Every finding on record at Hazel Hawkins Memorial Hospital D/P SNF

Based on observation, interview, and record review, the facility failed to develop and implement individualized, resident-centered care plans for 24 of 36 residents (Residents 84, 22, 28, 97, 98, 9, 60, 2, 5, 10, 50, 54, 58, 83, 91, 80, 34, 33, 41, 75, 64, 20, 66, and 6) who used bed rails or side rails (adjustable rigid bars attached to the side of a bed).These failures had the potential of unmet care needs for Residents 84, 22, 28, 97, 98, 9, 60, 2, 5, 10, 50, 54, 58, 83, 91, 80, 34, 33, 41, 75, 64, 20, 66, and 6's use of bed rails. Findings: 1. During an observation on 9/15/2025 at 10:42 a.m., inside Resident 84's room, Resident 84 was on bed with two bed rails installed and in an upright position. During a concurrent observation and interview with registered nurse A (RN A) on 9/17/2025 at 1:20 p.m., inside Resident 84's room, Resident 84's bed had two upper bed rails in an upright position. RN A confirmed the above observation and stated Resident 84 used the upper bed rails to assist her with mobility and transfers. The RN A further stated the use of bed rails should be care planned. During a concurrent interview with the director of staff development (DSD) and record review on 9/17/2025 at 3:40 p.m., the DSD reviewed Resident 84's list of care plans and confirmed there was no specific care plan developed for the use of bed rails. 2. During an observation on 9/15/2025 at 10:49 a.m., inside Resident 22's room, Resident 22 was not in the room. There were four bed rails installed on her bed, and the two upper bed rails were in an upright position. During a concurrent observation and interview with the RN A on 9/17/2025 at 1:21 p.m., inside Resident 22's room, Resident 22's bed had two upper bed rails in an upright position. RN A confirmed the above observation and stated Resident 22 used the upper bed rails to assist her with mobility and transfers. During a concurrent interview with the DSD and record review on 9/17/2025 at 3:48 p.m., the DSD reviewed Resident 22's list of care plans and confirmed there was no specific care plan developed for the use of bed rails. 3. During an observation on 9/15/2025 at 10:50 a.m., inside Resident 28's room, Resident 28 was seated on his wheelchair. There were four bed rails installed on his bed, and the upper two bed rails were in an upright position. During a concurrent observation and interview with the RN A on 9/17/2025 at 1:24 p.m., inside Resident 28's room, Resident 28's bed had two upper bed rails in an upright position. RN A confirmed the above observation and stated Resident 28 used the upper bed rails to assist him with mobility and transfers. During a concurrent interview with the DSD and record review on 9/17/2025 at 3:51 p.m., the DSD reviewed Resident 28's list of care plans and confirmed there was no specific care plan developed for the use of bed rails. 4. During an observation on 9/15/2025 at 10:58 a.m., inside Resident 97's room, Resident 97 was on the bed, there were four bed rails installed on her bed, and the upper two bed rails were in an upright position. During a concurrent observation and interview with the RN A on 9/17/2025 at 1:25 p.m., inside Resident 97's room, Resident 97's bed had two upper bed rails in an upright position. RN A confirmed the above observation and stated Resident 97 used the upper bed rails. During a concurrent interview with the DSD and record review on 9/17/2025 at 3:54 p.m., the DSD reviewed Resident 97's list of care plans and confirmed there was no specific care plan developed for the use of bed rails. 5. During an observation on 9/15/2025 at 11:02 a.m., inside Resident 98's room, Resident 98 was on the bed, there were four bed rails installed on her bed, and the upper two bed rails were in an upright position. During a concurrent observation and interview with the RN A on 9/17/2025 at 1:26 p.m., inside Resident 98's room, Resident 98's bed had two upper bed rails in an upright position. RN A confirmed the above observation and stated Resident 98 used the upper bed rails. During a concurrent interview with the DSD and record review on 9/17/2025 at 3:59 p.m., the DSD reviewed Resident 98's list of care plans and confirmed there was no specific care plan developed for the use of bed rails. 6. During an observation on 9/15/2025 at 11:04 a.m., inside Resident 9's room, Resident 9 was not in the room, there were four bed rails installed on his bed, and the upper two bed rails were in an upright position. During a concurrent observation and interview with the RN A on 9/17/2025 at 1:27 p.m., inside Resident 9's room, Resident 9's bed had two upper bed rails in an upright position. RN A confirmed the above observation and stated Resident 9 used the upper bed rails During a concurrent interview with the DSD and record review on 9/17/2025 at 4:04 p.m., the DSD reviewed Resident 9's list of care plans and confirmed there was no specific care plan developed for the use of bed rails. 7. During a concurrent observation and interview with the RN A on 9/17/2025 at 1:34 p.m., inside Resident 60's room, Resident 60's bed had two upper bed rails in an upright position. RN A confirmed the above observation and stated Resident 60 used the upper bed rail for transfers and bed mobility. During a concurrent interview with the DSD and record review on 9/17/2025 at 4:08 p.m., the DSD reviewed Resident 60's list of care plans and confirmed there was no specific care plan developed for the use of bed rails. During a review of the facility's policy and procedure titled, Plan – Resident Care, date reviewed 10/2010, indicated, A resident Care Plan will be initiated upon admission and completed within 14 days of admission. 8. During an observation on 9/15/25 at 12:52 p.m., in Resident 91's room, Resident 91 was not in the room. Resident 91's bed had two upper side rails installed. During a concurrent interview and record review with the DSD on 9/18/25 at 1:40 p.m., the DSD reviewed Resident 91's list of care plans and confirmed that there were no specific care plans that had been developed for the use of bed rails. 9. During an observation on 9/15/25 at 12:55 p.m., in Resident 58's room, Resident 58 was not in her room. Resident 58's bed had two upper side rails installed. During a concurrent interview and record review with the DSD on 9/18/25 at 1:43 p.m., the DSD reviewed Resident 58's list of care plans and confirmed that there were no specific care plans that had been developed for the use of bed rails 10. During an observation on 9/15/25 at 12:56 p.m., in Resident 83's room, Resident 83 was seated in the room. Resident 83's bed had two upper side rails installed During a concurrent interview and record review with the DSD on 9/18/25 at 1:37 p.m., the DSD reviewed Resident 83's list of care plans and confirmed that there were no specific care plans that had been developed for the use of bed rails. 11. During an observation on 9/15/25 at 12:57 p.m., in Resident 2's room, Resident 2 was sitting upright in bed, eating lunch and the bed had two upper side rails installed. During a concurrent interview and record review with the DSD on 9/18/25 at 1:28 p.m., the DSD reviewed Resident 2's list of care plan and confirmed that a specific care plan for bed rail use has not been developed. The DSD further confirmed that there were no focused care plans concerning bed rails. 12. During an observation on 9/15/25 at 12:58 p.m., in Resident 54's room, Resident 54 was in a wheelchair eating lunch and watching TV. Resident 54's bed had upper side rails installed. During a concurrent interview and record review with the director of staff development (DSD) on 9/18/25 at 1:46 p.m., the DSD reviewed Resident 54's list of care plans and confirmed that there were no specific care plans that had been developed for the use of bed rails for Resident 54. 13. During an observation on 9/15/25 at 12:59 p.m., in Resident 50's room, Resident 50 was in her wheelchair and maneuvered herself back to her bed. Resident 50's bed had two upper side rails installed. During a concurrent interview and record review with the DSD on 9/18/25 at 1:50 p.m., the DSD reviewed Resident 50's list of care plans and confirmed that there were no specific care plans that had been developed for the use of bed rails for Resident 50. 14. During an observation on 9/15/25 at 1:07 p.m., in Resident 5's room, Resident 5 was seated in a wheelchair while watching television (TV). Resident 5's bed had two upper side rails installed. During a concurrent interview and record review with the DSD on 9/18/25 at 1:29 p.m., the DSD reviewed Resident 5's list of care plans and confirmed there were no specific care plans that had been developed for the use of bed rails for Resident 5. 15. During an observation on 9/15/25 at 1:13 p.m., in Resident 10's room, Resident 10 was seated in the wheelchair while watching TV. Resident 10's bed had two upper side rails installed. During a concurrent interview and record review with the DSD on 9/18/25 at 1:31 p.m., the DSD reviewed Resident 10's list of care plans and confirmed that there were no specific care plans that had been developed for the use of bed rails for Resident 10. During a review of the facility's policy and procedure titled, Plan – Resident Care, date reviewed 10/2010, indicated, .A resident Care Plan will be initiated upon admission and completed within 14 days of admission; The written care plan will be reviewed and revised at the Resident Care Conference by the Interdisciplinary team within 14 days of admission; Resident Care Plans will be reviewed and revised as needed at least every 3 months at Resident Care Conference. 16. During an observation on 9/16/2025 at 9:20 a.m. in Resident 34's room, Resident 34's bed had bilateral side rails. Review of Resident 34's clinical record indicated she was admitted to the facility with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and atrial fibrillation (AFib, an irregular heart rhythm). Review of Resident 34's Acknowledgment of Assistive/Enabling Device use, dated 2/1/24 indicated it was medically necessary for upper half side rails for Resident 34. Review of Resident 34's care plans indicated there was no care plan regarding the use of mobility bars. 17. During an observation on 9/16/2025 at 9:41 a.m. in Resident 80's room, Resident 80's bed had bilateral side rails. Review of Resident 80's clinical record indicated she was admitted to the facility with diagnoses including hypotension (low blood pressure) and ataxia (poor muscle control that affects balance and coordination). Review of Resident 80's physician orders indicated she had an order, dated 7/31/25 for upper mobility bars up when in bed for bed mobility. Review of Resident 80's Side Rail Assessment Form, dated 7/30/25 indicated bilateral upper half rails were recommended. Review of Resident 80's care plans indicated there was no care plan regarding the use of mobility bars. During an interview on 9/19/2025 at 10:39 a.m., Licensed Vocational Nurse B (LVN B) confirmed Residents 34 and 80 did not have a separate care plan for mobility bars and should have had one. 18. During the observation of Resident 33 on 9/15/25 at 12:40 p.m., Resident 33 was sitting in her wheelchair. She was alert, calm, comfortable and verbally responsive. Resident 33 had her bilateral upper half side rails up. Review of Resident 33's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, she was admitted to the facility on [DATE]. Review of Resident 33's care plans indicated, Resident 33 did not have an individualized, resident-centered care plan for the side rails. 19. During the observation of Resident 41 on 9/15/25 at 12:42 p.m., Resident 41 was eating her lunch. She was alert, calm, comfortable and verbally responsive. Resident 41 had her bilateral upper half side rails up. Review of Resident 41's admission record indicated, she was admitted to the facility on [DATE]. Review of Resident 41's care plans indicated, Resident 41 did not have an individualized, resident-centered care plan for the side rails. 20. During the observation of Resident 75 on 9/15/25 at 12:52 p.m., Resident 75 was sitting in her wheelchair. She was alert, comfortable and verbally responsive. Resident 75 had her bilateral upper half side rails up. Review of Resident 75's admission record indicated, she was admitted to the facility on [DATE]. Review of Resident 75's care plans indicated, Resident 75 did not have an individualized, resident-centered care plan for the side rails. 21. During the observation of Resident 64 on 9/15/25 at 12:54 p.m., Resident 64 was eating lunch in his room. He had his bilateral upper half side rails up. Review of Resident 64's admission record indicated, he was admitted to the facility on [DATE]. Review of Resident 64's care plans indicated, Resident 64 did not have an individualized, resident-centered care plan for the side rails. 22. During the observation of Resident 20 on 9/15/25 at 12:58 p.m., Resident 20 was in the dining room, eating his lunch. Checked his bed and he had his bilateral upper half side rails up. Review of Resident 20's admission record indicated, he was readmitted to the facility on [DATE]. Review of Resident 20's care plans indicated, Resident 20 did not have an individualized, resident-centered care plan for the side rails. 23. During the observation of Resident 66 on 9/15/25 at 1:01 p.m., Resident 66 was in the dining room, eating his lunch with total assistance from the facility staff. Checked his bed and he had his bilateral upper half side rails up. Review of the admission record of Resident 66 indicated, he was admitted to the facility on [DATE]. Review of the care plans of Resident 66 indicated, Resident 66 did not have an individualized, resident-centered care plan for the side rails. 24. During the observation of Resident 6 on 9/15/25 at 1:01 p.m., Resident 6 was in his room eating his lunch. He was alert and verbally responsive. Resident 6 had his bilateral upper half side rails up. Review of the admission record of Resident 6 indicated, he was readmitted to the facility on [DATE]. Review of the care plans of Resident 6 indicated, Resident 6 did not have an individualized, resident-centered care plan for the side rails. During the concurrent review of the residents' care plans and interview with the DSD on 9/19/25 at 10:33 a.m., the DSD verified that Residents 33, 41, 75, 64, 20, 66, and 6 had bilateral upper half side rails that were up. DSD further verified that these residents did not have individualized, resident-centered care plans for their side rails. She then stated that she would update their care plans. During the interview with the interim director of nursing (IDON) on 9/19/25 at 12:59 p.m., IDON confirmed that the above residents did not have individualized, resident-centered care plans for their side rails and she would follow up on these concerns. Review of the facility's policy and procedure titled, Plan - Resident Care, reviewed on 10/2010 indicated, Basic Requirements of Care Plans: date, identifiable needs and problems, measurable and time-limited goals, approaches for accomplishing goals, discipline responsible for approach, evaluation Problems are added and goals set as conditions arise

