Every finding on record at Glenwood Health and Rehabilitation

Based on observations, staff interviews, and review of the facility policy titled Food Safety Requirements, the facility failed to ensure items stored in the cooler and dry food storage area were labeled, dated, and not beyond their expiration date. The facility also failed to ensure that items in the dry storage area were labeled with a use by date. In addition, the facility failed to ensure that staff hair nets covered all hair, logged steamtable food temperatures, kept food off floor for storage, and had education on how to use the 3-compartment sink. This deficient practice had the potential to adversely affect 44 of 44 residents receiving an oral diet. Findings include:Observation and interview on 03/06/2026 at 7:53 AM, the initial kitchen tour with the Dietary Manager and revealed the following observations:In the dry storage area, there were multiple cans of tuna that had an in date of 03/03/2026 but no use by date.In the dry storage area, there was a box of shredded wheat cereal with an expiration date of 10/2026, but there was no date to indicate when the box was opened.In the kitchen, on a rack in front of the walk in cooler, there was one full loaf of bread, one partial loaf of bread, one bag with hamburger buns, and a bag with two hoagie rolls sitting on top. None of the bread packages had open dates or expiration dates.In the walk in cooler, there were three tomatoes in a box, with one having a blackened area.In the walk in cooler, there was mayonnaise with an open date of 3/2 but no expiration date.In the walk in cooler, there was a container of Italian dressing with an in date of 02/17/2026 but no expiration date.In the walk in cooler, there was a black bag with a white carry out container containing a sandwich. Neither the bag nor the container was labeled.In the walk in freezer, there were boxes of frozen vegetables (squash/mixed vegetables) that did not have expiration dates.Dietary Aide (DA) AA and the dietary manager were observed wearing hair nets, but their hair was not fully covered. The Dietary Manager also had a beard but was not wearing a beard guard.Interview with the Dietary Manager reported that the loaves of bread were removed from the freezer yesterday. The box in the cooler/freezer indicated bread has a shelf life of five days once thawed. The dietary manager reported that he did not know who the sandwich belonged to, as it was not something from the facility kitchen. The dietary manager further acknowledged that items should be labeled and have use by dates.Observation and interview on 03/06/2026 at 2:15 PM of the three compartment sink with DA AA and DA OO revealed staff were confused about how to wash dishes in the sink and reported they typically wash dishes in the dishwasher but were unsure of the process for the three compartment sink.Observation and interview on 03/07/2026 at 4:20 PM with cook BB revealed she was washing the puree blender bowl, top, and blade in the three compartment sink. [NAME] BB washed and rinsed the bowl, top, and blade and then placed them in the sanitizing solution. The top and bowl were in the solution for less than 10 seconds, while the blade was in the solution for more than one minute. It was also noted that the sanitizing solution was poured directly into the sink with no measurements. [NAME] BB reported she was instructed to just pour a little of the sanitizing solution into the water because the dispenser for the sanitizing solution was not fully connected. The dispenser on the wall was observed dispensing only plain water, with the sanitizer not connected.Observation on 03/07/2026 at 5:10 PM during the kitchen tour for supper revealed the temperatures prior to serving were not documented. [NAME] BB reported she forgot to take the temperatures before starting the meal service.Interview on 03/08/2026 at 11:22 AM with the Dietary Manager revealed he does not have the expiration dates for the cans of tuna and would have to contact the vendor the following day. He further reported that no staff food should be kept in the walk in cooler and he had identified the staff member who placed the sandwich in the walk in cooler. The dietary manager further reported that anything in the cooler, dry storage, and freezer should be labeled with an in date and use by date, and staff should be following first in, first out practices.Interview on 03/08/2026 at 12:12 PM with the Dietary Manager confirmed that a spatula was used for serving the lasagna during supper on the previous day, and there was no way to ensure residents received the correct serving size. He reported that the facility does not have a six ounce scoop for serving but has a two ounce scoop and a one ounce scoop. The Dietary Manager then confirmed that he has not been wearing a beard guard and that all hair has not been covered under the hair net. Lastly, the dietary manager confirmed that he does not have documentation showing that education on how to use the three compartment sink has been provided for the kitchen staff.Observation on 03/08/2026 at 12:40 PM during a tour of storage revealed the emergency water supply in the conference room, with water boxes sitting directly on the floor and other items laid on top of some of the boxes. The Dietary Manager confirmed that the water should not be sitting directly on the floor.Review of the policy titled Food Safety Requirements, with an implementation date of 06/02/2025,documented Policy explanation and compliance Guidelines:.3.b. Dry food storage - keep foods/beverages in a clean, dry area off the floor and clear of ceiling sprinklers, sewer/waste disposal pipes, and vents.3.c.iv. Labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so it is used by its use by date, or frozen (where applicable)/discarded. 4.d. Holding - staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained.

Based on observations, staff interviews, and review of facility documents, the facility failed to ensure that puree menu serving sizes were followed to provide the correct nutritional value for one of one resident (R) who received a pureed meal. This deficient practice placed the resident receiving pureed meals at risk for inadequate caloric intake, unintentional weight loss, and potential medical complications related to insufficient nutrition.Findings Include: Review of the menu for 03/07/2026 revealed that the supper meal included lasagna Italian style, tossed salad with dressing, breadsticks, chocolate pudding, 2% milk, coffee/tea, and margarine.Review of the pureed menu with serving sizes for the supper meal on 03/07/2026 revealed a suggested 6 oz serving portion of lasagna.Observation and interview on 03/07/2026 at 4:26 PM of the pureed preparation for supper with [NAME] BB revealed that she used 11/2 spatulas to portion out the lasagna for the pureed meal. [NAME] BB was observed using a spatula to scoop one full spatula of lasagna, followed by a smaller portion on the spatula, and placing both into the blender before pureeing.Interview on 03/08/2026 at 12:12 PM with the Dietary Manager confirmed that when a spatula is used to portion meals, there is no way to ensure residents receive the correct serving size of lasagna. The Dietary Manager reported that the facility did not have a 6 oz scoop available for serving but did have 2 oz and 1 oz scoops. During a subsequent interview, the Dietary Manager reported and demonstrated that a container with multiple scoops of various sizes was available and confirmed that a 6 oz scoop was present but was not used during the supper meal service on 03/07/2026.

Based on record review, staff interviews, and the facility policy titled Residents' Personal Funds, the facility failed to notify six of 44 sampled residents and/or the residents' (R)responsible parties (R12, R32, R20, R34, R5, R15) when the residents' personal funds were within $200 of the Social Security Income (SSI) resource limit. The facility's failure to provide timely notification placed residents at risk of exceeding resource limits required for maintaining Medicaid eligibility during the renewal period. Review of the facility policy titled Resident Personal Funds, implemented on 12/29/2025, documented the following:Policy: The resident has a right to manage his or her financial affairs, including the right to know, in advance, what charges a facility may impose against a resident's personal funds. Notice of Citation Balances: The facility must notify each resident who receives Medicaid benefits when the amount in the resident's account reaches $200 less than the Supplemental Security Income (SSI) resource limit for one person.Record review revealed no documented evidence that the resident or responsible party was notified when the resident's personal funds exceeded the SSI resource limit.Record review of R5's account revealed a current balance of $3,248.89.Record review of R15's account revealed a current balance of $6,369.92.Record review of R12's account revealed a current balance of $2,766.49.Record review of R20's account revealed a current balance of $10,800.98.Record review of R32's account revealed a current balance of $4,193.67.Record review of R34's account revealed a current balance of $2,421.79.Interview on 03/07/2026 at 1:19 PM with the Business Office Manager revealed she was new to the position, having started on February 9, 2026. She stated that residents' accounts should not exceed $2,000, as doing so would affect their SSI eligibility. The Business Office Manager confirmed she had not notified any residents regarding their account balances. She further confirmed that the Patient Liability for March 2026 had already been deducted and that the remaining balances shown were the actual balances in the cited residents' accounts.Interview on 03/07/2026 at 1:30 PM with the Administrator revealed he was not aware that residents' accounts had exceeded $2,000. He also confirmed that resident accounts should not exceed the $2,000 resource limit.

Based on observations, staff interviews, and review of the policy Safe and Homelike Environment, the facility failed to ensure a homelike environment for one of 44 sampled resident rooms (room [ROOM NUMBER]).Findings Include:Review of the policy Safe and Homelike Environment documented that, Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment, allowing residents to use their personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility, both inside and outside, maximizes resident independence and does not pose a safety risk. Environment refers to any area in the facility that is frequented by residents, including (but not limited to) resident rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas.Observation on 03/06/2026 at 9:45 AM of room [ROOM NUMBER] revealed that the ceiling tiles had water stains. Resident R8 stated that he placed a trash can to catch water when it rained heavily outside. He reported that the last time he used the trash can to catch water was about three weeks ago, during the last heavy rainfall. R8 stated he reported the issue to nursing staff, who told him they also observed the water dripping.Interview on 03/08/2026 at 2:00 PM with the Maintenance Supervisor and Administrator during a walkthrough confirmed that there was a possible water leak. Both stated they were not aware of the issue until the state surveyor brought it to their attention. The Maintenance Supervisor, who had started in the position three weeks prior, stated he would replace the ceiling tiles but needed to identify and address the source of the leak first.

Based on observations, interviews, and review of facility policy titled Abuse, Neglect and Exploitation, the facility failed to ensure that one of three residents (R ) (R38) reviewed for free from verbal and physical abuse. Findings includeReview of Facility Incident Report Form dated 11/26/2025 regarding resident-to-resident abuse for an incident on 11/26/2025 between R44 and R38. The details of the report indicated R44 verbally and physically assaulted R38 while on the smoking porch. R44 struck R38 in the head repeatedly resulting in R38 falling and hitting his head on the ground.Record review revealed R38 admitted to the facility on [DATE] with diagnosis that included but not limited to Alzheimer's Disease with late onset, psychotic disturbance mood disturbance and anxiety.Review of Progress Note dated 11/26/2025 indicated that R38 was walking up the hall when another resident (R44) began to hit R38 in the face before staff were able to intervene by standing between the two residents. R38 was assessed by nursing and noted with bruising to left cheek. Per the notes R38 was unable to recall what happened.Record review for R44 revealed admission on [DATE] with diagnosis that included but was not limited to schizoaffective disorder, bipolar type and unspecified focal traumatic brain injury with loss of consciousness of unspecified duration.Review of Progress Notes on 11/26/2025 indicated that R44 was trying to get into the bathroom by the nurse station and was being redirected by nursing staff when R38 was ambulating up the hall. R44 then began yelling profanities at staff initially but became aggressive with R38 as he was ambulating in the hallway. Staff were able to calm R44 by allowing him a smoke break and he was placed on one to one. The Medical Doctor and Behavioral health services were notified of the incident. Resident remained on one to one by staff until he was transported to the behavioral health unit on 11/26/2025.Review of the R44's care plan indicated a history of behaviors related to schizophrenia with the last noted altercation with another resident being 06/15/2023 and verbal and physical aggression towards staff on 06/29/2025.Interview on 03/07/2026 at 9:43 AM with Resident R38 revealed that he did not recall the event in question and denied feeling fearful of anyone.

