Every finding on record at Hendersonville Health and Rehabilitation

Based on observations and interviews with staff, the facility failed discard expired leftover food ready for use in 1 of 1 walk-in cooler and failed to ensure the floor in the dry food storage area was clean in 1 of 1 kitchen. These practices had the potential to affect food served to residents. Findings included: a. During a walk-through observation of the kitchen and interview with the Assistant Dietary Manager (DM) on [DATE] at 8:52 AM through 9:45 AM revealed a 12-ounce package of sliced bologna with an expiration date of [DATE] being stored in the walk-in cooler ready for use with no resident name or or date on the package. The Assistant DM revealed she removed the bologna from freezer on [DATE] so it could thaw for a resident who had requested it and forgot to label and date the package when it was removed. b. An observation and interview conducted with the DM on [DATE] at 9:45 AM revealed the tile floor in the dry food storage area had crumb-like debris scattered underneath the metal shelving where food was being stored. A wrapped nutrition bar and can of soda was left on the floor underneath the shelving. The tile baseboard and floor underneath the metal shelving by the wall throughout the dry food storage area appeared dirty with thick black colored buildup of debris. The DM revealed the Dietary Aides swept and mopped the floors in the dry storage area daily. She observed the floors throughout the dry storage area underneath the metal shelving were dirty with a thick black colored buildup of debris and revealed Dietary Aide staff probably had a hard time reaching that area of the floor due to the metal shelving was attached to the wall making it difficult to reach. During an interview on [DATE] at 1:18 PM Dietary Aide #1 confirmed she worked and was the person who swept and mopped the floor in the dry food storage area by the end of her shift on [DATE]. Dietary Aide #1 revealed she had scrubbed the area and was able to reach underneath the metal shelving and to her the floor appeared clean. She revealed she did not observe a thick buildup of black colored debris on the tile floor. During an interview on [DATE] at 2:32 PM the Administrator revealed the bologna was requested by one resident and not in use of all residents. The Administrator revealed he wanted Dietary staff to do their best to keep the kitchen clean.

Based on observation, staff interviews, and resident interview, the facility failed to ensure a call light was functioning properly for 1 of 1 resident who required staff assistance for activities of daily living (Resident #80). The findings included: Resident #80 was admitted to the facility on [DATE]. The annual Minimum Data Set assessment dated [DATE] revealed Resident #80 had intact cognition. An observation and interview was conducted with Resident #80 on 09/08/24 at 11:38 AM. Resident #80 was lying in bed trying to get a hold of the pancake call light (round and flat that activates when touched) that was attached to the bed sheet and was hanging off the right side of the bed. Resident #80 stated she was wanting to sit up on the side of the bed and needed staff assistance. When Resident #80 attempted to press the call light, the light on the wall panel in her room and the light over her doorway in the hall did not activate. Nurse Aide (NA) #1 was notified Resident #80 was needing staff assistance and proceeded into Resident #80's room. A subsequent observation of the call light in Resident #80's room was conducted on 09/08/24 at 3:15 PM. Resident #80 was lying in bed, sleeping soundly, with the call light on the bed directly beside her. When the call light was pressed, the light on the wall panel in her room and the light over her doorway in the hall did not activate. Also, the call light for the empty bed that was in Resident #80's room was checked and the light on the wall panel and over the doorway did not activate. During an interview on 09/10/24 at 9:56 AM, NA #1 confirmed she was assigned to provide care to Resident #80 during first shift on 09/08/24 and was not aware that Resident #80's call light was not functioning. NA #1 explained she was in and out of Resident #80's room frequently on 09/08/24 and Resident #80 had not voiced any concerns to her about the call light. NA #1 stated typically when a call light was malfunctioning, there was an indicator on the light above the doorway and maintenance would be notified but she had not noticed anything. An observation and interview was conducted with the Weekend Nurse Supervisor on 09/08/24 at 3:15 PM. The Weekend Nurse Supervisor confirmed the light on the wall panel in the room or over the doorway did not activate when Resident #80's call light or the call light for the empty bed in the room were pressed. She was unaware the call lights were not working in Resident #80's room. She stated Resident #80 could use her call light for assistance and if they had known her call light was not working, they could have given Resident #80 a hand bell to use until the call light was repaired. She stated the Maintenance Director was in the facility today and she would notify him of the issue. An observation and interview was conducted with the Maintenance Director on 09/08/24 at 3:25 PM. The Maintenance Director confirmed the light on the wall panel in the room or over the doorway did not activate when Resident #80's call light or the call light for the empty bed in the room were pressed. The Maintenance Director explained when repairs were needed, typically nursing staff would enter a work order in the computer system or notify him verbally. The Maintenance Director stated he was unaware the call lights were not working in Resident #80's room and he had not received any work order or verbal notification from nursing staff. During a follow-up observation and interview on 09/09/24 at 9:32 AM, Resident #80 stated using her call light was a joke because she would push the call light when assistance was needed but it would take staff over a half an hour to respond during the day time, if at all, and at night, no one would respond. An observation of Resident #80's call light revealed when the call light was pushed, the light on the wall panel in her room and the light over the doorway in the hall both activated. During a follow-up interview on 09/10/24 at 3:52 PM, the Maintenance Director revealed he had been in his current position for 3 months. He stated he made daily rounds of resident rooms to check the water temperature and also checked to see if the call lights were functioning properly. The Maintenance Director explained he did not document his daily rounds or the rooms he checked if there were no issues identified and only documented if repairs were made. He could not recall the last time Resident #80's call light was checked for functioning. During an interview on 09/10/24 at 3:58 PM, the Administrator stated administrative staff members had assigned rooms for them to make daily rounds. During the daily rounds, he explained they used a checklist to guide observations and note any identified concerns which included checking the call lights to ensure they were working but they did not keep the checklists of the daily rounds that were completed. The Administrator stated Resident #80 was someone who used her call light frequently and he would have assumed that nursing staff would have noticed her call light was not working on 09/08/24 and put a work order into the facility system for maintenance to repair.

Based on observations, record review, and staff interviews the facility failed to assess the ability of a resident to self-administer medication for 1 of 1 resident with medication observed in the room (Resident #84). Findings included: Resident #84 was admitted to the facility 08/07/24. Review of the medical record revealed no documentation that Resident #84 was assessed for self-administration of medications. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #84 was moderately cognitively impaired. Review of Resident #84's physician orders revealed no current order for the use of an anti-fungal medication. Observations of Resident #84's overbed table on 09/09/24 at 9:35 AM, 09/10/24 at 3:36 PM, and 09/11/24 at 11:20 AM revealed a 3 milliliter (ml) medication pen with the active ingredient tolnaftate (antifungal medication) 1% lying on top of the table. An interview with Resident #84 on 09/09/24 at 9:35 AM revealed he usually applied the anti-fungal medication daily to treat fingernail fungus. An observation of Resident #84's fingernails on both hands on 09/09/24 at 9:35 AM revealed his fingernails had a yellowish discoloration with a ripple-like texture. In an interview with the Director of Nursing (DON) on 09/11/24 at 1:05 PM she confirmed the anti-fungal medication pen would be considered a medication and should not be left on Resident #84's overbed table. She stated staff rounded on resident rooms daily to check for medications left in resident rooms and that it was overlooked. A follow-up interview with the DON on 09/11/24 at 2:20 PM revealed if a resident wanted to self-administer medication they had to be assessed as safe to self-administer medication, a physician order was obtained, and the medication would be stored in the locked top drawer of the resident's dresser. The DON confirmed Resident #84 had not been assessed to self-administer medication. An interview with the Administrator on 09/11/24 at 2:38 PM revealed medications should not be left in a resident's room without a physician order. He stated staff rounded on resident rooms daily to check for medications left in the room and he felt the anti-fungal pen was overlooked because it looked similar to a writing pen.

