Every finding on record at Apostolic Christian Restmor

Based on interview and record review the facility failed to ensure a previously implemented fall intervention was in place to reduce the risk of a fall for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1 being transferred to the local area emergency room with a left forehead laceration, a left frontal scalp soft tissue hematoma, multiple skin tears and experiencing severe pain.Findings include: The facility's Fall Prevention Policy, dated 2/2025, documents Purpose: To provide as safe an environment as possible by taking measures to prevent falls to the extent possible. Policies: C. Every resident shall have safety measures included in the Care Plan from the time of admission. D. The Care Plan safety measures shall be revised as appropriate after a fall occurs and when deemed necessary by nursing. E. After every fall, the cause of the fall shall be determined if possible and measures taken to prevent a similar occurrence in the future. The Accident/Incident Policy, dated 3/2025, documents I. Definition: An incident is any unusual happening involving a resident or visitor. This includes falls with or without injury; injury with or without a fall.; behavior which involves danger or injury to self, another resident, employee, or visitors; wandering behavior that puts the resident or other residents in danger; any other happening not considered usual that may create a risk to resident, staff, visitor, or facility. L. Every accident/incident shall be investigated to attempt to determine cause. The nurse and the CNA (Certified Nursing Assistant) will complete an investigation for all falls. M. Following the investigation and with a probable cause of the fall is determined, recommendations to prevent a similar fall in the future shall be added to the care plan of the resident. The facility's Silent Bed Alarm Policy, dated 12/2024, documents I. Purpose: In conjunction with the fall management program, mobility monitors serve to alert the care giver that resident may need assistance. II. Policies: A. A silent bed alarm shall be used at the discretion of the admission nurse, charge nurse, clinical coordinator, Assistant Director of Nursing, or Director of Nursing after assessment of the resident indicates the resident is at risk for falls. B. A silent bed alarm consists of a box that is connected to the resident's call light system and a pressure sensitive pad that is placed on the mattress. G. It is important for the staff on the lanes to be aware of those residents with silent bed alarms and to respond to the call lights promptly. Resident safety is paramount to other duties. H. All silent bed alarms when triggered shall be interpreted as the resident communicating a need. Staff will make attempts to determine the need and provide assistance. I. It shall be the responsibility of each shift to make sure all silent bed alarms are properly connected and functioning. J. It will be the responsibility of the staff member placing the resident in bed or chair that the silent bed alarm is functioning properly by ensuring the green light is flashing and indicating the alarm is in use. III. Procedures: A. Determine the need for a silent bed alarm through fall risk evaluation. D. Check the proper function of the bed alarm by setting it off and observing that the call light turns on and the CNA's phone rings when the alarm is activated. R1's Face Sheet documents R1 admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Unspecified Dementia (moderate) with Anxiety, Chronic Kidney Disease (Stage 3), COPD (Chronic Obstructive Pulmonary Disease), Generalized Anxiety Disorder, Gastro-esophageal Reflux Disease, Hypertension, Personal History of Transient Ischemic Attack, and Age-Related Osteoporosis without current Pathological Fracture.R1's Fall Risk Assessment, dated 7/24/25, documents R1 is a high risk for falls. R1's current Care Plan documents Problem Start Date: 7/24/2023. Category: Falls. (R1) is at risk for falls related to impaired cognition and being impulsive and thinking that she is capable of doing more herself. Approach Start Date: 7/24/23: 1. Keep call light within reach. Instruct and encourage (R1) to use call light and wait for staff before getting out of bed or off toilet. 2. Keep most frequently used items and assistive devices within reach. 3. Ensure proper footwear is sworn before transfers- non-skin shoes, slippers, socks. 4. Keep room free of clutter. 5. Night light at night. 6. (Staff alerting bed alarm). Monitor for self-transfers and appropriate use of call light. Flowsheet: Fall Prevention. R1's Occurrence Report, dated 10/18/23 and signed by V4/RN (Registered Nurse), documents Description: (R1) found on the floor. Date/Time of Occurrence: Known, enter date/time: 10/18/23 at 3:30 AM. What was the resident trying to do when the fall occurred? Self-Transfer. Personal Alarm Ordered: yes. Resulted in: Laceration. Skin Tear. Taken to Hospital: Yes. Injury Site: Size: Approximately two-inch laceration at hairline left side of head. Skin tear left shoulder. Color: Bloody. Amount of Bleeding: Large. Body Part: head. Equipment: Bed alarm did not respond to (R1) getting out of bed. Care Plans: Equipment issue referred to Maintenance. New/Additional Fall Prevention Strategies Implemented: Other: Bed alarm replaced. What interventions or changes in routine were implemented by staff? Check bed alarm each shift. R1's Nurse Fall Investigation, dated 10/18/23 and signed by V4/RN, documents What happened: (R1) attempted to self-transfer. Where was the resident: In her room. Severity Level: Major Injury Laceration. Treatment: Sent to Emergency Department, attempted to stop the bleeding. Injury: Laceration to (R1's) head. After reviewing the investigation, what do you think was the cause: (R1) attempted to transfer-unable. Interventions: Replaced bed alarm due to not alarming. R1's Skin Integrity Events, dated 10/18/23 and signed by V4/RN, documents Description: Laceration left side of head at hairline. Type of Injury: Laceration. Location and Size of Skin Tear/Laceration: Approximately two-inch laceration. Depth of Skin Tear/Laceration: Moderate. Blood Loss- Note Amount and Control: Large Amount. Wound Edges: Irregular. Activity During Skin Tear/Laceration Occurrence: Fall. R1's Skin Integrity Events, dated 10/18/23 and signed by V4/RN documents R1 received a skin tear to the left shoulder related to the unwitnessed fall on 10/18/23. R1's Care Plan, dated 10/18/23, documents Problem Start Date: 7/24/2023. Category: Falls. (R1) is at risk for falls related to impaired cognition and being impulsive and thinking that she is capable of doing more herself. Approach Start Date: 10/18/23. 10/18/23 (R1) was found on the floor. Intervention bed alarm changed out as the pad was not working. R1's Census documents R1 had a hospital leave on 10/18/23 and didn't return to the facility from the local hospital until 10/23/25.R1's Medical Record did not include evidence of any other fall investigation with a root cause analysis (besides what was listed above) for R1's 10/18/23 fall. R1's Hospital Records, dated 10/18/23 documents Chief Complaint: Fall. Subjective: History of Present Illness: (R1) is a [AGE] year-old female patient sent to emergency room via Emergency Medical Services after unwitnessed fall. (R1) is from (local nursing home). Was found by nursing home staff on the floor next to her bed bleeding from her head with a large skin tear to her left shoulder and right arm. These same Hospital Records documented, Chest X-Ray, Bilateral Shoulder X-Rays, Left Elbow X- Rays, and Right-Hand X-Rays. Clinical History: Hypertensive former smoker with low blood pressure, altered mental status, and lacerations of the left shoulder and right arm status post fall. Narrative: Brain and Cervical Spine CT (Computed Tomography) without Intravenous Contrast. Findings: Small left frontal scalp soft tissue hematoma with probable overlying bandaging. Remainder of the scalp soft tissues are unremarkable. R1's Skin Integrity Events-Skin Ulcer Documentation, dated 10/23/23, documents Description: Left forehead large open wound. Dimension of Ulcer: 4cm (centimeters) x 2.5cm. Depth- Through the top layer of skin. Character of Wound bed: Other: Red, has blood and dried blood superior to open wound. Describe, if necessary: Depended wound is oval in shape, it has large open area. Surrounding tissue: Intact. Describe if necessary: superior skin was elevated appears to be a hematoma. Does the resident complain of pain at the site? Yes-Moans when dressed. R1's Skin Integrity Events, dated 10/23/23, documents Description: Skin tear left shoulder. Type of Injury: Skin Tear. Location and Size of Skin Tear/Laceration: Left shoulder 4.5cm x 3.5cm. Activity During Skin Tear/Laceration Occurrence: Fall.R1's Skin Integrity Events, dated 10/23/23, documents Description: Lower left leg. Type of Injury: Skin Tear. Location and Size of Skin Tear/Laceration: Lower Left Leg 1.5cm x 0.5cm. Activity during Skin Tear/Laceration Occurrence: Fall. R1's Skin Integrity Events: dated 10/23/23, documents Description: Three Skin Tears on Right Forearm. Type of Injury: Skin Tear. Location and Size of Skin Tear/Laceration: Cluster of three skin tears on right forearm. Bottom tear is 1.2cm x 0.4cm next skin tear is 90 degrees on the outer forearm it measures 2.5cm x 0.2cm and the third tear is parallel from dependent wound. This skin tear measures 1.7cm x 0.4cm. These three wounds have scabs on them but were created during the fall. Activity During Skin Tear/Laceration Occurrence: Fall. On 9/2/25 at 2:00 PM V6/R1's Family Member stated, I received a call from a nurse the morning of 10/18/23 notifying me that (R1) had fallen out of bed and that (R1) had a deep laceration to her left forehead and multiple skin tears. The nurse told me the bed alarm wasn't working properly so they were not alerted when (R1) was getting up on her own. It was then decided (R1) needed to go to the ER (Emergency Room) due to (R1's) deep laceration to her forehead and some loss of consciousness. V6 also stated when he arrived at the hospital, R1 was crying and experiencing severe pain. On 9/3/25 at 10:42 AM V4/RN stated R1's (staff alerting) bed alarm remained green while R1 was on the floor, but the alarm had never gone off when R1 had tried to get up from bed or had fallen. When R1 was transferred back onto the bed, the bed alarm remained green and still wasn't functioning properly. The alarm did not activate when we were moving her on or off the silent bed alarm. When paramedics arrived and transferred R1 from the bed to the gurney, the alarm then went off. The alarm was malfunctioning. V4 stated, When we would check the bed alarms on each shift, we (staff) would just look to see if the alarm was green. That typically meant they were working. If the alarm turned red, then that meant it wasn't working. We (or at least I) did not test the alarms any other way to determine if they were working properly or not. (R1) had a bed alarm in place for a fall precaution. (R1) had a large laceration observed to her left forehead with a large amount of blood surrounding (R1) on the floor. I also noticed a skin tear to (R1's) left shoulder. I called (V7/RN Supervisor) to come assist with transferring (R1) back to her bed. I then called (V5/R1's Family Member) first with no answer so then I called (V6/R1's Family Member) to let them know about (R1's) condition. (V7) then called (V8/R1's Primary Physician) to report (R1's) condition. It was determined after speaking to (V6) and then (V8) to send R1 out to the hospital due to the head laceration and her being lethargic. I did not get a chance to see if (R1) had any other skin tears at that time or measure any of the areas caused from the fall. On 9/3/25 at 11:47AM V7/RN Supervisor stated, (R1) was on the floor, and was observed to have had quite a bit of bleeding from (R1's) forehead. The blood had clotted and had stopped bleeding but there was a lot of blood on the floor surrounding (R1's) head. (R1) was lethargic at the time, kind of sleepy. I remember calling (V8/R1's Primary Physician) and letting them know what was going on and then getting (R1) sent out to the hospital. That was my focus because (R1) seemed injured. V7 also stated they (the facility) uses silent bed alarms for high-risk residents who fall to assist with fall prevention. On 9/2/25 at 2:01 PM V3/Director of Nursing stated any resident who is determined a high-risk fall, had fallen out of bed, or attempted to self-transfer would be placed on a silent bed alarm to help prevent falls, then the silent bed alarm would then be placed on the care plan for a fall intervention. V3 verified the only investigations from the fall the facility had was from V4/Registered Nurse who determined the root cause of the fall was the silent bed alarm had not been functioning properly when R1 got up, so staff were not alerted to get to R1 before R1 had fallen. V3 stated, The care plan intervention for (R1's) fall on 10/18/23 was to replace the malfunctioning bed alarm with a new alarm, so I am assuming the bed alarm was not functioning properly as it should. We (the facility) put in place around a year for staff to check the bed alarms each shift to ensure proper functioning, which include staff tapping on the bed alarm first to ensure the bed alarm beeps and is functioning properly prior to placing resident on the bed alarm.