Based on observations, interviews, and record reviews, the facility failed to ensure food was prepared in a manner which conserved flavor and nutritive value when: 1. Lunch was ready at 9:30 a.m. and was held at hot temperature for hours prior to meal service.2. The correct texture and recipe were not followed for pureed diet. These deficient practices had the potential to result in loss of nutrients and to decrease the food intake of residents and could negatively impact their nutritional status. Findings: 1.During a kitchen observation of the North Side on 9/17/25 at 9:27 a.m. with Dietary Supervisor (DS) and Dietary [NAME] (DC), DC stated she finished preparing pureed food at 9:10 a.m. DC also stated the main lunch dish, Beef Stroganoff, was cooked from scratch and was ready by 9:15 a.m. DS stated, Lunch is usually prepared early. DC showed the metal containers covered in aluminum foil containing food for lunch stored in an oven. DC opened two metal containers and showed white pureed food and beef stroganoff. DC stated the white pureed food was cauliflower. DS stated the temperature in the oven where lunch was stored was 200 F (Fahrenheit, a unit of temperature measurement). DS and DC verified all food to be served for lunch were already cooked. A review of facility's Lunch Menu for 9/17/25 indicated beef stroganoff, noodles, cauliflower with red peppers, wheat bread, apple slices, coffee or tea, milk. During lunch tray line observation on 9/17/25 at 11:45 a.m. with DS and DC, the first food cart containing lunch trays for residents was sent out at 11:53 a.m. During an interview with DS on 9/17/25 at 12:31 p.m., DS stated, Lunch was prepared too early today. A review of facility's Policy and Procedure (P&P) entitled Meal Service Procedures-Food Production, Service and Distribution Standards revised 9/2018, the P&P indicated, PolicyThe Food and Nutrition Services Department develops and maintains a mechanism to ensure the safe and accurate preparation, handling and distribution of food items. To preserve nutrient value . 2.During lunch test tray in the North Side building on 9/17/25 at 12:31 p.m. with Dietary Supervisor (DS), a Regular Diet and Pureed Diet test trays were prepared. DS verified the pureed noodles was not the right consistency and stated it was too thick. DS verified pureed noodles was sticky, lumpy, and bland. DS also verified the Regular Diet tray included cauliflower with red peppers while the Pureed Diet only had pureed cauliflower without any trace of red peppers. DS stated I don't know why she [Dietary Cook] did not include the red peppers. A review of facility's Lunch Menu for 9/17/25 indicated beef stroganoff, noodles, cauliflower with red peppers, wheat bread, apple slices, coffee or tea, milk. A review of Kitchen's Quantified Recipe for pureed Cauliflower w/ Red Peppers indicated ingredients included diced sweet peppers.A review of North Side building's Residents' Diet List indicated 10 residents were on Dysphagia I (pureed texture). A review of facility's Policy and Procedure (P&P) entitled Meal Service Procedures-Food Production, Service and Distribution Standards revised 9/2018, the P&P indicated, .Food Production Standards . To maintain constantly high quality production standards . RECIPES- Maintain and follow a file of standardized recipes.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:1. Registered nurse A (RN A) did not remove dirty gloves, perform hand hygiene (the act of cleaning hands with soap and water or an alcohol-based hand sanitizer to remove germs and prevent the spread of infections) and don (put on) a new pair of gloves before doing Resident 65's finger stick test (method of drawing drops of blood, most commonly used by people with high blood sugar to check their levels), and RN A did not perform hand hygiene after she picked the glove that fell on the floor and before putting on clean gloves prior to medication preparation;2. Registered nurse E (RN E) did not perform hand hygiene prior to medication administration;3. Certified nursing assistant C (CNA C) and licensed vocational nurse D (LVN D) did not perform hand hygiene in between assisting and feeding residents; and,4. Certified nursing assistant F (CNA F) did not change dirty gloves after Resident 12's toileting assistance, did not perform hand hygiene after removal of dirty gloves and before donning a new pair of gloves. These failures had the potential for the spread of infection and cross-contamination that could affect the eighty-nine residents residing in the facility, staff, and visitors. Findings: 1a. During the medication pass observation with registered nurse A (RN A) on 9/16/25 at 11:25 a.m., RN A was preparing to check the blood sugar of Resident 65 using the finger stick test. RN A sanitized her hands and put on a pair of gloves. But before she did the finger stick test of Resident 65, RN A kept on moving the bedside table and placed it beside the bed. RN A proceeded to do the finger stick test of Resident 65 without changing gloves, sanitizing hands and putting on new gloves. 1b. During the continued medication pass observation with RN A on 9/16/25 at 11:30 a.m., RN A went back to the medication cart to prepare the Novolog (insulin aspart, rapid-acting insulin that helps lower mealtime blood sugar spikes in adults and children with diabetes or high blood sugar) of Resident 65. RN A sanitized her hands and got a pair of gloves. She dropped one of the gloves on the floor and RN A picked it up with her sanitized hand and threw it in the garbage bin at the side of the medication cart. RN A then got another glove and put on the pair of gloves and proceeded to prepare the insulin aspart without sanitizing her hands first. During the interview with RN A on 9/16/25 at 3:15 p.m., RN A confirmed the above concerns. RN A further confirmed that she should not touch anything including, moving the bedside when she had already sanitized her hands and put on the gloves. RN A also confirmed that she should have sanitized her hands after she picked up the glove that fell on the floor and threw it in the garbage bin, before putting on a new pair of gloves. Review of Resident 65's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, she was admitted to the facility on [DATE] with the principal diagnosis (underlying cause of admission) of type 2 diabetes mellitus (adult onset high blood sugar levels) with other specified complications (unfavorable result of a health condition). Review of Resident 65's order summary report dated 9/15/25 indicated, Resident 65 had an order of Novolog FlexPen (pre-filled pen designed to administer insulin for the treatment of diabetes) subcutaneous (beneath, or under, all the layers of the skin) solution pen-injector 100 units (standards of measuring and expressing physical quantities)/ml (milliliter, unit of volume in the metric system), inject 3 units subcutaneously with meals and also as per sliding scale (dosing strategy for insulin where the amount administered is adjusted based on a person's current blood sugar level), for type 2 diabetes mellitus with other specified complications, ordered on 8/18/25. During the interview with the infection preventionist (IP) on 9/17/25 at 9:40 a.m., IP verified the above concerns. IP further verified that nurses should remove gloves, sanitize hands and put on new pair of gloves when she touched things or move bedside tables prior to doing finger stick tests. IP also verified that nurses should sanitize hands as well after picking up something from the floor, before putting on new pair of gloves. 2. During the concurrent medication pass observation and interview with RN E on 9/17/25 at 4:42 p.m., RN E, sanitized his hands, prepared the amlodipine besylate (used to treat high blood pressure or hypertension) 5 mg tablet of Resident 63 and then give it to Resident 63. But before giving the amlodipine, RN E moved the bedside table near the resident with his sanitized bare hands. He then proceeded to give the amlodipine besylate tablet without sanitizing his hands. RN E confirmed that he should have sanitized his hands first because he was touching and moving the table near the resident, before giving the medication of Resident 63. Review of Resident 63's admission record indicated, Resident 63 was admitted to the facility on [DATE] with the principal diagnosis of unspecified dementia (loss of memory, language, problem-solving and other thinking abilities), unspecified severity with agitation (state of severe restlessness or inner tension). Review of Resident 63's order summary report dated 9/18/25 indicated, Resident 63 had an order of amlodipine besylate oral tablet, 5 milligrams (mg, unit of weight), give 1 tablet by mouth one time a day for essential primary hypertension (condition characterized by persistently elevated blood pressure without identifiable underlying cause). Hold if systolic blood pressure (SBP, pressure in the arteries when the heart beats and pumps blood throughout the body) was below 100 millimeters of mercury (mmHg, unit of pressure most commonly used to measure blood pressure). During the interview with the interim director of nursing (IDON) on 9/19/25 at 12:59 p.m., IDON verified all the above concerns. IDON further verified that the nurse should have removed gloves, sanitized hands and put on new gloves before she did the fingerstick test, because she was touching and moving the bedside table prior to the test and should have also sanitized her hands after picking up the glove that fell on the floor before putting on clean gloves. IDON also verified that nurses should sanitize hands as well before giving medication, when they are touching the bedside table with bare hands before medication administration. Review of the undated facility's policy and procedure titled Hand Hygiene, indicated, Hand hygiene is the single most important procedure in preventing the spread of infection. This is an organization-wide policy. It applies to all care settings and services . Hand washing and hand antisepsis indications . Before and after having direct patient care . Before and after preparing and administering medications . If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations . 3. During Dining Observation on 9/15/25 at 12:20 p.m. in the Dining Room, Certified Nurse Aide (CNA) C was feeding Resident 89. CNA C tapped Resident 89's dining scarf and then proceeded to another table and started assisting and feeding Resident 62. CNA C was observed touching Resident 62's hands. CNA C left the room and Licensed Vocational Nurse (LVN) D took over the feeding of Resident 62. LVN D was sitting in between Resident 62 and Resident 92. LVN D wiped Resident 92's mouth using Resident 92's dining scarf and did not do hand hygiene before proceeding to continue feeding Resident 62. LVN stated, hand hygiene was needed in between assisting two residents. During an interview on 9/15/25 at 12:48 p.m. with CNA C, CNA C stated hand hygiene should have been done prior to assisting Resident 62. A review of facility's Policy and Procedure (P&P) entitled Policy: Hand Hygiene revised 1/3/2022, the P&P indicated, .1.Hand Washing and hand antisepsis indications: a.Hand washing is necessary in, but not limited to, the following situations:.2.Before and after having direct patient care 3.Between direct patient care contacts with different patients.13.Before and after contact with patients intact skin. 4.During an observation on 9/15/2025 at 11:14 a.m., inside Resident 12's room, the following were observed: 4a. CNA F came out of Resident 12's bathroom and threw some garbage wearing a pair of gloves, then he wheeled out Resident 12 from the bathroom by touching the wheelchair's handles with the same pair of gloves, and positioned Resident 12 beside her bed; 4b. CNA F removed the dirty gloves, did not perform hand hygiene, touched Resident 12's drawer handle to open and grabbed a pair of socks from the drawer; 4c. CNA F donned a new pair of gloves, without hand hygiene, and assisted Resident 12 in putting on her socks; 4d. CNA F removed his gloves, did not perform hand hygiene, went out to the hallway, touched the linen cart with unsanitized (dirty and carry germs, bacteria, and other mircroorganisms that can spread illness) hands, grabbed a clean hand towel, and handed the clean hand towel to Resident 12. During an interview with CNA F on 9/15/2025 at 11:18 a.m., CNA F confirmed the above observations and apologized for not performing hand hygiene every time he changed his gloves. CNA F stated he should have changed his gloves after he threw some garbage and he should have sanitized his hands before donning and upon removal of gloves. CNA F confirmed Resident 12 had a bowel movement and he assisted her with toileting. During an interview with the IP on 9/17/2025 at 9:36 a.m., the IP stated staff should perform hand hygiene before donning a new pair of gloves and after removal of gloves. The IP further stated the staff should use hand sanitizer if their hands were not visibly soiled. During a review of the facility's undated policy and procedure titled, Hand Hygiene, indicated, Hand washing is necessary in, but not limited to, the following situations . Before donning gloves and after removing gloves . Before and after handling patient body fluids, excretions or mucus membranes. i.e., urine, feces, sputum, blood. Gloves shall be used in addition to hand washing, not a substitute for. Hand hygiene must be completed after each glove removal.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 34) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when the physician did not document the reason a gradual dose reduction (GDR, stepwise tapering of a dose to determine if conditions can be managed by a lower dose or if the medication can be discontinued altogether) was contraindicated. This failure had the potential to result in unnecessary or prolonged use of the psychotropic medication, which could increase the resident's risk of experiencing side effects (undesirable effects from the medication).Findings:Review of Resident 34's clinical record indicated she was admitted to the facility with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and atrial fibrillation (AFib, an irregular heart rhythm).Review of Resident 34's physician orders indicated she had orders for Seroquel 25 milligrams (mg, unit of measurement) two times a day for agitation, delusion, and paranoia, dated 9/13/25 and sertraline 100 mg one time a day for depressionReview of Resident 34's Consultation Report, dated 5/15/26 indicated, If GDR [gradual dose reduction] is contraindicated at this time, please provide a risks vs benefits statement. The report further indicated the physician responded and checked the box, I decline the recommendation(s) above due to the reasons below. The physician's hand-written rationale indicated, Continue as ordered. There was no documentation of a risks vs benefits statement for Resident 34.During an interview on 9/19/2025 at 2:05 p.m., Licensed Vocational Nurse B (LVN B) stated she was unable to find further physician documentation. Review of the facility's policy, Psychotropic Medication Use, revised 4/1/22 indicated, Physician/Prescriber should document the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior.Review of the facility's policy, Medication Regimen Review, revised 6/5/24 indicated, If the attending physician/prescriber has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool) for one of 22 sampled residents (Resident 34) when Resident 34's MDS assessment did not reflect the use of antipsychotic medication (used to treat psychosis and other mental health disorders). This failure resulted in an inaccurate MDS assessment, which had the potential to affect the resident's care.Findings:Review of Resident 34's clinical record indicated she was admitted to the facility with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and atrial fibrillation (AFib, an irregular heart rhythm).Review of Resident 34's physician orders indicated she had orders for Seroquel 25 milligrams (mg, unit of measurement) two times a day for agitation, delusion, and paranoia, dated 9/13/25. Review of Resident 34's previous physician orders indicated she had orders for Seroquel starting in 11/2024.Review of Resident 34's Minimum Data Set (MDS, an assessment tool), dated 7/24/25 indicated the resident was taking an antipsychotic. The MDS further indicated, No - Antipsychotics were not received for the question, Did the resident receive antipsychotic medications .?During an interview on 9/19/25 at 1:26 p.m., the MDS Coordinator (MDS) stated the answer should be, Yes. The MDS stated she will submit a modification.