Based on observations, record review, staff interviews, and the facility's Catheter Care policy, the facility failed to ensure that urinary drainage tubing was kept uncoiled to allow unobstructed urine flow and prevent tension for one resident (R) (R49) out of three reviewed for catheter care. This deficient practice had the potential to increase R49's risk for a urinary tract infection.Findings include:Record review of the policy titled Catheter Care (dated 09/26/2025). It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate care and maintain their dignity and privacy when indwelling catheters are in use.Record review of the electronic health record (EHR) for R49 revealed the following diagnoses but not limited to urinary retention, pressure ulcer of sacral stage 4, and dementia.Record review of R49's EHR Significant Change Minimum Data Set (MDS) Assessment (dated 02/24/2026) revealed for Section C (Cognitive Patterns) a Brief Interview Mental Status (BIMS) score of 14. Section H (Bowel and Bladder) assessed requirement for catheter use.Record review of R49's EHR physician orders (dated 02/13/2026) revealed an order which stated Ensure Catheter Tubing is Secured with Clean Leg Strap/Securement Device & Drainage Bag is kept Below Level of Bladder every shift for placement.Record review of R49's EHR's lab/cultures laboratory reports revealed that resident was diagnosed with UTI in April 2025, June 2025, and July 2025.Record review of R49's EHR's care plan (created date 03/05/2026) revealed a focus area for catheter use to deter the prevention of urinary tract infection and trauma due to resident diagnoses of urinary retention/ obstructive and reflux uropathy unspecified, stage four pressure wound to sacrum. and hospice.Observation of R49 on 03/6/2026 at 11:03 PM revealed resident up in a wheelchair, in the dining room participating in activity a few minutes before lunch. An indwelling urinary catheter was noted attached to his wheelchair with dignity flap in place. A closer observation of the urinary drainage tubing revealed that the tubing was coiled in a loop obstructing/preventing flow.Observation of R49 on 03/07/2026 at 10:57AM with the MDS Coordinator, R49 was observed sitting in a wheelchair in the dining room visiting with family members. An indwelling urinary catheter was noted attached to her wheelchair with a dignity flap in place. A closer observation of the urinary drainage tubing revealed that the tubing was coiled in a loop, obstructing/preventing flow of urine. MDS Coordinator verified that the tubing was in a circular position.Interview and observation on 03/07/2026 at 5:25 PM of R49 with the MDS Coordinator, R49 was observed lying in bed in her room. An indwelling urinary catheter was noted attached to her bedrail with a dignity flap in place. A closer observation of the urinary drainage tubing revealed that the tubing was coiled in a loop, obstructing/preventing a downward flow of urine. The MDS Coordinator confirmed that the tubing was coiled and obstructing the flow of the urine. She repositioned the tube and reported that her certified nursing assistants will be provided training.Interview on 03/08/2026 at 11:34 PM with the Director of Nursing (DON) reviewed the photographic evidence for R49's catheter with the surveyor. The DON confirmed the facility direct care staff failed to ensure that the catheter drainage tubing was not coiled in a loop. She reported being unaware that CNAs was looping the tubing and failing to remove the kinks. She reported that her expectations are for licensed nursing staff and CNAs monitor residents' catheter for obstruction of flow to prevent the increase of urinary tract infections (UTI's).

Based on observations, staff interviews, record reviews and review of the facility policy titled, Food Safety Requirements, the facility failed to prepare and store food in accordance with professional standards of food service safety. Specifically, the facility failed to hold hot foods' temperatures appropriately prior to a meal service, failed to monitor the temperatures of hot foods being held prior to serving, and failed to remove decayed foods from refrigeration. The deficient practices had the potential to affect all 43 residents who received food from the facility's kitchen.Findings include:Review of the facility policy titled, Food Safety Requirements, implemented 6/2/2025 revealed, Food will be properly stored, prepared and distributed in a palatable manner within the 14-hour service window in accordance with standard and federal guidelines to ensure the nutritional needs of every resident are met. The policy revealed, 3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. The policy also indicated, c. Refrigerated storage - foods that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include, which included iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date, or frozen (where applicable)/discarded. The policy revealed, 4. When preparing food, staff shall take precautions at critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards, which included d. Holding - Staff shall monitor food temperatures while holding for delivery to ensure proper hot and cold holding temperatures are maintained. Staff should refer to the current FDA [Food and Drug Administration] Food Code and facility policy for food temperatures as needed.Review of the undated facility document titled, Heating, Holding, and Cooling Foods Correctly Staff In-service indicated, VI. Kitchen staff should hold hot foods correctly, which included, Serve food as quickly as possible after cooking, limiting holding time by preparing foods in small batches, if possible, and Check the internal temperature during holding, making sure hot foods are at least 135 degrees Fahrenheit (F) during the holding process.Review of the facility document titled, Seasoned [NAME] Beans, dated 9/22/2015 revealed, Instructions included Boil/steam beans until done. [NAME] to 140 degrees F; Drain, toss with margarine, season with salt & pepper; and Transfer to service pans, cover and hold at 135 degrees F.Observation with concurrent interviews on 9/9/2025 at 10:45 am revealed, a pan of creamed corn was stored on the steam table, and the temperature dial of the steam table was set to six with10 being the highest possible setting. The Dietary Manager (DM) stated the lunch meal service started at 12:00 pm. [NAME] (3) stated she removed the creamed corn from the oven between 10:15 am and 10:30 am and placed the creamed corn on the steam table because she did not want the creamed corn to continue cooking. [NAME] (3) stated that she did not check the temperature of the creamed corn before storing the creamed corn on the steam table for the meal service, and she did not know if the creamed corn reached 140 degrees F. [NAME] (3) removed the creamed corn from the steam table and placed the creamed corn in an oven set to 100 degrees F for hot holding. [NAME] (3) stated that it was her practice to place food in an oven set to 100 degrees F for hot holding. The oven was observed with a temperature setting of 100 degrees F and also contained a service pan of mechanically chopped ham with pineapple. [NAME] (3) stated the mechanically chopped ham with pineapple was placed in the oven set to 100 degrees F, about 30 to 45 minutes prior, for hot holding and would remain in the oven for hot holding until the lunch meal service at 12:00 pm. [NAME] (3) stated she did not check the temperature of the mechanically chopped ham with pineapples before or during hot holding.Observation with concurrent interview on 9/9/2025 at 10:47 am revealed, an uncovered 25-gallon stock pot containing green beans on the stove, and the stove was turned off. [NAME] (3) stated she turned the pot of green beans off between 10:15 am and 10:30 am, to allow the green beans to cool before putting the green beans in a service pan and then on the steam table for the meal service.Interview on 9/9/2025 at 10:48 am with the DM revealed, she did not notice the creamed corn was already on the steam table for hot holding. The DM stated she expected the cooks to use the oven for hot holding at a temperature of 140 degrees F instead of the steam table. The DM stated cooks should follow the guidance on the recipes regarding the temperature to hold foods hot until the meal tray line began. The DM stated the green beans should not be left on the stove with the temperature turned off but should be transferred to a service pan, covered, and held in the oven at 140 degrees F until the meal service.2. Observation with concurrent interview of the facility's walk-in refrigerator on 9/9/2025 at 11:05 am revealed, 12 tomatoes were stored in a cardboard box with a lid. The observation revealed the tomatoes had multiple areas of dark discoloration, and two tomatoes had white hair-like growth identified by the DM as mold. The observation also revealed two oranges stored in a cardboard box with a lid. The oranges were covered with black/white hair-like growth identified by the DM as mold. The DM stated she checked the refrigerated storage areas daily for properly stored items and removed any expired items she found. The DM stated that she had most recently checked the walk-in refrigerator that morning but stated, I missed these items.Interview with the Registered Dietician (RD) by telephone on 9/9/2025 at 2:44 pm revealed, the steam table should not be used for hot temperature holding, but hot foods should be placed in the oven and monitored to maintain a hot holding temperature of 140 degrees F. The RD stated that an oven set to 100 degrees F would not maintain hot foods of at least 140 degrees F. The RD stated that she expected hot foods to be placed on the steam table approximately 30 minutes before the meal service. The RD stated the staff should conduct daily checks of the cold food storage for expired items and remove any items that were stored past their use-by-date.Interviews with the Director of Nursing (DON) and the Administrator (ADM) on 9/10/2025 at 5:00 pm revealed, the DON stated that the dietary staff required some education regarding kitchen sanitation and safe cooking practices. The ADM stated that he expected the DM to check kitchen sanitation daily and oversee the cooks during meal preparation. The ADM stated he expected the cooks to follow a food safety and certification program's cooking practices and recommendations.

Based on staff and resident interviews, record review, review of the facility document titled, Resident Grievance/Concern/Complaint Report, and review of facility policy titled, Resident and Family Grievances, the facility failed to provide written grievance decision responses for two out of six residents (R) (R3 and R4) reviewed for grievances. Findings include:Review of the facility policy titled Resident and Family Grievances, implemented 9/1/2024, indicated, It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear or [sic] reprisal. The policy revealed, 10. Procedure included g. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official or designee will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum:i. The date the grievance was received.ii. The steps taken to investigate the grievance.iii. A summary of the pertinent findings or conclusions regarding the resident's concern(s).iv. A statement as to whether the grievance was confirmed or not confirmed.v. Any corrective action taken or to be taken by the facility as a result of the grievance.vi. The date the written decision was issued.1. Review of admission Record indicated the facility admitted R3 on 3/1/2024.Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/3/2025, indicated R3 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition.Review of the facility document titled, Resident Grievance/Concern/Complaint Report, dated 8/11/2025, revealed R3 voiced a grievance regarding another resident to the Social Services Director (SSD). The document indicated the grievance was resolved and indicated the Resident/Responsible Party was notified One-to-One. The Resident Grievance/Concern/Complaint Report revealed that it was signed by the SSD on 8/14/2025. The document revealed it did not indicate that a written decision regarding the conclusion of the investigation had been provided to R3.During an interview on 9/9/2025 at 11:48 am with R3 revealed, they filed grievances in the past that were resolved. R3 stated the SSD responded verbally in person about the grievances they had filed and had not offered a written response regarding the grievance decision. R3 stated they were not aware that a written response could be provided, and that they would like to have a written response regarding the investigation of their grievances.2. Review of the admission Record indicated the facility admitted R4 on 11/10/2023.Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/24/2025, indicated R4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition.Review of the facility document titled, Resident Grievance/Concern/Complaint Report, dated 7/27/2025 revealed, R4 voiced a grievance related to dietary concerns. The document indicated the grievance was resolved and indicated the Resident/Responsible Party was notified One-to-One. The Resident Grievance/Concern/Complaint Report was signed by the SSD on 7/29/2025. The document revealed it did not indicate that a written decision regarding the conclusion of the investigation had been provided to R4.Review of the facility document titled, Resident Grievance/Concern/Complaint Report, dated 8/11/2025 revealed, R4 voiced a grievance to the SSD regarding another resident. The document indicated the grievance was resolved and indicated the Resident/Responsible Party was notified One-to-One. The Resident Grievance/Concern/Complaint Report was signed by the SSD on 8/12/2025. The document revealed it did not indicate that a written decision regarding the conclusion of the investigation had been provided to R4.Review of the facility document titled, Resident Grievance/Concern/Complaint Report, dated 9/1/2025 revealed, R4 voiced a grievance to the SSD related to dietary concerns. The document indicated the grievance was resolved and indicated the Resident/Responsible Party was notified One-to-One. The Resident Grievance/Concern/Complaint Report was signed by the SSD on 9/3/2025. The document revealed it did not indicate that a written decision regarding the conclusion of the investigation had been provided to R4.During an interview on 9/9/2025 at 12:30 pm, R4 revealed they had filed grievances in the past that were resolved. R4 stated the SSD responded verbally about the grievances the resident had filed but had not offered a written copy. R4 stated they were unaware a copy could be provided, and they wanted a copy of the grievance.During an interview on 9/10/2025 at 4:00 pm, the SSD stated she had been the Grievance Official designee for the facility since 7/22/2025. The SSD stated she was responsible for the investigation and follow-up for grievances and complaints. The SSD stated that at the conclusion of her investigations of grievances, she made in-person contact with the resident or responsible party to let them know how the grievance was resolved. The SSD stated she was not aware a written response was required. The SSD stated she had not provided a copy of grievance resolutions for grievances she had investigated since starting at the facility in July 2025. During an interview on 9/10/2025 at 5:00 pm, the Director of Nursing (DON) stated she was not aware the facility was required to provide a written response to grievances, and she expected the grievance official or designee to follow the facility policy.During an interview on 9/10/2025 at 5:15 pm, the Administrator (ADM), stated he was not aware the facility was required to provide a written response to grievances, and he expected the grievance official or designee to follow the facility policy.

