft belt restraint. A physician telephone order dated 08/02/13 indicated Resident #15 was to have side rails on both sides of her bed for bed mobility and a soft belt restraint while up in her wheelchair every shift. A nursing care plan initiated on 08/05/13 indicated Resident #15 required a soft belt restraint due to a new [MEDICAL CONDITION] and dementia. The TARS for Resident #15 dated August 2013 indicated the soft belt restraint was used while the resident was up in wheelchair every shift. During an observation on 08/05/13 at 9:40 a.m., Resident #15 was sitting in her wheelchair in her room with a soft belt restraint across her waist. The restraint was wrapped around the back of the wheelchair and tied in a double knot. When the resident was asked if she could remove the soft belt restraint, she nodded her head yes and attempted to reach around to the back of the wheelchair. At this time, the resident was unable to reach the knots tied on the back of the wheelchair legs. During an interview on 08/06/13 at 3:40 p.m., LVN H said Resident #15 was confused and had an unsteady gait. He said the resident has fallen once that he knew of since her admission on 08/02/13. LVN H said the resident would not be able to get the soft belt restraint off, and depends on staff to release it. He said he was not aware if the resident had removed the soft belt restraint herself. LVN H said he would consider the soft belt a restraint. LVN H said the restraint would be released when the resident would go to the bathroom or to bed. During an observation and interview on 08/08/13 at 10:45 a.m., Resident #15 was sitting in her wheelchair with a soft belt restraint across her lap. The resident said she liked this belt much better than the soft belt restraint. The resident's husband said his wife "gets out of everything" and was afraid she will fall. The resident's husband said he caught her pulling the soft belt restraint over her shoulders one day and immediately called the nurses for help. The husband also said the resident has side rails on her bed, but she just crawled around them to get up. During an interview on 08/08/13 at 11:12 a.m., CNA P said Resident #15 would climb to the end of her bed and gets her leg caught between the bed and her side rail. During an interview on 08/08/13 at 9:25 a.m., the administrator said the beds and side rails had been in the facility since it opened. She did not know if she could find the manufacturer's recommendations for the side rails, but would look. No manufacturer's recommendations for side rails were provided by the facility. 3. A Medication Review Report (physician order) dated August 2013 indicated Resident #17, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. Those orders indicated the resident should have a soft belt restraint applied while up in the wheelchair for safety and side rails times two while in bed for safety. A Pre-Restraining assessment dated [DATE] indicated Resident #17 had a recommendation for a soft belt restraint while in the wheelchair. The assessment indicated the resident was very confused due to dementia and had a history of [REDACTED]. The most recent MDS dated [DATE] indicated Resident #17's cognitive skills were severely impaired, she required extensive assistance for bed mobility and transfers, was always incontinent of bowel and bladder, and used a trunk restraint daily. A nursing care plan dated 07/10/13 indicated Resident #17 required a soft belt restraint while in her wheelchair due to progressing dementia. It noted the resident does not understand she cannot stand without assistance and resident was a danger to herself. The care plan had an initiation date of 08/14/12. The TARS for Resident #17 dated July and August 2013 indicated the soft belt restraint was used while the resident was up in wheelchair for safety and side rails were up times two while in bed for safety. During an observation and an interview on 08/05/13 at 11:00 a.m., Resident #17 was sitting in the dining room for an activity. The resident was slumped in her wheelchair and she had a soft belt restraint that was tight fitting over her rib cage and under her axillary area that wrapped around the back of the wheelchair where it was tied in a double knot. LVN J said the residents are not supposed to get out of the restraints, but sometimes they do. She said Resident #17 had a soft belt restraint because she had a history of [REDACTED]. LVN J then repositioned Resident #17 in her wheelchair. During an observation on 08/05/13 at 4:17 p.m., Resident #17 was alone in her room with a soft belt restraint around her waist that was tied in a double knot behind the wheelchair, out of the resident's reach. When the resident was asked about the soft belt restraint and if she knew how to remove it, the resident did not respond. 4. A Medication Review Report (physician order) dated 07/01/13 indicated Resident #18 was admitted [DATE] with [DIAGNOSES REDACTED]. The orders indicated Resident #18 had a soft belt restraint applied at all times while in her wheel chair to be released and repositioned every 2 hours. The most recent MDS dated [DATE] indicated the resident had clear speech and was able to make herself understood as well as the ability to understand others. No negative behaviors were reported. Resident #18 required extensive assistance of 1 staff for bed mobility and transfers. She did not walk and used a wheelchair to propel herself around the facility using her feet. She had 2 falls since her last assessment. A care plan for the need for a soft belt restraint in the wheelchair initiated 9/20/11 and reviewed 6/24/13 indicated Resident #18 was a danger to herself and did not understand she could not stand without assistance. Interventions included: *check the resident every hour, release and reposition every 2 hours for 10 minutes. (Include those sitting in wheelchair for extended periods of time. Get them up, out of the wheelchair and walk to the bathroom, transfer to bed to change diaper.) *check the resident frequently to ascertain needs *Explain procedure to resident and family and discuss with them possible alternatives *provide verbal reminders to resident to call when assistance was needed. A care plan for fall risk dated 06/24/13 indicated staff interventions included use of a soft belt restraint while in the wheel chair as well as the chair alarm. A Restraint Reduction assessment dated [DATE] indicated Resident #18 leaned to the side, forward, and backward. She was partially weight-bearing with the assistance of 1 person. The resident had normal sitting balance and had a history of [REDACTED]. When she attempted to stand, she fell . The resident was not able to remember she was unable to stand or walk without help. Continue to use soft belt restraint in wheelchair. Resident #18 did not have medical justification for a soft belt restraint. During an observation on 08/05/13 at 4:00 p.m., Resident #18 was seated in her wheelchair at the dining room table. She had a soft belt restraint around her abdomen tied under the bottom of the wheelchair out of her reach. During an observation and interview on 08/05/13 at 5:50 p.m., Resident #18 finished dinner and was seated in her wheelchair in the common area near the nursing station. She had a soft belt restraint around her abdomen and tied in a double knot under her chair out of her reach. She said a long time ago, she untied it, but they tied it again. She said staff told her she had to keep it on and stay in the chair because she would fall. She said the soft belt restraint was used to keep her safe. During an interview on 08/06/13 at 9:15 a.m., LVN T said Resident #18 had a history of [REDACTED]. During an interview on 08/06/13 at 2:00 p.m., Resident #18's husband said he was aware of the risks of using the soft belt restraint and signed consent for its use. He said the resident forgot to ask for help and stood up which resulted in falls. He said she was in the facility because she had so many falls at home and they could no longer monitor her. He said he told Resident #18 she needed to keep it on to keep her safe. During an observation and interview on 08/07/13 at 4:45 p.m., Resident #18 was seated in her recliner in her room. She was alert and oriented. She said they changed the belt in her wheelchair to one that clasped in the front. She said the old soft belt restraint made her feel tied down. She said she was glad for the change. Resident #18 said she was aware she needed to stay safe in her wheelchair and needed to ask for assistance, but also was glad someone could get her out of the belt faster in case of an emergency. The resident did not know if she would be able to undo the new belt by herself. She was seated in her recliner and was not able to demonstrate whether or not she could release the belt. 5. A Medication Review Report (physician order) dated 07/01/13 indicated Resident #8 was admitted on [DATE] with [DIAGNOSES REDACTED]. The orders included an order for [REDACTED]. A pre-restraining assessment dated [DATE] indicated Resident #8 required side rails for mobility at night. The assessment had no medical justification for the side rails. A care plan for use of a soft belt restraint initiated 01/03/12 indicated Resident #8 needed the soft belt restraint due to his progressing dementia including weakness and falls, loss of balance, a [MEDICAL CONDITION], and he did not understand he could not stand without assistance. Staff interventions included: *check resident every hour, release and reposition every 2 hours for 10 minutes (included those seated in wheelchairs for extended periods of time. Get them up, out of the wheelchair and walk to the bathroom, transfer to bed to change