Every finding on record at Care One at Wilmington

Based on observation, record review and interview the facility failed for one Resident (#2) out of a total sample of 21 residents to ensure that following a skin tear, care was provided in accordance with professional standards of practice. Specifically, the facility failed to a.) obtain an order for treatment of a new skin tear and b.) failed to assess the skin tear on a weekly skin assessment.Findings include:The facility policy titled Skin Tears- Abrasions and Minor Breaks, Care of, dated as revised September 2013, indicated: Purpose: The purpose of this procedure is to guide the prevention and treatment of abrasions, skin tears, and minor breaks in the skin. Preparation:Obtain a physician's order as needed. Document physician notification in medical record.Review the resident's care plan, current orders, and diagnoses to determine resident needs. Check the treatment record.Generate non-pressure form and complete.Assemble the equipment and supplies as needed. Resident #2 was admitted to the facility in April 2024 and has diagnoses that include Parkinson's disease and atrial fibrillation. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/15/25, indicated that on the Brief Interview for Mental Status exam Resident #2 scored an 11 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated Resident #2 utilizes a wheelchair for mobility. During an initial observation on 7/29/25 at 8:03 A.M., Resident #2 was observed in bed. There were five steri-strips (thin adhesive bandages designed to keep shallow wounds closed as they heal) located on the back (dorsal) side of his/her right hand with a caked red and brown substance on them and two steri-strips on his/her right forearm. Resident #2 said that his/her skin tears very easily and that the nurses place the steri-strips on whenever he/she gets a skin tear. Resident #2 stated that the right hand injury was most recently sustained a few days prior when he/she was wheeling his/her wheelchair in the room and he/she got the hand caught between the wheel and the footboard. Review of the record on 7/29/25 at 11:06 A.M., failed to indicate:-any clinical progress notes or information regarding how Resident #2 sustained the skin tears or when the steri-strips were placed;-an order for the steri-strips;-an order to monitor the skin following the skin tears;-a care plan regarding the skin tears. Review of the active physician orders included the following:Eliquis oral tablet 5 milligrams (mg). Give 5 mg by mouth two times a day for anticoagulation for atrial fibrillation, start date 6/1/24.Monitor for signs and symptoms of anticoagulant therapy complications, every shift such as bleeding, bruising, frank blood, hematemesis, black tarry stool, hemoptysis, epistaxis, and hematuria. Document positive (+) changes in progress note, start date 12/19/24. Review of the Skin Check assessment, dated 7/29/25 at 11:11 A.M., failed to indicate any areas on Resident #2's hand or forearm or that steri-strips were in place. On 7/31/25 at 7:40 A.M., Resident #2 was observed in bed, asleep. The five steri-strips remained on his/her right hand and two on the right forearm. During an interview on 7/31/25 at 9:09 A.M., Certified Nursing Assistant (CNA) #1 said that Resident #2 requires total care and that he/she usually needs assist with the wheelchair but sometimes wheels him/herself short distances. She said that she observes all residents' skin with care and that if a new area is noted she reports it immediately to the Nurse. CNA #1 said that Resident #2's skin is very fragile and needs a lot of cream and that she had been off for several days and when she came in yesterday and she noticed the steri-strips on his/her hand and arm. CNA #1 said that she did not report it to the Nurse because she could tell the steri strips were old because they were dirty. During an interview on 7/31/25 at 9:17 A.M., Nurse #1 said that overall Resident #2's skin is good but that when she came into work one day last week she noticed new steri-strips on his/her right hand. Nurse #1 said that if a resident has a new skin tear the Nurse at the time should have initiated a Situation, Background, Assessment and Recommendations (SBAR) progress note, called the Physician and family, obtained an order to apply the steri-strip as well as an order to monitor the area each shift for signs and symptoms of infection and pain. Nurse #1 said that the Nurse should have written a note regarding the incident at the time it occurred. Nurse #1 reviewed the record and said that there was not an order for the steri-strips or to monitor the site for signs and symptoms of infection or pain. As well, she said that she was the Nurse that completed the skin assessment on 7/29/25 and should have noted the areas where the steri-strips were applied, but she did not. Nurse #1 reviewed Resident #2's July 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) and said that there was not an order for the steri-strips or a treatment ordered to Resident #2's hand or forearm. During an interview on 7/31/25 at 9:45 A.M., the Nurse Unit Manager said that at the time Resident #2 sustained the skin tear an SBAR should have been completed, the Physician and family notified, and that the Nurse should have written a one-time order to place steri-strips and to monitor for signs and symptoms of infection. The Nurse Unit Manager said that this order would go on the TAR until resolved. As well, she said that the area should have been documented on the weekly skin assessment completed on 7/29/25. During an interview on 7/31/2025 at 10:21 A.M., the Assistant Director of Nursing (ADON) said that when a resident sustains a skin tear an incident report should be initiated and that staff and the resident should be interviewed to determine how the injury was sustained. The ADON said a SBAR should also be completed, the Physician should be notified, a treatment order obtained and the order should be on the TAR. The ADON added that the areas should have been documented on the 7/29/25 weekly skin assessment.

Based on observations, record review and interviews, the facility failed to provide assistance with meals as needed for 1 Resident (#268) out of a total sample of 24 residents. Findings include: Review of the facility policy titled, Assistance with Meals, dated March 2022, indicated the following: *Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity. Findings include: Resident #268 was admitted to the facility in June 2023 with diagnoses including dysphagia. During an observation on 6/13/23 at 8:41 A.M., Resident #268 was observed eating breakfast while lying in bed in his/her room with no staff present to assist or supervise as needed. While taking a drink of his/her juice, the Resident was observed to spill the juice over his/her chest and lap. The Resident was also observed to have a moderate amount of eggs on his/her chest. When asked, the Resident said, I need help to eat. The privacy curtain was drawn and the Resident was not able to be observed from the hallway. During an observation on 6/13/23 at 12:37 P.M., Resident #268 was observed eating alone in his/her room while lying in bed. The Resident was observed to eat three spoonfuls of food and with each spoonful, dropped approximately half of the food onto his/her chest. Review of the discharge summary from Resident #268's prior hospitalization dated 6/10/23, indicated the following: *The patient presents with overall mild oropharyngeal dysphagia, and suspect possible underlying esophageal dysphagia given advanced age. (The Resident) has chronic history of dysphagia with frequent coughing on liquids at home. Would expect this to be exacerbated due to current altered mental status. At bedside today (the Resident) demonstrates improved tolerance for small sips of thin liquids. Daughter present and expresses preference for minimal diet modifications for quality of life. Therefore, recommend continuing regular diet, thin liquids by small single straw sip (pinch straw to limit size and rate). 1:1 feed. Pills crushed in puree. Please re-consult SLP (speech) as needed. Review of Resident #268's Activity of Living Care plan initiated on 6/10/23, indicated the following intervention: *Assist with daily hygiene, grooming, dressing, oral care and eating as needed. Review of Resident #268's Kardex (a form indicating the level of assistance a resident requires) indicated the following: *Eating: Assist of one(1) person. Review of the speech therapy evaluation dated 6/13/23 indicated Resident #268 requires one-on-one assistance with meals and cues as needed due to aspiration risk. Review of the occupational therapy evaluation dated 6/11/23 indicated Resident #268 is dependent with feeding tasks. During an interview on 6/14/23 at 10:09 A.M., the Speech Therapist said Resident #268 has been at this facility before and has a history of aspiration risk (trouble swallowing). The Speech Therapist said the Resident was evaluated at the hospital and the therapist there had recommended the Resident be supervised during meals. The Speech Therapist said she was asked to evaluate Resident #268 last night due to nursing observing the Resident coughing during meals. The Speech Therapist said she recommends the Resident has supervision throughout the entire meal and assistance if needed. During an interview on 6/14/23 at 10:28 A.M., the Director of Nursing and Unit Manager #2 confirmed Resident #268 should have supervision during meals.

Based on observation, record review and interviews, the facility failed to obtain a physician order for the use of a CPAP machine (a machine for Continuous Positive Airway Pressure to treat sleep apnea) for 1 Resident (#271) with a diagnosis of sleep apnea out of a total sample of 24 residents. Findings include: Review of the policy titled, CO CPAP/BiPAP Support, dated 6/7/18, indicated the following: *Purpose: 1. To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen. 2. To improve arterial oxygenation (PaO2) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease. 3. To promote resident comfort and safety. *Preparation: 2. Review the resident's medical record to determine his/her baseline oxygen saturation or arterial blood gases (ABGs), respiratory, circulatory, and gastrointestinal status. 3. review the physician's order to determine the oxygen concentration and flow, and the settings (CPAP, IPAP and EPAP) for the machine. *General Guidelines: 3. CPAP is used for treatment of obstructive sleep apnea. Resident #271 was admitted to the facility in June 2023 with diagnoses including acute respiratory failure and congestive heart failure. On 6/13/23 at 10:22 A.M., and 11:55 A.M., a CPAP machine was observed on Resident #271's bedside table. On 6/14/23 at 8:15 A.M., a CPAP machine was observed on Resident #271's bedside table. During this observation, Resident #271 said he/she uses the CPAP machine every night to sleep better and not snore. Review of the discharge paperwork dated 6/7 indicated in the history and physical that Resident #271 has a diagnosis of sleep apnea and uses a CPAP. Review of Resident #271's physician orders failed to indicate an order for the CPAP machine. Review of Resident #271's respiratory care plan last revised on 6/8/23 failed to indicate an intervention of the use of a CPAP machine or the settings of the machine. During an interview on 6/14/23 at 9:01 A.M., Unit Manager #1 and Unit Manager #2 said all residents who have a CPAP machine need to have a physician's order for its use and the order needs to include the setting the machine should run on. Unit Manager #1 said she was aware Resident #271 had a CPAP machine in his/her room to use at night. Both Unit Managers looked through Resident #271's current physician orders and confirmed there was no order for the use of the CPAP machine. During an interview on 6/14/23 at 9:01 A.M., the Director of Nursing said any resident using a CPAP machine should have an order for its use.

Based on observation, policy review and interview, the facility failed to secure medications on 2 of 3 nursing units. Findings include: Review of the facility's Medication Storage Policy, dated 11/2020, indicated The facility stores all drugs and biologicals in a safe, secure and orderly manner. On 6/13/23 at 8:15 A.M. the surveyor observed a pack of twenty four 50 mg (milligram) tablets of Trazodone (anti-depressant medication) on the nurses station deck on the second floor unit. There were no staff in the area. On 6/13/23 at 12:07 P.M., the surveyor observed a cup of liquid medication, a cup of 8 pills, 2 inhalers and 1 nasal spray on top of the medication cart on the first floor Unit. There were no staff in the area and the medications were accessible to residents and visitors in the area. The surveyor then approached Nurse #1 who said she was assigned to the medication cart. Nurse #1 said that she had left the medications on the cart when she stepped away to address a discharge in process. During an interview on 6/14/23 at 11:33 A.M., Unit Manager #2 said medications should never be left out if a nurse is not present.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was a risk for falls and required two staff members to provide assistance with transfers, the Facility failed to ensure staff consistently implemented interventions from his/her comprehensive plan of care, when on 05/20/21, Certified Nurse Aide (CNA) # 1 transferred Resident #1 into his/her wheelchair without the assistance of another staff member, Resident #1 hit his/her right hip on the side of the wheelchair, causing him/her severe pain, and he/she was transferred to the Hospital Emergency Department where he/she was diagnosed with a right proximal femur (hip) fracture requiring surgical repair. Findings include: The Facility's Policy titled, Care Plans, Comprehensive Person Centered, dated December 2016, indicated that a comprehensive, person centered care plan included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs shall be developed and implemented for each resident. Resident #1 was admitted to the Facility in May 2021, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], indicated that he/she required physical assistance from two staff members for transfers. During an interview on 06/29/21 at 11:49 A.M., the Director of Rehabilitation Services said Resident #1 was evaluated at the time of admission and required physical help from two staff members to safely provide him/her assistance with transfers. The Director said Therapy Evaluations are considered the Therapy Plan of Treatment/plan of care. The Facility's Internal Investigation, dated 05/21/21, indicated that on 05/20/21, around 9:30 P.M., Resident #1 told staff that a few minutes earlier, Certified Nurse Aide #1 transferred him/her from the toilet into his/her wheelchair, and his/her right hip hit the side of the wheelchair, and that he/she had been in severe pain since. The Investigation indicated that Resident #1's right leg was limp and internally rotated, and he/she required an urgent transfer to the hospital where he/she was diagnosed with a right proximal femur (hip) fracture requiring surgical repair. The Investigation indicated that Resident #1 required two staff members to safely assist him/her with transfers and CNA #1 failed to follow his/her care plan when he independently provided transfer assistance to Resident #1. Review of Resident #1's Hospital Medical Record, dated 05/21/21, indicated that Resident #1 was diagnosed with a right hip fracture with severe angulation (type of fracture displacement where the normal axis of the bone has been altered such that the distal portion of the bone points off in a different direction) and was admitted for medical treatment and surgical repair. Review of Resident #1's Documentation Survey Report (documentation completed by the Certified Nurse Aides on the level of assistance provided during Activities of Daily Living), dated May 2021, indicated that for seven days prior to his/her incident on 05/20/21, two staff members provided physical assistance while assisting him/her with all transfers. During an interview on 06/17/21 at 11:45 A.M., CNA #1 said that he assisted Resident #1 to the bathroom by himself and transferred him/her on/off the toilet without another staff member present. CNA #1 said he was unaware that Resident #1 required two staff members to provide him/her with transfer assistance. During an interview on 06/16/21 at 1:50 P.M., the Director of Nurses said that Resident #1's plan of care indicated that two staff members were required to provide him/her with transfer assistance. The Director said CNA #1 failed to follow Resident #1's plan of care related to transfers, and shortly after he provided Resident #1 with care on 05/20/21, he/she experienced extreme pain and was urgently sent out to the hospital. On 06/17/21, the Facility was found to be in Past Non-Compliance and presented the Surveyors with a plan of correction which addressed the area(s) of concern as evidenced by: A. Resident #1 was urgently transferred to the hospital after the accident/incident for further evaluation and care, he/she did not return to the Facility. B. All residents were re-assessed by the Social Worker on 05/21/21, for the potential to be adversely affected by the concern area, development and implementation of interventions by staff. C. All resident's comprehensive care plans were audited from, 05/24/21 to 05/26/21, to ensure the required number of staff to assist with transfers was accurately assessed and documented. D. An audit was completed from 05/24/21 to 05/26/21, 06/03/21, 06/14/21, and 06/16/21, to ensure that staff are using the appropriate transfer method to safely assist residents with transfers. E. All staff were re-educated on 05/21/21, regarding implementation of resident Comprehensive Care Plans, safe transfers, and gait belt use. F. Concern area (implementation of comprehensive care plans) addressed at QAPI on 05/21/21 and will continue to discuss with the committee as needed for compliance and safety. G. The Director of Nurses/Administrator is responsible for overall compliance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed as requiring two staff members to provide physical assistance to safety transfer, the Facility failed to ensure his/her safety was maintained to prevent an incident/accident resulting in an injury. On 05/20/21, Certified Nurse Aide (CNA) # 1 assisted Resident #1 with a transfer into his/her wheelchair without the assistance of another staff member, Resident #1 hit his/her right hip on the side of the wheelchair, causing him/her severe pain, and he/she was transferred to the Hospital Emergency Department, where he/she was diagnosed with a right proximal femur (hip) fracture requiring surgical repair. Findings include: Resident #1 was admitted to the Facility in May 2021, diagnoses included Strain of Muscle (Fascia and Tendon) of the right hip. Review of Resident #1's Admission Minimum Data Set (MDS), dated [DATE], indicated that he/she required physical assistance from two staff members for transfers. During an interview on 06/29/21 at 11:49 A.M., the Director of Rehabilitation services said that Resident #1 was evaluated at the time of admission and required physical help by two staff members to safely provide him/her assistance with all transfers. The Facility's Internal Investigation, dated 05/21/21, indicated that on 05/20/21, around 9:30 P.M., Resident #1 told staff that a few minutes earlier, Certified Nurse Aide #1 transferred him/her from the toilet, into his/her wheelchair, and his/her right hip hit the side of the wheelchair, and that he/she had been in severe pain since. The Facility's Investigation indicated that Resident #1's right leg was limp and internally rotated, and he/she required an urgent transfer to the hospital where he/she was diagnosed with a right proximal femur (hip) fracture requiring surgical repair. Review of the Grievance/Concern Form, dated 05/20/21, indicated that Resident #1 told staff that CNA #1 was rushing while helping him/her and his/her right hip hit the side of the wheelchair. Review of Resident #1's Situation, Background, Assessment, and Recommendation (SBAR) Note, dated 05/20/21, indicated that he/she had increased and severe pain in the right hip area after a transfer with staff (later identified as CNA #1). Review of Resident #1's Hospital Medical Record, dated 05/21/21, indicated that Resident #1 was diagnosed with a right hip fracture with severe angulation (type of fracture displacement where the normal axis of the bone has been altered such that the distal portion of the bone points off in a different direction) and was admitted for medical treatment and surgical repair. Review of Resident #1's Documentation Survey Report, dated May 2021, (documentation completed by CNA's regarding care or assistance provided to residents during Activities of daily Living) indicated that for seven days prior to his/her incident on 05/20/21, two staff members provided physical assistance while assisting him/her during all transfers. During an interview on 06/17/21 at 11:45 A.M., Certified Nurse Aide (CNA) #1 said that he assisted Resident #1 to the bathroom by himself and transferred him/her on/off the toilet without another staff member. During an interview on 06/16/21 at 1:50 P.M., the Director of Nurses said that CNA #1 independently provided Resident #1 with transfer assistance on 05/20/21, and shortly after, he/she experienced extreme pain and was urgently sent out to the hospital and diagnosed with a right hip fracture. The Director said that Resident #1 told staff that his/her right hip hit something during the transfer, which maybe the cause of his/her pain and injury. On 06/17/21, the Facility was found to be in Past Non-Compliance and presented the Surveyors with a plan of correction which addressed the area(s) of concern as evidenced by: A. Resident #1 was urgently transferred to the hospital after the accident/incident for further evaluation and care, he/she did not return to the Facility. B. All residents were re-assessed by the Social Worker on 05/21/21, for the potential to be adversely affected by the concern area, preventable accidents/incidents from the Facility. C. All resident's comprehensive care plans were audited from, 05/24/21 to 05/26/21, to ensure the required number of staff to assist with transfers was accurately assessed and documented. D. An audit was completed from 05/24/21 to 05/26/21, 06/03/21, 06/14/21, and 06/16/21, to ensure that staff are using the appropriate transfer method to safely assist residents with transfers. E. All staff were re-educated on 05/21/21, regarding implementation of resident Comprehensive Care Plans, safe transfers, and gait belt use. F. Concern area (accidents/incidents) addressed at QAPI on 05/21/21 and will continue to discuss with the committee as needed for compliance and safety. G. The Director of Nurses/Administrator is responsible for overall compliance.