Based on observation, interview, and record review, the facility failed to develop a baseline care plan to include instructions on the care of bed rails or side rails (adjustable rigid bars attached to the side of a bed) use for one (Resident 99) of 36 residents (residents with bed rails or side rails). This failure resulted in the installation and use of Resident 99's bed rails without a plan of care. This failure had the potential to result in Resident 99's serious injury.Findings:Review of Resident 99's clinical record titled, admission Record, dated 9/18/2025, indicated Resident 99 was admitted to the facility on [DATE] with diagnoses including non-displaced fracture (broken bone) of lesser trochanter of left femur (a small, cone-shaped bony bump on the inside, back part of the upper thigh bone [femur], near the neck of the bone joins the shaft), epilepsy (a neurological disorder characterized by recurrent, unprovoked seizures), and hyponatremia (a condition where the sodium level in the blood is too low).Review of Resident 99's clinical record titled, SNF [Skilled Nursing Facility]-Side Rail Assessment Form, dated 9/12/2025, indicated alternatives were attempted prior to bed rail or side rail use like bed was lowered, adequate lighting, call light was provided and a trapeze bar was used but unsuccessful. Further review, the interdisciplinary team's (IDT - a group of health care professionals from diverse fields who work toward a common goal for residents) decision based on the assessment indicated, YES-APPROPRIATE FOR UPPER SIDE RAIL USE.During an observation on 9/15/2025 at 11:04 a.m., inside Resident 99's room, Resident 99 was in bed, with four bed rails installed on his bed and the two upper bed rails were in upright position.During a concurrent observation and interview with registered nurse A (RN A) on 9/17/2025 at 1:27 p.m., inside Resident 99's room, Resident 99 was in bed and the bed had two upper bed rails in upright position. RN A confirmed the above observation and stated Resident 99 had been using the bed rails for mobility.During a concurrent interview with director of staff development (DSD) and record review on 9/17/2025 at 4:01 p.m., the DSD reviewed Resident 99's list of care plans and confirmed there was no baseline care plan related to bed rail use. The DSD further confirmed Resident 99 was admitted to the facility on [DATE].During an interview with licensed vocational nurse B (LVN B) on 9/19/2025, LVN B confirmed the use of bed rails for new admission should be included in the baseline care plan.During a review of the facility's policy and procedure titled, Plan - Resident Care, date reviewed 10/2010, indicated, A resident Care Plan will be initiated upon admission.

Based on observation, interview, and record review, the facility failed to ensure the proper use of side or bed rails (adjustable rigid bars attached to the side of a bed) for four (Residents 97, 99, 100, and 3) of 36 residents (residents who used bed or side rails) when:1.The physician's orders and informed consents (a process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment) were not obtained prior to use of bed or side rails for Resident 97 and Resident 99; and,2.Resident 100 and Resident 3 used side rails without a clinically appropriate indication.These failures had the potential to place Residents 97, 99, 100, and 3 at risk of entrapment and serious injury. Findings: 1a. During an observation on 9/15/2025 at 10:58 a.m., inside Resident 97's room, Resident 97 was in bed with four bed rails installed and the two upper bed rails were in an upright position. During a review of Resident 97's clinical records, there was no physician's order and informed consent obtained prior to use of bed rails. During a concurrent interview with the director of nursing (DSD) and record review on 9/17/2025 at 3:54 p.m., the DSD reviewed Resident 97's Side Rail Assessment, admission Record, Side Rail use consent, and order summary report. The DSD confirmed the following: a. Resident 97 was admitted to the facility on [DATE]; b. The Side Rail Assessment was completed on 9/9/2025 which indicated the use of the upper side rails were appropriate for Resident 97; and the informed consent and physician's order were just obtained on 9/16/2025. The DSD stated the informed consent and physician's order should have been obtained first prior to implementation of bed rail use. 1b. During an observation on 9/15/2025 at 11:04 a.m., inside Resident 99's room, Resident 99 was in bed with four bed rails installed and the two upper bed rails were in an upright position. During a review of Resident 99's clinical records, there was no physician's order and informed consent obtained prior to use of bed rails. During a concurrent interview with the DSD and record review on 9/17/2025 at 4:01 p.m., the DSD reviewed Resident 99's Side Rail Assessment, admission Record, Side Rail use consent, and order summary report. The DSD confirmed the following: a. Resident 99 was admitted to the facility on [DATE]; b. The Side Rail Assessment was completed on 9/12/2025 which indicated the use of the upper side rails were appropriate for Resident 97; and the informed consent and physician's order were just obtained on 9/16/2025. During an interview with licensed vocational nurse B (LVN B) on 9/19/2025 at 9:55 a.m., LVN B confirmed residents could use bed rails if the assessment was completed and it indicated an appropriate use of bed rails; informed consents and physician orders were obtained; and care plan for bed rails use was developed. During a review of the facility's policy and procedure titled, Side Rail, dated 3/2018, it indicated a physician's order and resident's consent will be obtained for side rail use. 2a. During an observation on 9/15/2025 at 11:11 a.m., inside Resident 100's room, Resident 100 was asleep in bed with four bed rails installed and the two upper bed rails were in an upright position. During a concurrent observation and interview with registered nurse A (RN A) on 9/17/2025 at 1:29 p.m., inside Resident 100's room, Resident 100 was in bed and her two upper bed rails were in an upright position. RN A confirmed the above observation and stated Resident 100 used the bed rails for bed mobility and transfers. During a concurrent interview with the DSD and record review on 9/17/2025 at 4:07 p.m., the DSD reviewed Resident 100's Side Rail Assessment Form dated 9/8/2025 and confirmed the interdisciplinary team's (IDT - a group of health care professionals from diverse fields who work toward a common goal for residents) decision indicated that the side rail use for Resident 100 was not indicated due to lack of medical necessity (refers to healthcare services or supplies that are reasonable and necessary [required for the diagnosis or treatment of an illness, or condition]). The DSD further confirmed she approved and signed Resident 100's Side Rail Assessment on 9/10/2025. The DSD stated Resident 100's side rails should have been lowered and zip tied to the bed frame. 2b.During an observation on 9/18/2025 at 8:50 a.m., inside Resident 3's room, Resident 3 was observed lying in bed with both upper bed rails in the upright position. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) G on 9/18/2025 at 9:03 a.m., Resident 3 remained in bed with both upper bed rails in the upright position. LVN G confirmed the observation and stated that Resident 3's upper bed rails should not have been in the upright position. A review of Resident 3's clinical record revealed no physician order or signed consent authorizing bedside rail use. A review of Resident 3's care plans revealed no care plan addressing the use of bedside rails. A review of Resident 3's Acknowledgment of Assistive/Enabling Device Use (AAD), dated 6/18/2024, indicated that the rails/bar must remain down at all times. During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 9/18/2025 at 1:55 p.m., the ADON reviewed Resident 3's clinical record and confirmed that there was no physician order, consent, care plan, or AAD authorizing bedside rail use. The ADON stated that side rail use for Resident 3 was not indicated and that her side rails should remain down at all times. A review of the facility's policy and procedure titled Side Rail, effective 3/2018, indicated: A physician's order will be obtained for side rail use . use of Side Rails must be addressed in the Resident Care Plan.

Based on observation, interview, and record review, the facility failed to ensure accurate accountability of medications and controlled substance (drug or other substance that can be easily abused and are under strict government control) for three of 13 randomly selected residents (Residents 56, 78 and 34) when: 1. Resident 56's Azithromycin (used to treat certain bacterial infections in many different parts of the body) antibiotic was not accounted for and reconciled accurately;2. Resident 78's Sulfamethoxazole -Trimethoprim (Cotrimazole, an antibiotic medication used to treat certain infections that are caused by bacteria) was not accounted for and reconciled accurately; and3. Resident 34's controlled medication was signed out of the Controlled Drug Administration Record (CDAR, an inventory or count sheet) without recording the time the medication was given and did not document in the medication administration record (MAR) as administered. These failures resulted in inaccurate accountability of medications and controlled substance which could potentially result in misuse or diversion. Findings: 1. During the concurrent inspection observation and interview with the director of staff development (DSD) on 9/15/25 at 10:28 a.m., checked the drawer for the controlled substances or medications of medication cart 1 (MC 1), where the antibiotics of residents were also stored. The medication pack containing the Azithromycin 250 milligrams (mg, measure of weight) of Resident 56, had 3 tablets left. Checked the antibiotic medication log (tool to track the patient's antibiotic intake to ensure it is taken correctly) of Resident 56, 4 tablets of Azithromycin 250 mg were still left. DSD verified that 1 tablet of Azithromycin 250 mg was not accounted properly. DSD further verified that the nurse should have signed out the antibiotic in the medication log, once it was taken from the medication pack and given to the resident. During the interview with the licensed vocational nurse D (LVN D) on 9/15/25 at 10:35 a.m., LVN D verified that she was not able to sign out the Azithromycin 250 mg antibiotic tablet when it was given to Resident 56. LVN D further verified that she should have signed the antibiotic medication log of Resident 56 when she took out the Azithromycin from the medication pack. Review of the admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) of Resident 56 indicated, he was admitted to the facility on [DATE]. Review of the order summary report of Resident 56 dated 9/15/25 indicated, Resident 56 had an order of Azithromycin 250 mg tablet, give 2 tablets by mouth one time a day on day one, then give 1 tablet by mouth one time a day for four days. 2. During further concurrent inspection observation and interview with DSD on 9/15/25 at 10:30 a.m., continued to check the drawer for the controlled medications of MC 1. The medication pack containing the Sulfamethoxazole -Trimethoprim, 800 mg -160 mg of Resident 78, had 2 tablets left. Checked the antibiotic medication log of Resident 78, 3 tablets of Sulfamethoxazole -Trimethoprim, 800 mg -160 mg were still left. DSD confirmed that 1 tablet of Sulfamethoxazole -Trimethoprim, 800 mg -160 mg was not accounted properly and would remind nurses about it. During the interview of LVN D on 9/15/25 at 10:35 a.m., LVN D verified that she was not able to sign out the Sulfamethoxazole - Trimethoprim 800 mg -160 mg antibiotic as well when she administered it to Resident 78 and would not do it next time. Review of Resident 78's admission record indicated, Resident 78 was admitted to the facility on [DATE]. Review of Resident 78's order summary report dated 9/15/25 indicated, Resident 78 had an order of Sulfamethoxazole-Trimethoprim, 800 mg -160 mg tablet, give 1 tablet by mouth every 12 hours for urinary tract infection (UTI, illness in any part of the urinary tract, the system of organs that makes urine), for 10 days, started on 9/6/25. During the interview with the interim director of nursing (IDON) on 9/19/25 at 12:59 p.m., IDON acknowledged that all medications should be properly accounted for and reconciled. IDON further acknowledged that nurses should have signed the antibiotics out in the antibiotic medication logs, once they took them out from the medication pack and would remind nurses about that. Review of the facility's undated policy and procedure titled, Medication Reconciliation Policy, indicated, This policy outlines the standardized process for performing medication reconciliation to ensure accurate and complete medication information is obtained and communicated at each transition of care. The goal is to prevent medication errors and promote patient safety by verifying and documenting all medications a patient is taking, including prescription Documentation of medication reconciliation will be completed as noted in the contents of the policy. 3. During an interview on 9/19/25 at 12:59 p.m., the IDON stated the narcotic medication should be signed out in the narcotic sheets [CDAR] and recorded in the MAR simultaneously. During a concurrent interview with the DSD and record review on 9/19/25 at 10:43 a.m., the DSD reviewed Resident 34's physician order dated 4/17/2025, CDAR for tramadol (an opioid narcotic medication for pain) HCl [Hydrochloride, a salt form of the drugs used to make it more stable and soluble medication] Oral Tablet 25 milligrams (mg, unit of measurement), 1 tablet, and the July 2025 MAR. The DSD confirmed the following: a. Resident 34 had a physician's order dated 4/17/2025, for tramadol HCl Oral Tablet 25 mg, 1 tablet every 4 hours as needed (PRN) for moderate to severe pain (4-6= moderate pain; 7-10 = severe pain); and b. Nursing staff signed out tramadol HCl 25 mg from the CDAR on 7/8/25 without recording the time the medication was given and did not document in the MAR to indicate the medication was administered to Resident 34. The DSD stated licensed nurses should have documented in the MAR to indicate they had given the medication. During an interview licensed vocation nurse H (LVN H) on 9/19/2025 at 1:14 p.m., LVN H stated that if controlled medication is not recorded accurately, it could lead to a double dose and a medication error. A review of the facility's policy and procedure (P&P) titled, Controlled Drugs: Administration dated 11/17/2022, the P&P indicated, Administration of designated controlled drugs shall be recorded on a Medication Administration Record (MAR) as well as a Controlled Substances Administration Record (CSAR), sometimes referred to as a Controlled Drug Administration Record (CDAR). and the ENTRIES include: Date and time of administration to the patient or adjustment to stock.

