Every finding on record at Brodie Ranch Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 3 of 5 residents (Residents #11, #73 and 103) reviewed for accidents.1. The facility failed to conduct a smoking safety evaluation for Residents #73 and 103 prior to survey entrance on 05/19/2026.2. The facility failed to address smoking in the care plan for Resident #73.These failures placed residents at risk of smoking-related and fall-related injuries. Review of the facility policy titled, Abuse: Prevention of and Prohibition Against, dated 10/2022, revealed, Because some cases of abuse are not directly observed, understanding resident outcomes of abuse can assist in identifying whether abuse is occurring or has occurred. Possible indicators of abuse include, but are not limited to: Bruises, skin tears and injuries of unknown source; Extensive injuries; Injuries in an unusual location; Occurrences, patterns, and trends that may constitute abuse; Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations. Review of the undated face sheet for Resident #73 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included type two diabetes mellitus (a disease that affects how the body uses blood sugar), chronic obstructive pulmonary disease (a long-term lung condition that causes airflow blockage and breathing difficulties), emphysema (a long-term lung condition that causes airflow blockage and breathing difficulties), muscle weakness, abnormalities of gait and mobility, lack of coordination, cognitive communication deficit (problems with communication due to impaired cognition), dementia, schizoaffective disorder (combination of schizophrenia and a mood disorder), and post-traumatic stress disorder.Review of the care plan for Resident #73 dated 05/20/2026 (the day after the recertification began) reflected the following: FOCUS(Resident #73) uses TobaccoGOALResident will Adhere to the Tobacco/Smoking Policies of the FacilityINTERVENTIONS-Educate Resident / Family on risks & health effects of tobacco use-Provide education regarding the adverse effects of smoking-Provide support to Resident Review of the admission MDS for Resident #73 dated 12/29/2025 reflected a BIMS score of 10, indicating a moderate cognitive impairment. It also reflected he did not use tobacco. Review of nursing assessments for Resident #73 reflected there was no smoking safety evaluation as of 05/19/2026. Review on 05/20/2026 reflected a smoking safety evaluation was added by RN I. It reflected he required supervised smoking (as all residents did at the facility) but had a low risk of injury. Review of nursing progress notes, incidents, and change in condition assessments for Resident #73 from January 2026 to 05/20/2026 reflected no report of smoking-related or other injury. Review of the undated face sheet for Resident #103 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included schizoaffective disorder bipolar type (combination of schizophrenia and a mood disorder), major depressive disorder, chronic obstructive pulmonary disease (a long-term lung condition that causes airflow blockage and breathing difficulties), epilepsy (seizure disorder), diabetes mellitus (disease causing difficulty processing blood sugar), polyneuropathy (loss of sensation and tingling in all extremities), rheumatoid arthritis (long-term autoimmune disorder that affects joints), anxiety disorder due to known physiological condition, repeated falls, muscle weakness, need for assistance with personal care, cognitive communication deficit (problems communicating due to cognitive impairment), unsteadiness on feet, lack of coordination, and abnormalities of gait and mobility. Review of the admission MDS for Resident #103 dated 12/09/2025 reflected a BIMS score of 13, indicating little or no cognitive impairment. It also reflected that she did not use tobacco currently. Review of the care plan for Resident #103 dated 10/02/2025 reflected the following: FOCUS(Resident #103 has Potential for a behavior problem r/t sitting on rollator off property and smoking. She goes to the nearby gas station to buy cigarettes; she sits out to smoke.GOALWill have fewer episodes by review date.INTERVENTIONS-Anticipate and meet needs.-Explain all procedures to before starting and allow to adjust to changes. Review of a physician progress note for Resident #103 dated 02/17/2026 reflected the following Patient is ambulatory with rolling walker aid. Patient is a current smoker, extensively educated patient on current health problems and risks from smoking, encouraged to quit but patient was adamant about not quitting. Review of nursing assessments for Resident #103 reflected there was no smoking safety evaluation until 05/19/2026. It reflected that she required supervised smoking (as all residents did at the facility) but had a low risk of injury. Review of nursing progress notes, incidents, and change in condition assessments for Resident #103 from January 2026 to 05/20/2026 reflected no report of smoking-related or other injury. Observation and interview on 05/19/2026 at 9:50 AM revealed Resident #73 lying in his bed. He stated that he was a smoker and had never been injured or felt unsafe smoking in the facility. Observation on 05/19/2026 at 1:00 PM revealed Resident #73 was seated in a chair in the outdoor smoking area and was smoking a cigarette. He was able to smoke without any obvious hazard to his person. The area was supervised by four staff members. Observation revealed Resident #103 was seated in her wheelchair and smoking a cigarette in the same area. She was able to smoke without any obvious hazard to her person. During an interview on 05/20/2026 at 10:09 AM, Resident #103 stated she had thought she might quit when she came here at first, but she started soon after she came here. She stated she had never had a smoking-related injury and felt safe smoking at the facility in the designated area. During an interview on 05/21/2026 at 3:28 PM, LPN F stated she sometimes conducted admission assessments but not often, as her hall was the long-term hall. She stated she had not seen a smoking safety assessment on every single admission checklist and did not know how the smoking evaluation got added to the admission assessments. She stated the residents who did smoke were supposed to have a smoking safety evaluation. During an interview on 05/21/2026 at 4:13 PM, the MDSN stated the admitting charge nurse should have done the smoking safety evaluation. She stated they had a morning meeting and that was where they discussed new residents who were smokers. She stated she did not think there was a process in place for a resident who entered the facility as a nonsmoker but decided to start smoking after they entered. During an interview on 05/21/2026 at 4:49 PM , the ADM stated he expected a smoking safety assessment to be completed for all smokers within 72 hours of admission. He stated if smoking was observed by staff after admission, he thought the care plan should be updated. He stated there was not a particular person whose role it was to update that information. He stated he did not know how they monitored for compliance with smoking safety evaluations and care planning. He stated the potential negative impact of not having a smoking safety evaluation or smoking on the care plan was burns. Review of facility policy dated 12/2023 and titled Smoking and Safety Measures reflected the following: It is the policy of this facility to provide a smoke-free environment for residents and staff. While our policy is to accommodate smoking opportunities, including the use of e-cigarettes, safety of our utmost concern. Therefore, smoking will be permitted only when the safety measures identified below are in place and followed. The policy did not include smoking safety evaluations or care planning.

Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 4 of 4 residents (Resident #10, Resident #12, Resident #55, and Resident #84) reviewed for resident rights. The facility failed to ensure that HS knocked on the doors of Resident #12, Resident #55, and Resident #84 when entering their rooms. The facility failed to ensure the privacy of Residents #12, #55, and #84 by not knocking before entering. The facility failed to ensure Resident #10 was dressed in his own clothing on 05/19/2026, 05/20/2026, and 05/21/2026. These failures placed residents at risk of poor self-esteem and feeling that their privacy was invaded. Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 3 of 3 residents (Resident #10, Resident #12, Resident #55, and Resident #84) reviewed for resident rights. The facility failed to ensure that HS knocked on the doors of Resident #12, Resident #55, and Resident #84 when entering their rooms. The facility failed to ensure the privacy of Residents #12, #55, and #84 by not knocking before entering. The facility failed to ensure Resident #10 was dressed in his own clothing on 05/19/2026, 05/20/2026, and 05/21/2026. These failures could place residents at risk of poor self-esteem and feeling that their privacy was invaded. Findings included: 1. Record review of Resident #12's face sheet, dated 05/21/2026, revealed a [AGE] year-old female admitted [DATE]. Resident #12 had diagnoses that included: Type 2 Diabetes with Neuropathy, Chronic Obstructive Pulmonary Disease (lung disease), and unspecified heart disease. Record review of Resident #12's admission MDS assessment, dated 03/18/2026, revealed Resident #12 did not have a BIMS score listed. Record review of Resident #12's care plan, dated 04/29/2026, did not reflect anything about privacy or knocking on the resident's door. Record review of Resident #55's face sheet, dated 05/19/2026, revealed a [AGE] year-old male, admitted [DATE] and readmitted [DATE]. Resident #55 had diagnoses that included: Legal Blindness, Type 2 Diabetes, and Chronic Obstructive Pulmonary Disease (heart disease). Record review of Resident #55's admission MDS assessment, dated 03/19/2026, revealed Resident #12 had a BIMS score of 12, which indicated moderate cognitive impairment. Record review of Resident #55's care plan, dated 04/13/2026, did not reflect anything about privacy or knocking on the resident's door. Record review of Resident #84's face sheet, dated 0/19/2026, revealed a [AGE] year-old male admitted [DATE]. Resident #84 had diagnoses that included: Type 2 Diabetes, chronic Obstructive Pulmonary Disease (heart disease), and kidney disease. Record review of Resident #84's admission MDS assessment, dated 05/06/2026, revealed Resident #84 had a BIMS score of 12, which indicated moderate cognitive impairment. Record review of Resident #84's care plan, dated 05/13/2026, did not reflect anything about privacy or knocking on the resident's door. During an observation on 05/19/2026 at 10:25 A.M., of HSWhen she was delivering clothes to residents in rooms [ROOM NUMBERS], she did not knock on the door to let the resident know that she was entering the room. During an interview on 05/19/2026 at 10:40 A.M., the HS stated if there's no one in the room, she doesn't knock on the door. The HS stated all staff were supposed to knock and notify residents before entering the room. The HS stated residents could be receiving care, and that if they don't knock, they could walk in on them. The HS stated it was a privacy issue when they did not knock before entering. The HS stated she received training on residents' privacy and that her most recent training was a month ago during a huddle before the shift started. During an interview on 05/21/2026 at 2:10 PM, the DON stated all staff should be knocking on residents' rooms before entering. The DON stated staff should knock on the door even if no one was in the room. The DON stated she had not seen any staff not knocking on the residents' doors. The DON stated if she saw staff not knocking on the door, she would pull them aside and remind them to knock. The DON stated that she could not remember when they had in-service training on privacy. The DON stated that the Assistant Director of Nursing conducted the training. The DON stated she was unaware of any negative outcomes for residents if staff did not knock on the door. During an interview on 05/21/2026 at 2:17 PM, the ADM stated all staff should knock on the door before going into a resident's room. The ADM stated if the staff's hands were full, they should announce their entry to the room. The ADM stated he had not seen any staff not knocking on doors and, if he did, he would correct the staff and provide in-service training. The ADM stated that if staff did not knock on the door, it could startle the residents and would not create a homelike environment. The ADM stated that they recently had in-service training on privacy on 5-18-2026. 2. Record review of the undated face sheet for Resident #10 reflected a [AGE] year-old male admitted [DATE]. His diagnoses included depression, cognitive communication deficit (problems with communication due to impaired cognition), muscle weakness, post-traumatic stress disorder, age-related physical debility, and chronic pain. Record review of the care plan for Resident #10, dated 04/20/2026, reflected the following: FOCUSADL Self Care Performance Deficit r/t age related physical debility, chronic pain syndrome, depression, muscle weaknessGOALWill maintain current level of function in Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene through the review date. Record review of the admission MDS assessment for Resident #10, dated 04/22/2026, reflected a BIMS score of 05, indicating a severe cognitive impairment. It also reflected he required substantial/maximal assistance in upper body dressing and was completely dependent on staff for lower body dressing. Record review of the dressing task for Resident #10, from 05/07/2026 to 05/21/2026, reflected he was dressed at 8:49 AM by CNA E and 17:03 PM on 05/19/2026 and 8:25 A.M. and 9:59 PM. Record review of OT notes for Resident #10, dated 05/20/2026, reflected the following: Patient demonstrates UB dressing tasks with Max a with cues for proper body mechanics and sequencing. Patient requires total a for LB dressing tasks with cues for log rolling and bridging. The note was signed by OT F at 5:46 PM on 05/20/2026. During observations on 05/19/2026 at 10:30 A.M. and 2:42 PM, Resident #10 was lying in his bed wearing a hospital gown. During an observation and interview on 05/20/2026 at 9:59 A.M., Resident #10 was lying in his bed with a hospital gown on. He stated he would like to put on his own shirt and pants, but he had not spoken with anyone about it. He stated no staff offered to help him change into his own shirt and pants. He stated he had shirts and pants in his drawer and closet. Observation revealed there were seven t-shirts hanging in his closet and four pairs of pants in his drawer. During an observation and interview on 05/21/2026 at 9:25 A.M., Resident #10 was lying in bed wearing a hospital gown. He stated the staff finally got him dressed in his own clothes the afternoon before but had not offered to help him dress that day. He stated they got him back in the hospital gown before he went to sleep the night before. During an observation on 05/21/2026 at 12:19 PM, Resident #10 was lying in bed in a hospital gown. During an interview on 05/21/2026 at 12:20 PM, CNA E stated she had worked on Resident #10's hall on 05/20/2026. She stated she had signed the dressing task in the POC system for the morning, but she could not remember if she dressed him in his own clothes. She stated when she saw him in the afternoon that day, he was in his clothes. She stated she did not know how he got dressed in his clothes. She stated she was not sure if she had asked him if he wanted to get dressed in his own clothes that morning when she documented that she had dressed him. She stated she was trained to offer to help residents dress in their own clothes, and she did not know why she did not assist Resident #10 on 05/20/2026. During an interview on 05/21/2026 at 12:29 PM, OT G stated she assisted Resident #10 in getting dressed on 05/20/2026 as part of his occupational therapy exercises. She stated she thought it was just before lunch that she helped him dress in his own clothes. She stated she would have expected residents to be assisted by CNAs in dressing in their own clothes by lunchtime, but sometimes residents refused to change. During an interview on 05/21/2026 at 3:28 PM, LPN F stated residents were supposed to be offered help dressing in regular clothes if they had them. She stated leaving them in hospital gowns did not maintain the residents' dignity. She stated this was supposed to be their home and no one would want to walk around their home in a backless hospital gown. She stated she monitored for compliance by doing rounds, but she did not work on the hall where Resident #10 lived. During an interview on 05/21/2026 at 4:49 PM, the ADM stated he expected residents to wear what they wanted to wear. He stated his expectation was if Resident #10 verbalized he wanted his clothes, then the aide should have helped him. He stated he expected staff to ask residents if they wanted to get dressed in regular clothes. He stated he monitored for compliance just by asking residents how they were doing and saying, Hey. He stated a potential negative impact on the resident of not being dressed in his own clothes was a dignity issue. Record review of the facility policy titled, Dignity Policy, dated 07/2017, revealed, As a resident of this nursing facility, you have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. You have the right to exercise your rights without interference, coercion, discrimination, or reprisal from the facility as a resident of the facility and as a citizen or resident of the United States. Staff are expected to knock and request permission before entering residents' rooms.

Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 11 residents (Resident #73) reviewed for comprehensive care plans. The facility failed to ensure Resident #73 was care planned for smoking and for compromised oral/dental status. This failure placed residents at risk of accident injury and not having nutritional needs met. Record review of the undated face sheet for Resident #73 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included type two diabetes mellitus (a disease that affects how the body uses blood sugar), chronic obstructive pulmonary disease (a long-term lung condition that causes airflow blockage and breathing difficulties), emphysema (a long-term lung condition that causes airflow blockage and breathing difficulties), muscle weakness, abnormalities of gait and mobility, lack of coordination, cognitive communication deficit (problems with communication due to impaired cognition), dementia, schizoaffective disorder (combination of schizophrenia and a mood disorder), and post-traumatic stress disorder. Record review of the admission MDS for Resident #73, dated 12/29/2025, reflected a BIMS score of 10, indicating a moderate cognitive impairment. It also reflected he did not use tobacco. Record review of the care plan for Resident #73, dated 05/20/2026 (the day after the recertification began), reflected the following: FOCUS(Resident #73) uses TobaccoGOALResident will Adhere to the Tobacco/Smoking Policies of the FacilityINTERVENTIONS-Educate Resident / Family on risks & health effects of tobacco use-Provide education regarding the adverse effects of smoking-Provide support to Resident The care plan also reflected the following, dated 01/07/2026 FOCUSHas nutritional problem or potential nutritional problemGOALWill maintain adequate nutritional status as evidenced by maintaining weight with no s/sx of malnutrition through review date.INTERVENTIONS-Honor resident rights to make personal dietary choices and provide dietary education as needed-Meals in dining room if resident is in agreement Observation and interview on 05/19/2026 at 9:50 AM revealed Resident #73 lying in his bed. He stated he only had a few teeth, and he really wanted dentures so he could eat better. He showed his mouth, and there were only three teeth visible on the top row. He stated that he smoked and had never been injured or felt unsafe smoking in the facility. Observation on 05/19/2026 at 1:00 PM revealed Resident #73 was seated in a chair in the outdoor smoking area and was smoking a cigarette. He was able to smoke without any obvious hazard to his person. The area was supervised by four staff members. During an interview on 05/21/2026 at 3:28 PM, LPN F stated she sometimes conducted admission assessments but not often, as her hall was the long-term hall. She stated she had not seen a smoking safety assessment on every single admission checklist and did not know how the smoking evaluation got added to the admission assessments. She stated the residents who did smoke were supposed to have a smoking safety evaluation. During an interview on 05/21/2026 at 4:13 PM, the MDSN stated the admitting charge nurse should have done the smoking safety evaluation. She stated they had a morning meeting and that was where they discussed new residents who smoked. She stated she did not think there was a process in place for a resident who entered the facility as a nonsmoker but decided to start smoking after they entered. She stated if a resident had a problem with their teeth, it should have been care planned under nutrition. She stated she did not have any role in completing Resident #73's admission assessments and paperwork, because she had only started in her role about three weeks prior. She stated a potential negative impact of not having care areas added tot eh care plan was the issue might not make it on the POC, and then the aides might not know they had to provide care. During an interview on 05/21/2026 at 4:49 PM , the ADM stated he expected a smoking safety assessment to be completed for all smokers within 72 hours of admission. He stated if smoking was observed by staff after admission, he thought the care plan should be updated. He stated there was not a particular person whose role it was to update that information. He stated he did not know how they monitored for compliance with smoking safety evaluations and care planning. He stated the potential negative impact of not having smoking on the care plan was burns and the potential negative impact of not having dental status on the care plan was weight loss. Record review of facility policy, dated 04/2025 and titled, Comprehensive Resident Centered Care Plan, reflected the following: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.

Based on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1of 3 residents (Resident #125) reviewed for incontinence care. The facility failed to ensure that :CNA C and CNA D handled personal care items with clean gloves while providing incontinent care for Resident #125. This failure could place the residents at the facility at risk of transmission of disease and infection.Findings included: Record review of Resident #125's face sheet, dated 05/20/26, reflected Resident #125 was admitted to the facility on [DATE]. Resident #125 was a [AGE] year-old female, diagnosed with type 2 diabetes, chronic kidney disease, muscle weakness, lack of coordination, cognitive communication deficit and major depressive disorder.Record review of Resident #125's quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating her cognition was intact. The MDS indicated that the Resident was dependent on one or more staff for personal hygiene. Record review of Resident #125's care plan dated 05/05/25 revealed she had ADL self-care performance deficit . The intervention was providing required ADL care. During an observation on 05/19/26 at 1:40 pm, CNA C and CNA D provided incontinent care to Resident #125. Both CNAs entered the resident's room, washed their hands, and donned disposable gloves. CNA C removed the soiled brief and cleaned Resident #125's front and back using wet wipes. However, she did so without changing her gloves after direct contact with feces, and she handled the wet wipe packet with the contaminated gloves. This action resulted in the contamination of the wipe packet. Subsequently, CNA C stored the contaminated packet, along with remaining wipes and other incontinent care items for Resident #125, in the drawer for future use.During an interview on 05/19/26 at 2:10 PM , CNA C requested a walk-through of the peri-care performed by her and CNA D to identify her errors. She stated that she should have changed her gloves at appropriate intervals and should not have handled the wet wipe packet with soiled gloves. CNA C expressed concern that her improper practices could facilitate the spread of infections. She noted that she had attended an in-service session a few weeks prior, which covered incontinent care and infection control protocols. She stated that she was nervous during the incident and inadvertently forgot to change her gloves before handling the wet wipe packet.In an interview on 05/19/26 at 1:55 pm , CNA D stated that she observed CNA C touching the wet wipe packet with contaminated gloves. She wanted to correct her but refrained from doing so in the presence of the HHSC surveyor, fearing it might be perceived as a violation of the survey process. CNA D stated that changing contaminated gloves before handling clean items was mandatory to prevent cross-contamination. She also stated that she attended a peri-care in-service a few weeks earlier with CNA C.During an interview on 05/21/26 at 3:45 PM, the DON stated that CNA C should not have handled the wet wipe packet with soiled gloves. She stated that both CNA C and CNA D were supposed to dispose of the contaminated wet wipe packet immediately rather than saving it for future use. The DON concluded that CNA C's improper practices increased the risk of disease transmission through contamination.Record review of facility policy Infection Control revised in March,2025 reflected : Policy:It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions. Procedure: Standard Precautions are infection prevention practices that apply to the care of all residents, regardless of suspected or confirmed infection or colonization status. They are based on the principle that all blood, body fluids, secretions, and excretions (except sweat) may contain transmissible infectious agents. Standard Precautions include:Proper selection and use of PPE, such as gowns, gloves, facemasks, respirators, and eye protection:Use and type of PPE is based on the predicted staff interaction with residents and the potential for exposure to blood, body fluids, or pathogens (e.g., gloves are worn when contact with blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated surfaces or equipment are anticipated).