Based on record review and interviews with the resident, staff, Consultant Pharmacist, and Medical Director (MD), the Consultant Pharmacist failed to identify drug irregularities and provide recommendations for 1 of 5 residents reviewed for unnecessary medications (Residents #34). The findings included: Resident #34 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus. Review of the physician's orders dated 05/31/23 revealed Resident #34 had an order to receive 10 units of Basaglar insulin subcutaneously once daily at bedtime for diabetes. The order specified to hold the insulin when Resident #34's capillary blood glucose (CBG) was lower than 150 milligrams per deciliter (mg/dL). Review of medical records revealed the Consultant Pharmacist had conducted a new admission medication regimen review (MRR) for Resident #34 on 06/05/23 and a subsequent monthly MRR on 06/12/23. He did not identify any drug irregularities and did not make any specified recommendations to the physician or nursing staff. The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #34 with intact cognition and indicated she had received insulin daily in the 7-day assessment periods. The diabetic care plan initiated on 06/08/23 for Resident #34 revealed she had the potential for complications related to diagnosis of diabetes. The goal was to remain free of signs of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) through the next review period. Intervention included to administer medications as ordered. A review of medication administration record (MAR) for May 2023 through June 2023 indicated Resident #34 had received 10 units of Basaglar insulin subcutaneously at bedtime from 3 different nurses, 10 times within 15 days when her CBGs were less than 150 mg/dL prior to insulin administration on the following nights: - 05/31/23 when CBG = 135 mg/dL - 06/01/23 when CBG = 138 mg/dL - 06/02/23 when CBG = 127 mg/dL - 06/03/23 when CBG = 122 mg/dL - 06/07/23 when CBG = 100 mg/dL - 06/09/23 when CBG = 114 mg/dL - 06/10/23 when CBG = 92 mg/dL - 06/11/23 when CBG = 144 mg/dL - 06/12/23 when CBG = 120 mg/dL - 06/14/23 when CBG = 88 mg/dL During a phone interview conducted on 06/15/23 at 10:10 AM. Nurse #3 stated she worked second shift on 06/03/23 and 06/09/23 and confirmed she had administered Basaglar insulin for Resident #34 in both shifts. She explained she did not notice the perimeter set by the physician and acknowledged that the insulin should be held when Resident #34's CBG was less than 150 mg/dL. A phone interview was conducted with Nurse #4 on 06/15/23 at 10:24 AM. She stated she worked second shift on 06/02/23 and 06/12/23 and confirmed she had administered Basaglar insulin for Resident #34 in both shifts. She explained she did not notice the perimeter set by the doctor in the computer and acknowledged that the insulin should be held when Resident #34's CBG was less than 150 mg/dL, as ordered by the physician. During an interview conducted on 06/15/23 at 10:51 AM, Resident #34 stated she had received Basaglar insulin once every night since her admission on 05/31/23. She denied having any episode of low blood sugar so far. A phone interview was conducted on 06/16/23 at 10:19 AM with the Consultant Pharmacist. He stated he had reviewed Resident #34's medication regimen twice since her admission. However, he did not make any recommendation to the physician or nursing so far. He noted Resident #34 was taking Basaglar insulin and her blood glucose levels were well controlled. He did not notice the perimeter set by the physician to hold insulin when the CBG was less than 150 mg/dL. During a phone interview conducted on 06/16/23 at 10:42 AM, the MD stated it was his expectation for the Consultant Pharmacist to identify all drug irregularities during MRRs and alert the physician and nursing staff in a timely manner. A phone interview was conducted with the Administrator on 06/16/23 at 10:47 AM. He expected the Consultant Pharmacist to identify and report all drug irregularities to the physician and nursing in timely manner. During a phone interview conducted on 06/16/23 at 11:04 AM, the Director of Nursing stated it was her expectation for the Consultant Pharmacist to identify and document all drug irregularities during MRRs and make recommendation to the physician and nursing staff in timely manner.

Based on record review and interviews with the resident, staff, Consultant Pharmacist, and Medical Director (MD), the facility failed to prevent a significant medication error when nurses failed to follow physician's parameter as ordered during insulin administration. As a result, Resident #34 received 10 doses of unnecessary Basaglar insulin within 15 days. This affected 1 of 5 residents reviewed for unnecessary medications (Resident #34). The findings included: Resident #34 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus. Review of the physician's orders dated 05/31/23 revealed Resident #34 had an order to receive 10 units of Basaglar insulin subcutaneously once daily at bedtime for diabetes. The order specified to hold the insulin when Resident #34's capillary blood glucose (CBG) was lower than 150 milligrams per deciliter (mg/dL). The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #34 with intact cognition and indicated she had received insulin daily in the 7-day assessment periods. The diabetic care plan initiated on 06/08/23 for Resident #34 revealed she had the potential for complications related to diagnosis of diabetes. The goal was to remain free of signs of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) through the next review period. Intervention included to administer medications as ordered. A review of the medication administration records (MARs) for May 2023 through June 2023 revealed Resident #34 had received 10 units of Basaglar insulin subcutaneously at bedtime from 3 different nurses, 10 times within 15 days when her CBGs were less than 150 mg/dL prior to insulin administration on the following nights: - 05/31/23 when CBG = 135 mg/dL - 06/01/23 when CBG = 138 mg/dL - 06/02/23 when CBG = 127 mg/dL - 06/03/23 when CBG = 122 mg/dL - 06/07/23 when CBG = 100 mg/dL - 06/09/23 when CBG = 114 mg/dL - 06/10/23 when CBG = 92 mg/dL - 06/11/23 when CBG = 144 mg/dL - 06/12/23 when CBG = 120 mg/dL - 06/14/23 when CBG = 88 mg/dL Further review of MARs revealed Resident # 34's morning blood glucose levels were within the normal limits. It ranged from 94 mg/dL to 168 mg/dL. During a phone interview conducted on 06/15/23 at 10:10 AM. Nurse #3 stated she worked second shift on 06/03/23 and 06/09/23 and confirmed she had administered Basaglar insulin for Resident #34 in both shifts. She explained she did not notice the parameter set by the physician and acknowledged that the insulin should be held when Resident #34's CBG was less than 150 mg/dL. A phone interview was conducted with Nurse #4 on 06/15/23 at 10:24 AM. She stated she worked second shift on 06/02/23 and 06/12/23 and confirmed she had administered Basaglar insulin for Resident #34 in both shifts. She explained she did not notice the parameter set by the doctor in the computer and acknowledged that the insulin should be held when Resident #34's CBG was less than 150 mg/dL, as ordered by the physician. During an interview conducted on 06/15/23 at 10:51 AM, Resident #34 stated she had received Basaglar insulin once every night since her admission on 05/31/23. She denied having any episode of low blood sugar so far. A phone interview was conducted with the MD on 06/15/23 at 11:15 AM. He explained Basaglar was a long-acting insulin, and it could affect blood glucose levels in the morning. He stated Resident #34's morning blood glucose levels were within the normal ranges in the past 15 days. He stated he did not understand why nurses would not follow the parameter attached to the order. It was his expectation for nurses to follow his order and parameter all the time. During an interview conducted on 06/15/23 at 11:39 AM, the Director of Nursing acknowledged that the incident was a medication error, and it could potentially be a significant medication error. It was her expectation for all the nursing staff to follow physician's order and parameter all the time. An interview was conducted on 06/15/23 at 12:20 PM. The Administrator stated the incident was a significant medication error as it could trigger hypoglycemia. He expected nursing staff to pay attention to the physician's order and ordered parameters when administering medications. It was his expectation for all the nursing staff to follow the physician's order all the time.