Based on interview and record review, the facility failed to ensure the pharmacist's medication regimen review (MRR) recommendations for one of 22 residents (Resident 34) were followed-up and acted upon. This failure had the potential for the resident to suffer unnecessary adverse side effects that could negatively impact her physical, mental, and psychosocial well-being.Findings:Review of Resident 34's clinical record indicated she was admitted to the facility with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities) and atrial fibrillation (AFib, an irregular heart rhythm).Review of Resident 34's physician orders indicated she had orders for gabapentin (medication used to prevent seizures or nerve pain) 100 milligrams (mg, unit of measurement) in the morning and gabapentin 200 mg at bedtime for neuropathic pain, dated 3/2/25.Review of Resident 34's Consultation Report, dated 5/21/25 indicated the pharmacist recommended, Please evaluate these medications [Loratadine, Sertraline, Quetiapine, Gabapentin] as possibly contributing to this fall [Resident 34's fall on 5/14/25] and consider decreasing Gabapentin to 100mg bid [twice a day] If this therapy is to continue, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that the medication is not believed to be contributing to falls in this individual; and b) the facility interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences.Review of Resident's clinical record indicated there was no documented evidence that adverse consequences of gabapentin were monitored for Resident 34.During an interview on 9/19/25 at 2:05 p.m., Licensed Vocational Nurse B (LVN B) stated she was unable to find further physician documentation. She confirmed there was no monitoring for adverse consequences of gabapentin.Review of the facility's policy, Medication Regimen Review, revised 6/5/24 indicated, Facility should encourage physician/prescriber or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR.

Based on interview, and document review, the facility failed to review and/or revise their policy and procedure in compliance with federal regulations and with accepted professional standards when the facility did not revise or update their side rail policy and procedure annually. This failure had the potential to compromise residents' health and safety.Findings:Review of the facility's policy and procedure titled, Side Rail, indicated the last review and revision was 3/2018.During a concurrent interview with the director of staff development (DSD) and document review on 9/18/2025 at 10:09 a.m., the DSD reviewed the Side Rail policy and procedure and confirmed the last time it was reviewed was in 2018. The DSD stated they reviewed their policy and procedures yearly.During a concurrent interview with the interim director of nursing (IDON) and document review on 9/19/2025 at 1:38 p.m., the IDON reviewed the Side Rail policy and procedure and confirmed it was revised in 2018. IDON stated they have a Patient Care Policy Committee, and they meet annually to review or revise their policy and procedures. The IDON further stated their Side Rail policy and procedure should have been revised in 2024 and their plan moving forward was to review all their policy and procedures.During a review of the undated facility document titled, Continuous Quality Improvement Report, indicated, Patient Care Policy Committee . meets Annually . Topic discuss are the following: revisions, implement and review of Policy and Procedures, area of concerns, what action taken.

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice related to pain management for one of four sampled residents (Resident 1) when Resident 1 did not receive the right dosage of oxycodone (a controlled drug used to treat moderate to severe pain) to manage severe pain to right hip. This failure had the potential to affect Resident 1's well-being. Findings: Review of Resident 1's clinical record titled, Admission Record, indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including displaced subtrochanteric fracture of right femur (a severe injury to the thigh bone where the fractured ends is out of alignment), aftercare following joint replacement surgery (a procedure in which a surgeon removes a damaged joint and replaces it with new, artificial part), polyneuropathy (multiple nerve damage), presence of right artificial hip, and need assistance with personal care. Review of Resident 1's 5-day minimum data set (MDS, federally mandated resident assessment tool) assessment dated [DATE], indicated Resident 1's brief interview for mental status (BIMS, a tool used to assess cognition [knowing, learning, and understanding things]) score was 13 (0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Further review revealed, Resident 1 had frequently experienced pain, and frequently limited her participation in rehabilitation therapy (a form of treatment to restore function to those recovering from an injury or surgery) sessions, and day to day activities because of pain over the last 5 days. Review of Resident 1's clinical record titled, Order Summary Report, indicated an order of oxycodone hydrochloride (HCl)10 milligrams (mg, unit of measurement) every 6 hours as needed for moderate to severe pain which was ordered on 11/30/2024. Review of Resident 1's list of care plan titled, The resident had pain ., date initiated 12/2/2024, indicated, Anticipate the resident's needs for pain relief and respond immediately to any complaint of pain .Monitor Pain every shift and PRN [pro re nata - as the need arises] when giving PRN meds [medications] (0= no pain, 1-3= mild pain, 4-6= moderate pain, 7-10= severe pain). Review of Resident 1's December medication administration record (MAR, a record of medications given), indicated an order of oxycodone HCl 5 mg started on 11/30/2024, to be given every 6 hours as needed for moderate pain (4-6 pain scale). Further review indicated on 12/1/2024 at 2:36 a.m., Resident 1 had pain scale of 8 (severe pain) and on 12/2/2024 at 6:00 a.m., Resident 1 had pain scale of 7 (severe pain). Resident 1 was given 5 mg of oxycodone HCl on both times which was indicated for moderate pain. During a phone interview with Resident 1's family member on 12/12/2024 at 8:43 a.m., Resident 1's family member stated their complaint was about how the facility managed Resident 1's pain. Resident 1's family member further stated, their mother was supposed to get 10 mg of oxycodone every 6 hours but Resident 1 was given 5 mg instead. Resident 1's family member confirmed Resident 1 had dislocated her right hip which made her experienced severe right hip pain. During a concurrent interview with registered nurse A (RN A) and record review on 12/12/2024 at 2:00 p.m., RN A reviewed Resident 1's December MAR. RN A confirmed Resident 1 had severe pain on 12/1 at 2:36 a.m. and on 12/2 at 6:00 a.m. and was only given 5 mg of oxycodone HCl. RN A further confirmed the 5 mg of oxycodone HCl should only be given for complained of moderate pain which was 4-6 in pain scale. RN A stated the order for the use of 10 mg of oxycodone HCl should have been clarified because the given parameter for moderate to severe pain had caused confusion. During a concurrent interview with registered nurse B (RN B) and record review on 12/12/2024 at 2:26 p.m., RN B reviewed Resident 1's December MAR. RN B confirmed Resident 1 should have been given 10 mg of oxycodone HCl for pain scale of 8 and 7. During a phone interview with registered nurse C (RN C) on 12/12/2024 at 2:44 p.m., RN C confirmed she was one of Resident 1's nurses. RN C stated the pain scale of 7-10 was an indication of severe pain and oxycodone HCl 10 mg was ordered for severe pain. During a concurrent interview with interim director of nursing (IDON) and record review on 12/12/2024 at 2:52 p.m., IDON reviewed Resident 1's December MAR. IDON confirmed on 12/1 at 2:36 a.m. and on 12/2 at 6:00 a.m., Resident 1 had severe pain and should have been given oxycodone HCl 10 mg. During a review of the facility's policy and procedure titled, Pain Management, dated 11/05, indicated, .pain also will be assessed at minimum of every shift, and as needed. Pain will be documented on pain MAR. 3. Licensed nurse will assess pain and document the pain level on the supplemental documentation of MAR when any PRN pain medication was given.