Based on observations, staff interviews, and review of the facility's policies titled, Food Storage and Sanitation/Infection Control, the facility failed to remove food items by the discard date; failed to label and date food items for storage; failed to remove dented food cans; failed to store food items off the floor; and failed to maintain food temperatures above 135 degrees on the steam table to prevent food borne illness. The deficient practice had the potential to affect 42 residents who received an oral diet and were served food from the kitchen. Findings included: Review of the facility's policy titled Food Storage revealed leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Review of the facility's policy titled Sanitation/Infection Control revealed all potentially hazardous foods are kept at an internal temperature of 45 degrees F (Fahrenheit) or lower-, or 140-degrees F or higher while being held and served. 1. Observation on 11/8/2024 at 8:25 am of the walk-in refrigerator revealed a clear plastic bag labeled Sandwich Meat 10/20/2024 and 11/5/2024. Interview on 11/8/2024 at 8:25 am with Dietary [NAME] BB revealed that 10/20/2024 was the date the sandwich meat was placed in the bag, and 11/5/2024 was the discard date. Dietary cook BB revealed that the sandwich meat should have been removed and discarded by 11/5/2024. Dietary cook BB also revealed that the Dietary Manager (DM) would usually go through the walk-in refrigerator and let dietary staff know if food items needed to be discarded. 2. Observation on 11/8/2024 at 8:25 am of the walk-in refrigerator revealed an opened one-gallon container of BBQ sauce with no open date. Continued observation revealed two small plastic bags both containing cut onions with no label or date. Continued observation on 11/8/2024 at 8:30 am of the dry storage area revealed an opened package of [NAME] Gravy Mix stored with no open date. Interview on 11/8/2024 at 8:25 am to 8:35 am with dietary cook BB revealed that dietary staff were supposed to label and date any leftover food items, and that staff should date opened food items before storage. Dietary cook BB confirmed that the [NAME] Gravy Mix had been opened and stored with no open date and confirmed that the BBQ sauce had been opened and stored with no open date. The DM confirmed that the two plastic bags with onions had no label or date. Continued interview with the DM revealed that she expected dietary staff to label and date opened or used food items before storing. 3. Observation on 11/8/2024 at 8:30 am of the dry storage area revealed a large metal rack containing canned food items. Continued observation revealed a large can of fruit cocktail with a large dent on the side towards the top. Interview on 11/8/2024 at 8:30 am, dietary cook BB confirmed that the can of fruit cocktail had a large dent and was in the rack with all the other canned food items. Dietary cook BB revealed that all dietary staff assisted with putting away grocery items after delivery and staff were supposed to place dented cans in the designated area away from other cans. Interview on 11/8/2024 at 9:00 am, the DM confirmed that the can of fruit cocktail had a large dent to the side and was not placed in the dented can area for staff not to use. The DM revealed that a newly employed dietary aide had put away the canned food items and did not know that cans with dents were placed in the dented can area. 4. Observation on 11/8/2024 at 8:30 am of the dry storage area revealed 20 cases of bottled water on the floor. Interview on 11/8/2024 at 8:30 am with dietary cook BB confirmed that the cases of bottled water were on the bare floor in the dry storage area. Dietary cook BB revealed that with the recent hurricane members of the community had donated cases of water to the facility. Interview on 11/8/2024 at 9:00 am the DM confirmed that the cases of water were on the bare floor. The DM confirmed that food items should not be on the bare floor and should be elevated. The DM stated that she was trying to find storage space for the cases of water and was having difficulties. Observation on 11/9/2024 at 8:15 am of the emergency food supplies revealed they were stored in a closet in the kitchen area. Continued observation revealed 20 cases of bottled water were stored on the floor in the closet. Interview on 11/9/2024 at 8:15 am, the DM confirmed that the cases of water were being stored on the floor. The DM reveled that the cases of bottled water were from the dry storage area, and she was still in the process of finding elevated storage space for them. The DM confirmed that no food items should be stored on the floor. 5. Steam table temperatures were completed on 11/9/2024 at 12:20 pm with the DM assisting using the facility's calibrated food thermometer. The following food items were not held at the appropriate temperatures while being served in the steam table: Chicken tenders had a temperature of 121 degrees, chopped chicken tenders had a temperature of 116 degrees, ground chicken tenders had a temperature of 94 degrees, and puree peas had a temperature of 103 degrees. Interview on 11/9/2024 at 12:20 pm, the DM confirmed all the tested food temperatures. The DM revealed that food items held in the steam table should be 135 degrees or higher. The DM revealed that they have not had any issues maintaining temperatures of foods on the steam table and not sure why the temperatures were not appropriate today.

Based on observations, staff interviews, review of facility documents, and review of a job description titled, Plant Operations Manager, the facility failed to ensure the resident's living area was clean and in good repair for seven of 14 rooms (Rm) on the 100 hall (Rm 108, 109, 110, 111, 112, 113 and 114), and the facility also failed to ensure that two of two shower rooms were free of clutter and in good repair. Specifically, the facility failed to ensure Rm 109, 111, 112, and 113 had clear running water streaming from the bathroom sink faucet, and that Rm 108, 110, and 114 were in good repair as evidenced by missing floor tiles in the bathroom and missing base boards on the wall in Rm 110. Findings included: Review of the facility documents titled, Task Due this week revealed a list of duties under Category, that included water temperatures-Test and log the hot water temperatures, and Rooms-room inspections. Review of the job description for Plant Operations Manager included under Facility Maintenance Functions: Repair/replace major and minor plumbing systems, build/install walls, doors, drywall, trim work, ceiling track systems. Replace ceiling and floor tile. Observation on 11/8/2024 at 7:50 am of room [ROOM NUMBER] revealed the bathroom had missing floor tile under the sink, the water had low stream when turned on full blast, and room had strong urine odor that illuminated out in the hallway. Observation on 11/8/2024 at 7:55 am of room [ROOM NUMBER] revealed bathroom sink slow draining with brown rust colored water coming from the faucet. Observation on 11/8/2024 at 8:00 am of room [ROOM NUMBER] revealed two bath basins stored on top of sink unbagged and resting one inside another, base board missing on the right side of the room under the television. Observation on 11/8/2024 at 8:05 am of room [ROOM NUMBER] revealed bathroom sink slow room draining, brown rust colored water coming from faucet. Observation on 11/8/2024 at 8:10 am of room [ROOM NUMBER] revealed bathroom sink had brown rust colored water coming from the faucet. Observation on 11/8/2024 at 8:15 am of room [ROOM NUMBER] revealed bathroom sink was slow draining, brown rust colored water coming from faucet. Observation on 11/8/2024 at 8:20 am of room [ROOM NUMBER] revealed tile missing behind the commode wall discolored with the sheet rock bubbled up in the corner of the bathroom to the right of the commode, large coffee colored stain in the middle of the bathroom floor facing the door, puddle of rust colored fluid on the floor under the sink. Interview on 11/8/2024 at 8:30 am with the Maintenance Director revealed that he was unaware of the concern with the water being brown in the rooms on the 100 hall and stated that it may be an issue with the copper pipes that are in the building. Further interview revealed that he was not aware of the repairs that needed to be completed in room [ROOM NUMBER] and room [ROOM NUMBER] however, he was working on getting the rooms in the facility repaired. During interview, all observations of the brown colored water coming from the bathroom sinks, and the needed repairs for rooms [ROOM NUMBERS], were confirmed by Maintenance Director during walking rounds. Observation on 11/8/2024 at 9:00 am of shower room on the 200 hall revealed there were wheelchairs, mattresses from residents bed, one being an air flow mattress with the pump, IV (Intravenous) poles, laundry baskets, empty large clear storage container, broken bedside table, three boxes of residents briefs, residents clothes hanging from IV pole, two clean linen carts, and two soiled linen carts stored in the shower room area leaving one stall available for resident use. Observation on 11/8/2024 at 9:15 am of shower room on the 100-hall revealed the bathroom had three shower stalls with only one available stall for resident use. Stall one had wheelchair parts on a large white wire rack that included wheelchair footrests, bedside commode, prosthetics leg, fall mat, a pair of shoes, Geri-chair with bed pads, and shower bed. The second shower stall had a wet dirty mop, wheelchairs, bed mattresses, walkers, and fall mats stored. Interview on 11/8/2024 at 9:20 am with the facility Maintenance Director revealed that the items had been stored in the shower rooms ever since he had started working at the facility three months ago and he would try to find another place to store the items that were in both shower rooms. Interview on11/8/2024 at 9:25 am with Corporate Maintenance Director revealed he worked with the corporate office and worked at several of the company's facilities. He stated that he visited the facility periodically and had been at the facility three times in the past to work on different tasks, such as painting the walls. He revealed that it had not been reported to him nor had they had any issues with water or sewage problems. He revealed it could be a city problem because the water system was being managed the city. Interview on 11/8/2024 at 9:30 am with Maintenance Director and [NAME] President (VP) of Environmental Services verified that the city was managing the facility water system. VP reported he and the Maintenance Director would be working to address any environmental concerns, and that the facility completed water testing annually for Legionella and they had not had any concerns or issue with it. Interview on 11/9/2024 at 10:00 am with the Administrator revealed that she expected for the facility to be clean and in good repair. Further interview also revealed that the shower rooms should not have any supplies stored in them and that it should be stored outside of the facility in the storage shed.

Based on observations, staff interview, and review of the facility's policy titled, Medication Administration Guidelines, the facility failed to ensure one of one medication storage rooms were free of expired medications and that the Medication storage room was secure and only accessible to licensed staff. Findings included: Review of the facility policy titled, Medication Administration Guidelines dated December 2023 revealed under Safe Medication Administration, Purpose: The purpose of these guidelines is to promote the health and safety of the residents we serve by ensuring the safe assistance and administration of medications and treatments. Medication rooms are to be kept locked at all times. All expired medications or medications to be destroyed are to be taken off the medication cart and properly destroyed per the environmental protection agency. Observation on 11/8/2024 at 10:30 am and 2:30 pm, nurses at the nursing station were noted entering the medication storage room located in the nursing station without using a key. Med room observation on 11/09/2024 at 1:40 pm revealed the nurse entered the drug storage room without a key and the following medications were expired that were stored in the floor stock medication cabinet: two boxes of Bisacodyl suppositories expiration date of 7/2024, four bottles of zinc 50 milligrams (mg) expiration date 10/2024, and four bottles of Vitamin B6 50 mg expiration date 6/2024. All observations were confirmed at time of discovery by Registered Nurse (RN) AA. Observation and interview on 11/9/2024 at 2:30 pm revealed the drug storage room door was opened by this surveyor without the use of a key while the DON was present. Interview revealed that the door should always be locked and only assessable for licensed staff. DON confirmed that door was not locked during observation.

Based on staff interviews, record review, and a review of the facility's policy titled, Preadmission Screening and Resident Review (PASRR), the facility failed to submit for a PASRR Level II after a new mental health diagnosis was added, and the development of behaviors for one resident (R) (R37) out of 19 residents reviewed. This deficient practice had the potential to affect the appropriate level of care and services provided for R37. Findings include: Review of the facility policy titled Preadmission Screening and Resident Review (PASRR), effective date August 2022 revealed, Purpose: PASRR is a review required under the State Medicaid program that identifies the specialized services for an individual with mental illness and mental retardation (MI/MR) residing in a nursing facility and be offered the most appropriate setting for their needs. PASRR assures that psychological, psychiatric, and functional needs are considered in long term care. The facility Social Services Director is accountable for this process. Process: When the Social Worker is submitting documentation for Level II review, the medical history, current medications, and physical exam report must be included. A psychological evaluation including intelligence testing, and a functional evaluation will also be needed. Social Services resident care planning should include a review of diagnosis and/or change in status which could include the need for specialized services. Review of the admission PASRR Level 1 dated 2/19/2024, completed at the hospital prior to admission revealed R37 had no diagnosis of a serious mental illness, developmental disabilities, or related condition. Review of electronic medical records (EMR) for R37 revealed diagnoses included but not limited to unspecified psychosis not due to a substance or known physiological condition. Review of R37's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed: Section C-Cognitive Patterns: Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Review of R37's care plan dated 9/5/2024 revealed: Resident has behaviors of being physically aggressive to others, physical aggression toward another resident, behaviors of being verbally aggressive toward staff, and uses psychotropic medications r/t (related to) diagnosis of psychosis. Review of Physicians Orders included but not limited to Quetiapine Fumarate tablet 50 mg (milligrams) 1 tablet by mouth at bedtime for adjustment disorder with disturbance of conduct related to unspecified psychosis not due to a substance or known physiological condition; Quetiapine Fumarate oral tablet 25 mg 1 tablet by mouth at bedtime for adjustment disorder with disturbance of conduct related to unspecified psychosis not due to a substance or known physiological condition. Take with 50 mg to = (equal) 75 mg. R37 was receiving psych services. Interview with the Social Service Director (SSD) on 11/9/24 at 8:47 am revealed R37 did not have a PASRR Level II because it looked like the admission person did not know that he had substance abuse. The SSD revealed that she was supposed to update the PASRR, but it slipped through the cracks, and she did not update it. SSD revealed that R37 just started having behaviors and that she should have updated the PASRR once behaviors developed. Interview with the Director of Nursing (DON) on 11/9/24 at 9:18 am revealed the SSD was responsible for the PASRR's. She confirmed that R37 had behaviors and revealed that R37 would become agitated while ADL (Activities of Daily Living) care was being provided for him. She revealed that R37 yelled and screamed at staff and R37 was care planned for behaviors. She revealed that care plan meetings are held with R37's sister; that the SSD talked to R37, and he was receiving [named] behavioral health services. The DON confirmed that a level II PASRR should have been submitted for R37.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Respiratory System Management Standard, the facility failed to prevent the spread of infections by not cleaning and storing a nebulizer mask for one of two residents (R) (R43), receiving nebulizer treatments. Findings included: Review of the facility's policy titled, Respiratory System Management Standard dated August 2021 under the subtitle Aerosolized Medication (Neb Med) revealed, number 17 Rinse the nebulizer and mouthpiece. Shake to air dry and store in a plastic bag that is labeled with the resident's name and room number. Nebulizer and mouthpiece may also be stored in the machine if storage shelf is available. Review of the Electronic Health Record (EHR) for R43 revealed, the resident admitted to the facility with diagnoses of but not limited to, pleural effusion and shortness of breath (SOB). Review of R43's Admission Minimum Data Set (MDS) assessment dated [DATE] for Sections C (Cognitive Patterns) revealed, a Brief Interview for Mental Status (BIMS) score of 14 that indicated little to no cognitive impairment; Section O (Special Treatments, Procedures, and Programs), revealed respiratory therapy administered five days in the last seven days. Further review of the EHR revealed physician orders dated 9/21/2024 for ipratropium-albuterol inhalation solution 0.5-2.5 (3) three MG (milligram)/3ML (milliliter), 1 (one) vial inhale orally two times a day for SOB (shortness of breath); sodium chloride inhalation nebulization solution 3 %, 1 vial inhale orally via nebulizer two times a day for SOB; albuterol sulfate inhalation nebulization solution (2.5 MG/3ML) 0.083%, 3 ml inhale orally via nebulizer every 6 (six) hours as needed for SOB. Observations on 11/8/2024 at 8:12 am and 10:25 am revealed R43's nebulizer mask on the bedside table not cleaned, unbagged, or labeled with the resident's name and room number. Further observation conducted on 11/9/2024 at 9:14 am with the Director of Nursing (DON) revealed R43's nebulizer mask stored on the bedside table not cleaned, unbagged, or labeled with the resident's name and room number. An interview was conducted during that time with the DON who confirmed the nebulizer was not stored properly. She revealed the charge nurses assigned were responsible for making sure nebulizer masks are cleaned and stored in a plastic bag. The DON revealed her expectations of staff were to clean and store all patient care equipment after use. DON stated she would replace the nebulizer mask, bag it and provide education to staff immediately. Interview on 11/9/2024 at 1:09 pm with Registered Nurse (RN) AA revealed she was the nurse assigned to R43 and verified it was the nurses' responsibility to make sure nebulizer masks were cleaned and bagged once the medication had been administered to the resident.