Based on observation, interview, and record review the facility failed to perform facial grooming for one of one (R12) resident reviewed for activities of daily living in the sample of 30. Findings include: The facility's undated Residents' Rights and Responsibilities' policy documents Quality of Life: 7. The right to reside and receive services with reasonable accommodations of individual needs and preferences, except where the health or safety of the individual or other residents would be endangered. R12's Minimum Data Set/MDS Assessment, dated 1/23/25, documents R12 is cognitively intact and requires substantial/maximal staff assistance for personal hygiene. On 4/15/25, at 10:54am, R12 sat in her room with several long white chin whiskers. On 4/16/25, at 9:55am, R12 sat in her room with several long white chin whiskers noted. V25 Certified Nursing Assistant/CNA exited R12's room and stated that R12 just had a shower. On 4/16/25, at 9:58am, R12 stated that she knows she has chin whiskers and that they are long. I can feel them and don't like them. They make me feel uncomfortable. I want them to pull them out. R12 confirmed she just had a shower and that her chin whiskers were not groomed. On 4/16/25, at 10:05am, V25 CNA confirmed R12 has long chin whiskers and stated the following: A couple of weeks ago V25 left a note in report to the nurse about calling R12's family for them to get R12 a ladies razor since the other kind of razors hurt her. Unsure who the nurse was or if she did anything about it. I've been off two weeks after that. V25 said that (R12) was trying to pull them out and said, they are so pesky, and they keep coming back.

Based on observation, interview, and record review, the facility failed to ensure pressure relieving interventions were utilized as ordered for one (R44) of three residents reviewed with pressure ulcers in a sample of 30. Findings include: The Intensive Skin Care Program policy, dated 02/2003, documents The facility's purpose is to ensure residents with pressure ulcers receive necessary treatment and services to promote healing and prevent new sores from developing. All direct care staff shall receive education upon hire and annually thereafter regarding the prevention and treatment of pressure ulcers. Any individual at risk to develop a pressure ulcer should be placed on a pressure reducing device, such as foam, static air, alternating air, gel or water mattress. R44's Face Sheet documents R44 was admitted on [DATE] with diagnoses of Kyphosis, Lordosis and Compression Fracture of Lumbar Vertebra. R44's Progress Notes dated 9/6/24 documents R44 had an open area (pressure ulcer) on her spine from her bra rubbing. R44's current Care Plan for April 2025 documents an intervention for R44's pressure ulcer was to utilize a reactive air mattress (electric powered air pressure relieving mattress). On 4/15/25 at 10:35 AM, R44 was observed lying in bed and the reactive air mattress unit was not on and not functioning. On 4/15/25 at 11:25 AM, V6 (Licensed Practical Nurse) looked at R44's reactive air mattress unit, confirmed air mattress was not functioning, and was unsure how long it was not functioning. V6 stated I am not familiar with this unit and don't know how to use this mattress. I'll have to ask. On 4/15/25 at 11:45 AM, V7 (Maintenance) and V8 (Maintenance) confirmed R44's air mattress was not functioning and was not reported to him. V8 replaced R44's reactive air mattress unit and stated the prior unit was not functioning. On 4/18/24 at 10:25 AM, V3 (Chief Nursing Officer) confirmed the reactive air mattress should have been functioning and agreed the facility did not have a process in place to ensure the reactive air mattress units were functioning.

Based on observation, interview, and record review the facility failed to document skin changes for a resident on an anticoagulant with known bruises for one (R37) of five residents reviewed for skin conditions in a sample of 30. Findings include: The facility's Intensive Skin Care Program, dated 2/2023, documents II. Policy: D. A daily skin inspection will be done by direct care staff during cares and any new redness or discoloration, or discomfort will be reported to the charge nurse immediately, who will assess and make appropriate interventions according to protocol. The facility's Medical Records policy, dated April 2024, documents IV. Resident Medical Record: A. Records shall be kept current. Entries shall be written in ink or typed; shall be dated, signed, and shall include the profession or title of the person making the entry. B. 11. Periodic summary of resident's condition and status of nursing goals. R37's current Physician Order Sheet/POS documents an order for Eliquis 5mg (milligrams) twice per day. On 4/15/25, at 12:42pm, R37 was in bed. Multiple scattered deep purple bruised areas are on R37's right and left forearms. R37's Progress note, dated 1/31/25, documents There is scattered bruising on all extremities. No redness or breakdown noted. R37's clinical record has no further documentation of R37's scattered bruising to her upper extremities since 1/31/25. No documentation of specific sizes, locations, or description of R37's skin condition. On 4/17/25, at 11:15am, V12 Registered Nurse/RN stated that V12 is aware of R37's bruises and stated that R37 is on a blood thinner which can cause bruising. On 4/17/25, at 11:23am, V12 RN verified R37's bruises on her bilateral wrists and forearms. On 4/17/25, at 2:15pm V23 and V24 Certified Nursing Assistants both stated they had awareness of R37's current upper extremity bruises and that the nurses have been informed. R37's current Care plan for April 2025 does not document the current skin condition of multiple bruises on R37's upper extremities. On 4/18/25, at 2:00pm. V3 Chief Nursing Officer confirmed that the last documentation regarding R37's upper extremity bruising was on 1/31/25. V3 stated The nurses should have kept documenting on her bruises.