Based on observation, interview, and record review, the facility failed to ensure proper use of bed rails (side rails, safety rails, and grab/assist bars) for 86 of 88 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 287, 387, 388, 389, and 390) when: 1. There was no documentation that the facility obtained informed consent (documentation that the resident/resident's responsible party and the facility are in agreement for certain items or services made available to the Resident, after the resident/resident's responsible party are educated on the item/service) prior to using bed rails for 86 of 88 residents. 2. There was no documentation that risks and benefits were explained to the residents or responsible parties (RP, individuals designated to make decisions on behalf of the residents) prior to using bed rails for 86 of 88 residents, 3. There was no documentation that the facility assessed for risk of entrapment (becoming trapped between the bed rail and mattress) prior to using bed rails for 86 of 88 residents and 4. There was no documentation that alternatives were attempted prior to using bed rails for 86 of 88 residents. These failures had the potential to place the residents at risk of entrapment and serious injury. Findings: During an interview with Registered Nurse (RN) N on 3/12/224 at 11:45 a.m., RN N stated she was the admission nurse, and all residents had a standing order for upper half rails up when in bed for bed mobility to use the upper side rails upon admission. During an interview with Certified Nursing Assistant (CNA) O on 3/13/2024 at 8:50 a.m., CNA O stated that all Northside Skilled Nursing Facility (SNF) residents were using the upper half bedside rails. During an observation and interview with CNA P on 3/13/24 at 9:34 p.m., the beds of Residents 33, 10, 29, 287, 8, 35, and 6 were inspected. All seven beds had partial side rails (part of a whole, [full side rails are attached to the side of a bed along the full or whole length of the bed]) bilaterally (on both sides). CNA P confirmed the above observation and stated all the upper half bedside rails were set up for those residents. A review of Resident 33's face sheet (summary of a resident's important information) indicated Resident 33 was admitted to the facility on [DATE]. A review of Resident 33's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent, or assessed for risk of entrapment prior to using the bedside rails upon admission on 8/30/2018. A review of Resident 10's face sheet indicated Resident 10 was admitted to the facility on [DATE]. A review of Resident 10's clinical records indicated that there was no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent, or assessed for risk of entrapment prior to using the bedside rails upon admission on 9/11/2023. A review of Resident 29's face sheet indicated Resident 29 was admitted to the facility on [DATE]. A review of Resident 29's clinical records indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent, or assessed for risk of entrapment prior to using the bedside rails upon admission on 9/11/2023. A review of Resident 287's face sheet indicated Resident 287 was admitted to the facility on [DATE]. A review of Resident 287's clinical records indicated there was no documentation that the facility attempted alternatives or assessed for risk of entrapment prior to using the bedside rails upon admission on 2/28/2024. A review of Resident 8's face sheet indicated Resident 8 was admitted to the facility on [DATE]. A review of Resident 8's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent, or assessed for risk of entrapment prior to using the bedside rails upon admission on 9/20/2023. A review of Resident 35's face sheet indicated Resident 35 was admitted to the facility on [DATE]. A review of Resident 35's clinical records indicated there was no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent, or assessed for risk of entrapment prior to using the bedside rails upon admission on 9/11/2018. A review of Resident 6's face sheet indicated Resident 6 was admitted to the facility on [DATE]. A review of Resident 6's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent, or assessed for risk of entrapment prior to using the bedside rails upon admission on 8/30/2018. During an interview with RN N on 3/18/2024 at 11:24 a.m., RN N stated that she was an admission nurse and did not assess for risk of entrapment, attempt alternatives, explain risks and benefits, or obtain informed consent before setting up the bedside rails upon admission. She confirmed that no documentation indicated that the facility attempted alternatives, explained risks and benefits, obtained informed consent, or assessed for risk of entrapment prior to using the bedside rails upon admission for Northside SNF residents, including Residents 33, 10, 29, 287, 8, 35, 6, 38, 57, 40, 52, 55, 46, 71, 44, 63, 21, 75, 5, 12, 31, 24, and 9. During an interview with the Director of Nursing (DON) on 3/18/2024 at 11:45 a.m., the DON confirmed that no documentation indicated that the facility attempted alternatives, explained risks and benefits, obtained informed consent, or assessed for risk of entrapment prior to using the bedside rails upon admission for all the residents. The DON stated that the interdisciplinary team (IDT) did some assessment but not prior to using the bedside rails. The DON further stated that staff started explaining the risks and benefits of using the bedside rails and obtaining informed consent since January 2024. A review of the facility's policy and procedure (P&P) titled Side Rail indicated all beds are equipped permanently mounted Safety Side Rails. When ordered, these should be kept in a raised position at all times, except when a staff member is at the bedside giving nursing care . During an interview with the DON on 3/19/2024 at 9:49 a.m., the DON stated that the Side Rail P&P needed to be revised to require that the facility attempt alternatives, explain risks and benefits, obtain informed consent, and assess for risk of entrapment prior to residents using the bedside rails upon admission. 44185 During an observation on 3/11/24 at 9:35 a.m., Resident 81's four half side rails were up. Review of Resident 81's face sheet indicated, Resident 81 was admitted to the facility on [DATE]. A review of Resident 81's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to the facility. During an observation of Resident 51 in her room on 3/11/24 at 9:40 a.m., her bed's two half side rails were up. Review of Resident 51's face sheet indicated, Resident 51 was admitted to the facility on [DATE]. Review of Resident 51's physician order, dated 3/6/19, indicated, Resident 51 had an order for upper half side-rails up when in bed for bed mobility. A review of Resident 51's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails, or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 1's room on 3/11/24 at 9:42 a.m., Resident 1's bed's two half side rails were up. Review of Resident 1's face sheet indicated, Resident 1 was readmitted to the facility on [DATE]. A review of Resident 1's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails, or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 72's room on 3/11/24 at 9:45 a.m., Resident 72's bed with two 1/4 side rails were up. Review of Resident 72's face sheet indicated, Resident 72 was admitted to the facility on [DATE]. A review of Resident 72's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation in the room of Resident 66 on 3/11/24 at 9:50 a.m., two half side rails were up for Resident 66's bed. Review of the face sheet of Resident 66 indicated, Resident 66 was admitted to the facility on [DATE]. A review of Resident 66's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 67's room on 3/11/24 at 9:52 a.m., one half side rail was up for Resident 67's bed. Review of Resident 67's face sheet indicated, Resident 67 was admitted to the facility on [DATE]. A review of Resident 67's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for using side rails and assessed for risk of entrapment prior to using the bedside rails upon admission to the facility. During an observation of Resident 36 in his room on 3/11/24 at 9:55 a.m., three half side rails were up for Resident 36's bed. Review of Resident 36's face sheet indicated, Resident 36 was admitted to the facility on [DATE]. A review of Resident 36's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 3 in her room on 3/11/24 at 11:00 a.m., two 1/4 side rails were up for Resident 3's bed. Review of Resident 3's face sheet indicated, Resident 3 was admitted to the facility on [DATE]. A review of Resident 3's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 42 in his room on 3/11/24 at 11:35 a.m., two half side rails were up for Resident 42's bed. Review of Resident 42's face sheet indicated, Resident 42 was admitted to the facility on [DATE]. A review of Resident 42's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 11's room on 3/13/24 at 10:30 a.m., two half side rails were up for Resident 11's bed. Review of Resident 11's face sheet indicated, Resident 11 was admitted to the facility on [DATE]. A review of Resident 11's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 80 in his room on 3/11/24 at 11:43 a.m., one 1/4 side rail was up for Resident 80's bed. Review of Resident 80's face sheet indicated, Resident 80 was admitted to the facility on [DATE]. A review of Resident 80's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 73 in his room on 3/11/24 at 11:47 a.m., Resident 73's bed was had two upper half side rails, plus one 1/4 side rail at foot of the bed, up. Review of Resident 73's face sheet indicated, Resident 73 was admitted to the facility on [DATE]. A review of Resident 73's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 61 in his room on 3/11/24 at 11:50 a.m., Resident 61's bed had two upper 1/4 side rails up. Review of Resident 61's face sheet indicated, Resident 61 was admitted to the facility on [DATE]. A review of Resident 61's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 47 in his room on 3/11/24 at 11:55 a.m., Resident 47's bed had upper two half side rails up. Review of Resident 47's face sheet indicated, Resident 47 was admitted to the facility on [DATE]. Review of Resident 47's physician order, with the order date of 1/25/23 indicated, Resident 47 had an order for upper half side-rails up when in bed for bed mobility. A review of Resident 47's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 60 in his room on 3/11/24 at 12:00 p.m., Resident 60's bed was with two half upper side rails were up. Review of Resident 60's face sheet indicated, Resident 60 was readmitted to the facility on [DATE]. A review of Resident 60's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 43 in his room on 3/11/24 at 12:02 p.m., Resident 43's bed was with two half upper side rails were up. Review of Resident 43's face sheet indicated, Resident 43 was admitted to the facility on [DATE]. A review of Resident 43's clinical records indicated lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. Review of Resident 43's physician order, with the order date of 8/24/22 indicated, Resident 43 had an order of upper half side-rails up when in bed for bed mobility. During an observation of Resident 82 in his room on 3/11/24 at 12:15 p.m., Resident 82's bed was with one half upper side rail up. Review of Resident 82's face sheet indicated, Resident 82 was admitted to the facility on [DATE]. Review of Resident 82's physician order, with the order date of 6/29/23 indicated, Resident 82 had an order of upper half side-rails up when in bed for bed mobility. A review of Resident 82's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 22 in his room on 3/11/24 at 12:10 p.m., Resident 22's bed was with two half upper side rails up. Review of Resident 22's face sheet indicated, Resident 22 was readmitted to the facility on [DATE]. A review of Resident 22's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an observation of Resident 13 in his room on 3/11/24 at 12:12 p.m., Resident 13's bed was with two half upper side rails up. Review of Resident 13's face sheet indicated, Resident 13 was readmitted to the facility on [DATE]. A review of Resident 13's clinical records lacked documentation to indicate the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During a concurrent review of the above residents' clinical records and interview with licensed vocational nurse Q (LVN Q) on 3/18/24 at 2:52 p.m., LVN Q verified, all the above residents have standing orders for side rails but these residents (Residents 81, 51, 1, 72, 66, 67, 36, 3, 42, 11, 80, 73, 61, 47, 60, 43, 82, 22 and 13) did not receive informed consents prior to use of side rails; risks and benefits were not provided for use of using side rails at the time of admission; did not have assessments for entrapments prior to use of side rails; and, did not have evidence of documentations for attempted alternatives prior to use of side rails. During an interview with the director of nursing (DON) on 3/19/24 at 11:30 a.m., DON verified that the above residents did not receive: informed consents prior to use of side rails; risks and benefits were not provided for use side rails at the time of admission; did not have assessments for entrapments prior to use of side rails; and, did not have evidence of documentations for attempted alternatives prior to use of side rails. 46552 During an initial tour observation on 3/11/2024 at 10:26 a.m., resident 27's bed's both upper side rails were up. Review of Resident 27's face sheet indicated Resident 27 was admitted to facility on 5/5/2015 and readmitted on [DATE]. Review of Resident 27's physician's order, dated 5/17/2027, indicated Resident 27 had an order for upper half rails up when in bed for bed mobility. A review of Resident 27's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent (process of communication between resident and facility for agreement or permission to use side rails for bed) for use of side rails or assessed for risk of entrapment (being caught in) prior to using the bedside rails upon admission to facility. During an initial tour on 3/11/2024 at 10:30 a.m., observed Resident 54's bed's both upper side rails were up while Resident 54 was in bed. Review of Resident 54's face sheet indicated Resident 54 admitted to facility on 8/2/2023. Review of Resident 54's physician order, dated 8/10/23, indicated Resident 54 had an order for upper half rails up when in bed for bed mobility. A review of Resident 54's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 11:02 a.m., Resident 25's bed had both upper side rails up. Review of Resident 25's face sheet indicated Resident 25 admitted to facility on 1/29/2022. Review of Resident 25's physician order, dated 1/29/22, indicated Resident 25 had an order for upper half rails up when in bed for bed mobility. A review of Resident 25's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 11:02 a.m., Resident 49's bed was with both upper side rails up while Resident 49 was not in bed. Review of Resident 49's face sheet indicated Resident 49 was initially admitted to facility on 5/14/2019 and readmitted on [DATE]. Review of Resident 49's physician order, dated 4/1/21, indicated Resident 54 had an order for upper half rails up when in bed for bed mobility. A review of Resident 49's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 11:15 a.m., Resident 78's bed was with both upper side rails up. Review of Resident 78's face sheet indicated Resident 78 admitted to facility on 2/9/2023. Review of Resident 78's physician order, dated 9/25/2023, indicated Resident 78 had an order for upper half rails up when in bed for bed mobility. A review of Resident 78's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 11:20 a.m., noted both upper side rails up for Resident 62's bed. Review of Resident 62's face sheet indicated Resident 62 admitted to facility on 2/9/2023. Review of Resident 62's physician order, dated 2/9/2023, indicated Resident 62 had an order for upper half rails up when in bed for bed mobility. A review of Resident 62's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 11:25 a.m., noted both upper side rails up for Resident 30's bed. Review of Resident 30's face sheet indicated Resident 30 initially admitted to facility on 10/10/2017 and readmitted to facility on 9/29/2022. Review of Resident 30's physician order, dated 8/16/2022, indicated Resident 30 had an order for upper half rails up when in bed for bed mobility. A review of Resident 30's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 11:30 a.m., noted both upper side rails up for Resident 39's bed. Review of Resident 39's face sheet indicated Resident 39 initially admitted to facility on 10/28/2020 and readmitted to facility on 3/20/2023. Review of Resident 39's physician order, dated 3/20/2023, indicated Resident 39 had an order for upper half rails up when in bed for bed mobility. A review of Resident 39's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation and interview with resident 53 on 3/11/2024 at 11:45 a.m., noted both upper side rails up for Resident 53's bed. Review of Resident 53's face sheet indicated Resident 53 admitted to facility on 4/5/2022. Review of Resident 53's physician order, dated 4/5/2022, indicated Resident 53 had an order for upper half rails up when in bed for bed mobility. A review of Resident 53's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 12:00 p.m., noted both upper side rails up for Resident 15's bed. Review of Resident 15's face sheet indicated Resident 15 admitted to facility on 9/20/2023. Review of Resident 15's physician order, dated 9/20/2023, indicated Resident 15 had an order for upper half rails up when in bed for bed mobility. A review of Resident 15's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 12:15 p.m., noted both upper side rails up for Resident 79's bed. Review of Resident 79's face sheet indicated Resident 79 admitted to facility on 4/6/2023. Review of Resident 79's physician order, dated 4/6/2023, indicated Resident 79 had an order for upper half rails up when in bed for bed mobility. A review of Resident 79's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 12:18 p.m., noted both upper side rails up for Resident 64's bed. Review of Resident 64's face sheet indicated Resident 64 admitted to facility on 8/12/2020. Review of Resident 64's physician order, dated 8/12/2020, indicated Resident 64 had an order for upper half rails up when in bed for bed mobility. A review of Resident 64's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 12:22 p.m., noted both upper side rails up for Resident 19's bed. Review of Resident 19's face sheet indicated Resident 19 admitted to facility on 11/22/2021. Review of Resident 19's physician order, dated 11/22/2021, indicated Resident 19 had an order for upper half rails up when in bed for bed mobility. A review of Resident 19's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 12:30 p.m., noted both upper side rails up for Resident 41's bed. Review of Resident 41's face sheet indicated Resident 41 admitted to facility on 2/6/2017. Review of Resident 41's physician order, dated 3/6/2019, indicated Resident 41 had an order for upper half rails up when in bed for bed mobility. A review of Resident 41's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 12:55 p.m., noted both upper side rails up for Resident 7's bed while Resident 7 was not in bed or in room. Review of Resident 7's face sheet indicated Resident 7 admitted to facility on 2/8/2023. Review of Resident 7's admission diagnoses include TIA. Review of Resident 7's physician order, dated 2/28/2023, indicated Resident 7 had an order for upper half rails up when in bed for bed mobility. A review of Resident 7's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 1:00 p.m., noted both upper side rails up for Resident 17's bed. Review of Resident 17's face sheet indicated Resident 17 admitted to facility on 7/6/2021. Review of Resident 17's physician order, dated 7/6/2021, indicated Resident 17 had an order for upper half rails up when in bed for bed mobility. A review of Resident 17's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 1:15 p.m., noted both upper side rails up for Resident 20's bed. Review of Resident 20's face sheet indicated Resident 20 admitted to facility on 5/20/2017. Review of Resident 20's physician order, dated 3/6/2019, indicated Resident 20 had an order for upper half rails up when in bed for bed mobility. A review of Resident 20's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 1:20 p.m., noted both upper side rails up for Resident 56's bed. Review of Resident 56's face sheet indicated Resident 56 admitted to facility on 12/8/2020. Review of Resident 56's physician order, dated 12/8/2020, indicated Resident 56 had an order for upper half rails up when in bed for bed mobility. A review of Resident 56's clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 12:35 p.m., noted only left upper side rail up for Resident 37's bed. Review of Resident 37's face sheet indicated Resident 37 admitted to facility on 5/18/2016. Review of Resident 37's physician order, dated 3/6/2019, indicated Resident 37 had an order for upper half rails up when in bed for bed mobility. A review of Resident 37s clinical records indicated no documentation that the facility attempted alternatives, explained risks and benefits, obtained informed consent for use of side rails or assessed for risk of entrapment prior to using the bedside rails upon admission to facility. During an initial observation on 3/11/2024 at 1:50 p.m., noted both upper side rails up for Resident 70's bed. Review of Resident 70's face sheet indicated Resident 70 admitted to facility on 7/27/2023. Review of Resident 70''s admission diagnoses include diabetes type 2 (too much sugar in the body), and depression. Review of Resident 70's physician order, dated 7/27/2013, indicated Resident 70 had an order for upper half rails up when in bed for bed mobility. A review of Resident 70's clinical records indicated no doc