Based on observation, record review and interview the facility failed to implement infection control practices to prevent the transmission of infectious disease, including Covid-19 when, 1.) staff failed to perform hand hygiene, doff (take off) Personal Protection Equipment (PPE) appropriately and 2.) failed to ensure that laboratory service personnel did not potentially contaminate resident's environment on 1 of 3 resident care units. Findings include: On 1/11/2021 at approximately 8:00 A.M., during the entrance conference interview with the Administrator and Director of Nurses (DON), the DON said the facility currently had 15 residents who tested positive for Covid-19 and were receiving care on a designated unit. The Administrator said staff providing care on the resident care units, (not designated as Covid-19 positive), wear a KN95 mask, eye protection, and use gowns for high contact care. Review of the Center for Disease Control and Prevention (CDC) guidance titled How to take off (Doff) PPE dated 12/14/2020 indicated the following: 1. Remove Gloves-Ensure glove removal does not cause additional contamination of hands, gloves can be removed using more than one technique (e.g., glove-in-glove or bird break). 2. Remove gown- Untie all ties (or unsnap all buttons), some gown ties can be broken rather than untied. Do so in a gentle manner, avoiding forceful movement. Reach up to the shoulders and carefully pull gown down away from the body, roll the gown down in an acceptable manner and dispose in a trash receptacle. 3. Healthcare personnel may now exit the patient room 4. Perform hand hygiene. Further review of the CDC guidance indicated the following under the title Hand Hygiene Health Care Personnel (HCP) should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. Review of the Centers for Disease Control and Prevention (CDC) document titled; Core Infection Prevention and Control Practices for Safe Healthcare Delivery, dated March 15, 2017, indicated the following: Use standard precautions to care for all patients in all settings. Standard precautions include reprocessing of reusable medical equipment between each patient and when soiled. Maintain separation between clean and soiled equipment to prevent cross contamination On 1/11/2021 review of the facility's bed roster, indicated the Baldwin/Cain unit had 23 residents who were negative for Covid-19 and 29 residents who had recovered from Covid-19. On 1/11/21 at 8:48 A.M., the surveyors observed the(NAME)Cain Unit. The following observations were made: 1. CNA #1 exited a resident's room carrying breakfast trays with gloved hands and wearing a gown. CNA #1 walked down the hall and placed the breakfast trays in the food truck. CNA #1, then doffed her gown in front of the food truck, walked down the hall and threw the contaminated gown in a trash bin. CNA #1 walked back to the food tray truck while removing her gloves and put them in a trash bin. Without performing hand hygiene CNA #1 then opened the linen closet, contaminating the door handle and the supplies she removed from the closet. CNA #2 exited a resident room, doffed his gown in the hall, rolled the gown while walking down the hall and place the gown in the bin. During an interview on 1/11/21 at 9:00 A.M., CNA # 1 said gowns and gloves are doffed before exiting a resident room, gowns are placed in a bag and put it in a bin in the hall. CNA #1 said hand hygiene is done using Alcohol Based Hand Rub (ABHR) which is on the wall outside the resident room. CNA #1 said she did not follow the above steps. During an interview on 1/11/21 at 9:30 A.M., the Director of Nursing (DON) said that gowns should not be worn in the hall and should be doffed and placed in a bag (for containment) before staff leaves a resident's room. 2. On 1/11/2021 at 9:08 A.M., Laboratory Technician (LT#1), (an outside vendor, who provides laboratory services to residents with medical orders) was in a room occupied by a resident who was negative for Covid-19, completing a laboratory service. A large duffle bag, which stored the laboratory equipment, was on the bed of the resident potentially contaminating the bed linens. LT#1 put items into the bag and exited the room. During an interview on 1/11/2021 at 11:04 A.M., LT#1 said she provided laboratory services to multiple residents in the facility. LT#1 said she sanitizes the bag after leaving the building when she returns to her car. LT#1 said she places the bag on either the floor or a bed while providing services. During an interview on 1/11/2021 at 2:09 P.M., the DON said LT#1 should not have placed the bag directly on the resident's bed and should not have the bag in the room at all. Staff wearing contaminated gowns and gloves in the hall, not performing hand hygiene and placing potentially contaminated equipment on a resident bed fails to abide by the standard and transmission-based precautions identified by the CDC.

Based on observation, interview and record review, the Facility failed to follow the plan of care for 2 Residents (#84 and #61) out of a total sample of 25 Residents. Findings include: 1. For Resident #84 the Facility failed to supervise him/her while eating in his/her room. Resident #84 was admitted to the Facility in 7/2013 with [DIAGNOSES REDACTED]. On 10/02/18, at 8:26 A.M., the Surveyor observed Resident #84 eating breakfast in his/her room without staff supervision. On 10/04/18, at 8:30 A.M., the Surveyor observed Resident #84 sitting up in bed eating in his/her room without staff supervision. Review of the Minimum Data Set ((MDS) dated [DATE], indicated Resident #84 required supervision with the assistance of one staff member for support for eating, section G0110H Review of the care plan dated 7/4/15, and revised 7/25/18, indicated Resident #84 required supervision/assist of 1 to complete meals. Review of the Certified Nursing Assistant (CNA) daily documentation for the months of 9/2018 and 10/2018 indicated that Resident #84 needed continuous supervision with all meals. Review of the Speech Therapy evaluation dated 8/6/18, indicated that the treatment [DIAGNOSES REDACTED]. The evaluation also indicated that Resident #84 is on aspiration precautions which included him/her to be up and out of bed for all meals and for at least 30 minutes after the meal. During an interview with the MMQ Nurse on 10/04/18 at 8:58 A.M., she said that for residents that want to eat in their room but need to be supervised with eating, a nursing staff member will stay in their room with them. During an interview on 10/4/18, at 9:05 A.M., Certified Nurses Assistant (CNA) #1 said that if someone requires supervision with eating and doesn't go to the lounge to eat, the staff go in the room with him/her to watch them while they eat to keep them safe and to encourage them. 2. For Resident #61 the Facility failed to ensure the suspension heel lift booties were in place per the medical plan of care. Resident #61 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set, dated dated [DATE] indicated that Resident # 61 had a Brief Interview of Mental Status (BIMS) of 3 out of 15 which indicates a severe cognitive impairment and he/she required the assistance of 2 staff for bed mobility, transfers, dressing and is dependent for bathing. Further review of the MDS indicated that Resident #61 was at risk of developing pressure ulcers. Review of the medical record indicated that Resident #61 scored a 9 on the Norton Plus Skin assessment dated [DATE], indicating that he/she was a high risk for pressure ulcer development. Review of the physician's orders [REDACTED]. Review of the Care Plan for actual skin breakdown, related to bilateral buttocks abrasion, soft heels, impaired mobility, incontinence and indicated Resident #61 was to have bilateral heel lift suspension booties on at all times except for care. On 10/04/18 at 10:46 A.M., the Surveyor observed Resident #61 sitting in his/her recliner. Resident #61 was wearing socks with slippers and did not have the heel lift suspension booties on. On 10/4/18 at 2:00 P.M., the Surveyor observed Resident #61 lying in bed without the heel lift suspension booties on. One bootie was on a chair and the other one was on the dresser. During an interview with Nurse #1, on 10/4/18 at 2:00 P.M., she said that there was an order on the treatment administration record for Resident #61 to wear heel lift suspension booties at all times except during care. She said that the heels of Resident #61 were intact, but had some redness. She said the Certified Nursing Assistant (CNA) must have forgotten to put the booties back on after care.

Based on observation and interview, the facility failed to maintain the Main Kitchen, the Nourishment Kitchens and the Second Floor Dining Room in a sanitary manner. Findings include: 1. During the initial kitchen tour on 7/19/17 at 8:30 A.M. with the dietitian, the surveyor observed the following: Nectar thickened milk was held on the tray line at room temperature. A temperature check (using the facility's thermometer) of the nectar milk indicated the milk registered 58 degrees F. (Cold food should be held at 41 degrees F or below when served from the tray line). An opened jar of jelly was observed stored on a shelf at room temperature. The jar label read: refrigerate after opening. The following equipment was dirty: ice scoop and ice scoop holder, the can opener blade, the knife holder, 2 transport carts, the lower shelf of the reach-in refrigerator and the lower metal shelf in the food store room. The ice machine door was not in good condition with broken corners which prevented adequate cleaning. Access to the hand wash sink was blocked by a stack of 6 trays. The Dietitian, present with the Surveyor, acknowledged the above observations. 2. During the tour of the nourishment kitchens on 7/24/17 at 8:30 A.M. with the Food Service Director (FSD), the surveyor observed the following: On the Harnden Unit, the inside of the microwave had dried on food stains. The ice scoop holder did not have drainage holes to allow melted ice water to drain from the holder. On the Palmer Unit, the refrigerator door gasket was cracked. The light bulb was burnt out. The top inside surface of the microwave had food stains and the microwave plate had baked on food. On the Second Floor, the refrigerator light bulb was burned out. The freezer portion of the refrigerator had hardened food debris from melted ice cream and other frozen products. The refrigerator door gasket was split and food debris had accumulated there. The FSD, present with the Surveyor, acknowledged the above observations. 3. In the Second Floor Dining Room, the refrigerator shelves were sticky from spilled beverages, the freezer door shelf had food stains and the refrigerator door gasket was cracked. The steam table shelf was dirty. The hand wash sink contained 2 dirty beverage cups with white liquid (appeared to be left over milk) in them. The cabinets and the counter top behind the steam table contained activity supplies. During the noon meal service in the Second Floor Dining Room, coleslaw was kept at room temperature during the tray line. A temperature check (using the facility's thermometer) of the coleslaw indicated a reading of 55 degrees F. Milk and thickened milk on the serving cart were kept at room temperature. A temperature check (using the facility's thermometer) of the milk and thickened milk indicated readings of 63 and 54 degrees F. respectively. The FSD discarded the milk. (Cold food should be maintained at 41 degrees F or below when served from the tray line). 4. The dining room contained a bus cart holding dirty dishes and food debris. Before all the residents had finished eating, staff were scraping food from dirty dishes into side waste bins on the bus cart. At 12:55 P.M., dietary staff removed the bus cart from the dining room and transported the uncovered bus cart with the dirty dishes and food debris through part of the hallway of the Second Floor Resident Unit to the elevator and then through part of the First Floor Resident Unit to the Kitchen Dish Machine Room. On 7/26/17 at 9:30 A.M., during an interview, the FSD indicated that the dirty dishes should be scraped in the Dish Machine Room.

Based on record review and staff interview, the Facility failed to ensure that appropriate quality control testing was performed on 4 out of 7 of facility's Blood Glucose Monitoring Systems (Glucometers) , in accordance with manufacturer's requirements, to ensure safe operation. Findings included: On 7/21/17, at 12:30 P.M., a family interview took place in Resident #14's room. Resident #14's spouse told the surveyor that he/she had concerns about the finger stick glucose readings for Resident #14. He/she explained in detail, that his/her concerns were related to the accuracy of the glucometer readings. He/She was unable to recall specific dates, but stated that on several occasions (3-4 times) over the past two months, the glucometer gave a high glucose reading, and when he requested a repeat test, the result was significantly lower. He/she recalled that on one occasion a fingerstick blood glucose was 300, and the repeat fingerstick blood glucose was 250. He /she then expressed concerns about Resident #14 not receiving the correct dose of Insulin due to the testing inaccuracy. At 1:00 P.M., the facility's July Quality Control Record Sheets for all 7 of the facility's glucometers were reviewed. The Split Unit's July Quality Control Record showed that on 7/7/17, 7/10/17 and 7/13/17, no Quality Control testing was performed on the Split Unit's Glucometer. The Cain Unit's July Quality Control Record showed that on 7/8/17 and 7/15/17, no Quality Control testing was performed on the Cain Unit's Glucometer. The Baldwin Unit's July Quality Control Record showed that on 7/13/17, the acceptable low control range for testing was 84-105, the low control result was recorded as 83. No corrective action was taken and no testing was repeated. On 7/18/17, the acceptable high control range for testing was 213-266, the high control result was recorded as 2. No corrective action was taken and no testing was repeated. The Palmer Unit's July Quality Control Record showed that on 7/19/17, the acceptable high control range for testing was 213-266, the high control result was recorded as 441. No corrective action was taken and no testing was repeated. Review of the Glucocard Vital Blood Glucose Monitoring System's User Instruction Manual indicated that: If the result is outside the range printed on the test strip bottle, repeat the test. If the control solution result continues to fall outside of the required range, the system may not be working correctly. Do Not Use the system to test your blood. At 2:00 P.M., the Split, Cain, Baldwin, and Palmer Unit's Glucometer Quality Control Records were reviewed with the Assistant Director of Nursing (ADON). The ADON stated that the glucometers need to be checked for quality control every day and if the Quality Control result is outside of range, then the test is to be repeated, or words to that effect. The ADON then acknowledged that the glucometers were not appropriately checked for quality control.

Based on record review and staff interviews, the facility failed to develop comprehensive care plans which include individualized, measurable objectives and appropriate interventions for 4 sampled residents (#4, #10, #13 and #18) in a total sample of 23 residents. 1. For Resident #4, the facility failed to develop comprehensive, individualized care plans for communication and dental care. Resident #4 was admitted to the facility in 10/2015, with [DIAGNOSES REDACTED]. On 8/11/16, review of the medical record indicated that on the admission Minimum Data Set (MDS) dated , 11/6/15, and on the significant change MDS, dated [DATE], the Care Area Assessment (CAA) indicated that a care plan for communication and dental care should be developed. During record review, there was no evidence that there was a care plan for either communication or dental care. Record review indicated that the resident signed a consent form 6/15/16 to see a dentist. There was no evidence dental care was offered and there was no evidence that there was an appointment made to see a dentist. Review of the admission MDS dated [DATE], and significant change MDS dated [DATE], indicated that the resident had obvious or likely cavity or broken natural teeth. On 8/12/16, at 11:30 A.M., Surveyor #1 requested a copy of all of Resident #4's care plans from Regional Nurse #1. Care plans provided by Regional Nurse#1 failed to include a plan of care for communication and dental care as indicated by the 4/15/16 MDS. On 8/16/16, at 2:30 P.M. an interview with the MDS Coordinator, Director of Nursing (DON), Regional Nurse #2, Nursing Home Administrator and Administrator in Training took place. During this time, the MDS coordinator said she thought the dental care plan fell under the Activity of Daily Living care plan, which indicated that resident is an assist of one person with bathing, dressing and hygiene, and therefore there was not a comprehensive and individualized care plan for dental care for Resident #4. She did not say why there was no care plan for communication included in resident record. (See F411) 2. For Resident #10, the facility failed to develop a comprehensive, individualized care plan for dental care. Resident #10 was admitted to the facility in 11/2014, with [DIAGNOSES REDACTED]. On 8/11/16, review of the medical record indicated that on the annual MDS, dated [DATE], the CAA indicated a care plan for dental care should be developed. The MDS indicated that Resident #10 had obvious or likely cavity or broken natural teeth, as well as inflamed or bleeding gums or loose teeth. During record review, there was no evidence that there was a care plan for dental care. On 8/12/16, at 11:30 A.M., Surveyor #1 requested a copy of all of Resident #10's care plans from Regional Nurse #1. Care plans provided by Regional Nurse #1 failed to include a plan of care for dental care as indicated by the 12/20/15 MDS. On 8/16/16, at 2:30 P.M. an interview with the MDS Coordinator, Director of Nursing, Regional Nurse #2, Nursing Home Administrator and Administrator in Training took place. During this time, the MDS coordinator said she thought the dental care plan fell under the Activity of Daily Living care plan, which indicated that resident is an assist of one person with bathing, dressing and hygiene, and therefore there was not a comprehensive and individualized care plan for dental care for Resident #10. 3. For Resident #13, the facility failed to develop a comprehensive, individualized care plan for [MEDICAL CONDITION], cognitive loss, visual function and communication. Resident #13 was admitted to the facility in 7/2015, with [DIAGNOSES REDACTED]. On 8/12/16, review of the medical record indicated that on the annual MDS dated , 7/13/16, the CAA indicated a care plan for [MEDICAL CONDITION], cognitive loss, visual function and communication should be developed. During record review, there was no evidence that there was a care plan for [MEDICAL CONDITION], cognitive loss, visual function and communication. On 8/12/16, at 11:30 A.M., Surveyor #1 requested a copy of all of Resident #13's care plans from Regional Nurse #1. Care plans provided by Regional Nurse #1 failed to include a plan of care for [MEDICAL CONDITION], cognitive loss, visual function and communication as indicated by the 7/13/16 MDS. On 8/16/16, at 2:30 P.M. an interview with the MDS Coordinator, Director of Nursing, Regional Nurse #2, Nursing Home Administrator and Administrator in Training took place. During this interview, there was no indication as to why the care plans were not developed. 4. For Resident #18, the facility failed to develop a comprehensive, individualized care plan for dental care. Resident #18 was admitted to the facility in 11/2010, and readmitted ,[DATE], with [DIAGNOSES REDACTED]. On 8/16/16, review of the medical record indicated that on the annual MDS dated , 6/22/16, the CAA indicated a care plan for dental care should be developed. The MDS indicated that the resident had obvious or likely cavity or broken natural teeth. Further record review indicated that the dentist noted actions required by the nursing home staff for dental care are: 1. Resident requires assistance with toothbrushing and/or brushing coated tongue. 2. Perform oral hygiene twice daily, morning and evening. On 8/16/16, at 1:00 P.M. during record review, there was no evidence that there was a care plan for dental care as indicated on the 6/22/16 annual MDS. On 8/16/16, at 2:30 P.M. an interview with the MDS Coordinator, Director of Nursing, Regional Nurse #2, Nursing Home Administrator and Administrator in Training took place. During this time, the MDS coordinator said she thought the dental care plan fell under the Activity of Daily Living care plan, which indicated that resident is an assist of one person with bathing, dressing and hygiene, and therefore there was not a comprehensive and individualized care plan for dental care for Resident #18.