Based on observation, staff interviews, and review of facility's policy titled, Puree Food Preparation, the facility failed to ensure that dietary staff followed recipes and measured ingredients when preparing puree food to prevent compromising the nutritive value and flavor for one resident out of 42 who was ordered a puree consistency diet. Findings included: Review of the facility policy titled Pureed Food Preparation revealed, portion out the number of pureed items needed to prepare puree meals for all residents. The policy stated use liquids sparingly so that the finished product will hold form. Observation on 11/9/2024 at 11:00 am of dietary cook BB prepare puree chicken tenders for the lunch meal revealed she placed one and one half fried chicken tenders in the blender bowl and pulsed into ground texture. Dietary cook BB then added an unmeasured amount of milk to the blender bowl and pureed the chicken tenders. The consistency of the puree chicken tenders was soup like, and dietary cook BB added a small packet of food thickener in order to thicken to proper puree consistency. Interview on 11/9/2024 at 11:00 am dietary cook BB confirmed that she did not measure the amount of milk added to the chicken tenders. The cook revealed that she added too much milk and therefore needed to add the food thickener to thicken the puree chicken tenders to the proper consistency. Observation on 11/9/2024 at 11:10 am of dietary cook BB puree cooked peas for lunch meal revealed she placed one, four-ounce spoonful of peas in the blender bowl. The cook began to puree. She then opened the blender lid and poured an unmeasured amount of cooked peas from a plastic container into the blender. Dietary cook BB added an unmeasured amount of milk at this time and pureed the peas into puree consistency. Interview on 11/9/2024 at 11:10 am, dietary cook BB confirmed that she did not measure the extra cooked peas added to the blender and did not measure the milk added as well. Continued interview with dietary cook BB revealed that she sometimes measured the liquid she adds when she purees food items. Dietary cook BB revealed that she did not know if there were recipes available for puree food items to review. Interview on 11/9/2024 at 11:10 am with the Dietary Manager (DM) revealed that she expected dietary staff to measure the ingredients when preparing puree foods. The DM confirmed that dietary cook BB did not puree the chicken tenders and the cooked peas properly. The DM confirmed that the cook added too much liquid to the chicken tenders which caused the need to add food thickener. The DM also revealed that the dietary cook should have used the juices from the cooked peas instead of milk for the liquid for puree. The DM revealed that she was not able to find a recipe for puree chicken tenders or for puree peas for dietary staff to use for production.

Based on observation, record review, staff and resident interview, and review of facility policy titled Pain Management, the facility failed to stop and address one resident's expression of pain during wound treatment, resulting in harm for one resident (R#39) of 15 sampled residents. Actual harm was identified on 7/22/23 when Licensed Practical Nurse (LPN) AA failed to administer pain medication to R#39 prior to providing wound care and upon R#39's nonverbal expressions of and verbalizing of pain, which resulted in severe pain during the treatment for R#39. Findings include: A review of the facility policy titled, Pain Management, dated 8/21, revealed: Purpose: To provide compassionate, appropriate assessments and interventions to control resident's pain using appropriate pain management techniques. A medical record review revealed that R#39 was admitted on [DATE] with diagnoses including but not limited to acquired absence of right leg below knee, infection following a procedure, and other surgical site, sequela. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE], Section - C -Cognition, revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. Section M-Skin Conditions revealed R#39 has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Section J-Health Conditions revealed R#39 was not on a scheduled pain regimen. A review of R#39's comprehensive person-centered care plan entitled, Pain, revealed Administer medications as ordered. Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. Monitor/record/report to Nurse any sign/symptoms of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). Record review revealed resident had current orders for Tramadol Hydrochloride (HCL) Oral Tablet 50 milligram (MG) give one tab by mouth every six hours as needed for moderate to severe pain with a start date of 7/5/23 and Acetaminophen Oral Tablet 500 MG give one tab every six hours as needed for pain related to infection following a procedure with a start date of 7/5/23. During observation on 7/22/23 at 1:45 p.m. of wound care provided by Licensed Practical Nurse (LPN) AA for R#39. LPN AA began to remove the tape from the wound in the area above the right knee. R#39 screamed out aah aah. LPN AA asked if she was hurting him, and R#39 stated that it hurts. LPN AA questioned R#39 about what hurt and R#39 informed LPN AA that the way that LPN AA was pulling the tape off hurt him. LPN AA stopped pulling at the tape and stuck her head out of R#39's room door and asked a staff member if they could check with the nurse to see if R#39 could have something for pain. LPN AA then continued the wound treatment. LPN AA proceeded to pat the area around the tape with the gauze. R#39 made facial grimaces and closed his eyes. LPN AA continued with removing the dressing. Staff knocked at door and informed LPN AA that they did not know where the nurse was. LPN AA removed the dressings and continued with wound care. LPN AA removed gloves, sanitized her hands, and patted areas on the right thigh with a normal saline soaked gauze. R#39 yelled out and started hitting self in the head with both fists clenched. LPN AA continued with wound care. LPN AA asked R#39 what was hurting. R#39 stated, I guess where the toes were. LPN AA continued with wound care applying three xeroform dressings covering the wounds on R#39's thigh. LPN AA then covered two areas with a bordered dressing. LPN BB entered the room around 2:07 p.m. and LPN AA informed LPN BB that R#39 needed something for pain. LPN BB exited the room and returned to the room at 2:10 p.m. and administered R#39 pain medication at this time. LPN BB stated that she gave R#39 a tramadol. Observation of wound care revealed throughout the treatment R#39 would close eyes, hit self in head with both fists clenched, make facial grimaces, and yell out, aah, aah, aah . LPN AA stated that she was not going to put the last piece of tape over the xeroform dressing. LPN AA wrapped the area with a cling dressing. LPN AA informed R#39 that she was going to let the pain medication kick in, and that she would be back in 30 minutes to put the tape on the remaining area. Interview with LPN BB on 7/22/23 at 2:13 p.m. revealed R#39 has an order for Tylenol 500 mg every six hours as needed for pain, and he has an order for Tramadol every six hours as needed for moderate to severe pain. LPN BB stated that she did not know that LPN AA was going to do R#39 treatment at that time. LPN BB stated that before she does wound care, she makes sure that she gives residents something for pain. LPN BB also stated that R#39 received 500 mg of Tylenol at 6:45 a.m. but he had not received any tramadol, on this shift, prior to his wound treatment. Interview with LPN AA on 7/22/23 at 2:17 p.m. revealed she should have stopped the treatment immediately. LPN AA stated that she has been back at the facility for one week. She stated that she worked at the facility two years ago. LPN AA stated that she did not receive in-service or education on pain management upon her return. LPN AA stated that she was a seasoned nurse and that she has been doing wound care for years. She stated that she knew better and that she should have stopped and got R#39 something for pain. Interview with the Director of Nursing/Regional Nurse Consultant (DON/RNC) on 7/22/23 at 2:53 p.m. revealed her expectations is for the nurses to ask residents about pain prior to providing wound care, and to medicate if needed. She stated that nurses should also check for effectiveness before continuing wound care. Interview with Certified Nursing Assistant (CNA) CC on 7/23/23 at 8:15 a.m. revealed she is familiar with R#39 and his care. CNA CC stated that she usually works night shift. She stated that R#39 is very pleasant. CNA CC stated that when R#39 is in pain he will put his call light on. She stated that she would notify the nurse and the nurse would bring him something for the pain. CNA CC stated that sometimes when R#39 is in pain he will say that he can't take it anymore. She stated that he would ask her to pray with him and pray that he makes it through the ordeal. CNA CC stated that R#39 sometimes complains of pain related to his amputation and pain to his stomach. Review of Nursing Progress Notes dated 7/22/23 at 2:17 p.m. revealed give one tablet every six hours as needed for moderate to severe pain. Resident given PRN pain medication after treatment complete. When asked what his pain was on a scale of 1-10 resident stated it was a 2/10. Will monitor effectiveness. A review of the Nursing Progress Notes /Skin/Wound Notes dated 7/22/23 at 4:54 p.m. revealed during dressing change today at around 1:30 p.m. writer caused a quarter size skin tear to the top of resident's right thigh just above the knee. Wound NP notified. New order to discontinue all current treatment orders to right leg. Cleanse wounds to right below the knee amputation (BKA) with wound cleanser, blot dry, apply xeroform, cover with non-stick dry dressing, wrap with gauze. Avoid applying tape to the skin on the right BKA. Resident is aware of new orders and voices no concerns at this time.

Based on observation, record review and interviews, the facility failed to implement the care plan for one of 15 sampled residents (R) (R#7). Findings included: Review of R#7's medical record revealed diagnoses of but not limited to Alzheimer's disease, allergy, depression, and anxiety. Review of R#7's quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognition: Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment; Section O-Special Treatments: no oxygen indicated. Review of R#7's care plans revealed the following: Resident has altered respiratory status/difficulty breathing related to history of shortness of breath and anxiety. She has a diagnosis of allergies and dry eyes. Interventions included to adjust oxygen as ordered and staff assist keeping tubing off the floor when observed. Observation on 7/21/23 at 1:21 p.m. revealed R#7's O2 tubing was noted touching the ground. O2 tubing noted wrapped around the side rail, no available bag for resident to put tubing in. Observation on 7/22/23 at 9:00 a.m. revealed O2 tubing wrapped around the bed rail and no available bag to store tubing when not in use. Interview on 7/22/23 at 3:51 p.m. with the Director of Nursing (DON) revealed the oxygen tubing's should be stored off the floor. She indicated the tubing is changed and labeled weekly and should be stored in a bag. She also would expect the tubing be put in a bag when not in use or have a bag available for the resident to put it in when not in use so she would not have to wrap it around the side rail. Interview on 7/23/23 at 8:34 a.m. with Licensed Practical Nurse (LPN) LPN AA revealed the resident doesn't use the oxygen during the day. She indicated the oxygen tubing should be put in a bag and not stored on the floor. She indicated the night shift changes the tubing weekly. Interview on 7/23/23 at 8:47 a.m. with the MDS Coordinator revealed if a resident doesn't use her O2 in the seven days look back period she would not code O2 use on the MDS. She reported that the care plan indicated to keep the tubing off the floor and stored in a bag. She further reported the staff should be following the care plan.