Based on observation, interview and record review, the facility failed to develop and implement, comprehensive, resident-centered, care plans for five out of twenty sampled residents, (Residents 51, 42, 47, 43 and 82), when the activity care plans of Residents 51, 42, 47, 43 and 82, were not comprehensive and resident-centered. These failures had the potential to result in the residents not receiving the interventions necessary to maintain their highest level of well-being. Findings: 1. Review of Resident 51's face sheet (a document that gives resident's information at a quick glance) indicated, Resident 51 was admitted to the facility on [DATE] with diagnoses including unspecified atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), unspecified chronic kidney disease (longstanding disease of the kidneys leading to renal failure) and essential primary hypertension (abnormally high blood pressure that's not the result of a medical condition). During an observation of Resident 51 on 3/11/24 at 9:40 a.m., Resident 51 was sitting in her wheelchair, alert, calm and verbally responsive. Review of Resident 51's active physician orders as of 3/12/24 indicated, Resident 51 may participate in activities as desired, ordered on 1/21/19. During the interview with the activity director (AD), on 3/13/24 at 2:21 p.m., AD stated that they do room visits three times per week and had her nails and hair done. AD further stated that Resident 51 also had communions in her room, twice per month. Review of Resident 51's care plans indicated, Resident 51 did have one on one room visits three times per week in the interventions of her activity care plan but there were no specific activities to be provided during the room visits and this intervention was not updated since it was created on 1/25/19. Resident 51's activity care plan, was not comprehensive and resident-centered, that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During a concurrent record review of Resident 51's activity care plan and interview with the quality assurance registered nurse (QARN), on 3/15/24 at 9:14 a.m., QARN verified, Resident 51 did not have specific activities to be provided during the room visits, and the one-on-one room visit activity care plan intervention was not updated since it was created on 1/25/19. QARN further verified, Resident 51's activity care plan, was not comprehensive and resident-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. QARN stated she would notify the AD to update this intervention in the activity care plan of Resident 51. During an interview with AD, on 3/15/24 at 11:45 a.m., AD verified, Resident 51 did not have specific activities to be provided during the room visits and the one-on-one room visit activity care plan intervention was not updated since it was created on 1/25/19. AD further verified, Resident 51's activity care plan, was not comprehensive and resident-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. AD then stated that Resident 51 should have a comprehensive, resident-centered activity care plan; and that, she will update Resident 51's activity care plan. 2. Review of Resident 42's face sheet indicated, Resident 42 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (adult onset and most common type of diabetes which is a condition that occurs when the blood glucose is too high), unspecified hyperlipidemia (a condition in which there are high levels of fat particles in the blood) and essential primary hypertension (abnormally high blood pressure that's not the result of a medical condition). During an observation of Resident 42 on 3/11/24 at 11:35 a.m., Resident 42 was lying in bed in his room, alert, calm and comfortable. Review of Resident 42's activity initial assessment on 3/11/22 indicated, Resident 42 likes to watch television shows, listen to country and western music, playing solitaire (card game) and going out into the garden. During the interview with the activity director (AD), on 3/13/24 at 2:24 p.m., AD stated that they do room visits three times per week, socializing with Resident 42, playing music and watching movies. AD further stated that Resident 42 also wanted to play with the iPad [brand name of a touchscreen tablet computer]. Review of Resident 42's care plans indicated, Resident 42 did have one-on-one room visits three times per week in the interventions of his activity care plan but there were no specific activities to be provided during the room visits; and that, this intervention was not updated since it was created on 3/8/22. Resident 42's activity care plan, was not comprehensive and resident-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. During a concurrent record review of Resident 42's activity care plan and interview with the QARN, on 3/15/24 at 9:16 a.m., QARN verified, Resident 42 did not have specific activities to be provided during the room visits; and that, the one-on-one room visit activity care plan intervention was not updated since it was created on 3/8/22. QARN further verified, Resident 42's activity care plan was not comprehensive and resident-centered; such that, it would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The QARN stated she would notify the AD to update this intervention in the activity care plan of Resident 42. During an interview with AD, on 3/15/24 at 11:47 a.m., AD verified, Resident 42 did not have specific activities to be provided during the room visits and the one-on-one room visit activity care plan intervention was not updated since it was created on 3/8/22. AD further verified, Resident 42's activity care plan, was not comprehensive and resident-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. AD then stated that Resident 42 should have comprehensive, resident-centered activity care plan and she will update Resident 42's activity care plan. 3. Review of Resident 47's face sheet indicated, Resident 47 was admitted to the facility on [DATE] with diagnoses including Huntington's disease (an inherited condition in which nerve cells in the brain break down over time), unspecified severe protein-calorie malnutrition (refers to a nutritional status in which reduced availability of nutrients leads to changes in body composition and function characterized by obvious significant muscle wasting, loss of subcutaneous fat or significantly reduced functional capacity) and unspecified atrial fibrillation. During an observation of Resident 47 on 3/11/24 at 11:55 a.m., Resident 47 was lying in bed in his room, alert, calm, and comfortable. Review of Resident 47's active physician orders indicated, Resident 51 may participate in activities as desired, ordered on 1/25/23. During the interview with the activity director (AD), on 3/13/24 at 2:08 p.m., AD stated that they do one on one room visits twice per day, socializing with Resident 47, watching Netflix (streaming service that offers a wide variety of shows) channels and doing sensory stimulation. Review of Resident 47's care plans indicated, Resident 47 did have one-on-one room visits but just three times per week in the interventions of his activity care plan and there were no specific activities to be provided during the room visits and this intervention was not updated since it was created on 1/25/23. Resident 47's activity care plan, was not comprehensive and resident-centered; such that, it would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During a concurrent record review of Resident 47's activity care plan and interview with the QARN, on 3/15/24 at 9:08 a.m., QARN verified, Resident 47 did not have the right frequency of the one-on-one room visits; there were no specific activities to be provided during the room visits; and, the one-on-one room visit activity care plan intervention was not updated since it was created on 1/25/23. QARN further verified Resident 47's activity care plan was not comprehensive and resident-centered; such that, it would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs and would notify the AD to update this intervention in the activity care plan of Resident 47. During an interview with AD, on 3/15/24 at 11:40 a.m., AD verified, Resident 47 did not have the right frequency of one-on-one room visits; there were no specific activities to be provided during the room visits; and, the one-on-one room visit activity care plan intervention was not updated since it was created on 1/25/23. AD further verified Resident 47's activity care plan was not comprehensive and resident-centered; such that, it would include measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. AD then stated that Resident 47 should have a comprehensive, resident-centered activity care plan; and that, she will update Resident 47's activity care plan. 4. Review of Resident 43's face sheet indicated, Resident 43 was admitted to the facility on [DATE] with diagnoses including unspecified Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), unspecified hyperlipidemia and unspecified acute kidney failure (a condition in which the kidneys suddenly could not filter waste from the blood). During an observation of Resident 43 on 3/11/24 at 12:02 p.m., Resident 43 was lying in bed in his room, confused and could not talk. Review of Resident 43's active physician orders as of 3/12/24 indicated, Resident 43 may participate in activities as desired, ordered on 8/24/22. During the interview with the activity director (AD), on 3/13/24 at 2:08 p.m., the AD stated that they do one-on-one room visits three times per week, socializing with Resident 43 and reading the bible. Review of Resident 43's care plans indicated, Resident 43 did have one-on-one room visits three times per week in the interventions of his activity care plan, but there were no specific activities to be provided during the room visits and this intervention was not updated since it was created on 8/24/22. Resident 43's activity care plan, was not comprehensive and resident-centered; such that, it would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During a concurrent record review of Resident 43's activity care plan and interview with the QARN, on 3/15/24 at 9:11 a.m., the QARN verified, Resident 43 did not have specific activities to be provided during the room visits and the one-on-one room visit activity care plan intervention was not updated since it was created on 8/24/22. QARN further verified, Resident 43's activity care plan, was not comprehensive and resident-centered; such that, it would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The QARN stated she would notify the AD to update this intervention in the activity care plan of Resident 43. During an interview with AD, on 3/15/24 at 11:42 a.m., the AD verified Resident 43 did not have specific activities to be provided during the room visits and the one-on-one room visit activity care plan intervention was not updated since it was created on 8/24/22. AD further verified, Resident 43's activity care plan, was not comprehensive and resident-centered; such that, it would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. AD then stated that Resident 43 should have a comprehensive, resident-centered activity care plan. She stated she would update Resident 43's activity care plan. 5. Review of Resident 82's face sheet indicated, Resident 82 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non-dominant side, unspecified hyperlipidemia and unspecified hyperglycemia (high blood glucose or high blood sugar). During an observation of Resident 82 on 3/11/24 at 12:15 p.m., Resident 82 was sitting in the wheelchair in his room, alert, oriented, and comfortable. Review of Resident 82's active physician orders as of 3/12/24 indicated, Resident 82 may participate in activities as desired, ordered on 6/29/23. During the interview with the activity director (AD), on 3/13/24 at 2:28 p.m., AD stated that Resident 82 had no room visits because he goes out to the activity room and participates in the activities. Resident 82 does socialization, exercise, morning coffee, watching television and reading. Review of Resident 82's care plans indicated, Resident 82 had one-on-one room visits three times per week in the interventions of his activity care plan, and this intervention was not updated since it was created on 6/29/23. Resident 82's activity care plan, was not followed and it was not comprehensive and resident-centered; such that, it would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During a concurrent record review of Resident 82's activity care plan and interview with the QARN, on 3/15/24 at 9:18 a.m., QARN verified, Resident 82's activity care plan, was not comprehensive and resident-centered; such that, it would include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. QARN further verified that the one-on-one room visit intervention in the activity care plan of Resident 82 was not followed or updated and would notify the AD to update the activity care plan of Resident 82. During an interview with AD, on 3/15/24 at 11:49 a.m., AD verified, Resident 82's activity care plan, was not followed. AD further verified that Resident 82's activity care plan was not comprehensive and resident-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. AD then stated that Resident 82 should have a comprehensive, resident-centered activity care plan; and that, she will update Resident 82's activity care plan. During an interview with the director of nursing (DON), on 3/19/24 at 11:25 a.m., DON verified that residents should have comprehensive and resident-centered activity care plans that include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs; and that, the activity care plans of the above residents should be updated. Review of the facility's policy and procedure titled, Care Plan - How to Write, effective 1/7/2006, and reviewed 10/2010, indicated, Each resident upon admission and change of condition will have an individualized written care plan to reflect his/her healthcare and nursing needs. The plan will be developed with resident, family, significant other, licensed nurse, physician and interdisciplinary team (IDT, group of professionals from varioushealthcare disciplinhes that brings together knowledge to help people receive the care they need) . Each nursing diagnosis recorded on the care plan must have resident centered expected outcomes (goals, objectives) and dates, including resolution dates - all outcomes should be specific and measurable to the individual resident . Determine nursing interventions for the resident .