diaper). *check with resident frequently to ascertain needs *exercises to maintain range of motion *keep call light and most frequently used personal items within reach *make sure resident attended activities and was provided with adequate stimulation. Resident #8's care plan for side rails initiated on 01/03/12 indicated the side rails were not used as a restraint, but were an aid in mobility, turning, and repositioning. Staff interventions were to check on the resident every hour for safety and to check with him frequently to ascertain his needs. The bed was to be placed in the lowest position before leaving the room. An incident report dated 06/24/13 at 7:37 p.m. indicated Resident #8 was found on the floor beside his bed. He denied pain, no injuries were noted, and he was able to move all 4 extremities without difficulty. The report indicated the resident made an attempt to get out of bed without staff assistance. The resident was assisted back to bed. The bed alarm, side rails, and call light were put in place. Nursing notes dated 07/02/13 at 10:45 p.m. indicated Resident #8 continued to try to climb out of bed. An incident reported dated 07/05/13 at 11:28 p.m. indicated staff found Resident #8 with swelling and bruising to his right upper chest. The area was tender to touch and the resident cried out in pain as his right arm was lifted to check the injury. Bruising was also noted to the resident's right inner arm and left hand. The report indicated the resident said he fell . An x-ray report dated 07/05/13 indicated there was no fracture. The most recent MDS dated [DATE] indicated Resident #8 was moderately impaired in his cognitive skills for decision-making and required cues and supervision. His speech was clear and he had the ability to make himself understood as well as understand others. He was totally dependent on 2 staff for transfers. Resident #8 had limited range of motion in all of his extremities. He did not walk, but could propel himself around the unit in his wheelchair. The MDS indicated he used a trunk restraint in his chair or out of bed daily. A Restraint Reduction assessment dated [DATE] indicated Resident #8 was a good candidate for the use of a soft belt restraint. He attempted to stand from his wheelchair and was unable to weight bear. He had a history of [REDACTED]. The assessment indicated the resident did not need side rails, but he used them for mobility. He was unable to remember to call for assist and unable to understand he could not stand without multiple people to assist him. There was no medical justification for the side rails or soft belt restraint. During an observation on 08/05/13 at 10:06 a.m., Resident #8 was self-propelling in his wheelchair. He had a soft belt restraint just above his waist, double-tied behind the wheelchair. During observations on 08/05/13 at 4:05 p.m. and at 6:00 p.m., Resident #8 was seated in his wheelchair at the dining room table with a soft belt restraint double-tied behind the wheelchair. During an interview on 08/05/13 at 6:00 p.m., CNA Q said Resident #8 wore the soft belt restraint to keep him safe. She said the resident would fall if he stood up. During an observation and interview on 08/06/13 at 9:07 a.m., Resident #8 propelled himself in his wheelchair. He wore a soft belt restraint just above his waist double tied behind the wheelchair. The resident said he did not know what it was and tried to lift it off. He was unable to reach behind the wheelchair to untie the belt. During an interview on 08/06/13 at 3:00 p.m., the DON said Resident #8 had several falls. She said he wore a soft belt restraint because he reached over far enough to fall out of his wheelchair. The DON said when the resident was first admitted , he had a chair alarm and fell frequently, so they changed to the soft belt restraint. She said she saw him get out of his belt restraint before by lifting the belt over his head. During an observation and interview on 08/06/13 at 3:30 p.m., Resident #8 was in his bed awake. The bed was against the wall. No side rail was up on that side. The full side rail was up on the side of the bed facing the door. Resident #8 thrashed around in bed and scooted half way down the mattress toward the end of the bed. He was confused and said he wanted help. The resident did not attempt to use the side rails for mobility. He used his feet and arms to scoot his body. She said the side rail was up to keep the resident from falling out of bed. CNA Q said with and without the side rails, the resident slid down in bed. She said she was told by staff the resident had fallen out of bed, but she did not observe it and did not know when it happened. CNA Q said she was told Resident#8 had tried to climb over the side rail. LVN S shook the side rail and said she felt it was sturdy. When she shook the side rail, the space between the mattress and side rail was wider. LVN S said she could see the potential for Resident #18 to get stuck in the side rail while trying to get out of bed. During an interview on 08/07/13 at 9:43 a.m., the DON said if the staff believed a resident would attempt to crawl over the side rails, side rails would not be used on that resident. During an observation and interview on 08/07/13 at 9:45 a.m., Resident #8 propelled himself down the hall in his wheelchair. The soft belt restraint was in place and tied behind his wheelchair. He said he did not know what it was and attempted to pull it off. He could not reach behind the wheelchair to untie the belt. During an interview on 08/07/13 at 3:37 p.m., LVN S said Resident #8 had side rails for safety because he had a history of [REDACTED]. 6. A Medication Review Report (physician order) August 2013 indicated Resident #14, admitted [DATE], [AGE] years old with [DIAGNOSES REDACTED]. Those orders indicated the resident was to have side rails up times two while in bed for mobility and a soft belt restraint on at all times while up in her wheelchair. The most recent MDS dated [DATE] indicated Resident #14 had cognitive impairment, required extensive assistance from two people for bed mobility and transfers, and was always incontinent of bowel and bladder. Resident #14 had no behaviors, did not wander, and did not resist care. Resident #14 used a wheel chair and had no physical restraints. A Pre-Restraining assessment dated [DATE] indicated Resident #14 was unsteady on her feet, loses her balance, and had a history of [REDACTED]. There was no recommendation for a soft belt restraint and no medical justification for the side rails. Treatment administration records dated May and June 2013 indicated Resident #14 had side rails initiated on 05/23/13. A treatment administration record dated July 2013 indicated Resident #14 had side rails and soft belt restraint. The soft belt restraint was initiated 07/29/13. A nursing care plan dated 07/25/13 indicated Resident #14 required side rails for safety due to the resident attempts to get out of bed and falls. The resident does not understand she cannot stand without assistance and the resident is unable to remember to call for assistance. A physician telephone order dated 07/29/13 indicated Resident #14 was to have a soft belt restraint while up in wheelchair. A nursing care plan dated 07/29/13 indicated Resident #14 required a soft belt restraint due to progressing dementia. The resident did not understand she could not stand without assistance. The resident was unable to remember to call for assistance and the resident was a danger to herself. A list of residents with side rails for mobility and side rails for safety provided on 08/05/13 did not indicate Resident #14 had side rails. During an observation on 08/05/13 at 9:58 a.m., Resident #14 was in bed asleep with one full side rail up to the outside of bed. During an observation and interview on 08/05/13 at 5:45 p.m., Resident #14 was in bed awake with full side rails up times two. Resident #14 said she could not get out of bed without help and had to wait until the nurses said it was okay. Resident #14 said she could not get the side rails down. During an observation on 08/05/13 at 6:05 p.m., Resident #14 was in bed eating dinner with the side rails up times two. During an observation on 08/06/13 at 9:30 a.m., Resident #14 was in the dining room in her wheelchair. Resident #14 had a soft belt restraint around her waist double-knotted to back of the wheel chair. During an observation and interview on 08/06/13 at 11:37 a.m., Resident #14 was in the dining room in her wheelchair. Resident #14 had the soft belt restraint around her waist double knotted to the back of the wheelchair. Resident #14 said she could not reach the back of her wheelchair to get the soft belt off and she had to wait for the nurses to take it off. During an interview on 08/06/13 at 3:50 p.m., LVN J said Resident #14 was weak and family requested the side rails for mobility. LVN J said the resident would not be able to get the soft belt restraint off or the side rails down and depended on staff to put down the side rails and take off the soft belt restraint. LVN J said she would consider the soft belt restraint and side rails a restraint if used for safety. During an observation on 08/07/13 at 9:25 a.m., Resident #14 was