Based on observation, record review and interviews with the resident and staff, the facility failed to ensure a dependent resident could access the light switch located behind the bed for 1 of 2 residents reviewed for accommodation of needs. (Resident #139) A. Resident #139 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #139 with intact cognition. The MDS indicated walking between locations inside or outside the room, and locomotion off unit did not occur for Resident #139 during the assessment periods. Review of Resident #139's medical records revealed she had moved to her current room on 06/09/23. During an observation conducted on 06/12/23 at 8:37 AM, the switch for the light fixture behind Resident #139's bed was attached with a cord approximately 4 inches in length. The switch was located on the wall approximately 5 feet from the floor and around 4 feet from Resident #139's bed. Resident #139 was unable to reach the cord connected to the switch from the bed if needed. An interview was conducted with Resident #139 on 06/12/23 at 8:38 AM. She stated the access cord to the light switch behind the bed had been in disrepair since she moved to this room on 06/09/23. She indicated that she was bed bound and non-ambulatory. She did not have any control of the lights behind her bed as she could not reach the switch on the wall from her bed. She had to rely on nursing staff to control the light each time and it was very inconvenient to her. During a subsequent observation conducted on 06/13/23 at 2:44 PM, the access cord attached to the light switch behind Resident #139's bed remained in disrepair. During a joint observation was conducted with Nurse Aide (NA) #1 and Nurse #2 on 06/13/23 at 2:56 PM, the access cord for the light switch for the light behind the bed remained inaccessible from Resident #139's bed. A joint interview was conducted with NA #1 and Nurse #2 on 06/13/23 at 2:58 PM. Both nursing staff confirmed Resident #139 was bed bound and acknowledged that the switches on the wall were unreachable for Resident #139 from the bed. They had provided care for Resident #139 in the past 2 days but did not notice the access cord for the light switch behind the bed was broken. During an interview conducted with the Maintenance Manager on 06/13/23 at 3:24 PM, he stated he did a walk through for the whole building to identify repair needs at least once monthly. Other than that, he depended heavily on the staff to report repair/maintenance needs through the electronic work order reporting system. He acknowledged that the access cord to control the switches for the light fixture behind the bed was inaccessible from Resident #139's bed. An interview was conducted with the Director of Nursing (DON) on 06/15/23 at 11:39 AM. She stated it was her expectation for all the staff to be more attentive to the residents' home enviornment. All the residents should have accessibility and full control of their light fixture all the time. An interview was conducted on 06/15/23 at 12:20 PM with the Administrator. He expected nursing staff to pay more attention to residents' home and reported repair needs to Maintenance Manager in timely manner. It was his expectation for all the residents to have accessibility and full control of the light fixtures to accommodate their needs.

Based on observation and staff interviews, the facility failed to safeguard protected health information (PHI) for 1 of 5 medication carts by leaving confidential PHI unattended and exposed in an area accessible to the public (Medication cart of 100 Hall). The findings included: 1.Resident #139 admitted to the facility on [DATE]. A continuous observation was made on 06/14/23 from 8:12 AM through 8:14 AM of an unattended medication cart on the 100 Hall. Nurse #3 left the medication cart with the Medication Administration Record (MAR) in the computer exposed when she was providing care for Resident #139 in the room. The computer screen showed the name, picture, and other PHI of Resident #139. Nurse #3 returned to the medication cart approximately 2 minutes later at 8:14 AM to close the computer partially to about a 30 degrees angle without turning on the privacy protection screen. Then, she returned to Resident #139's room. She returned to the medication cart again about 5 minutes later at 8:19 AM and turned on the privacy protection screen. During an interview conducted on 06/14/23 at 8:20 AM, Nurse #3 explained she was distracted by Resident #139 who asked for assistance when she was doing medication pass. She stated residents' PHI should not be exposed or left unattended and acknowledged that it was her oversight. She stated she had Health Insurance Portability and Accountability Act (HIPAA) training at least once yearly and the last training was completed a few months ago. An interview was conducted with Unit Manager #2 on 06/14/23 at 9:19 AM. She stated nursing staff should turn on the privacy protection screen when they were away from the medication cart to avoid exposing residents' PHI. It was her expectation for all the nursing staff to follow HIPAA guidelines when working in the facility. During an interview conducted on 06/15/23 at 11:39 AM, the Director of Nursing (DON) expected all the staff to safeguard residents' PHI and follow HIPAA guidelines all the time. During a phone interview conducted on 06/15/23 at 12:20 PM, the Administrator stated all residents' confidential PHI should be protected. It was his expectation for all the staff to follow HIPAA guidelines when working in the facility.

Based on observations and staff interviews, the facility failed to maintain a door with splintered wood and exposed rough layer of wood in good repair for 1 of 11 sampled resident rooms (412). Findings included: On 6/12/23 at 10:08 AM an observation of room [ROOM NUMBER] revealed the door at the entrance of the room was scraped with an area on the edge of the door approximately wheelchair armrest height of 2 x 1 inches was missing the outer layer of the wood with visible splinters. The bottom corner edge of the door was observed with the outer layer of the wood peeled away from the door, exposing a rough, unfinished layer of the door. On 6/13/23 at 2:35 PM an observation for room [ROOM NUMBER] revealed the door was unchanged from the previous observation on 6/12/23. On 6/15/23 at 11:15 AM an observation of room [ROOM NUMBER] revealed the door was unchanged from the previous observation on 6/12/23 and 6/13/23. On 6/15/23 at 11:40 AM the Administrator and Maintenance Supervisor were shown the damaged door in room [ROOM NUMBER]. The Maintenance Supervisor stated he was not aware of the damaged door, and it had not been reported to him. He stated he completed monthly rounds of the rooms and had not observed the damage to the door in room [ROOM NUMBER]. The Administrator stated the Administrative Staff completed daily rounds and normally reported any concerns during their daily morning meetings and damage to the door in room [ROOM NUMBER] had not been reported. On 6/15/23 at 11:46 AM the Administrator stated that the door of room [ROOM NUMBER] should have been reported to Maintenance and repaired.

Based on observation, record reviews, and staff interviews, the facility failed to store an opened nasal spray in a safe and secure manner for 1 of 3 residents review for medication storage. (Resident #18) The findings included: Review of facility's medication storage policy and procedure dated 09/30/22 indicated all drugs and biologicals should be stored in a safe, secure, and orderly manner to prevent the possibility of mixing medications of several different residents. Resident #9 admitted to the facility on [DATE] with diagnosis included seasonal allergies. Resident #18 admitted to the facility on [DATE]. During an observation conducted on 06/12/23 at 11:12 AM for Resident #18, a bottle of opened fluticasone nasal spray was left unattended on top of the bed side table in the room. An interview was conducted with Resident #18 on 06/12/23 at 11:15 AM. She did not know a nasal spray was left unattended in her room and the length of time it had been sitting on her bed side table. She added the nasal spray was not for her and did not know why it was left in her room. During an interview conducted on 06/12/23 at 11:18 AM, Medication Aide #1 denied she had left the nasal spray in Resident #18's room. She stated did not notice the nasal spray was left unattended in Resident #18's room when she did medication pass that morning. She explained the nasal spray was not for Resident #18. It is for Resident #9 who stayed across the hall. She indicated the nasal spray was last used on the evening of 06/11/23 according to the Medication Administration Records (MARs). She reported it could have been left in Resident #18's room accidentally by the nurse who worked on 06/11/23 night. Review of MARs confirmed the fluticasone nasal sprays was prescribed for Resident #9. It was last administered by Nurse #1 on 06/11/23 at 9:00 PM. Phone interview with Nurse #1 was attempted but unsuccessful. He was unavailable to answer the call and did not return the call. An interview was conducted with the Unit Manager #1 on 06/12/23 at 11:34 AM. She stated nursing staff should not leave any medications unattended in resident's rooms. She confirmed the fluticasone nasal sprays was for Resident #9 and did not know why it was left in Resident #18's room. It was her expectation for the facility to remain free of unattended medication. During an interview conducted on 06/15/23 at 11:39 AM, the Director of Nursing (DON) expected nursing staff to follow the policy and procedure of medication storage and keep the facility free of unattended medications. An interview was conducted with the Administrator on 06/15/23 at 12:20 PM. He expected nursing staff to be more attentive to resident's home environment. It was his expectation for the facility to remain free of unattended medication.