Based on observation, record review and interviews, the facility failed to follow-up on recommendations from the Registered Dietician (RD) related to nutritional assessments for one of 15 sampled residents (R) (R#28). Findings included: A review of the clinical record revealed that R#28 was admitted to the facility on [DATE] with diagnosis to include Major Depressive Disorder, Gastro-Esophageal Reflux Disease (GERD), Cognitive Communication Deficit, Adult Failure to Thrive and Vascular Dementia. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that R#28 presented with a Brief Interview for Mental Status (BIMS) score of 13, meaning that the resident has moderately impaired cognition, that he requires supervision and set up only for eating, has no swallowing disorders, was at the height of 65 inches and weighed 150 lbs. (pounds). If further noted that the resident had loss 5% (percent) or more in the last month or loss of 10% or more in last six months. A review of the care plan dated 3/28/23 revealed that R#28 is at risk of altered nutritional status and on 4/7/23, R#28 triggered for 7.5 and 10% weight loss. Interventions included diet as ordered, refer resident to RD, and supplements as ordered. A review of the clinical record revealed the following weights for R#28: On 7/5/23, R#28 weighed 146.0 lbs. On 6/26/23, R#28 weighed 147.2.0 lbs. On 5/16/23, R#28 weighed 143.0 lbs. On 4/28/23, R#28 weighed 144.0 lbs. On 1/30/23, R#28 weighed 166.0 lbs. On 12/1/22, R#28 weighed 166.0 lbs. A review of the Dietary Progress Notes/Assessments dated 5/10/23 revealed that R#28 had a significant weight loss of greater than 10% in the last 180 days. The RD noted that the resident did not enjoy the Mighty Shakes and would refuse them. It was recommended to offer ice-cream with lunch and dinner to support weight maintenance. A review of the Dietary Progress Notes/Assessments dated 7/21/23 revealed that R#28 had a significant weight loss of greater than 10% in the last 180 days. It was documented that the RD recommended to discontinue the Mighty Shakes supplement and offer ice-cream with lunch and dinner to support weight maintenance. A review of the dietary tray card dated 7/23/23 revealed that the resident had no supplements printed on the tray card. On 7/22/23 12:55 p.m. R#28 was observed sitting in his wheelchair outside of his room. His meal tray was in the room on the bedside table. He ate zero percent of the meal and stated that he was not hungry. No supplements were observed on his tray. During an interview with Licensed Practical Nurse (LPN) GG on 7/23/23 at 11:07 a.m. she stated that the resident had an order for a Mighty Shake supplement three times a day at 7:30 a.m., 11:30 a.m., and 5:30 p.m. She stated that the resident would drink the supplement sometimes, but she is an agency nurse, so she doesn't know if he consumes the supplement when given by other facility staff. During an interview with the Unit Manager (UM) on 7/23/23 at 11:15 a.m., she stated that when the Registered Dietician (RD) make recommendations, the RD gives her a form and she follows up with physician, the MDS (Minimum Data Set) Coordinator to care plan the recommendation with dietary manager. She stated that she had not received any recommendations for R#28 in May 2023 or in July 2023. During an interview with the Director of Nursing (DON) on 7/23/23 at 11:25 a.m. she stated that the RD will send her an email with all recommendations, and she follows up with the recommendation by the end of the next day. She stated that she notifies the Nurse Practitioner for approval and puts the order in the doctor's box to be signed. She then updates the order in the Electronic Medical Record, and documents in the clinical record that the responsible party is notified. She stated that she also follows up with dietary department. She stated that she did not receive anything related to dietary supplement recommendations for R#28. After reviewing the medical record and the RD notes, she confirmed that the RD made recommendation in May 2023 and July 2023 and the recommendations should have been followed up on. On 7/23/23 11:38 a.m. an interview was conducted with the Certified Dietary Manager (CDM) FF. She stated that she had been the acting CDM since April 2023 and has been training CDM EE since May 2023. She stated that when the RD comes in and makes recommendations, she will email the recommendations to her. The CDM then emails the recommendation to the DON and the UM. Once she receives the order from nursing, she make sure the recommendation is input into the system, so it prints on the tray card. She confirmed that she had received recommendations for R#28 on 5/11/23 to add ice cream at lunch and dinner via email and forwarded it over to the UM but never received the approved order. On 7/23/23 11:49 a.m. CMD EE confirmed that she had not received the approved order from nursing for the May 2023 or the July 2023 recommendations by the RD. During an interview on 7/23/23 at 12:17 p.m. with the RD, she confirmed that she made recommendations for R#28 in May 2023 and July 2023 to provide R#28 ice cream with meals.

Based on observations, resident and staff interviews, record review and review of the facility policy titled Respiratory System Management Standard the facility failed to ensure one (1) resident (R) R#7 of five (5) residents with an order for oxygen (O2) therapy had an oxygen machine that was clean and sanitized and oxygen tubing was stored in a manner that prevented cross contamination. Finding include: Review of the facility policy titled Respiratory System Management Standard (dated August 2022) revealed: Oxygen Therapy Protocol-Procedures to follow in order: 15. Attach a clean, dated plastic bag to the oxygen source to be used to store the equipment when not in use. Plastic bags are replaced weekly and as needed. Review of R#7's diagnoses revealed but not limited to Alzheimer's disease, allergy, depression, and anxiety. Review of R#7's quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognition: Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment. Observation on 7/21/23 at 1:21 p.m. revealed R#7's O2 tubing noted wrapped around the side rail, no available bag for resident to put tubing in. Resident indicated she uses the O2 at night only and she said she wraps it around the railing. Tubing was noted touching the ground. Oxygen machine noted to have dust and dried grime build up on it. The machine was off. Observation on 7/22/23 at 9:00 a.m. revealed O2 tubing wrapped around the bed rail. Nasal part not on the floor at this time. Machine still noted to be dusty with grime build up. Machine was off and no available bag to put tubing in. During an interview and observation on 7/22/23 at 3:51 p.m. with the Regional Nurse Consultant (RNC) who is the acting Director of Nursing (DON) it was revealed the oxygen machine should be cleaned and the oxygen tubing should be stored off the floor. She indicated the tubing is changed and labeled weekly and should be stored in a bag. It was also reported that the oxygen machines are cleaned weekly at the same time. Observation of R#7's machine with the RNC/DON revealed dark colored drip marks down the front and back of the oxygen machine with dust buildup on the flat surfaces. She indicated this was unacceptable and she would get it cleaned right away. RNC/DON reported that she would expect the tubing to be placed in a bag when not in use or have a bag available for the resident to put it in when not in use so she would not have to wrap it around the side rail. Interview on 7/23/23 at 8:34 a.m. with Licensed Practical Nurse (LPN) LPN AA revealed the resident does not use the oxygen during the day. She indicated the oxygen tubing should be put in a bag and not stored on the floor. She indicated the night shift changes the tubing weekly.

Based on interviews and record review, the facility failed to have evidence to support that there was Registered Nurse (RN) Coverage for eight consecutive hours for eight days (1/7/23, 2/3/23, 2/6/23, 2/7/23, 2/8/23, 2/9/23, 2/10/23, and 2/16/23) of the last quarter. Findings included: A review of the Payroll Based Journal (PBJ) data revealed that the facility failed to have eight hours of registered nursing staffing on 1/7/23 (Saturday); 2/1/23 (Wednesday); 2/3/23 (Friday); 2/6/23 (Monday); 2/7/23 (Tuesday); 2/8/23 (Wednesday); 2/9/23 (Thursday); 2/10/23 (Friday); and 2/16/23 (Thursday). During an interview with the Regional Operations Manager on 7/23/23 at 10:14 a.m. she confirmed that she has been with the corporation since 2014. She stated the Human Resources (HR) Director for the facility does the final schedule. She reviewed it last week; she has only been here two weeks, and this is something that she will be responsible for going forward but she does not report the PBJ data. During an interview on 7/23/23 at 10:18 a.m. with the Unit Manager (UM), she stated that she works with the HR Director to make sure all hours are covered when the schedule is created. She has been working at the facility for two years and she has been in the role of UM since May 2023. She confirmed that she does not report the PBJ data. During an interview with the HR Director on 7/23/23 at 10:20 a.m. she stated that she has been at the facility for one year and seven months. She confirmed that she does not report the PBJ data. During an interview with the Administrator on 7/23/23 at 10:26 a.m. he stated that he does not report PBJ data. He stated that the electronic system coordinates with the time clock and that no one has ever had to report PBJ at the facility. He stated that he believes it coordinates to the time clock but is not sure. He stated that he was not working at the facility when the January 2023 and February 2023 data was reported. He stated that the reporting requirement to PBJ was not a conversation that had when he was hired. He believes he has access to the system, but he does not yet know how to do that. On 7/23/23 at 11:21 a.m. the Administrator stated that the Payroll Manager for the corporation informed him the RNs are salaried employees, so they do not clock in, but they have written time sheets. They are working with the payroll managers to get electronic copies of evidence to confirm RN coverage for the dates in question. The facility presented additional documentation that RNs were employed but they were not able to present documentation that there was an RN in the building on all the dates in question reported to the PBJ. The facility provided a Missing Punch Correction document dated 2/1/23 indicating RN coverage from 12:30 p.m. to 9 p.m. This document had two signatures acknowledging the time.

Based on observations, staff interviews, and review of the facility policies titled, Cleaning & Maintenance and Safe Food Handling & Handling the facility failed to ensure that the kitchen was maintained in a clean and sanitary condition. Specifically, the facility failed to ensure that the oven was clean and free from debris. The facility also failed to remove expired food from the walk-in cooler as well as ensure that all foods were labeled and dated. This had the potential to affect 36 of 37 residents receiving an oral diet. Findings include: Review of facility policy titled, Cleaning and Maintenance dated [DATE] located under item equipment header number ten: Ranges, grills and ovens are cleaned after each use. Heavy cleaning is scheduled to ensure buildup of soil is cleaned. Review of the facility policy titled, Safe Food Handling & Labeling [DATE] revealed under item Label, Date, and Cover: Always label, date, and cover each item with a use by date. All expired food items must be discarded, and the food label followed. Initial kitchen tour observation on [DATE] from 9:00 a.m. until 10:00 a.m. revealed upon entry to the kitchen that the stove had a dark build up at the base of the stove. There were drippings on the stove top and the drippings were running down the side of the stove. Inside of the stove had noticeable large food build up. This observation was confirmed with the Dietary Manager (DM), at this time. Continued observation revealed a plastic bag of open brown gravy mix, in the dry food pantry, that was not labeled or dated with an open by date. This observation was confirmed with the DM. Observation of the walk-in-cooler revealed a covered aluminum pan of ham laying on the shelf unlabeled and undated. A medium size tin pan of cut up fruit unlabeled with no open date. The following were observed with no open dates or labels listed: one gallon of Ranch dressing, five pounds of Greek yogurt, one bottle of Salsa, one gallon of mayonnaise, one gallon of sweet relish, and one container of Tortilla shells. Further observation revealed a Tupperware bowl of Cream of Chicken Soup in a Tupperware bowl that had an expiration date of [DATE]. This observation was confirmed with the DM, at the time of this observation. Interview with the Dietary Manager (DM) on [DATE] at 9:00 a.m. revealed that there was a cleaning schedule that was posted in the kitchen for staff to follow. The stove was to be cleaned daily by the dietary aide and the Dietary Aide should sign off on the cleaning scheduled after completion. Review of the cleaning schedule that was posted on the wall revealed the last time the stove was cleaned was on [DATE]. Interview with the DM on [DATE] at 3:00 p.m. revealed that he was not aware of the policies for food storage and kitchen cleanliness. The DM stated that he realized that he would need to have better procedures in place for cleaning and food labeling and storage. Interview with Dietary Aide FF on [DATE] at 10:00 a.m. revealed the stove was cleaned on [DATE] but access to cleaning materials was not available to clean the stove. A soft cloth with Dawn dish liquid was used instead to clean the stove. Dietary Aide FF confirmed that the stove was not properly cleaned. Interview with the Administrator on [DATE] at 10:15 a.m. revealed the expectation is that the Dietary Manager should ensure that the stove is cleaned per the schedule and that food labeling storage is followed properly.