Based on observation, interview, and record review, the facility failed to provide supervision and utilize assistance devices to prevent accidents for 7 of 23 residents reviewed for accidents. (Resident #s 6, 15, 17, 8, 36, 16, and 20) The staff utilized a soft belt restraint to prevent Resident #6 from getting out of his wheelchair. The staff was aware that Resident #6 was able to slide under the restraint as he had been found on the floor with the restraint around his chest numerous times. Resident #15 had side rails in use. She was able to crawl around the side rails to get out of bed. Resident #16 had uncontrollable body movements and full side rails in use. The padding of the rails would not stay in place and there was a gap between the mattress and side rail large enough to allow entrapment of a body part. The resident received multiple skin tears from the side rails. Residents #17, 36, and 8 had soft belt restraints in use while they were in their wheelchairs. The soft belt restraints were around the residents' rib cages and tied in the back of their wheelchairs. Resident #36 had side rails with a gap large enough to entrap a body part. Resident #20 had full side rails in use. There were no assessments or physician orders [REDACTED]. This facility did not ensure all residents reviewed for side rails and safety devices: * were safe from physical injury such as bruises and skin tears and potential injury such as fracture or suffocation by climbing over or around the side rails, wedging in between the side rail and the mattress, and not utilizing a personal alarm. * were re-assessed for side rail use after they were known to entrap themselves between the mattress and the side rail. * had physician orders [REDACTED]. * provide evidence less restrictive safety measures were attempted prior to utilizing side rails. An Immediate Jeopardy situation was identified on 08/07/13. The Immediate Jeopardy was removed on 08/08/13. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to ensure all in-service training was completed and evaluate the effectiveness of its corrective systems. This failure could place the 15 residents with lap belts and the 33 residents with side rails at risk for compression injuries, fractures, bruising, suffocation, or death. Findings included: 1. Physician orders [REDACTED]. The orders indicated the resident was to have a soft belt restraint for safety to prevent him from standing while he was up in his wheelchair. An MDS dated [DATE] indicated Resident #6's cognitive status as modified independence-some difficulty in new situations. The assessment indicated the resident needed the extensive assistance of one person for transfers and that trunk restraints were used daily. A nursing progress note dated 05/28/13 at 12:11 p.m. indicated Resident #6 was found by a CNA in his room, on the floor, with the wheelchair flipped over on him with his soft belt restraint in place. An incident report dated 05/28/2013 at 12:11 p.m. indicated Resident #6 was found by a CNA in his room with the wheelchair flipped over. A Comprehensive Care Plan dated 05/29/2013 (received 08/06/13) indicated Resident #6 had a need for a soft belt in his wheelchair due to progressing dementia and the resident did not understand that he was not supposed to stand without assistance. This care plan indicated the resident was a danger to himself. Care plans for Resident #6 dated May, June, July, and August 2013 indicated the soft belt restraint was used while the resident was up in his wheelchair for his safety. A nursing progress note dated 06/13/13 at 4:15 p.m. indicated Resident #6 had an un-witnessed fall out of his chair trying to get into bed and that he was halfway in wheelchair with one knee on the ground. The documentation did not reflect whether the soft belt was in place at this time. An incident report dated 06/13/13 at 3:30 p.m. indicated Resident #6 fell out of his chair trying to get into bed. The resident was still half way in the wheelchair, but one knee hit the ground. An incident report dated 07/08/13 at 1:02 p.m. indicated Resident #6 had an unwitnessed fall. The resident was found sitting on the floor in his room. The report indicated the resident slipped out of his wheel chair under his soft belt restraint. The report was signed by the administrator and DON. A nursing progress note dated 07/25/13 at 3:20 p.m. indicated Resident #6 had an un-witnessed fall and was found sitting on the floor in front of his wheelchair next to his bed. The resident said he wanted to get into his bed. The documentation did not reflect whether the soft belt restraint was in place at this time. A nursing progress note dated 07/30/13 at 5:12 p.m. indicated Resident #6 had an unwitnessed fall and was found lying on the floor in his room facing upwards. The documentation did not reflect whether the soft belt restraint was in place at this time. During an observation and interview on 08/05/13 at 10:35 a.m. Resident #6 was observed in a wheelchair with a soft belt restraint around his waist. The soft belt restraint was tied behind the resident's wheelchair, crisscrossed in the back and tied to the legs of the wheelchair, out of his reach. LVN J said the resident removed the soft belt restraint before and they had to reposition the ties behind the wheelchair to keep him from reaching the tie and releasing. She said the soft belt restraint was to keep him in his wheelchair to keep him from falling. During observations on the following dates Resident #6 was observed with the lap belt crisscrossed behind his wheelchair and tied to the legs of the wheelchair out of his reach: *8/5/13 at 11:55 a.m., *8/5/13 at 3:30 p.m., *8/6/13 at 11:58 a.m. *8/6/13 at 12:30 p.m. and *8/7/13 at 9:20 a.m. During an interview on 08/07/13 at 9:10 a.m. CNA M said Resident #6 wiggles out from under his soft belt restraint and slides to the floor. CNA M said that she had passed by his room once and found the resident halfway between the wheelchair and the floor with the soft belt restraint across the top of his chest. During an interview on 08/07/13 at 9:20 a.m. LVN J indicated Resident #6 wiggles and leans forward to get out of his soft belt restraint. The nurse said the resident had been found with the soft belt restraint around his chest while he was sitting on his wheelchair foot pedal. During an interview on 08/07/13 at 9:25 a.m. CNAs F and X indicated Resident #6 wiggles until he is able to get out of his soft belt restraint that was on the wheelchair. CNA F said Resident #6 has been found on the floor and in the bed after he got out of his wheelchair while the soft belt restraint was attached. CNA X said that Resident #6 was found in his room with his arms raised and caught up in the soft belt restraint. Both CNAs said they had found the resident on the floor out from under his soft belt restraint at least a dozen times or more. During an interview on 08/07/13 at 10:15 a.m. the DON said she was aware that Resident #6 was able to get loose from the soft lap belt, but she did not know how. The DON said she was aware that the soft belt restraint were being tied and placed out of the reach of the residents. The DON said if a resident kept getting out of their restraint, then there was a need to do try something else. The DON did not identify measures that were put into place to ensure the safety of Resident #6. During an observation on 08/07/13 at 9:30 a.m. Resident #6 was observed slipping his arm under the soft belt restraint, wiggling to the edge of his wheelchair and attempting to pull the soft belt restraint over his head to get out of the wheelchair. CNA X stopped Resident #6 and re-positioned him in his wheelchair after surveyor intervention. During an interview on 08/07/13 at 12:30 p.m., the administrator said she did not see how the soft belt restraints were a problem. She said the staff frequently monitored Resident #6. The current (undated) Restraint Policy indicated, "The use of restraints in the aging population impairs the quality of life, produces immobility and all of the associated complication, which contribute to and expedite mental and physical deterioration. Therefore, the medical staffs who practice at this facility have determined that no restraints will be used on any resident of this facility. " Soft belt manufacturer, JT Posey, Application Instruction Sheet, 2006, Warnings indicated, "...After applying a restrictive product, always monitor to make sure the patient is not able to slide down, or fall off the chair seat...f their body weight becomes suspended off the chair...chest compression and suffocation could result...Discontinue use immediately if the patient is able to slide forward or down underneath the device..." Application instructions: chair indicated, "Put the belt over the patient's lap...Bring the straps over the hips...Secure them... with a quick-release tie or buckle". 