Based on observation, staff interview and policy review the facility failed to maintain proper hand hygeine during meal tray preparation in the main kitchen and failed to store food under sanitary conditions in the main kitchen and on 1 of 2 nursing units. Findings include: 1. Breakfast meal tray preparation was observed on 8/12/16, from 7:10 A.M. to 7:30 A.M. During this time The Dietary Aide (DA) walked over to the trash container and with a bare hand lifted the lid to throw away an unidentified item, therefore contaminating her hands. Without performing hand hygeine she put on gloves, therefore contaminating her gloves, and began placing utensils onto a meal tray to be used for resident meal consumption. The surveyor immediately brought this observation to the attention of the Food Service Director (FSD) who then stopped the tray preparation and had the DA perform hand hygeine and put on clean gloves. The FSD said the DA should have washed her hands and put on clean gloves. An undated Handwashing Policy was received from the Administrator on 8/16/16, at 7:30 A.M., which indicated that handwashing should be carried out with soap and water immediately after you come into contact with potentially infectious material. 2. Observation of the 2nd floor kitchenette on 8/12/16, at 9:55 A.M., revealed two 1/2 gallons of whole milk were opened and undated, a disposable Dunkin Donuts container of iced coffee was unlabeled, a container of Polaner strawberry fruit spread was opened and unlabeled, a liter of diet shasta ginger ale was opened and undated, a liter of shasta ginger ale was opened and undated, and a liter of shasta cola was opened and undated. Observation of the main kitchen on 8/12/16, at 10:05 A.M., revealed a container of nectar thickened cranberry juice was opened and undated, a liter of Shasta ginger ale was opened and undated, a gallon container of ranch salad dressing was opened and undated, a gallon container of salsa was opened and undated, a gallon container of mustard was opened and undated, and a 1/2 gallon of milk was opened and undated. During an interview with the FSD on 8/12/16, at 10:30 A.M., he said the items in the 2nd floor kitchenette should have been labeled by the nursing staff when they were opened and the Dunkin Donuts container should not be stored in a resident kitchenette. He said that the items in the main kitchen should have been labeled when they were opened by kitchen staff. During an interview with the Administrator on 8/12/16 at 11:00 A.M., he said he would have the unlabeled and dated in the refrigerators removed and replaced. Observation of the 2nd floor medication cart on 8/12/16, at 12:00 P.M., revealed a container of honey thick cranberry juice that was opened and undated and a container of honey thick orange juice that was opened and undated. At the time of the observation, an interview with the Assistant Director of Nursing (ADNS)took place, she said the containers should have been dated when they were opened and she would remove them and have them replaced. An undated, Food Storage, Labeling and Dating policy was received from the Administrator on 8/16/16, at 7:30 A.M., which states all foods are to be labeled following delivery, preparation or opening using an approved label that includes but is not limited to product name, delivery date, and date opened.

Based on record reviews and interviews the facility failed to ensure initial and/or routine dental services were provided for 1 of 23 sampled residents, (#4). 1. For Resident #4, the facility failed to provide resident with initial and routine dental care. Resident #4 was admitted to the facility in 10/2015, with [DIAGNOSES REDACTED]. On 8/11/16, review of the admission Minimum Data Set (MDS) dated , 11/6/15, and the significant change MDS, dated [DATE], indicated that the resident had obvious or likely cavity or broken natural teeth. Record review indicated that resident signed a consent form 6/15/16 to see a dentist. There was no evidence that dental care was offered and there was no evidence that there was an appointment made to see a dentist. On 8/16/16, at 2:30 P.M., an interview with the MDS Coordinator, Director of Nursing, Regional Nurse #2, Nursing Home Administrator and Administrator in Training took place. There was no explanation as to why dental care had not been arranged.

Based on observation, record review and staff interview, the facility failed to intervene in a timely manner and respond to an emergent situation, shortness of breath with increased respirations, increased heart rate and clamminess, for one Resident (#15) in a sample of 24 Residents while the Resident's medical condition deteriorated. Findings include: Resident #15 was admitted to the nursing facility on 3/2011 with [DIAGNOSES REDACTED]. The Resident has a cardiac pacemaker. A Quarterly Minimum Data Set Assessment, dated 6/3/13, documents the Resident as alert and oriented with a BIMS (brief interview of mental status) score of 15 out of 15 (cognitively intact). The Resident has no speech, vision or hearing deficits. The Resident requires extensive physical assistance for activities of daily living and is totally dependent for mobility and transfers. Resident #15 experiences shortness of breath both upon exertion and when sitting at rest. On 6/5/13, while conducting observation rounds at 9:30 A.M., the Surveyor overheard Medication Nurse #1 leaving a telephone message for a Nurse Practitioner regarding Resident #15. Medication Nurse #1 stated that Resident #15 had experienced increased shortness of breath, that a nebulizer treatment had been given and that the Resident was actually worse after the nebulizer treatment. Medication Nurse #1 reported that the Resident's heart rate was 130 and that respirations were 48 breaths per minute (normal range is 10-15 breaths per minute). Medication Nurse #1 ended the phone call by asking the Nurse Practitioner to call back and let him/her know what to do next. As Medication Nurse #1 left the nurses' station and proceeded down the hall, this Surveyor inquired as to the identity of the Resident. This Surveyor followed Medication Nurse #1 into Resident #15's room. Resident #15 was observed at 9:31 A.M. to have been left alone, to have oxygen on (at 2 liters per minute) and was very short of breath. The Resident was sweating profusely and his/her skin was cool to the touch. The Resident was observed with moderate to severe physical shaking. Resident #15 stated that he/she did not feel well. The Resident was observed to be alert. Medication Nurse #1 was observed to touch Resident #15's arm, noting that he/she was sweating profusely. Medication Nurse #1 stated to Resident #15 that the Nurse Practitioner had been called and that he/she was awaiting a call back for further instructions. At 9:33 A.M. Wheezing could be heard from the Resident's lungs upon approaching the Resident's bed and fluid could be heard with each breath. Resident #15's color became more pale and again the Resident stated that he/she did not feel well. Medication Nurse #1 stated that the Nurse Practitioner should be calling back shortly. However, the Resident was having increased difficulty breathing and was shaking more violently. This Surveyor instructed Medication Nurse #1 to call 911 at 9:33 A.M. (after Medication Nurse #1 had stood by the bedside for 2 minutes without doing anything after stating he/she was waiting for the Nurse Practitioner to call back and observations of the Resident with increased respiratory distress). Medication Nurse #1 left the room without calling for any additional help from staff, leaving the Resident with this Surveyor. Upon calling 911, the receptionist notified Unit Manager #1 (who was going into morning meeting) that 911 had been called from his/her Unit. Unit Manager #1 entered Resident #15's room at 9:35 A.M. and observed the Resident. Unit Manager #1 requested that someone get the Glucometer as the Resident was diabetic. Resident #15 then stated again that he/she did not feel well. Resident #15 continued to violently shake and sweat profusely, his/her color remained very pale. (Worsening condition from 9:30 A.M.) Upon conducting a fingerstick blood sugar reading, the Glucometer display read ' LO ' ( per Unit Manager #1 this indicated a blood sugar level of less than 20 milligrams per deciliter). Unit Manager #1 asked the Assistant Director of Nurses to get the Glucose Gel from the medication cart. However, a tube of the Glucose Gel could not be located in the cart and had to be obtained from the medication room . (despite the Resident not exhibiting signs of [DIAGNOSES REDACTED], the Resident's glucose level was not rechecked before administering the Glucose gel, even though the Resident presented as alert and responsive. [DIAGNOSES REDACTED] (low blood sugar) would have affected the Resident's alertness and ability to respond). At 9:37 A.M., as Unit Manager #1 began to administer 15 milligrams of the Glucose Gel, the fire department arrived simultaneously. Unit Manager #1 report that the Resident's blood glucose level had tested as below 20 milligrams per deciliter to the responders. However, with the Resident alert and responding appropriately, the fire department responders rechecked the Resident's blood sugar and found the blood sugar to be 486 milligrams per deciliter. The fire department began transport to the hospital at 9:45 A.M. The 6/5/13 Patient Care Report (from the emergency medical technician) documents the following: ? A carbon [MEDICATION NAME] level of 30 millimeters per milligram (normal range 23-29). ? Heart rate reading as high as 162 beats per minute. Rapid [MEDICAL CONDITION] Fibrillation. ? Respiratory rates as high as 46, documented as labored. ? [MEDICAL CONDITION] (continuous positive airway pressure - a type of ventilation in which mild pressure is used to keep the airways open). An interview with Medication Nurse #1, which was conducted by the Director of Nurses on 6/5/13 at 11:00 A.M,. was reviewed. Medication Nurse #1 stated that he/she did not think Resident #15's condition was an emergency as he/she had a similar event in May 2013. However, review of the INTERACT communication form, dated 5/13/13, documented that the Resident's pulse was 85 beats per minute (versus 130 on 6/5/13) and respirations were 22 (and not 48 breaths per minute on 6/5/13). The form documents that the Resident was short of breath and diaphoretic (cool sweat). However, the symptoms were relieved when the Resident was put back to bed with the head of the bed up. (Clearly, the 5/13/13 episode is not comparable in seriousness to the 6/5/13 episode as vital signs were much more compromised in the 6/5/13 episode). Unit Manager #1 was interviewed on 6/5/13 at 11:45 A.M. regarding the false low blood sugar obtained from the Glucometer. Unit Manager #1 stated that the Glucometer had not been recalibrated (after the clearly contradicting reading from the fire department) and in fact, the glucometer was found back in the medication cart (indicating that the Glucometer would have been used to test blood sugar levels for other Residents that day). Medication Nurses #2 and #3, also working on the first floor unit were asked by this Surveyor, to recheck the calibration of the Glucometers located on their medication carts, however, neither nurse knew to set the Glucometer in test mode before conducting a Control Solution Test. The Resident was admitted to the Telemetry Unit at the hospital after receiving 10 units of IV (intravenous) Insulin in the emergency room . The Director of Nurses', when interviewed on 6/5/13 at 12:00 P.M., could not explain how Medication Nurse #1 could compare the two events with very different presentations nor why Medication Nurse #1 had not called for assistance from other licensed staff on the unit. The Director of Nurses stated that the facility had just been inserviced on Code Blue in May 2013 by their ambulance service. However, further questioning revealed that only Cardiac and Respiratory Arrest had been covered in the inservice. The Director of Nurses' then provided a policy for medical emergencies. While the policy outlined assessing a Resident and calling the Physician, the policy only stated to 'provide emergency care as necessary ' and did not outline what that procedure was. The Blood Glucose Monitoring policy was reviewed on 6/3/13. While the policy detailed how to perform finger stick blood sugar tests, it did not contain any information on the procedure of a low blood sugar reading. The Director of Nurses' stated that all nurses would immediately be inserviced on responding to a medical emergency.

Based on staff interviews and observation, the facility failed to develop and maintain an infection control program designed to maintain a safe, sanitary environment for 1 Resident (#12) in a sample of 24 Residents and 3 non sampled (NS) Residents (NS Residents 1, 2 and 3). Findings include: Environmental tours were conducted on 6/4/13 and 6/5/13 and the following was observed: 6/4/13 : - room [ROOM NUMBER] - NS Resident #1 had a nebulizer machine on the nite stand. The mouthpiece was left uncovered on top of the machine. - Room, 126 - NS Resident #2 had a nebulizer machine on the nite stand. The mouthpiece was left uncovered on top of the machine. - room [ROOM NUMBER] - NS Resident #3 had a BIPAP (bi-level positive air pressure) machine which was observed on the bedside table. The tubing and face mask were observed to be laying on the bedside table (standards of practice call for the tubing to be hung when not in use to drain any pooled water and to cover the face mask/nasal pads when not in use). 6/5/13: - room [ROOM NUMBER] - Resident #12 had a nebulizer machine on the bedside table. The face mask was lying on the machine without a cover. - room [ROOM NUMBER] - NS Resident #1 had a nebulizer machine on the nite stand. The mouthpiece was left uncovered on top of the machine. The above observations were shared with the Director of Nurses on 6/6/13. The Director of Nurses stated that mouthpieces of the nebulizer machines should have been covered. She also stated that staff should have hung the tubing of the BIPAP machine and covered the mouthpiece when not in use.

Based on record review and staff interview, the facility failed to ensure that 1 of 7 applicable Residents (#5) in a total sample of 24, who sustained repeated falls, was provided adequate supervision and effective interventions to prevent further falls. Findings include: For Resident #5, with a history of falls prior to admission, continued to sustain multiple repeated falls after admission. The facility failed to develop interventions related to the resident's ability and continued to utilize interventions that relied on the resident to be compliant, call for assistance and wait for staff to respond. The clinical record was reviewed on 6/4/13. Resident #5 was admitted to the facility in 9/2012. [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] identified the resident as sometimes able to understand with a Brief Interview for Mental Status (BIMS) which scored 2 out of a possible score of 15. This indicated severely impaired cognitive ability. The resident required extensive assistance with all activities of daily living except limited asstance for eating. The resident was frequently incontinent of bowel and bladder, had a fall history and weighed 99 lbs (pounds). The resident was at risk for skin breakdown and received an antidepressant medication. The resident has an activated health care proxy and is a DNR (Do Not Resuscitate). The corresponding Falls Care Plan (10/1/12) included the following: Goal: Remain free from fall related injury. Interventions: * call bell within reach * area well lit and clutter-free * appropriate shoes for ambulation * reinforce safety teaching * utilize walker for transfer as needed * ensure wheelchairs are locked prior to transfer * transfer with the assist of 1-2 * fall risk numerical assessment quarterly * PT/OT as ordered The clinical record indicated that the resident sustained [REDACTED]. The interventions initiated as a result of dementia, lack of safety awareness and impulsiveness included: * a wheelchair with anti-tippers and anti-roll backs * an alarmed velcro seatbelt at all times - able to self release * a bed alarm at all times * bilateral 1/2 siderails * if resident is fully awake and co-operative, use one assist for transfers. Otherwise, use two assist for transfers with a gait belt. * recommendation to discipline staff for leaving the resident alone in the dining room or TV room. The resident continued to fall. Review of nursing progress notes, incident reports and falls investigation, indicated on 1/23/13 at 9:15 A.M., the resident was found on the floor on his/her left side in front of the bathroom doorway. The alarm was sounding. The resident stated, "I had to pee." The resident had bare feet. Staff documented that it was known that the resident takes socks off in bed. Nevertheless, the intervention which was put in place was, "Try to keep non-skid socks on in bed." Toileting was not addressed. The resident complained of left elbow pain approximately 45 minutes after the fall. The Quartely MDS dated [DATE] continued to identify the resident as above with the addition of impaired vision and now, always incontinent of bowel and bladder. The resident also received (as needed) PRN pain medication for occasional pain of 3 in a possible score of 10. The resident continues to fall since admission and weighs 91 lbs. The Falls care plan remained as above with the addition of 1/23/13, "Non-skid socks on while in bed." There was no indication on the care plan or the care card how this was to be accomplished as the resident was known to take them off in bed. Interview on 6/4/13 at 10:00 A.M. with Nurse #1, likewise was unable to identify how this would be accomplished. Review of nursing progress notes, incident reports and falls investigation, indicated that between 4/12/13 and 5/17/13 the resident fell 4 more times. On 4/12/13 at 7:00 A.M., the resident was found on the bathroom floor lying on his/her back with head in corner under the sink. The resident stated that he/she hit his/her head on the sink. Bed alarm was on and functioning. Red shoulder was noted. The investigation indicated that the alarm was unable to be heard over the floor buffer. The intervention was that "Administration would discussed floor machinery with head of housekeeping. Fifteen minute checks for one week." There was no documented outcome regarding the discussion between the Administrator and the head of housekeeping. On 4/24/13 at 5:30 A.M., the resident was found on the floor in his/her room with a 2 centimeters (cm) by 4 cm skin tear bleeding from the left arm. The intervention was to" toilet the resident on 5:00 A.M. rounds. Get the resident out of bed and placed in a wheelchair for safety. Do not allow the resident to return to bed." Although the falls investigation indicated "floor mat on each side of the bed," it was not present on the care plan. On 5/11/13 at 2:15 P.M, while the resident was being transported to his/her room in a wheelchair, the resident placed both feet on the floor. When the Certified Nurse Aide (CNA) stopped the wheelchair, the resident fell face forward, struck his/her forehead and fell back landing on his/her back. The velcro belt was off during the transport. There was a light blue bruise approximately 3 cm mid forehead. The intervention was "to use foot rests during transfers and transports when the resident is sleepy." Care plan indicates, velcro seat belt at all times. This was not followed. On 5/17/13 at 7:50 A.M., the resident was in bed sleeping. When the bed alarm sounded, the resident was ambulating in the hallway just outside the bedroom doorway. The resident grabbed onto the linen cart and the cart rolled away. When the resident lost balance, a staff person reached the resident and lowered the resident to the floor. The resident's right elbow brushed the wall while the resident was being lowered to the floor. The resident later complained of elbow pain and slight swelling was noted. The intervention was to "get the resident out of bed to toilet at 5:00 A.M. rounds (this is a repeat intervention) then brought to common areas in wheelchair or recliner for continuous supervision." It was noted on the Falls care plan that "continuous supervision" was crossed out on the same date (5/17/13). Interview with Nurse #1 on 6/4/13 at 11:00 A.M. regarding the appropriateness of the above interventions, the resident's inability to be reliable with follow through and the failure of staff to follow the established interventions, met with no response. Interview with the Director of Nursing on 6/6/13 at 11:30 A.M., indicated a lack of awareness that the interventions in place were not effective in preventing repeated falls.