Based on observations, record review and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions previously put in place following the annual recertification survey conducted on 10/14/21. This was for one deficiency originally cited in October 2021 in the area of Safe/Clean/Comfortable/Homelike Environment and was subsequently recited on the current annual recertification survey of 06/16/23. The duplicate citation during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag was cross referenced to: F584: During the annual recertification survey conducted on 06/16/23, the facility failed to repair a door with splintered wood and exposed rough layers of wood in good condition for 1 of 11 sampled resident rooms (412). During the annual recertification survey conducted on 10/14/21, the facility failed, to maintain the base of a toilet in sanitary condition, maintain a bedside commode in good condition, maintain doors in good condition and maintain wheelchair brakes in sanitary condition reviewed for a safe, clean, comfortable, and homelike environment. An interview was conducted on 06/16/23 at 1:57 PM with the Administrator. The Administrator revealed he started in his position in April 2023 and had met twice with the Quality Assurance Committee and they continue to meet monthly. The Administrator explained the facility reviewed the previous five 5 years of survey results and the concerns with the environment was ongoing. He revealed room rounds were done Monday through Friday to capture environment issues and included to check the doors in resident rooms for repair needs. He revealed him, the Maintenance Supervisor, and Environmental Services walk around once week to look for life safety concerns and check the condition of the building and look for damaged doors.

Based on record review, staff and resident interview the facility failed to treat a resident in a dignified manner when Nurse Aide #2 spoke to her in a manner that made her feel terrible for 1 of 5 residents (Resident #6) reviewed for dignity. The findings include: Resident #6 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #6 was moderately cognitively impaired and had no behaviors or rejection of care. During an interview on 6/12/23 at 10:00 AM Resident #6 revealed that Nurse Aide #2 had called her a devil and witch during breakfast. An interview with Nurse Aide #2 on 6/13/23 at 2:16 PM revealed that she had taken Resident #6 her breakfast tray in the morning of 6/12/23 and Resident #6 had stated in a repetitive and increasing louder voice she's here!. Nurse Aide #2 stated that she had replied with yeah, the devil is here and Resident #6 stated you sure are. Nurse Aide #2 then stated to Resident #6, Why are you being a grumpy witch? Nurse Aide #2 indicated that she knew it wasn't appropriate to say that but she's only human and she should have just left the room. A follow up interview with Resident #6 on 6/14/23 at 8:55 AM revealed that the way Nurse Aide #2 spoke to her made her feel terrible but no other staff has spoken to her that way. She stated that she slept well last night and was looking forward to breakfast. An interview with the Director of Nursing and the Administrator on 6/13/23 at 4:42 PM revealed that Nurse Aide #2 informed them about the incident with the Resident #6 on 6/13/23 at 2:30 PM. The Administrator then did a grievance report. They sent Nurse Aide #2 home that afternoon pending further investigation. The Director of Nursing stated her expectation was that everyone be respectful to each other and Nurse Aide #2's response was not appropriate. An interview with the Director of Nursing and the Administrator on 6/14/23 at 10:43 AM revealed that Nurse Aide #2 would no longer work with Resident #6.

Based on observations, record review, and staff interviews, the facility failed to remove expired food stored ready for use in 1 of 1 walk-in refrigerator, and ensure staff had all hair covered during food production which had the potential to cause cross-contamination of food served to residents in 2 of 6 dietary staff. Findings included: 1. An observation in the walk-in refrigerator on [DATE] at 9:39 AM revealed a sealed plastic bag of sliced onions dated [DATE]. The sliced onions showed signs of spoilage that included discoloration, a fluid coating, and foul odor. Signage titled Refrigeration Date Storage Chart posted on the outside door of the walk-in refrigerator and observed on [DATE] at 9:39 AM stated, cut or prepared vegetables should be used or discarded in 7 days. Follow up observation on [DATE] at 2:27 PM revealed the same sealed plastic bag of sliced onions dated [DATE] in the walk-in refrigerator. Interview with the Dietary Manager (DM) on [DATE] at 2:27 PM revealed the onions were expired and should not have been kept in the walk-in refrigerator beyond 7 days. The Administrator stated in an interview on [DATE] at 11:53 AM that her expectation was expired foods be thrown away and not used. 2. Observation in the kitchen on [DATE] at 10:37 AM revealed Dietary Aide (DA) # 1 cleaning out a tray cart. DA #1's hair was fashioned in a bun with loose ends of hair hanging down the front and sides of her head. A hair net covered the bun and not the loose ends of hair hanging down the front or sides of her head. A continuous observation on [DATE] from 11:26 AM through 11:35 AM revealed DA #1's hair fashioned in a bun with loose ends of hair hanging down the front and sides of her head. A hair net covered the bun and not the loose ends of hair hanging down the front or sides of her head as she unwrapped slices of cheesecake, pureed, then scooped them into individual dessert containers. A continuous observation on [DATE] from 11:43 AM through 12:15 PM revealed DA #1's hair fashioned in a bun with loose ends of hair hanging down the front and sides of her head. A hair net covered the bun and not the loose ends of hair hanging down the front or sides of her head as she assembled resident trays on the service line, and routinely reached into the refrigerator for perishable food items. Interview with DA #1 on [DATE] at 1:41 PM revealed a hair net needed to be on her head to enter the kitchen and she usually wore it covering her full head of hair. DA #1 stated her hair net had a habit of slipping back on her head. Observation on [DATE] at 10:54 AM revealed Cook #1's hair fashioned in a bun with loose ends of hair hanging down the front and sides of her head. A hair net covered the bun and not the loose ends of hair as she covered containers of macaroni and cheese. Interview with Cook #1 on [DATE] at 10:54 AM revealed the hair net was supposed to be covering her head and she stated it may have slipped off. Interview with the DM on [DATE] at 12:21 PM revealed his expectation was that hair nets cover all of the head of hair. Interview with the Administrator on [DATE] at 11:53 AM revealed her expectation was that hair be restrained and this included hair being pinned back. The Administrator stated typically a hair net was worn and a hair net was preferred when hair was restrained.