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one of eight residents (Resident #11) reviewed for ??.The facility failed to report to Health and Human Services an injury of unknown origin that occurred on 04/15/2026 when Resident #11 had an unwitnessed fall with injury and could not tell staff what happened. This failure could place residents at risk of abuse, neglect, pain, and diminished quality of life.Findings included: Record review of Resident #11s face sheet, dated 01/05/26, revealed an [AGE] year-old female admitted [DATE]. She had diagnoses which included dementia (severe cognitive decline in memory, thinking, reasoning), Alzheimer's disease (progressive disease that destroys memory and other important mental function), unsteadiness on feet, lack of coordination, and heart disease. Record review of Resident #11's quarterly MDS assessment, dated 04/21/2026, revealed Resident #11 had a BIMS score of 03 indicating severe cognitive impairment. The MDS also revealed the resident had one fall since admission (the incident on 04/15/2026). The MDS also revealed that Resident #11 was dependent on staff for transfers. Record review of Resident #11's care plan, updated 04/16/2026, revealed, [Resident #11] had an actual fall with injury on 04/15/2026. Interventions were, Ensure resident is not left unsupervised in the room while in wheelchair. If the resident feels tired encourage her to rest in bed, as tolerated. The care plan also stated [Resident#11] is at risk of falls related to poor safety awareness, impaired mobility, weakness, Alzheimer's disease, dementia. The interventions was be sure the call light is within reach and encourage to use it to call for assistance when needed. Keep needed items, water, in reach. Record review of Resident #11's progress notes, dated 04/15/2026 at 11:00 a.m. by LPN G, stated, Resident was observed lying on the floor, face lying on the left side, and area was bleeding from the left side in room. Wheelchair was behind resident. 911 called. Assessment done. Vital signs taken. Resident able to move extremities and talking in Spanish as usual. Dressing applied toarea on left side of head. Vital signs taken. Laceration noted on left side of head and on left cheekbone. Son was called and notified and stated to send resident to the hospital. Record review of Resident #11's skin assessment, dated 04/15/2026, revealed, Laceration to left side of face with skin glue on it, side of head with 4 staples, bruising to left arm upper and lower, abrasion to left lower leg, swelling and bruising to left eye. During an interview with LPN G on 05/21/2026 at 1:48 p.m., she said she was the nurse on duty when Resident #11 was injured on 04/15/2026. She said Resident #11 had an unwitnessed fall and could not tell the staff what happened. She said the policy was to send the resident out for observation when the resident had an injury. She said Resident #11 returned from the hospital with a glue substance on her cheek and four staples in her head. She said Resident #11 did not say what happened. She said Resident #11 only spoke Spanish. She said she reported Resident #11's injury to the DON and the ADM. She said the DON was responsible for reporting the incident to Health and Human Services. She said the facility had a two-hour window to report. During an interview with the DON on 05/21/2026 at 1:53pm., she said she remembered the incident with Resident #11 on 04/15/2026. She said Resident #11 fell and hit her head. She said it was an unwitnessed fall. She said the resident could not tell the staff what happened. She said the policy for injury of unknown origin was the DON and ADM would talk about the incident and determine if it needed to be reported. She said the way she was laying on the floor was clear she had a fall. She said she knew she was supposed to report an injury of unknown origin, but the DON and ADM knew it was from a fall. She could not say how the DON and ADM knew the resident fell. She said she did not know how not reporting an injury of unknown origin could affect the residents. The DON then said Resident #11 had a roommate, but she could not say for sure the roommate saw Resident #11 fall. She said the DON and ADM knew Resident #11 fell so that was why they did not report the incident. During an interview with the ADM on 05/21/2026 at 2:00 p.m., he said he was responsible for reporting incidents to Health and Human Services. He said he was aware of a fall Resident #11 had on 04/15/2025 where she was sent out to the hospital. He said Resident #11 had an unwitnessed fall. He said the resident could not tell staff what happened. He said the nurse determined Resident #11 had a fall He said he would not consider Resident #11's incident an injury of unknown origin because he said Resident #11 had a history of falls. He said the DON talked to the roommate. He said he did not know if the roommate Resident #11 fell. He said he was supposed to report an injury of unknown origin within two hours. He said if there was an injury of unknown origin there could be an ongoing harm. He said he did not report Resident #11's incident because he did not find it suspicious and said the incident did not fit the criteria of injury of unknown origin. Record review of the facility policy titled, Abuse: Prevention of and Prohibition Against, dated 10/2022, revealed, Because some cases of abuse are not directly observed, understanding resident outcomes of abuse can assist in identifying whether abuse is occurring or has occurred. Possible indicators of abuse include, but are not limited to: Bruises, skin tears and injuries of unknown source; Extensive injuries; Injuries in an unusual location; Occurrences, patterns, and trends that may constitute abuse; Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.

Based on observation, interview, and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 2 (Residents #113 and 87) of 6 residents reviewed for PASARR.The facility failed to perform a new PASRR assessment on Resident #113 when he was newly diagnosed with bipolar disorder.The facility failed to refer Resident #87 for a level II PASRR evaluation despite her qualifying diagnosis of paranoid personality disorder.This failure could place residents at risk of not receiving the services and support needed.Findings Included: Record review of Resident #113's face sheet, dated 05/21/26, revealed a [AGE] year-old male admitted [DATE] with diagnoses that included chronic pain syndrome, need for assistance with personal care, vitamin D deficiency, cognitive communication deficit, major depressive disorder and bipolar disorder.Record review of Resident #113's annual MDS assessment, dated 03/13/26, revealed a BIMS score of 11 which indicated he had moderately impaired cognition. The MDS also indicated Bipolar Disorder and Depression were included in his active diagnoses. Record review of Resident#113's care plan completed on 03/30/26 revealed there was no care plan for Bipolar disorder or depression.Record review of Resident# 113's diagnoses revealed he had a diagnosis of bipolar disorder newly identified on 08/25/25.Record review of Resident #113's PASRR Level 1 assessment indicated that it was conducted on 10/08/20199, at which time the resident was noted to be negative for mental illness. Further record review indicated no subsequent PASRR assessments were performed following the diagnosis of bipolar disorder on 08/25/25.Record review of the undated face sheet for Resident #87 reflected a [AGE] year-old female admitted [DATE]. Her diagnoses included paranoid personality disorder (fear ) , generalized anxiety disorder, and dementia.Record review of the care plan for Resident #87, dated 10/02/2025, reflected the following: FOCUS(Resident #87) is at risk for impaired cognitive function or impaired thought processes related to personality disorderGOALWill maintain current level of cognitive function through the review date.INTERVENTIONSAdminister medications as ordered.Engage in simple, structured activities that avoid overly demanding tasks.Give step by step instructions one at a time as needed to support cognitive function.Keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion.Record review of the admission MDS assessment for Resident #87, dated 03/20/2026, reflected that she could or would not participate in the BIMS assessment, indicating severe cognitive impairment. It also reflected that she had verbal behaviors 1-3 times rejection of care behavior every day during the two-week review period. Record review of the PASRR level I evaluation for Resident #87, dated 10/01/2025, reflected she had a primary diagnosis of dementia and had no diagnosis of mental illness.During an observation and interview on 05/19/2026 at 9:44 A.M., Resident #87 was sitting in a dining chair in the corner of her room. She stated she knew someone was killing the children and putting poison in their breakfast cereal. She did not respond to efforts to redirect the interview.During an interview on 05/19/2026 at 2:03 PM, the LG for Resident #87 stated she had never thought about PASRR services for Resident #87 and thought they might be good for her.During an interview on 05/21/26 at 2:20 PM, the MDSN stated she was responsible for conducting PASRR assessments but was unable to locate a PASRR screening following Resident #113's new diagnosis. She stated she inadvertently missed PASRR assessment. The MDSN said that the absence of a new PASRR assessment due to the qualifying diagnosis could result in Resident#113 not receiving additional services to which he might be entitled. The MDSN stated she was new to the position and had also not review Resident #87's chart to see if she needed a PASRR referral.During a telephone interview on 05/21/26 at 3:10 pm, the NP stated she was not aware of Resident #113's bipolar diagnosis from 08/25/25. She reported she knew the resident well and observed no signs or symptoms consistent with bipolar disorder. The NP stated she was unaware of any medications the resident was taking for bipolar disorder and indicated she needed to verify whether the diagnosis was incorrect or if the resident missed treatment. She further stated that, given the current condition of Resident #113, she would not prescribe psychiatric medication for bipolar disorder, as there were no behavioral concerns with him at present.During an interview on 05/21/26 at 3:45 pm, the DON stated the MDSN should have identified residents with newly qualifying criteria that would necessitate a PASRR assessment by conducting appropriate screenings. The DON said that the impact of this negligence on Resident #113 was minimal, as he was receiving other psychiatric interventions. She stated she was unsure of the potential benefits Resident #113 might have missed if he tested positive for PASRR following his recent diagnosis.Record review of facility policy, dated 01/2022, titled, PASRR, reflected the following: Policy: The facility will designate an individual to follow up on ALL residents have received a PASRR Level I screening. If Facility serves a resident with a positive PASRR Level I screening, the facility MUST have obtained A PASRR Level II evaluation from the Local Authority or have a documented attempts to follow up with the Local Authority to obtain the PASRR Level II evaluation.Procedure: Nursing Individual MUST:A. Coordinate with referring entities to ensure that any person seeking admission to a Medicaid-Certified NF received a PASRR Level I screening for an intellectual disability (ID), related condition (DD) also know as developmental disability or mental illness (MI) prior t or upon admissionB. Coordinate with the local Intellectual/ Development Disability and/or Local Mental Health Authority (Local Authority) to ensure a PASRR Level II Evaluation is conducted when an individual 's PASRR Level I screening indicates the individual may have an ID, DD, or MI.C. Coordinate with the local authority to ensure that the individual is properly assessed for any specialized services recommended in the Level II evaluation as being needed when a determination of ID, DD, or MI is made. (Under 40 TAC Chapter 19, the NF is responsible for assessing the individual for PT, (Occupational Therapy), and ST needs and for Durable Medical Equipment.D. Convene the IDT meeting within 14 days.E. Provide nursing facility specialized services agreed to in the IDT meeting within 30 days after IDT meeting.F. Coordinate and cooperate with the LIDDA/LMHA Service Planning Team

Based on observation, interview, and record review, the facility failed to assist residents in obtaining routine dental care for 1 of 11 residents (Resident #73) reviewed for dental needs. The facility failed to offer Resident #73 dental services or refer him to be seen by a dentist. This failure placed residents at risk of pain and poor nutrition.Review of the undated face sheet for Resident #73 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included type two diabetes mellitus (a disease that affects how the body uses blood sugar), chronic obstructive pulmonary disease (a long-term lung condition that causes airflow blockage and breathing difficulties), emphysema (a long-term lung condition that causes airflow blockage and breathing difficulties), muscle weakness, abnormalities of gait and mobility, lack of coordination, cognitive communication deficit (problems with communication due to impaired cognition), dementia, schizoaffective disorder (combination of schizophrenia and a mood disorder), and post-traumatic stress disorder. Review of the admission MDS for Resident #73 dated 12/29/2025 reflected a BIMS score of 10, indicating a moderate cognitive impairment. It also reflected that he had abnormal mouth tissue (ulcers, masses, oral lesions), obvious or likely cavity or broken natural teeth, and inflamed or bleeding gums or loose natural teeth. Review of the care plan for Resident #73 dated 01/07/2026 reflected the following: FOCUSHas nutritional problem or potential nutritional problemGOALWill maintain adequate nutritional status as evidenced by maintaining weight with no s/sx of malnutrition through review date.INTERVENTIONS-Honor resident rights to make personal dietary choices and provide dietary education as needed-Meals in dining room if resident is in agreement. Review of documents in Resident #73's clinical record from December 2026 to 05/20/2026 reflected nothing related to dental services. Observation and interview on 05/19/2026 at 9:50 AM revealed Resident #73 lying in his bed. He stated he only had a few teeth, and he really wanted dentures so he could eat better. He showed his mouth, and there were only three teeth visible on the top row. He said he wanted to see a dentist but had not seen one since he admitted to the facility. During an interview on 05/20/2026 at 1:15 PM, the ADM stated the SW was out on leave, but he would obtain the information about whether Resident # 73was referred for dental services. He came back a few minutes later and said Resident #73 had not been referred for dental services and had not seen the dentists since his arrival at the facility. The ADM stated he was referring Resident #73 to the dentist because Resident #73 was entitled to be referred to the dentist. He stated he did not know if anyone had followed up for consent from Resident #73 after trying a week ago to obtain them. He stated Resident #73 was relatively easy to locate. During an interview on 05/20/2026 at 4:49 PM, the ADM stated it was his expectation that residents who needed dental care would be referred to the dentist. He stated the failure to refer a resident to the dentist could result in nutritional problems or unaddressed pain. Review of an email received from the ADM on 05/21/2026 at 9:26 AM reflected the following: For (Resident #73), they attempted to have him sign the consent forms last week to begin dental treatments, but he was unavailable. I've spoken to the provider, and they said they would be able to get him on their schedule once consents are signed. Review of the facility policy dated 04/2025 and titled Dental Services reflected the following: It is the policy of this Facility to ensure that its residents who require dental services on a routine or emergency basis have access to such services without barrier. It is likewise the policy of the Facility to repair or replace the dentures of a resident except in those situations where the loss or damage directly results from the action of an alert and oriented resident who is responsible for his/her own medical decisions.For Medicaid residents, the Facility will provide all emergency dental services and those routine dental services to the extent covered under the Medicaid state plan. The Facility will inform the resident of the deduction for the incurred medical expense available under the Medicaid state plan and will assist the resident in applying for the deduction.In order to comply with the Facility's obligations as set forth in 42 CFR Section 483.55, the Facility will: Provide, or obtain from an outside resource, routine, and emergency dental services for each resident. Assist the resident as necessary or requested to make appointments for dental services or arrange for transportation to and from dental services locations. Promptly, and within three days, refer a resident with lost or damaged partial or full dentures, and/or documented the extenuating circumstances that led to a delay. Document what the Facility did to ensure that a resident with missing or damaged partial or full dentures could still eat and drink adequately while awaiting dental services. Not charge a resident for the loss or damage of partial or full dentures determined to, by Facility policy, to be the Facility's responsibility.