Based on record review, interview and observation for 1 of 4 sampled residents (Resident #1) the Facility failed to ensure that 1 of 1 targeted resident (Resident #1) was supervised in the dining room during the lunch meal. On 7/30/12, at approximately 4:45 P.M., Certified Nurse Aide (CNA) #1 escorted Resident #1 into the dining room and then left the room to provide care to another resident. Resident #1 was at a high risk for falls and care planned for supervision. While there were no staff in the dining room, Resident #1 fell and sustained a fractured left hip. It was determined that the Facility did not provide continuous supervision in the dining during the lunch meal for at risk residents. Findings include: The Facility's incident report, dated 8/03/12, indicated that on 7/30/12, at approximately 4:45 P.M., nursing staff found Resident #1 lying on the dining room floor. The report indicated that Resident #1's personal alarm activated, but staff were not supervising Resident #1 at the time of the fall. The report indicated that Resident #1 was diagnosed with [REDACTED]. The Facility's fall management program, dated 1/01/2009, indicated that residents considered a fall risk should not be left alone while in the bathroom and that these residents needed to be in view of a staff member. The fall management program did not reference the level of staff supervision required for residents at risk for falls who are in the dining room. The physical therapy evaluation, dated 7/12/12, indicated that Resident #1 required moderate to maximum staff assistance to move from a sitting to standing position due to poor balance, decreased muscle strength, and dementia diagnosis. . The plan of care, dated 7/12/12, indicated that Resident #1 was at risk for falls due to a [DIAGNOSES REDACTED]. Care plan interventions included a chair alarm and the assistance of staff for transfers. The admission Minimum Data Set (MDS) assessment, dated 7/19/12, indicated Resident #1: required extensive staff assistance with transfers and ambulation; had an unsteady balance during transitions and walking; used a walker and a wheelchair for mobility; was diagnosed with [REDACTED]. The fall risk assessment, dated 7/20/12, indicated that Resident #1 was at a high risk for falls. The incident report, dated 7/28/12, indicated that he/she fell on this date on his/her bedroom floor. The report indicated that there was no injury. The physical therapy note, dated 7/30/12 (prior to the fall) indicated that Resident #1 required minimum assistance (provided by 2 staff) for transfers. ` The nurse's note, dated 7/30/12, indicated that on this date nursing staff found Resident #1 lying on the floor in the main dining room. The note indicated that Resident #1's fall was unwitnessed. The note indicated that Resident #1 complained of left hip pain and was sent to the Hospital for further examination. The Surveyor interviewed CNA #1 on 9/25/12 at 3:10 P.M. CNA #1 said that on 7/30/12 she wheeled Resident #1 into the dining room for dinner. CNA #1 said that Resident #1 was at risk for falls and required supervision. CNA #1 said that she heard another resident's personal alarm activated in the hallway and she left to help that resident. CNA #1 said that, though Resident #1 required supervision in the dining room because of his/her fall risk, Resident #1 appeared calm and was preparing to eat and did not seem to be at risk at this time. CNA #1 said that, while in the hallway, she heard Resident #1's personal alarm sounding and she ran to the dining room. CNA #1 said that Resident #1 was lying on the floor. CNA #1 said that there were no other staff in the dining room at this time. The Surveyor interviewed the Unit Manager on 8/30/12 at 11:50 A.M. The Unit Manager said that Resident #1 required staff supervision while in the dining room. The Unit Manager provided a list of residents who lived on Resident #1's unit and required supervision due to their high risk for falls. The Unit Manager said that Resident #2, Resident #3 and Resident #4 were at a high risk for falls and required supervision while in the dining room. The Unit Manager said that specific staff were not always assigned to supervise the dining room during meal time, but that if a resident was at risk for falls and required staff supervision, then a staff member was required to remain in the dining room and supervise the identified resident. The falls-risk list (undated) for Resident #1's unit indicated that Resident #2, Resident #3 and Resident #4 were at a high risk for falls and required supervision. The Surveyor interviewed the Director of Nurses (DON) on 8/30/12 at 8:10 A.M. The DON said that Resident #1 was at a high risk for falls and required staff supervision while in the dining room. The DON said that it was the Facility's implicit policy that staff were required to supervise residents at risk for falls while they were in the dining room. The DON said that supervision was defined as keeping the at-risk resident within view. The Hospital History and Physical, dated 7/30/12, indicated that Resident #1 fell at the Facility and X-rays showed a non-displaced subcapital fracture of the left hip. The Surveyor observed the unit dining room on 8/30/12 from 11:30 A.M. to 11:45 A.M. The Surveyor observed staff escorting residents into the dining room and placing them at the tables. The Surveyor observed nursing staff escort Resident #3 into the dining room and seat him/her at a table. The Surveyor observed that nursing staff then left the dining room to locate other residents to bring to lunch and during this time period there were no staff in the dining room to supervise Resident #3. The Surveyor observed that Resident #3 did not wear a personal alarm and there were no other interventions to manage his/her risk for falls. The Surveyor observed the Unit Manager ask a staff person to enter the dining room and remain there to supervise Resident #3 and the other residents all ready seated.

Based on observation, review of menus and Resident and Staff interviews, the facility failed to follow the planned menu for 2 meals during 1 day of survey. Findings include: During the Entrance Conference, the Administrator stated that the facility was presently without a Food Service Supervisor (FSS). On 7/17/12, a review of the Lunch menu for 7/17/12 indicated that the vegetable to be served at Lunch for those Residents receiving regular diets was Lima Beans. On 7/17/12, the Lunch meal was observed on the Baldwin Unit. Residents receiving a regular diet instead received peas not Lima Beans as their vegetable. On 7/17/12 at 3:00 P.M., the surveyor reviewed the Dinner menu for 7/17/12. It indicated the following information: The meal to be served for regular diets was Potato Encrusted Fish with Confetti Rice, Yellow Squash, a Dinner Roll and a Cherry Cream Cheese Bar for dessert. The National Dysphagia Diet Level 2 Mechanically altered meal to be served was Flake Fish Fillet, Mashed Potatoes, Yellow Squash. a Pureed Dinner Roll/Bread and a sugar cookie for dessert. The Liberal Renal meal to be served was Fish Fillet, Confetti Rice, Yellow Squash, a Dinner Roll/Bread and a cookie for dessert. On 7/17/12, observation of the dinner meal prep was made between 4:00 P.M. and 5:00 P.M. At 4:25 P.M., the fish had been cooked and preparation for the line was about to begin. The only fish observed to have been cooked and prepared for this meal was the Potato Encrusted Fish. In addition, neither Dinner Rolls, Cherry Cream Cheese Bars nor Sugar Cookies were observed prepared for this meal. Individually wrapped Chocolate Chip cookies were observed on a cart. An interview was conducted with the Cook at 4:30 P.M. He stated that he did not prepare the Flake Fish or the Fish Fillet. He went on to state that his former Employer told him that he could serve Potato Encrusted Fish to those Residents receiving the National Dysphagia Diet Level 2 Mechanically altered meal and that he had been doing so for over a month. He did not provide a revised written menu to reflect this information. He further stated that he did not prepare the Fish Fillet for those Residents receiving a Liberal Renal Diet. When asked why, he stated he just "didn't." When asked why no dinner rolls were being served to any of the Residents, he stated that staff did not have time to get to it. He was then asked why Residents receiving a regular diet were not being served the Cherry Cream Cheese Bar for dessert and why Residents receiving a National Dysphagia Diet Level 2 Mechanically altered meal were not receiving a sugar cookie. He stated that he did not know why he was "switching them off the Residents' menu." He stated that the Residents will instead be receiving a soft cookie for dessert. Kitchen Staff were unable to provide accurate information as to how many Residents were to receive the National Dysphagia Diet Level 2 Mechanically altered meal. They were able to confirm that 5 Residents were to receive a Liberal Renal Diet. Present during the above interviews was a FSS from a sister facility who came in to assist the facility during the Survey. She was present during the above interviews. At 4:35 P.M., she instructed the Cook to take out Tilapia (fish) and cook it for those residents who require a National Dysphagia Diet Level 2 Mechanically altered and a Liberal Renal Diet. Tilapia was observed being cooked through at least 5:00 P.M., when the surveyor left the kitchen. On 7/18/12, the Lunch menu stated that Residents receiving a National Dysphagia Diet Level 2 Mechanically altered meal were to receive a Pureed Dinner Roll/Bread and those Residents receiving a Liberal Renal Diet were to receive a Dinner Roll/Bread. Three non-sampled Residents (A, B and C) who received pureed diets did not receive a Dinner Roll/Bread and two non-sampled Residents (D and E) did not have a Dinner Roll/Bread. On 7/19/12 at 11:00 A.M., the Menu Substitution Log dated between 4/12 and 7/12 was reviewed. The following information was identified: In 4/12: 4/2/12-4/7/12, and 4/10/12, various foods were identified as not being in stock and other foods were substituted. In 5/12: On 5/3/12, 5/7/12 and 5/11/12, various food items were identified as not being in stock, thereby requiring food substitutions. On 5/19/12, Baked Ham was identified as not being served for lunch as it was frozen and too late to thaw. Franks and Beans were substituted. In 6/12: 6/3/12-6/5/12, 6/11/12-6/12/12, 6/18/12 and 6/21/12, various food items were identified as not being in stock, thereby requiring food substitutions. In 7/12: On 7/16/12, Rice Pudding was identified as not being in stock for dinner and Banana and Chocolate pudding puree were substituted. On 7/17/12, Squash was not served during the dinner meal as the kitchen ran out of this item. Tomato Salad was substituted instead. On 7/18/12, Ziti was not served during the dinner meal as the cook did not see it on the shelf and therefore substituted Pasta instead. An interview was held with the Administrator on 7/18/12 at 3:00 P.M. He stated that he was unaware of number the food substitutions taking place and that he would address it.

Based on observation and staff interview, the facility failed to maintain and/or assure sanitary conditions as kitchen staff failed to ensure proper hygienic food handling techniques during the preparation on food. Findings include: Surveyor observation of the kitchen on 7/17/12 between 4:00 P.M. and 5:00 P.M. revealed unsanitary conditions as evidenced by the following: 1. During observation of the tray line at 4:15 P.M., the surveyor observed the cook wearing a heavily soiled shirt. At 4:20 P.M., the cook was observed donning gloves. Then, with his right gloved hand, he placed a clean spoodle (a serving utensil) into a container of cooked rice. He was then observed rubbing his right gloved hand twice onto his heavily soiled shirt. Without removing his now soiled right glove, he was then observed gripping a clean second spoodle with his soiled right gloved thumb and placing the now contaminated spoodle into a cooked container of squash. Without removing the contaminated right glove, the cook at 4:25 P.M. was observed ladling food onto food plates on the food line. In doing so, he was observed using his contaminated right glove to move food around on five different plates. The Food Service Supervisor from a sister facility, was present and was informed of the above observations. She stated that she would speak to the cook. On 7/18/12 at 7:15 A.M., the Diet Kitchen on the Baldwin Unit was observed. Inside the freezer was a large strawberry ice cream container that had an ice cream scoop imbedded in the ice cream. On 7/18/12 at 3:00 P.M., an interview was held with the Administrator and he was informed of the above observations. He stated he would address the issues noted.

Based on record review and staff interview, the facility failed to provide complete and accurate information to the physician, for 1 resident (#1), in a sample of 28 residents, who was not informed that Resident #1 was found entrapped between the mattress of their bed and side rail, resulting in incomplete information being provided to the state's Medical Examiner. The findings include: While conducting the entrance tour on [DATE] at 9:15 A.M., the Regional Director of Operations informed the survey Team Coordinator, that Resident #1 had fallen on [DATE] during the night shift and subsequently died . The DON (Director of Nurses) stated during an interview, on [DATE] at 9:15 A.M., that the state's Medical Examiner had been called, by the DON, after the DON arrived at the nursing facility and reviewed the incident at 2:00 A.M. The Medical Examiner wanted to know what the Primary Care Physician would list as the cause of death. The DON stated that the Primary Care Physician was called, by the DON, at approximately 3:00 A.M., and the Primary Care Physician responded that the cause of death would be documented as Dementia. The DON stated that the Medical Examiner was called back and when informed of the cause of death, declined the case. The DON further stated that the funeral home had been called and the resident had been taken to the funeral home. Further interview with the DON on [DATE] at 9:30 A.M., revealed that the resident had been found at 11:50 P.M. on [DATE], during rounds, with the resident's head stuck between the mattress and the siderail of the resident's bed, with the resident's lower body on the floor next to the bed. The DON was asked for the written fall report completed by staff on duty at the time of the fall. Review of the Accident/Incident report, and accompanying written statements by staff on duty at the time of the fall were reviewed on [DATE] at 11:00 A.M. Findings include: * Certified Nursing Assistant (CNA) #2 documented that he/she was conducting rounds when Nurse #2 came outside of room [ROOM NUMBER] calling for staff assistance at 11:55 P.M. CNA #2 documented that Resident #1 was "found falling down on the mat and head stuck on upper side of the bed. Supervisor asked me and the nurse to assist him/her putting him/her (the resident) to bed." * Nurse #4 (,[DATE] Supervisor) documented that the second floor nurse (Nurse #2) had called and asked for Nurse #4 to "come to the floor right away. Found resident in B bed sitting on, or close to the floor with upper body in between side rail and the bed, facing towards the door. Unresponsive, color pale, hands noted to be mottled. The side rail was lifted off, was on his/her neck area." * Nurse #3 documented that he/she was called to room [ROOM NUMBER] (the written statement does not specify by whom) and instructed to call the Supervisor quickly. "When I entered room [ROOM NUMBER], I saw the said resident sitting on the floor with his/her head facing out between the mattress and the right side rail." * Nurse #2 documented that at 11:50 P.M., "patient found to be sitting on the floor beside inside (between) beds. He/she was on his/her buttocks in an upright but slouched position with his/her head between the half siderail and mattress facing toward the doorway. alarm in place, but not sounding. Patient noted to be pale, no pulse or respirations. Non responsive. Alarm sounded as his/her back lifted from mattress. 1:30 A.M., MD (medical doctor) notified and responded - order for RN (registered nurse) pronouncement obtained." * Nurse #5 documented "received a call from (Nurse #2) and asked if I would come up to pronounce a resident. Went into resident room. Resident noted to be on the floor, on his/her back, on the right side of bed. Pale, not breathing, non-responsive. Noted to have acorn sized indentation under left jaw and dime sized indentation beneath right jaw. Ecchymotic area noted on anterior neck. ,[DATE] Supervisor (Nurse #4) called Director of Nurses for guidance on how to handle this situation. Administrator came into facility, under advisement, call was placed to (Primary Care Physician) and order obtained to pronounce." The DON was again interviewed on [DATE] at 11:00 A.M. The DON stated that he/she received a call at 12:00 A.M., from Nurse #4 and was told how the resident was found. The DON stated that he/she then called the Administrator and that the Regional Director of Operations and the Regional Clinical Service Specialist were called and informed of the situation (fall and death). The DON stated that he/she arrived at the facility at 2:00 A.M., on [DATE] and observed Resident #1 in the bed. The DON stated that he/she did not see any bruising on the resident at that time (even though the pronouncing nurse had documented indentations under the right and left jaw and bruising on the anterior neck). The funeral home was not called at that time due to the family of Resident #1 was on their way to the facility. The DON stated that he/she then got written statements from the nursing staff and placed a call to the Medical Examiner's office. The DON stated that the Medical Examiner was called and that the Medical Examiner wanted to know what the cause of death would be listed as on the death certificate. A second call was placed to the Primary Care Physician and the DON stated that the Primary Care Physician stated that the cause of death would be documented as Dementia. The DON stated that he/she had called the Primary Care Physician back to make sure Nurse #2 had given the physician all of the information (however, this information was contradicted during the interview on [DATE] with the Primary Care Physician). The DON stated that he/she again called the Medical Examiner back with the [DIAGNOSES REDACTED]. The DON was asked if the Medical Examiner was told of the bruising on the anterior neck and indentations on the left and right sides of the jaw. The DON stated that the Medical Examiner had not been told that because he/she had not seen any bruising. The DON was instructed by the Surveyor to call the Primary Care Physician and ask that he/she come to the facility to speak with the survey team. The DON was further instructed by the survey team to call the Medical Examiner and report the specific condition the resident was found in (with head stuck between mattress and bed rail) and of the bruising to the anterior neck. At 11:10 A.M., the Clinical Service Specialist informed the survey team that the funeral home had been called and asked not to start the embalming process. The Clinical Service Specialist also informed the survey team that the Medical Examiner would be taking the case after being given the additional information regarding the circumstances the resident's body was found in as well as the bruising. The Primary Care Physician came into the facility on [DATE] and was interviewed at 11:30 A.M. The Primary Care Physician stated that he/she had been called by one of the nurses on duty, at approximately 2:00 A.M. on [DATE]. The Primary Care Physician stated that he/she was told that "the resident was found dead during rounds" by Nurse #2. The Primary Physician further stated that he was called a second time and was asked by the DON "if the resident was found dead and in bed, what would the cause of death be?" The Primary Care Physician stated not knowing/not being told the circumstances under which the resident was found, that he/she had replied that the [DIAGNOSES REDACTED]. Nurse #2 stated during an interview, conducted on [DATE] at 4:47 P.M., that at 11:50 P.M., on [DATE], upon entering room [ROOM NUMBER], Resident #1 was observed with the lower portion of his/her body on the floor. The resident's head was observed to be stuck between the air mattress and the quarter side rail on the right side of the bed. Nurse #2 stated that he/she called for the second nurse on duty (Nurse #3) and asked Nurse #3 to notify the registered nurse on the first floor (Nurse #5) as well as the Supervisor for the ,[DATE] shift (Nurse #4). Nurse #2 was asked if he/she had called the resident's physician. Nurse #2 stated that he/she was directed to not make any calls until the DON and Administrator arrived in the building. Nurse #2 stated that after the DON and Administrator arrived at the facility, Nurse #2 was instructed by the DON to call the resident's Primary Care Physician and to report only that the resident had been found to have expired during rounds and not to elaborate on how the resident was found (in what position nor to inform that the resident's head and neck were stuck in the bed rail). Nurse #4 (who worked from 11:00 P.M. on [DATE] until 7:00 A.M. on [DATE]) was interviewed on [DATE] at 6:04 A.M. Nurse #4 is designated as the ,[DATE] nursing supervisor. Nurse #4 stated that he/she was called to the second floor unit at 11:50 P.M., on [DATE] to room [ROOM NUMBER]. Nurse #4 stated that the resident's head was between the mattress and the side rail and was protruding through the bottom third of the side rail. Nurse #4 stated that the resident's "face appeared to be forward and resting on the bottom metal bar." Nurse #4 stated that CNA #2 held the side rail and pulled it outward while Nurse #4 held the resident's head and then lowered the resident to the floor once the resident's head was released from the side rail and mattress. Nurse #4 confirmed that there were indentations on both sides of the neck, left indentation greater than the right and a "dark pink area noted on resident's neck laterally, approximately 2 inches from under chin and extending down the neck." Nurse #4 stated that he/she then called the DON and described how the resident was found. Nurse #4 stated that he/she was told not to make any calls until the Administrator arrived. Nurse #4 stated that the Administrator viewed the resident and made a phone call. The Administrator then instructed Nurse #4 to have Nurse #2 call the physician and give as little information as possible. Nurse #4 stated that the Administrator told him/her "patient expired - found on rounds." (Per the Clinical Service Specialist, when Nurse #4 was interviewed by the Clinical Service Specialist on [DATE], Nurse #4 told her/him that it was the DON and not the Administrator who told him/her to state "patient expired-found on rounds"). Nurse #4 further stated that he/she had been told by the DON that the DON had called the physician and told him/her how the resident was found (the physician stated during an interview on [DATE], that he/she was unaware of how the resident was found until after surveyors had requested he/she be notified and asked to speak with surveyors on [DATE]). Nurse #5 (who worked from 11:00 P.M. on [DATE] until 7:00 A.M. on [DATE]) was interviewed on [DATE] at 6:20 A.M. Nurse #5 (who was working the first floor Palmer Unit, and was the only Registered Nurse in the facility) was the registered nurse called to the Baldwin/Cain Unit to perform the RN pronouncement. Nurse #5 stated that he/she was called by Nurse #2 at 11:50 P.M. on [DATE] and was told "I need your help - a resident has passed away - its a bad situation - resident was stuck on the railing." Nurse #5 stated that when he/she arrived at the resident's room the resident was lying on the floor mat. Nurse #5 stated that he/she observed a acorn size indentation beneath the left jaw, a dime size indentation beneath the right jaw and a bruise noted on the trachea, lateral anterior neck approximately 1 ,[DATE] inches. Nurse #5 stated that the bruised area was slightly indented. Nurse #5 stated that he/she heard Nurse #2 report to the physician "doing rounds and found resident expired." Nurse #5 stated that the physician had asked if the resident had any recent illness and was told no. The Clinical Service Specialist stated that he/she had interviewed Nurse #2, Nurse #4 and Nurse #5 on [DATE]. After the interviews, the Clinical Service Specialist stated that the three nurses had confirmed the DON had told them to provide limited information to the resident's Primary Care Physician.