Based on observation, staff interview, and clinical record review, the facility failed to follow the care plan related to the use of a wedge or pillow to be placed in between the siderails and mattress to prevent entrapment in the siderails, and to evaluate for the use of a winged mattress and to implement a low bed with mats for one Resident (R) #28, who had documentation of putting her legs through or under the siderails on 12/5/15, 4/28/16, and 7/1/16. In addition, the facility failed to follow the care plan related to monitoring for behavior change when medication was being adjusted or changed, and R#28 had a fall from the gerichair in an unsupervised area on 10/24/16 after an antianxiety med had been decreased. Review of the facility's form CMS-672, Resident Census and Conditions of Residents, revealed that the facility's census was 40. Eight residents were reviewed for accidents, and the sample size was 29 residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 11/17/16 at 10:00 a.m., the Administrator and Interim Administrator were notified that Immediate Jeopardy (IJ) existed as of 4/28/16 at 42 C.F.R. 483.25 Quality of Care (F 323 at a Scope and Severity (S/S) of J), and at 42 C.F.R. 483.20 Resident Assessment (F 282 at S/S of J). The IJ was related to failure to reassess for the safe continued use of bed siderails for R #28, who had documentation in the Nurse's Notes on 4/28/16 of leg entrapment in the siderail with resultant skin tears of the right leg, and again on 7/1/16, where she was found with her legs between the siderail and mattress with extensive abrasions to the left leg. An approved Allegation of Compliance was received on 11/18/16. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on 11/18/16, but the facility remained out of compliance at a lower scope and severity of D while the facility continues to educate the staff, monitors the actions taken, the Quality Assurance program evaluates the effectiveness of the actions, and the facility develops a plan of correction. Findings include: Review of R #28's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of a Psychiatric History & Physical dated 4/17/14 noted that the resident had a [MEDICAL CONDITION] after a gunshot wound to the head, with a history of auditory and visual hallucinations and paranoid/persecutory delusional ideations, severe behavior problems, psychomotor agitation, and poor impulse control. Review of Physician's Telephone Orders dated 8/5/14 and the current November 2016 physician's orders [REDACTED]. Review of R #28's care plans revealed a Focus statement that on 4/28/16 the resident positioned her leg between the top bed rails and had a skin tear to the right knee and under the right knee. Review of the interventions of this care plan included for a wedge/pillow to be placed in between upper side rails and mattress to prevent further occurrence. Review of R #28's risk for impaired skin integrity care plan related to incontinence and a history of self-inflected scratches revealed that it was revised on 7/1/16 to note the resident was observed lying crossway and had legs between bed and rail causing an abrasion to the left lower leg. Review of the interventions for this care plan revealed an intervention for a low bed with mats, and to assess for need for a winged mattress. Additional interventions for the risk for impaired skin integrity with a revision date of 5/7/16 included to place a pillow between the resident and siderails to prevent further skin impairment. On 11/9/16 at 8:15 a.m., 11:54 a.m., and 3:00 p.m., 11/10/16 at 9:15 a.m.; 11/15/16 at 11:08 a.m.; and 11/16/16 at 6:59 a.m., 11:15 a.m. and 11:31 a.m., R #28 was observed in a standard hospital-type bed and mattress with one or both top siderails up, but no cushion or wedge was observed in place between the mattress and siderails During interview with the DON on 11/16/16 at 9:19 a.m., she stated that she thought they had discussed use of a winged mattress after the incident on 7/1/16 when R #28 got her legs between the mattress and siderail, but she could provide no documentation of this. During interview with CNA AA on 11/17/16 at 10:36 a.m., she verified that R #28 required cushions between the mattress and siderails, and that the CNA ' s on the night shift did not always do this. During interview with CNA BB on 11/17/16 at 10:47 a.m., she stated that R #28 had periods of agitation with spastic movement of her legs when in bed, and had observed her at times where there was no wedge between the siderail and mattress. Review of the CNA Activities of Daily Living notebook revealed that R#28 ' s information was not updated to reflect the use of siderails, cushions, or other safety devices. Review of R#28's risk for falls care plan dated 5/7/16 revealed that she may have a geri-chair while out of bed to enable her freedom of movement and to maintain current level of socialization while out of bed. Further review of the falls care plan revealed that it was revised on 10/24/16 to note that R#28 was observed on the floor in common area, gerichair turned on its side, and had a skin tear to right elbow. Review of her activities care plan revised 5/7/16 revealed that she spent most of the time in her room or bed related to [MEDICAL CONDITION], and because she became very anxious when out of bed. Review of her alteration in thought process related to impaired short and long term memory and [MEDICAL CONDITION] care plan revised on 5/7/16 revealed an intervention to monitor behavior change occurring when medication was being adjusted or changed. Review of Physician's Telephone Orders dated 10/12/16 noted to discontinue [MEDICATION NAME] 1 milligram (mg) three times daily, and start [MEDICATION NAME] 1 mg twice daily for anxiety. During interview with the Occupational Therapy Assistant (OT-A) GG on 11/15/16 at 10:05 a.m., she stated that R #28 was always kicking her legs and moving her arms when up in the geri-chair. During interview with the DON on 11/15/16 at 11:00 a.m., she stated that R #28 had a recent [MEDICATION NAME] dose reduction, after which the resident showed an increase in her agitation and movement of her extremities. During further interview the DON verified that because of this, R #28 should have been monitored more closely and not left alone in the front lobby. During interview with LPN FF on 11/15/16 at 11:08 a.m., she stated that R #28 had been real fidgety prior to the fall from her gerichair on 10/24/16, and that her agitation had gotten worse after her [MEDICATION NAME] dosage was decreased. Cross-refer to F 323. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The resident that was identified on 11/11/16 (R#28) was removed from the bed with half rails at 6:00 p.m. and placed in her positioning chair for feeding of the evening meal. During that time, a low bed and mats were placed in her room. After eating, R#28 was placed in the low bed with mats on each side of the bed. 2. On 11/16/16, at 6:30 p.m., every fifteen (15) minute checks were implemented to be completed for the first 24 hours, then every 30 minutes for next 24, then, one hour for 24, then every 2 hours. These checks will continue until 11/21/16. The DON and administrator will review resident audit tool daily and administrator will revise the frequency of checks by LPN and RN. The State team came in room and approved safety of bed at 6:30 p.m. 3. On 11/16/16 at 7:00 p.m., the DON completed Enabler Data Collection and Evaluation Tool, Side Rail Screen Tool, Fall Risk Assessment Tool resulting in a score of 16 which placed her at high risk for falls. At this time, Side Rail Tool indicates that no rails would be used and it is safer for her to have low bed with mats. Nursing staff continues checks every 30 minutes throughout the night. The care plan was updated also. 4. On 11/17/16 at 7:30 a.m. the DON and Administrator checked to see that 15 minute checks continued throughout the night on the Frequency Monitoring Tool. 5. On 11/17/16 at 6:00 a.m. the Incident reports from 7/1/16 through 11/17/16 were reviewed by DON and other licensed nurses to assure that, if any interventions were planned, that they were implemented and currently in place. Residents' care plans were updated to reflect current status of the resident. 6. On 11/17/16 at 2:00 p.m. all Residents' care plans were reviewed and MDS nurse implemented a C.N.A. Kardex tool for each resident. This tool will be updated daily for each resident that may have an incident, and routinely on quarterly and annual assessments. On-duty 7-3, 3-11, and 11-7 C.N.A. staff have been in-serviced. C.N.A.'s in-service by the DON was completed on 11/18/16. 7. On 11/18/16 the Restraint policy was reviewed. 8. Upon new admission the Resident will be assessed for potential half rail use as an enabler to assist them to reposition. These reviews will again be performed quarterly by the DON beginning on 11/17/16. 9. On 11/17/16 one hundred percent (100%) of on-duty direct care staff were in-serviced on changes in Resident-specific Kardex. 10. On 11/18/16 one hundred percent (100%) of on-duty direct care staff were in-serviced about the R#28 and the changes made to insure safety including: the change to low bed without side rails; protective pads in place on floor and the frequency of safety rounds. 11. On 11/18/16 a total of 40% of the direct care staff has received this in-service to date. 12. On 11/18/16 the on-coming 3/11 p.m. shift will contain an additional 5 staff who will receive in-service prior to beginning shift. That represents an additional 14% of staff. 13. On 11/18/16 the on-coming 11/7 a.m. shift will contain an additional 3 staff who will receive in-service prior to beginning shift. That represents an additional 9% of staff. 14. On-going the remaining direct care staff will receive an in-service on these topics prior to beginning their next assigned shift. 15. The as needed (PRN) staff and any remaining unscheduled staff members will receive in-service via a call-in meeting to be held by the DON. 16. On 11/21/16 all direct care staff shall have been educated about the Kardex changes and the changes specific to this R#28. That will equate to 100% of active direct care staff. 17. In QAPI monthly meeting, all residents who were assessed for rail-enabler use will be reviewed; and, for three months, administrator will check the monitor audit tools. The results of these checks will be reported to the monthly QAPI committee by the administrator. The State Survey agency validated the implementation of the facility's Credible Allegation of Jeopardy removal (AOC) as follows: 1. Observation by surveyor of R#28 on 11/16/16 at 6:30 p.m. moved to a low bed without side rails, with mats on both sides of the bed. 2. Review of Frequency Monitoring Tool on 11/17/16 by surveyor confirmed every 15 minute safety checks by staff from 11/16/16 at 6:30 p.m. through review time of 3:00 p.m. and review of Side Rails Screen tool for R#28 and Care Plan update confirmed at this time. 3. Review of Care Plans and Kardex for R#23, R#27, R#25 and R#48 revealed no update required. 4. The inservice sign-in sheets reviewed by survey team to confirm that staff had been in-serviced. 5. Interviews, by the surveyors, with the following staff revealed they had attended in-services and were aware of changes in the Plan of Care for R#28 and new Minimum Data Set (MDS) Kardex Report which is located in the Certified Nursing Assistant (CNA) Flow Sheet Book. CNA AA was interviewed on 11/18/2016 at 1:10 p.m. who confirmed being in-serviced on Kardex Report, Side Rails and that R#28 was now in a low bed with frequent safety checks. CNA BB was interviewed on 11/18/2016 at 1:25 p.m. and was knowledgeable of changes to R#28 ' s Plan of Care, had received in-service on new Kardex update and for frequent safety checks for the R#28. Licensed Practical Nurse (LPN) QQ was interviewed on 11/18/2016 at 11:00 a.m. confirmed being in-serviced on the CNA MDS Kardex update, Side Rail evaluation for resident ' s with side rails, and the changes to R#28 ' s Plan of Care such as low bed, mats on the floor and frequent safety checks. Interview with LPN KK on 11/18/2016 at 4:36 p.m. revealed that she had been in-serviced on MDS Kardex change for residents and injury prevention. She was aware of the changes in the Plan of Care for R#28. An interview with LPN LL on 11/16/2016 at 6:22 p.m. revealed that he had been in-serviced on the Safety Precautions for residents, including R#28, and was aware of the changes to the Plan of Care for R#28. An interview on 11/18/2016 at 3:15 p.m. with LPN FF revealed she had attended an in-service regarding Safety Precautions and the MDS Kardex changes in the CNA Flow Sheet Book. She was aware of the changes to R#28's Plan of Care.