Based on observations and staff interviews the facility failed to maintain the base of a toilet in sanitary condition for 1 of 15 rooms (Room #302), maintain a bedside commode in good condition for 1 of 3 bedside commodes (Room #302), maintain doors in good condition for 2 of 15 rooms (Room #309 and Room #310), and maintain wheelchair brakes in sanitary condition for 1 of 13 wheelchairs (Wheelchair #1) reviewed for a safe, clean, comfortable, and homelike environment. Findings included: 1. An observation of the bathroom of Room #302 on 10/11/21 at 10:21 PM revealed a black substance that was easily removable at the base of the toilet and the front metal bar of a beside commode that was sitting over the toilet had an area of rust to the front bar. Observations of the bathroom of Room #302 on 10/13/21 at 2:20 PM and on 10/14/21 at 8:11 AM revealed the base of the toilet and the rust to the bedside commode remained unchanged. A joint interview with the Administrator and Maintenance Director on 10/14/21 at 2:08 PM revealed administrative staff rounded on the rooms daily and should have seen and reported the black substance at the base of the toilet and rust on the bedside commode. They explained work order requests could be put into a computerized system to alert maintenance of concerns or staff could document concerns on the daily room rounding sheet. The Maintenance Director stated the black substance to the base of the toilet was due to a leaking wax ring and would be repaired immediately. He stated housekeeping staff should have seen and reported the rust to the bedside commode when they cleaned bathrooms daily. Both the Administrator and Maintenance Director stated missing the concerns with the toilet and bedside commode were oversights by staff. 2. (a). An observation of the bathroom door of Room #309 on 10/11/21 at 03:12 PM revealed a linear scrape with rough edges. Observations of the bathroom door of Room #309 on 10/13/21 at 2:06 PM and on 10/14/21 at8:28 AM revealed the door remained unchanged. (b). An observation of the bathroom door of room #310 on 10/11/21 at 03:19 PM revealed 2 linear scrapes mid-way up the door with rough edges. Observations of Room #310's bathroom door on 03/12/21 at 09:39 AM, 10/13/21 at 1:54 PM, and 10/14/21 at 8:33 AM revealed the door remained unchanged. A joint interview with the Administrator and Maintenance Director on 10/14/21 at 2:08 PM revealed administrative staff rounded on the rooms daily and should have seen and reported the scrapes to the bathroom doors. They explained work order requests could be put into a computerized system to alert maintenance of concerns or staff could document concerns on the daily room rounding sheet. Both the Administrator and Maintenance Director stated missing the concerns with the bathroom doors was an oversight by staff. 3. An observation of the brakes of Wheelchair #1 on 10/11/21 at 03:18 PM revealed dried debris to both brakes. Observations of the brakes of Wheelchair #1 on 10/12/21 at 9:40 AM, on 10/13/21 at 1:55 PM, and on 10/14/21 at 8:34 AM revealed the debris on the brakes remained unchanged. A joint interview with the Administrator and Maintenance Director on 10/14/21 at 2:08 PM revealed administrative staff rounded on the rooms daily and should have seen and reported the dried debris to the brakes of Wheelchair #1. They explained work order requests could be put into a computerized system to alert maintenance of concerns or staff could document concerns on the daily room rounding sheet. A follow-up interview with the Administrator on 10/14/21 at 2:58 PM revealed all wheelchairs were pressure washed by maintenance monthly and they were last deep cleaned a month ago. She also stated wheelchairs were wiped down weekly and as needed by housekeeping and Wheelchair #1's brakes having dried debris on them was an oversight by staff.

Based on observations, record review, and resident and staff interviews, the facility failed to provide adaptive equipment for 2 of 5 residents (Resident #14 and Resident #81) reviewed for nutrition. Findings included: 1. Resident #14 was admitted to the facility 03/06/18 with diagnoses including paralysis of all four limbs and anxiety. A Physician's order dated 06/25/21 revealed Resident #14 was to receive a low concentrated sugar diet with built up utensils (utensils with larger handles) and a scoop plate (a plate with a lip that enables food to be placed on utensils more easily) for meals. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #14 was cognitively intact and required extensive assistance with eating. Resident #14's nutrition care plan last updated 09/28/21 revealed she desired weight loss and was on a therapeutic diet. The goal was to not have weight gain through the next review. Interventions included providing adaptive feeding equipment as ordered/needed/recommended, administering medications as ordered, providing diet as ordered, encouraging her to eat slowly, and monitoring her weight. An observation of Resident #14 on 10/11/21 at 12:30 PM revealed she was eating her lunch meal on a regular plate. Review of Resident #14's meal tray ticket at the same date and time revealed she was to receive her food on a scoop plate. An interview with Resident #14 on 10/11/21 at 12:31 PM revealed she was supposed to receive her meals on a scoop plate but for the past couple of days she had received her food on a regular plate. Resident #14 stated a scoop plate was easier for her to use when feeding herself and she preferred to receive her food on a scoop plate. An interview with Nurse Aide (NA) #1 on 10/11/21 at 12:34 PM revealed she served Resident #14 her meal tray for lunch on 10/11/21 and saw that her meal tray ticket stated she was to receive her food on a scoop plate. NA #1 stated she was not sure why Resident #14 did not receive her food on a scoop plate and she was not sure if she should notify the nurse or not. NA #1 confirmed she did not notify the kitchen or Resident #14's nurse that she did not receive her food on a scoop plate. She stated Resident #14's food was served on a regular plate from time to time and she was not sure why she did not always receive her food on a scoop plate. An interview with the Occupational Therapist (OT) on 10/11/21 at 2:08 PM revealed Resident #14 was supposed to receive her food on a scoop plate because she had a lack of coordination and the scoop plate was helpful for her to place food on her utensils. She explained the scoop plate should be provided with all meals including sandwiches or finger foods. The OT stated if Resident #14 did not receive her meals on a scoop plate NAs should notify Resident #14's nurse. An interview with the Dietary Manager on 10/11/21 at 2:35 PM revealed if residents had orders for adaptive equipment the type of adaptive equipment was listed on the resident's meal tray ticket. He explained the process for plating food was for a Dietary Aide to notify the Cook if any adaptive plates were ordered when the food was plated. The Dietary Manager stated the last Dietary Aide on the tray line was to check the meal tray for accuracy before the meal tray left the kitchen. He stated if a resident meal ticket stated they were to receive adaptive equipment he expected the resident to receive the ordered adaptive equipment. An interview with Dietary Aide #2 on 10/11/21 at 2:39 PM revealed she was the last dietary staff member to check lunch meal trays before they left the kitchen on 10/11/21. She stated she was responsible for checking Resident #14's meal tray for accuracy and it was an oversight that Resident #14 did not receive a scoop plate. An interview with the Administrator on 10/14/21 at 12:59 PM revealed if a resident had orders for adaptive meal equipment, she expected the resident to receive the adaptive equipment. 2. The medical record revealed Resident #81 was admitted to the facility 01/08/20 with diagnoses including [CONDITION(S)] (paralysis on one side of the body) and stroke. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #81 was severely cognitively impaired and required extensive assistance for eating. Resident #81's nutrition care plan last updated 09/15/21 revealed she was at risk for aspiration (food or liquids being sucked into the airway). The goal was for Resident #81 to be free from any signs or symptoms of aspiration through the next review. Interventions included providing adaptive feeding equipment as ordered/needed/recommended, providing her diet as ordered, and observing her for coughing, fever, or changes in breathing. Resident #81's diet order dated 09/17/21 revealed she was to receive a no added salt diet with food cut into bite sized pieces and a scoop dish for all meals. An observation of Resident #81 on 10/11/21 at 12:35 PM revealed she was feeding herself lunch and her food was served on a regular plate. Observation of Resident #81's meal tray card at the same date and time revealed she was to receive her food on a scoop plate. An interview with Nurse Aide (NA) #1 on 10/11/21 at 12:34 PM revealed she served Resident #81 her meal tray for lunch on 10/11/21 and saw that her meal tray ticket stated she was to receive her food on a scoop plate. NA #1 stated she was not sure why Resident #81 did not receive her food on a scoop plate and she was not sure if she should notify the nurse or not. NA #1 confirmed she did not notify the kitchen or Resident #81's nurse that she did not receive her food on a scoop plate. An interview with the Occupational Therapist (OT) on 10/11/21 at 2:08 PM revealed Resident #81 was supposed to receive her food on a scoop plate because her stroke affected her right arm which was her dominant hand and left her with visual deficits on her right side. She stated Resident #81 had to feed herself with her left hand and the scoop plate was helpful for her to place food on her utensils or pick up finger foods. The OT confirmed the scoop plate should be provided with all meals including sandwiches or finger foods. The OT stated if Resident #81 did not receive her meals on a scoop plate NAs should notify Resident #81's nurse. An interview with the Dietary Manager on 10/11/21 at 2:35 PM revealed if residents had orders for adaptive equipment the type of adaptive equipment was listed on the resident's meal tray ticket. He explained the process for plating food was for a Dietary Aide to notify the Cook if any adaptive plates were ordered when the food was plated. The Dietary Manager stated the last Dietary Aide on the tray line was to check the meal tray for accuracy before the meal tray left the kitchen. He stated if a resident meal ticket stated they were to receive adaptive equipment he expected the resident to receive the ordered adaptive equipment. An interview with Dietary Aide #2 on 10/11/21 at 2:39 PM revealed she was the last dietary staff member to check lunch meal trays before they left the kitchen on 10/11/21. She stated she was responsible for checking Resident #81's meal tray for accuracy and it was an oversight that Resident #81 did not receive a scoop plate. An interview with the Administrator on 10/14/21 at 12:59 PM revealed if a resident had orders for adaptive meal equipment, she expected the resident to receive the adaptive equipment.