Based on observations, record review and staff interviews, the facility failed to comprehensively assess 4 of 7 residents with restraints/devices (Residents #1, #14, #20 and #22) in a total sample of 28, to ensure the residents were utilizing the least restrictive restraints/devices for the least amount of time necessary to treat medical symptoms. In addition, the facility failed to complete an entrapment assessment for Resident #1 per facility protocol and manufacturer's recommendation for the use of an air mattress. The findings include: 1. The facility failed to assess for entrapment risk prior to implementing the use of an air mattress bed with quarter side rails for Resident #1, who subsequently became entrapped between the air mattress of the bed and side rail resulting in death. The Annual MDS (Minimum Data Set) Assessment, dated [DATE] documented that the resident had short and long term memory loss and severely impaired in daily decision making. The resident sometimes understands verbal content and is rarely understood, with no speech. The resident was documented as being resistive to care. The resident required extensive assistance of two people for bed mobility and required total care for all activities of daily living. The resident was documented as having no limitations in range of motion to both upper and lower extremities. The resident has had no falls. The resident was assessed as being at risk for developing a pressure ulcer with pressure reducing device utilized in the bed. The resident was documented as using a trunk restraint. The Quarterly MDS Assessment, dated [DATE], documented no change to the resident's status from the [DATE] Annual Assessment. The most recent side rail assessment was completed on [DATE] as part of a re-admission resident assessment. The assessment documented that the resident demonstrates poor bed mobility and was utilizing side rails for positioning and support. The recommendation of the assessment was for ,[DATE] side rails to be utilized to provide safety. There were no further side rail assessments completed since [DATE]. Review of the medical record on [DATE] at 9:30 A.M., revealed that an air mattress had been ordered for Resident #1 on [DATE]. There was no documentation to determine that the air mattress and the ,[DATE] side rails had been assessed for the possibility of entrapment. Interview with the DON on [DATE] at 11:00 A.M., revealed that the maintenance department (with no specific person in maintenance identified as being responsible) was responsible for placing the air mattress on the bed and ensuring that there was not an entrapment risk. However, no documentation of any assessment completed could be found. Interview with the Regional Director of Operations on [DATE] at 12:00 P.M., revealed that the maintenance department used an FDA (Food and Drug Administration) approved device to measure the space between side rails and mattresses whenever a mattress was placed on the bed. The Regional Director of Operations showed surveyors a form that would have been filled out when the mattress was placed, however, this form had not been filled out on [DATE] when the mattress was placed on Resident #1's bed. Review of the manufacturer's guidelines for the Blue Chip Supreme Air mattress in place on the bed in room [ROOM NUMBER]B revealed that the space between the side rail at the bottom corner and the mattress should be no wider than 2 ,[DATE] inches. Safety tips for the operating instructions for this air mattress document "consider the appropriate use of side rails on the patients bed." A CPR (cardio-pulmonary resuscitation) valve is located on the air mattress and the manufacturer's instruction include to "in the event of [MEDICAL CONDITION], twist the CPR (valve) to release air. It will take less than 10 seconds to deflate the mattress." Resident #1 weighed 118 pounds and per the manufacturer's guidelines, a weight of ,[DATE] pounds should have inflation setting of ,[DATE]. Observation of the bed in room [ROOM NUMBER]B revealed that a Blue Chip Supreme Air mattress was on the bedframe (inflated with the inflation settings correct (between 1 and 2) for the resident's weight) with bilateral quarter side rails. The air mattress was noted to have soft sides which compressed downward with minimal weight placed on the edge of the mattress. When the side of the mattress was compressed, the space between the siderail and the mattress edge was greater than the allowable 2 ,[DATE] inches (the space measured 6 inches and not the allowable 2 ,[DATE] inches). The DON was again interviewed regarding the air mattress on Resident #1's bed on [DATE] at 4:00 P.M. The DON stated that an entrapment assessment is completed whenever an air mattress or specialty mattress was placed on a resident's bed. However, no entrapment assessment had been documented as completed when the air mattress was placed on Resident #1's bed on [DATE]. The DON stated that the resident's heels had begun to break down and an air mattress had been implemented to prevent further skin breakdown. The DON stated that maintenance staff had placed one air mattress on the bed, but found that it did not fit the bed properly and had then applied the air mattress which was on the bed on [DATE]. The DON stated that maintenance staff had assessed the air mattress to ensure proper size and inflation, however, no documentation could be provided to confirm that this assessment was completed. The Regional Director of Operations was observed on [DATE] at 4:00 P.M., conducting entrapment assessments with a maintenance worker. The Regional Director of Operations stated that the maintenance department conducted the entrapment assessments utilizing an FDA approved entrapment assessment mechanism. There was no evidence that nursing staff had been inserviced on how to assess for entrapment risk when utilizing air mattresses nor evidence that nursing staff had been inserviced regarding the CPR valve that would deflate the air mattress in 10 seconds. The Director of Nurses during an interview on [DATE] at 4:00 P.M., confirmed that there was no evidence of inservicing regarding entrapment assessments and use of the CPR valve for nursing staff. 2. For Resident #14, the facility failed to comprehensively assess the use of a velcro alarm seatbelt to determine if the velcro alarm seatbelt was the least restrictive device for the least amount of time. Resident #14 was admitted to the facility [DATE] with with [DIAGNOSES REDACTED]. Review of the resident's clinical record on [DATE] at 10:30 A.M., indicated the resident's Annual Minimum Data Set ((MDS) dated [DATE] and the most recent quarterly MDS dated [DATE] identified the resident as being totally dependent with Activities of Daily Living (ADLs) and was frequently incontinent of bowel and bladder. In addition, the resident required the use of a trunk restraint on a daily basis. The facility identified the resident as a high risk for falls and had a history of [REDACTED]. Observation of this resident on 6 of 8 days of survey ([DATE] at 10:30 A.M., [DATE] at 2:30 A.M. and 3:00 P.M., [DATE] at 1:00 P.M., [DATE] at 7:20 A.M., [DATE] at 11:00 A.M. and [DATE] at 8:35 A.M.), revealed the resident was seated in a Tilt-N-Space chair with a velcro alarm seatbelt in place. Further record review on [DATE] at 4:05 P.M., indicated the resident had a current physician's orders [REDACTED]. On [DATE] at 4:10 P.M., review of the facility's "Quarterly Restraint Review" form revealed the following information was to be completed: 1. Review date. 2. Type of Restraint. 3. Original Order Date. 4. Current Order. 5. Continued Use of Restraint. If Yes, Reasons. 6. Decision to Reduce? Yes or No. 7. Reduction Plan. 8. IDT Signatures. On [DATE] at 4:15 P.M., review of the Quarterly Restraint Reviews completed on [DATE] and [DATE] (these were the two most current restraint reviews completed for this resident), revealed the resident had utilized a velcro alarm seatbelt since [DATE]. The two restraint reviews were not complete as there were no answers to the questions, (#5 and #6). Interview with Unit Manager #2 on [DATE] at 9:30 A.M., indicated Unit Manager #2 was the staff person responsible for completing the Quarterly Restraint Reviews and Unit Manager #2 was unaware that the Quarterly Restraint Reviews were not complete since ,[DATE]. Unit Manager #2 indicated the facility did not assess the resident for the least restrictive device to be used for the least amount of time since ,[DATE]. Interview with the Assistant Director of Nurses and review of the facility's restraint policy on [DATE] at 11:50 A.M., revealed the facility's restraint policy and procedure stated: "Assess resident's need for least restrictive restraint use." However, further review of the facility's restraint policy and interview with the Assistant Director of Nurses revealed that although, the facility assessed for the least restrictive restraint/device use, the facility failed to assess for the device/restraint use for the least amount of time. 3. For Resident #22, the facility failed to comprehensively assess the use of a velcro alarm seatbelt to determine if the velcro alarm seatbelt was the least restrictive device for the least amount of time. Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 9:30 A.M., review of the quarterly MDS assessment, dated [DATE], indicated the resident was totally dependent with ADLs (activities of daily living) and required the use of a trunk restraint daily. Review of the resident's clinical record on [DATE] at 9:40 A.M., revealed that the resident had a current physician's orders [REDACTED]. Further record review revealed the resident was identified as a high risk for falls and had a history of [REDACTED]. On 4 of 8 days of survey ([DATE] at 11:00 A.M., [DATE] at 9:35 A.M., [DATE] at 2:05 P.M., and [DATE] at 8:35 A.M.), surveyor observed the resident sitting the television room in a wheelchair with a velcro alarmed seatbelt in place. Further record review on [DATE] at 9:05 A.M., revealed the Quarterly Restraint Reviews dated [DATE], [DATE] and [DATE] (which were not completed quarterly) indicated the resident utilized the velcro alarmed seatbelt since [DATE]. The Restraint Reviews did not indicate if a reduction plan had been conducted or if the velcro alarmed seatbelt was the least restrictive device for the least amount of time since ,[DATE]. Interview with Unit Manager #2 on [DATE] at 9:30 A.M., confirmed the resident utilized the device since [DATE] and the Quarterly Restraint Reviews did not indicate the device used was assessed for least restrictive and/used for the least amount of time. 4. For resident #20, the facility failed to comprehensively assess the use of a velcro alarm seatbelt to determine if the velcro alarm seatbelt was the least restrictive device for the least amount of time. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 9:00 A.M., review of the quarterly MDS dated [DATE] indicated the resident required extensive assistance with ADLs, limited assistance with eating and required the use of a trunk restraint daily. Review of the resident's clinical record on [DATE] at 11:00 A.M., revealed that the resident had a current physician's orders [REDACTED]. Further record review revealed the resident was identified as a high risk for falls and had a history of [REDACTED]. On 4 of 8 days of survey ([DATE] at 12:00 P.M. and 5:25 P.M., [DATE] at 9:30 A.M., [DATE] at 2:00 P.M., and [DATE] at 8:30 A.M.), surveyor observed the resident sitting in a wheelchair in the hallway next to the nurses' station with a velcro alarmed seatbelt in place. Further record review on [DATE] at 9:05 A.M., revealed the Quarterly Restraint Review dated [DATE] and [DATE] indicated the resident utilized the velcro alarmed seatbelt since [DATE]. The two restraint reviews did not indicate if a reduction plan had been conducted since [DATE]. Interview with Unit Manager #2 on [DATE] at 9:30 A.M., confirmed the Quarterly Restraint Reviews did not indicate if the device used was the least restrictive and/used for the least amount of time since [DATE].