Based on observation, interview, and record review the facility failed to ensure sanitary practices of both kitchens and their foods were stored under sanitary conditions when: 1. A wilted head of lettuce, green onion, and cut salad were stored in a refrigerator; 2. No air gap (space between the top of the drain overflow and the discharge pipe or hose to prevent back flow of contaminated water) for a dishwasher, ice machine, 3-way sink (commercial and manual dishwashing sink), and food preparation sink in kitchen; 3. The egg salad stored in a refrigerator was measured at 44.5 degrees Fahrenheit (a unit of measurement of temperature) These failures had the potential to result in food borne illnesses among residents in the facility. Findings: 1.During an initial kitchen 1 observation and interview with facility's certified dietary manager L (CDM L) on 3/11/24 at 10:00 a.m., a wilted, brown colored head of lettuce, yellow and black colored wilted bunch of green onion leaves, and wilted cut salad in a plastic bag were in a refrigerator in kitchen 1. CDM L acknowledged these observations. CDM L discarded all three items, and stated dietary staff should have discarded them from the refrigerator. 2.During an initial kitchen 2 observation with facility's CDM M on 3/11/2024 at 4:00 p.m., there was no air gap for the dishwasher, ice machine, 3-way sink, and food preparation sink in kitchen 2. During an interview with CDM M on 3/11/2024 at 4:10 p.m., CDM M acknowledged there were no air gaps for these four items in the kitchen 2. CDM M stated there should be air gaps for all of the four items according to safe sanitary practices. During an interview with facility's plant operations manager (POM) on 3/13/2024 at 2:34 p.m., POM confirmed there were no air gap or back flow devices in kitchen 2 for above four areas. POM stated this building old, grandfathered and followed old plumbing requirements when kitchen 2 was built. POM also stated above four areas should have air gaps to prevent potential back flow of contaminated water from sewage line. POM further stated there was no facility's policy and procedure for air gap. 3. During a follow up kitchen 2 observation and interview with CDM M on 3/14/2024 at 4:07 p.m., the egg salad in a refrigerator measured 44.5-degree Fahrenheit. CDM M acknowledged above finding. CDM M discarded the egg salad. CDM M stated cold foods should be stored at equal or below 40-degrees Fahrenheit in the refrigerator. During an interview with facility's registered dietitian (RD) on 3/15/2024 at 12:02 p.m., RD stated dietary staff should have verified and discarded wilted, color changed vegetables from refrigerator in kitchen 1. RD also stated dietary should have discarded foods from refrigerator that should be cold with temperatures above 40 -degrees Fahrenheit in kitchen 2. RD further stated there was a risk for water backflow and a contamination of the water supply for kitchen 2 for the aforementioned items without air gaps. Review of facility's policy and procedure (P&P) titled, Shelf Life of Fruit and Vegetable Products, reviewed 2/2022, the P&P indicated, PM Cook (or CDM) will inspect fruits and vegetables daily. Produce showing signs of spoilage or color change will be discarded immediately. Review of Food & Drug Administration (responsible for protecting the public health by ensuring the safety, efficacy, and security of human and veterinary drugs, biological products, and medical devices: and by ensuring the safety of nation's food supply .) 's Food Code 2022 for 5-202.13 Backflow Prevention, Air Gap guidelines indicated An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, Or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). Review of facility's P&P titled, Label & Dating Guidelines, reviewed 2/2024, indicated, Cold foods, left over Storage/Holding Temperature 40-degree Fahrenheit.

Based on interview and record review, the facility failed to refer 2 of 18 sampled residents (Resident 6 and 35) to the appropriate agency for a level two PASRR (pre-admission screening and resident review, a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care) evaluation when 1.Resident 6's PASRR Level one was positive, and 2.Resident 35 was diagnosed with schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality) not due to a substance or known physiological condition after admission. This failure had the potential to put the residents at risk of not receiving appropriate care and services. Findings: 1. A review of Resident 6's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including psychotic disorder (a collection of symptoms that affect the mind, where there has been some loss of contact with reality), Major depressive disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), Anxiety disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) vascular dementia with behavioral disturbance (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). A clinical record review indicated that Resident 6 was diagnosed with a psychotic disorder (a mental disorder characterized by a disconnection from reality), not due to a substance of known physiological condition on 2/4/2019. A clinical record review indicated that Resident 6's PASRR level one evaluation was positive on 6/22/2022, and no documentation indicated that Resident 6's PASRR level two evaluation was completed at that time. A reveiw of Resident 6's physician's order, dated10/1/2023, indicated she received Olanzapine (antipsychotic medication that helps to manage symptoms of mental health conditions such as seeing, hearing, feeling or believing things that others do not, feeling unusually suspicious or having muddled thoughts, feeling agitated or hyperactive, very excited, elated, or impulsive ) 5 milligrams (mg, unit of dose measurement) one tablet by mouth two times a day to vascular dementia with behavioral disturbance. During an interview with the Minimum Date Set Coordinator (MDSC) on 3/19/24 at 11:01 a.m., The MDSC stated she was responsible for the PASRR program and confirmed that no documentation indicated Resident 6's Level 2 evaluation was completed until 3/18/2024. The MDSC further stated that Resident 6's PASRR level one evaluation was positive in June 2022 and she should have received a PASRR level two evaluation at that time. 2. A review of Resident 35's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including major depressive disorder, dementia with behavioral disturbance, and schizophrenia. A review of Resident 35's physician order indicated that Resident 35 received Seroquel tablet 25 mg by mouth two times a day related to schizophrenia on 3/31/2023. During an interview with the MDSC on 3/19/24 at 11:05 a.m., The MDSC confirmed that no documentation indicated that Resident 35's Level 2 evaluation was completed until 3/18/2024. The MDSC stated that MDS staff should have referred Resident 35 for a level 2 PASRR evaluation after she was diagnosed with schizophrenia to ensure Resident 35 could receive appropriate care and services. During an interview with the Director of Nursing (DON) on 3/19/24 at 12:57 p.m., The DON confirmed that no documentation indicated that PASRR Level 2 evaluations were completed for residents 6 and 35 until 3/18/2024. The DON further stated that the MDS staff should have referred those two residents for PASRR 2 evaluation to ensure they could receive proper treatment and care. A review of the facility's undated policy, titled PASRR General Overview, indicated, The PASRR process is divided into two components . the RR process is completed for current NF residents, readmission, or inter-facility transfers when there is a significant change in the individual's physical or mental condition . A level 1 screening is used to identify if an individual has, or is suspected of having a PASRR condition, then a Level 2 Evaluation will be performed, and a determination made .

Based on interview and record review, the facility failed to document care consistent with professional standards of practice, to prevent pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) from possibly getting worse for one out of six residents (Resident 238) investigated with pressure ulcer, when staff did not document whether they turned and repositioned Resident 238 every two hours, from 6/23/23 to 6/27/23. This failure resulted in the lack of documentation for whether Resident 238 was turned and repositioned. Findings: Review of Resident 238's face sheet (a document that gives resident's information at a quick glance) indicated, Resident 238 was admitted to the facility on [DATE] with diagnoses including fracture (a complete or partial break in a bone) of unspecified part of neck of right femur (thigh bone), subsequent encounter for closed fracture (bone is broken but the skin is intact) with routine healing, unspecified heart failure (a chronic condition in which the heart doesn't pump blood as well as it should) and unspecified Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Review of Resident 238's admission skin pressure ulcer assessment (comprehensive evaluation) dated 6/23/23, indicated, Resident 238 had suspected deep tissue injury (persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues), sacral (located below the lumbar spine and above the tailbone) coccygeal (at the very bottom of the spine, also known as the tailbone) pressure ulcer measuring 8 centimeters (cm, unit of length) x 9 cm, with the center of the wound covered with a layer of glossy/shiny drainage surrounded by non-blanchable (discoloration of the skin that does not turn white when pressed) redness, which was a suspected deep tissue injury, measuring, 2 cm x 0.7 cm x 0.1 cm. Resident 238 to be turned and repositioned routinely. Review of Resident 238's skin pressure ulcer assessment dated [DATE], indicated, there were no changes in Resident 238's pressure ulcer. Review of Resident 238's care plan for her pressure ulcer indicated, turning and repositioning of Resident 238 every 2 hours and as needed in bed in the interventions, revised on 8/22/23. Review of Resident 238's turning and repositioning program task documentation for certified nursing assistants, indicated that it was initiated at 12:00 p.m., on 6/28/23. During an interview with quality assurance registered nurse (QARN) on 3/19/24 at 10:00 a.m., QARN verified that the task of turning and repositioning of Resident 238 every 2 hours was initiated on 6/28/23 and not on admission to the facility, which was 6/23/23. During an interview with the director of nursing (DON) on 3/19/24 at 11:08 a.m., DON verified that the task for the certified nursing assistants to turn and reposition Resident 238 every 2 hours was started on 6/28/23, and not on 6/23/23. DON further verified that there was no documentation to indicate Resident 238 was turned and repositioned every 2 hours, from 6/23/23 to 6/27/23. The certified nursing assistants started to document the task of turning and repositioning every 2 hours on 6/28/23. Review of the undated facility's policy and procedure titled, Skin Care and Wound Management, indicated, All residents are considered at risk for pressure ulcer/injury development. All residents have preventative measures in place that include pressure redistribution mattresses on all beds, wheelchair cushion, heel boots or suspension, frequent repositioning per certified nursing assistant (CNA) and activities of daily living (ADL, personal care related activities) care, incontinent care provided with skin cleansers/wipes and barrier cream application if needed.

Based on observation, interview and record review, the facility failed to follow physician's orders for oxygen (a component of air essential to living organisms) rate administration for 1 of 3 sampled resident (Resident 48). This failure had the potential to compromise Resident 48's health and well-being. Findings: Review of Resident 48's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 48 readmitted to facility on 3/6/2023. Review of Resident's admission diagnoses including systemic inflammatory response syndrome (a condition in which there is inflammation [a normal part of the body's response to injury or infection] throughout the whole body), anemia (a condition in which the body does not have enough healthy red blood cells to provide oxygen to body tissues), and chronic kidney disease (a gradual loss of kidney function over the time). Review of Resident 148's physician orders ,dated 3/7/2024, indicated, Oxygen at 2 LPM (LPM: liters per minute, oxygen measured in liters per minute) via nasal cannula (NC, a medical device to provide supplemental oxygen to residents) continuously for SOB (shortness of breath - difficulty in breathing)/anemia. During an observation on 3/11/2024 at 2:36 p.m., Resident 48's room air concentrator's (RAC, a medical device that takes in air from the room and filters out nitrogen (a component of air) to provides higher amounts of oxygen) oxygen rate was set at 2.5 LPM, which was delivered via NC for Resident 48. During a second observation on 3/12/2024 at 9:39 a.m., Resident 48's RAC's oxygen rate was set at 2.5 LPM via NC. During a concurrent review of Resident 48's physician orders for oxygen rate and an interview with registered nurse I (RN I) on 3/1/2024 at 9:44 a.m., RN I confirmed Resident 48's RAC was set to deliver oxygen at a rate of 2.5 LPM. RN I confirmed Resident 48 had an order for oxygen rate for 2 LPM. RN I adjusted RAC's oxygen rate to 2 LPM and stated staff should have verified and followed the physician order for oxygen rate for Resident 48. RN I stated staff should have set oxygen rate at 2 LPM, and not at 2.5 LPM for Resident 48 as ordered. During an interview with director of nursing (DON) on 3/15/2024 at 11:21 a.m., the DON stated staff should have set RAC at rate of 2 LPM for Resident 48. Review of facility's policy and procedure (P&P) titled, Oxygen Therapy-Nasal Cannula and Simple Mask, effective 01/08, indicated, Set the flowmeter to the setting ordered by the physician. Turn on the oxygen at the flow rate as ordered.

Based on observation, interview, and record review, the facility had a medication error rate of 5.88% when two medication errors occurred out of 34 opportunities during the medication administration for two of 12 residents (Residents 30 and 31). Both residents did not receive their medications as ordered. The failures resulted in medications not given according to the physician's orders and had the potential for them not receiving the full therapeutic effects of the medications. Findings: 1. During a medication administration observation with Registered Nurse (RN) A on 3/11/24 at 11:49 a.m., she was observed giving two medications to Resident 30 including a bottle of Systane Lubricant Eye drops. At the bedside, RN A instilled one drop of Systane eye solution into each of the resident's eyes. A review of Resident 30's physician's order, dated 10/9/22, indicated for Refresh Tears Solution (Carboxymethylcelulose Sodium) [active ingredient, a type of lubricant], to instill 1 drop in both eyes three times daily for dry eyes. During a concurrent interview and record review with RN A on 3/11/24 at 2:09 p.m., a review of the active ingredients on the Systane Lubricant Eye drops (used earlier for Resident 30) indicated two lubricant products: polyethylene glycol 0.4% and propylene glycol 0.3%. RN A confirmed the physician's order indicated Refresh Tears Solution while she administered Systane Eye drops. She acknowledged both products were not the same as they did not have the same active ingredients. 2. During an interview on 3/11/24 at 4:05 p.m., in front of Resident 31's room, RN B stated she was being oriented by RN C on medication administration. On 3/11/24 at 4:07 p.m. in the presence of RN C, RN B was observed preparing a medication for Resident 31. She poured 5 milliliters (mL, unit of measurement) of valproic acid (a medication to manage seizures) 250 milligrams (mg) per 5 mL into a small medication cup. On 3/11/24 at 4:11 p.m., RN B was observed bringing the 5-mL valproic acid liquid cup along with a 30-mL cup of water into Resident 31's room. At the resident's bedside, she disconnected the resident's enteral tube and checked the resident residual volume (the amount of liquid drained from a stomach following administration of enteral feed) and the tube placement. Then, RN B attached the syringe to the resident's gastrostomy tube (also called a G-tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) and poured the valproic acid liquid into the tube without flushing the tubing with water first. During an interview on 3/11/24 at 4:26 p.m., in the presence of RN C, RN B acknowledged she should have flushed the resident's enteral tubing with water first before pouring the medication into it. A review of Resident 31's physician's order, dated 10/27/23, indicated to give valproic acid solution 250 mg/5mL, give 500 mg via G-tube two times a day related to UNSPECIFIED CONVULSIONS. During a concurrent interview and record review with RN B and RN C on 3/11/24 at 5:08 p.m., they reviewed Resident 31's physician's order for valproic acid and confirmed it indicated to give 500 mg (or 10 mL). A review of the pharmacy label on the valproic acid bottle also indicated to GIVE 500 mg = (10 ML) BY MOUTH VIA G-TUBE TWO TIMES A DAY. Both nurses confirmed it was an error by giving only 5 mL. RN C stated, We will give another 5 mL now. During an interview with the Director of Nursing (DON) on 3/12/24 12:22 p.m., she stated the resident's G-tube should be flushed with water before, between, and after medication administration. A review of the facility's policy and procedures (P&P) titled Medication Administration, dated 1/2021, indicated: Medications are administered in accordance with written orders of the prescriber. Regarding the medication administration through the enteral tubes, the P&P indicated: Enteral tubes are flushed with at least 15 mL of water before administering any medications and after all medications have been administered.