Based on observation, interview, and record review the facility failed to provide safe transfer for one (R1) of three residents reviewed for transfers in a sample of three. This failure resulted in R1 being sent out to the hospital and suffering from bruising, left elbow hematoma and a head laceration. Findings include: The facility's Fall Prevention policy, dated April 2024, documents Purpose: To provide as safe an environment as possible by taking measures to prevent falls to the extent possible. The facility's Lift Policy, dated January 2022, documents I. Purpose - To prevent injury to residents and staff during transfers and to reduce physical strain on staff .J. The Instruction manual for the lift shall be available at each care base for reference. The procedure for transfer with the lift outlined in the manual shall be followed. The facility's Instruction Manual for the (mechanical lift), undated, documents the following: Intended Use: 'Mechanical lift' shall always be handled by a trained caregiver and in accordance with the instructions outlined in these Operating and Product Care Instructions and To lift from a chair: Place the sling around the patient so that the base of his/her spine is covered, and the head support area is behind the head .Raise the patient by operating the handset control, move the lifter away from the chair then carefully lift the positioning handle until the patient is reclined in the sling - the head support will now come into use. R1's current Face sheet documents R1 has diagnosis including but not limited to Vascular Dementia, unspecified severity, with agitation and Anxiety Disorder. R1's Minimum Data Set/MDS assessment, dated 4/30/24, documents R1 is severely cognitively impaired, dependent on staff for all cares including transfers, and has no behaviors. R1's current Care plan documents R1 is at risk for falls related to her impaired cognition and aphasia as evidenced by R1's diagnosis of Vascular Dementia. R1's Care plan documents FALL ON (7/22/2024): Fall from lift. CAUSE: Poor core strength; Equipment placement. INTERVENTION: Stays of the sling will be positioned at mid back; Staff Inservice regarding (mechanical lifts) and sling placement. R1's Care plan also states R1 requires staff assistance with all of her ADL's (Activities of Daily Living) and Resident is full (mechanical lift) and (from) transfers to bed to complete toileting functions. R1's Progress Note, dated 7/22/24 and signed by V3 Assistant Director of Nursing, documents Called to resident's room at 12:30 for fall. Resident lying supine on floor, moderate amount of blood from posterior head. This note also documents R1 was transferred by ambulance to the local hospital at 1:37pm. R1's Event Report, dated 7/22/24, created by V2 Director of Nursing/DON documents the following: The occurrence was on 7/22/24, at 12:30pm. Resident unable to state what she was doing when the fall occurred due to impaired cognition and being nonverbal. Locomotion was with staff assist. Staff witness is (V7 Certified Nursing Assistant/CNA). This occurred in resident room during staff transfer, resulting in left elbow hematoma, posterior head laceration, and transfer to hospital ER (emergency room ). This same Event Report also documents Location/Condition/Statement/Event Scene: Called to residents' room at 12:30pm. Resident lying supine of floor. Staff report she was being transferred from (reclining) chair to bed via (mechanical lift) after lunch. When lifted from the chair, the resident extended her upper body and fell backwards out of the sling. Staff report the stays of the sling were positioned lower, and when she moved back, it seemed to aid in her falling out easier. Hit posterior head on the leg of the lift; Primary Cause: Sling placement; New/Additional Fall Prevention Strategies Implemented: Other (be specific) - Staff in-service regarding proper sling placement; and Description: Fall (7/22/24): fell from (mechanical lift), sling placed too low on back. When she extended back, it aided in her falling backwards from sling. Cause: Poor core strength. Equipment issue. Intervention: Stays of the sling will be positioned at mid back. R1's Event Report, dated 7/22/24, documents R1 has a left elbow hematoma and posterior head laceration. R1's Nurse Progress note, dated 7/22/24, documents Resident lying on floor, moderate amount of blood from posterior head. R1's Nurse Progress note, dated 7/23/24, documents bruising noted to R1's left arm and left inner leg. On 8/27/24, at 12:34pm, V7 Certified Nursing Assistant/CNA stated The (mechanical lift) sling slipped (R1) backwards while transferring (R1) from the (reclining) wheelchair to bed. I believe the sling was positioned under her incorrectly. The sling was already under (R1). V7 also stated Usually it (the sling) stays in position when in the wheelchair, but this time it was not. It was not far up enough behind her head and upper back. I determined that as I started lifting her up, then I realized. I started to bring her back down to put her in the chair and that's when it flipped her out. V7 stated that V7 should have made sure the sling was 100% positioned correctly. On 8/27/24, at 1:45pm, R1 sat quietly in a reclining wheelchair in her room with a mechanical lift sling underneath her. At this time, V9 and V10 CNAs hooked the sling to the mechanical lift, lifted R1 up, and transferred R1 to bed. During this time, R1, nonverbal and sitting still, appeared slightly anxious with eyes wide open; R1 was gripping V10's hand tightly. On 8/27/24, at 2:21pm, V2 Director of Nursing/DON stated the following The findings were that the lift sling was not positioned appropriately under (R1) at the time and her jerking movement caused her to fall out the back. Typically, the top of the sling is above the head, and I think it was positioned down too far. The stays are elongated plastic pieces that allows stability and for the sling to be positioned appropriately. Not sure if maybe (R1) had slid down on the sling while it was under her for a few hours while in the (reclining wheelchair) and the CNA (V7) maybe didn't notice that. V2 also stated (V7) should have ultimately checked placement (of the sling) under (R1) at the time to make sure it was positioned appropriately. We educated (V7) afterwards. On 8/27/24, at 2:40pm, V3 Assistant Director of Nursing/ADON stated the following: I got called to (R1's) room and (R1) had fallen out of the lift. I did most of the investigation. (V7 CNA) said that when (V7) was getting (R1) out of the (reclining) chair with the (mechanical lift), (V7) had (R1) lifted up when (R1) kind of jerked and slipped backwards out of the sling. When I got there the sling was still hooked up to the lift itself. V3 also stated I think the stays were positioned down too far by the top of her buttocks and usually the bottom of them should be at mid back. When she jerked and moved backwards, they kind of aided (R1) in pushing herself back. V3 stated that the sling was already under (R1) and that When hooking up to the lift we want them to pull up the back part of the sling, so the stays are positioned correctly at the back. (V7) should have done this before hooking it (R1's sling) up to the lift.

Based on observation, interview, and record review the facility failed to ensure resident fall interventions were in place and functioning for one of five (R34) residents reviewed for falls in a sample of 26. This failure resulted in R34 having falls and suffering from nasal bone fractures. Findings include: The facility's Fall Prevention policy, dated January 2024, documents Purpose: To provide as safe an environment as possible by taking measures to prevent falls to the extent possible. Policies: C. Every resident shall have safety measures included in the Care Plan from the time of admission. D. The Care Plan safety measures shall be revised as appropriate after a fall occurs and when deemed necessary by nursing. E. After every fall, the cause of the fall shall be determined if possible and measures taken to prevent a similar occurrence in the future. F. Every employee shall participate in fall prevention by observing and reporting safety hazards. R34's clinical record documents R34 is severely cognitively impaired with diagnoses including: Vascular Dementia, moderate, with behavioral disturbance, Unspecified Psychosis, Frontal Lobe Deficit following Subarachnoid Hemorrhage, Nontraumatic Subarachnoid Hemorrhage, Weakness, Neuritis, Ataxia, and Anxiety disorder. On 4/16/24, at 09:51am, R34 sat in her wheelchair with green and yellow bruising noted to both upper cheeks and across her nose. At this time, while feeding R34, V16 Registered Nurse/RN stated that R34 fell about a week ago and fractured her nasal bones. R34's current Care plan documents (R34) is a high fall risk related to Dementia with poor safety awareness, incontinence, medication side effects, need for assist with ADLs (Activities of Daily Living) and not always being receptive to assistance, combative at times, confusion and history of previous falls. This same Care Plan includes interventions of Provide resident with silent bed check (bed alarm) and Staff to anticipate her needs and support her when her silent bed check is alarming initiated on 12/29/22; and (R34) is to only have 1 pillow and 1 blanket in her room with an approach date of 4/8/24. R34's Fall Event Report, dated 2/7/24, documents R34's fall occurred in R34's room while ambulating with primary cause listed as bed alarm not alarming during time of fall. This report also states New/Additional Fall Prevention Strategies Implemented: Other (be specific) - new alarm pad. What interventions or changes in routine were implemented by staff? - Staff to check bed alarm and replace if needed. R34's Fall Event report, dated 4/6/24 by V6 Licensed Practical Nurse/LPN, documents the following: R34's fall occurred at 7:55pm, personal alarm is ordered and in use, fell while ambulating. Skin tear and possible facial fracture - await x-rays. Hematoma and skin tear bridge of nose. Last time resident observed 7:25pm in bed awake by V5 Memory Care Coordinator. V17 Certified Nurse Assistant/CNA heard a cry out and found (R34) on floor in small hallway between bathroom and closet. Three blankets noted on floor previously noted on recliner. Primary Cause: Resident carrying multiple blankets during ambulation. Care plans: Equipment issue (bed alarm not functioning) referred to Maintenance. Other - Bed alarm replaced and confirmed working status. New/additional fall prevention strategies implemented: Re-arrange furniture/reduce clutter in room. Interventions or changes in routine implemented by staff: Resident to have one pillow and one blanket in her room. Other - She has multiple blankets in her room, three were with her at the time of the fall, most likely she tripped over them. R34's radiology report, dated 4/7/24, documents: Intact orbits but nasal bone fracture with several components appearing depressed. On 4/17/24, at 12:23pm V11 CNA stated (R34) has a bed alarm so that we are aware of when she gets up and moving and we can assist her. At this time, V11 verified there are two bedspreads on (R34's) empty bed. V11 stated It is okay since she is not in the bed, it's so she doesn't have as much to get tangled up in. When she is in the room, we make sure things are in order. If we were to put her to bed, we would take one blanket off. On 4/17/24, at 1:30pm, V10 Director of Memory Care and V13 CNA toileted R34. V13 left the room then V10 assisted R34 to lay down in R34's bed. On 4/17/24, at 1:43pm, R34 was lying in bed with two bedspreads over her and one pillow under her head. Two Afghan blankets and one pillow were on R34's recliner. At this time V13 CNA verified that R34 has two blankets on her while in bed. V13 stated She is to have only one pillow and one blanket because she was wrapped up in them when she fell ; I think it was her personal blankets. V13 verified two Afghan blankets and one pillow were on R34's recliner in (R34's) room. On 4/17/24, at 1:47pm, V10 Director of Memory Support stated We felt that layers of blankets on (R34) attributed to her fall (on 4/6/24). The ones with her during the fall are heavier. We use lighter blankets on her now. As for a pillow, sometimes she has one and at times she needs two - depending on the position and angle she is in in her bed. (R34) is a hoarder and gathers blankets and things from her bed and chair. At this time V10 reviewed and confirmed that R34's Care plan states R34 is only to have one blanket and one pillow in her room and that (R34's) room should've had that now. V10 also stated It is very important to be sure R34's alarm is on when laying her down. You can hear it beep when she sits on it. Whoever lays her down should be sure it's working. On 4/17/24, between 2:10pm - 2:20pm, V5 Memory Care Coordinator stated that V5 put (R34) to bed prior to R34's fall on 4/6/24. V5 does not recall if there were items on (R34's) bed or recliner. (R34) had a bed alarm. It is under the sheets. I do remember seeing it. It turns on when she sits down. I don't remember hearing it. At this time V5 showed this writer the bed alarm device hanging on the wall behind R34's bed. V5 sat on the bed and the bed alarm device sounded in a short ring tone and a light turned green on the device. When V5 stood up the alarm alerted the nurse call system and the light on this bed alarm device turned red. V5 stated that V5 does not routinely pay attention to the alarm or whether it is functioning or not. I do not know why she has it. V5 also stated that when V5 put R34 to bed (on 4/6/24) V5 put just one fleece blanket on R34. There might have been another one on her recliner. It is possible for her to take a blanket from the chair. She hoards and gets fixated on things. On 4/17/24 at 5:10pm, V6 Licensed Practical Nurse/LPN stated, Basically, we spent a lot of time with (R34) throughout that night (4/6/24). She was restless. Later, a CNA (V17) alerted me that (R34) was on the floor. They said that (V5 Memory Care Coordinator) had assisted (R34) to lie down. When V17 went into (R34's) room and saw (R34) on the floor there were three blankets around (R34). (R34) picks them up and gathers them at times. They were throw blankets. They were on the floor around (R34). They would have been taken from (R34's) recliner chair. I know that because I saw them in that chair earlier, multiple times. (R34's) bed alarm was not sounding according to (V17). We tested it and it was not working. When (R34) lies down it will make a small sound, a beep. Typical protocol is to make sure it is working. I am not sure if it is inspected regularly. (R34) has the bed alarm to alert us when she is up. In a perfect world we would have been able to get to her sooner if it had been sounding. (R34's) bed alarm is a fall intervention to alert us that (R34) is up and so that (R34) doesn't have a fall .This fall's intervention is to have one pillow and one blanket in the room with (R34) when she is in bed, so she doesn't have the ability to gather blankets and fall again. (R34) commonly collects blankets and items. On 4/18/24, at 2:15pm, V2 Director of Nursing/DON confirmed that R34's bed alarm was not sounding during (R34's) falls on 2/7/24 and 4/6/24 and that (R34's) bed alarm is a fall prevention intervention. V2 stated the following: Depending on where staff were at the time of the fall it is possible for them to get into her room in time, but also depending on how fast R34 was moving. I reviewed (R34's) 4/6/24 fall investigation and was told that the blankets were last seen in the chair. V2 verified that R34's Care plan intervention (post 4/6/24 fall) is for one pillow and one blanket in the room - no extra. They are to remove extra blankets from her room and can't have any heavy blankets in there. I had told staff yesterday to remove them once (R34) was lying down. I guess staff didn't think the two Afghans could trip (R34) up. They should have removed them. R34's bed alarm should have been working. Personally, if I laid (R34) down I would check to make sure it was working. It beeps. It's hard to miss it. The idea of the bed alarm is to hopefully be able to get to the resident before they might fall.