Based on observation, staff interview, facility and hospital clinical record review, review of Food and Drug Administration (FDA) guidance on reducing entrapment in hospital beds, and facility Side Rails policy and procedure review, the facility failed to provide an environment that was free from the potential accident hazard of entrapment within the siderail and/or between the siderail and mattress for one Resident (R) #28. In addition, the facility failed to provide supervision to prevent an accident for R #28, who had uncontrolled body movements and was left in an unsupervised location resulting in a fall from a gerichair with abrasions. Additionally, the facility failed to supervise one resident (R #50) after leaving a bottle of enteral formula at his bedside, resulting in him drinking some of the formula leading to aspiration and hospitalization . Review of the facility's form CMS-672, Resident Census and Conditions of Residents, revealed that the facility's census was 40. Eight residents were reviewed for accidents, and the sample size was 29 residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 11/17/16 at 10:00 a.m., the Administrator and Interim Administrator were notified that Immediate Jeopardy (IJ) existed as of 4/28/16 at 42 C.F.R. 483.25 Quality of Care (F 323 at a Scope and Severity (S/S) of J), and at 42 C.F.R. 483.20 Resident Assessment (F 282 at S/S of J). The IJ was related to failure to reassess for the safe continued use of bed siderails for R #28, who had documentation in the Nurse's Notes on 4/28/16 of leg entrapment in the siderail with resultant skin tears of the right leg, and again on 7/1/16, where she was found with her legs between the siderail and mattress with extensive abrasions to the left leg. An approved Allegation of Compliance was received on 11/18/16. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on 11/18/16, but the facility remained out of compliance at a lower scope and severity of D while the facility continues to educate the staff, monitors the actions taken, the Quality Assurance program evaluates the effectiveness of the actions, and the facility develops a plan of correction. Findings include: Review of the facility's Side Rails policy and procedure dated February 2016 revealed that prior to implementation, side rail utilization is evaluated by the interdisciplinary team to determine the reason for side rail use and any alternative devices that may be used to achieve the same goal. Review to include the risk for entrapment. Review alternatives to side rail use that will meet the identified need, including a concave mattress, placing the bed lower to the floor and surrounding the bed with a soft mat. Observe resident for the following risk factors of side rail use, including increased difficult behaviors such as agitation. Review effectiveness of interventions and progress towards goals during Care Management meeting. Modify goals and interventions as indicated. Review of R #28's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of a Psychiatric History & Physical dated 4/17/14 noted that the resident had a brain injury after a gunshot wound to the head, with a history of auditory and visual hallucinations and paranoid/persecutory delusional ideations, severe behavior problems, psychomotor agitation, and poor impulse control. Review of her Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had severe cognitive impairment, and that she needed extensive assistance by one staff member for bed mobility. Review of R #28's care plans revealed a Focus statement that on 4/28/16 the resident positioned her leg between the top bed rails and had a skin tear to the right knee and under the right knee. Review of the interventions of this care plan included to re-orient the resident on proper ways of laying in the bed and to refrain from placing extremities between bed rails as/if warrants; staff to check on resident every hour for repositioning if/as warrants; and wedge/pillow to be placed in between upper side rails and mattress to prevent further occurrence. Further review of her care plans included an alteration in thought process related to impaired short term memory and long term memory from a traumatic brain injury. Review of R #28's risk for impaired skin integrity care plan related to incontinence and a history of self-inflected scratches revealed that it was revised on 7/1/16 to note the resident was observed lying crossway and had legs between bed and rail causing an abrasion to the left lower leg. Further review of the interventions for this care plan updated on 7/1/16 revealed an intervention for a low bed with mats, and to assess for need for a winged mattress. Additional interventions for the risk for impaired skin integrity with a revision date of 5/7/16 included to place a pillow between the resident and siderails to prevent further skin impairment, and to monitor chair and bed positioning. Review of R#28's risk for falls related to a history of falls, psychotropic drug usage and poor safety awareness care plan noted an intervention that may use siderails while in bed to enable the resident to assist with turning and repositioning and to enable resident freedom of movement while in bed. Further review of the care plans revealed a problem statement dated 8/10/16 that the resident had swelling above and below the left knee and would not stretch the leg out. The resident complained of pain to the left leg and did not have full Range of Motion (ROM). Review of an associated intervention revealed to monitor for one hour for repositioning. Review of Physician's Telephone Orders dated 8/5/14 and the current November physician's orders [REDACTED]. Review of siderail assessments dated 1/26/16, 4/22/16, and 10/18/16 revealed that R#28 had alterations in safety awareness due to cognitive decline, and that side rails were indicated and served as an enabler to promote independence in position and bed mobility. Further review of these assessments revealed that they did not assess for the risk for the resident to climb over the rails, nor the potential or history of becoming entrapped within or under a rail. During interview with Licensed Practical Nurse (LPN) OO on 11/8/16 at 9:29 a.m., she stated that R #28 had half siderails, was physically capable of getting out of bed on her own, and that the siderails did not prevent her from voluntarily getting out of bed. Observation and measurements taken of the two siderails on both sides at the top of R #28's bed on 11/16/16 at 11:15 a.m. revealed that there were three openings in each rail, the largest opening measuring seven and one-quarter inches by six and one-half inches, and the smallest opening was seven and one-half inches by five and three-quarter inches. Further observation revealed that the majority of the perimeter of the siderails were padded on the outside and inside, but the inner bar containing the bed controls was not padded. Review of Nurse's Notes revealed the following entries: 12/3/15 12:40 p.m. 2 inch X 4 inch red bruising noted on right fibula. Resident stated she hit it on the bed earlier. 12/5/15 8:00 p.m. Resident very agitated sticking legs through bed rails throwing pillow off bed yelling out. Checked left leg no lacerations noted, full range of motion (ROM) no pain. Put body in center bed, repositioned 4 times. 12/9/15 1:15 p.m. Resident lying in bed hollering out, went to bedside, blood noted on bottom right side rail, resident stated she had a scratch on her knee. Pulled covers back abrasion noted to right knee. 12/11/15 1:30 p.m. Resident scraped her toes on foot board of her bed. Resident was slid down to bottom of bed where her feet was touching foot board. Small abrasion noted to left foot 3rd and 4th digits. 12/13/15 7:50 p.m. Resident has been kicking rails earlier this shift. 3/26/16 4:00 a.m. Resident continues to rub legs and feet on mattress hanging legs off right side of bed. Turns self sideways cross bed. 4/28/16 8:30 p.m. Resident was found by Certified Nursing Assistant (CNA) with her leg between top siderail. After removing this nurse noted two skin tears to right knee and one just below right knee. 5/13/16 2:30 p.m. New order to apply duoderm pad to wound on fibula surface of right leg. A Patient at Risk (PAR) Nurse's Note dated 5/13/16 noted Interventions Initiated: Protective cushioning or padding to side rails. 7/1/16 8:00 p.m. Resident was observed lying crossways the bed with her legs between the rail and the bed, causing an abrasion on left lower leg, left knee, and small abrasions on right leg. 8/10/16 8:45 a.m. Called to resident by Licensed Practical Nurse (LPN) and CNA to assess resident left leg. Upon observation writer noted swelling above and below left knee no redness noted at this time. Resident is unable/unwilling to move left leg and there is pain upon passive range of motion. Transported to hospital. Review of a Physician's Telephone Order dated 8/10/16 at 8:45 a.m. revealed an order to transfer to the hospital to be evaluated and treated as needed for swelling and inability to move the left leg/knee. Review of an ED (Emergency Department) Physician Documentation dated 8/10/16 revealed that R #28 had complaints of left knee pain and swelling, cause unknown, denies fall. Further review of the ED report noted that there was swelling of the left knee, and it was tender over the patella, and the resident was unable to raise or lower the leg nor bear weight and had an abrasion to the left knee. Review of a left knee x-ray done at this time revealed that there was no acute fracture or dislocation, with a discharge clinical impression of swelling of the left knee joint. During interview with the Director of Nursing (DON) on 11/15/16 at 10:39 a.m., she stated that siderail assessments were done quarterly, and that a resident should be reassessed for continued siderail use if there was an incident involving a siderail. During further interview she verified the documentation in the Nurse's Notes on 7/1/16 that noted R #28 had her legs between the siderail and bed, and received abrasions to her leg. The DON further stated that siderail assessments had been done on 4/22/16 and 10/18/16, but could find no evidence that an assessment for continued siderail use was done around 7/1/16, after the leg entrapment with injury. During continued interview, the DON stated that the padding was added to the siderails after the incident on 7/1/16, but verified this would not prevent R#28 from getting entrapped in the rail, only to help prevent an abrasion. The DON further stated that R#28 had spastic movements and constantly moved about in bed, causing leg injuries. During interview with LPN FF on 11/15/16 at 11:08 a.m., she stated that on 7/1/16 she observed R#28 with her body crossway across the mattress with her head toward the hallway door, and that both of the resident's legs but mostly the left leg were caught between the bottom of the top siderail closest to the window, and the mattress. LPN FF further stated that the resident was moving her legs back and forth in an attempt to free them from under the siderail, and that it scraped her left leg from the knee down to mid-shin. Observation of R#28's left leg at this time revealed what appeared to be an old, shiny whitish scar tissue from the knee down the shin. During further interview with LPN FF at this time, she stated that the siderails were not padded prior to the incident on 7/1/16. Further observations of R#28 at this time revealed that there was two padded siderails up at the top of the bed, and no pillow, wedge, or other cushioning device was seen between the resident and the siderails. During additional observations of R#28 on 11/9/16 at 8:15 a.m., 11:54 a.m., and 3:00 p.m., 11/10/16 at 9:15 a.m.; 11/15/16 at 11:02 a.m.; and 11/16/16 at 6:59 a.m., 11:15 a.m. and 11:31 a.m., she was noted in the bed with one or both top siderails up, but no cushion or wedge was observed in place between the mattress and siderails. Review of an investigation Witness Statement related to the siderail incident for R#28 on 7/1/16 at 8:00 p.m. noted: Resident was found lying sideways in bed with legs under the upper siderail. Left leg noted to have extensive abrasions. Small abrasions on right leg. First aid and range of motion (ROM) done. ROM intact. Review of R #28's Event Investigation Interview Record dated 7/1/16 at 8:00 p.m. noted that R #28 was observed lying crossways in the bed with legs between bed and siderail, resulting in an abrasion on bilateral lower extremities, left leg needing treatment. Review of the Incident/Accident Report dated 7/1/16 at 8:00 p.m. noted abrasion to bilateral lower extremities (BLE). One bedrail up. Resident observed lying crossways in the bed with legs between bed and rail, causing an abrasion on BLE. The section for what should be done about why this happened to prevent a possible reoccurrence? noted low bed for resident with mats, assess need for low winged bed with mats, med review, treatment order to left lower leg to prevent infection, Occupational Therapy screen. Review of a diagram showing the location of injury on this report noted the anterior left leg was marked as having an abrasion from the knee all the way down to the ankle, and less extensive injury to the right lower leg. Review of a Physician's Telephone Order dated 7/1/16 at 9:00 p.m. noted to cleanse abrasion to left lower leg with wound cleanser, apply triple antibiotic ointment, cover with Telfa and wrap with kling daily until healed. During interview with Certified Nursing Assistant (CNA) DD on 11/16/16 at 8:06 a.m., she stated that R#28 could position herself crossway in the bed with her legs against the siderail, and that the resident was always moving her arms and legs. During further interview with CNA DD on 11/16/16 at 8:15 a.m., she stated that she had observed R#28 ' s legs within the siderails before, and had to get a nurse to assist her to help free the resident ' s legs. The CNA further stated that she could not remember the dates, but that she had seen this happen twice before. During interview with CNA BB on 11/16/16 at 8:26 a.m., she stated that R#28 was able to turn several positions in the bed, including crossway. During interview with the DON on 11/16/16 at 8:29 a.m., she stated that she had never known a resident to become entrapped in a siderail. She further stated that she didn't know why R#28 was sent to theER on [DATE] with a leg injury. During interview with the interim Administrator on 11/16/16 at 8:40 a.m., he stated that he started working at the facility on 9/26/16 and had not heard anything from any of the existing staff regarding any resident becoming entrapped in a siderail. During further interview, he stated that any gaps between the mattress and siderail should be filled. During interview with CNA PP on 11/16/16 at 9:07 a.m., she stated that R#28 moved around in the bed a lot and had spasms, so they monitored her more often, but there was no set schedule to do so. She further stated that in the last couple of months she had actually seen the resident sideways in the bed with her head on the side closest to the window, and her right leg was through the siderail. During further interview CNA PP stated that R#28 scraped her leg on the siderail at that time because she was having spasms, that she reported it to the nurse, and that there were four siderails up at that time with her