Based on observation, interview, and record review, the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail or to ensure correct installation, use, and maintenance of bed rails for 1 of 25 residents (Resident #1) reviewed for bed rails. The facility failed to ensure an assessment was conducted for risk of entrapment and that the use of bed rails was added to the care plan for Resident #1prior to installation. Resident #1 became entrapped in her bed rails on [DATE] and found deceased with her head and neck between the rails and her mattress. The noncompliance was identified as Past Noncompliance. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of injury or death from entrapment in bed rails.Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included fracture of base of neck of left femur (broken hip bone), severe dementia, repeated falls, cognitive communication deficit (trouble communicating due to cognitive impairment, and need for assistance with personal care. Review of the admission MDS for Resident #1 dated [DATE] reflected a BIMS score of 03, indicating severe cognitive impairment. It reflected she required substantial staff assistance with bed mobility and was completely dependent on staff to transfer from bed to chair. Review of the care plan for Resident #1 dated [DATE] reflected the following: Focus: ADL Self Care Performance Deficit r/t UNSPECIFIED DEMENTIA.Goal: Will safely perform daily ADL's with staff assistance and/or supervision through the review date.Interventions: BED MOBILITY(ROLL LEFT AND RIGHT, SIT TO LYING, LYINGTO SITTING ON SIDE OF BED): Requires x1 staff participation to reposition and turn in bed. Encourage to participate to the fullest extent possible with each interaction. The care plan reflected no mention of bed rails or the risk of entrapment. Review of the miscellaneous documents for Resident #1 reflected a bed rail consent form signed and by Resident #1's FM and dated [DATE] with the following information: I (FM), representative for (Resident #1) have been fully informed of the potential dangers in the usage of the bedside rails. Possible dangers include:1. Suffocation:a period due to being caught between bed rail and side mattressb. Due to being caught in triangular space created by the white angle between bedside rail and headboard with mattress curve.2. Bedside rail land in bed in trapa. Insertion of head between widely spaced to vertical bars in the bedside rails.b. Insertion of body between mattress and bedside rail.3. Bedside rail and off bed entrapmenta. Sliding either on abdomen or back through space between upper and lower rails, becoming lodged in the space.4. Increased potential of injury due to fall from calling over the top of the bedside rails or out the end of bed over the footboard.Each of these situations stated above have been known to cause injury and/or even death.Having been informed, I consent to the use of bedside rails as follows:Check one:Upper bed side rails used only. Review of the assessments for Resident #1 from [DATE] to [DATE] reflected no assessment for bed rail safety. Review of the physician orders for Resident #1 from [DATE] to [DATE] reflected no order for bed rails. Review of a death in facility MDS for Resident #1 dated [DATE] reflected that she was discharged from the facility on [DATE] for the reason of deceased . Review of a facility self-reported incident dated [DATE] reflected the following: (CNA H) observed patient (Resident #1) on the floor and reported her position to (LVN A). Upon assessment, (LVN A) observed the patient seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the bed mattress. The patient was unresponsive; CPR was initiated. EMS arrived onsite and assumed care. The patient was pronounced deceased . Review of a written statement from LVN A on [DATE] reflected: Approximately 5 AM CNA came out of room and reported that (Resident #1) was on floor. Upon entering room, this writer observed resident lying on floor on right side of bed. This nurse observed resident body position in a sitting position on right side of bed with head resting between side rail and bed mattress. This nurse immediately called for help and CPR was initiated after resident was placed on floor in position to perform CPR. EMS was notified immediately. Review of a written statement from CNA H on [DATE] reflected the following: ADM interviewed CNA to discuss incident on 3/29. He stated he made a round at approximately 2 AM and patient was observed resting calmly. He rounded again close to 5 AM and observed the patient partially out of bed with her head pinned between the assist bar and the mattress, he notified LVN charge nurse and CPR was initiated. During an interview on [DATE] at 10:18 AM, the county ME stated her understanding was that Resident #1 was found with her head and neck wedged between the mattress and the bed rails. She stated the ME office's investigator went to the scene, but Resident #1 had already been moved when the staff and EMS gave her CPR. The ME stated she found bruising and abrasions around Resident #1's neck and jawline during the autopsy and two spots of hemorrhaging in the neck muscle. She stated these injuries were consistent with being trapped between the mattress and the bed rails. She stated she would not be able to make a final determination of cause of death until all the pathology results came back, but it was likely that she would determine the cause of death to be strangulation on the bed rails or asphyxiation on the mattress. During an interview on [DATE] at 10:36 AM, a FM for Resident #1 stated he received a call from the ADM on Sunday morning [DATE] very early, probably before 06:00 AM. He stated the ADM said he was sorry about what had happened and notified him that Resident #1 had become entangled in the bed frame, and they were unable to revive her. He stated the police officer at the scene told him something about the scene did not look right but he did not specify. The FM stated he spoke to the ME investigator and got her card but was told he would not know the outcome of the autopsy for several weeks. He stated he had signed a consent for bed rails when Resident #1 first admitted to the facility, but she had not had any bed rails on her bed at that time. An attempt was made to interview LVN A by phone on [DATE] at 12:18 PM. A voicemail was left but not returned as of [DATE]. Observation on [DATE] at 12:43 PM revealed Resident #1's room was empty and her bed had a sign on it with the words DO NOT USE printed five times. The 1/3 bed rails were the same make and model as the bed frame, and a low air loss mattress was on the bed frame. The rails were not loose or ill-fitting, and there was very little space between the mattress and the rails. However, the mattress could be compressed so much due to being an air mattress, that significant space could be made between the mattress and the rails. During an interview on [DATE] at 12:48 PM, the MAINT stated he thought he had installed the bed rails on Resident #1's bed about two weeks ago, but he was not sure and did not have the date documented anywhere. He stated he was told to install the rails by a charge nurse, but he did not remember who. He stated he received a work order for a low air loss mattress for Resident #1 on [DATE], and he thought the bed rail installation might have been around that time, but he was not sure. The MAINT stated the normal procedure for adding bed rails was they got the consent from the resident or responsible party, the resident was assessed by therapy and the rest of the clinical team, and then a physician order for the bed rails, and then he got a work order. He stated in the case of Resident #1's bed rails, he had not thought it had occurred differently than normal. He stated he had thought all the clinical steps had been accomplished by the time the nurse asked him to install the bed rails. He stated he ensured bed rails were installed safely by checking the policy and the manufacturer's instructions. He stated there was a maximum allowable distance between the rails and the mattress, depending on the manufacturer, and he measured every time he installed them. He stated there was also a maximum weight capacity, but not a minimum. He stated Resident #1 was not at all overweight and did not come close to the maximum capacity. He stated he checked all bed rails in the facility monthly during a walk through. He stated the potential negative outcome of the bed rail policy and procedure not being followed was injury and ultimately even death could happen. He stated after Resident #1's death, he was in-serviced on making sure the process went as it should. He now had to receive instructions to install bed rails directly from the IDT (DONs, ADON, DOR, SW) and there was a specific work order he would receive only if the IDT made the request. He stated he was made aware that he could no longer install bed rails based on word-of-mouth requests. He stated he also received the facility policy on bed rails and a facility policy on abuse/neglect/exploitation and took a quiz indicating knowledge of those topics. During an interview on [DATE] at 01:22 PM, the DON stated she had worked at the facility for eight months. She stated the procedure that should have happened before bed rails were installed was there should have been an assessment for safety from entrapment and to make sure that the bed rails would only be for bed mobility and not to prevent falls. She stated the facility did not use bed rails to prevent falls. She stated the facility had revamped their process for installing bed rails. She stated the first step in the change was to ensure the bed did not have rails installed when it was made ready for a new resident. She stated the process for approving bed rails would be exclusively for the IDT from here on out and would never be done at the level of the charge nurse. She stated the process did not happen as it should for Resident #1's bed rails. She stated the risk of entrapment assessment was not conducted, there was no physician order, and the bed rails focus was not added to Resident #1's care plan. She stated the IDT, which included nursing, therapy, and maintenance, should have met and done the assessment and obtained a physician order. She stated part of the procedure was to attempt alternatives to bed rails prior to installation, and they did not attempt other alternatives. She stated the rails were for bed mobility, though, so there would not be other appropriate alternatives. She stated after investigating, she thought the bed rails were installed entirely because they were requested by Resident #1's responsible party. The DON stated she did not know exactly what the facility policy said about bed rails, though she did read it. She stated she had been so shaken by what had occurred that she did not remember exactly what the policy stated. She stated her regional leadership had not asked why the failure to utilize the process occurred. The DON stated the first intervention was to start the process from admission by ensuring there were no bed rails on the bed at admission. She stated she in-serviced the nurses on never allowing a new resident to get in a bed with bed rails in it until they got the go ahead from the IDT. The CNAs were also in-serviced, and everyone knew that bed rails were never placed on a resident bed until there was informed consent, an assessment, a physician order, and a care plan item. She stated the issue had been added to the facility QAPI, and they would be monitoring it for several months before it the QAPI concluded their monitoring period. She stated she received in-servicing about the correct procedure from her corporate clinical supervisor. During an interview on [DATE] at 01:45 PM, the ADM stated he had been called at 05:25 AM on [DATE] to be notified that Resident #1 had become entangled in the bed rails and had expired. The ADM stated the facility was full of police officers when he arrived. He stated the police were not accusing anyone of anything, but the medical examiner investigator came out, and he understood they decided to perform an autopsy. He stated they did not know how she passed, but the way they described how she was found, he thought it was possible she was strangled on her bedrails or was trapped and asphyxiated. He stated to his knowledge, Resident #1 did not have an assessment for risk of entrapment, a physician order, or a care plan item for bed rails. He stated after Resident #1's death, they did a full sweep of all residents, auditing to ensure that if they had bed rails, they had all the required elements in place. He stated during the audit, he was not sure how many residents were identified who had bed rails and did not have an assessment for risk of entrapment. The ADM stated he could not say why the procedure did not happen the way it was supposed to, but it was the DON's and his responsibility to ensure it did. He stated he was re-educated by his corporate leadership on the correct procedure for installing bed rails, and they added the failure to their QAPI to ensure it never happened again. He stated he and his DONs had in-serviced everyone at the facility and had procedures in place on their performance improvement plan to address new hires and newly admitted residents. An attempt was made on [DATE] at 02:27 PM to interview CNA H. A voicemail was left but contact was not returned as of [DATE]. Review of facility policy titled Bed Rails and revised [DATE], reflected the following: PolicyIt is the policy of this facility to attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails.DefinitionsEntrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail.Bed rails are adjustable metal or rigid plastic bars that attached to the bed. They are available in a variety of types, shapes, and sizes ranging from full to 1/2, 1/4, or 1/8 length. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. Examples of bed rails include, but are not limited to:-Side rails, bedside rails, and safety rails; and-Grab bars and assist bars.Procedure:After the facility has attempted alternatives to bed rails and determined that these alternatives failed to meet the residents assessed needs, the facility interdisciplinary team. IDT will assess the resident for risks of entrapment. The risks and benefits regarding the use of bed rails will be considered for each resident.If the use of bed rails is recommended by the IDT, the facility must obtain informed consent from the resident, or if applicable, the resident representative for the use of bed rails prior to installation or use.The facility should maintain evidence that it has provided sufficient information prior to installation so that the resident or resident representative could make an informed decision. Information that the facility must provide to the resident, or resident representative includes, but are not limited to:Before bed rails are installed or used, the facility should: a. Check with the manufacturers or review manufacturer use requirements to verify the bed rails mattress and bed frame are compatible, as in many instances, bed rails and mattresses are or maybe purchased separate separately from the bedframe. Bed rail should be selected and placed to discouraged climbing over the rails to get in and out of bed, which may result in falling over bed rails.when installing and using bed rails, the facility shall: a. Ensure that the bed dimensions are appropriate to accommodate the size (Height and weight) Of the resident. b. Verify the bed rails to be installed are appropriate for the size and weight of the resident using the bed. c. Install bed rails using the manufacturer's instructions and specifications to ensure a proper fit and safe spacing.Update the resident care plan as needed related to the identified and/or ongoing need or resident choice for the use of bed rails. a. If the IDT determines bed rails are no longer needed or appropriate for resident use, discontinue the use of bed rails. Review of an undated QAPI binder related to Resident #1's death reflected the following documents. Review of a QAPI meeting sign-in sheet dated [DATE] reflected the following attendees: physician by phone, DON, ADM, ADON, MDS nurse, treatment nurse, marketing/admissions, dietary, maintenance, social services, human resources, rehab, rehabilitation, business office, and two clinical resource nurses Review of an undated root cause analysis reflected the following Problem IdentificationThe QIT identified deficiencies related to assessment completion, provider, orders, and care planning processes that placed the facility below benchmark expectations.Assessment route causesAssessments are not consistently updated following changes and condition. Risk assessments may lack sufficient detail or are not completed timely limiting early identification of resident risk and intervention.Orders root causeProvider orders are not always obtained or updated promptly upon following assessment findings. Communication delays between nursing staff and provide providers contribute to gaps between assessment findings and corresponding orders.Care planning root causesCare plans are not consistently revised to reflect updated assessments or new provider orders, resulting in interventions being implemented in practice, but not always clearly reflected or individualized in the care plan.Contributing FactorsWorkflow pressures, staffing turnover, competing clinical priorities, and limited interdisciplinary communication contribute to delays an assessment, order, initiation, and care plan updates.Corrective actions implementedTargeted education provide provided on timely assessment completion, provide provider, notification, and care plan updates. Increased DON and unit manager oversight implemented along with weekly audits and real-time feedback.Monitoring and sustainabilityOngoing QIT monitoring, monthly QA review, continued audits, and leadership oversight to ensure sustained compliance and improved outcomes. Review of a QAPI Performance Improvement Plan reflected the following: Item identified/problem and goalPatient bed rail entanglementReduce risk of bed rail-related injuryOngoing monitoring for improvement and review at QAPIIntervention/action planMedical Director notificationOmbudsman notificationAd hoc QAPIDON provided education to trainers regarding abuse and neglectAdmissions processes regarding bed rails reviewed and in-service is completed with DON, ED, and IDT by clinical resourceIn service all nurses involved with admissions process regarding bed railsAudit of bed rails currently in useInspection of bed rails currently in useVerify consent on file for all bed rails in useVerify order and care plan for all bed railsComplete bed rail, safety evaluation for all with bed railsAudit of low air loss mattresses currently in useVerify order and care plan for all LAL mattresses in useComplete fall risk assessment for all with LAL mattressStaff education regarding use of enabler/bed railStaff education regarding use of enabler/bed railStaff education regarding false safetyStaff education regarding LAL mattressAudit admissions for completion weeklyAudit of LL mattress and bedside rails weekly times four then monthly times threeOngoing monitoring for improvement to be reviewed at QAPI monthlyCompletion date/date resolved[DATE] Review of an electronic work order system list of facility wide bed rail checks reflected monthly checks from [DATE] to [DATE].Review of a bed rail inspection checklist dated [DATE] reflected that all rooms were checked for bed rails present and in good condition.Review of in-service dated [DATE] and presented by the ADM reflected the following and were signed by all available employees:admission process regarding bed rails education provided regarding appropriate admission processBed rail safetyAir mattressesFall prevention/identifying high fall risksMobility support barsTwo-hour safety checksReview of a facility-wide audit reflected that all 114 residents had been audited for bed rails and the consents, orders, assessments, and care plans of all residents with bed rails had been verified or updated. Of these, 24 residents had no bed rail safety assessment prior to [DATE].Review of bed rail safety assessments for Residents #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25 were all dated [DATE]. They were all assessed as safe to use bed rails for mobility.Review of care plans for Residents #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25 reflected they all had care plans for bed rails updated on [DATE] or [DATE].Review of physician orders for Residents #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25 reflected they all had orders updated on [DATE].During an interview on [DATE] at 11:49 AM, CNA I stated she worked the 6 AM to 2 PM shift at the facility. She stated she knew that bed rails were for positioning and not to prevent falls. She stated she had received some in-servicing about bed rails and air mattresses when she returned to work on Monday [DATE]. She stated she was trained to observe that residents were not looking like they would get stuck in their bed rails when she did her rounds. She stated she was told that information about bed rail safety was also in the resident care plan. She stated the protocol if she saw a problem with the bed rails was to make sure the resident was safe and then notify the charge nurse. She stated she did know Resident #1, because CNA I was the restorative aide and took the weight measurements on all residents, but she did not work directly with Resident #1. CNA I stated Resident #1 was nervous and agitated a lot. She stated she received some in-servicing related to residents who had dementia and were nervous would be more vulnerable to abuse and neglect. She stated she knew if she had concerns about abuse and neglect she would report to the abuse coordinator, who was the ADM.During an interview on [DATE] at 11:56 AM, LVN B stated she worked the 6 AM to 6 PM shift. She stated she made sure residents were safe with their bed rails by doing checks on each resident every two hours. She stated checking bed rail safety was constant and frequent. She stated there was an enhanced policy and procedure in which only the IDT could decide on bed rails. She stated when she returned to work on Monday [DATE], the facility had removed all the bed rails and was conducting new assessments, adding focus areas to care plans, and making sure there were orders for every set of bed rails used. She stated she was in-serviced on the new procedure before she started working on Monday morning [DATE] as well as on bed rail safety and LAL mattresses. She stated she had heard about Resident #1's death but did not know very much about it, as that occurred on a hall where she did not work.During an interview on [DATE] at 12:04 PM, LVN C stated he worked 6 AM to 6 PM and always worked on the hall where Resident #1 had lived. He stated he had been retrained on the process of resident bed rails. He stated the first issue was that the purpose for bed rails should only be for repositioning and not fall prevention. He stated Resident #1 had dementia, but she was able to use her bed rails to assist with her brief changes and changing her clothing. He stated the next step in the procedure was to notify the IDT and they would get consent from the family and notify the resident or responsible party about the risks and benefits of bed rails. He stated after that, a safety evaluation was done and then a physician order obtained. He stated finally the bed rails would go into the care plan. He stated there was a consent for bed rails included in the resident admission packet, so they got that signed for almost every resident. LVN C stated there was nothing about Resident #1 and her bed that made him concerned about risk of entrapment.During an interview on [DATE] at 12:19 PM, LVN D stated she usually worked the 6 PM to 6 AM shift. She stated she had been in serviced on the new policy and procedure for bed rails. She stated that the new policy and procedure was what usually happened but sometimes the charge nurses took it upon themselves to get bed rails for residents. She stated that they could do the assessment themselves before, and that they could ask for a physician order, but now everything had to go through the IDT. She stated she was also asked to check on residents with bed rails every two hours and make sure that the bed rails and air mattresses were safe.During an interview on [DATE] at 12:20 PM, LVN E stated she worked the 6 AM to 6 PM shift at the facility. She stated she had participated in a review of every single resident in the facility, but she had only reviewed residents on her hall. She had gone through and written down if they had bed rails, and then she checked to see if they had a consent, an assessment, an order, and that bed rails were in the resident care plans. She stated that she cannot remember if any of the residents she looked at did not have bed rail safety assessments in place. She stated from now on only the IDT could determine if a resident can use bed rails. She stated if a resident or responsible party wanted bed rails, she had to let the DON know and that would start the process. During an interview on [DATE] at 12:23 PM, LVN F stated she worked the 6 PM to 6 AM shift regularly. She stated she had been off work and has not been back to work since [DATE], but she got a phone call informing her of the new process. She stated that if a resident was going to have bed rails, they needed to notify somebody on the management team like the director of rehab or the DON. She stated what happened from there was that the IDT gets consent and a physician order, does an assessment, and then added bed rails to the care plan. They were told to make sure to review all the care plans from the list of residents who had bed rails in case there were any interventions they did not know about. They also had an abuse and neglect in-service, but they have those once a month and she was very familiar with the process. They had in-services on bed rail safety and LAL mattresses. She stated when she had to have an in-service, the DON or ADON came in on her shift- usually at the end of the shift, but sometimes at the beginning.During an interview on [DATE] at 12:27 PM LVN G stated she worked the 6 PM to 6 AM shift at the facility. She stated that there was a death related to bed rails, and so the facility had gone over the entire policy and procedure and retrained everybody on a new policy and procedure. She stated that if the resident or their family wanted bed rails, or if she as a nurse thought a resident could benefit from bed rails, they had to either put a note in the 24 hour logbook or report directly to somebody on the IDT, which included the DON, ADONs, Director of rehab and maybe some other people. She stated the IDT took it from there. She stated they were supposed to be rounding on residents every two hours anyway, but they were reminded to look at the bed rails every time they rounded and make sure they were safe. She stated she had not seen or encountered anything that concerned her about bed rails in the facility. During an interview on [DATE] at 12:30 PM CNA J stated he worked the 10 PM to 6 AM shift at the facility. He stated he had never seen any problem bed rails. He stated he took care of Resident #1 sometimes and he did not notice anything unsafe. He stated the procedure for allowing bed rails happened above his level, but he was still trained on the process and now he knows that he could not just ask for bed rails for a resident. He stated they can only have bed rails if they were doing it to help move in bed. He stated they were supposed to check on the residents with bed rails and make sure to notice if there are any problems or anything unsafe happening. He stated they were supposed to report to their charge nurse if they see anything that looks unsafe. He has never seen anything like that.During an interview on [DATE] at 12:35 PM CNA K stated she worked the 6 AM to 2 PM shift at the facility. She stated she had to look out for bed rails and air mattresses because the resident can get stuck in there and be hurt. She stated the bed rails should be in the care plan and she looked at care plan sometimes, especially on the point of care system. She stated she always had to notice if the resident was being hurt by the rails, like skin, tears or other injuries or if the resident ever got stuck in the bed rails. She stated that she got some training about bed rails over the last two days and about abuse and neglect prevention and reporting. During an interview on [DATE] at 12:40 PM CNA L stated she worked the 2 PM to 10 PM shift at the facility. She stated bed rails were usually really helpful for residents and staff. She stated they got trained when she came to work yesterday about checking resident bed rails and checking air mattresses and making sure that nothing got stuck. She said they were also trained on rounding every two hours and on abuse and neglect.During an interview on [DATE] at 12:45 PM CNA M stated she worked the 10 PM to 6 AM shift at the facility and worked on the hall where Resident #1 had lived. She stated she had been at the facility the night Resident #1 was found but was not assigned Resident #1 that night. She stated after she came back to work, she had a lot of in-services about bed rails, mattresses, safety, and abuse and neglect. She stated residents were not supposed to have bed rails without an order. She stated they had to check for safety and if they saw anything with residents that was not safe, they had to report it immediately. She stated that was important to the overnight shift, because that was when residents were in bed the most and sleeping.Observation on [DATE] from 02:30 PM to 03:30 PM revealed Residents #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27 had properly fitted bed rails on 1/3 the length of their beds, and the bed rails were the same make and model as the beds. There were no hazards identified with the bedrails. During these observations, Residents # 2, 3, 4, 5, 8, 10, 13, 14, 15, 16, 20, 21, 22, 24, and 25 were observed in the beds with bed rails, and no obvious hazardous situation was observed for any resident.The noncompliance was identified as Past Noncompliance. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for 1 of 25 (Resident #1) residents reviewed for care plans. The facility failed to ensure an assessment was conducted for risk of entrapment and that the use of bed rails was added to the care plan for Resident #1 prior to installation. She became entrapped in the bed rails on [DATE] and found deceased with her head and neck between the rails and her mattress. The noncompliance was identified as Past Noncompliance. The non-compliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of injury or death from entrapment in bed rails.Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included fracture of base of neck of left femur (broken hip bone), severe dementia, repeated falls, cognitive communication deficit (trouble communicating due to cognitive impairment, and need for assistance with personal care. Review of the admission MDS for Resident #1 dated [DATE] reflected a BIMS score of 03, indicating severe cognitive impairment. It reflected she required substantial staff assistance with bed mobility and was completely dependent on staff to transfer from bed to chair. Review of the care plan for Resident #1 dated [DATE] reflected the following: Focus: ADL Self Care Performance Deficit r/t UNSPECIFIED DEMENTIA.Goal: Will safely perform daily ADL's with staff assistance and/or supervision through the review date.Interventions: BED MOBILITY(ROLL LEFT AND RIGHT, SIT TO LYING, LYINGTO SITTING ON SIDE OF BED): Requires x1 staff participation to reposition and turn in bed. Encourage to participate to the fullest extent possible with each interaction. The care plan reflected no mention of bed rails or the risk of entrapment. Review of the miscellaneous documents for Resident #1 reflected a bed rail consent form signed and by Resident #1's FM and dated [DATE] with the following information: I (FM), representative for (Resident #1) have been fully informed of the potential dangers in the usage of the bedside rails. Possible dangers include:1. Suffocation:a period due to being caught between bed rail and side mattressb. Due to being caught in triangular space created by the white angle between bedside rail and headboard with mattress curve.2. Bedside rail land in bed in trapa. Insertion of head between widely spaced to vertical bars in the bedside rails.b. Insertion of body between mattress and bedside rail.3. Bedside rail and off bed entrapmenta. Sliding either on abdomen or back through space between upper and lower rails, becoming lodged in the space.4. Increased potential of injury due to fall from calling over the top of the bedside rails or out the end of bed over the footboard.Each of these situations stated above have been known to cause injury and/or even death.Having been informed, I consent to the use of bedside rails as follows:Check one:Upper bed side rails used only. Review of the assessments for Resident #1 from [DATE] to [DATE] reflected no assessment for bed rail safety. Review of the physician orders for Resident #1 from [DATE] to [DATE] reflected no order for bed rails. Review of a death in facility MDS for Resident #1 dated [DATE] reflected that she was discharged from the facility on [DATE] for the reason of deceased . Review of a facility self-reported incident dated [DATE] reflected the following: (CNA H) observed patient (Resident #1) on the floor and reported her position to (LVN A). Upon assessment, (LVN A) observed the patient seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the bed mattress. The patient was unresponsive; CPR was initiated. EMS arrived onsite and assumed care. The patient was pronounced deceased . Review of a written statement from LVN A on [DATE] reflected: Approximately 5 AM CNA came out of room and reported that (Resident #1) was on floor. Upon entering room, this writer observed resident lying on floor on right side of bed. This nurse observed resident body position in a sitting position on right side of bed with head resting between side rail and bed mattress. This nurse immediately called for help and CPR was initiated after resident was placed on floor in position to perform CPR. EMS was notified immediately. Review of a written statement from CNA H on [DATE] reflected the following: ADM interviewed CNA to discuss incident on 3/29. He stated he made a round at approximately 2 AM and patient was observed resting calmly. He rounded again close to 5 AM and observed the patient partially out of bed with her head pinned between the assist bar and the mattress, he notified LVN charge nurse and CPR was initiated. During an interview on [DATE] at 10:18 AM, the county ME stated her understanding was that Resident #1 was found with her head and neck wedged between the mattress and the bed rails. She stated the ME office's investigator went to the scene, but Resident #1 had already been moved when the staff and EMS gave her CPR. The ME stated she found bruising and abrasions around Resident #1's neck and jawline during the autopsy and two spots of hemorrhaging in the neck muscle. She stated these injuries were consistent with being trapped between the mattress and the bed rails. She stated she would not be able to make a final determination of cause of death until all the pathology results came back, but it was likely that she would determine the cause of death to be strangulation on the bed rails or asphyxiation on the mattress. During an interview on [DATE] at 10:36 AM, a FM for Resident #1 stated he received a call from the ADM on Sunday morning [DATE] very early, probably before 06:00 AM. He stated the ADM said he was sorry about what had happened and notified him that Resident #1 had become entangled in the bed frame, and they were unable to revive her. He stated the police officer at the scene told him something about the scene did not look right but he did not specify. The FM stated he spoke to the ME investigator and got her card but was told he would not know the outcome of the autopsy for several weeks. He stated he had signed a consent for bed rails when Resident #1 first admitted to the facility, but she had not had any bed rails on her bed at that time. An attempt was made to interview LVN A by phone on [DATE] at 12:18 PM. A voicemail was left but not returned as of [DATE]. Observation on [DATE] at 12:43 PM revealed Resident #1's room was empty and her bed had a sign on it with the words DO NOT USE printed five times. The 1/3 bed rails were the same make and model as the bed frame, and a low air loss mattress was on the bed frame. The rails were not loose or ill-fitting, and there was very little space between the mattress and the rails. However, the mattress could be compressed so much due to being an air mattress, that significant space could be made between the mattress and the rails. During an interview on [DATE] at 12:48 PM, the MAINT stated he thought he had installed the bed rails on Resident #1's bed about two weeks ago, but he was not sure and did not have the date documented anywhere. He stated he was told to install the rails by a charge nurse, but he did not remember who. He stated he received a work order for a low air loss mattress for Resident #1 on [DATE], and he thought the bed rail installation might have been around that time, but he was not sure. The MAINT stated the normal procedure for adding bed rails was they got the consent from the resident or responsible party, the resident was assessed by therapy and the rest of the clinical team, and then a physician order for the bed rails, and then he got a work order. He stated in the case of Resident #1's bed rails, he had not thought it had occurred differently than normal. He stated he had thought all the clinical steps had been accomplished by the time the nurse asked him to install the bed rails. He stated he ensured bed rails were installed safely by checking the policy and the manufacturer's instructions. He stated there was a maximum allowable distance between the rails and the mattress, depending on the manufacturer, and he measured every time he installed them. He stated there was also a maximum weight capacity, but not a minimum. He stated Resident #1 was not at all overweight and did not come close to the maximum capacity. He stated he checked all bed rails in the facility monthly during a walk through. He stated the potential negative outcome of the bed rail policy and procedure not being followed was injury and ultimately even death could happen. He stated after Resident #1's death, he was in-serviced on making sure the process went as it should. He now had to receive instructions to install bed rails directly from the IDT (DONs, ADON, DOR, SW) and there was a specific work order he would receive only if the IDT made the request. He stated he was made aware that he could no longer install bed rails based on word-of-mouth requests. He stated he also received the facility policy on bed rails and a facility policy on abuse/neglect/exploitation and took a quiz indicating knowledge of those topics. During an interview on [DATE] at 01:22 PM, the DON stated she had worked at the facility for eight months. She stated the procedure that should have happened before bed rails were installed was there should have been an assessment for safety from entrapment and to make sure that the bed rails would only be for bed mobility and not to prevent falls. She stated the facility did not use bed rails to prevent falls. She stated the facility had revamped their process for installing bed rails. She stated the first step in the change was to ensure the bed did not have rails installed when it was made ready for a new resident. She stated the process for approving bed rails would be exclusively for the IDT from here on out and would never be done at the level of the charge nurse. She stated the process did not happen as it should for Resident #1's bed rails. She stated the risk of entrapment assessment was not conducted, there was no physician order, and the bed rails focus was not added to Resident #1's care plan. She stated the IDT, which included nursing, therapy, and maintenance, should have met and done the assessment and obtained a physician order. She stated part of the procedure was to attempt alternatives to bed rails prior to installation, and they did not attempt other alternatives. She stated the rails were for bed mobility, though, so there would not be other appropriate alternatives. She stated after investigating, she thought the bed rails were installed entirely because they were requested by Resident #1's responsible party. The DON stated she did not know exactly what the facility policy said about bed rails, though she did read it. She stated she had been so shaken by what had occurred that she did not remember exactly what the policy stated. She stated her regional leadership had not asked why the failure to utilize the process occurred. The DON stated the first intervention was to start the process from admission by ensuring there were no bed rails on the bed at admission. She stated she in-serviced the nurses on never allowing a new resident to get in a bed with bed rails in it until they got the go ahead from the IDT. The CNAs were also in-serviced, and everyone knew that bed rails were never placed on a resident bed until there was informed consent, an assessment, a physician order, and a care plan item. She stated the issue had been added to the facility QAPI, and they would be monitoring it for several months before it the QAPI concluded their monitoring period. She stated she received in-servicing about the correct procedure from her corporate clinical supervisor. During an interview on [DATE] at 01:45 PM, the ADM stated he had been called at 05:25 AM on [DATE] to be notified that Resident #1 had become entangled in the bed rails and had expired. The ADM stated the facility was full of police officers when he arrived. He stated the police were not accusing anyone of anything, but the medical examiner investigator came out, and he understood they decided to perform an autopsy. He stated they did not know how she passed, but the way they described how she was found, he thought it was possible she was strangled on her bedrails or was trapped and asphyxiated. He stated to his knowledge, Resident #1 did not have an assessment for risk of entrapment, a physician order, or a care plan item for bed rails. He stated after Resident #1's death, they did a full sweep of all residents, auditing to ensure that if they had bed rails, they had all the required elements in place. He stated during the audit, he was not sure how many residents were identified who had bed rails and did not have an assessment for risk of entrapment. The ADM stated he could not say why the procedure did not happen the way it was supposed to, but it was the DON's and his responsibility to ensure it did. He stated he was re-educated by his corporate leadership on the correct procedure for installing bed rails, and they added the failure to their QAPI to ensure it never happened again. He stated he and his DONs had in-serviced everyone at the facility and had procedures in place on their performance improvement plan to address new hires and newly admitted residents. An attempt was made on [DATE] at 02:27 PM to interview CNA H. A voicemail was left but contact was not returned as of [DATE]. Review of facility policy titled Bed Rails and revised [DATE], reflected the following: PolicyIt is the policy of this facility to attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails.DefinitionsEntrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail.Bed rails are adjustable metal or rigid plastic bars that attached to the bed. They are available in a variety of types, shapes, and sizes ranging from full to 1/2, 1/4, or 1/8 length. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. Examples of bed rails include, but are not limited to:-Side rails, bedside rails, and safety rails; and-Grab bars and assist bars.Procedure:After the facility has attempted alternatives to bed rails and determined that these alternatives failed to meet the residents assessed needs, the facility interdisciplinary team. IDT will assess the resident for risks of entrapment. The risks and benefits regarding the use of bed rails will be considered for each resident.If the use of bed rails is recommended by the IDT, the facility must obtain informed consent from the resident, or if applicable, the resident representative for the use of bed rails prior to installation or use.The facility should maintain evidence that it has provided sufficient information prior to installation so that the resident or resident representative could make an informed decision. Information that the facility must provide to the resident, or resident representative includes, but are not limited to:Before bed rails are installed or used, the facility should: a. Check with the manufacturers or review manufacturer use requirements to verify the bed rails mattress and bed frame are compatible, as in many instances, bed rails and mattresses are or maybe purchased separate separately from the bedframe. Bed rail should be selected and placed to discouraged climbing over the rails to get in and out of bed, which may result in falling over bed rails.when installing and using bed rails, the facility shall: a. Ensure that the bed dimensions are appropriate to accommodate the size (Height and weight) Of the resident. b. Verify the bed rails to be installed are appropriate for the size and weight of the resident using the bed. c. Install bed rails using the manufacturers instructions and specifications to ensure a proper fit and safe spacing.Update the resident care plan as needed related to the identified and/or ongoing need or resident choice for the use of bed rails. a. If the IDT determines bed rails are no longer needed or appropriate for resident use, discontinue the use of bed rails. Review of an undated QAPI binder related to Resident #1's death reflected the following documents. Review of a QAPI meeting sign-in sheet dated [DATE] reflected the following attendees: physician by phone, DON, ADM, ADON, MDS nurse, treatment nurse, marketing/admissions, dietary, maintenance, social services, human resources, rehab, rehabilitation, business office, and two clinical resource nurses Review of an undated root cause analysis reflected the following Problem IdentificationThe QIT identified deficiencies related to assessment completion, provider, orders, and care planning processes that placed the facility below benchmark expectations.Assessment route causesAssessments are not consistently updated following changes and condition. Risk assessments may lack sufficient detail or are not completed timely limiting early identification of resident risk and intervention.Orders root causeProvider orders are not always obtained or updated promptly upon following assessment findings. Communication delays between nursing staff and provide providers contribute to gaps between assessment findings and corresponding orders.Care planning root causesCare plans are not consistently revised to reflect updated assessments or new provider orders, resulting in interventions being implemented in practice, but not always clearly reflected or individualized in the care plan.Contributing FactorsWorkflow pressures, staffing turnover, competing clinical priorities, and limited interdisciplinary communication contribute to delays an assessment, order, initiation, and care plan updates.Corrective actions implementedTargeted education provide provided on timely assessment completion, provide provider, notification, and care plan updates. Increased DON and unit manager oversight implemented along with weekly audits and real-time feedback.Monitoring and sustainabilityOngoing QIT monitoring, monthly QA review, continued audits, and leadership oversight to ensure sustained compliance and improved outcomes. Review of a QAPI Performance Improvement Plan reflected the following: Item identified/problem and goalPatient bed rail entanglementReduce risk of bed rail-related injuryOngoing monitoring for improvement and review at QAPIIntervention/action planMedical Director notificationOmbudsman notificationAd hoc QAPIDON provided education to trainers regarding abuse and neglectAdmissions processes regarding bed rails reviewed and in-service is completed with DON, ED, and IDT by clinical resourceIn service all nurses involved with admissions process regarding bed railsAudit of bed rails currently in useInspection of bed rails currently in useVerify consent on file for all bed rails in useVerify order and care plan for all bed railsComplete bed rail, safety evaluation for all with bed railsAudit of low air loss mattresses currently in useVerify order and care plan for all LAL mattresses in useComplete fall risk assessment for all with LAL mattressStaff education regarding use of enabler/bed railStaff education regarding use of enabler/bed railStaff education regarding false safetyStaff education regarding LAL mattressAudit admissions for completion weeklyAudit of LL mattress and bedside rails weekly times four then monthly times threeOngoing monitoring for improvement to be reviewed at QAPI monthlyCompletion date/date resolved[DATE] Review of an electronic work order system list of facility wide bed rail checks reflected monthly checks from [DATE] to [DATE].Review of a bed rail inspection checklist dated [DATE] reflected that all rooms were checked for bed rails present and in good condition.Review of in-service dated [DATE] and presented by the ADM reflected the following and were signed by all available employees:admission process regarding bed rails education provided regarding appropriate admission processBed rail safetyAir mattressesFall prevention/identifying high fall risksMobility support barsTwo-hour safety checksReview of a facility-wide audit reflected that all 114 residents had been audited for bed rails and the consents, orders, assessments, and care plans of all residents with bed rails had been verified or updated. Of these, 24 residents had no bed rail safety assessment prior to [DATE].Review of bed rail safety assessments for Residents #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25 were all dated [DATE]. They were all assessed as safe to use bed rails for mobility.Review of care plans for Residents #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25 reflected they all had care plans for bed rails updated on [DATE] or [DATE].Review of physician orders for Residents #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, and 25 reflected they all had orders updated on [DATE].During an interview on [DATE] at 11:49 AM, CNA I stated she worked the 6 AM to 2 PM shift at the facility. She stated she knew that bed rails were for positioning and not to prevent falls. She stated she had received some in-servicing about bed rails and air mattresses when she returned to work on Monday [DATE]. She stated she was trained to observe that residents were not looking like they would get stuck in their bed rails when she did her rounds. She stated she was told that information about bed rail safety was also in the resident care plan. She stated the protocol if she saw a problem with the bed rails was to make sure the resident was safe and then notify the charge nurse. She stated she did know Resident #1, because CNA I was the restorative aide and took the weight measurements on all residents, but she did not work directly with Resident #1. CNA I stated Resident #1 was nervous and agitated a lot. She stated she received some in-servicing related to residents who had dementia and were nervous would be more vulnerable to abuse and neglect. She stated she knew if she had concerns about abuse and neglect she would report to the abuse coordinator, who was the ADM.During an interview on [DATE] at 11:56 AM, LVN B stated she worked the 6 AM to 6 PM shift. She stated she made sure residents were safe with their bed rails by doing checks on each resident every two hours. She stated checking bed rail safety was constant and frequent. She stated there was an enhanced policy and procedure in which only the IDT could decide on bed rails. She stated when she returned to work on Monday [DATE], the facility had removed all the bed rails and was conducting new assessments, adding focus areas to care plans, and making sure there were orders for every set of bed rails used. She stated she was in-serviced on the new procedure before she started working on Monday morning [DATE] as well as on bed rail safety and LAL mattresses. She stated she had heard about Resident #1's death but did not know very much about it, as that occurred on a hall where she did not work.During an interview on [DATE] at 12:04 PM, LVN C stated he worked 6 AM to 6 PM and always worked on the hall where Resident #1 had lived. He stated he had been retrained on the process of resident bed rails. He stated the first issue was that the purpose for bed rails should only be for repositioning and not fall prevention. He stated Resident #1 had dementia, but she was able to use her bed rails to assist with her brief changes and changing her clothing. He stated the next step in the procedure was to notify the IDT and they would get consent from the family and notify the resident or responsible party about the risks and benefits of bed rails. He stated after that, a safety evaluation was done and then a physician order obtained. He stated finally the bed rails would go into the care plan. He stated there was a consent for bed rails included in the resident admission packet, so they got that signed for almost every resident. LVN C stated there was nothing about Resident #1 and her bed that made him concerned about risk of entrapment.During an interview on [DATE] at 12:19 PM, LVN D stated she usually worked the 6 PM to 6 AM shift. She stated she had been in serviced on the new policy and procedure for bed rails. She stated that the new policy and procedure was what usually happened but sometimes the charge nurses took it upon themselves to get bed rails for residents. She stated that they could do the assessment themselves before, and that they could ask for a physician order, but now everything had to go through the IDT. She stated she was also asked to check on residents with bed rails every two hours and make sure that the bed rails and air mattresses were safe.During an interview on [DATE] at 12:20 PM, LVN E stated she worked the 6 AM to 6 PM shift at the facility. She stated she had participated in a review of every single resident in the facility, but she had only reviewed residents on her hall. She had gone through and written down if they had bed rails, and then she checked to see if they had a consent, an assessment, an order, and that bed rails were in the resident care plans. She stated that she cannot remember if any of the residents she looked at did not have bed rail safety assessments in place. She stated from now on only the IDT could determine if a resident can use bed rails. She stated if a resident or responsible party wanted bed rails, she had to let the DON know and that would start the process. During an interview on [DATE] at 12:23 PM, LVN F stated she worked the 6 PM to 6 AM shift regularly. She stated she had been off work and has not been back to work since [DATE], but she got a phone call informing her of the new process. She stated that if a resident was going to have bed rails, they needed to notify somebody on the management team like the director of rehab or the DON. She stated what happened from there was that the IDT gets consent and a physician order, does an assessment, and then added bed rails to the care plan. They were told to make sure to review all the care plans from the list of residents who had bed rails in case there were any interventions they did not know about. They also had an abuse and neglect in-service, but they have those once a month and she was very familiar with the process. They had in-services on bed rail safety and LAL mattresses. She stated when she had to have an in-service, the DON or ADON came in on her shift- usually at the end of the shift, but sometimes at the beginning.During an interview on [DATE] at 12:27 PM LVN G stated she worked the 6 PM to 6 AM shift at the facility. She stated that there was a death related to bed rails, and so the facility had gone over the entire policy and procedure and retrained everybody on a new policy and procedure. She stated that if the resident or their family wanted bed rails, or if she as a nurse thought a resident could benefit from bed rails, they had to either put a note in the 24 hour logbook or report directly to somebody on the IDT, which included the DON, ADONs, Director of rehab and maybe some other people. She stated the IDT took it from there. She stated they were supposed to be rounding on residents every two hours anyway, but they were reminded to look at the bed rails every time they rounded and make sure they were safe. She stated she had not seen or encountered anything that concerned her about bed rails in the facility. During an interview on [DATE] at 12:30 PM CNA J stated he worked the 10 PM to 6 AM shift at the facility. He stated he had never seen any problem bed rails. He stated he took care of Resident #1 sometimes and he did not notice anything unsafe. He stated the procedure for allowing bed rails happened above his level, but he was still trained on the process and now he knows that he could not just ask for bed rails for a resident. He stated they can only have bed rails if they were doing it to help move in bed. He stated they were supposed to check on the residents with bed rails and make sure to notice if there are any problems or anything unsafe happening. He stated they were supposed to report to their charge nurse if they see anything that looks unsafe. He has never seen anything like that.During an interview on [DATE] at 12:35 PM CNA K stated she worked the 6 AM to 2 PM shift at the facility. She stated she had to look out for bed rails and air mattresses because the resident can get stuck in there and be hurt. She stated the bed rails should be in the care plan and she looked at care plan sometimes, especially on the point of care system. She stated she always had to notice if the resident was being hurt by the rails, like skin, tears or other injuries or if the resident ever got stuck in the bed rails. She stated that she got some training about bed rails over the last two days and about abuse and neglect prevention and reporting. During an interview on [DATE] at 12:40 PM CNA L stated she worked the 2 PM to 10 PM shift at the facility. She stated bed rails were usually really helpful for residents and staff. She stated they got trained when she came to work yesterday about checking resident bed rails and checking air mattresses and making sure that nothing got stuck. She said they were also trained on rounding every two hours and on abuse and neglect.During an interview on [DATE] at 12:45 PM CNA M stated she worked the 10 PM to 6 AM shift at the facility and worked on the hall where Resident #1 had lived. She stated she had been at the facility the night Resident #1 was found but was not assigned Resident #1 that night. She stated after she came back to work, she had a lot of in-services about bed rails, mattresses, safety, and abuse and neglect. She stated residents were not supposed to have bed rails without an order. She stated they had to check for safety and if they saw anything with residents that was not safe, they had to report it immediately. She stated that was important to the overnight shift, because that was when residents were in bed the most and sleeping.Observation on [DATE] from 02:30 PM to 03:30 PM revealed Residents #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, and 27 had properly fitted bed rails on 1/3 the length of their beds, and the bed rails were the same make and model as the beds. There were no hazards identified with the bedrails. During these observations, Residents # 2, 3, 4, 5, 8, 10, 13, 14, 15, 16, 20, 21, 22, 24, and 25 were observed in the beds with bed rails, and no obvious hazardous situation was observed for any resident.The noncompliance was identified as Past Noncompliance. The non-compliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began.