2. Physician orders [REDACTED]. Those orders indicated the resident was to have side rails on both sides of the bed for mobility. A pre-restraining assessment effective date 08/02/13 indicated Resident #15 was unsteady on her feet, loses balance, and has a history of falls. The assessment recommendations for restraints was side rails. A physician telephone order dated 08/02/13 indicated Resident #15 was to have side rails on both sides of her bed for bed mobility. A nursing care plan initiated on 08/05/13 did not address the use of side rails for Resident #15. The TARS for Resident #15 dated August 2013 indicated restrictive device was monitored every two hours. During an interview on 08/08/13 at 11:12 a.m., CNA P said Resident #15 would climb to the end of her bed and gets her leg caught between the bed and her side rail. During an interview on 08/08/13 at 9:25 a.m. the administrator said the beds and side rails had been in the facility since it opened, [AGE] years ago. She did not know if she could find the manufacturer's recommendations for the side rails, but would look. No manufacturer's recommendations for side rails were provided by the facility. "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment " accessed 8/13/13 via <http://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm 9.pdf> indicated, " ...FDA received approximately 691 entrapment reports over a period of [AGE] years from January 1, 1985, to January 1, 2006 ... These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly ... residents, especially those who are frail, confused, restless, or who have uncontrolled body movement ...Long-term care facilities reported the majority of the entrapments. " 3. Physician orders [REDACTED]. Those orders indicated the resident should have a soft belt restraint applied while up in the wheelchair for safety and side rails times two while in bed for safety. The most recent MDS dated [DATE] indicated Resident #17's cognitive skills were severely impaired, she required extensive assistance for bed mobility and transfers, was always incontinent of bowel and bladder, and used a trunk restraint daily. A nursing care plan dated 07/10/13 indicated Resident #17 required a soft belt restraint while in her wheelchair due to progressing dementia. It noted the resident did not understand she could not stand without assistance and resident was a danger to herself. The care plan had an initiation date of 08/14/12. The TARS for Resident #17 dated July and August 2013 indicated the soft belt restraint was used while the resident was up in wheelchair for safety and side rails were up times two while in bed for safety. During an observation and an interview on 08/05/13 at 11:00 a.m., Resident #17 was sitting in the dining room for an activity. The resident was slumped in her wheelchair and she had a soft belt restraint tight-fitting over her rib cage and under her axillary area that wrapped around the back of the wheelchair where it was tied in a double knot. LVN J said the residents were not supposed to get out of the restraints, but sometimes they do. She said Resident #17 had a soft belt restraint because she had a history of [REDACTED]. LVN J then repositioned Resident #17 in her wheelchair. During an observation on 08/05/13 at 4:17 p.m., Resident #17 was alone in her room with a soft belt restraint around her waist that was tied in a double knot behind the wheelchair out of the resident's reach. When the resident was asked about the belt and if she knew how to remove it, the resident did not respond. 4. A nursing care plan dated 07/29/13 indicated Resident #36, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. Resident #36 required a soft lap belt and side rails because of progressing dementia the resident does not understand that she cannot stand without assistance. She was weak and required assistance of two persons for transfers and does not walk. Resident #36 was indicated to be a danger to herself. The care plan indicated the resident could move around in bed, but did not attempt to crawl over the rails. During an observation on 8/5/13 at 4:00 p.m. Resident #36 was seated in her geri-chair at the assisted table in the dining room on unit 5. She had a soft belt restraint over her chest and under her arms that was double tied at the back of the chair. A list of residents with side rails for mobility and side rails for safety provided on 08/05/13 did not indicate Resident #36 had side rails. During an observation on 08/06/13 at 6:15 p.m., the maintenance supervisor measured three and three fourths inches between Resident #36's mattress and side rails. This space was large enough to allow entrapment of the resident's limbs. During an interview on 8/7/13 at 3:37 p.m. LVN S said Resident #36 had side rails for safety because she would roll off the bed and had a history of [REDACTED].#36's bed were shaky and believed there was enough space for the resident to get a limb or her head stuck between the side rails and mattress. 5. A physician orders [REDACTED]. The orders included an order for [REDACTED]. The orders also noted the resident should have a body alarm placed on the head of his bed and attached to his shirt at all times while in bed and side rails x 2 for mobility. A pre-restraining assessment dated [DATE] indicated Resident #8 required side rails for mobility at night. The care plan for use of the soft belt restraint initiated 01/03/12 indicated Resident #8 needed the soft belt restraint due to his progressing dementia including weakness and falls, loss of balance, a hip fracture, and he did not understand he could not stand without assistance. Staff interventions included: * check resident every hour, release and reposition every 2 hours for 10 minutes (included those seated in wheelchairs for extended periods of time. Get them up, out of the wheelchair and walk to the bathroom, transfer to bed to change diaper). * check with resident frequently to ascertain needs * exercises to maintain range of motion * keep call light and most frequently used personal items within reach * make sure resident attended activities and was provided with adequate stimulation. Resident #8's care plan for side rails initiated on 01/03/12 indicated the side rails were not used as a restraint, but were an aid in mobility, turning, and repositioning. Staff interventions were to check on the resident every hour for safety and to check with him frequently to ascertain his needs. The bed was to be placed in the lowest position before leaving the room. An incident report dated 06/24/13 7:37 p.m. indicated Resident #8 was found on the floor beside his bed. He denied pain, no injuries were noted, and he was able to move all 4 extremities without difficulty. The report indicated the resident made an attempt to get out of bed without staff assistance. The resident was assisted back to bed. The side rails were raised prior to the incident. Nursing notes dated 07/02/13 at 10:45 p.m. indicated Resident #8 continued to try to climb out of bed. An incident reported dated 07/05/13 at 11:28 p.m. indicated staff found Resident #8 with swelling and bruising to his right upper chest. The area was tender to touch and the resident cried out in pain as his right arm was lifted to check the injury. Bruising was also noted to the resident's right inner arm and left hand. The report indicated the resident said he fell . An x-ray report dated 07/05/13 indicated there was no fracture. The most recent MDS dated [DATE] indicated Resident #8 was moderately impaired in his cognitive skills for decision-making and required cues and supervision. His speech was clear and he had the ability to make himself understood as well as understand others. He was totally dependent on 2 staff for transfers. Resident #8 had limited range of motion in all of his extremities. He did not walk, but could propel himself around the unit in his wheelchair. The MDS indicated he used a trunk restraint in his chair or out of bed daily. A Restraint Reduction assessment dated [DATE] indicated Resident #8 was a good candidate for the use of a soft belt restraint. He attempted to stand from his wheelchair and was unable to weight bear. He had a history of [REDACTED]. The assessment indicated the resident did not need side rails, but he used them for mobility. He was unable to remember to call for assist and unable to understand he could not stand without multiple people to assist him. During an observation on 08/05/13 at 10:06 a.m., Resident #8 was self-propelling in his wheelchair. He had a soft belt restraint just above his waist, double-tied behind the wheelchair. During observations on 08/05/13 at 4:05 p.m. and at 6:00 p.m., Resident #8 was seated in his wheelchair at the dining room table with a soft belt restraint double-tied behind the wheelchair. During an interview on 08/05/13 at 6:00 p.m., CNA Q said Resident #8 wore the soft belt restraint to keep him safe. She said the resident would fall if he stood up. During an observation and interview on 08/06/13 at 9:07 a.m., Resident #8 propelled himself in his wheelchair. He wore a soft belt restraint just above his waist double tied behind the wheelchair. The resident said he did not know what it was and tried to lift it off. He was unable to reach behind the wheelchair to untie the soft belt restraint. During an interview on 08/06/13 at 3:00 p.m., the DON said Resident #8 had several falls. She said he wore a soft belt restraint because he reached over far enough to fall out of his wheelchair. The DON said when the resident was first admitted , he had a chair alarm and fell frequently, so they changed to the soft belt restraint. She said she saw him get out of his belt restraint before by lifting the belt over his head. During an observation and interview on0 8/06/13 at 3:30 p.m., Resident #8 was in his bed awake. The bed was against the wall. No side rail was up on that side. The full side rail was up on the side of the bed facing the door. Resident #8 thrashed around in bed and scooted half way down the mattress toward the end of the bed. He was confused and said he wanted help. The resident did not attempt to use the side rails for mobility. He used his feet and arms to scoot his body. The sign above his dresser indicated a bed alarm was to be attached to the bed and his shirt at all times while in bed. He was not wearing bed alarm. CNA Q said Resident #8 should have had the bed alarm on. When she applied the alarm, it only buzzed lightly. She said it should have sounded loudly and said the batteries needed to be replaced. She said the side rail was up to keep the resident from falling out of bed. CNA Q said with and without the side rails, the resident slid down in bed. She said she was told by staff the resident had fallen out of bed, but she did not observe it and did not know when it happened. CNA Q said she was told Resident#8 had tried to climb over the side rail. There was approximately 4 inches between the mattress and side rail. LVN S shook the side rail and said she felt it was sturdy. When she shook the side rail, the space between the mattress and side rail was wider. LVN S said she could see the potential for Resident #18 to get stuck in the side rail while trying to get out of bed by himself. During an interview on 08/07/13 at 9:43 a.m., the DON said if the staff believed a resident would attempt to crawl over the side rails, side rails would not be used on that resident. During an observation and interview on 08/07/13 at 9:45 a.m., Resident #8 propelled himself down the hall in his wheelchair. The soft belt restraint was in place and tied behind his wheelchair. He said he did not know what it was and attempted to pull it off. He could not reach behind the wheelchair to untie the belt. During an interview on 08/07/13 at 3:37 p.m., LVN S said Resident #8 had side rails for safety because he had a history of [REDACTED]. 