Based on observation, record review and staff interview, the facility failed to ensure that the resident environment remained free of accident hazards and failed to adequately supervise 5 residents in a sample of 28 (Residents #1, #4, #5, #25 and #28) and 4 non sampled (NS) residents (Residents NSA, NSB, NSC and NSD). Findings include: 1. The facility failed to assess for entrapment risk prior to implementing the use of an air mattress bed with quarter side rails for Resident #1. The facility failed to provide adequate staffing on the ,[DATE] shift (Please refer to F353), and failed to ensure staff adequately monitored Resident #1, resulting in the entrapment of Resident #1 between the mattress of the bed and side rail resulting in death. An Annual MDS (Minimum Data Set) Assessment, dated [DATE] documented that the resident had short and long term memory loss and was severely impaired in daily decision making. The resident sometimes understands verbal content and is rarely understood, with no speech. The resident was documented as being resistive to care. The resident required extensive assistance of two people for bed mobility and required total care for all activities of daily living. The resident was documented as having no limitations in range of motion to both upper and lower extremities. The resident has had no falls. The resident was assessed as being at risk for developing a pressure ulcer with pressure reducing device utilized in the bed. The resident was documented as using a trunk restraint. A Quarterly Assessment, dated [DATE] documents no change to the resident's status from the [DATE] Annual Assessment. The most recent side rail assessment was completed on [DATE] (there were no other side rail assessments completed after [DATE]) as part of a re-admission resident assessment. The assessment documented that the resident demonstrated poor bed mobility and was utilizing side rails for positioning and support. The recommendation of the assessment was for ,[DATE] side rails to be utilized to provide safety. A physical therapy evaluation, completed on [DATE] and reviewed on [DATE], documented that the resident exhibited restless movements of bilateral lower extremities and had increased tone to the left upper and lower extremity. The resident was documented as having facial grimacing and cries out with left upper extremity ranging. While conducting the entrance tour on [DATE] at 9:15 A.M., the Regional Director of Operations informed the survey Team Coordinator, that Resident #1 had fallen on [DATE] during the night shift and subsequently died . The DON (Director of Nurses) stated during an interview, on [DATE] at 9:15 A.M., that the state's Medical Examiner had been called, by the DON, after the DON arrived at the nursing facility and reviewed the incident at 2:00 A.M.. The Medical Examiner wanted to know what the Primary Care Physician would list as the cause of death. The DON stated that the Primary Care Physician was called, by the DON, at approximately 3:00 A.M., and the Primary Care Physician responded that the cause of death would be documented as Dementia. The DON stated that the Medical Examiner was called back and when informed of the cause of death, declined the case. The DON further stated that the funeral home had been called and the resident had been taken to the funeral home. Further interview with the Director of Nurses on [DATE] at 9:30 A.M., revealed that the resident had been found at 11:50 P.M. on [DATE] during rounds, with the resident's head stuck between the mattress and the siderail of the resident's bed, with the resident's lower body on the floor next to the bed. The Director of Nurses was asked for the written fall report completed by staff on duty at the time of the fall. Review of the Accident/Incident report, and accompanying written statements by staff on duty at the time of the fall were reviewed on [DATE] at 11:00 A.M. * Certified Nursing Assistant (CNA) #2 documented that he/she was conducting rounds when Nurse #2 came outside of room 217 calling for staff assistance at 11:55 P.M. CNA #2 documented that Resident #1 was "found falling down on the mat and head stuck on upper side of the bed. Supervisor (Nurse #4) asked me and the nurse to assist him/her putting him/her (the resident) to bed." * Nurse #4 (,[DATE] Supervisor) documented that the second floor nurse (Nurse #2) had called and asked for Nurse #4 to "come to the floor right away. Found resident in B bed sitting on, or close to the floor with upper body in between side rail and the bed, facing towards the door. Unresponsive, color pale, hands noted to be mottled. The side rail was lifted off, was on his/her neck area." * Nurse #3 documented that he/she was called to room 217 and instructed to call the Supervisor quickly. "When I entered room 217, I saw the said resident sitting on the floor with his/her head facing out between the mattress and the right side rail." * Nurse #2 documented that at 11:50 P.M. "patient found to be sitting on the floor beside inside (between) beds. He/she was on his/her buttocks in an upright but slouched position with his/her head between the half siderail and mattress facing toward the doorway, alarm in place but not sounding. Patient noted to be pale, no pulse or respirations. Non responsive. Alarm sounded as his/her back lifted from mattress. 1:30 A.M., MD (medical doctor) notified and responded - order for RN (registered nurse) pronouncement obtained." * Nurse #5 documented "received a call from (Nurse #2) and asked if I would come up to pronounce a resident. Went into resident room. Resident noted to be on the floor, on his/her back, on the right side of bed. Pale, not breathing, non-responsive. Noted to have acorn sized indentation under left jaw and dime sized indentation beneath right jaw. Ecchymotic area noted on anterior neck. ,[DATE] Supervisor (Nurse #4) called Director of Nurses for guidance on how to handle this situation. Administrator came into facility, under advisement, call was placed to (Primary Care Physician) and order obtained to pronounce." The Director of Nurses (DON) was again interviewed on [DATE] at 11:00 A.M. The DON stated that he/she received a call at 12:00 A.M. from Nurse #4 and was told how the resident was found. The DON stated that he/she then called the Administrator and that the Regional Director of Operations and the Regional Clinical Service Specialist were called and informed of the situation (fall and death). The DON stated that he/she arrived at the facility at 2:00 A.M. on [DATE] and observed Resident #1 in the bed. The DON stated that he/she did not see any bruising on the resident at that time (even though the pronouncing nurse had documented indentations under the right and left jaw and bruising on the anterior neck). The funeral home was not called at that time due to the family of Resident #1 was on their way to the facility. The DON stated that Nurse #2 was told to call the physician. The DON stated that he/she then got written statements (see the above statements) from the nursing staff and placed a call to the Medical Examiner's office. The DON stated that the Medical Examiner was called and that the Medical Examiner wanted to know what the cause of death would be listed as on the death certificate. A second call was placed to the Primary Care Physician and the DON stated that the Primary Care Physician stated that the cause of death would be documented as Dementia. The DON stated that he/she had called the Primary Care Physician back to make sure Nurse #2 had given the physician all of the information (however this information was contradicted during the interview on [DATE] with the Primary Care Physician). The DON stated that she again called the Medical Examiner back with the [DIAGNOSES REDACTED]. The DON was asked if the Medical Examiner was told of the bruising on the anterior neck and indentations on the left and right sides of the jaw. The DON stated that the Medical Examiner had not been told that because he/she had not seen any bruising. The DON was instructed by the Surveyor to call the Primary Care Physician and ask that he/she come to the facility to speak with the survey team. The DON was further instructed by the survey team to call the Medical Examiner and report the specific condition the resident was found in (with head stuck between mattress and bed rail) and of the bruising to the anterior neck. At 11:10 A.M. the Clinical Service Specialist informed the survey team that the funeral home had been called and asked not to start the embalming process. The Clinical Service Specialist also informed the survey team that the Medical Examiner would be taking the case after being given the additional information regarding the circumstances the resident's body was found in as well as the bruising. The Primary Care Physician came into the facility on [DATE] and was interviewed at 11:30 A.M. by the surveyors. The Primary Care Physician stated that he/she had been called at approximately 2:00 A.M. on [DATE]. The Primary Care Physician stated that he/she was told by Nurse #2, that "the resident was found dead during rounds." The Primary Physician further stated that he was called a second time and was asked by the DON "if the resident was found dead and in bed, what would the cause of death be?" The Primary Care Physician stated not knowing/not being told the circumstances under which the resident was found, that he/she had replied that the [DIAGNOSES REDACTED]. At 11:45 A.M. on [DATE], the DON and Administrator approached the surveyors to explain the Quality Improvement project which had started in [DATE] regarding falls on the second floor. The Administrator stated that there had been a noted increase in falls on the second floor. The Quality Improvement project resulted in Hourly Walking Rounds being implemented once staff education had been completed. The Hourly Walking Rounds required licensed staff and CNAs to conduct alternating hourly rounds to ensure resident safety, with the licensed staff conducting rounds on the even hours and CNAs conducting rounds on the odd hours. AT 12:20 P.M. on [DATE], the Surveyor obtained and copied the Hourly Walking Rounds sheets for [DATE] and [DATE]. Review of the [DATE] Hourly Walking Rounds sheet revealed that on [DATE] hourly rounds were conducted at 4:00 P.M., 5:00 P.M., 6:00 P.M., 7:00 P.M., 8:00 P.M., 9:00 P.M. and 10:00 P.M. The 11:00 P.M. rounds had not been signed off as completed. Review of the positioning sheet, for Resident #1, dated [DATE] from 3:00 P.M. to 11:00 P.M. was blank (no indication of any positioning changes nor what position the resident had been placed at 10:00 P.M. or 11:00 P.M. on [DATE].) CNA #1 (who worked the ,[DATE] shift on [DATE] and was assigned to provide personal care to Resident #1) was interviewed on [DATE] at 2:10 P.M. CNA #1 confirmed that he/she had provided care to Resident #1 on [DATE]. CNA #1 stated that he/she had provided positioning to Resident #1 at 8:00 P.M. and 10:00 P.M. with CNA #5 (as resident required the assistance of 2 people for repositioning) and that the resident was left on his/her back in the center of the bed with the head of the bed slightly elevated. CNA #1 confirmed that he/she had not completed the Hourly Walking Round at 11:00 P.M. (The CNA was responsible for the 11:00 P.M. rounds). CNA #1 stated that he/she believed that the ,[DATE] shift was responsible for conducting the 11:00 P.M. walking rounds. CNA #1 further stated that the resident was not able to utilize the side rails (by holding on to the side rail) to assist in positioning. CNA #5, was interviewed on [DATE] at 4:30 P.M., and confirmed that he/she had assisted CNA #1 on [DATE] at 8:00 P.M. only with Resident #1's repositioning and incontinent care. Nurse #1 (who worked the ,[DATE] shift on [DATE] on the second floor unit) was interviewed on [DATE] at 2:57 P.M.. Nurse #1 confirmed that he/she had conducted Hourly Walking Rounds at 4:00 P.M., 6:00 P.M., 8:00 P.M. and 10:00 P.M. Nurse #1 could not state what position Resident #1 was placed in at 10:00 P.M., stating that he/she had checked the residents to ensure each resident was in the proper bed. Nurse #1 stated that Resident #1 did not move independently in the bed. CNA #2 (who worked from 11:00 P.M. on [DATE] until 7:00 A.M. on [DATE]), was interviewed on [DATE] at 3:30 P.M. CNA #2 stated that on [DATE], at 11:00 P.M. there were only 2 licensed staff and him/herself on the unit (although 3 CNAs were scheduled for this 60 bed unit). CNA #2 stated that a second CNA did not report to the unit until 11:30 P.M. and a third CNA did not report until 12:00 A.M. CNA #2 stated that Nurse #2 and he/she started to conduct rounds at 11:00 P.M. CNA #2 stated that the second floor unit was "hectic" on [DATE] at 11:00 P.M. CNA #2 stated that he/she and Nurse #2 responded to residents being found out of bed and wandering as well as completing incontinent care for a resident found out of bed and wet. In addition, CNA #2 stated that a resident had lowered themselves to the floor from a wheelchair at the far end of the corridor which both CNA #2 and Nurse #2 responded to. At 11:30 P.M., on [DATE], when the second CNA (#3) reported to the unit, Nurse #2 began his/her safety rounds, while the 2 CNAs began to gather supplies to provide incontinent care to the residents on the unit. At 11:50 P.M., on [DATE], CNA #2 heard Nurse #2 call out "come see" from room 217. Upon entering the room, CNA #2 stated that Resident #1 was found sitting on the floor, with his/her head wedged between the air mattress and the bottom third of the quarter side rail on the right side of the bed. CNA #2 stated that the resident was facing towards the door with his/her face protruding through the lower third of the side rail (with the side rail having a top, bottom and middle bar) and that the resident's neck was pressed into the bottom and front corner of the side rail. CNA #2 then accompanied the surveyors to room 217 and demonstrated the position of the resident's body when found on [DATE] at 11:50 P.M. CNA #2 stated he/she had assisted the ,[DATE] nursing supervisor (Nurse #4) in removing the resident's head from between the air mattress and the side rail. CNA #2 stated that they had to pull the side rail away from the bed, approximately 4 inches before the resident's head was dislodged from the bedrail (the staff did not use the CPR (cardio-pulmonary resuscitation) feature on the air mattress to deflate the mattress and create room to dislodge the resident). Review of the manufacturer's guidelines for the Blue Chip Supreme Air mattress in place on bed 217B revealed that the space between the side rail at the bottom corner and the mattress should be no wider than 2 ,[DATE] inches. Safety tips for the operating instructions for this air mattress document "consider the appropriate use of side rails on the patients bed." A CPR valve is located on the air mattress and the manufacturer's instruction include to "in the event of cardiac arrest, twist the CPR (valve) to release air. It will take less than 10 seconds to deflate the mattress." Observation of the bed in room 217B revealed that a Blue Chip Supreme Air mattress was on the bedframe (inflated with the inflation settings correct for the resident's weight) with bilateral quarter side rails. The air mattress was noted to have soft sides which compressed downward with minimal weight placed on the edge of the mattress. When the side of the mattress was compressed, the space between the siderail and the mattress edge was greater than the allowable 2 ,[DATE] inches. The DON was again interviewed on [DATE] at 4:00 P.M. regarding the air mattress on Resident #1's bed. The DON stated that an entrapment assessment is completed whenever an air mattress or specialty mattress was placed on a resident's bed. However, no entrapment assessment had been documented as completed when the air mattress was placed on Resident #1's bed on [DATE]. The DON stated that the resident's heels had begun to break down and an air mattress had been implemented to prevent further skin breakdown. The DON stated that maintenance staff (no specific maintenance staff person was identified) had placed one air mattress on the bed, but found that it did not fit the bed properly and had then applied the air mattress which was on the bed on [DATE]. The DON stated that maintenance staff had assessed the air mattress to ensure proper size and inflation. However, no documentation could be provided to confirm that this assessment was completed. The Regional Director of Operations was observed on [DATE] at 4:00 P.M., conducting entrapment assessments with a maintenance worker. The Regional Director of Operations stated that the maintenance department conducted the entrapment assessments utilizing an FDA approved entrapment assessment mechanism. The Director of Nurses during an interview on [DATE] at 4:00 P.M., confirmed that there was no evidence of inservicing regarding entrapment assessments and use of the CPR valve to deflate the air mattress within 10 seconds for nursing staff. Nurse #2 (who worked from 11:00 P.M. on [DATE] until 7:00 A.M. on [DATE] on the second floor unit) was interviewed on [DATE] at 4:47 P.M. Nurse #2 confirmed that at 11:00 P.M. on [DATE], that there were only 2 licensed staff and one CNA on the unit. Nurse #2 stated that the ,[DATE] CNAs had left. Nurse #2 confirmed that the unit was very busy at the start of shift at 11:00 P.M., (describing the atmosphere as being "a full moon" with multiple residents awake and out of bed) and that he/she began to assist CNA #2 who was responding to alarms sounding due to 9 residents who were; getting out of bed, wandering the hallways in wheelchairs, disrobing and closing doors to resident rooms. In addition, Nurse #2 stated that he/she and CNA #2 had to stop and provide incontinent care to one of the residents whose alarm had sounded. Nurse #2 and CNA #2 also responded to a resident who had lowered him/herself onto the floor in the hallway. Nurse #2 also stated he/she had to stop to check on a resident who barricaded his/her bedroom door with furniture. Nurse #2 stated then when the second CNA (#3) reported to the unit at 11:30 P.M. on [DATE], he/she began to conduct safety rounds (which included removing furniture which a resident had used to barricade his/her door). Nurse #2 stated that in addition, a resident was walking up and down the hallways, closing the doors of resident rooms. Nurse #2 stated that at 11:50 P.M. on [DATE], upon entering room 217, Resident #1 was observed with the lower portion of his/her body on the floor. The resident's head was observed to be stuck between the air mattress and the quarter side rail on the right side of the bed. Nurse #2 stated that he/she called for the second nurse on duty (Nurse #3) and asked Nurse #3 to notify the registered nurse on the first floor (Nurse #5) as well as the Supervisor for the ,[DATE] shift (Nurse #4). Nurse #2 was asked if he/she had called the resident's physician. Nurse #2 stated that he/she was directed to not make any calls until the DON and Administrator arrived in the building. Nurse #2 stated that after the DON and Administrator arrived at the facility, Nurse #2 was instructed by the DON to call the resident's Primary Care Physician and to report only that the resident had been found to have expired on rounds and not to elaborate on how the resident was found (in what position nor to inform that head and neck were stuck in the bed rail). Nurse #4 (who worked from 11:00 P.M. on [DATE] until 7:00 A.M. on [DATE]) was interviewed on [DATE] at 6:04 A.M. Nurse #4 is designated as the ,[DATE] nursing supervisor. Nurse #4 stated that he/she was called to the second floor unit at 11:50 P.M. on [DATE] to room 217. Nurse #4 stated that the resident's head was between the mattress and the side rail and was protruding through the bottom third of the side rail. Nurse #4 stated that the resident's "face appeared to be forward and resting on the bottom metal bar. Nurse #4 stated that CNA #2 held the side rail and pulled it outward while Nurse #4 held the resident's head and then lowered the resident to the floor once the resident's head was released from the side rail and mattress. Nurse #4 confirmed that there were indentations on both sides of the neck, left indentation greater than the right and a "dark pink area noted on resident's neck laterally, approximately 2 inches from under chin and extending down the neck." Nurse #4 stated that he/she then called the DON and described how the resident was found. Nurse #4 stated that he/she was told not to make any calls until the Administrator arrived. Nurse #4 stated that the Administrator viewed the resident and made a phone call. The Administrator then instructed Nurse #4 to call the physician and give as little information as possible. Nurse #4 stated that the Administrator told him/her "patient expired - found on rounds." ( Per the Clincal Service Specialist, when Nurse #4 was interviewed by the Clinical Service Specialist on [DATE], Nurse #4 told her/him that it was the DON and not the Administrator who told him/her to state "patient expired-found on rounds"). Nurse #4 further stated that she had been told by the DON that the DON had called the physician and told him/her how the resident was found (the physician stated during an interview on [DATE], that he was unaware of how the resident was found until after surveyors had requested he/she be notified and asked to speak with surveyors on [DATE]). Nurse #5 (who worked from 11:00 P.M. on [DATE] until 7:00 A.M. on [DATE]) was interviewed on [DATE] at 6:20 A.M. Nurse #5 (who was working the first floor Palmer Unit and the only Registered Nurse in the building) was the registered nurse called to the Baldwin/Cain Unit to perform the RN pronouncement. Nurse #5 stated that he/she was called by Nurse #2 at 11:50 P.M. on [DATE] and was told "I need your help - a resident has passed away - its a bad situation - resident was stuck on the railing." Nurse #5 stated that when he/she arrived at the resident's room the resident was lying on the floor mat. Nurse #5 stated that he/she observed a acorn size indentation beneath the left jaw, a dime size indentation beneath the right jaw and a bruise noted on the trachea, lateral anterior neck approximately 1 ,[DATE] inches. Nurse #5 stated that the bruised area was slightly indented. Nurse #5 stated that he/she heard Nurse #2 report to the physician "doing rounds and found resident expired." Nurse #5 stated that the physician had asked if the resident had any recent illness and was told no. Nurse #3 (who worked from 11:00 P.M. on [DATE] until 7:00 A.M. [DATE]) was interviewed on [DATE] at 6:50 A.M. Nurse #3 confirmed that he/she had been working the second floor unit at the time of Resident #1's fall. Nurse #3 confirmed that there were 2 nurses on the unit (Nurses # 2 and #3) and only one CNA from 11:00 P.M. to 11:30 P.M. on [DATE]. Nurse #3 also confirmed that the third CNA did not arrive on the second floor unit until 12:00 A.M. (10 minutes after Resident #1 was found). Nurse #3 confirmed that the resident was sitting on the floor with his/her head between the siderail and the mattress. Nurse #3 stated that the "side rail was holding the right side of the resident's face." The Physical Therapist was interviewed on [DATE] at 9:17 A.M., regarding Resident #1's [DATE] evaluation. The Physical Therapist stated that the evaluation conducted on [DATE] was completed while the resident was in the wheelchair to assess proper positioning and seating. The Physical Therapist was asked if the resident could roll in bed independently. The Physical Therapist stated that the resident would require moderate assistance of one person to be able to roll in bed. The Physical Therapist stated that the resident was not able to utilize the side rails secondary to stiffening of the resident's arms. The Physical Therapist described multiple joint stiffening including elbows and shoulders for Resident #1. The Physical Therapist stated that he/she did not notice the resident with restless leg movements in bed and when last seen by the Physical Therapist, required the assistance of two people to move to the edge of the bed and transfer into a chair. On [DATE] at 5:00 P.M., a tour was conducted of the first floor Palmer Unit and the second floor Baldwin/Cain Unit. The Palmer Unit was observed to have 7 beds with the Blue Chip Air Supreme mattresses and 6 residents with a Blue Chip Power Pro air mattress. Three beds, not identified on the list of air mattresses used on the Palmer Unit, had an air mattress on the bed. The Baldwin/Cain Unit was found to have 1 bed with the Blue Chip Air Supreme mattress and 1 bed with a Blue Chip Power Pro air mattress. Five other resident beds had other types of specialty mattresses. At least two of the air mattresses, which were used in conjunction with quarter side rails, on the Palmer Unit could be compressed on the edge of the mattress creating a gap between the lower front corner of the side rail and the mattress approximately 6 inches (and not the 2 ,[DATE] inches allowed via the entrapment assessment tool). The Regional Director of Operations, when told of the findings concerning air mattresses on the units at 5:15 P.M. on [DATE], stated that all air mattresses and specialty mattresses would be assessed by the facility immediately as well as the need for side rails for each resident. The Regional Director of Operations was observed to proceed to assess air mattresses and entrapment risk with side rails using an FDA approved measuring device. The Regional Director of Operations stated that any specialty mattress which posed a risk of entrapment would be removed from service and replaced for those residents who really needed a specialty mattress. 2. For Resident #4, the facility failed to properly ensure the resident's safety while providing care, resulting in the resident falling from the bed and fracturing his/her right great toe. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On [DATE] at 1:45 P.M., review of the resident's plan of care for potential for falls originally dated ,[DATE], revealed the following approaches: *Dependent on two plus via mechanical lift for transfer *Two blue mats on floor on each side of bed while in bed *Bed/chair alarms, check for functioning and placement every shift. On [DATE] at 1:45 P.M., review of the annual minimum data set ((MDS) dated [DATE] and the quarterly assessment dated [DATE], revealed that the resident had impaired short and long term memory and severely impaired decision making skills. The resident was totally dependent for all activities of daily living. Review of the nurses' notes on [DATE] at 1:45 P.M., revealed that on [DATE] at 9:00 A.M., the nurse viewed the resident. The resident was in bed with the bed at the lowest position possible and the blue mats (mats on the floor to protect the resident if s/he falls out of bed) and bed alarm were intact. At 9:15 A.M., the certified nurses aide (CNA) "yelled for help, resident on floor beside bed crying in pain, bed was in high position, pads removed, alarm undone (as care was being provided)." An x-ray was ordered and the resident was diagnosed with [REDACTED]. Review of the incident report dated [DATE], revealed that "the CNA was providing personal care to (the resident). The CNA had the bed adjusted in the high position for this care and had taken the bed alarm off to prevent it from alarming while turning (the resident). When finished providing care, the CNA turned to obtain a Hoyer pad from the resident's wheelchair to place under him/her before transfer. While the CNA's back was turned, (the resident) slid from the bed onto the floor." (The care plan for falls for this resident calls for the assistance of 2 people for transfers via a hoyer lift.) Interview with the Director of Nurses (DON) at 3:15 P.M. on [DATE], confirmed that the CNA had turned his/her back on the resident and the resident fell out of bed. The DON further stated that the CNA has been in-serviced and knows not to turn his/her back on the resident. Observation of the resident revealed that on [DATE] from 1:45 P.M. to 4:30 P.M., on [DATE] at 10:00 A.M. and 1:45 P.M. and on [DATE] at 9:00 A.M., the resident was in a reclined Geri-chair in the small TV room next to the nurses station. On [DATE] at 4:30 P.M., the resident was observed in bed, rocking back and forth with his/her legs contracted (drawn up to his/her chest). On [DATE] at 9:30 A.M., the resident was again observed in the small TV room. The resident would always be contracted, with his/her knees drawn up to his/her chest. 3. For Resident #5, the facility failed to provide supervision and to utilize a bed alarm, per his/her plan of care, in order to prevent the resident from falling in the hallway at 4:45 AM and fracturing his/her left elbow. Resident #5 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the [DATE] Quarterly MDS assessment revealed that the resident had impaired short and long term memory and severely impaired decision making skills. The resident transferred with extensive assistance of two people and ambulated with extensive assistance of one person. Review of the plan of care dated ,[DATE], included the following; *Ambulates with supervision to reach destination *Anti-skid socks when in bed *Bed alarm *Physical therapy evaluation *Evaluate for a Merrywalker, [DATE] (this intervention was not successful). Review of the nurses' notes on [DATE] at 2:40 P.M., revealed that between [DATE] and [DATE], the resident experienced 5 falls. After each of these falls, an intervention was put in place to prevent further falls. Further review of nurses' notes on [DATE] revealed that on [DATE], at 4:45 A.M., the resident experienced a 6th fall and was found lying in the hallway. Due to the resident's confusion, the resident was unable to tell the nurse how s/he had fallen. Review of the incident report and investigation statements revealed that the resident had gotten up from bed and that the bed alarm was off at the time of the fall. On [DATE], nursing staff noticed swelling and a bruise on the resident's left forearm. A stat x-ray revealed a left forearm/elbow fracture for which the resident was hospitalized . Interview with Unit Manager #2 on [DATE] at 4:00 P.M. revealed that the alarm was not functioning at the time of the fall. Observation of the resident revealed that on [DATE] from 1:45 P.M. to 4:30 P.M., the resident was reclining in the hall near the nurses' station in a Geri-chair. The resident would consistently rub his/her Geri-leg protectors. On [DATE], the resident was again in the Geri-chair. On [DATE], from 9:00 A.M. to 12:00 P.M. and again on [DATE], at 9:00 A.M., 10:00 A.M., 1:00 P.M., 2:00 P.M., and 3:00 P.M., the resident was always observed in the hall near the nurses station sitting in the Geri-chair and rubbing the Geri-leg protectors. 4. For Resident NSB, the facility failed to provide a chair alarm to prevent accidents, per the resident's plan of care. Resident NSB was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review on [DATE] at 9:20 A.M., of the annual minimum (MDS) data set [DATE], revealed that the resident had impaired short and long term memory and severely impaired decision making skills. The resident transferred with extensive assistance of two people and ambulated with extensive assistance of one person. Review on [DATE] at 9:20 A.M., of the plan of care for falls and the treatment record dated ,[DATE], revealed that the resident was to have a bed alarm when in bed and a chair alarm when in a chair. Observation on [DATE] at 6:16 P.M., of the documentation on the Hourly Walking Rounds sheets, revealed that the staff had signed off the sheets at 6:00 P.M., indicating that the resident had safety equipment (a chair alarm) in place. Observation on [DATE] at 6:16 P.M., reveal