Based on interviews and record reviews, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention for 1 (Resident #1) of 4 residents reviewed for notification of changes. The facility failed to ensure Resident #1's representative was notified after Resident #1 had an unwitnessed fall on 09/16/25. This failure could result in the family or representative not being aware of conditions that may require them to make medical decisions.Findings included: Review of Resident #1's face sheet printed 09/23/25 reflected an [AGE] year-old male admitted to the facility on [DATE] and discharged on 09/17/25. His diagnoses included unspecified dementia, hypertension (high blood pressure) congestive heart failure, and prostate (a gland below the bladder in males) cancer with metastasis (spread to other organs). Review of Resident #1's admission MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 9, which indicated moderately impaired cognition. Section J (Health Conditions) reflected he had a fall in the month prior to admission. Review of Resident #1's care plan, initiated 09/12/25, reflected in part, Focus: Resident #1 is at risk for falls r/t hx of recurrent fall, unsteady gait, cognitive impairment. Goal: Will be free of falls through the review date. Interventions: Anticipate and meet needs, be sure the call light is within reach and encourage to use it to call for assistance as needed. Keep needed items in reach. Review of Resident #1's nursing progress note dated 09/16/25 at 5:46 PM by LVN A, reflected in part, Resident was observed on floor of resident's restroom. Resident stated that he was using the restroom and after standing up from the toilet, his legs became weak, and he fell to the floor. On-call NP notified. ADON made aware. Communication note placed in NP/MD binder. Facility fall protocol and neurochecks initiated. Review of Resident #1's nursing progress noted dated 09/17/25 at 12:21 PM by LVN B reflected in part, This nurse was notified by residents FM that resident was complaining of pain in left hip and left shoulder and was requesting pain medication or to go to the hospital. This nurse evaluated resident, found resident grimacing and guarding his left arm and left leg. During a telephone interview on 09/22/25 at 12:45 PM, Resident #1's FM stated they were notified of the 09/16/25 fall by Resident #1 when he called on the morning of 09/17/25 and described the fall, lying on the floor, and his pain. The FM stated she was the emergency contact and should have been notified on 09/16/25. The FM stated there were no missed calls and no messages on her phone from the facility. The FM stated when she contacted the facility on 09/17/25, and the nurse confirmed that the resident had fallen the day before. During an interview on 09/23/25 at 5:36 AM, LVN A stated she cared for Resident #1 on 09/16/25 when he had a fall. LVN A stated she was notified by a CNA that Resident #1 was on the floor. She stated she went to the room to assess the resident. LVN A stated Resident #1 had been using the toilet, stood up, was dizzy, and fell. LVN A stated Resident had a skin tear on his left hand, right arm by the elbow, and on his scalp. She stated she was not sure if the tear on the scalp was new because it was not bleeding. LVN A stated she assessed the resident, they got him up to a wheelchair, and then assisted him into bed. She stated she completed a full head-to-toe assessment. She stated the Resident #1 was able to extend his arms and move his legs. She stated, He had good range of motion in his legs. She stated the Resident #1 denied pain throughout the shift except when she cleaned the skin tear on the left elbow. She stated she notified the NP and the ADON. LVN A stated the resident was his own responsible party, so she did not contact a family member. During an interview on 09/23/25 at 10:07 AM, RN C described the assessments, documentation, and notifications that were made after a resident had a fall. She stated they had to notify a family member or other emergency contact, Even if the resident was responsible for their own finances. During an interview on 09/23/25 at 10:47 AM, the DON stated she assessed Resident #1 on 09/17/25. She stated she was spoke with the LVN A and provided education about family notification. She stated it did not meet her expectations that the family was not notified when Resident #1 fell. She stated the family had the right to know about any changes at all, including falls. The DON stated she was responsible to provide training, but the ADON and resource nurse also helped to train. She stated she had recently provided training on assessing after falls. During an interview on 09/23/25 at 11:18 AM, the ADON stated family was notified of any change such as a fall, a skin tear, a medication does increase. She stated if the family was not informed of a change or event, the family may think the facility was trying to hide something. During an interview on 09/24/25 at 1:20 PM, the ADM stated when there was a fall, he expected the Resident's emergency contact was notified. He stated in the case of Resident #1, Resident #1 was his own financial responsible party, but his emergency contact was not notified, which did not meet his expectations. Review on an in-service Orders and RP notification, dated 07/07/25, reflected in part, Documentation: Your nursing note must clearly indicate that both the family/responsible party and the provider were notified, including the date and time of notification. 8 nurses signed the attendance sheet. Review of the Fall Management System policy revised April 2025, reflected in part, 3. When a resident sustains a fall, a physical assessment will be completed by a license nurse, with results documented in the medical record. a. The attending Physician and Resident Representative shall be notified of the fall and the resident status.