6. physician's orders [REDACTED]. Resident #16's [DIAGNOSES REDACTED]. A physician order [REDACTED]. A nursing progress note dated 06/03/13 at 4:28 a.m. indicated that Resident #16 was hitting her right knee on the edge of her bed, resulting in a skin tear. A quarterly Minimum Data Set ((MDS) dated [DATE] for Resident #16 noted her cognition was severely impaired. Resident #16's functional status included the need for extensive assistance of one for her bed mobility, transfers, dressing, toilet use and locomotion. The resident was totally dependent for eating, personal hygiene, and bathing. A nursing progress note dated 06/23/13 at 8:47 p.m. indicated that Resident #16 was kicking her leg and scraping the top of her right foot on the side rail of the bed. A Comprehensive Care Plan dated 06/26/13 indicated the resident needed side rails due to excessive and uncontrolled movement. The date initiated was 10/17/11. A nursing progress note dated 6/30/13 at 9:31 a.m., indicated Resident #16 was seated in her wheelchair too close to her side rails and was found with multiple skin tears to both of her legs, a blister to top of her left foot, a skin tear to her left knee, a skin tear to her right shin, and a skin tear to top of her right foot. A nursing progress note dated 08/05/13 at 3:18 p.m., indicated that Resident #16 had a skin tear to her left shin. The resident could not tell them how it happened. During an observation and interview on 08/05/13 at 10:04 a.m., Resident #16 had full side rails up on each side of her bed. The side rails were padded, but the pad nearest the wall had fallen between the side rail and the mattress exposing the top half of the side rail. LVN J said that the side rails were for the resident's safety due to her [DIAGNOSES REDACTED]. The side rails were to keep the resident from falling out of the bed and the pads were to keep her from injuring herself when she was unable to control her movements. During an observation on 08/05/13 at 4:22 p.m., Resident #16 was in her bed and the side rails were up on both sides with pads. The side rail nearest the wall was halfway exposed due to the pad falling in the gap between the side rail and the mattress. During an observation and interview on 08/06/13 at 3:45 p.m., Resident #16 was in her bed with side rails up on both sides with pads. On the side of the bed closest to the wall, the pad had fallen between the resident's mattress and the side rail leaving the top of the railing exposed above the pad. The side rails were loose and wobbly. There was approximately 3 to 4 inches between the mattress and the side rail leaving a gap that could trap an arm or leg between the mattress and the side rail. LVN Z said it was difficult to keep the pad in place on the side of the resident's bed due to the space between the rail and the mattress. The undated Restraint Policy indicated, "The use of restraints in the aging population impairs the quality of life, produces immobility and all of the associated complication, which contribute to and expedite mental and physical deterioration. Therefore, the medical staffs who practice at this facility have determined that no restraints will be used on any resident of this facility. " The undated Policy and Procedure for Restraint Assessment, Reduction, and Consent indicated " Side rails are considered as a restraint if used as a minimal restraint for resident safety or as to treat a medical condition i.e. seizure disorder or involuntary movements. 7. A physician order [REDACTED]. Side rails and a soft belt restraint were not ordered. The most recent MDS dated [DATE] indicated Resident #20 required extensive assistance from one person for bed mobility and transfers. She sometimes understood others and made herself understood. Resident #20 did not reject care or wander. She used a wheelchair. She had no falls since her prior assessment. According to this assessment Resident #20 did not have any physical restraints. A nursing care plan dated 06/18/13 indicated Resident #20 was a wanderer and at risk for falls. There were no interventions for side rails or a soft belt restraint indicated. A list of residents with side rails for mobility and side rails for safety provided by the assistant administrator on 08/05/13 did not indicate Resident #20 had side rails. During an observation and interview on 08/06/13 at 3:30 p.m., Resident #20 was sitting up in bed fidgeting with her covers with two full side rails raised. LVN K said Resident #20 was confused and used the side rails for mobility. She said the resident could not ask to have the side rails let down and had not tried getting out of bed. The administrator and administrative assistant were notified on 08/07/13 at 10:35 a.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's revised Plan of Removal was accepted on 08/07/13 at 6:56 p.m. and included: " *the facility will be free of restraints with the exception being when a physician determines that the risks of restraints are outweighed by the benefits. *the 14 residents who have been utilizing soft belt devices would have an expedited reassessment and notify the physician(s) of the suggested least restrictive device. *within 1 hour Resident #6 was reassessed for need of least restrictive device from soft belt to Velcro seat belt with front closure and was being monitored every 2 hours by nursing staff. *the least restrictive device will be reassessed ongoing for at least the next 14 days for need and then at least every 90 days thereafter, as well as care planned. *all direct care staff will be immediately in-serviced on proper placement of least restrictive devices ... to be accomplished within 72 hours. *all other residents with devices would be reassessed for least restrictive device within 48 hours. *all devices would be care-planned and reassessed ongoing for at least the next 14 days and thereafter at least every 90 days for need and least restrictive device. *side rails will be used only for medically indicated residents and must be padded. Residents who request side rails for security must be mentally capable of making the request and be able to request that the side rails be lowered if desired. *residents with side rails will be assessed and care planned at least every 90 days for use or least restrictive device. " The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Five CNAs were interviewed and said they had been inserviced on 08/07/13 and 08/08/13 on restraints. They gave the definition of a restraint. Stated the facility was restraint free. They gave examples of restraints and indicated they were not responsible for assessing the residents for restraints. The CNAs listed risks of restraints and stated that a restraint would not be used in the facility. Two nurses were interviewed and said they had been inserviced on 08/07/13 and 08/08/13 on restraints. The explained what a restraint was and said the facility was restraint free. The nurses gave examples of restraints, reasons to use a restraint, and risks of restraints. Restraint reduction reassessments, physician orders, updated care plans, and nursing notes were reviewed on 20 residents. Physician orders [REDACTED]. The updated care plans indicated a restraint reduction reassessment had be done, what kind of least restrictive device would be used, and interventions for monitoring the resident. The nursing notes indicated a restraint reduction reassessment had been done, the restraint that was discontinued, the new least restrictive device that was being used, and the resident would be monitored. Eleven residents were observed for side rails use. The residents without medical need had no side rails in use. On 08/08/13 at 7:00 p.m., the administrator and assistant administrator were informed the IJ was removed; however, the facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to ensure all in-service training was completed and evaluate the effectiveness of the corrective systems. An undated list provided by the administrative assistant on 08/05/13 indicated 33 residents had side rails in use and 15 had soft belt restraints.