Based on observation, staff interview and record review, the facility failed to ensure adequate staffing was in place to meet the needs of its residents for one of four units. Findings included: At the entrance conference with the facility on 9/12/11 at 8:30 A.M., the Director of Nurses (DON) revealed that the second floor nursing unit held 60 residents and the unit was described as a dementia unit (although it was not a certified dementia unit). The DON revealed the staffing for the 11:00 P.M. to 7:00 A.M. shift consisted of 2 Licensed Nurses and 3 Certified Nursing Assistants (CNAs). On 9/12/11 at 9:30 A.M., a review of the Nursing Schedule for 9/11/11 from 11:00 P.M. to 7:00 A.M., revealed Nurse #2, Nurse #3, CNA #2, CNA #3 and CNA #4 were scheduled to work on this unit. Nurse #2 was interviewed on 9/12/11 at 4:45 P.M. Nurse #2 confirmed that at 11:00 P.M. on 9/11/11, that there were only 2 licensed staff and one CNA on the unit. Nurse #2 stated that the 3-11 CNAs had left. Nurse #2 confirmed that the unit was very busy at the start of shift at 11:00 P.M., (describing the atmosphere as being "a full moon" with multiple residents awake and out of bed) and that he/she began to assist CNA #2 who was responding to alarms sounding due to 9 residents who were; getting out of bed, wandering the hallways in wheelchairs, disrobing and closing doors to resident rooms. In addition, Nurse #2 stated that he/she and CNA #2 had to stop and provide incontinent care to one of the residents whose alarm had sounded. Nurse #2 and CNA #2 also responded to a resident who had lowered him/herself onto the floor in the hallway. Nurse #2 also stated he/she had to stop to check on a resident who barricaded his/her bedroom door with furniture. (Safety rounds could not be completed from 11:00 P.M. to 11:30 P.M. due to Nurse #2 and CNA #2 responding to resident needs as documented above.) Nurse #2 stated then when the second CNA (#3) reported to the unit at 11:30 P.M. on 9/11/11, he/she began to conduct safety rounds (which included removing furniture which a resident had used to barricade his/her door). Nurse #2 stated that in addition, a resident was walking up and down the hallways, closing the doors of resident rooms. Nurse #3 was interviewed on 9/13/11 at 6:50 A.M. Nurse #3 stated that Nurse #4 informed him/her at 11:10 P.M., that one of the scheduled CNAs had gone home sick and another CNA (CNA #4) was called to replace the sick CNA. Nurse #3 stated he/she told Nurse #4 that there was only one CNA (CNA #2) present on the unit at the start of the shift. CNA #2 was interviewed on 9/12/11 at 3:30 P.M. CNA #2 stated that on 9/11/11, at 11:00 P.M., there were only 2 licensed staff and him/herself on the unit (although 3 CNAs were scheduled for this 60 bed unit). CNA #2 stated that a second CNA (CNA #3) did not report to the unit until 11:30 P.M., but the time sheets revealed that the CNA had punched in at 11:15 P.M. A third CNA (CNA #4) did not report until 12:00 A.M., but the time sheets revealed that the CNA had punched in at 11:30 P.M. When the Administrator was asked why the CNAs were late arriving on the nursing unit, the Administrator was unable to state why and the facility would investigate the time lapses. CNA #2 stated that Nurse #2 and he/she started to conduct safety rounds at approximately 11:00 P.M. CNA #2 stated that the second floor unit was hectic on 9/11/11 at 11:00 P.M. CNA #2 stated that he/she and Nurse #2 responded to residents being found out of bed and wandering as well as completing incontinent care for a resident found out of bed and wet. In addition, CNA #2 stated that a resident had lowered him/herself to the floor from a wheelchair at the far end of the corridor which both CNA #2 and Nurse #2 responded to. At 11:30 P.M., on 9/11/11, when the second CNA (#3) reported to the unit, Nurse #2 continued his/her safety rounds, while the 2 CNAs began to gather supplies to provide incontinent care to the residents on the unit. At 11:50 P.M., on 9/11/11, CNA #2 heard Nurse #2 call out "come see" from room [ROOM NUMBER]. Upon entering the room, CNA #2 stated that Resident #1 was found sitting on the floor, with his/her head wedged between the air mattress and the bottom third of the quarter side rail on the right side of the bed. CNA #2 stated he/she did not observe CNA #4 on the nursing unit until 12:00 A.M. The DON confirmed that the second floor nursing unit did not have the 3 CNAs scheduled for that unit, to provide adequate staff on 9/11/11 from 11:00 P.M. to 12:00 A.M. to adequately care for the residents.

Based on staff interviews, observations and the deficient practice identified during the annual recertification survey, the facility failed to ensure that the quality assurance program identified issues, developed and implemented plans of action for care and services provided to the residents, and evaluated that the plans were effective. Findings included: A meeting was held with the Administrator and the Director or Nurses on [DATE] at 11:45 A.M., to discuss concerns related to a resident fall which resulted in a death. The Administrator stated that a Performance Improvement project had been implemented in [DATE] for falls. The Administrator stated that there had been an increase in falls noted on the second floor. The facility had implemented Hourly Walking Rounds which required licensed staff and CNAs to alternate every hour to perform safety checks. The Administrator stated that all staff had been in-serviced on the Hourly Walking Rounds and that the facility had seen a decrease in falls since the hourly rounds had been started. The Administrator stated that hourly walking rounds included a check that safety equipment utilized by each resident was in place and functioning, and that the residents were where they were suppose to be at the time the check was completed. The administrator stated that the facility had seen a 50% reduction in falls since the inception of Hourly Walking Rounds. 1. Resident #1 had a fall from bed which resulted in the resident becoming entrapped between the side rail and the mattress and died on [DATE]. The resident was found during rounds at 11:50 P.M. on [DATE]. AT 12:20 P.M. on [DATE], the surveyor obtained and copied the Hourly Walking Rounds sheets for [DATE] and [DATE]. Review of the [DATE] Hourly Walking Rounds sheet revealed that on [DATE] hourly rounds were conducted at 4:00 P.M., 5:00 P.M., 6:00 P.M., 7:00 P.M., 8:00 P.M., 9:00 P.M. and 10:00 P.M.. The 11:00 P.M. rounds had not been signed off as completed. CNA #1 (who worked the ,[DATE] shift on [DATE] and was assigned to provide personal care to Resident #1) was interviewed on [DATE] at 2:10 P.M. CNA #1 confirmed that he/she had provided care to Resident #1 on [DATE]. CNA #1 confirmed that he/she had not completed the Hourly Walking Round at 11:00 P.M. CNA #1 stated that he/she believed that the ,[DATE] shift was responsible for conducting the 11:00 P.M. walking rounds. Nurse #1 (who worked the ,[DATE] shift on [DATE] on the second floor unit) was interviewed on [DATE] at 2:57 P.M. Nurse #1 confirmed that he/she had conducted Hourly Walking Rounds at 4:00 P.M., 6:00 P.M., 8:00 P.M. and 10:00 P.M., stating that he/she had checked the residents to ensure each resident was in the proper bed. Nurse #1 stated that he/she had not checked for safety equipment utilization or functioning during the 10:00 P.M. rounds. Please refer to F323, Example #1. 2. Two other residents had falls (Resident #25 on [DATE] and Resident #28 on [DATE]). Both falls were found to have occurred when safety equipment was not functioning or had not been utilized (this was after hourly walking rounds had been implemented). Please see F323, Examples #4 and #5. 3. Interview with the DON on [DATE] revealed that all staff had been in-serviced a second time regarding Hourly Walking Rounds on [DATE] and [DATE] and the in-service, per the DON, included what the staff were to check for. However, during a monitoring visit conducted on [DATE] at 7:00 P.M., the Hourly Walking Rounds sheet had not been completed for the Cain part of the second floor unit (the unit is called Baldwin/Cain and the staff on [DATE] had split the unit by corridors) for 4:00 P.M., 5:00 P.M. and 6:00 P.M. The Assistant Director of Nurses (ADON), when shown the incomplete form at 7:00 P.M. on [DATE], stated that "perhaps they (the staff on unit) wait until end of shift to fill in the form." (The ADON was unfamiliar with the policy regarding when and how the form was to be filled out.) In addition, although the 6:00 P.M. Hourly Walking Rounds had been signed off as completed on [DATE] on the Baldwin side of the second floor unit on [DATE], 3 Residents (NSA, NSB and NSC) were found to have alarms not attached either in bed or to the chair the resident sat in (if staff had conducted walking rounds for safety, the missing alarms should have been identified). 4. On [DATE], at 2:40 P.M. 2 CNAs (CNA #13 and #14) and 3 licensed nurses (Nurse # 13 and #14 as well as Unit Manager #2) were interviewed regarding what was checked while conducting Hourly Walking Rounds. * CNA #13 stated that all residents who had an orange sticker (indicating a fall risk) should have side rails up on their beds. * CNA #14 stated that rounds were to make sure residents were safe and positioned well. * Nurses #13 and #14 stated that all resident rooms and the activity room located on the second floor were checked to ensure that all residents were safe. * Unit Manager #2 stated that walking rounds were conducted for those residents in their bedrooms only. It was not until [DATE] that a plan of action was implemented to effectively address consistency with Hourly Walking Rounds. Interview with the Administrator on [DATE], confirmed that the plan of action implemented by the Quality Improvement Committee since ,[DATE] had not been accurately evaluated for effectiveness. Additionally, no new effective plans of action were implemented which were effective in addressing falls once the initial plan of action (hourly walking rounds) was found to be not implemented as planned.