Based on observation, interview, and record review, the facility failed to prepare foods by methods that conserve nutritive value, flavor, and appearance in the facility's only kitchen for 20 of 21 residents (Resident #42, Resident #47, Resident #63, Resident #19, Resident #361, and confidential group interview (15 of 16 residents)). The [NAME] prepared food as early as 2 hours and 45 minutes prior to meal service as observed on 03/24/2025 at 9:15 a.m. and 03/25/2025 at 9:35 a.m. The [NAME] held food in shallow pans uncovered on top of the stove for more than 2 hours and 45 minutes prior to meal service. Regular test tray rendered a low temperature and bland flavor. Pureed test tray rendered a low temperature and bland flavor. Food lacked seasoning and was unacceptable to residents. Food was prepared and held at low temperatures for hours prior to meal service. Puree food was served to residents with visible lumps and required chewing. Food was served at unpreferable and unappetizing temperature for the residents. Facility was aware of the resident's complaints about food being served at unappetizing temperatures and not flavorful, and the complaints were not addressed. These failures could compromise and destroy nutritive value of food and placed residents, who ate food from the kitchen, at risk of illness or injury. Finding included: Observation on 03/24/2025 at 9:15 a.m., during the initial brief tour of the kitchen, revealed the following: Mealtime schedule posted in the entrance of the dining room noted lunch was served at 12:00 p.m. The vegetable for the regular, mechanical soft, and puree diets, which consisted of broccoli, was in a shallow pan filled with water sitting on the stove uncovered. Observation on 03/24/2025 at 1:06 p.m. of the survey test tray revealed the following: Regular test tray was delayed and delivered 66 minutes after the start of the meal service time of 12:00 p.m. o meatballs were salty in flavor. o peaches and cream were bland in flavor. Observation on 03/25/2025 at 9:35 a.m. to confirm time for temperature checks revealed the following: The vegetables for the regular, mechanical soft, and puree diets, which included green and yellow squash, was in a shallow pan filled with water sitting on the stove uncovered. Observation on 03/25/2025 at 11:37 a.m. to complete temperature checks on cooked foods ready for food service revealed: Squash for regular and mechanical soft meals remained on the stove with burner off and uncovered rendered a temperature for pan #1 of 135 degrees and pan #2 of 88 degrees. Observation on 03/25/2025 at 1:13 p.m. of the survey test tray revealed the following: Regular test tray was delayed and delivered 73 minutes after the start of meal service time of 12:00 p.m. Puree test tray was delayed and delivered 73 minutes after the start of meal service time of 12:00 p.m. Regular diet chicken fried chicken temperature reading was 149 degrees. Regular diet zucchini temperature reading was 95 degrees and was bland in flavor. Regular diet mashed potatoes temperature reading was 99 degrees, and creamy and bland in flavor. Pureed zucchini temperature reading was 90 degrees and was mushy and bland in flavor. Pureed chicken fried chicken temperature reading was 89 degrees, had a greasy flavor, no seasoning, and bland in flavor. Pureed cake had visible lumps which required chewing and was bland in flavor. During an interview on 03/24/2025 at 10:06 a.m., Resident #42 stated the facility needs a new cook .the food, we are not going to talk about. Resident #42 would not go into details. During an interview on 03/24/2025 at 10:48 a.m., Resident #47 stated, some of the food is good and some is bad referring to the flavor. During an interview on 03/24/2025 at 11:04 a.m. Resident #63 stated, the food is not appetizing, the food comes cold, and it is the same thing all the time. During an interview on 03/24/2025 at 3:40 p.m. Resident #19 stated, the food is cold, breakfast eggs are almost always cold, and lunch and dinner is usually lukewarm, but never hot. A confidential group interview on 03/25/2025 at 2:00 p.m. revealed 15 out of 16 residents stated the food is constantly cold, not flavorful, and lacks variety. During an interview on 03/26/2025 at 10:46 a.m., the DM stated the cook begins preparing lunch at 9:00 a.m., and at 11:30 am, cooked food temperatures should be checked followed by serving at 12:00 p.m. During an interview on 03/26/2025 at 10:56 a.m., the AD stated that Resident Council information was provided to the ADM and DON. She stated the complaints of cold food, needing food warmers, and not flavorful foods is consistent, and she notified the DM each time. She stated she oversees the Resident Council activities. She stated the kitchen changed a few things such as more vegetables but has not resolved the consistent complaints. She stated lunch is scheduled at 12:00 p.m. in the dining room followed by service to the resident rooms 30 minutes later. She stated lunch typically begins at 12:00 p.m. with some variations of 15-20 minutes. During an interview on 03/26/2025 at 11:19 a.m. with Resident #361, she stated the food is not bad and stated that sometimes breakfast is cold but states the facility staff are getting it worked out. During an interview on 03/26/2025 at 11:57 a.m., CNA G stated the residents' food is usually out in the halls at 12:30 p.m. or later. CNA G stated she could not recall the resident's specific complaints regarding cold food. During an interview on 03/26/2025 at 12:12 p.m., CNA H stated, at times, she will take the trays and warm them up if the residents ask. She stated this usually occurs because they left the tray sitting for some time. During an interview on 03/26/2025 at 12:33 p.m., CNA I stated breakfast is served about 8:00 a.m. in hallway 400 and. stated lunch is usually served about 12:30 p.m. or 12:45 p.m. He stated he received some complaints about cold food and options, which he reported to the charge nurse. During an interview on 03/26/2025 at 1:47 p.m., CK D stated she normally begins preparing lunch at 10 a.m. for all diets, at 10:30 a.m. - 11:00 a.m. she begins to observe meal tickets, at 11:30 a.m. conducts cooked food temperature checks, and at 12:00 p.m. begins meal service for dining room tickets. She stated she usually begins meal service for room tickets about 12:25 p.m. She said she is very strict about having the plates hot and if they are not hot, she will enter them into the oven to warm up before serving. She states she does not send her food out cold. She stated that she has received a few resident complaints due to lack of flavor but stated she cannot do much to adjust the flavor of the foods as she follows the recipes and the residents do not like this response. She stated there are some foods that come with more salt than others at times, such as gravy. During an interview on 03/26/2025 1:59 p.m., DA E stated that she has heard complaints of food not having flavor, but stated on occasion she will taste the food for the cook, and she believes it is seasoned well and flavorful. During an interview on 03/26/2025 2:04 p.m., DA F stated food is cold at times as kitchen staff will deliver the carts of food to the resident hallways, and direct care staff will leave them sitting for a bit of time, which could potentially cause the food to be cold. She stated breakfast is prepared and trays are ready by 7:30 a.m. for dining room service but could not recall what time meals are taken out to the residents in the dining room nor the hallways. She stated she has tasted the food and has not seen a concern with the flavor. During an interview on 03/26/2025 at 2:09 p.m., the DM stated vegetables and starch foods should be prepared no earlier than 90 minutes before meal service. She stated that food preparation can start 3 hours before meal service. She stated that she is not sure why CK D would begin preparing vegetables more than 165 minutes before meal service but would discuss this with her. She stated she is not sure why there are issues with food coming out cold. She stated the AD has notified her of food being served cold to the residents. She stated she has not been notified by the AD of resident complaints regarding the flavor of the foods. She stated that she and the other cooks follow the recipes and the seasoning recommended. She stated she also meets with residents on one-on-one to get information on their preferences. She stated this is the first she has heard that food is not flavorful. She stated residents notified her of more fruits and vegetables being requested. She stated that foods being cold can be contributed to not having hot plate bottoms with lids, which has been conveyed to the dietician and AD who communicate to ADM. She stated she does not get complaints about foods directly and has not been given information from resident council meetings or AD. During an interview on 03/26/2025 at 3:15 p.m., the DM stated her corporate resource staff instructed her to respond to surveyor that there is no set-in stone time for kitchen staff to begin preparing foods to the time when food is served. She stated she believes it should be no more than 3 hours prior to meal service Giving the DM the example of zucchini sitting from 9:35 a.m. until 12:00 p.m., she agreed this was too long for vegetables to be out in the open uncovered. She stated vegetables should be the last item to cook for meal service, and that is what she trains her staff to follow. Review of the facility's document titled Grievances from March 2024 to March 2025 revealed: 07/20/2024 resident states that lunch tray comes out late and that he had to go get it from a cart. Review of the facility's document titled Resident Council Meeting Minutes from April 2024 to March 2025 revealed: April 2024 Resident Council attendees discussed food variety and service; and requested more variety food options for snack and meals. July 2, 2024 Resident Council attendees discussed that a lot of the food is still being brought to them cold; Requested to get hot plates/warming carts to keep the food warm; Complained that when they can order the fried eggs, they come out cold; Do not like the catfish - not enough flavor; Stated that the noodles are being overcooked and coming out rubbery; Requested to have more variety of side options other than oranges and applies. September 6, 2024, Resident Council attendees discussed food still coming out cold, even in the dining room; and requested to get food warming carts and better lids to help keep the food from getting cold. October 4, 2024, Resident Council attendees discussed the request for food warmers to keep the food from coming out cold; and also requested for more seasoning on the meat. November 8, 2024, Resident Council attendees discussed food coming out cold; requested for warming carts and better food covers to keep the food warm; and wants the meats and sides to be more seasoned. December 6, 2024, Resident Council attendees discussed wanting the meats and sides to have more seasoning. January 10, 2025, Resident Council attendees discussed food trays being delivered to the rooms cold; and requested food warming carts to keep the food from getting cold. February 7, 2025, Resident Council attendees discussed the meat and vegetables needing more seasoning; and requested baked veggies instead of boiled. March 12, 2025 Requested for the vegetables to be baked instead of boiled. Review of the facility's document titled Diet and Nutrition Care Manual reviewed and approved on 05/23/2024 by Medical Director, Administrator, Registered Dietician Nutritionist, Director of Nursing, Speech Language Pathologist, and Food Service Director reflected: IDDSI Food and Drink Texture Descriptions Food/Drink Consistency Level 4, Extremely Thick - Pureed Does not require chewing. No lumps Foods to Avoid on an IDDSI Level 4: Pureed Diet Food Characteristics and Examples of Foods to AVOID visible lumps in pureed food or yogurt.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 10 residents (Resident #31, Resident #71, and Resident #76) reviewed for rights. The facility failed to ensure CNA B knocked on Resident #31, Resident #71, and Resident #76's doors when going into the residents' rooms. The deficient practice could place residents at risk of feeling like their privacy was being invaded or the facility was not their home. Findings included: Review of Resident #31's Face Sheet dated 03/24/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #31's diagnoses included heart disease, muscle wasting, shortness of breath, pain in joint, cognitive communication deficit (problems with communication), dysphagia (difficulty swallowing), heart failure, morbid (severe) obesity, dependency on oxygen, anxiety (feeling of uneasiness or worry), unsteadiness on feet, chest pain, hyperlipidemia (high cholesterol), and hypertension (high blood pressure). Record review of Resident #31's Quarterly MDS assessment dated [DATE] revealed Resident #31 had a BIMS score of 12 indicating moderate cognitive impairment. Review of Resident #71's Face Sheet dated 03/24/2025 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #71's diagnoses included dementia (memory, thinking, difficulty), muscle wasting, unsteadiness on feet, abnormalities of gait and mobility, need for assistance with personal care, pain in left knee, muscle weakness, hypertension (high blood pressure), dysphagia (difficulty swallowing), and cognitive communication deficit (problems with communication). Record review of Resident #71's Quarterly MDS dated [DATE] revealed Resident #71 had a BIMS score of 04 indicating severe cognitive impairment. Review of Resident #76's Face Sheet dated 03/24/2025 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #76's diagnoses included disorder of brain, epilepsy (seizure disorder), lack of coordination, urinary tract infection, muscle wasting, dysphagia (difficulty swallowing), cerebral infraction (stroke), cognitive communication deficit (problems with communication) and retention of urine. Record review of Resident #76's Quarterly MDS dated [DATE] revealed Resident #76 had a BIMS score of 11 indicating moderate cognitive impairment. Observation of 400 hall on 03/24/2025 at 12:55 p.m., revealed CNA B did not knock on Resident #31, Resident #71 and Resident #76's door before entering. An interview with Resident #31 on 03/25/2025 at 9:06 a.m., revealed that staff did not always knock on her door. She said that staff would forget to knock. She would like for them to knock all the time because there were times she would be changing. She said it irritated her when staff would come in and out so much without knocking. An interview with Resident #76 on 03/25/2025 at 9:14 a.m., revealed that staff did not always knock. He said that he would like for staff to knock all the time. He said he would get irritated when staff just walked into his room, especially when he had the door closed. During an attempted interview with Resident #71 on 03/25/2025 at 9:25 a.m., she only said she was good, but she was cold and wanted some coffee. An interview with CNA B on 03/19/2025 at 1:11 p.m., revealed that she had been trained on resident rights. She said the policy for knocking was that staff were supposed to always knock before entering. She said that all staff were required to knock before entering the resident's room. She said that there was no time that the staff should not knock before entering. She said if staff did not knock, the resident may feel disrespected or that staff were invading their privacy. She said that the charge nurse or management monitor to ensure staff were knocking on the residents' doors. She said that the charge nurse or management monitored by observations and asking the residents. She said she was not sure why she did not knock on the residents' doors before entering. An interview with the DON on 03/26/2025 at 9:09 a.m., revealed she and staff had been trained on resident rights. She said the policy was that staff were to knock on the door and allow a coherent resident to respond. She said that for a noncoherent resident, staff were to knock on the door, and tell the resident what they were and what they were there for. She said that staff were to knock except if it was an emergency such as the resident on the floor. she said it was important for staff to knock because it was the resident's right. She also said that if staff did not knock on the door, the resident may feel exposed. She said that all management was responsible for monitoring to ensure staff were knocking. She said that management monitored it by doing frequent rounds, and in-service trainings. She said she did not know why the staff were not knocking on the doors. An interview with the ADM on 03/26/2025 at 9:20 a.m., revealed that he and staff had been trained on resident rights. He said the policy was to knock on the door and inform the resident what they were there to do. He said all staff were supposed to knock before entering the residents' room. He said that it was important for staff to knock on the residents' door for their privacy. He said the resident may feel like their privacy was not being respected. He also said the resident may not know who the staff member was, and it may scare them. He said that the charge nurse and all department heads were to monitor to ensure that staff were knocking on the door. He said management monitored knocking by observation of the halls. He said he did not know why staff were not knocking on residents' doors before entering. Record Review of Resident Rights dated July 2017 revealed residents have the right to be treated with respect and dignity. Residents have the right to personal privacy and confidentiality.