Based on observation, interview, and record review, the facility failed to ensure dietary staff wrote the date on food packages that were newly opened. This failure has the potential to affect all 57 residents residing in the facility. Findings Include: The Department of Health and Human Services Centers for Medicare & Medicaid Services [CMS], CMS Form-671, dated 4/17/2024, document 57 residents reside in the facility. On 4/16/2024, at 9:30 a.m., an initial kitchen tour was conducted with V8/Dietary Staff. During the initial tour, the following frozen-packaged food items were open and undated: chicken wings, chicken strips, pizza topping, vegetable burgers, zucchini slices, carrots, mixed vegetables, and a case of raw biscuits. On 4/16/2024, at 9:30 a.m., V8 confirmed no dates were written on the items. On 4/16/2024, at 10:00 a.m., V7/Assistant Director of Dietary Services provided policies for the kitchen. V7 confirmed the policies do not address the dating of food items when they are opened and the opened food items should have been dated. V7 stated that policies will be reviewed and updated to reflect placing the date on food packages when they are opened.

Based on observation, interview, and record review the facility failed to prevent employee to resident abuse for one of two residents (R26) reviewed for abuse in the sample of 26. This failure resulted in V3 (CNA/Certified Nursing Assistant) rough handling R26 during cares, resulting in R26 crying and sustaining bruises, a hematoma, and pain to the left arm. Findings include: The facility's Abuse Prevention and Abuse Reporting policy dated 12/2017 documents, Purpose: To assure the prevention of mistreatment, neglect, or abuse of residents or misappropriation of residents' property to the extent it is in the control of the facility. Policy: Residents of this facility will be free from abuse, neglect, or misappropriation of resident property. Every employee who suspects abuse, neglect, or misappropriation of resident property will follow proper abuse investigation and reporting procedures in accordance with state and federal law. Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enable through the use of technology. Mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Mistreatment is defined as inappropriate treatment or exploitation of a resident. R26's MDS (Minimum Data Set) Assessments dated 11-13-22 and 2-13-23 document R26 is cognitively intact. R26's Progress Notes dated 1-3-23 at 2:19 PM and signed by V4 (RN/Registered Nurse Supervisor) document, (R26) reported to (V6/CNA/Certified Nursing Assistant) and nurse that other staff member (V3/CNA) was jerking resident around. (R26) showed staff member some bruising on her arm. Notifications made to (V1/Administrator), (V2/Director of Nursing), (V10/Social Service Director), (V12/R26's Power of Attorney), and (V13/R26's Physician). R26's Progress Notes dated 1-4-23 at 11:38 AM and signed by V5 (LPN/Licensed Practical Nurse) documents, (R26) has two circular bruises to mid anterior forearm quarter sized. The bruise that is closer to elbow is swollen slightly presenting a hematoma. Pain when touched with facial grimacing. Resident denies pain when it is not being touched. Another circular bruise to right mid anterior forearm also the size of a quarter. V3's Termination Checklist dated 1-3-23 documents, Termination Reason: Unsatisfactory performance. V11's (Director of Human Resources) typed statement dated 1-4-23 and included in V3's employee record documents V3 did provide rough handling to the resident (R26) by improperly rolling her over, which caused significant bruising to (R26's) arm and concerns that V3 was forcefully providing cares to residents who were declining them, which is a violation of their resident rights. On 03/21/23 at 9:45 AM R26 was lying in bed reading a book. R26 stated, A few months ago CNA/Certified Nursing Assistant (V3) jerked me by my arm and caused bruises. It hurt really bad. She was in a bad mood that day and was being rough. It hurt. I had turned her (V3) in for not giving me a bath and I think that was her (V3) way of getting back at me. I know the CNA was fired and no longer works here. On 03/21/23 at 01:00 PM V5 (LPN/Licensed Practical Nurse) stated, (R26) had reported to me that (V3) did not wash her up. I reported (V3's) concerns to (V8/Clinical Coordinator). A few days later I was helping (R26). (R26) was very upset and reported to me that (V3) had an attitude with her after (R26) had reported (V3) for not giving her a bath. (R26) told me that (V3) was rough with her and had grabbed her by the arm roughly and caused finger-print bruises to the left forearm. (R26) told me she felt very uncomfortable around (V3) and felt like (V3) was retaliating against her since (R26) had turned (V3) in for not giving her a bath. I had only worked with (V3) one day and the day I worked with (V3) she was very argumentative. 03/21/23 01:10 PM V8 (Clinical Coordinator) stated, (V5) had reported to me that (R26) said (V3) did not give her a bath. I spoke with (V3) and (V3) said she did give (R23) a bath and (R23) just probably forgot. I spoke with (R26), and she said (V3) did not give her a bath. (R26) is alert and orientated. On 03/21/23 at 1:15 PM V6 (CNA) stated, On (1-3-23) I was working day shift with (V3). That was the first day I had worked with (V3). (V3) was very argumentative with me that day and was upset because she did not get a break. (V3) was acting like she did not want to be here and was angry. I asked (V3) to wash up (R26). Around 10:00 AM or 10:30 AM (V3) was still complaining about not getting a break. I got fed up, so I told (V3) to just go take a break and we would handle the residents. I was tired of hearing (V3) complain. Me and V7 (CNA) went in to care for (R26) while (V3) was on break. When I entered (R26's) room, (R26) had tears and said that (V3) had grabbed her roughly by the arm. (R26) said she was in pain and had fingerprint fresh bruises to her left arm. (R26) said she did not want (V3) in her room anymore. I felt terrible that I had even asked (V3) to wash (R26) up. I immediately reported (R26's) bruises and allegations to (V4/Supervising RN). All I know is (V3) never did return from her break.

Based on interview and record review the facility failed to implement care plan goals and interventions for anticoagulant and antidiabetic medications for one resident (R41) of 26 (R41) in a sample of 26. Findings include: The facility's Interdisciplinary Care Plan policy, revised 08/11, documents to assure the provision of care to meet the needs identified in the comprehensive assessment of every resident to achieve and maintain optimal resident status. R41's current Physician Order Report documents to inject insulin glargine (antidiabetic) 32 units subcutaneous every night, for type 2 diabetes mellitus. This form also documents to take Apixaban (anticoagulant) 5 milligrams twice daily, for a history of venous thrombosis and embolism. R41's current care plan does not documents goals and interventions concerning the use of an anticoagulant or antidiabetic agent. On 3/23/23 at 9:30am, V2, Director of Nursing, verified that R41's care plan does not document goals and interventions for the use of an anticoagulant or antidiabetic agent. V2 stated that both medications should be addressed on the care plan.