Based on observation, interview, and record review, the facility failed to ensure medications were labeled and stored appropriately when insulin (medication to lower blood sugar) pens were not labeled with an expiration date when stored at room temperature; expired medications were identified in two of two medication carts, and in two of two medication rooms; and the temperature was not being monitored and maintained twice daily for two out of two medication refrigerators as per facility policy and procedures (P&P). This failure had the potential for the insulin to be administered past the 28-day expiration date; expired medications given to the residents; and loss of drug potency due to unmonitored temperatures. Findings: 1. During a visit to the Northside Medication Room with Licensed Vocational Nurse (LVN) D on 3/11/24 at 9:21 a.m., the medication refrigerator was identified. A quick review of the contents inside reflected it contained several refrigerated medications including two boxes of flu vaccine and two syringes of pneumococcal vaccine (help prevent infections caused by certain types of bacteria called pneumococcus). LVN D stated the staff monitored the refrigerator temperature twice daily (day shift and night shift). A review of the temperature logs (in a binder) with LVN D indicated the staff did not consistently monitor the temperature during the day shift. The monitoring was missing (not documented) 3 days in December 2023, 3 days in January 2024, and 1 day in March 2024. LVN D verified the refrigerator temperature log was incomplete. During this visit to the medication room with LVN D, two out of two Epipens (life-saving medication used when someone is experiencing a severe allergic reaction, known as anaphylaxis) were identified in a medication drawer with an expiration date of 9/2023. LVN D confirmed the Epipens were expired. 2. On 3/11/24 at 9:42 a.m., an inspection of Team 1 Medication Cart (on Northside) was inspected with LVN E. Two Basaglar KwikPens (pre-filled pens containing long-acting insulin) for two residents were stored at room temperature and without a written expiration date, and one of one Glutose 15 (oral glucose gel - used to treat low blood sugar levels) with an expiration date of 2/29/24. LVN E confirmed the Glutose 15 had expired and the insulin pens had no expiration date. She stated they were unopened. For Basaglar KwikPen storage, a review of the Lexi-comp, a nationally known drug information resource, indicated to store unopened prefilled pens at room temperature . for 28 days. 3. On 3/11/24 at 10:18 a.m., an inspection of the Medication Cart on Southside with Registered Nurse (RN) A identified a bottle of famotidine (medication to treat stomach upset) that had an expiration date of 1/2024. RN A confirmed this finding. 4. During a visit to the Southside Medication Room on 3/11/24 at 9:30 a.m., the medication refrigerator was identified. It contained numerous refrigerated medications including several syringes of flu vaccine. A review of the temperature logs, from June 2023 to March 2024, indicated they were incomplete or not logged during the day shift: 4 days in September 2023, 6 days in October 2023, and 2 days in February 2024. RN A acknowledged the missing temperature monitoring. Additionally, the following expired products were identified and confirmed with RN A during this same visit: - Two of two Glutose15 tubes: expired [DATE] - Two of two boxes, each containing 100 counts of zinc sulfate 220 milligrams (a mineral used to replenish low levels of zinc or prevent zinc deficiency): expired 2/2024 - A tray containing 16 (sixteen) 10-mL single vials of sterile water for injection (a diluent to mix with intravenous products): expired 12/2023. During an interview with the Director of Nursing (DON) on 3/12/24 at 12:22 p.m., she stated her expectation is that the staff monitor medication refrigerator twice daily to make sure the temperature is within range because the efficiency of meds depends on the temp. A review of the facility's P&P titled Storage of Medications, dated 1/2021, indicated: Medications and biologicals are store properly, following manufacturer's or provider pharmacy recommendation, to maintain their integrity and to support safe effective drug administration, The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily, Insulin products should be stored in the refrigerator until opened, and Outdated . medications . are immediately removed from stock .

Based on observation, interview and record review, the facility failed to ensure to accommodate food dislikes for one out of three sampled residents (Resident 58). This failure had the potential for decreased meal intake and negative effects on health and well-being for Resident 58. Findings: During lunch observation in the facility's south building's dining room on 3/11/2024 at 12:23 p.m., cut pieces of carrots along with other food items were on Resident 58'slunch plate. Review of Resident 58's lunch tray card, dated 3/11/2024, indicated under dislikes No: Carrots, Cauliflower. Review of facility's lunch menu for 3/11/2024 indicated carrots lyonnaise along with other food items. During a concurrent interview, and record review of Resident 58's lunch tray card with certified nursing assistant K (CNA K), on 3/11/2024 at 12:30 p.m., CNA K acknowledged carrots under dislikes for Resident 58. CNA K stated dietary staff should not have provided carrots to Resident 58 as indicated under food dislikes for Resident 58. During an interview with facility's certified dietary manger L (CDM L) on 3/11/2024 at 12:36 p.m., CDM L confirmed Resident 58's lunch tray card indicated carrots under food dislikes; however, Resident 58 received carrots for lunch. CDM L stated dietary staff should not have served carrots to Resident 58. During a concurrent interview and record review of Resident 58's lunch tray card with facility's registered dietitian (RD) on 3/15/2024 at 12:25 p.m., RD stated dietary staff should have read food dislikes and not served carrots for Resident 58 for lunch on 3/11/2024. Review of facility's policy and procedure (P&P) titled, Dietary Services, effective 02/96, indicated, Special requests by residents are sent, in writing to dietary. Resident receives those special requests unless contraindicated by diet.

Based on The facility failed to prevent accidents for one resident (Resident 62) when staff did not provide supervision to prevent falls and did not develop, revise and/or implement resident centered care plan and interventions to prevent future falls for Resident 62. These failures resulted in Resident 62 falling 18 times and one fall resulted in a left [MEDICAL CONDITION]. Review of Resident 62's admission record indicated, Resident 62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 62's comprehensive Minimum Data Set (MDS, an assessment tool) dated 10/31/18, indicated she had a brief interview for mental status (BIMS) and scored 6 (a score of 0 -7 indicates severe cognitive impairment). Resident 62 required extensive assistance (staff to provided weight bearing support) with one-person physical assist on transfer from one surface to another (bed, chair, wheelchair), locomotion on unit, locomotion off unit, personal hygiene and toilet use. Resident 62's balance was not steady and she can only be stabilized with staff assistance for moving from seated to standing position, move on and off the toilet and surface to surface transfers. During an interview with the Minimum Data Set Coordinator 1 (MDSC 1) on 4/17/19 at 10:24 a.m., she stated the Bowel and Bladder assessment dated [DATE], indicated bladder retraining was done (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) with no improvement noted. No other evidence of bowel and bladder re-training programs were provided. The MDSC further stated Resident 62 was not on a toileting program. Review of Resident 62's Morse Fall Scale (method of assessing a patient's likelihood of falling) dated 11/16/18 scored 75, indicating a high risk for falling. The assessment further indicated Resident 62 exhibited impaired gait (cannot walk unassisted, difficulty rising from chair) and Resident 62 overestimates or forgets limits in ambulation (walk) safety. During an interview and concurrent record review of Resident 62's Interdisciplinary (IDT, staff from different disciplines who work to together to plan and provide care) Post Fall Review summary with the MDSC 1 on 4/17/18 at 4:23 p.m., she confirmed Resident 62 had 29 falls from 3/21/18 to 3/29/19. On 11/26/18, Resident 62 fell and broke her left hip, which was her 19th fall. Reviews of several of Resident 62's Change of Condition (C[NAME]) Evaluations and Interdisciplinary Post Fall Reviews from 3/21/18 to 11/26/18 it indicated Resident 62 had fallen 19 times with scenarios such as attempting to go to the bathroom and transferring to and from the wheelchair or the sofa. Review of Resident 62's high risk for falls care plan, initiated on 10/10/16, indicated Resident 62 as high risk for falls related to gait and balance problems, psychoactive (medications capable of affecting the mind) drug use, history of falls, cognitive deficits, very forgetful due to [DIAGNOSES REDACTED]. Some interventions included to continue to remind, re-educate resident not to transfer unassisted, educate family to report any fall incidents and call staff for help, encourage and arrange with family to come and help with 1:1 (one to one) supervision, continue frequent rounds every 15 to 30 minutes, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. No evidence of monitoring for rounds or frequent visual checks were provided. During an interview with the MDSC 1 on 4/18/19 at 8:18 a.m., she stated frequent visual checks and care plan intervention of every 1 hour checks are not being documented and monitored. Review of Resident 62's IDT Post Fall Reviews from 3/21/18 to 11/26/18, indicated Resident 62 had fell 19 times and 11 of those falls were unwitnessed. During an interview and concurrent record review Resident 62's post fall care plans with the MDSC 1 on 4/17/18 at 1:20 p.m., she indicated the IDT team conducted a review on each fall and developed care plan interventions appropriate for the fall incident. She confirmed there were no new interventions put in place for Resident 62's falls on 3/29/18, 7/20/18, and 9/26/18. Review of Resident 62's IDT post fall review dated 11/26/18, indicated staff heard someone shouting for help in Resident 62's room and found her on the floor and the resident's left leg was lying over her right lower extremity. Resident 62 complained of severe pain on her left leg, It further indicated Resident 62 had poor safety awareness and was non-complaint with safety and did not ask for assistance when needed and the root cause of the fall was her impulsivity. During an interview with the DON on 4/17/18 at 4:07 p.m., she stated on 11/26/18 at 6:05 a.m. and 6:15 a.m., Resident 62 was in bed sleeping, then on 6:40 a.m. a certified nursing assistant (CNA) and a licensed vocational nurse (LVN) heard a noise from Resident 62's bedroom and found the resident lying on the floor. The DON further stated the root cause of Resident 62's fall was because of her non-compliance with safety and transfers without calling for assistance. Review of Resident 62's X-ray (photographic or digital image of a part of the body report) dated 11/26/18, indicated Resident 62 had a displaced left intertrochanteric fracture ([MEDICAL CONDITION] located at the bony protrusions on the thighbone). During an interview with LVN L on 4/18/19 at 9:19 a.m., he indicated Resident 62 had an unwitnessed fall on 11/26/18 at around 6:40 a.m. Resident 62 was found lying on the floor in her room near the bathroom door. Resident 62 complained of severe pain on her leg and was sent to the emergency room (ER). During an interview with LVN L on 4/18/19 at 11:44 a.m., he indicated Resident 62 needed extensive assistance in toileting and transfers. He further stated Resident 62 needed supervision at all times due to her confusion. During an interview with physical therapist J (PT J) on 4/18/19 at 12:22 p.m., she indicated Resident 62 needed supervision from staff for surface to surface transfers. Resident 62 was not capable of motor planning (ability to conceive, plan, and carry out movement and coordination of the arms, legs, and other large body parts from beginning to end). PT J further stated Resident 62's behavior was very unpredictable and unsafe. During an interview with the LVN K on 4/18/19 at 2:30 p.m., he stated Resident 62 was not able to safely transfer herself and needed assistance for transfers. He further stated we need to keep an eye on Resident 62, and she should always be in staff's line of sight. Review of the facility policy, Care Plan - How to write dated 1/7/06, indicated each resident upon admission and change of condition will have an individualized written care plan to reflect his/her healthcare and nursing needs. The policy further stipulated the care plan must have resident centered expected outcomes (goals, objectives) . outcomes should be specific and measurable. Review of the facility policy, Fall Prevention and risk reduction dated 4/15 indicated Based upon total score of the fall risk evaluation, a comprehensive plan of care will be implemented to prevent resident's fall when it is preventable and minimize fall resulted injuries as much as possible.