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1 (Hall 200-MA Cart) of 7 Medication carts reviewed for drug storage. The facility failed to ensure one medication cart (Hall 200-MA Cart) was locked and that medications were securely stored. This failure could place residents at risk to obtain and take medications not prescribed for them which could result in resident's harm due to adverse medication reactions. Findings include: Observation on 03/26/25 at 11:15 AM revealed the medication cart, assigned to MA-A located on 200 hall, was unattended and unlocked for approximately 10 minutes, and medications were accessible to residents. The cart was unlocked, and multiple staff walked down the hall and past the unlocked medication cart but failed to lock the cart. In an interview on 3/26/25 at 11:20 AM, MA-A stated, the policy was to keep the medication cart locked 24 hours a day/7 day a week and to never leave it unattended unlocked. He stated it was important to keep the cart locked because anybody could steal the drugs and residents could take the pills. He also stated, if a resident had taken the pills, then staff would have to call the nurse and the doctor to report it. He stated the resident could become sick and could require hospitalization if they had taken medications from the cart. He stated that he was told to go to the dining room and he messed-up and forgot to lock the cart. In an interview with RN-C on 3/26/25 at 11:29 AM, she stated, the policy was to keep the medication cart locked. She stated it was important to keep residents or anybody else from getting medications. She stated residents getting the medications could be dangerous and a resident could take a controlled medication. She stated a resident could take a medication that they were allergic to. She also stated the resident could get sick, intoxicated, or die by taking medications from the cart. In an interview on 3/26/25 at 12:56 PM, the DON stated, the policy was for the medication cart to be locked to secure the medications. She stated it was important to secure medications and avoid having residents opening the cart and getting medications. She stated residents could take medication from the cart which could cause adverse effects with their own medications. She also stated examples of adverse effects could include nausea or headaches. In an interview on 3/26/25 at 12:58 PM the ADM stated, the policy for medication pass was the charge nurse should lock the medication cart if going away from the cart at any time. He stated this was important, so a resident doesn't get in the cart and take medications not prescribed for them. He stated the unlocked cart could result in drug diversions and residents could miss getting their medications. He also stated that residents could take medications that were contraindicated with their own medications and that could cause adverse unwanted affects. He stated an example of an adverse effect possible was a laxative could cause excessive bowel movements. A record review of facility policy titled, Medication Storage in The Facility-FAC19Rev 2 and dated 11/13/18 reflected the following: .Medications and biological's are stored safely, securely, and properly . The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .

Based on interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not elope from the facility from an emergency exit door after CNA C utilized the exit code to the emergency door. LVN B observed the resident at a gas station after leaving work and did not stay with him until someone from the facility could assist. The temperature outside was a high of 95 degrees. He was later taken to the hospital where he tested positive for cocaine. This deficient practice placed residents at risk for unsafe elopements, falls, injuries, dehydration, and hospitalization . An Immediate Jeopardy (IJ) existed from 08/03/24 - 08/04/24. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation. This deficient practice placed residents at risk for unsafe elopements, falls, injuries, dehydration, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including type II diabetes, pressure ulcers, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), acute kidney failure, and acquired absence of right leg below the knee. Review of Resident #1's admission MDS assessment, dated 05/19/24, reflected a BIMS of 9, indicating a moderate cognitive impairment. Section E (Behavior) reflected he had not exhibited any wandering behaviors. Section GG (Functional Abilities and Goals) reflected he utilized a wheelchair. Review of Resident #1's admission care plan, dated 06/21/24, reflected he was at risk for re-traumatization related to history of trauma and relocation stress syndrome or transfer trauma related to being homeless with an intervention of monitoring behavior episodes and attempting to determine the underlying cause. Review of Resident #1's Elopement/Wandering Evaluation, dated 06/16/24, reflected he was a low risk of elopement. Review of Resident #1's psychologist assessment, dated 06/21/24, reflected the following: [Resident #1] is new to this provider, introduced self as psychologist. Discussion focused on his desire to be outside of the facility. He reported I want to go out on pass . Review of Resident #1's progress notes, dated 06/26/24 and documented by the DON, reflected the following: [Resident #1] began screaming that he wanted to be discharged . Review of Resident #1's psychologist assessment, dated 07/22/24, reflected the following: [Resident #1] approached provider in the common area. He as communicating a desire to understand how he can sign out of the facility. Review of Resident #1's progress notes, dated 08/03/24 at 4:11 PM and documented by the DON, reflected the following: Staff reported [Resident #1] left the facility and went to the store the staff verified that the resident was not in the facility . Review of Resident #1's progress notes, dated 08/03/24 at 6:09 PM and documented by the DON, reflected the following: Admin spoke with [Resident #1]'s [FM D] regarding the resident leaving. [FM D] reports that [Resident #1] frequents a store on (road), (store). Staff in route to location. Review of Resident #1's progress notes, dated 08/03/24 at 6:19 PM and documented by the DON, reflected the following: Notified NP of [Resident #1] leaving the facility. The NP reports the resident has a history of leaving previous facilities. Review of Resident #1's progress notes, dated 08/03/24 at 6:50 PM and documented by the DON, reflected the following: Clinical Resource found [Resident #1] at the store and the resident refusing to return to (facility). 911 was called per family request . Review of Resident #1's progress notes, dated 08/03/24 at 10:34 PM (late entry) and documented by LVN A, reflected the following: [LVN B] leaving work and noticed [Resident #1] at gas station next to facility. [LVN B] notified this writer [LVN B] stopped and spoke with [Resident #1] this notified ADON that [Resident #1] at gas station and that I was going to check on him when this writer arrived at gas station, [Resident #1] was not at location, returned to facility notified ADON and this writer and staff along with ADON started search throughout facility and surrounding facility after search this writer returned to gas station to research premises and bathroom at gas station drove around neighborhood to continue search then returned to facility to notify ADON, DON, and ADM. [sic] Review of Resident #1's ER records, dated 08/03/24, reflected the following: Acute Psychosis - Found by EMS yelling at pedestrians, UDS positive for cocaine. - Likely 2/2 crack cocaine superimposed on schizophrenia. During an interview on 08/07/24 at 8:36 AM, the ADM and DON stated CNA C on the 300 hall left through the emergency door using the door code on 08/03/24. The ADM stated he was not sure how she got the code as only himself, the DON, and the MAINTD had the code. He stated this exit was to be used for emergencies only. He stated CNA C did not ensure the door was latched. He stated after staff realized Resident #1 was missing, he reviewed video footage and observed him leaving through the 300 hall door around 1:30 PM. The DON stated LVN B called LVN A around 2:30 PM and stated she saw Resident #1 at the gas station near the facility. The DON stated LVN A went to the gas station but he was no longer there. The ADM stated they had their clinical resources from other facilities assist with a search and he was found around 6 PM at a store his FM (D)'s suggestion. The ADM stated the Resident #1's FM (D) wanted him to be sent to the hospital for evaluation where cocaine was found in his system. The ADM stated although he had a history of leaving facilities AMA, he had a low elopement risk and had never voiced wanting to leave or exhibited exit-seeking behaviors. The DON stated the emergency exit door codes were changed monthly and she had conducted an in-service regarding the codes when she first started in May (2024) and had re-in-serviced staff starting on 08/03/24 and going forward. During an interview on 08/07/24 at 9:42 AM, CNA C stated Resident #1 had never voiced wanting to leave the facility or exhibited exit-seeking behaviors. She stated the day he left (08/03/24), she last saw him around lunchtime (12:00 PM) when she asked him if he wanted to eat in the dining room or in his room. She stated he ate in the dining room and she did not see him again before her shift ended. She stated around 1:40 PM, she needed to take trash and dirty laundry outside to get ready for the on-coming shift. She stated she could not remember how she got the code to the emergency exit doors. She stated she should have not utilized it but she was trying to get everything cleaned up quick and it was easier to dispose of her trash and laundry outside of the door. She stated she wished the door had closed quicker so he had not been able to leave. She stated she no longer had the code and she had been in-serviced on not utilizing emergency exit doors for any reason unless there was a true emergency. During an interview on 08/07/24 at 11:26 AM, the LSRD stated he was notified on 08/03/24 that the exit door codes had possibly been compromised and he notified the ADM immediately because he knew how to re-set the codes. He stated he knew the codes were re-set that day (08/03/24). He stated it was important for staff not to utilize emergency exit doors as they were for emergencies, such as fires, only. During a telephone interview on 08/07/24 at 2:49 PM, Resident #1's FM D stated she believed the facility was aware Resident #1 had a history of leaving facilities. She stated she made it very clear that while at the facility he was not to be outside of the facility alone. She stated the NP was very familiar with his history. She was very tearful and stated it was very upsetting to her that he was able to leave. She stated when she received the call that he was missing, her heart dropped. She stated he was still in the hospital and being treated for dehydration and high kidney levels. She stated he also had drugs in his system. She stated he would not be discharged until a facility with a locked unit had an available bed for him. During an interview on 08/08/24 at 1:45 PM, the ADMC stated she had been in-serviced on exit door codes and elopement. She stated she did not know the codes for the emergency exit doors and only the ADM and MAINTD had the codes. She stated if they needed the code they could call them at any time, or just press on the bar for 15 seconds and the door would open. She stated the emergency exit doors were only for emergencies such as a fire. She stated if she saw a resident off-site, she would stay with the resident and call the ADM and/or DON immediately. She stated the only residents that could be outside alone were the ones not in the elopement binders which were located at the nurses' station and Receptionist's desk. During an interview on 08/08/24 at 1:52 PM, CNA E stated she was in-serviced on elopement procedures before her shift several days prior. She stated if there was an elopement or a resident missing, a code green should be called. She stated residents that were a high-elopement risk were in the elopement binders located at the nurses' station and Receptionist desk. She stated as a CNA it was important to lay her eyes on each of her residents at least every hour. She stated no door codes should be given out to any families, residents, or vendors. She stated she did not know the codes to the emergency exit doors and they should not be used except during an emergency. During an interview on 08/08/24 at 2:18 PM, the SW stated she had been in-serviced several days prior on the elopement process, how to determine which residents were at a higher risk, and their code status (code green was for elopement). She stated residents that were at a higher risk were in elopement binders located that the nurses' station and Receptionist desk. She stated there were also elopement assessments in their charts. She stated if a resident was missing, it was important to determine if they were out on pass. She stated if they still could not be located, she would notify the ADM and DON immediately. She stated if she saw a resident out in the community, she would stay with them and call the ADM/DON to ensure they got back to the facility safely. She stated she did not know the code to the emergency exit doors and only the ADM and MAINTD did, but if there were an emergency, the handle could always be pressed for 15 seconds until the door unlocked. During an interview on 08/08/24 at 2:31 PM, the ADON stated he was in-serviced on elopement. He was able to state where the elopement binders were located. He stated floor staff should be laying eyes on their residents at a minimum of every two hours. He stated if a resident could not be found, the ADM and DON should be notified immediately. He stated if he saw a resident out in the community, he would stay with them to make sure they were safe and would contact the ADM and DON. He stated he did not know the code to the emergency exit door and they should never be used except for emergencies. During an interview on 08/08/24 at 2:55 PM, LVN F stated she had been in-serviced on elopements several days ago. She stated there were elopement binders at the nurses' station and Receptionist desk which contained the residents that were at a high-risk of elopement. She stated elopement assessments were completed when they were admitted and she always asked if they had a history of it. She stated it was important to notice if a resident was continuing to go to the front door all the time to ensure they did not leave with a visitor going in/out. She stated she did not know the code to the emergency exit doors and those doors should only be utilized for an emergency. She stated if a resident was missing, code green would be called, which was their code for an elopement. During an interview on 08/08/24 at 3:04 PM, LVN G stated he was with agency but had been in-serviced on elopements prior to his shift that day. He stated residents that were a high-risk of elopement had behaviors such as wandering aimlessly. He stated there also was an elopement binder with residents at high risk at the nurses' station and the Receptionist desk. He stated if a resident could not be found he would call a code green. He stated he would then immediately notify the ADM and DON. He stated he did not know the code to the emergency exit doors and any other door cods were not to be given out to any residents, family members, or vendors. Review of an in-service, dated 05/02/24 and conducted by the DON, reflected all stat were in-serviced on the exit doors at the end of resident halls were for emergencies only and that the codes had been changed. Review of an in-service, dated 08/03/24 and conducted by the CRN, reflected the ADM and DON were in-serviced on their Elopement Policy. Review of the facility's IDT meeting notes, dated 08/03/24, reflected all residents' wandering/elopement assessments were reviewed and/or updated as necessary. Review of the facility's Ad Hoc QAPI meeting agenda, dated 08/04/24, reflected the ADM, DON, ADON, SW, MD, and CRN were in attendance. Review of an invoice from a door company, dated 08/04/24, reflected all doors were tested for working alarms/wander guard systems to ensure they were in working order. Review of a Counseling/Disciplinary Notice, dated 08/04/24, reflected CNA C received a written warning for the following: [CNA C] was counseled regarding improper use of emergency exit due to safety. [CNA C] used emergency exit door to take out trash after lunch. Review of a Counseling/Disciplinary Notice, dated 08/04/24, reflected LVN B received counseling/written warning for not staying with Resident #1 when she saw him at the gas station. Review of in-services, from 08/03/24 - 08/04/24, reflected all staff were in-serviced on emergency exits, reporting elopements, door codes, notifying the ADM/DON, and staying with a resident until help arrived if seen off the facility premises. Review of the facility census, from 08/03/24 - 08/07/24, reflected daily head counts were being conducted for all residents. Review of the facility's Elopement/Unsafe Wandering Policy, revised 01/2022, reflected the following: It is the policy of this facility to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. . Elopement occurs when a resident leaves the facility premises or a safe area without authorization (i.e. an order for discharge, appointment, or leave of absence) and/or any necessary supervision to do so. An Immediate Jeopardy (IJ) existed from 08/03/24 - 08/04/24. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation.