Based on observation, interview, and record review, the administrator and DON failed to ensure resources were managed effectively to provide care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 7 of 23 residents reviewed for restraints. (Resident #s 6, 15, 14, 20, 17, 18, and 8) The administrator and DON did not monitor restraint usages to ensure: *medical justification was in place for use, *the restraint was applied correctly, *a quick release could be accomplished in the event of an emergency, *the resident could self-release the restraint, *assessment for less restrictive device was completed, and *implement their restraint policy and procedures. The staff utilized a soft belt restraint to prevent Resident #6 from getting out of his wheelchair. The staff was aware that Resident #6 was able to slide under the restraint as he had been found on the floor with the restraint around his chest numerous times. Resident #15 had a soft belt restraint in use while in her wheelchair. She was able to pull the seatbelt over her chest and shoulders. Residents #17, 18, and 8 had soft belt restraints in use while they were in their wheelchairs. The soft belt restraints were around the residents' rib cages and tied in the back of their wheelchairs. Resident #14 had a soft belt restraint in use that was double tied in the back of her wheelchair and side rails for her bed due to attempts to get out of bed and falls. Resident #15 had side rails in use. She was able to crawl around the side rails to get out of bed. Resident #8 had side rails for bed mobility and a bed alarm while in bed for safety. Resident #20 had cognitive impairment and was fidgety in bed. She had full side rails in use. An Immediate Jeopardy situation was identified on 08/07/13. The Immediate Jeopardy was removed on 08/08/13. The facility remained out of compliance at a pattern of potential for more than minimal harm due to the facility's need to ensure all in-service training was completed and evaluate the effectiveness of its corrective systems. This failure could place the 15 residents with soft belt restraints and the 33 residents with side rails at risk of unnecessary restriction of movement, lack of staff supervision, and injury or death. Findings included: During an interview on 08/07/13 at 10:15 a.m., the DON said she was aware that residents were able to get loose from the soft belt restraint , but she did not know how. The DON said she was aware that the soft belt restraints were being tied and placed out of the reach of the residents. The DON said if a resident kept getting out of their restraint, then there was a need to do try something else. The DON did not identify measures that were put into place to ensure the safety of residents with the soft lap belt. During an interview on 08/07/13 at 12:30 p.m., the administrator said she did not see how the soft belt restraints were a problem that could lead to an immediate jeopardy. During an interview on 08/08/13 at 9:25 a.m. the administrator said the beds and side rails had been in the facility since it opened [AGE] years ago. She did not know if she could find the manufacturer's recommendations for the side rails, but would look. No manufacturer's recommendations for side rails were provided by the facility. 1. Physician orders [REDACTED]. The orders indicated the resident was to have a soft belt restraint for safety to prevent him from standing while he is up in his wheelchair. An MDS dated [DATE] indicated Resident #6's cognitive status as modified independence-some difficulty in new situations. The assessment indicated the resident needed the extensive assistance of one person for transfers and that trunk restraints were used daily. A nursing progress note dated 05/28/13 at 12:11 p.m. indicated Resident #6 was found by a CNA in his room, on the floor, with the wheelchair flipped over on him with his soft belt restraint in place. An incident report dated 05/28/13 at 12:11 p.m. indicated Resident #6 was found by a CNA in his room with the wheelchair flipped over. A Comprehensive Care Plan dated 05/29/13 (received 08/06/13) indicated Resident #6 had a need for a soft belt restraint in his wheelchair due to progressing dementia and the resident did not understand that he was not supposed to stand without assistance. This care plan indicated the resident was a danger to himself. The care plans for Resident #6 dated May, June, July, and August 2013 indicated the soft belt restraint was used while the resident was up in his wheelchair for his safety. A nursing progress note dated 06/13/13 at 4:15 p.m. indicated Resident #6 had an unwitnessed fall out of his chair trying to get into bed and that he was halfway in wheelchair with one knee on the ground. The documentation did not reflect whether the soft belt restraint was in place. An incident report dated 06/13/13 at 3:30 p.m. indicated Resident #6 fell out of his chair trying to get into bed. The resident was still halfway in the wheelchair, but one knee hit the ground. An incident report dated 07/08/13 at 1:02 p.m. indicated Resident #6 had an un-witnessed fall. The resident was found sitting on the floor in his room. The report indicated the resident slipped out of his wheel chair under his soft belt restraint. The report was signed by the administrator and DON. A nursing progress note dated 07/25/2013 at 3:20 p.m. indicated Resident #6 had an unwitnessed fall and was found sitting on the floor in front of his wheelchair next to his bed. The resident said he wanted to get into his bed. The documentation did not reflect whether the soft belt restraint was in place. A Pre-Restraining assessment dated [DATE] indicated Resident #6 had a recommendation for side rails and a soft belt restraint while in the wheelchair. The assessment had no medical justification for the side rails and soft belt restraint. A nursing progress note dated 07/30/13 at 5:12 p.m. indicated Resident #6 had an unwitnessed fall and was found lying on the floor in his room facing upwards. The documentation did not reflect whether the soft belt restraint was in place. During an observation and interview on 08/05/13 at 10:35 a.m., Resident #6 was in a wheelchair with a soft belt restraint around his waist. The soft belt restraint was tied behind the resident's wheelchair, crisscrossed in the back, and tied to the legs of the wheelchair, out of his reach. LVN J said the resident removed the soft belt restraint before and they had to reposition the ties behind the wheelchair to keep him from reaching the tie and releasing it. She said the soft belt restraint was to keep him in his wheelchair to keep him from falling. During observations on the following dates and times, Resident #6 was in his wheelchair with the soft belt restraint crisscrossed behind his wheelchair and tied to the wheelchair legs out of his reach: *08/05/13 at 11:55 a.m., *08/05/13 at 3:30 p.m., *08/06/13 at 11:58 a.m. *08/06/13 at 12:30 p.m., and *08/07/13 at 9:20 a.m. During an interview on 08/07/13 at 9:10 a.m., CNA M said Resident #6 wiggles out from under his soft belt restraint and slides to the floor. CNA M said she passed by his room once and found the resident halfway between the wheelchair and the floor with the soft belt restraint across the top of his chest. During an interview on 08/07/13 at 9:20 a.m., LVN J indicated Resident #6 wiggles and leans forward to get out of his soft belt restraint. The nurse said the resident had been found with the soft belt restraint around his chest while he was sitting on his wheelchair foot pedal. During an interview on 08/07/13 at 9:25 a.m., CNAs F and X indicated Resident #6 wiggles until he was able to get out of hissoft belt restraint that was on the wheelchair. CNA F said Resident #6 had been found on the floor and in the bed after he got out of his wheelchair while the soft belt restraint was attached. CNA X said Resident #6 was found in his room with his arms raised and caught up in the soft belt restraint . Both CNAs said they had found the resident on the floor out from under his soft belt restraint at least a dozen times or more. During an observation on 08/07/13 at 9:30 a.m., Resident #6 was slipping his arm under the soft belt restraint, wiggling to the edge of his wheelchair, and attempting to pull the soft belt restraint over his head to get out of the wheelchair. 2. Physician orders [REDACTED]. These orders indicated the resident was to have side rails on both sides of the bed for mobility and a soft belt restraint while in her wheelchair. A Pre-Restraining Assessment signed 08/05/13 indicated Resident #15 was unsteady on her feet, loses balance, and has a history of falls. The recommendations for a soft belt restraint indicated frequent re-direction and reminders to use the call light for help were alternatives to restraints used. The recommendations note indicated the resident required a soft belt restraint while in her wheelchair because she would not stay seated due to her confusion. The assessment had no medical justification for the side rails and soft belt restraint. A physician telephone order dated 08/02/13 indicated Resident #15 was to have side rails on both sides of her bed for bed mobility and a soft belt restraint while up in her wheelchair every shift. A nursing care plan initiated on 08/05/13 indicated Resident #15 required a seatbelt restraint due to a new [MEDICAL CONDITION] and dementia. The TARS for Resident #15 dated August 2013 indicated the soft belt restraint was used while the resident was up in wheelchair every shift. During an observation on 08/05/13 at 9:40 a.m., Resident #15 was sitting in her wheelchair in her room with a soft belt restraint across her waist. The restraint was wrapped around the back of the wheelchair and tied in a double knot. When the resident was asked if she could remove the belt, she nodded her head yes and attempted to reach around to the back of the wheelchair. At this time, the resident was unable to reach the knots tied on the back of the wheelchair legs. During an interview on 08/06/13 at 3:40 p.m., LVN H said Resident #15 was confused and had an unsteady gait. He said the resident has fallen once that he knew of since her admission on 08/02/13. LVN H said the resident would not be able to get the soft belt restraint off, and depends on staff to release it. He said he was not aware if the resident had removed the soft belt