Based on observation, interview, and record review the facility failed to ensure a resident with limited range of motion received individualized treatment and services based on their comprehensive assessment to maintain, improve or prevent further decrease in range of motion for two of 13 residents (R49, R26) reviewed for range of motion in a sample of 26. Findings include: A Restorative Nursing: Positioning and ROM (range of motion) for Nursing Assistants course dated 2022 states, Range of Motion, or ROM, and proper positioning are important for the well-being of the people you care for. Immobility causes muscles and tendons to shrink, limiting mobility and making joint movement painful. If immobility continues, a contracture will eventually form. Proper range of motion techniques can help prevent these from developing. 1. R49's Minimum Data Set (MDS) assessment dated [DATE] documents R49 requires extensive assistance of two people for bed mobility, transfers and personal hygiene but requires extensive assistance of one person for dressing and toilet use. This same MDS documents R49 has a functional limitation in range of motion to both lower extremities and requires the use of a wheelchair for mobility. In addition, R49's MDS documents that R49 does not receive any passive or active range of motion program/services to maintain or improve R39's range of motion; or to address R49's functional limitation to both lower extremities. R49's list of current diagnoses includes Osteoarthritis. R49's Contracture Risk assessment dated [DATE], documented by V15 (MDS/Care Plan Coordinator), documents that R49 is very limited in her ability to perform activities of daily living (ADLs) and has minimal hypertonicity or weakness. This assessment documents that R49 has the present joint condition of moderately limited but does not indicate which joints are included in this assessment. This same assessment documents that R49 has Connective Tissue Disorders such as Osteoarthritis which contribute to R49's contracture risk. In addition, this assessment documents that no referrals for services are necessary and that R49's current care plan will continue. R49's care plan dated 8/15/22 documents that R49 is at risk or has contractures related to Alzheimer's disease and poor mobility. This same care plan documents the goal of this care plan is to increase or maintain R49's current function. The care plan intervention to address R49's contracture risk and functional limitation in range of motion includes, ROM's daily per physician's order. R49's physician's orders sheet (POS) dated 2/20/23 to 3/20/23 does not include any orders for R49 to have a range of motion program. On 3/20/23 at 10:48a.m. R49 was in her room seated in a wheelchair and was able to answer questions appropriately. R49 stated that she is unable to stand or walk and uses her wheelchair to propel herself around the facility. R49 also stated the facility is not providing a range of motion program to maintain or improve her joint mobility. On 3/20/23 at 11:09a.m. V16 (Certified Nurse Aide/CNA) stated that she is a regular CNA on R49's hall. V16 stated that there is no specific ROM program or plan for providing ROM to specific joints for R49. When asked if she provides ROM to R49's hips because she is wheelchair bound, V16 stated that she usually just provides some general ROM to R49's arms and legs when she is dressing R49 in the morning. V16 stated she does not know what other CNAs do for R49 since there is no specific ROM program in place. 31682 2. R26's MDS (Minimum Data Set) Assessments dated 11-13-22 and 2-13-23 document R26 is cognitively intact, has functional limitations in range of motion to one side of the upper extremity and both sides of the lower extremities, and does not receive any restorative nursing programs to address R26's limitations in range of motion. R26's Contracture Risk assessment dated [DATE] documents R26 is at moderate risk of developing contractures. R26's Progress Notes dated 1-15-23 document R26 discussed with the rehabilitation aide request to discharge facility maintenance (restorative) program due to cost and R26's program would be discontinued. R26's Care Plan dated 3-1-23 documents R26 has impaired functional ability and mobility due to age, immobility, severe osteoarthritis, of multiple sites that impacts range of motion to bilateral lower extremities and bilateral upper extremities, weakness, arthralgias, history of falls, chronic pain, and a baker's cyst to the left knee. On 03/20/23 at 10:01 AM R26 stated, I have arthritis all over my body. I had an injury to my right shoulder and cannot lift my arms above my head. No one does exercises or therapy with me. R26 was lying in bed. R26's feet were contracted at the ankles and were facing outwards. R26 was unable to lift her arms above the chest level. On 03/20/23 at 10:05 AM V6 (Certified Nursing Assistant/CNA) stated, We (facility staff) do not do range of motion with (R26). I guess were probably should be. On 3/20/23 at 11:44a.m. and on 3/22/23 at 10:19a.m. V2 (Director of Nurses/DON) stated that residents are assessed for contractures using the Contracture Risk Assessment. V2 stated that if there are any problems found, the resident will be started on a range of motion program. V2 stated residents can also pay for a Functional Maintenance program which is priced at $10.00 per session. V2 stated, (R26) refused restorative programs because she did not want to pay the ten-dollar fee per session that the facility charges for restoratives. V2 also stated that R49's family declined to enroll R49 in the Functional Maintenance Program. On 3/21/23 at approximately 10:00a.m. V15 stated that CNAs provide some range of motion exercises to residents during cares. V15 stated there is no range of motion services provided based on individual resident's assessed needs, but instead, it is left up to the CNAs to determine how they will provide a resident with range of motion since they know the residents. V15 verified that R49 and R26's MDS assessment document that neither resident is receiving a ROM program. V15 stated that was because neither of these residents received a minimum of 15 minutes of ROM per day as is required by the MDS assessment in order to document that ROM was provided.

Based on observation, interview, and record review, the facility failed to ensure resident medications were administered as per Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in a medication error rate of 12 percent. Findings include: The facility's policy Medication Schedule, dated April 2008, documents, I. Purpose: To standardize a consistent, safe, and accurate schedule of medication administration throughout (named facility). II. Policies. F. All medications will be given according to the MEDICATION SCHEDULE, subject to change by the specific order of the Physician and recommendations according to categories listed below. This policy's MEDICATION SCHEDULE documents that medications ordered 'with meals' are to be scheduled at 8:00 am, 12 noon, and 5:00 pm. R14's POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] *Must be taken with meals* and Metamucil (Reguloid) capsule 0.52 gm (Grams) two capsules PO (orally) with Special Instructions: give 2 caps (capsules) with 8 oz (ounces) of liquid BID (twice a day). On 4-19-22, at 10:30am, R14 was in bed and stated that R14 just woke up (at 10:10am) and does not eat breakfast. On 4-19-22, at 10:40 am during medication pass, V4 Registered Nurse/RN administered the following medications to R14: [MEDICATION(S)] capsule 10mg (milligrams) one capsule PO (by mouth), Cranberry 450mg/Vitamin C one capsule PO, [MEDICATION(S)] capsule 3000 units one capsule PO, [MEDICATION(S)] 0.5mg one tablet, Reguloid capsule 0.52 gm (Grams) two capsules PO, Potassium Chloride micro tab 20 mEq (milliequivilents) ER (Extended Release) one capsule PO, and Vitamin C 500mg one PO. The medication blister packs of R14's Potassium Chloride ER and [MEDICATION(S)] included red pharmacy labels stating, Take with food, and R14's blister pack of Reguloid contained a red pharmacy label stating, Take with full glass of water. At this time all of R14's medications were given to R14 with approximately 120 ml (milliliters) (4 ounces) of water and no food. On 4-19-22, at 2:20 pm, V4 Registered Nurse/RN verified that the pharmacy labels on R14's Potassium Chloride ER and [MEDICATION(S)] blister packs state, Take with food and the Reguloid blister pack's pharmacy label states: Take with full glass of water. V4 verified V4 did not give these medications with food or with a full glass of water. V4 confirmed V4 gave them with 120ml of water and did not inform the resident to drink more water at the time the medications were given. V4 stated that (R14) doesn't eat breakfast and lunch is served around 11:30am. V14 stated that those two medications should be taken with food and that V4 should have given (R14) a full glass (8 ounces) of water.

Based on record review and interview, the facility failed to ensure foot pedals were applied to a wheelchair prior to transporting a resident, for one of three residents (R5) reviewed for falls in a sample of five. This failure resulted in R5 abruptly dropping his feet during wheelchair transport, causing R5 to fall forward, hitting his nose and sustaining a fracture of the nasal bone. Findings include: The facility policy titled Wheelchair Safety Policy (August 2016), documents Wheelchair Pedals: 1. Pedals will be applied to the wheelchair as needed for resident mobility, as designated in the care plan. 2. To prevent injuries, staff, volunteers, and visitors are discouraged from pushing a resident in a wheelchair unless they have front pedals. Instead, staff are encouraged to walk beside the resident. 3. Removing the wheelchair pedals prior to transferring the resident to and from the wheelchair can lessen the risk for skin tears. A Plan of Care, dated 7/13/21, documents R5 has the diagnoses of Right Sided [CONDITION(S)] and [CONDITION(S)] following a [CONDITION(S)], Muscle Weakness, Fatigue, and Stiffness of the Right and Left Ankles. The 7/13/21 Plan of Care identifies R5 as At risk for falls (related to) age, immobility, medications, Dementia, unsteady gait, intermittent confusion, needing extensive assist with (Activities of Daily Living) and a fall risk score of 15. A CNA (Certified Nursing Assistant) Fall Investigation, dated 8/02/21, documents R5 was, being pushed in (wheelchair), put foot down and fell on his nose. The CNA Fall Investigation further documents R5 as being transferred by staff down the hall and (R5) put feet down while being transported. A Nurse Fall Investigation, dated 8/02/21, documents (R5) was being transported to hair salon in facility (in wheelchair). He put his foot down and (tipped) over and (fell ). The 8/02/21 Nurse Fall Investigation documents Cause of fall: (Wheelchair) had no pedals. The conclusion at the end of the investigation documents, After reviewing the investigation, what do you think was the cause: Root Cause - No pedals were on the (wheelchair). Interventions: Place pedals when not self propelling. Nursing Progress Notes, dated 8/02/21, document nursing staff notified the Physician of R5's fall immediately after it occurred and a portable x-ray of the nose was ordered. A Portable X-ray Report, dated 8/02/21, documents, Reason: Contusion to nose; Swelling Bruising and Findings: Lateral view demonstrates contour deformity. Overlying soft tissue swelling. Impression: Findings suggest subtle nondisplaced fracture of the nasal bone. On 8/11/21 at 10:48 a.m., V13 (Volunteer) stated that on 8/02/21 he approached R5 to take him to the barber. V13 stated R5 was in his recliner at the time and asked a staff member to transfer R5 to his wheelchair. After the staff member transferred R5 to the wheelchair, V13 stated he asked the staff member (V13 could not recall who) if R5 needed foot pedals, and that staff member stated R5 did not need them. V13 stated as he was pushing R5 down the hallway, R5 abruptly put his feet down which caused R5 to fall forward onto his face. V13 stated R5 did have obvious injury and redness to his nose immediately after the fall. On 8/11/21 at 11:09 a.m., V14 (Therapy Aide) stated she was asked by V13 on the morning of 8/02/21 to transfer R5 from his recliner to his wheelchair. V14 stated R5 has right-sided weakness and requires staff assistance with a gait belt and walker to safely transfer. V14 stated R5 will usually self propel in his wheelchair, so the foot pedals were not on the wheelchair at that time. V14 could not recall if V13 directly asked if R5 had foot pedals at that time. When questioning V14 on her knowledge of the facility Wheelchair Safety Policy and the statement that staff, volunteers, and visitors are discouraged from pushing a resident in a wheelchair unless they have front pedals, V14 stated she was aware, but had forgotten. On 8/11/21 at 2:31 p.m., V4 (Assistant Director of Nursing) stated R5 does have pedals for his wheelchair; however, she believes V13 did not communicate with the staff that he would actually be transporting R5 in the wheelchair. V4 stated she is responsible for education in the facility and was unaware volunteers were transporting residents in wheelchairs, so they have had no formal training on wheelchair safety. V4 concluded that R5's wheelchair should have had foot pedals to elevate and rest his feet, if he was being transported by wheelchair.