Based on record review and staff interview, the facility failed to implement the plan of care for 5 Residents (#4, #5, #14, #25 and #28) out of a sample of 28 and 4 non-sampled (NS) Residents (NSA, NSB, NSC and NSD). Findings include: 1. For Resident #5, who sustained a fall, resulting in a fracture, the facility failed to ensure that the resident utilized a bed alarm in order to alert the staff when the resident was out of bed and walking in the hallway with the potential to fall. Resident #5 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the 3/16/2011 and 6/8/2011 quarterly assessments revealed that the resident had impaired short and long term memory and severely impaired decision making skills. The resident transferred with extensive assistance of two people and ambulated with extensive assistance of one person. Review of the plan of care dated 11/2010, included the following; *Ambulates with supervision to reach destination *Anti-skid socks when in bed *Bed alarm *Physical therapy evaluation *Evaluate for a Merrywalker, 4/4/2011 (this intervention was not successful). Review of nurses notes on 9/13/11 at 2:40 P.M., revealed that on 4/8/11 at 4:45 A.M., the resident was found lying in the hallway. Review of the incident/accident report revealed that the resident had gotten up from bed and that the bed alarm was off (the alarm did not sound as the alarm was in the off position) at the time of the fall. On 4/8/11, the nursing staff noticed swelling and a bruise on the resident's left forearm. A stat (immediate) x-ray revealed a left forearm/elbow fracture for which the resident was hospitalized . Interview with Unit Manager #2 on 9/13/11 at 4:00 P.M., revealed that the alarm was not functioning at the time of the fall. Please refer to F323, Example #3. 2. For Resident NSB, the facility failed to utilize the chair alarm as required in the resident's plan of care. Resident NSB was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review on 9/21/11 at 9:20 A.M., of the Annual Minimum Data Set (MDS)dated 6/29/11, revealed that the resident had impaired short and long term memory and severely impaired decision making skills. The resident transferred with extensive assistance of two people and ambulated with extensive assistance of one person. Review on 9/21/11 at 9:20 A.M., of the plan of care for falls and the treatment record dated 9/2011, revealed that the resident was to have a bed alarm when in bed and a chair alarm when in a chair. Observation on 9/18/11 at 6:16 P.M., of the documentation on the Hourly Walking Rounds sheets, revealed that the staff had signed off the sheets at 6:00 P.M., indicating that the resident had safety equipment (a chair alarm) in place. Observation on 9/18/11 at 6:16 P.M., revealed that the resident was sitting in a chair without a chair alarm in place. Upon watching the surveyor's view of the lack of a chair alarm, a CNA (certified nurses aide) obtained a new chair alarm and attached it to the resident's chair. 3. For Resident #4, the facility failed to follow the resident's plan of care for a low bed, bed alarm and assistance of 2 people for transfers, resulting in the resident falling from the bed and fracturing his/her right great toe. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 9/12/11 at 1:45 P.M., review of the resident's plan of care for potential for falls originally dated 2/2011, revealed the following approaches: *Dependent on two plus via mechanical lift for transfer *Two blue mats on floor on each side of bed while in bed *Bed/chair alarms, check for functioning and placement every shift. On 9/12/11 at 1:45 P.M., review of the annual minimum data set ((MDS) dated [DATE] and the quarterly assessment dated [DATE], revealed that the resident had impaired short and long term memory and severely impaired decision making skills. The resident was totally dependent for all activities of daily living. Review of the nurses' notes on 9/12/11 at 1:45 P.M., revealed that on 6/26/11 at 9:00 A.M., the nurse viewed the resident. The resident was in bed with the bed at the lowest position possible and the blue mats (mats on the floor to protect the resident if s/he falls out of bed) and bed alarm were intact. At 9:15 A.M., the certified nurses aide (CNA) "yelled for help, resident on floor beside bed crying in pain, bed was in high position, pads removed, alarm undone (as care was being provided)." An x-ray was ordered and the resident was diagnosed with [REDACTED]. Review of the incident report dated 6/27/11, revealed that "the CNA was providing personal care to (the resident). The CNA had the bed adjusted in the high position for this care and had taken the bed alarm off to prevent it from alarming while turning (the resident). When finished providing care, the CNA turned to obtain a Hoyer pad from the resident's wheelchair to place under him/her before transfer. While the CNA's back was turned, (the resident) slid from the bed onto the floor." Interview with the Director of Nurses (DON) at 3:15 P.M. on 9/12/11, confirmed that the CNA had turned his/her back on the resident and the resident fell out of bed. The DON further stated that the CNA has been in-serviced and knows not to turn his/her back on the resident. Observation of the resident revealed that on 9/12/11 from 1:45 P.M. to 4:30 P.M., on 9/13/11 at 10:00 A.M. and 1:45 P.M. and on 9/14/11 at 9:00 A.M., the resident was in a reclined Geri-chair in the small TV room next to the nurses station. On 9/14/11 at 4:30 P.M., the resident was observed in bed, rocking back and forth with his/her legs contracted (drawn up to his/her chest). On 9/20/11 at 9:30 A.M., the resident was again observed in the small TV room. The resident would always be contracted, with his/her knees drawn up to his/her chest. 6. For Resident #14, the facility failed to provide the resident with bivalve booties as per medical plan of care. Resident #14 was admitted to the facility 4/16/2010 with with [DIAGNOSES REDACTED]. Record review on 9/13/2011 at 9:00 A.M., revealed the resident had a current physician order [REDACTED]. On 4 of 8 days of survey, (on 9/13/2011 at 12:00 P.M.,on 9/14/2011 at 12:05 P.M., on 9/15/2011 at 9:35 A.M. and 9:45 A.M., and 9/19/2011 at 7:30 A.M.) , the resident was observed sitting in a wheelchair in the sitting/television room across the nursing station with one bootie on and not two booties as per medical plan of care. On 9/15/2011 at 10:00 A.M., interview with Nurse #8 confirmed the resident had a current physician's orders [REDACTED]. 7. On 9/15/11, the Clinical Service Specialist informed the Survey Team that all the CNAs and Licensed staff had been educated on Hourly Walking Rounds to ensure that all residents were safe and that all safety devices were being utilized. Observations completed on 9/18/11 from 6:00 P.M. to 7:30 P.M. and from 10:45 P.M. to 1:00 A.M., Non-Sampled Residents (NS) NSA's, NSC's, and NSD's plans of care were not followed. a. Hourly Walking Rounds were completed and initialed on 9/18/11 at 6:00 P.M. to ensure that Resident NSA had a bed alarm in place. However, at 6:15 P.M., the Surveyor observed no alarm on the resident's bed. At 6:35 P.M., Resident NSA was observed lying sideways on the bed and restless, again, with no bed alarm in place. The Surveyor informed the licensed nurse that a bed alarm was required for the resident's bed. A review of Resident NSA's medial record on 9/21/11 at 10:05 A.M. indicated that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident was assessed to be at high risk for falls, although Resident NSA had not fallen within the last 6 months. Resident NSA's physician orders [REDACTED]. b. Hourly Walking Rounds were completed and initialed on 9/18/11 at 6:00 P.M. by the licensed nurse. At 6:15 P.M., the Surveyor observed Resident NSC lying in bed and a bed sensor pad cord hanging off the bed. There was no alarm box present. The Surveyor informed the licensed nurse that a bed alarm box was needed on the resident's bed. A review of Resident NSC's medical record on 9/21/11 at 11:25 A.M. revealed that the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident NSC's MDS assessment, dated 5/13/11, indicated that the resident required the physical assistance of two people with transfers and ambulation. Resident NSC's original physician order, dated 7/9/09, and which remained current revealed that Resident NSC required a bed alarm at all times. c. A review of the Hourly Walking Rounds record was conducted on 9/18/11 at 11:50 P.M. The walking rounds record indicated that Hourly Walking Rounds had been completed at 9:00 P.M. by CNA #12. CNA #11 stated, during an interview (conducted on 9/18/11 at 11:55 P.M.), that he/she was completing 12:00 A.M. Hourly Walking Rounds on the nursing unit (at 11:50 P.M.) and was told by CNA #12 that the bed alarm on Resident NSD's bed was not functioning on 9:00 P.M. rounds. This was reported to the licensed nurse to be replaced. A review of the Hourly Walking Rounds record dated 9/18/11 indicated that the documentation was not completed at 11:00 P.M. (to indicate that 11:00 P.M. rounds had been completed). CNA #11 was interviewed on 9/18/11 at 11:55 P.M. CNA #11 stated that CNA #12, who conducted Hourly Walking Rounds at 9:00 P.M., refused to conduct Hourly Walking Rounds with CNA #11 at 11:00 P.M. The Surveyor observed CNA #11 replace Resident NSD's bed alarm box, however, the bed alarm remained non-functioning. The Surveyor observed CNA #11 replace Resident NSD's senor bed pad, connect the new bed sensor pad to the alarm box, and the bed alarm became functioning (the alarm was not replaced immediately when found to not function at 9:00 P.M., a 2 hour delay occurred between when the alarm was reported malfunctioning and when the alarm was replaced). Nurse #12 was interviewed on 9/19/11 at 12:10 A.M. Nurse #12 stated that Resident NSD's bed alarm box and/or bed sensor pad should have been replaced when the supervisor brought the new alarm boxes and sensor pads to the unit before his/her arrival on the unit at 10:40 P.M. A review of Resident NSD's medical record on 9/21/11 at 12:45 P.M., revealed that Resident NSD was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident NSD's physician orders [REDACTED]. d. On 9/21/11 at 10:35 A.M. the Surveyor observed Resident NSA lying in bed. Resident NSA's bed alarm was attached to the bed sensor alarm and held together with tape. When the Surveyor attempted to activate Resident NSA's bed alarm, the bed alarm did not sound on the first attempt. Review of the Hourly Walking Rounds revealed that the Hourly Walking Rounds were completed and initialed at 10:00 A.M. by the licensed nurse. The Surveyor said the licensed nurse told him/her that Resident NSA's alarm was difficult at times and was functioning properly despite the tape. The Surveyor observed Resident NSA lying sideways on the bed at 11:20 A.M. and the bed alarm had not sounded. Unit Manager #2 replaced Resident NSA's bed alarm box with a new alarm box which did not require tape to hold the sensor pad in place. The Clinical Service Specialist, when told of the taped alarm connection on 9/21/11 stated that taping a connection was not acceptable and the alarm system should have been replaced immediately. Please refer to F323, Examples #2, #3, #4 and #5. 4. For Resident #28, the facility failed to implement the plan of care in regards to ensuring that an alarmed clip seatbelt was applied and working, resulting in a fall. Resident #28 was admitted to the nursing facility in September 2010 with [DIAGNOSES REDACTED]. An Annual MDS, dated [DATE], and reviewed on 9/21/11, documents the resident as having both long and short term memory loss and severely impaired in daily decision making. The resident required the extensive assistance of 2 people for transfers and did not ambulate, using a wheelchair for mobility. The resident was documented as having a trunk restraint and did not have any recent falls. Observation of the resident on 9/12/11 at 9:00 A.M., 11:00 A.M., 1:00 P.M. and 2:00 P.M. , 9/13/11 at 9:00 A.M., 10:00 A.M., 2:00 P.M. and 4:00 P.M., 9/14/11 at 8:30 A.M., 10:15 A.M., 12:45 P.M. and 2:00 P.M. and 9/15/11 at 11:25 A.M. and 1:00 P.M., revealed that the resident had an alarmed clip seatbelt while in a high back wheelchair, with the back of the chair slightly reclined. The resident would often reach forward and stretch downward towards the footrests of the wheelchair. The resident was observed to fold his/her body in half in order to reach the footrest of the wheelchair, with his/her chest and upper body resting on her thighs. Resident #28 was also observed to reach over the side of the wheelchair towards the floor. On 9/18/11, Nurse #7 informed this surveyor that Resident #28 had fallen out of his/her wheelchair, while in the lobby with his/her family member at 3:30 P.M. that day. Nurse #7 stated that the alarmed clip seatbelt was not on at the time of the fall. The resident had not sustained an injury. Nurse #7 stated that he/she believed the family member had disconnected the alarmed clip seatbelt while visiting. Interview with the resident's family member, on 9/18/11 at 6:00 P.M., with Nurse #7, revealed that the family member had taken Resident #28 off the second floor unit after the noon meal. After spending some time outdoors, Resident #28's family member had brought the resident into the lobby area of the nursing facility. Resident #28's family member stated that he/she had dozed off in the chair beside Resident #28 and woke up by the sound of Resident #28 falling. Resident #28's family member was asked if the alarmed clip seatbelt had been on the resident before the fall. Resident #28's family member stated that the alarmed clip seatbelt had not been on. The family member was asked if he/she had undone the alarmed clip seatbelt while with Resident #28 and stated he/she had not. The family member was asked if the alarm had made any sound prior to the resident's fall. The family member stated that the alarm had not sounded. The incident report completed for the fall of 9/18/11, dated 9/18/11 was reviewed on 9/19/11 at 9:00 A.M., with accompanying written statements. Nurse #9 did not document whether the resident used an alarm or whether it was sounding. Nurse #10 circled "a bed" for alarms and wrote "no". and that the resident was in a chair. Nurse #11 documented that the resident did use an alarm and that it was sounding. The DON was interviewed on 9/19/11 at 9:30 A.M., and the Clinical Service Specialist was interviewed on 9/19/11 at 10:30 A.M., regarding the discrepancies between the family member's statements regarding the alarmed seatbelt and the written statements of Nurses #9, #10 and #11. The Clinical Service Specialist stated that he/she would also conduct an investigation to assure that all written statements were complete and accurate. The Clinical Service Specialist stated on 9/19/11 at 4:00 P.M., that the investigation had been completed. The Clinical Service Specialist stated that Resident #28's seatbelt had been released at lunchtime on 9/18/11. The CNA responsible for this resident on 9/18/11 during the 7-3 shift confirmed for the Clinical Service Specialist that the alarmed seatbelt had not been re-applied before the family member took Resident #28 off the second floor unit. The Clinical Service Specialist stated that the family member would not have heard an alarm because the alarm was shut off when the seatbelt was released by staff. Please refer to F323, Example #4. 5. The facility failed to ensure that an alarm was in place and functioning per the resident's plan of care to prevent an accident for Resident #25. Resident #25 was admitted to the nursing facility in February 2004 with [DIAGNOSES REDACTED]. The resident was documented as requiring the extensive assistance of one for transfers and was not ambulatory. Review of the medical record on 9/20/11 at 3:00 P.M. revealed that the resident had a fall without injury on 7/2/11. A nurse's note, dated 7/2/11 documents that the "resident was found sitting next to bed, holding onto rail. CNA said found him/her lying on the floor. Alarm on not sounding." Review of the Fall Investigation statements from three CNAs and the nurse on duty at the time of the fall, revealed that the resident was found at 1:00 A.M. All of the statements documented that the alarm was used by the resident, but did not sound. None of the statements or the Fall Investigation report document whether the alarm was turned on or off. A statement completed by the nurse on duty documented that the bed alarm and pad were changed after the fall.

Based on observation, record review and staff interview, the facility failed to ensure that certified nurses aides (CNAs) were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 4 Residents (#1, #4, #5 and #28) out of a sample of 28 residents and 4 non-sampled (NS) Residents (NSA, NSB, NSC and NSD). Findings include: Interview with the Director of Nurse at 11:45 A.M. on 9/12/11, revealed that the nursing facility had implemented Hourly Walking Rounds as a result of a Quality Improvement project completed due to an increased incidence of falls on the second floor unit. The DON stated that the CNAs had been previously educated in April, 2011 regarding hourly walking rounds. Further interview revealed that the facility was re-educating all nurses and CNAs regarding hourly walking rounds and entrapment. This re-education would take place between 9/12/11 and 9/13/11. Review of the employee annual review form on 9/20/11 at 2:45 P.M., revealed that supervisors were instructed on the form to identify specific areas that each employee needed to work on in the coming year based on resident care needs in the facility as well as any identified weaknesses for each employee. However, review of 4 of 4 CNAs who had been employed longer than a year, out of 7 CNAs reviewed, revealed that the only comment, which appeared on all 4 CNA's reviews were that "should attend mandatory in-services and/or participate in the corporate online in-servicing program. There were no identified weaknesses for individual CNAs to work on, nor any identified resident care needs which needed to be worked on. For example: 1. For Resident #1, the CNAs failed to understand their role and responsibilities when conducting hourly walking rounds. The CNAs also failed to understand that hourly rounds included monitoring for possible entrapment between the resident's mattress and side rails. In addition, staff did not adequately monitor Resident #1, resulting in the entrapment of Resident #1 between the mattress of the bed and side rail resulting in death. Interviews on 9/19/11 with CNA #10 (6:30 A.M.), #13 (2:45 P.M.), #14 (2:45 P.M.) and #15 (3:45 P.M.) revealed that they were unable to state what they were checking/monitoring during hourly walking rounds. The CNAs could only state that the residents could get trapped in bed, but not what to look for. The CNAs were unable to state how to assess and monitor for the possibility of entrapment. Please refer to F323, Example #1. 2 For Residents #5, NSA, NSB, NSC and NSD, the CNAs failed to understand their role and responsibilities when conducting hourly walking rounds which included monitoring residents requiring a bed and/or chair alarm. a. For Resident #5, the facility failed to ensure that the resident's bed alarm was functioning properly. Review on 9/13/11 at 2:40 P.M., of the incident/accident report revealed that on 4/8/11, the resident had gotten up from bed and that the bed alarm was off. As a result of the bed alarm not being on and unable to sound and alert staff, the resident was able to ambulate into the hall where s/he fell . On 4/8/11 the nursing staff noticed swelling and a bruise on the resident's left forearm. A stat (immediate) x-ray revealed a left forearm/elbow fracture for which the resident was hospitalized . Please refer to F282, Example #1 and F323, Example #3. b. For Resident NSB, the facility failed to ensure that the CNAs appropriately monitored chair alarms. Observation on 9/18/11 at 6:16 P.M., revealed that even though the hourly walking rounds were documented as being completed at 6:00 P.M., Resident NSB did not have an alarm attached. Further observation revealed that on 9/18/11 at 6:16 P.M., Resident NSB was sitting in a chair without a chair alarm in place. Upon watching the Surveyor's observation of the lack of a chair alarm, a CNA (certified nurses aide) obtained a new chair alarm and attached it to the resident's chair. Please refer to F282, Example #2. c. For Residents NSA and NSC, the facility failed to ensure that the CNAs appropriately monitored bed alarms. Observation on 9/18/11 between 6:15 P.M. and 6:35 P.M., revealed that even though the hourly walking rounds were documented as being completed at 6:00 P.M., Residents NSA and NSC were observed in bed without a bed alarm in place. d. For Resident NSD, the facility failed to ensure that the CNAs appropriately monitored bed alarms. CNA #11 was interviewed regarding Resident NSD on 9/18/11 at 11:55 P.M. CNA #11 stated that CNA #12, who conducted Hourly Walking Rounds at 9 PM, refused to conduct Hourly Walking Rounds with CNA #11 at 11:00 P.M. The Surveyor observed CNA #11 replace Resident NSD's bed alarm box. However, the bed alarm continued to not function. The Surveyor observed CNA #11 replace the resident's sensor bed pad, connect the new bed sensor pad to the alarm box, and the bed alarm became functioning (the alarm was not replaced immediately when found to not function, a 2 hour delay occurred between when the alarm was reported malfunctioning and when the alarm was replaced). Please refer to F282, Example #5. 3. For Resident #4, the CNAs failed to understand their role and responsibilities when conducting activities of daily living, including the need for safety and implementing the plan of care for totally dependent residents. For Resident #4, a CNA failed to properly attend to the resident while providing care, resulting in the resident falling from the bed and fracturing his/her right great toe. Interview with the Director of Nurses (DON) at 3:15 P.M. on 9/12/11, confirmed that a CNA had turned his/her back on the resident at which time the resident fell out of bed. According to the DON, the CNA has been inserviced regarding turning his/her back on a resident during care. Please refer to F323, Example #2. 4. For Resident #28, the CNAs failed to understand their role and responsibilities when conducting hourly walking rounds in monitoring for residents requiring an alarm clip seat belt. Observation of the resident on 9/12/11 at 9:00 A.M., 11:00 A.M., 1:00 P.M. and 2:00 P.M., 9/13/11 at 9:00 A.M., 10:00 A.M., 2:00 P.M. and 4:00 P.M., 9/14/11 at 8:30 A.M., 10:15 A.M., 12:45 P.M. and 2:00 P.M. and 9/15/11 at 11:25 A.M. and 1:00 P.M., revealed that the resident had an alarmed clip seatbelt while in a high back wheelchair with the back of the chair slightly reclined. The resident would often reach forward and stretch downward towards the footrests of the wheelchair. The resident was observed to fold his/her body in half in order to reach the footrest of the wheelchair, with his/her chest and upper body resting on his/her thighs. Resident #28 was also observed to reach over the side of the wheelchair towards the floor. During a monitoring visit, conducted on 9/18/11, Nurse #7 informed this surveyor that Resident #28 had fallen out of his/her wheelchair, while in the lobby with his/her family member at 3:30 P.M. that day. Nurse #7 stated that the alarmed clip seatbelt was not on at the time of the fall. The resident had not sustained an injury. Further review on 9/19/11 at 4:00 P.M., of the investigation revealed that the Clinical Service Specialist stated that Resident #28's seatbelt had been released at lunchtime on 9/18/11. The CNA responsible for this resident on 9/18/11 during the 7-3 shift confirmed for the Clinical Service Specialist that the alarmed seatbelt had not been re-applied, per plan of care, before the family member took Resident #28 off the second floor unit. Please refer to F282 Example #3 and F323, Example #4. 5. On 9/20/2011 at 2:45 P.M., interview with the Staff Development Coordinator confirmed although inservice training is conducted, not all of the CNAs attend as required. Please refer to F497, Example #1.