herself. LVN H said he would consider the soft belt a restraint. LVN H said the restraint would be released when the resident would go to the bathroom or to bed. During an observation and interview on 08/08/13 at 10:45 a.m., Resident #15 was sitting in her wheelchair with a seatbelt across her lap. The resident said she liked this belt much better than the soft belt. The resident's husband said his wife "gets out of everything" and was afraid she will fall. The resident's husband said he caught her pulling the soft belt over her shoulders one day and immediately called the nurses for help. The husband also said the resident has side rails on her bed, but she just crawls around them to get up. During an interview on 08/08/13 at 11:12 a.m., CNA P said Resident #15 would climb to the end of her bed and gets her leg caught between the bed and her side rail. 3. Physician orders [REDACTED]. Those orders indicated the resident should have a soft belt restraint applied while up in the wheelchair for safety and side rails times two while in bed for safety. A Pre-Restraining assessment dated [DATE] indicated Resident #17 had a recommendation for a soft belt restraint while in the wheelchair. The assessment indicated the resident was very confused due to dementia and had a history of [REDACTED]. The most recent MDS dated [DATE] indicated Resident #17's cognitive skills were severely impaired, she required extensive assistance for bed mobility and transfers, was always incontinent of bowel and bladder, and used a trunk restraint daily. A nursing care plan dated 07/10/13 indicated Resident #17 required a soft belt restraint while in her wheelchair due to progressing dementia. It noted the resident does not understand she cannot stand without assistance and resident was a danger to herself. The care plan had an initiation date of 08/14/12. The TARS for Resident #17 dated July and August 2013 indicated the soft belt restraint was used while the resident was up in wheelchair for safety and side rails were up times two while in bed for safety. During an observation and an interview on 08/05/13 at 11:00 a.m., Resident #17 was sitting in the dining room for an activity. The resident was slumped in her wheelchair and she had a soft belt restraint that was tight fitting over her rib cage and under her axillary area that wrapped around the back of the wheelchair where it was tied in a double knot. LVN J said the residents are not supposed to get out of the restraints, but sometimes they do. She said Resident #17 had a soft belt restraint because she had a history of [REDACTED]. LVN J then repositioned Resident #17 in her wheelchair. During an observation on 08/05/13 at 4:17 p.m., Resident #17 was alone in her room with a soft belt restraint around her waist that was tied in a double knot behind the wheelchair, out of the resident's reach. When the resident was asked about the belt and if she knew how to remove it, the resident did not respond. 4. Physician orders [REDACTED]. The orders indicated Resident #18 had a soft belt restraint applied at all times while in her wheel chair to be released and repositioned every 2 hours. The most recent MDS dated [DATE] indicated the resident had clear speech and was able to make she understood as well as the ability to understand others. No negative behaviors were reported. Resident #18 required extensive assistance of 1 staff for bed mobility and transfers. She did not walk and used a wheelchair to propel herself around the facility using her feet. She had 2 falls since her last assessment. A care plan for the need for a soft belt restraint in the wheelchair initiated 9/20/11 and reviewed 6/24/13 indicated Resident #18 was a danger to herself and did not understand she could not stand without assistance. Interventions included: *check the resident every hour, release and reposition every 2 hours for 10 minutes. (Include those sitting in wheelchair for extended periods of time. Get them up, out of the wheelchair and walk to the bathroom, transfer to bed to change diaper.) *check the resident frequently to ascertain needs *explain procedure to resident and family and discuss with them possible alternatives *provide verbal reminders to resident to call when assistance was needed. A care plan for fall risk dated 06/24/13 indicated staff interventions included use of a soft belt restraint while in the wheel chair as well as the chair alarm. A Restraint Reduction assessment dated [DATE] indicated Resident #18 leaned to the side, forward, and backward. She was partially weight-bearing with the assistance of 1 person. The resident had normal sitting balance and had a history of [REDACTED]. When she attempted to stand, she fell . The resident was not able to remember she was unable to stand or walk without help. Continue to use soft belt in wheelchair. During an observation on 08/05/13 at 4:00 p.m., Resident #18 was seated in her wheelchair at the dining room table. She had a soft belt restraint around her abdomen tied under the bottom of the wheelchair out of her reach. During an observation and interview on 08/05/13 at 5:50 p.m., Resident #18 finished dinner and was seated in her wheelchair in the common area near the nursing station. She had a soft belt restraint around her abdomen and tied in a double knot under her chair out of her reach. She said a long time ago, she untied it, but they tied it again. She said staff told her she had to keep it on and stay in the chair because she would fall. She said the belt was used to keep her safe. During an interview on 08/06/13 at 9:15 a.m., LVN T said Resident #18 had a history of [REDACTED]. During an interview on 08/06/13 at 2:00 p.m., Resident #18's husband said he was aware of the risks of using the soft belt restraint and signed consent for its use. He said the resident forgot to ask for help and stood up which resulted in falls. He said she was in the facility because she had so many falls at home and they could no longer monitor her. He said he told Resident #18 she needed to keep it on to keep her safe. During an interview on 08/07/13 at 4:45 p.m., Resident #18 was seated in her recliner in her room. She was alert and oriented. She said they changed the belt in her wheelchair to one that clasped in the front. She said the old soft belt restraint made her feel tied down. She said she was glad for the change. Resident #18 said she was aware she needed to stay safe in her wheelchair and needed to ask for assistance, but also was glad someone could get her out of the belt faster in case of an emergency. The resident did not know if she would be able to undo the new belt by herself. She was seated in her recliner and was not able to demonstrate whether or not she could release the belt. 5. Physician orders [REDACTED]. The orders included an order for [REDACTED]. A pre-restraining assessment dated [DATE] indicated Resident #8 required side rails for mobility at night. The assessment had no medical justification for the side rails. A care plan for use of a soft belt restraint initiated 01/03/12 indicated Resident #8 needed the soft belt restraint due to his progressing dementia including weakness and falls, loss of balance, a [MEDICAL CONDITION], and he did not understand he could not stand without assistance. Staff interventions included: *check resident every hour, release and reposition every 2 hours for 10 minutes (included those seated in wheelchairs for extended periods of time. Get them up, out of the wheelchair and walk to the bathroom, transfer to bed to change diaper). *check with resident frequently to ascertain needs. *exercises to maintain range of motion. *keep call light and most frequently used personal items within reach. *make sure resident attended activities and was provided with adequate stimulation. Resident #8's care plan for side rails initiated on 01/03/12 indicated the side rails were not used as a restraint, but were an aid in mobility, turning, and repositioning. Staff interventions were to check on the resident every hour for safety and to check with him frequently to ascertain his needs. The bed was to be placed in the lowest position before leaving the room. An incident report dated 06/24/13 at 7:37 p.m. indicated Resident #8 was found on the floor beside his bed. He denied pain, no injuries were noted, and he was able to move all 4 extremities without difficulty. The report indicated the resident made an attempt to get out of bed without staff assistance. The resident was assisted back to bed. The bed alarm, side rails, and call light were put in place. Nursing notes dated 07/02/13 at 10:45 p.m., indicated Resident #8 continued to try to climb out of bed. An incident reported dated 07/05/13 at 11:28 p.m., indicated staff found Resident #8 with swelling and bruising to his right upper chest. The area was tender to touch and the resident cried out in pain as his right arm was lifted to check the injury. Bruising was also noted to the resident's right inner arm and left hand. The report indicated the resident said he fell . An x-ray report dated 07/05/13 indicated there was no fracture. The most recent MDS dated [DATE] indicated Resident #8 was moderately impaired in his cognitive skills for decision-making and required cues and supervision. His speech was clear and he had the ability to make himself understood as well as understand others. He was totally dependent on 2 staff for transfers. Resident #8 had limited range of motion in all of his extremities. He did not walk, but could propel himself around the unit in his wheelchair. The MDS indicated he used a trunk restraint in his chair or out of bed daily. A Restraint Reduction assessment dated [DATE] indicated Resident #8 