Based on observation, interview and record review, the facility failed to implement a [CONDITION(S)] care plan with access site assessment and interventions for one of one resident (R147) reviewed for [CONDITION(S)] in a sample of 25. Findings include: A facility policy Baseline Care Plan Policy dated May 2019 documents: It is the policy of the facility to develop a baseline care plan with 48 hours of admission. Along with the baseline care plan is a summary of the care plan that is provided to the resident and representative in a language that can be understood. The objective is the completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. This policy further documents, D. Services and treatments to be administered by the facility and personnel acting on behalf of the facility. R147's face sheet documents an admitted [DATE] and R147's current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Every Shift 1-(7:00 a.m.- 3:00 p.m., Shift 2-3:00 p.m.-11:00 p.m., Shift 3-11:00 p.m.) - 7:00 a.m. (R147) has shunt in right arm for [CONDITION(S)]. On 5/17/2021 at 11:00 a.m., R147 was observed with a [CONDITION(S)] access site on her right arm. R147's Minimum Data Set (MDS) assessment dated [DATE], documents that R147 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), indicating she is cognitively intact, and that R147 receives [CONDITION(S)]. R147's current computerized Care Plan does not document a focus area for [CONDITION(S)] or treatment and care of the [CONDITION(S)] access site to R147's right arm. On 5/19/2021 at 2:00 p.m., V3 Assistant Director of Nursing (ADON) stated that the [CONDITION(S)] care plan for R147 got missed on admission and was not added until 5/19/2021. On 5/19/2021 at 2:10 p.m.,V2 Director of Nursing (DON) stated that a resident on [CONDITION(S)] should most definitely have a [CONDITION(S)] care plan.

Based on observation, interview and record review, the facility failed to follow the Centers for Disease Control and Prevention (CDC) guidance and the facility's COVID-19 staffing policies to identify and prepare a designated area with dedicated staff to care for and monitor residents with confirmed COVID-19. This has the potential to affect all 91 residents. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 12/11/2020 the facility remains out of compliance at a severity level two. The facility is still in the process of monitoring the effectiveness of adherence to COVID-19 policies. Findings include: The Centers for Disease Control and Protection (CDC) recommendations dated 5/13/2020, state People with COVID-19 have had a wide range of symptoms reported-ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to [MEDICAL CONDITION]. People with these symptoms may have COVID-19: Fever or chills; Cough; Shortness of breath or difficulty breathing; Fatigue; Muscle or body aches; Headache; New loss of taste or smell; Sore throat; Congestion or runny nose; Nausea or vomiting; Diarrhea. This list does not include all possible symptoms. CDC will continue to update this list as we learn more about COVID-19. The Centers for Disease Control and Protection recommendations dated 6/25/2020, state Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. Identify HCP (Healthcare Personnel) who will be assigned to work only on the COVID-19 care unit when it is in use. Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, implement use of Transmission-Based Precautions, prioritize for testing, transfer to COVID-19 unit if positive). A CDC Preparing for COVID-19 in Nursing Homes guidance updated 11/20/2020 states Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at risk of being affected by respiratory pathogens like COVID-19 and other pathogens. This guidance also states As demonstrated by the COVID-19 pandemic, a strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP). This policy further states, Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19, and Identify HCP who will be assigned to work only on the COVID-19 care unit when it is in use. The facility Emergency Staffing Plan for Coronavirus Disease 2019 (COVID-19) dated May 2020 documents To create a staffing model to manage positive cases(s) of COVID-19 in this facility. In the event this facility would have a positive case of COVID-19 in a resident, the following staffing plan will be implemented. 1. A predetermined, dedicated team of nurses and CNAs will be assembled who will serve in the COVID-19 designated area. No one on this team will float to other areas in the facility to work until the facility has resolved all positive cases in accordance with CDC and IDPH. The facility Infection Prevention and Control Policy for Suspected or Confirmed Coronavirus (COVID-19) dated July 2020 documents Coronavirus (COVID-19) is a respiratory illness that is primarily transmitted from person to person via large droplets generated by coughing and sneezing. Elderly individuals are at an increased risk of becoming infected due to compromised immunity and complicities. The usual signs and symptoms of COVID-19 are cough, fever, shortness of breath, and sore throat. This policy further states It is the policy of this facility to minimize exposures to respiratory pathogens and promptly identify residents with Clinical Features and an Epidemiologic risk for the COVID-19 and to adhere to Standard, Contact and Droplet Precautions, including the use of eye protection if necessary. A resident currently residing in the facility with known or suspected COVID-19, immediate infection prevention and control measures will be put into place, and further states In addition to these recommendations, any recommendations set forth by the local health department, state health department, and the CDC will also be followed. The policy also states The location of the COVID-19 care unit will be set up per facility plans and dedicated HCP will be providing care to these residents. If possible, these HCP will have a dedicated break room, restroom and work area that are separate from HCP working in the other areas of the facility. The facility Infection Prevention and Control Policy and Procedure for Coronavirus (COVID-19) Policy undated documents Coronavirus (COVID-19) is a respiratory illness that is primarily transmitted from person to person via droplets generated by coughing and sneezing. Elderly individuals are at an increased risk of becoming infected due to compromised immunity and comorbidities. The policy further states It is the policy of this facility to minimize exposures to respiratory pathogens and promptly identify residents with Clinical Features and an Epidemiologic Risk for COVID-19 and to adhere to Standard, Contact and Droplet Precautions, including the use of eye protection when necessary. For a resident currently residing in the facility with known or suspected COVID-19, immediate infection prevention and control measures will be implemented. and further states A Suspected COVID-19 Resident or Positive COVID-19 Resident Currently Residing in the Facility. Resident. 1) As a measure to limit HCP exposure and conserve PPE, this facility will designate a unit/area within the facility, with dedicated HCP, to care for residents with suspected or confirmed COVID-19, and further states Dedicated COVID-19 Unit HCP: 1) Dedicated HCP will have the proper training on infection prevention measures, including the use of and steps to properly put on and remove recommended PPE (gloves, eye protection, NIOSH-approved N95 or equivalent or higher-level respirator or face mask if respirator is not available, and gowns-See Attachment B), cleaning and disinfection policies and procedures, and specimen collection procedures. 2) Staffing needs will be met as the number of residents with suspected or confirmed COVID-19 infection increases and if HCP become ill are excluded from work. This policy further states Facilities and the COVID-19 Unit: 1) The location of the COVID-19 care unit will be set up per facility plans and dedicated HCP will be providing care to these residents. If possible, these HCP will have a dedicated break room, restroom and work area that separate from CP working in the other areas of the facility. The current facility floor plan highlights that {Hall A} is the designated COVID-19 wing and currently is full to capacity and the facility floor plan further highlights that there are five rooms on {Hall B} with positive COVID-19 residents (R1, R2, R3, R4, R5) and are being housed with 10 residents who have tested negative and additionally highlights that there are two rooms on {Hall C} with positive COVID-19 residents (R6, R7) and are being housed with 7 residents who have tested negative. The facility Surveillance Line List for COVID-19 Outbreaks documents that on 11/30/2020, R2, R3, R5, R6, R7 tested positive for COVID-19 and on 12/3/2020, R1 and R4 tested positive for COVID-19. The December staffing schedule documents that there is only one nurse scheduled on {Hall B} for each shift. The facility staffing assignment sheet dated December 6, 2020, documents that V8 (Registered Nurse) is the only nurse working on {Hall B} from 6:00 a.m. until 3:30 p.m., and V15 (Registered Nurse) is the only nurse working from 2:45 p.m. to 11:15 p.m. on {Hall B}. On 12/6/2020 at 10:15 a.m., V5 (Infection Control Nurse) stated that they currently have 24 residents in the facility positive with COVID-19. There is one designated COVID-19 unit on {Hall A}, but it is full and so now they have 7 additional residents who have tested positive for COVID-19 and five of those residents are still located on {Hall B} and the other two residents are still located on {Hall C}. {Hall B} and {Hall C} are not designated COVID-19 wings. {Hall B} currently has 10 residents who have tested negative for COVID-19 and {Hall C} has 7 residents who have tested negative for COVID-19. {Hall B} has only one nurse on the hall and she is taking care of both positive and negative COVID-19 residents. On 12/6/2020 at 10:45 a.m., V13 (Certified Nurse Assistant) stated that there are both positive COVID-19 residents on {Hall B} and she is taking care of the 10 residents who have tested negative and the nurse is taking care of all the residents on this hall, both positive and negative COVID-19 residents. On 12/6/2020 at 10:50 a.m., V14 (Certified Nurse Assistant) stated that she is only taking care of the residents on {Hall B} who are COVID-19 positive and that if the resident is more than a one person assist, she will ask someone for help, and that is usually the nurse. The nurse on this hall {Hall B} is taking care of both positive and negative COVID-19 residents. On 12/6/2020 at 11:45 a.m., V3 (Director of Nursing) stated, Some of our residents who tested positive didn't want to relocate to the designated COVID-19 wing and we felt it might be more detrimental to their mental state if we moved them, so we didn't move them and we put them in isolation and left them on a hall where there are residents who are still testing negative for COVID-19. We did not have a dedicated nurse on {Hall B} to care for just the COVID-19 positive residents. On 12/6/2020 at 12:35 p.m., V8 (Registered Nurse) stated that she is the only nurse on {Hall B} and that she is caring for both COVID-19 positive residents (R1, R2, R3, R4 and R5) as well as the residents (R8, R9, R10, R11, R12, R13, R14, R15, R16, and R17) who have tested negative for COVID-19 and that is how it has been since they started testing positive a few weeks ago. On 12/7/2020 at 9:56 a.m., V1 (Chief Operating Officer/COO) stated, Our designated unit on {Hall A} currently has 20 beds and that 17 of the beds were occupied as of Sunday 12/6/2020 and that the two beds that are available were male beds. There were no more beds on the designated COVID unit to place these other positive residents, so we had them remain on their halls where there are residents who have tested negative. All these recent positive cases began on 11/29/2020 and that is when the dedicated COVID unit on {Hall A} had reached capacity. V1 further stated, We have had positive and negative residents remain on {Hall B} and {Hall A} since 11/30/2020. On 12/8/2020 at 10:15 a.m., V1 stated, We still have both positive and negative residents on the same hall, {Hall B} and {Hall C}. They are so close to coming off of quarantine that we hate to move them just for a few days. On 12/9/2020 at 10:10 a.m., V10 (Contract Tracing Manager, Local Health Department) stated that services were offered to the facility to assist in setting up COVID-19 units, but she is not aware of them asking for their help to develop or give guidance or have them come in to review their system for setting up designated units and zones for isolating and quarantine residents with COVID-19. On 12/10/2020 at 10:30 a.m., V12 (Assistant Director of Nursing) verified that only one nurse was scheduled for the month of December on {Hall B} and that the nurse on {Hall B} is taking care of both positive COVID-19 residents as well as residents who have always tested negative for COVID-19 and further stated that there is not a dedicated nurse for the residents on {Hall B} on the 11:00 p.m. to 7:00 a.m. shift and that the nurse floats between {Hall D} and {Hall B}. V12 ADON stated that there are only negative COVID-19 residents on {Hall D}. The daily census report dated 12/6/2020 document that R1, R2, R3, R4, R5, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17 reside on {Hall B} and R6, R7, R18, R19, R20, R21, R22, R23 and R24 reside on {Hall C}. The daily census report dated 12/8/2020 document that R1, R2, R3, R4, R5, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17 continue to reside on {Hall B} and R6, R7, R18, R19, R20, R21, R22, R23 and R24 continue to reside on {Hall C}. The facility Census and Condition of Reports dated 12/9/2020 and signed by V12 ADON documents that at the time of the survey 91 residents resided in the facility. An Immediate Jeopardy was identified on 12/6/2020 at 1:00 p.m. The Immediate Jeopardy began on 11/30/2020 when the facility failed to remove COVID-19 positive residents from the units where COVID-19 negative residents reside as well as allow nurses on {Hall B} to continue to care for both positive COVID-19 and negative COVID-19 residents up until 12/10/2020. On 12/8/2020 at 10:45a.m., V1 was notified of the Immediate Jeopardy situation. On 12/11/2020 at 2:30 p.m., the surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V1 verified that all new and current positive COVID-19 residents are to be located on a designated COVID-19 unit. The facility floor plan documents the COVID-19 unit as {Hall A}. A current resident list documents that positive COVID-19 residents as of 12/11/2020 are located on {Hall A}. 2. V12 verified that only dedicated staff will be caring for positive COVID-19 residents on a designated COVID-19 unit. 3. V1 verified that he will be responsible for ensuring compliance with the dedicated COVID-19 unit and dedicated COVID-19 staff and that he will be given a daily report and ensure that the dedicated COVID-19 unit is appropriately staffed and that no staff will care for both positive COVID-19 residents and negative COVID-19 residents on their shifts. 4. V1 verified that effective immediately, any future residents who test positive for COVID-19 will be relocated on a designated COVID-19 wing and have dedicated staff that will only work with positive COVID-19 residents. 5. V1 verified that an additional COVID-19 wing will be designated and staffed with dedicated staff in the event the current COVID-19 wing reaches capacity.