Based on observation, resident and staff interviews and record review, the facility failed to accurately code the application of a left resting hand splint on two consecutive Minimum Data Set (MDS) assessments for 1 of 1 resident (Resident #9) reviewed for positioning/mobility. Findings included: A review of Resident #9's medical record revealed her most recent re-admission to the facility was on 9/28/16 with [DIAGNOSES REDACTED]. A review of Resident #9's Restorative Plan dated 11/20/18 revealed the following information: The last treatment day from Occupational Therapy (OT) was on 12/3/18 and restorative start date was on 12/4/18. The Restorative Plan addressed continuation of splinting and passive range of motion with directions to apply the left resting hand splint for 4 hours on and 4 hours off a day for 6 days a week. A review of Resident #9's Care Plan which was last updated on 3/12/19 revealed the following approach listed under Activities of Daily Living (ADL) Functional/Rehabilitation Potential: Nurse to ensure left resting hand splint is applied daily. Left resting hand splint to be worn x 4 hours daily as tolerated. Nurse to remove left resting hand splint daily (to be worn x 4 hours daily as tolerated). Monitor for and report to provider and rehabilitation services any indicators of trauma to skin, skin damage/irritation/redness or indicators of pain related to left resting hand splint use. A review of Resident #9's annual MDS assessment dated [DATE] revealed she was cognitively intact, did not refuse treatment and care, and was totally dependent with all ADL. The MDS further indicated no use of splint or brace assistance. A review of Resident #9's quarterly MDS assessment dated [DATE] revealed no use of splint or brace assistance. A review of Resident #9's Restorative Nursing Services flow sheets from (MONTH) (YEAR) to (MONTH) 2019 revealed day to day documentation from the Restorative Aide (RA) of the splint application, signature of the RA and signature of the MDS Coordinator on the front page. On 7/23/19 at 1:55 PM, an observation and interview with Resident #9 was conducted. Resident #9 was observed wearing a splint to her left hand. Resident #9 stated she wears the splint daily, but she takes it off during meal times and when she plays bingo. On 7/24/19 at 11:01 AM, an interview with the RA revealed she has been working with Resident #9 since (MONTH) (YEAR) providing passive range of motion exercises and applying a splint to her left hand. The RA stated Resident #9 has never refused restorative treatment but Resident #9 usually took her left hand splint off prior to eating or if she was going to bingo. The RA further stated that she would go back and re-apply Resident #9's splint to left hand without problems. An interview with the Rehab Director was conducted on 7/24/19 at 1:40 PM. The Rehab Director stated Resident #9 was currently receiving OT Services but did not include the application of the left resting hand splint. She further stated the RA was responsible for the application of the splint since 12/4/18 when the Restorative Plan started. An interview was conducted with the MDS Coordinator on 7/24/19 at 3:26 PM. The MDS Coordinator stated that Resident #9 was on the Restorative Program from 12/4/18 to present. She stated that in order to code the application of the splint on Resident #9's annual MDS and quarterly MDS, they need to have all the components which included the care plan and the restorative progress notes indicating that the service was provided at least three times during the 7-day look-back period. During this interview, the MDS Coordinator looked at Resident #9's flow sheets and stated that she missed coding Resident #9's left resting hand splint on both her annual MDS and quarterly MDS. She further stated that she had made an error and was not sure why she did not code the splint for Resident #9. She said the Quarterly MDS dated [DATE] was recently completed but hasn't been transmitted yet so she could still make the correction, but she would have to correct the annual MDS dated [DATE]. On 7/24/19 at 3:45 PM, an interview with the Director of Nursing (DON) was conducted with the Corporate MDS Nurse present. The DON stated that if all the components needed to code the splint on the MDS were present, Resident #9 should have been coded for her left resting hand splint. She further stated that both the annual MDS dated [DATE] and the quarterly MDS dated [DATE] for Resident #9 were coded inaccurately. She was not sure why the MDS Coordinator had made this error on Resident #9's MDS. On 7/25/19 at 8:06 AM, a follow-up interview with the MDS Coordinator revealed she realized the reason she did not code the splint application on Resident #9's Annual and Quarterly MDS was due to a lack of nursing evaluation and note within the 7-day look-back period. She stated that the nursing evaluation was a descriptive nursing note regarding the application of the splint which could have been written by any nurse. She further stated she was not sure why there wasn't a note in Resident #9's medical record but that she signed off on the Restorative Nursing Services flowsheets once a month. A follow-up interview was conducted with the DON and the Assistant Director of Nursing (ADON) on 7/25/19 at 9:18 AM. Both the DON and the ADON were unsure about whether a nursing note was required about the splint application on Resident #9. The DON stated that if the MDS Coordinator's signature on the restorative nursing notes was enough evidence that she had evaluated it, then this would be considered as meeting the criteria and all the components were present to code the splint for Resident #9. They both stated that if this was the case, then the annual MDS and the quarterly MDS for Resident #9 were coded incorrectly. On 7/25/19 at 11:06 AM, an interview with the Administrator revealed that it was his expectation that the MDS Coordinator coded Resident #9's MDS assessments accurately and documented on the medical record about Resident #9's progress regarding her splint application. The Administrator further stated that the MDS Coordinator was probably not aware that she should be documenting, and that he would need to re-educate the MDS Coordinator and make sure this issue was corrected.

Based on observations, record review, and resident and staff interviews the facility failed to store a medication in a locked storage area by leaving a medication unattended in a resident's room for 1 of 1 resident observed to have a medication in their room (Resident #86). Findings included: 1. Resident #86 was admitted to the facility 04/20/19 with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #86 was cognitively intact and required extensive assistance with bed mobility, transfers, and dressing. Review of the care plans last updated 07/03/19 revealed Resident #86 was not care planned to self-administer medications. An observation on 07/22/19 at 12:08 PM revealed Resident #86 took 2 white capsules from a medication cup on her meal tray and swallowed them. Resident #86 stated the nurse had brought the pills in a few minutes before and that the nurses did not usually leave medications at the bedside unattended. An interview with Nurse #2 on 07/22/19 at 12:11 PM revealed the 2 capsules in the cup on Resident #86's lunch tray were [MEDICATION NAME] (a medication that lowers the phosphorous level of people receiving [MEDICAL TREATMENT]). Nurse #2 stated she should not have left the medication in Resident #86's room unattended and she should have watched Resident #86 take the medication. Nurse #2 stated she forgot to stay with Resident #86 while she was taking her medication. Nurse #2 stated Resident #86 did not have a physician's orders [REDACTED]. An interview with the Director of Nursing (DON) on 07/22/19 at 12:19 PM revealed medication should not be left at the resident's bedside and the nurse should visualize the resident taking the medication. An interview with the Administrator on 07/25/19 at 12:30 PM revealed he expected the nurse to be present when residents took their medication.