was a good candidate for the use of a soft belt restraint. He attempted to stand from his wheelchair and was unable to weight bear. He had a history of [REDACTED]. The assessment indicated the resident did not need side rails, but he used them for mobility. He was unable to remember to call for assist and unable to understand he could not stand without multiple people to assist him. There was no medical justification for the side rails or soft belt restraint. During an observation on 08/05/13 at 10:06 a.m., Resident #8 was self-propelling in his wheelchair. He had a soft belt restraint just above his waist, double-tied behind the wheelchair. During observations on 08/05/13 at 4:05 p.m. and at 6:00 p.m., Resident #8 was seated in his wheelchair at the dining room table with a soft belt restraint double-tied behind the wheelchair. During an interview on 08/05/13 at 6:00 p.m., CNA Q said Resident #8 wore the soft belt restraint to keep him safe. She said the resident would fall if he stood up. During an observation and interview on 08/06/13 at 9:07 a.m., Resident #8 propelled himself in his wheelchair. He wore a soft belt restraint just above his waist double tied behind the wheelchair. The resident said he did not know what it was and tried to lift it off. He was unable to reach behind the wheelchair to untie the belt. During an interview on 08/06/13 at 3:00 p.m., the DON said Resident #8 had several falls. She said he wore a soft belt restraint because he reached over far enough to fall out of his wheelchair. The DON said when the resident was first admitted , he had a chair alarm and fell frequently, so they changed to the soft belt restraint. She said she saw him get out of his belt restraint before by lifting the belt over his head. During an observation and interview on 08/06/13 at 3:30 p.m., Resident #8 was in his bed awake. The bed was against the wall. No side rail was up on that side. The full side rail was up on the side of the bed facing the door. Resident #8 thrashed around in bed and scooted half way down the mattress toward the end of the bed. He was confused and said he wanted help. The resident did not attempt to use the side rails for mobility. He used his feet and arms to scoot his body. She said the side rail was up to keep the resident from falling out of bed. CNA Q said with and without the side rails, the resident slid down in bed. She said she was told by staff the resident had fallen out of bed, but she did not observe it and did not know when it happened. CNA Q said she was told Resident#8 had tried to climb over the side rail. LVN S shook the side rail and said she felt it was sturdy. When she shook the side rail, the space between the mattress and side rail was wider. LVN S said she could see the potential for Resident #18 to get stuck in the side rail while trying to get out of bed. During an interview on 08/07/13 at 9:43 a.m., the DON said if the staff believed a resident would attempt to crawl over the side rails, side rails would not be used on that resident. During an observation and interview on 08/07/13 at 9:45 a.m., Resident #8 propelled himself down the hall in his wheelchair. The soft belt restraint was in place and tied behind his wheelchair. He said he did not know what it was and attempted to pull it off. He could not reach behind the wheelchair to untie the belt. During an interview on 08/07/13 at 3:37 p.m., LVN S said Resident #8 had side rails for safety because he had a history of [REDACTED]. 6. A medication review report August 2013 indicated Resident #14, admitted [DATE], [AGE] years old with [DIAGNOSES REDACTED]. Those orders indicated the resident was to have side rails up times two while in bed for mobility and a soft belt restraint on at all times while up in her wheelchair. The most recent MDS dated [DATE] indicated Resident #14 had cognitive impairment, required extensive assistance from two people for bed mobility and transfers, and was always incontinent of bowel and bladder. Resident #14 had no behaviors, did not wander, and did not resist care. Resident #14 used a wheel chair and had no physical restraints. A Pre-Restraining assessment dated [DATE] indicated Resident #14 was unsteady on her feet, loses her balance, and had a history of [REDACTED]. There was no recommendation for a soft belt restraint and no medical justification for the side rails. Treatment administration records dated May and June 2013 indicated Resident #14 had side rails initiated on 05/23/13. A treatment administration record dated July 2013 indicated Resident #14 had side rails and soft belt restraint. The soft belt restraint was initiated 07/29/13. A nursing care plan dated 07/25/13 indicated Resident #14 required side rails for safety due to the resident attempts to get out of bed and falls. The resident does not understand she cannot stand without assistance and the resident is unable to remember to call for assistance. A physician telephone order dated 07/29/13 indicated Resident #14 was to have a soft belt while up in wheelchair. A nursing care plan dated 07/29/13 indicated Resident #14 required a soft belt restraint due to progressing dementia. The resident did not understand she could not stand without assistance. The resident was unable to remember to call for assistance and the resident was a danger to herself. A list of residents with side rails for mobility and side rails for safety provided on 08/05/13 did not indicate Resident #14 had side rails. During an observation on 08/05/13 at 9:58 a.m., Resident #14 was in bed asleep with one full side rail up to the outside of bed. During an observation and interview on 08/05/13 at 5:45 p.m., Resident #14 was in bed awake with full side rails up times two. Resident #14 said she could not get out of bed without help and had to wait until the nurses said it was okay. Resident #14 said she could not get the side rails down. During an observation on 08/05/13 at 6:05 p.m., Resident #14 was in bed eating dinner with the side rails up times two. During an observation on 08/06/13 at 9:30 a.m., Resident #14 was in the dining room in her wheelchair. Resident #14 had a soft belt restraint around her waist double-knotted to back of the wheel chair. During an observation and interview on 08/06/13 at 11:37 a.m., Resident #14 was in the dining room in her wheelchair. Resident #14 had the soft belt restraint around her waist double knotted to the back of the wheelchair. Resident #14 said she could not reach the back of her wheelchair to get the soft belt off and she had to wait for the nurses to take it off. During an interview on 08/06/13 at 3:50 p.m., LVN J said Resident #14 was weak and family requested the side rails for mobility. LVN J said the resident would not be able to get the soft belt off or the side rails down and depended on staff to put down the side rails and take off the soft belt restraint. LVN J said she would consider the soft belt and side rails a restraint if used for safety. During an observation on 08/07/13 at 9:25 a.m., Resident #14 was in her bedroom in her wheelchair with the soft belt restraint around her waist tied in a bow to the back of the wheelchair out of her reach. During an observation on 08/08/13 at 1:30 p.m. Resident #14 was in bed with side rails up on both sides of the bed. 7. A physician order [REDACTED]. Side rails and a seat belt were not ordered. The most recent MDS dated [DATE] indicated Resident #20 required extensive assistance from one person for bed mobility and transfers. She sometimes understood others and made herself understood. Resident #20 did not reject care or wander. She used a wheelchair. She had no falls since her prior assessment. According to this assessment Resident #20 did not have any physical restraints. A nursing care plan dated 06/18/13 indicated Resident #20 was a wanderer and at risk for falls. There were no interventions for side rails or a seat belt indicated. A list of residents with side rails for mobility and side rails for safety provided by the assistant administrator on 08/05/13 did not indicate Resident #20 had side rails. A Pre-Restraining assessment dated [DATE] indicated Resident #20 had a recommendation for Posey rolls (a restraint belt which allows the person to roll side to side in bed) for bed parameters. There was no Pre-Restraining Assessment in the clinical record prior to 08/08/13. The assessment had no medical justification for the Posey rolls or side rails. During an observation and interview on 08/06/13 at 3:30 p.m. Resident #20 was sitting up in bed fidgeting with her covers with two full side rails raised. LVN K said Resident #20 was confused and used the side rails for mobility. She said the resident could not ask to have the side rails let down and had not tried getting out of bed. The current (undated) Restraint Policy indicated, "The use of restraints in the aging population impairs the quality of life, produces immobility and all of the associated complication, which contribute to and expedite mental and physical deterioration. Therefore, the medical staffs who practice at this facility have determined that no restraints will be used on any resident of this facility". Soft belt restraint manufacturer, JT Posey, Application Instruction Sheet, 2006, Warnings indicated, " ...After applying a restrictive product, always monitor to make sure the patient is not able to slide down, or fall off the chair seat ...If their body weight becomes suspended off the chair ... chest compression and suffocation could result ... Discontinue use immediately if the patient is able to slide forward or down underneath the device ... " Application instructions: chair indicated, " Put the belt over the patient's lap ...Bring