leg through a lower rail. During interview with the DON on 11/16/16 at 9:19 a.m., she stated that the staff should only be using one siderail when the resident was in the bed for bed mobility and positioning. During further interview the DON stated she thought they had discussed use of a winged mattress after the incident on 7/1/16, but she could provide no documentation of this discussion about alternatives to siderail use. The DON stated that interventions that had been implemented included padding to the siderails; they dressed the resident in long pants and shirts with long sleeves; applied protective sleeves for her legs and arms; and assessed the meds she was on. During interview with the DON on 11/16/16 at 10:28 a.m., she stated that she did not have any documentation of an investigation done for the injury to R #28's right knee on 8/10/16 when she had to be sent to the ER, but figured that she probably banged it on a siderail. During interview with the DON on 11/16/16 at 12:02 p.m., she verified that there was no documentation as to why the resident needed treatment to the right fibula on 5/13/16, but verified the PAR note on the same date that contained an intervention for protective cushioning or padding to the siderails. During interview with LPN QQ on 11/16/16 at 12:26 p.m., she stated that R #28 moved around a lot, and would bump herself on the gerichair and siderails. During further interview, she stated that the resident had four siderails at one time, but couldn't remember when the bottom two rails were removed. During interview with CNA RR on 11/16/16 at 3:51 p.m., she stated that she sometimes found R#28 sideways in the bed, and had to straighten her up. During observation on 11/16/16 at 6:20 p.m., R#28 was observed to have been placed in a low bed without siderails, and had fall mats on each side of the bed. During interview with CNA AA on 11/17/16 at 10:36 a.m., she verified that R#28 required cushions between the mattress and siderails, and that the CNA ' s on the night shift did not always do this. During interview with CNA BB on 11/17/16 at 10:47 a.m., she stated that R#28 had periods of agitation with spastic movement of her legs when in bed, and had observed her at times where there was no wedge between the siderail and mattress. Review of the CNA Activities of Daily Living notebook revealed that R #28 ' s information was not updated to reflect the use of siderails, cushions, or other safety devices. Review of the document Guidance for Industry and FDA Staff: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued by the FDA division of the U.S. Department of Health and Human Services on 03/10/06, revealed the following: The term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. To reduce the risk of head entrapment, openings in the bed system should not allow the widest part of a small head (head breadth measured across the face from ear to ear) to be trapped. Country-specific anthropometric data show that a 1st percentile female head breadth may be as small as 95 millimeters (mm) (3 ¾ inches). A dimension of 120 mm (4 ¾ inches) encompasses the 5th percentile female head breadth in all data sources used to develop these recommendations, and includes 1st percentile female head breadth as reported in some data sources. FDA is therefore using a head breadth dimension of 120 mm (4 ¾ inches) as the basis for its dimensional limit recommendations. 2. Review of R #28's Fall Risk assessment dated [DATE] revealed a score of 14, indicating that she was at high risk for falls. Review of R#28's risk for falls care plan dated 5/7/16 revealed that she may have a geri-chair while out of bed to enable her freedom of movement and to maintain current level of socialization while out of bed. Further review of the falls care plan revealed that it was revised on 10/24/16 to note that R #28 was observed on the floor in common area, gerichair turned on its side, and had a skin tear to right elbow. Review of her activities care plan revised 5/7/16 revealed that she spent most of the time in her room or bed related to traumatic brain injury, and because she became very anxious when out of bed. Review of her alteration in thought process related to impaired short and long term memory and traumatic brain injury revised on 5/7/16 revealed an intervention to monitor behavior change occurring when medication was being adjusted or changed. Review of Physician's Telephone Orders dated 10/12/16 noted to discontinue Ativan 1 milligram (mg) three times daily, and start Ativan 1 mg twice daily for anxiety. Review of a Fax Cover Sheet to the resident's attending physician dated 11/3/16 noted that R#28's spastic movement of her arms and legs had greatly increased since her Ativan was decreased to twice a day resulting in more skin tears and injuries; may we increase it back to Ativan 1 mg three times daily. Review of Physician's Telephone Orders dated 11/8/16 revealed an order to increase the Ativan to 1 mg three times a day for increased spastic movements of the upper and lower extremities. Review of Nurse's Notes dated 11/8/16 at 2:45 p.m. revealed a new order was received to increase Ativan dosage to three times daily due to increased spastic movements by resident since med reduced on 10/12/16, causing more skin tears and injuries. Review of R#28's Event Investigation Interview Record dated 10/24/16 at 11:30 p.m. noted that staff responded to Help, went into common area (day room) and observed the resident lying on the floor, gerichair turned over beside the resident. An abrasion to the right elbow was noted. Review of the Written Statement Detailed Account of Events attached to the Interview Record noted that the resident was found on the floor in the Day Room between her wheelchair and the sofa. During interview with the Occupational Therapy Assistant (OT-A) GG on 11/15/16 at 10:05 a.m., she stated that she was aware that R#28 had a fall recently from the gerichair, but did not realize that she had actually tipped the chair over. OT-A GG further stated that gerichairs were very heavy, and it would be very hard for the resident to be able to turn it over. She added during additional interview that she had observed R#28 in the gerichair before, and that the resident was always kicking her legs and moving her arms. During interview with the DON on 11/15/16 at 10:39 a.m., she stated that R#28 was not a frequent faller, but that she had a lot of muscle spasms. She further stated that if a resident was left in the front lobby, she would expect staff to monitor the resident's safety every 30 to 60 minutes. The DON stated during further interview, at this time, that the resident had agitated-type movements of her extremities, and that she was usually kept where the staff could monitor her. She further stated that residents that needed to be closely monitored were usually put in the dining room, as it was continuously staffed, and did not know why this was not done. During interview with the DON on 11/15/16 at 11:00 a.m., she stated that R#28 had a recent Ativan dose reduction, after which the resident showed an increase in her agitation and movement of her extremities. During further interview the DON verified that because of this, R#28 should have been monitored more closely and not left alone in the front lobby. During interview with LPN FF on 11/15/16 at 11:08 a.m., she stated that R#28 had been real fidgety prior to the fall from her gerichair on 10/24/16, and that her agitation had gotten worse after her Ativan dosage was decreased. LPN FF further stated that they usually put R #28 in the activity/dining room when out of bed for closer observation as there was staff in that room at all times. She further stated that although staff walked through the front lobby at times, it was not continuously monitored, and she did not know why R #28 was left unattended in the front lobby on the day of the fall. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The resident that was identified on 11/11/16 (R#28) was removed from the bed with half rails at 6:00 p.m. and placed in her positioning chair for feeding of the evening meal. During that time, a low bed and mats were placed in her room. After eating, R#28 was placed in the low bed with mats on each side of the bed. 2. On 11/16/16, at 6:30 p.m., every fifteen (15) minute checks were implemented to be completed for the first 24 hours, then every 30 minutes for next 24, then, one hour for 24, then every 2 hours. These checks will continue until 11/21/16. The DON and administrator will review resident audit tool daily and administrator will revise the frequency of checks by LPN and RN. The State team came in room and approved safety of bed at 6:30 p.m. 3. On 11/16/16 at 7:00 p.m., the DON completed Enabler Data Collection and Evaluation Tool, Side Rail Screen Tool, Fall Risk Assessment Tool resulting in a score of 16 which placed her at high risk for falls. At this time, Side Rail Tool indicates that no rails would be used and it is safer for her to have low bed with mats. Nursing staff continues checks every 30 minutes throughout the night. The care plan was updated also. 4. On 11/17/16 at 7:30 a.m. the DON and Administrator checked to see that 15 minute checks continued throughout the night on the Frequency Monitoring Tool. 5. On 11/17/16 at 6:00 a.m. the Incident reports from 7/1/16 through 11/17/16 were reviewed by DON and other licensed nurses to assure that, if any interventions were planned, that they were implemented and currently in place. Residents' care plans were updated to reflect current status of the resident. 6. On 11/17/16 at 2:00 p.m. all Residents' care plans were reviewed and MDS nurse implemented a C.N.A. Kardex tool for each resident. This tool will be updated daily for each resident that may have an incident, and routinely on quarterly and annual assessments. On-duty 7-3, 3-11, and 11-7 C.N.A. staff have been in-serviced. C.N.A.'s in-service by the DON was completed on 11/18/16. 7. On 11/18/16 the Restraint policy was reviewed. 8. Upon new admission the Resident will be assessed for potential half rail use as an enabler to assist them to reposition. These reviews will again be performed quarterly by the DON beginning on 11-17-16. 9. On 11/17/16 one hundred percent (100%) of on-duty direct care staff were in-serviced on changes in Resident-specific Kardex. 10. On 11/18/16 one hundred percent (100%) of on-duty direct care staff were in-serviced about the R#28 and the changes made to insure safety including: the change to low bed without side rails; protective pads in place on floor and the frequency of safety rounds. 11. On 11/18/16 a total of 40% of the direct care staff has received this in-service to date. 12. On 11/18/16 the on-coming 3/11 p.m. shift will contain an additional 5 staff who will receive in-service prior to beginning shift. That represents an additional 14% of staff. 13. On 11/18/16 the on-coming 11/7 a.m. shift will contain an additional 3 staff who will receive in-service prior to beginning shift. That represents an additional 9% of staff. 14. On-going the remaining direct care staff will receive an in-service on these topics prior to beginning their next assigned shift. 15. The as needed (PRN) staff and any remaining unscheduled staff members will receive in-service via a call-in meeting to be held by the DON. 16. On 11/21/16 all direct care staff shall have been educated about the Kardex changes and the changes specific to this R#28. That will equate to 100% of active direct care staff. 17. In QAPI monthly meeting, all residents who were assessed for rail-enabler use will be reviewed; and, for three months, administrator will check the monitor audit tools. The results of these checks will be reported to the monthly QAPI committee by the administrator. The State Survey agency validated the implementation of the facility's Credible Allegation of Jeopardy removal (AOC) as follows: 1. Observation by surveyor of R#28 on 11/16/16 at 6:30 p.m. moved to a low bed without side rails and mats on both sides of the bed. 2. Review of Frequency Monitoring Tool on 11/17/16 at 8:30 a.m., by the surveyor, confirmed every 15 minute safety checks by staff from 11/16/16 at 6:30 p.m. through review time of 3:00 p.m. and review of Side Rails Screen tool for R#28 and Care Plan update confirmed at this time. 3. Review, by the survey team, of the Enabler Data Collection and Evaluation Tool, Side Rail Screen Tool, Fall Risk Assessment Tool for R#28 confirmed the assesssment were completed indicating the resident was at high risk for falls. The interventions were confirmed on 11/16/16 at 6:30 p.m. 4. Review of Frequency Monitoring Tool on 11/17/16 at 8:30 a.m. confirmed that safety checks had been completed through out the night and reviewed by the DON and Administrator. 5. Confirmation by the survey team that all resident's had been assessed through use of the Incident Reports from July 1, 2016 through November 17, 2016. 6. Review of Care Plans and Kardex for R#23, R#27, R#25 and R#48 revealed that no update required. 7. Confirmation with the Administrator and review of the Restraint Policy revealed that a review was completed and supplied to the survey team. No change was noted but will implement current Restraint and Falls policy. 8. The survey team was unable to confirm that new admission were assessed at this time but continues. 9. Inservice sign-in sheets reviewed by survey team to confirm that staff had attended in-services with 100% of on-dutystaff being inserviced by 11/17/16 related to Resident Specific Kardex. 10. Review of the sign in sheets and interviews with staff revealed that as of 11/18/16, only the 11:00 p.m. until 7:00 a.m. staff were remaining to be inserviced. Interviews by the survey team revealed the following staff had attended the inservices and were aware of the changes implemented related to R#28, as well as, changes to the care plans and resident specific Kardex. CNA AA was interviewed on 11/18/2016 at 1:10 p.m. who confirmed being in-serviced on Kardex Report, Side Rails and that R#28 was now in a low bed with frequent safety checks. CNA BB was interviewed on 11/18/2016 at 1:25 p.m. and was knowledgeable of changes to R28 ' s Plan of Care, had received in-service on new Kardex update and for frequent safety checks for the R#28. Licensed Practical Nurse (LPN) QQ was interviewed on 11/18/2016 at 11:00 a.m. confirmed being in-serviced on the CNA MDS Kardex update, Side Rail evaluation for resident ' s with side rails, and the changes to R#28 ' s Plan of Care such as low bed, mats on the floor and frequent safety checks. Interview with LPN KK on 11/18/2016 at 4:36 p.m. revealed that she had been in-serviced on MDS Kardex change for residents and injury prevention. She was aware of the changes in the Plan of Care for R#28. An interview with LPN LL on 11/16/2016 at 6:22 p.m. revealed that he had been in-serviced on the Safety Precautions for residents, including R#28, and was aware of the changes to the Plan of Care for R#28. An interview on 11/18/2016 at 3:15 p.m. with LPN FF revealed she had attended an in-service regarding Safety Precautions and the MDS Kardex changes in the CNA Flow Sheet Book. She was aware of the changes to R#28 ' s Plan of Care. 17. An interview with the Administrator on 11/18/16 at 3:00 p.m. revealed all residents assessed for use of rail-enablers will be reviewed for three months and th