Based on observations, record review, family, and staff interviews the facility failed to implement care plan approaches and/or interventions to reduce the risk for fall related injuries for 1 of 3 residents reviewed for falls (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] assessed Resident #1's cognitive abilities were moderately impaired and needed extensive assistance with activities of daily living (ADL) for bed mobility, dressing, toilet use, and personal hygiene. There were no falls prior to admission, entry, or reentry. The Care Area Assessment (CAA) reviewed Resident #1's daily living needs after being admitted for long term related to a recent [MEDICAL CONDITION] who required extensive to total assistance with ADL's and transfers. There was no history of falls, but the CAA identified a risk for falls due to immobility, incontinence, and medication. The care plan initiated 01/04/19 identified Resident #1 was at risk for falls and fall related injuries due to immobility, incontinence, and medication. The goal was to remain free from falls and/or injury through the next review. Interventions included keep the bed in a low and locked position, place frequently used items within reach of the resident, keep the call light within reach, and encourage the resident to call for assistance. Review of a fall incident report dated 01/24/19 at 3:53 AM, Nurse #1 documented she was notified by Nurse Aide (NA) #1, Resident #1 was on the floor. The report described the fall occurred when NA #1 turned the resident on her left side and when she reached for a cream product on the nightstand beside the bed, the resident's lower extremities started to slide off the bed. NA #1 was unable to stop Resident #1 from sliding off the bed to the floor. Nurse #1 entered the room and observed Resident #1 face down on the floor. Nurse #1 notified the on-call physician and obtained an order to send the resident to the emergency room to be evaluated and treated due to the fall. Resident #1's care plan for falls was revised on 01/24/19. The new interventions included 2-person assistance for all self-care tasks, including hygiene and position changes in the bed, place a high/low bed with fall mats x 2, and maintain the bed in lowest position with fall mats on the floor on both sides when left unattended. During an interview on 02/11/19 at 12:36 PM, a family member stated staff told him fall mats would be placed on the floor after Resident #1 returned from the hospital. He revealed the mats were never placed after Resident #1 returned from the hospital. Observations of Resident #1 resting in bed with no staff present revealed on: 02/11/19 at 12:36 PM no fall mats were placed on the floor beside the bed, 02/11/19 at 4:19 PM no fall mats were placed on the floor beside the bed, 02/12/19 at 9:31 AM no fall mats were placed on the floor beside the bed. During an interview on 02/11/19 at 1:44 PM Nurse #2 reviewed the Resident #1's care information and confirmed fall mats were to be placed on the floor on both sides of the bed when she was unattended. The interview further revealed Nurse #2 was unsure why there were no mats observed on 02/11/19 but she stated she would look into it. During an interview on 02/11/19 at 1:51 PM, Nurse Aide #2 explained she was a new employee and only worked as needed. She had provided care for Resident #1 only a few times. She was aware Resident #1 required 2- person assistance with activities of daily living and was transferred using a mechanical lift. She did know where and how to access resident care information using the Nurse Aide computer program used by the facility, but wasn't aware of other care plan interventions for Resident #1. During an interview on 02/12/19 at 12:53 PM, the Director of Nursing revealed it was her expectation care plan approaches and/or interventions would be implemented and in place which included fall mats on both sides of the bed.

Based on observations, record reviews, and interviews the facility failed to provide modified utensils and cups for 5 of 6 residents (Resident #50, Resident #47, Resident #98, Resident #73, and Resident #53) reviewed for adaptive equipment. The findings included: 1. A quarterly Minimum Data Set ((MDS) dated [DATE] for Resident #50 revealed she had [DIAGNOSES REDACTED]. Resident #50 was cognitively intact and required extensive assistance with eating. The quarterly MDS coded Resident #50 as having a swallowing disorder and receiving a therapeutic diet. The care area assessment (CAA) for nutrition dated 7/27/17 revealed Resident #50 required a weighted spoon. A working care plan (a quick care reference guide for the nurse aides caring for each resident) dated 10/27/15 indicated Resident #50 was to receive adaptive feeding equipment as needed. A care plan for Resident #50 for the potential for dehydration last updated 5/2/18 indicated she should receive adaptive equipment as needed or recommended. On 6/4/18 at 12:35 PM Resident #50 was observed in the main dining room feeding herself with regular utensils. An observation of Resident#50's tray card at the same date and time stated she was to receive weighted utensils. In an interview with the Dietary Manager (DM) on 6/4/18 at 12:35 PM she stated Resident #50 should have received weighted utensils and she was not sure why the resident did not receive them. The DM stated all residents with orders for adaptive equipment should receive adaptive equipment. 2. A quarterly MDS for Resident #47 dated 4/16/18 revealed he had [DIAGNOSES REDACTED]. Resident #47 was coded as being cognitively intact and required extensive assistance with eating. Resident #47 was also coded as having a swallowing disorder and receiving a therapeutic diet. A working care plan for Resident #47 dated 5/14/18 stated he was to receive adaptive feeding equipment as needed or recommended. On 6/4/18 at 12:45 PM Resident #47 was observed in the main dining room feeding himself with regular utensils. An observation of Resident #47's tray card at the same date and time stated he was to receive foam handled utensils. In an interview with nurse #3 on 6/4/18 at 12:45 PM she stated Resident #47 should have foam handle utensils and she was not sure why the resident did not have them. In an interview with the DM on 6/4/18 at 12:47 PM she stated Resident #47 should have had foam handled utensils but the kitchen had run out of foam and it was being reordered. The DM further stated she was not sure how long the foam for utensils had been unavailable. 3. An annual MDS dated [DATE] for Resident #98 revealed she had [DIAGNOSES REDACTED]. Resident #98 was coded as being cognitively impaired and required extensive assistance with eating. Resident #98 was also coded as having a swallowing disorder and receiving a mechanically altered diet. A working care plan for Resident #98 dated 5/7/18 stated she must have cups with lids and was to receive adaptive feeding equipment as needed or recommended. A care plan for Resident #98 last updated 5/29/18 for potential for weight loss stated resident was to receive adaptive feeding equipment as needed or recommended. On 6/4/18 at 12:50 PM Resident #98 was observed in the main dining room being assisted with her lunch tray. Resident #98 had 2 cups of liquid on her tray with no lids in place. An observation of Resident #98's tray card at the same date and time stated she was to receive all drinks in a sippy cup. In an interview with the DM on 6/4/18 at 12:52 PM she stated the facility considers any cup with a lid a sippy cup. The DM also stated that Resident #98 did not receive a lid for either cup on her lunch tray. The DM further stated nurses or nurse aides (NAs) were responsible for providing liquids to residents when they ate in the dining room. The DM stated nursing should have placed lids on both of Resident #98's cups. An interview with NA #2 on 6/4/18 at 12:57 PM revealed nurses and NAs are responsible for setting up and delivering resident beverages when residents eat in the dining room. NA #2 stated that a sippy cup was a cup with a lid in this facility. 4. An annual MDS dated [DATE] for Resident #73 revealed she had [DIAGNOSES REDACTED]. Resident #73 was coded as being cognitively impaired and requiring extensive assistance with eating. Resident #73 was also coded as having a swallowing disorder and receiving a mechanically altered diet. A working care plan dated 9/19/16 for Resident #73 stated she required adaptive equipment as needed or recommended. A care plan for Resident #73 last updated 5/22/18 for potential weight loss stated resident was to receive adaptive equipment as needed or recommended. On 6/4/18 at 1:01 PM Resident #73 was observed in the main dining room being assisted with set up of her lunch tray. Resident #73 had regular utensils on her tray. An observation of Resident #73's tray card at the same date and time stated she was to receive foam handled utensils. In an interview with NA #2 on 6/4/18 at 1:01 PM she stated Resident #73 should have had foam handled utensils, the kitchen should have sent them, and it was an oversight that she did not get them. 5. A quarterly MDS for Resident #53 dated 4/19/18 revealed she had [DIAGNOSES REDACTED]. Resident #53 was coded as being cognitively intact and requiring extensive assistance with eating. Resident #53 was also coded as having a swallowing disorder and receiving a mechanically altered diet. A working care plan dated 5/7/18 stated Resident #53 stated she required adaptive feeding equipment as needed or recommended. A care plan for Resident #53 last updated 5/3/18 for being at risk for aspiration stated Resident #53 was to receive adaptive equipment as needed or recommended. On 6/6/18 at 8:19 AM Resident #53 was observed in the main dining room eating her breakfast tray. Resident #53 had regular utensils on her tray. An observation of Resident 53's tray card at the same date and time stated she was to receive foam handled utensils. In an interview with NA #3 on 6/6/18 at 8:19 AM she stated resident #53 should have received foam handled utensils and she went to the kitchen to get the correct utensils. An interview on 6/6/18 at 4:46 PM with the Administrator revealed he expected residents to receive adaptive equipment as ordered or recommended.