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, the comprehensive person-centered care plan, and the residents' choices for one (Resident #2) of four residents reviewed for quality of care. The facility failed ensure Resident #2 was assessed by a nurse after he was found on the ground in the dining room on [DATE]. He laid on the ground for over an hour and a half until family members arrived and assisted him to bed. There was no nursing documentation or incident report created by RN H. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 5:22 PM. While the IJ was removed on [DATE] at 3:55 PM, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not receiving necessary medical care, harm, and death. Findings included: Review of Resident #2's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including age-related physical debility, repeated falls, muscle wasting and atrophy (wasting away), and history of stroke and heart attack. Review of Resident #2's quarterly MDS assessment, dated [DATE], reflected a BIMS score of 00, which indicated his cognition was severely impaired. Section E (Behavior) reflected he had not had any physical or verbal behavioral symptoms directed toward others. Section GG (Functional Abilities and Goals) reflected he required substantial/maximal assistance with being able to sit to stand. J (Health Conditions) reflected he had not had any recent falls. Review of Resident #2's quarterly care plan, dated [DATE], reflected he was at risk for falls related to gait/balance problems and being unaware of safety needs and had actual falls on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] with an intervention of monitoring/documenting/reporting for s/sx: pain, bruises, change in mental status, new onset: confusion, sleepiness, agitation. Review of Resident #2's progress notes in his EMR, from [DATE], reflected no documentation about him being found on the floor in the dining room. Review off the facility's 24-hour report, dated [DATE], reflected no documentation regarding the incident in the evening of [DATE]. Review of Resident #2's vitals in his EMR, on [DATE] reflected the last time his blood pressure, o2 sats, respirations, and pulse were taken was in the morning of [DATE]. Review of Resident #2's progress note, dated [DATE] at 3:27 AM and documented by LVN I, reflected the following: CNA requested this nurse to check on [Resident #2]. Upon assessment, [Resident #2] noted with no signs of life. No apical pulse, no breath sounds, no BP. DNR on file and confirmed by 2 nurses. DON notified. Call placed to EMS to pronounce. Review of Resident #2's progress note, dated [DATE] at 3:55 AM and documented by LVN I, reflected the following: EMS arrived. EKG confirmed [Resident #2] deceased . Pronounced at 3:54 AM. Observation of a photograph of Resident #2, dated [DATE] at 7:34 PM and taken by CR J, revealed Resident #2 laying on his right side in the dining room next to his wheelchair. He was covered with a blanket. Observation of a photograph of Resident #2, dated [DATE] at 8:05 PM and taken by FM K, revealed Resident #2 laying on his back in the dining room next to his wheelchair. His eyes were slightly open and there was a small, darkened area above his left eye. Observation of video footage from the dining room on [DATE] revealed Resident #2 roll into the dining room in his wheelchair around 6:35 PM. Two aides were seen walking up to him and talking to him and then they walked away. Resident #2 rolled over to the left (and further from the viewpoint of the video camera) a few tables. Due to tables and chairs partially obstructing the view, it was hard to fully determine what happened next. It did appear that Resident #2 laid a sheet/blanket on the ground. No one is seen pushing him out of his wheelchair, but he either fell or laid on top of the sheet/blanket around 6:38 PM. It was unknown if he hit any part of his body on the way down. There were no staff members seen in the footage at that time. CNA M noticed him on the floor and went over to him. He then left the dining room to get RN H. RN H went to Resident #2 and bended slightly at the knees to speak to him. Due to the tables and chairs obstructing the view, no movement by Resident #2 was observed. RN H spent about two minutes with him and then left the dining room. He did not reappear in the footage until Resident #2's FM K and L arrived and transferred Resident #2 to his wheelchair. During a telephone interview on [DATE] at 10:31 AM, FM K stated she received a call from RN H around 7:35 PM notifying her that Resident #2 was on the ground and they were unable to get him up. She stated she and FM L arrived at the facility at 8:05 PM they found him on the ground in the dining room with no staff around. She stated RN H told them he was unable to get him up or assess him because he had been so combative. She stated FM L was able to get him into his wheelchair without anyone offering to assist. She stated he was not aggressive or combative at all. She stated RN H still did not assess him, he just messed with his catheter because there had been a kink in the tubing. She stated they pushed him to his room and got him into bed without any offer of assistance by staff. She stated she then noticed a small laceration above his left eye. She stated she had seen him earlier that day and it had not been there. She stated he had been more alert during the day and it worried her. She stated before she and FM L left the facility, RN H did not perform any kind of assessment. She stated just a few hours later around 4:00 AM she got a fall notifying her that Resident #2 had passed away. She stated it broke her heart to think he spent his last night laying on the cold, hard floor. During an interview on [DATE] at 10:52 AM, CR J stated he was having a hard time because his friend had passed away earlier that morning. He stated the night prior, [DATE], he was notified by another resident that Resident #2 was on the floor in the dining room. He stated he went to the dining room and brought a blanket for him. He stated he took a picture and waited for FM K and L to get there. He stated from 7:30 PM - 8:05 PM, no staff members checked on him. He stated when FM L assisted him to his wheelchair, he was not aggressive or combative. During an interview on [DATE] at 11:34 AM, RN H stated he was working the night before, [DATE]. He stated he did not see Resident #2 get out of the wheelchair but a CNA came and notified him that he was on the floor, but he could not remember what time it had been. He stated he did remember the residents had been done eating by that point and were not in the dining room. He stated he walked into the dining room and asked him what happened and Resident #2 told him to leave him alone. He stated he couldn't conduct an assessment and do neuro checks because he was being combative. He stated after about five minutes, he decided he could not force him to get up, but believed he was safe, and he would try a little later. He stated his plan was to hopefully let him calm down, give it time, and maybe he would want to get up. He stated he ended up not trying to assess him again. He stated he was not sure how much time went by until FM K and L arrived. He stated he explained to them right away that Resident #2 had put himself on the floor and would not let them (staff) do anything. He stated FM L was able to get him into the wheelchair, they talked to him for a bit, and put him to bed. He stated he was not combative towards them. He stated he did not do any neuro checks after they left because he would not let him. He stated as far as documentation and an incident report, he was guilty and he messed up. He stated he felt like he remembered notifying LVN I upon shift change. During a telephone interview on [DATE] at 2:41 PM, the NP stated she as notified yesterday evening ([DATE]) that Resident #2 either fell or laid himself on the ground. She stated she was told he would not let the staff get him up but the family was eventually able to do so. She stated she her expectations would be that once he was finally up, some kind of assessment be conducted, such as vitals, neuro checks, ensured he did not his head, range of motion, and a full-body skin check. She stated it would not be okay for a resident to be left on the ground for over an hour and a half. She stated if staff had been unable to get him up or assess him, she would assume they would have notified her and also have a staff member sit with him to monitor him. She stated she would also expect to see ample documentation regarding the incident along with an incident report. During a telephone interview on [DATE] at 2:47 PM, LVN I stated RN H did notify her that Resident #2 had put himself on the floor on the evening of [DATE]. She stated she was not told how long he was on the floor. She stated RN H told her he was unable to assess him because he was combative. She stated she was able to assess him because he was resting. During an interview on [DATE] at 3:58 PM, the DON stated her expectations, from the incident the night prior with Resident #2, would be that RN I assessed his behavior. She stated she knew the family came to visit almost every night and she was not sure if RN I was just waiting for them to get there to help intervene. She stated the NP had been working with the resident every day on his combativeness and agitation. She stated he had recently been started on Seroquel. She stated her expectation would be that the nurse conducted an assessment after the resident was gotten up. She stated RN I should have documented the incident in Resident #2's progress notes and should have created an incident report. She stated it was important to document thoroughly so everyone was on the same page with what was going on with the residents. Review of the facility's Fall Management System Policy, revised ,d+[DATE], reflected the following: It is the policy of this facility to provide each resident with appropriate assessments and interventions to prevent falls and to minimize complications if a fall occurs. . 3. When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record. Review of the facility's Incidents and Accidents Policy, reviewed ,d+[DATE], reflected the following: a. Render timely assistance. Do not move the victim until he/she has been examined for possible injuries; b. If possible, move the injured to the treatment room, or if it is a resident in his/her room, move the resident to his or her bed; and c. If assistance is needed, summon help. If you cannot leave the victim, ask someone to report to the nurses' station that help is needed; 2. Licensed nurse will assess the resident, including vital signs, neuro checks if needed, complaints of pain and location, and determine of treatment or additional care is needed, including accessing the EMS system. The ADM and DON were notified on [DATE] at 5:22 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on [DATE] at 12:45 PM: F684: Quality of Care: The notification of Immediate Jeopardy states as follows: On [DATE], the facility failed to assess or assist Resident #1 after he transferred himself onto the floor and laid there for over an hour and a half without being checked on. The facility had no way of knowing if the resident had fallen or had hit his head and no monitoring took place. The facility failed to provide any documentation in Resident #1's chart or complete an incident report regarding this incident. Resident #1 passed away approximately eight hours later. 1. Medical Director was notified by DON of the IJ on [DATE] at 6:48 pm. 2. Incident reports from the last 7 days were audited to ensure assessment of resident was completed. An audit was completed on [DATE] by regional clinical resource team. 3. Licensed nursing staff were in-serviced regarding managing residents with combative behaviors on [DATE] by DON/designee. Full-time, PRN, contracted staff, or new licensed nurses will be in-serviced prior to their shift. 4. DON was in-serviced by clinical Resource and quiz completed on [DATE]. This training included: head to toe assessment of patients after a fall and initiation of neurological checks and completion of incident report. 5. Licensed Nurse involved was provided with 1:1 counseling regarding resident assessments and incident report documentation on [DATE] by ED. 6. In-servicing began on [DATE] for Licensed Nurses to include head to toe assessment of patients after a fall and initiation of neurological checks and completion of incident reports. Will be completed by [DATE] by DON or designee. Any Nurse who has not received the in-service will not be allowed to work until in-service has been completed. Any contracted staff, PRN or new licensed nurse will be in-serviced prior to their shift. In-service will be completed by DON/Designee. ED/DON or designee will review staffing schedule daily to ensure in-services are completed until reviewed by QAPI committee x 3 months and found to be in substantial compliance. 7. All licensed nursing staff will be in-serviced regarding the process of completing head-to-toe assessment after a fall and initiation of neurological checks upon hire, annually, and as needed by DON/designee starting on [DATE] and will be ongoing. 8. DON or Designee will monitor incidents and accidents daily during morning meeting to ensure completion of a head-to-toe assessment and initiation of neurological checks as needed. This practice will be ongoing. 9. Weekend Nursing supervisor will review incidents and accidents on Saturday and Sunday during the weekend to ensure completion of a head-to-toe assessment and the initiation of neurological checks. This will be reviewed through QAPI committee x 3 months to ensure substantial compliance. 10. Ad-hoc QAPI with IDT, medical director, and governing body representatives was completed on [DATE] to discuss findings of immediate jeopardy and POR; F684. 11. Summary of IJ and corrective action results will be reviewed by QAPI Committee monthly x 3 months beginning [DATE] or until substantial compliance established to ensure ongoing compliance. The Surveyor monitored the POR on [DATE] as followed: During interviews conducted on [DATE] between 1:38 PM - 3:40 PM, two RNs and five LVNs from both shifts stated they were in-serviced on falls, assessments, and aggressive behaviors before they worked their most recent shifts. They all stated if a resident was found on the floor, they would treat it as an unwitnessed fall which included a head-to-toe assessment, ROM, and neuro checks would be initiated. All stated they would complete an incident report and would document thoroughly in the resident's chart. They stated they would report the fall to the DON, family, and NP immediately after assessing the resident. They all stated they would not get a resident off the ground until they were assessed because they needed to make sure they were not injured before moving them. They stated if they were combative/resisting, they would stay with the resident because anything could happen quickly especially if they possibly hit their head. They stated they would call another nurse for assistance and if they still could not get the resident to comply, they would contact the NP. They all stated documentation was imperative because if you did not document, it did not happen, and it was important for the following nurses to know the details of the incident. Review of the facility's Ad Hoc QAPI agenda, dated [DATE], reflected the MD, ADM, DON, CRN, two ADMs from sister facilities, two DONs from sister facilities, and two Regional Nurses were in attendance. Review of an Audit of Incident Reports, from [DATE] - [DATE] and conducted by the CRN, reflected all incident reports were reviewed to ensure residents had been assessed appropriately after their falls and the appropriate parties had been notified. Review of an in-service entitled Falls and Documentation, dated [DATE] and conducted by the CRN, reflected the ADM and DON were in-serviced on the following: If a fall occurs or patient observed on floor, Nurse should complete a full head to toe skin assessment, including ROM to ensure no injuries immediately, if fall is unwitnessed neuro checks should be started, if neuro checks are already being conducted from prior incident, then new neuro checks should be initiated. Neuro checks should also be initiated for witnessed falls if patient has injury to head. An incident report should be completed, a pain assessment and fall risk assessment, if skin injury occurs then a skin assessment should be completed as well. If patient refuses assessment, document and call MD/NP/RP immediately. Review of an in-service entitled Falls and Documentation, dated [DATE] - [DATE] and conducted by the CRN, reflected nurses from all shifts (Including RN H) were in-serviced on the following: If a fall occurs or patient observed on floor, Nurse should complete a full head to toe skin assessment, including ROM to ensure no injuries immediately, if fall is unwitnessed neuro checks should be started, if neuro checks are already being conducted from prior incident, then new neuro checks should be initiated. Neuro checks should also be initiated for witnessed falls if patient has injury to head. An incident report should be completed, a pain assessment and fall risk assessment, if skin injury occurs then a skin assessment should be completed as well. If patient refuses assessment, document and call MD/NP/RP immediately. Review of Post-Fall quizzes, dated [DATE] - [DATE], reflected all nurses took and passed a quiz on what to do after a resident had a fall. Review of an in-service entitled Managing Behaviors in Persons with Dementia, dated [DATE] - [DATE] and conducted by the CRN, reflected nurses from all shifts (including RN H) were in-serviced on different ways of managing/approaching/caring for residents with Dementia and/or behaviors. Review of Managing Behaviors in Persons with Dementia quizzes, dated [DATE] - [DATE], reflected all nurses took and passed a quiz on how to care for residents with aggressive behaviors. Review of a Counseling/Disciplinary Notice, dated [DATE], reflected RN H received a written warning for the following: [RN H] failed to conduct an assessment on a resident post-fall. [RN H] did not write a progress note nor an incident report. [RN H] will be counseled 1:1 on appropriate assessments and how to address residents with combative behaviors. The ADM and DON were notified on [DATE] at 3:55 that the IJ had been removed. While the IJ was removed on [DATE] at 3:55 PM, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interviews and record reviews, the facility failed to ensure a verbal abuse alleged violation was thoroughly investigated with Resident #1 and Resident #2. The facility failed to investigate an allegation made by Resident #1 during a separate facility reported incident. The facility failed to investigate Resident #1's allegation of verbal abuse, in a facility reported incident that involved Resident #1 and another resident. Resident #1 made an allegation of verbal abuse against Resident #2. This failure could place residents at risk to prevent further abuse, neglect, and exploitation; and it potentially prevents the facility to take corrective actions to prevent abuse, neglect, and exploitation. Findings included: Review of Resident #1's face sheet, dated 05/31/2024, revealed an [AGE] year-old-female with an initial admitted [DATE] and an admitted [DATE], with diagnoses of cellulitis (bacterial skin infection) of right lower limb, diabetes, muscle wasting, cognitive communication deficit (problems with communication that have an underlying cause in a cognitive deficit rather than a primary language or speech deficit), hypertensive heart and chronic kidney disease, depression, and unspecified dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities). Review of Resident #1's annual MDS assessment, dated 04/17/2024, revealed a BIMS summary score of 12 indicating a moderate cognitive impairment. Review of Resident #2's face sheet, dated 05/31/2024, revealed a [AGE] year-old female with an admitted [DATE], with diagnoses of unspecified dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities), delirium ( serious change in mental abilities that causes confused thinking and lack of awareness of surroundings), muscle wasting, need for assistance with personal care, muscle weakness, cognitive communication deficit (problems with communication that have an underlying cause in a cognitive deficit rather than a primary language or speech deficit), and age related debility. Review of Resident #2's quarterly MDS, dated [DATE], revealed a BIMS summary score of 03 indicating a severe cognitive impact. Review of Resident #1's progress note, no date, revealed a nursing note dated 05/27/2024 at 15:45 (03:45 p.m.) created by LVN A stating, Note Text: Alert and it was reported to write that resident had thrown a cup of cold water on another resident. Resident admitted that she did throw a cup of water on the other resident (Resident #2) because she always talking sexual talk to her (Resident #1) and she (Resident #1) does not like it. Review of Resident #2's progress note, revealed a nursing note dated 05/27/2024 at 15:45 15:45 (03:45 p.m.) stating, Note Text: Alert and another resident (Resident #1) threw a small blue cup of cold water on this resident (Resident #2) because this resident was talking to the other resident. further note revealed, No c/o (complains of) pain/discomfort noted. No apparent injuries noted. Record review of the Facility's incident and accident report, dated 05/30/204, revealed Resident to Resident incident that listed Resident #1 and Resident #2 both dated and timed 05/27/2024 at 03:45 p.m. Interview on 05/31/2024 at 10:10 a.m., when asked if she was afraid of any staff or any residents, Resident #1 stated, no I'm (I am) not scared, I grew up tough, no one will mess with me. When asked if she could recall the events on 05/27/2024 with Resident #2. Resident #1 stated, no, no I don't (do not) really remember. Interview on 05/31/2024 at 11:17 a.m., LVN A confirmed she documented both Resident #1 and Resident #2's progress notes of the events on 05/27/2024 at 15:45 15:45 (03:45 p.m.). LVN A stated Resident #1 threw the cup at Resident #2, LVN A stated she completed an incident report, and she reported the incident to ADM. LVN A stated she was aware of reporting all ANE (Abuse, Neglect, and Exploitation) allegations and incidents to the ADM, LVN A stated that, if we don't (do not) report ANE, it places residents at risk. Interview on 05/31/2024 at 11:29 a.m., DON stated she was aware of Resident #1 throwing a cup of water to Resident #2, although she was not aware of the nature, cause, or reason. DON stated, I did not know she (Resident #2) did anything in an aggressive way, it was not reported to me in that nature, I did not know the reason had been anything sexual at all. DON stated it was not reported to her as an incident that involved abuse. DON stated it was not involved in the current self-reported incident that involved Resident #1 and another resident that occurred that same day. Interview on 05/31/2024 at 11:48 a.m., ADM stated LVN A never mentioned the incident involving Resident #1 and Resident #2 to him, ADM added, I was not aware the incident was rooted in a sexual comment, and this is the first time I had heard of it. ADM stated he does not recall having discussed this in the stand up meeting the following day. ADM stated, this should have been discussed with me (ADM), and that if the incident was brought to my (ADM) attention, I would have initiated an investigation and follow the investigation procedure for the facility's ANE policy. Interview on 05/31/2024 at 12:53 p.m., Psych stated she had services with Resident #1 related to another self-reported incident on 05/27/2024, Resident #1 had not display any signs of fear, or signs of verbal or sexual abuse. Psych stated that her diagnoses and conditions do involve episodes of paranoia, Psych stated that Resident #1 had not recall any incident that involved Resident #2. Psych did reiterate that Resident #1 did have generalize paranoia that could associated with her (Resident #1's) Dementia. Psych stated based on her assessment Resident #1 did not have any negative affects from that day based on her psychological assessment. Record review of the Facility's Resident to Resident incident, no date, revealed an incident that involved Resident #1, reported by LVN A, on 05/27/2024 at 15:45 (03:45 p.m.): Nursing description: Reported that resident had thrown a small cup of cold water on another resident. Resident Description: Resident stated that she did throw the water on the other resident because the other resident is always talking sexual talk to her. Immediate action taken: Assessment done. Family called. Resident on 1-1 intervention, no injuries noted, and staff intervened to prevent altercation. Other resident assisted away from area staff without injuries. Record review of the Facility Abuse: Prevention of and Prohibition Against Policy, revision/review date 10/2022, revealed a policy that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Further review of the Facility's policy revealed: Section F. Investigation, 1. All identified events are reported to the Administrator immediately.

Based on observation, interview, and record review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals and included regular re-evaluation of residents to identify changes that require modification of the discharge plan and to reflect these changes in the discharge plan for one of one resident (Resident #1) reviewed for discharge planning. The facility failed to ensure Resident #1 had a discharge plan in place. This failure placed residents at risk of not having a plan in place to address residents post discharge needs. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included hemiplegia and hemiparesis (paralysis on one side of the body), cognitive communication deficit (problems with communication caused by cognitive impairment), aphasia following cerebral infarction (loss of speech following a stroke that cause death of brain tissue), and depressive episodes. Review of the admission MDS for Resident #1 dated 04/03/24 reflected a BIMS score of 13, indicating intact cognition. Review of the care plan for Resident #1 dated 04/03/24 reflected Wishes to stay in the facility for long term care. Discharge goals are: stay in the facility for long term care. Establish a pre-discharge plan with the resident, family/caregivers and evaluate progress and revise plan as needed. Review of the progress notes for Resident #1 from 03/27/24 to 05/22/24 reflected no notes pertaining to discharge planning or transfer to another NF. Review of documents in Resident #1's electronic medical record reflected no documents related to discharge planning or transfer to another NF. Observation and interview on 05/22/24 at 02:14 PM revealed Resident #1 in his room calling out to the surveyors as they passed by his open door. He was in his wheelchair, and he could not speak clear words but had a laminated page of letters attached to his wheelchair. Using his finger to point at letters and spell words, he stated that he wanted to move to a specific local nursing facility. He stated he had told people at the facility he wanted to move, but they had done nothing and had not spoken with him to update him on their progress. During an interview on 05/22/24 at 04:10 PM, the SW stated she was doing some discharge planning for Resident #1, and his family did not want him to transfer. She stated she had reached out to the other facility, and they had not answered or returned her phone calls until this afternoon. She stated she planned to reach out to the family before she sent any clinical documents/referral paperwork to the other facility. She stated she did not know if Resident #1 needed to have his family involved in his decision-making. The SW stated she would have to look at his chart for cognitive status and medical power of attorney. She stated if there was a medical power of attorney in place, she would have to consult that person. The SW stated she did not know he had a BIMS score of 13 and was his own responsible party. She stated she did not know his family members were only listed as emergency contacts in his profile. She stated she had not discovered that information yet, because she had not been able to contact the facility where he wanted to move. The SW stated she now had an email where she could send the referral. She stated she had been working on it. The SW stated her caseload for residents who were actively discharging was around 8 to ten, and that was not a huge caseload. She stated Resident #1 expressed his desire to move to the other facility about a month ago. She stated she had not documented any of her efforts to reach the facility he desired to move to on the EMR, but she had a notebook where she documented each time she contacted the facility where he wanted to move . The SW stated she had visited with Resident #1 every other week about her progress. The SW stated she visited him today at 03:40 PM to update him. The SW stated a potential negative impact of not having discharge planning under way was, theoretically, a resident would feel his wants were not being addressed. She stated it was important to develop and implement discharge planning because it was the resident's right, and they should have had the opportunity to move if they wanted to move. During observation and interview on 05/22/24 at 04:27 PM, the DON provided an electronic tablet with a note-taking application open and a note titled with Resident #1's name on the screen. The note had a date of 05/22/24 and had several marginally legible handwritten electronic notes indicating dates and times of phone calls made to the facility where Resident #1 wanted to move. During an interview on 05/22/24 at 04:43 PM, the ADM stated he found out from Resident #1 that he wanted to move to another facility a couple weeks ago and told the SW about it. The ADM stated he was not sure if Resident #1 was pending Medicaid and had not been approved yet, but he thought that might be the hang up and the reason why the referral had not been initiated. The ADM stated he would think the SW would have made a note in the EMR when she reached out to the other facility. The ADM stated he stops and sees Resident #1 frequently, because Resident #1 was on his morning rounds. The ADM stated usually the issues Resident #1 had were that he was missing something or some small problem. The ADM stated the SW's perception may have been that the resident's FM is at the facility often, has a lot to say about his care, and is somewhat hovering so the SW may have assumed the FM would be making the decisions for Resident #1. The ADM stated that was not the facility policy, and the discharge planning should have been initiated and documented. Review of facility policy dated 11/2016 and titled Discharge Planning Process reflected the following: It is the policy of the facility that the discharge planning process focuses on the resident's discharge goals, involving the residents as active partners. The discharge process should effectively transition them to post-discharge care, and minimize clinical or other factors which are related to the possibility of readmission. 1. The Facility's discharge planning process shall: a. Provide and document sufficient preparation and orientation to residents, in a form and manner that the resident can understand, to ensure safe and orderly transfer or discharge from the Facility. f. Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. If participation by the resident and the representative is determined not practicable for the development of the resident's discharge plan, an explanation shall be documented in the resident's medical record. 2. For residents who were transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, the facility shall assist residents and their resident representatives in selecting a post-acute care provider by using data that includes but is not limited to a. SNF, HHA, or LTCH standardized patient assessment. b. Data on quality measures; and, c. Data on resource used to the extent the data is available. 4. The facility shall document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer.