Based on observation, interview, and record review the facility failed to document and obtain treatment for [REDACTED]. Findings include: The facility's Notification of Changes in Resident Status policy dated 02/2017 documents, Purpose: To assure that the physician, the resident, and/or the resident representative is informed in a timely manner of changes in the condition of the resident that may require physician attention or orders. If diarrhea and/or upset stomach condition persists over 24 hours, notify the physician, or acute onset of three or more episodes of loose stools. On 02/10/20 at 11:36 AM, R153 was sitting in her wheelchair. R153 stated, I have had diarrhea four times today. No one has done anything for it. On 02/11/20 at 09:30 AM, R153 was lying in bed and had her hand resting on her left abdomen. R153 stated, I have had diarrhea for two days now. Today I have had diarrhea three times already. I keep getting really bad cramping. I want them (the staff) to get me something for the diarrhea and let the doctor know. R153's Occupational Daily Treatment Note dated 2-11-20 documents, (R153) complains of diarrhea today and feeling low energy. R153's Progress Notes do not include any documentation of R153 having diarrhea or R153's Physician being notified of the need for treatment for [REDACTED]. On 02/11/20 at 9:40 AM, V5 (Certified Nursing Assistant) stated, I help (R153) to the bathroom. (R153) has been having diarrhea stools this morning. The nurse is aware. On 02/11/20 at 9:45 AM, V4 (Registered Nurse) stated, An employee in therapy informed me yesterday that (R153) had blood in her stool and was having diarrhea. I have not notified the physician or gotten a treatment for [REDACTED].

Based on interview and record review the facility failed to document the resident specific needs that could not be met, efforts to meet the resident specific need, a comprehensive care plan with goals addressing a resident's needs and a notice of involuntary discharge for one of five residents (R1) reviewed for discharge in a sample of five. Findings include: R1's medical record documents that R1 was admitted on [DATE]. R1 has a current medical [DIAGNOSES REDACTED]. R1's progress note dated 11/12/19 at 4:16 PM, documents: V8 (R1's physician/MD) stated that she is going to send (R1) to behavioral health hospital (BHH) for observation and treatment. It is understood that we have attempted multiple interventions that have not decreased (R1)'s behaviors. She is unpredictable with no known trigger to be identified. R1's progress note dated 11/12/19 at 4:30 PM, documents: (R1) was approached by V3 (Assistant Director of Nursing/ADON), verbally told resident that emergency medical service (EMS) was here to transport her for evaluation. R1's hospital clinical note dated 12/2/19 documents: Spoke to V2 (Director of Nursing/DON), the treatment team decided that they are formally discharging (R1) because the facility does not believe they are able to keep the other residents safe. V7 (Mental health clinician/MHC) informed (V2) that (R1) has not been aggressive towards other patients. R1's medical record does not include physician documentation of the specific resident needs that cannot be met by the facility, facility attempts to meet R1's needs and the services the receiving facility can provide to meet the needs of R1 which could not be met at the facility. R1's medical record does not document a comprehensive care plan with goals of the specific needs that facility could not meet or attempts to meet those needs, or a discharge summary which resulted in R1's involuntary discharge. On 12/10/19 at 8:00am, V7 stated the BHH did not receive physician documentation of the specific needs that could not be met, facility attempts to meet the resident needs and the services the receiving facility can provide to meet those needs. On 12/11/19 at 10:18 AM, V11 (Certified Nursing Assistant/CNA) stated that R1 has a history of refusing cares and staff normally has to walk on eggshells around her. V11 stated that R1's behaviors would get to the point where they would have to call V9 (Power of Attorney/POA) in to the facility to help with R1's cares. V11 stated that R1 would spit, yell and swing at staff and the behaviors have increased in frequency over the last six months to the point where it is every day. V11 stated that R1 has targeted other residents and started hitting them over the last couple of months. On 12/11/19 at 10:35 AM, V12 (CNA) stated that she has worked with R1 over the last [AGE] years and she has seen R1 go from being independent to having behaviors. V12 stated that a lot of times staff would have to come get her to help with R1's cares because R1 would listen to V12 and cooperate. V12 stated that over the last 6 months R1's behaviors have increased and become more frequent. V12 stated that R1's behaviors got to the point where she would not listen to her anymore. V12 stated that R1 would flip and without warning or justification start hitting, spitting and yelling at other residents and staff. On 12/11/19 at 11:00 AM, V6 (Clinical Coordinator/Registered Nurse/RN) stated that she would be called down to the unit when R1 started having increased behaviors. V6 stated that R1 would refuse to get changed and started to hit, spit, yell and scratch at staff and residents. V6 stated that she would add interventions for behavior in R1's care plan but it got to the point where the interventions were not working so V8 ordered [MEDICATION NAME] for R1. V6 stated they discussed with V8 on sending R1 in for evaluation and treatment when the [MEDICATION NAME] became ineffective. On 12/10/19 at 4:00pm V2 verified that there was no documentation in R1's medical record of the physician's recommendation, the specific needs the facility could not meet, the facility efforts to meet those needs, the specific services the receiving facility can provide to meet the needs of R1 which could not be met at the facility, a comprehensive care plan with goals addressing R1's behavior or resident specific needs, or a discharge summary which resulted in R1's involuntary discharge. V2 also verified that no documentation was provided to the BHH for R1 at the time of involuntary discharge on 12/2/19.

Based on interview and record review the facility failed to provide the ombudsman and resident's representative with written notice of involuntary discharge for one of five residents (R1) reviewed for discharge in a sample of five Findings include: The facility's Admission, Transfer, and Discharge policy dated (MONTH) (YEAR), documents If a termination and transfer or discharge by the facility is indicated, the resident and/or family members, resident representative, responsible party or guardian shall receive at least a 30-day written notice accompanied by a request for hearing form and self-addressed, stamped envelope of the regional health officer. R1's nursing progress note dated 11/12/19 documents R1 left facility via stretcher with at 4:40 pm to be evaluated at emergency room . R1's nursing progress note dated 11/15/19 documents daughter (V9) and power of attorney (POA) called on 11/13/19 and agreed to bed hold policy. R1's clinical records (behavioral health hospital) dated 12/2/19 at 7:58 am documents V2 (Director of Nursing/DON) is formally discharging (R1) and will notify V9 (POA). On 12/10/19 at 9:08 am V9 stated that on 11/15/19 she received a call that R1 was being sent to a behavioral health hospital for evaluation and treatment. V9 stated that she did not hear from facility administration until 12/2/19 when she received a call stating that R1 was being discharged from the facility. V9 stated that she did not receive any type of written notification and stated she felt the decision was unethical given that R1 had lived there for [AGE] years. V9 stated that on 12/8/19 she went to the facility to pick up R1's belongings because the facility had everything packed up for her. On 12/10/19 at 10:35 am V1 (Chief Operations Officer) stated We didn't see it as an involuntary discharge because V9 (POA) was in agreement to the discharge, but looking at it after the fact, we should have given (R1) a written notice of involuntary discharge. On 12/11/19 at 8:00am V10 (Ombudsman) stated the facility contacted his office asking if they should have given R1 a written notice of involuntary discharge prior to discharging R1. V10 stated that his office did not receive an involuntary notice of discharge for R1 and advised the facility that R1 should have been given a written notice of involuntary discharge prior to discharge.

Based on interview and record review, the facility failed to provide a written notification of bed hold to a resident's power of attorney for one (R1) of five residents reviewed for discharge in a sample of 5. Findings include: Facility Bedhold Policy dated (MONTH) (YEAR), documents: The resident or their representative must give notice of the intention to reserve a bed before or within 24 hours of the resident's discharge. Such notice shall be verified and filed by the Admissions Department in the resident's Admission file. A copy of facility Bedhold Policy will also be given at the time a resident exits for a therapeutic leave. Therapeutic leave is defined as a resident being out of the facility for greater than 24 hours. R1's progress note dated 11/12/19 at 4:16 PM, documents: V8 (R1's physician/MD) stated that she is going to send (R1) to behavioral health hospital (BHH) for observation and treatment. It is understood that we have attempted multiple interventions that have not decreased (R1)'s behaviors. She is unpredictable with no known trigger to be identified. R1's progress note dated 11/12/19 at 4:30 PM, documents: (R1) was approached by V3 (Assistant Director of Nursing/ADON) verbally told resident that emergency medical service (EMS) was here to transport her for evaluation. On 12/10/19 at 9:08 AM, V7 stated that she was never given any written information on the bedhold. On 12/10/19 at 11:20 AM, V4 (Social Services Director) verified that R1 and V7 were not provided with written notification of bed hold policy. On 12/10/19 at 3:05 PM, V2 (Director of Nursing/DON) verified that R1 and V7 were informed of the bed hold policy verbally and there was no written notification.

Based on observation, interview and record review, the facility failed to allow a resident to return to the facility following hospitalization for one (R1) of five residents reviewed for discharge in a sample of five. Findings include: R1's progress note dated 11/12/19 at 4:16 PM, documents: V8 (R1's physician/Facility MD) stated that she is going to send R1 to behavioral health hospital (BHH) for observation and treatment. It is understood that we have attempted multiple interventions that have not decreased (R1)'s behaviors. She is unpredictable with no known trigger to be identified. R1's progress note dated 11/12/19 at 4:30 PM, documents: (R1) was approached by V3 (Assistant Director of Nursing/ADON) verbally told resident that emergency medical service (EMS) was here to transport her for evaluation. R1's hospital clinical record dated 11/25/19 at 12:03 AM documents (R1) has not had any agitation or aggression noted. (R1) allowed staff to change her with no agitation or aggression towards staff during cares. R1's BHH records dated 11/25/19 at 9:30 am documents V9 (power of attorney/POA) discussed that facility will be here today to evaluate R1 and we anticipate discharge tomorrow. On 12/10/19 at 10:00 AM, V3 stated she was asked to go to the hospital (BHH) and assess R1 for discharge back to the facility. V3 stated that she went to the BHH the afternoon of 11/25/19 and assessed R1. V3 stated she reported her assessment back to V2 (Director of Nursing/DON) but did not document anything in R1's medical record. On 12/2/19 R1's BHH records documents: Spoke to V2 (DON), the treatment team decided that they are formally discharging (R1) because the facility does not believe they are able to keep the other residents safe. V7 (Mental health clinician/MHC), informed V2 that (R1) has not been aggressive towards other patients. On 12/3/19 R1's BHH record documents (R1) has been formally discharged from facility, V15 (psychiatrist/BHH MD) spoke with V8 (facility MD) for peer to peer meeting as requested by facility. V15 stated V8 had no objection to the plan for (R1)'s medication and that V8 expressed facility staff is concerned about the compliance with medication, rather than any specific medication. On 12/12/19 at 12:35 PM, R1 was observed sitting in chair in hallway with blanket draped over her. R1 was sitting quietly with eyes closed. V7 (Mental Health Clinician/MHC) stated that R1 is very polite and not a threat to the other residents. On 12/12/19 at 12:40 PM, V7 stated that V14 (Psychiatrist/BHH MD) and V15 both felt that R1 was safe to be around other residents and therefore appropriate to be discharged back to the facility on [DATE]. On 12/11/19 at 10:00 AM, V8 stated she spoke to V15 and was informed that R1 has not been taking her medication consistently and that she didn't have an issue with medication R1 was taking, but the inconsistency of taking them. V8 stated she told V15 that she felt R1 was not safe to return to the facility and that she had concerns about the safety of other residents On 12/12/19 at 12:35 PM, V7 stated that when V15 spoke to V8 back on 12/3/19, in his medical opinion, R1 did not pose a safety risk to other residents and R1 was appropriate to return to the facility. On 12/10/19 at 10:40 AM, V2 stated (V8) was in agreement of not accepting (R1) back due to her aggressive behavior and posing a risk to staff and other residents. V2 confirmed R1 was not allowed to return to the facility.

Based on observation, interview, and record review, the facility failed to complete a risk of entrapment assessment and attempt alternatives prior to initiating side rails for five of seven residents (R18, R22, R24, R26, R50) reviewed for side rails in the sample of 28. Findings include: The facility's Guide to Bed Safety, dated 10/2000, documents, Potential risks of bed rails may include: Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress; More serious injuries from falls when patients climb over rails. 1. On 3/12/18 at 8:30 AM, R18 was laying in bed with bilateral side rails in the upright position 2. On 3/11/19 at 10:55 AM, R22 had bilateral half side rails attached to R22's bed and in an upright position. 3. On 3/11/19 at 10:30 a.m. R24 and V7 (R24's family) were seated in R24's room. R24's bed had unpadded half side rails in the up position on each side of the bed. V7 stated that R24's side rails are up at all times on R24's bed. R24's physical restraint assessment (undated) documents that R24 has one-half bed rails to aid with bed mobility and transfers. This same assessment does not document what alternatives were tried prior to initiating the bed rails. On 3/14/19 at 10:40 a.m. V3 (Director of Nurses) stated that there is no documentation that alternatives were tried or individualized entrapment risks were assessed prior to initiating R24's side rails. 4. On 03/11/19 at 10:25 AM, two half upper side rails were attached to R26's bed and were secured in the up position. R26 pointed to the side rails and stated, Using them (side rails) is the only way I can maneuver in bed. I immediately requested them. I couldn't go without them. 5. On 03/11/19 at 03:43 PM R50's bed had bilateral half side rails attached and upright on R50's bed. R18, R22, R24, R26, and R50's medical records have no documentation of a risk of entrapment assessment being completed. On 3/14/19 at 10:00 a.m., V3 stated that residents using side rails do not have risk of entrapment assessments, including R18, R22, R24, R26, and R50.