Based on observation, interview, and record review the facility failed to have the results of the most recent survey of the facility posted in a place readily available to residents, family members and legal representatives for 1 of 1 survey results books. The facility failed to ensure a binder placed on a table at the entrance of the facility and titled Survey Results contained the results of the most recent full recertification survey. This failure placed residents at risk of not having all the information necessary to make decisions about living at the facility. Findings included: Observation on 03/29/24 at 12:50 PM revealed a white three-ring binder on a console table just inside the entrance doors to the facility. The binder had Survey Results printed on the front. Within the binder were results of State Agency surveys dating back to 2021, but the results from the most recent full recertification survey, held from 02/06/24 to 02/08/24, were not present anywhere in the binder. The binder did contain a Notice of Accepted Plan of Correction Form referencing the full recertification survey dated 02/08/24. Review of the Statement of Deficiencies form CMS-2567 dated 02/08/24 reflected the facility was cited for failure to ensure the right to survey results. Review of the State Agency Notice of Accepted Plan of Correction found in the Survey Results binder on 03/29/24 reflected the following: The plan of correction and/or evidence of compliance may be accepted as determination of correction in lieu of conducting an on-site follow-up visit. A desk review may be performed. If, during a future visit, violations or deficiencies that were considered corrected through a desk review are discovered not to have been corrected, enforcement actions may be recommended. The notice was dated 03/20/24 and signed by the State Agency program manager assigned to the facility. During confidential interviews on 03/29/24 between 12:55 PM and 01:40 PM, four anonymous residents stated they had wondered what the results of State Agency investigations were and remembered that results were available on the table by the front doors. One resident stated s/he would like to have been able to see the results prior to entering the facility so s/he would know if the facility was a safe place to live. Another resident stated s/he felt the facility was his/her home and s/he should know what was happening in his/her home. S/he also stated s/he would want to know if the same problems were happening to others as were happening to him/her. S/he stated there were times when s/he had an issue and did not speak up about it, because s/he was afraid s/he was the only person with the problem. The other two resident did not elaborate but said it was important to them to have the survey results available for them or their family members to read. During an interview on 03/29/24 at 02:30 PM, the ADM stated ensuring the survey results were available to residents, family members, and visitors was his responsibility. He stated he had just started working at the facility as the administrator two weeks prior and had already inquired about obtaining a copy of the survey results from 02/08/24. He stated he thought he had requested the survey results the week prior, but he was not certain which day he had made the request. The ADM stated the only potential negative outcome he could imagine of the survey results not being available to residents was that residents might be more outspoken about a problem they were having if they could see in writing that the problem was also a problem for others in the facility and according to the regulations. Review of facility policy dated 10/04/16 and titled Resident Rights reflected the following: Information and Communication. You have the right to: . examine the results of the most recent survey of the facility conducted by Federal or State surveyors, and any plan of correction in effect with respect to the facility.

Based on observation , interview, and record review, the facility failed to ensure all residents had a private place for telephone communications without being overheard. The facility failed to ensure there was an area for residents to have private telephone communications. This failure could place residents at risk to lose their ability to communicate privately on the telephone, and could result in a decline in their psychosocial well-being and quality of life. Findings included: Observation on 02/07/2024 at 11:37 AM revealed a small table with a land line telephone, a sign that reflected, Resident Phone and a chair was located next to the nurse's station. In an interview on 02/07/2024 at 11:40 the Acting ADM stated the residents needed a private place to use a phone. He further stated when he was the ADM at the facility they had a portable phone the residents could take to a private area, and he was unsure when the current phone was set up. In a confidential interview during resident council on 0/2/07/2024 at 3:00 PM three residents stated there was not enough privacy for using the phone. They stated the only resident phone was located next to a busy and noisy nurse's station where a lot of people gathered to talk, and they were unable to hear the person they were attempting to speak with. The residents stated it was a concern among many of the residents who used the phone near the nurse's station, because only a few had cell phones. In a confidential resident interview on 02/07/2024 at 3:15 PM, a resident stated having the phone located next to the nurse's station is an invasion of privacy. She stated, It is too loud to be able to hear or have a conversation. She said, There needs to be honor and respect for the residents, and the staff are not doing that. In a confidential resident interview on 02/07/2024 at 3:20 PM, a resident stated most of the time when they want to use the phones it is during rush hours and it is too loud near the nurse's station for them to be able to use it. He stated a lot of staff like to gather near the nurse's station and make noise or talk loudly. When using the phone, he gets frustrated because of all the noise and must hang up and plan for another time to make his call in the evening when there is no noise. In an interview on 02/08/2024 at 3:51 PM the Aacting ADM stated his expectation was residents should have the right to make a private phone call if they choose. He further stated it would be a violation of their rights to not have a private place for phone calls and could be upsetting to them. Record review of an undated facility Policy/Procedure- Nursing Administration Resident Rights reflected, 18. To have reasonable access to a telephone for private conversations while in the Nursing Center. Observation on 02/07/2024 at 12:14 PM of a posting of Residents Rights located near the Social Worker's office and posted on 02/07/2024 revealed: Privacy and Confidentiality You have a right to: Privacy, including privacy during visits, phone calls and while attending to personal needs.

Based on interview and observation, the facility failed to provide a private space for residents' monthly council meetings and the confidential resident group meeting during survey for 9 of 9 confidential residents reviewed for resident council. The facility did not provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to exercise their rights of being able to voice their grievances in a private space without uninvited staff being present. Findings Included: Observation and interview on 02/07/24 at 03:15 PM, during a confidential resident group meeting held in the dining room with 9 residents revealed at various times during the resident group meeting 2 dietary staff entered the dining room while the residents were answering questions and voicing their opinions/concerns. There were signs on the doors entering the dining room that reflected do not enter resident group in progress. 1 dietary staff member was observed moving metal tray carts in the dining room, and there were loud noises coming from the metal tray carts being moved as well as dishes/pots and pans in the kitchen. The residents stated that happened frequently in their meetings which has made it difficult to hear one another and creates distractions. During an interview on 02/08/24 at 11:30 AM the Activities Director stated she would normally let management know during the 2 PM huddle and via email that resident council would be happening in the dining room, so their direct employees would know not to bother them. She stated there was not another area for the residents to meet in private. She stated she would place signs on the doors and sometimes stand at the door to prevent any staff from entering the dining room. She also stated she would notify dietary staff before the meeting not to come out of the kitchen until after the resident group meeting. She stated that the residents had expressed concerns about the interruptions before and staff interrupting were asked to leave the dining room. During an interview on 02/08/24 at 3:51 PM the Acting ADM stated that he thought residents should be able to hold resident council meetings in private without interruptions if they chose. He said sometimes they would allow staff to visit with the permission of the council president and other residents in the meeting. He said a negative outcome to resident council interruptions or loud noises would be the residents could lose their train of thought or not be understood correctly by one another. Policy: During an interview on 02/08/24 at 12:00 PM requesting facility policy on privacy related to resident council, the BOM stated they did not have any internal facility specific policy for it. During an observation on 02/07/2024 at 01:00 PM of a posting of Residents Rights located near the social workers office reflected: Privacy and Confidentiality You have a right to: - Privacy, including privacy during visits, phone calls and while attending to personal needs.

Based on interview and record review, the facility failed to provide care according to professional standard of practice and in accordance with physician order for one (Resident #1) of two residents reviewed for quality of care in that, in that: The facility failed to ensure the transparent dressing covering Resident #1's central line site to her right chest was changed after returning from the hospital on 03/30/23. Resident #1's dressing had not been changed in approximately 37 days. There were no physician orders in place for the permcath, dressing changes for the permcath, or monitoring the site for signs and symptoms of infection . This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/06/23 at 3:45 PM. While the IJ was removed on 05/08/23 at 12:30 PM, the facility remained out of compliance at a level of no actual harm that is not immediate jeopardy at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents with central lines at risk for major infection, decreased quality of care, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease, type II diabetes, chronic kidney disease, and age-related physical debility. Review of Resident #1's significant change in status MDS assessment, dated 04/09/23, reflected a BIMS of 11, indicating a moderate cognitive impairment. Section O (Special Treatments, Procedures, and Programs) reflected received dialysis while not a resident of the facility and received hospice care as a resident. Review of Resident #1's initial care plan, dated 04/20/23 , reflected she had a terminal prognosis related due end of stage renal disease with an intervention of working cooperatively with her hospice to ensure all needs are met. It did not address a central line. Review of Resident #1's hospital discharge paperwork, dated 03/28/23, reflected the following: IMPRESSION: 2. Right-sided dual-lumen catheter (designed for over-the-wire placement, providing two separate working channels for second wire placement or injection) with tip terminating at the cavoatrial junction (the point at which the superior vena cava meets and melds into the superior wall of the cardiac right atrium). Review of Resident #1's hospice admission agreement, dated 04/05/23, reflected she was admitted back onto hospice services (that day). Review of Resident #1's NP note, dated 04/05/23, reflected she had revoked hospice (on 03/28/23) and went to the hospital. She was now back on hospice. It further reflected she had a permcath to her right chest. Review of Resident #1's physician orders in her EMR, on 05/06/23, reflected no orders for the permcath, dressing changes for the permcath, or monitoring the site for signs and symptoms of infection since her initial admission. Review of Resident #1's nursing progress notes in her EMR, from 03/28/23 - 05/06/23, reflected no documentation of dressing changes to her permcath site. During an observation on 05/06/23 at 12:28 PM, Resident #1 was in her wheelchair in her room with her head down. A permcath was noted on the right side of her chest, the dressing was dirty around the edges. The date on the dressing was smeared and illegible. During an interview on 05/06/23 at 12:34 PM, Resident #1's nurse, LVN A, stated dressings to central line sites should be changed every 3-5 days. She stated Resident #1 used to go to dialysis, and they would change the dressing. She stated Resident #1 stopped going to dialysis a few weeks ago and she did not change the dressing because it was secured around the permcath site, and she would only change it if there was a hole in the dressing to prevent any infection issues. During a telephone interview on 05/06/23 at 1:07 PM, Resident #1's HN B stated Resident #1's family opted to leave the permcath in after they decided to stop dialysis in lieu of hospice services. She stated it was her expectations that the facility was monitoring the site and changing the dressing every seven days and PRN. She stated if they were not doing that, there was a 100% infection control issue. She stated if they were not caring for the site, she should have been notified immediately so she could change the dressing appropriately. During an interview on 05/06/23 at 2:16 PM, the DON stated the last time Resident #1 received dialysis was on 03/28/23. She stated her permacath dressing was being changed three days at the dialysis center when she received dialysis treatment. She stated the dialysis center sent her to the hospital (03/28/23) because she complained of chest pain. She stated this revoked her hospice services. She stated the hospital ran tests and determined there was fluid buildup around her heart. She stated at the hospital the family decided getting back on hospice was a more appropriate route for Resident #1, and she did not receive dialysis after returning from the hospital. She stated, In all honesty, I thought the permcath had been removed. There was clearly a lack of communication between the facility and the hospice agency. She stated it was very concerning there were no physician orders, and that the dressing had not been changed since she returned from the hospital, as it should be changed every seven days (for transparent film dressings), especially since it was not being flushed regularly. She stated transparent film dressings are changed every seven days, and gauze and tape dressing are changed at least every two days to assess the site. She stated the central line site should have orders to be monitored every shift to assess for redness, warmth, and drainage. She stated without receiving proper care or monitoring, it could lead to thrombosis which could cause a devastating stroke or a devastating infection. During an interview on 05/06/23 at 3:14 PM with the ADM, he stated all dressings need to be changed as ordered by the physician. He stated all central line sites needed to be monitored regularly to ensure there are no changes or any signs of infection. Review of the facility's undated Central Line Training Policy reflected the following: After obtaining access, the management of central catheters revolves around preventing catheter-based skin site or bloodstream infections, central line thrombosis, and mechanical complications. . Routine inspection of the central line, regardless of location, should be performed daily. A daily inspection should ensure that the line is properly in place, free from infection, and in working order. Dressing changes for central lines should occur every 7 days with a sterile dressing if using Biopatch or every two days with a gauze dressing. However, if the dressing has a break in the seal or becomes visibly soiled, it should be changed. . The goal of routine central line management is to reduce catheter-based infections. Complications such as abscess, cellulitis, and bacteremia are common and lead to poor patient outcomes, increased use of antibiotics, and increased hospital length stay. Central line management is a crucial skill necessary on a routine basis to help lessen or prevent catheter-based complications . The ADM and DON were notified on 05/06/23 at 3:45 PM that an Immediate Jeopardy had been identified due to the above failures. The IJ template was provided to the ADM and DON pm 05/06/23 at 3:45 PM. The following POR was accepted on 05/08/23 at 11:00 AM: On 5/6/23 an abbreviated survey was initiated at (facility). On 5/6/23 the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Threat states as follows: Care and Treatment of a Central Line for Dialysis Problem 1: The dressing for Resident #1 had not been changed since 4/15/23 Action: DON assessed site at on 5/6/23 at 1615 and no signs of infection were present on resident #1. Notified NP at 1630 of results of assessment of central line for resident #1 and received orders for dressing change for 5/6/23 and every 7 days until catheter is removed. Dressing Changed by DON on 5/6/23 at 1700 for resident #1. Medical Director, (name), notified on 5/6/23 at 2030 by ADM DON attempted to notify daughter of Resident #1 1630 on 5/6/23 Start Date: 5/6/23 Completion Date: 5/6/23 Responsible: DON Action: DON/designee to review all patients with Central Lines for appropriate care and treatment Start Date: 5/6/23 Completion Date: 5/6/23 Responsible: DON Action: DON/Nurse designee to conduct Central Line sweep of all patients in facility to identify the presence of central line Start Date: 5/6/23 Completion Date: 5/6/23 Responsible: DON Action: DON and nurse managers that will provide education will be educated by Clinical Resources on monitoring and care of a central line. Start Date: 5/6/23 Completion Date: 5/6/23 Responsible: ADM Action: DON/designee to educate all current nurses on monitoring and care of a central line prior to taking a shift. All new nurses, PRN nurses, Agency nurses, and any nurse on leave will be educated on monitoring and care of a central line before taking a shift by DON/designee and will be ongoing. Start Date: 5/6/23 Completion Date: 5/7/23 Responsible: ADM Monitoring: DON/designee to review weekly residents with central lines to verify that dressings were changed. This will be ongoing monitoring. Start Date: 5/6/23 Completion Date: 5/7/23 Responsible: DON Problem 2: Orders and/or Careplans not present Action: DON/designee and NP reviewed orders on all identified residents with central lines. Start Date: 5/6/23 Completion Date: 5/6/23 Responsible: DON Action: DON/designee will review careplans on all identified residents with central lines. Start Date: 5/6/23 Completion Date: 5/7/23 Responsible: DON Action: DON and nurse managers that will provide education will be educated by Clinical Resources on notification to MD/NP if appropriate treatment is not in place and any change of condition related to access site. Start Date: 5/6/23 Completion Date: 5/6/23 Responsible: ADM Action: DON/designee to educate all current nurses on notification to MD/NP if appropriate treatment is not in place and any change of condition related to access site prior to taking a shift. All new nurses, temporary nurses, and any nurse on leave will be educated on notification to MD/NP if appropriate treatment is not in place and any change of condition related to access site before taking a shift by DON/designee and will be ongoing. Start Date: 5/6/23 Completion Date: 5/7/23 Responsible: ADM Monitoring: DON/designee to review weekly residents with central lines to verify that orders are correct. This will be ongoing monitoring. Start Date: 5/6/23 Completion Date: 5/7/23 Responsible: DON Monitoring: DON/designee to review admissions and readmissions for presence of central line to ensure orders and care plans are appropriate. This will be ongoing monitoring. Start Date: 5/6/23 Completion Date: 5/7/23 Responsible: DON Involvement of Medical Director The Medical Director was notified about the immediate Jeopardy on 5/6/23. The Director of Nursing will review all related changes in processes with the Medical Director. Involvement of QA On 5/6/23 an Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, and director of nursing to review plan of removal. The IDT will review central line monitoring process with the Medical Director monthly during QAPI for three months. The Surveyor monitored the Plan of Removal from 05/07/23 - 05/08/23 as followed: Review of Resident #1's progress notes in her EMR, documented by the DON on 05/06/23 at 7:39 PM reflected the following: Permcath dressing change: [DON] removed old dressing using clean technique. Site assessed - no drainage, skin breakdown, warmth or dislodgement noted upon inspection, slight redness around site from dressing removal noted Site re-dressed using aseptic technique and dated. Next dressing change to occur 05/12/23, and then weekly until removal. Orders in place for continued monitoring of site every shift. Review of Resident #1's physician's order, dated 05/06/23, reflected central line/midline care: Change central line/permcath dressing Q seven days and PRN. Review of Resident #1's physician order, dated 05/06/23, reflected monitor permcath cite for signs and symptoms of infection Q shift and to notify MD/NP of any changes. Review of a documented skin sweep, conducted on 05/06/23 by the DON, reflected there were only two residents in the facility with central lines. Review of in-services conducted, from 05/06/23 - 05/08-23, reflected all nurses had been in-serviced on Care Treatment of Central Lines before starting their next shift by either the DON or the RNC: 1. All central lines are to be monitored every shift - The catheter line should be monitored for intact dressing, presence, or absence of redness, warmth, swelling, drainage, or pain. Changes must be notified to MD/NP 2. All central catheter dressings with biopatch are to be changed every 8 days and as necessary. Central line dressings with gauze are to be changed every 2 days. 3. All patients with central lines must have an order for dressing change and monitoring of the site. 4. All patients must have a care plan that addresses care and monitoring of central lines 5. All patients on admission/readmission to be assessed for the presence of central lines and orders and care plans will be initiated. 6. Notify MD/NP if appropriate order is not in place or a change of condition related to central lines is observed. Review of Central Line Treatment and Care Questionnaires, from 05/06/23 - 05/08/23, reflected all nurses answered the questionnaire correctly before starting their next shift. During an observation and interview on 05/07/23 at 2:02 PM, Resident #1 was in her room sitting in her wheelchair. Her permcath dressing was clean and was dated 05/06/23. The resident voiced that she was not in any pain and had no concerns. During interviews on 05/07/23 from 2:06 PM - 2:24 PM, two LVNs and one RN stated they had been in-serviced and took a questionnaire regarding care for central lines before starting their shifts. They were all able to answer questions regarding appropriate dressing change timelines, monitoring the site every shift, and what signs and symptoms to monitor. During an interview on 05/08/23 at 11:23 AM, the DON stated she changed Resident 1's dressing on 05/06/23 and there was no drainage, warmth, or signs of infection, only redness around the dressing site. She stated Resident #1 showed no signs or symptoms of pain. She stated she and her RNC had been responsible for in servicing each nurse before the start of their shift. She stated they were keeping a log by utilizing their daily staffing sheets and high-lighting the name of the nurse once they were in-serviced. She stated upon any new admission, she was responsible for the initial skin assessment to determine if the resident had a central line. She stated she had spoken with Resident #1's hospice nurse to notify her of the new orders, and requested they moved towards removing the permcath if the family was agreeable. During an interview on 05/08/23 at 11:45 AM, Resident #1's NP stated it was extremely important to monitor central line sites and change the dressing as appropriate. She stated dressings with gauze should be changed every two days if a resident did not go to dialysis. She stated the site not being care for appropriately could lead to sepsis. During interviews on 05/08/23 from 11:34 AM - 12:04 PM, one LVN and two RNs stated they had been in-serviced and took a questionnaire regarding care for central lines before starting their shifts. They were all able to answer questions regarding appropriate dressing change timelines, monitoring the site every shift, and what signs and symptoms to monitor. The ADM and DON were notified 05/08/23 at 12:30 PM that the IJ had been lowered. While the IJ was lowered on05/08/23 at 12:30 PM, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of pattern identified due to the facility's need to evaluate the effectiveness of the corrective systems.