Based on observations and staff interviews the facility failed to remove expired food for 1 of 1 walk in coolers and label and date potentially hazardous food after opening for 1 of 1 kitchen storage rooms. The findings included: 1. Initial observation of walk in cooler on [DATE] at 9:35 am revealed a bag of pre-packaged coleslaw available for use with an expiration date of [DATE]. 2. Initial observation of the kitchen storage room on [DATE] at 9:42 am revealed the following foods were unlabeled and undated: 1 bag of [MEDICATION NAME] spaghetti 1 bin of sugar 1 bin of flour An interview with the Dietary Manager (DM) on [DATE] at 9:45 am revealed that all food should be discarded or used before the expiration date. The DM further stated all food in the kitchen storage room should be labeled and dated at the time it was opened. An interview with the Administrator on [DATE] at 4:46 pm revealed it was his expectation food in the walk in cooler or kitchen storage room be labeled and dated at the time it was opened.

Based on observations, record reviews, and resident and staff interviews the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions that the committee had previously put into place. This failure related to three recited deficiencies that were originally cited following the [DATE] annual recertification survey, recited following the [DATE] complaint investigation and recited again on the current recertification and complaint investigation survey. The recited deficiencies were in the areas of safe/clean/comfortable/homelike environment, free of accident hazards/supervision/devices, and food procurement, store/prepare/serve - sanitary. The continued failure of the facility during three federal surveys of record show a pattern of the facility's inability to sustain an effective Quality Assurance Program. Findings included: This tag is cross referenced to: 1. a. 483.10 Safe/Clean/Comfortable/Homelike Environment: Based on observations, staff and resident interviews, the facility failed to maintain residents' wheelchairs in good repair for 2 of 8 sampled residents reviewed (Residents #18 and #58). During the annual recertification survey of [DATE] the facility was cited for failure to label and store personal care items in a resident's shared bathroom. b. 483.25 Free of Accident Hazards/Supervision/Devices: Based on observations, record review, and staff interviews the facility failed to ensure equipment was in working order for 1 of 3 residents reviewed for mechanical lift transfers (Resident #26). During the complaint investigation of [DATE] the facility was cited for failure to provide a safe environment and maintain safe use of side rails on a resident's bed who got his head stuck in the side rail of his bed and his head had to be released from inside the rail by fire rescue personnel. c. 483.60 Food Procurement, Store/Prepare/Serve - Sanitary: Based on observations and interviews the facility failed to remove expired food for 1 of 1 walk in coolers and failed to label and date potentially hazardous food after opening for 1 of 1 kitchen storage rooms. During the annual recertification survey of [DATE] the facility was cited for failure to maintain freezer temperatures at 0 degrees Fahrenheit, failure to ensure all dishes stored ready for use were completely dry with no water on the surfaces, and failed to ensure fly activity measures were effective to prevent fly activity over the kitchen meal service line. During an interview on [DATE] at 5:00 PM the Administrator stated after the recertification survey of [DATE] the Quality Assessment and Assurance (QAA) committee met to review the areas of concern and systems were put into place to correct the deficiencies cited. He explained the monitoring of the systems put into place were overshadowed by the areas of concern identified during the complaint investigation of [DATE] and for the first part of this year, their focus has been identifying, correcting and monitoring the safety of side rail use for the residents. The Administrator added the repeated areas of concern would be reviewed by the QAA committee to discuss and develop a plan of action.

Based on observations, record review and staff interviews the facility administration failed to administer a safe, systemic approach with the use of side rails and failed to conduct regular inspection of all bed frames, mattresses and bed rails as a part of a regular maintenance program when a resident (Resident #1) got his head stuck in the side rail of his bed and his head had to be released from inside the rail by fire rescue personnel in 1 of 81 beds with side rails with openings that had the potential for entrapment out of a total of 130 beds in the facility. Immediate Jeopardy began on 10/24/17 when on the admission MDS side rails were not coded as a restraint for Resident #1. Immediate Jeopardy was removed on 11/18/17 when the facility provided and implemented a Credible Allegation of Compliance. The facility remains out of compliance at a scope and severity level of E (Pattern with no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put into place are effective. Findings included: 1. Cross refer to F 221: Based on observations, record review and physician and staff interviews the facility failed to provide an environment free from restraints when a resident (Resident #1) got his head stuck in the side rail of his bed and his head had to be released from inside the side rail by fire rescue personnel in 1 of 81 beds with side rails with openings that had the potential for entrapment out of a total of 130 beds in the facility. 2. Cross refer to F 278: Based on record reviews and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) of a resident for use of side rails as a potential restraint. The resident (Resident #1) got his head stuck in the side rail of his bed and his head had to be released from inside the side rail by fire rescue personnel for 1 of 4 sampled residents who had side rails on their beds. 3. Cross refer to F 279: Based on observations, record review and staff interviews the facility failed to develop a comprehensive care plan which included side rails as a potential restraint for 1 of 1 sample residents reviewed for physical restraints. Resident #1's head was entrapped in the side rail of his bed and he had to be released from the side rail by fire rescue personnel (Resident #1). 4. Cross refer to F 323: Based on observations, record review and physician and staff interviews the facility failed to provide a safe environment and maintain safe use of side rails on a resident's bed for a resident (Resident #1) who got his head stuck in the side rail of his bed and his head had to be released from inside the rail by fire rescue personnel in 1 of 81 beds with side rails with openings that had the potential for entrapment out of a total of 130 beds in the facility. During an interview with the Administrator on 11/19/17 at 2:43 PM he stated he felt the facility had to be more proactive instead of reactive to make sure equipment for residents was safe. He further stated they could not let their guard down and new systems put into place had to stay in place. He explained he and the Director of Nursing completed a facility assessment and had discussed the need to purchase new beds but they were a large capital expense for the facility. The Administrator, ADON, Regional Consultant of Clinical Services and Corporate Consultant of Clinical Services were informed of Immediate Jeopardy on 11/18/17 at 3:00 PM. The facility provided an acceptable credible allegation for immediate jeopardy removal on 11/18/17 at 8:45 PM. Credible allegation for Hendersonville Health and Rehabilitation F490- Hendersonville Health and Rehab will assure the facility administers in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited; On 11/15/17 at approximately 6:30 AM resident # 1 (room [ROOM NUMBER] B) was found by an employee #1. Employee #1, the NA/MA, was working as his medication aide on the 100 hall. She had been working the 7 PM to 7 AM shift. She was on the 100 hall from 11 PM to 7 AM. Employee #1 was in room [ROOM NUMBER] B @ 5:30 AM and resident #1 was in the bed with his head elevated at approximately 45 degrees. Employee #1 gave him his morning medications and noted nothing abnormal about the resident. Employee #1 returned to room [ROOM NUMBER] B at approximately 6:30 AM to check his blood pressure. At that time, Employee #1 noted the top of resident #1's head up to the bridge of his nose was stuck through the side rail on the left side of his bed and his legs were still in the bed. The side rails on both sides of his bed were up. He was on an air mattress. He was talking and answering questions that Employee #1 was asking him. Employee # 1 did not attempt to assist resident #1 at that point. Employee #1 immediately stepped outside the door and asked Employee # 2 (CNA) to get a nurse. Nurse #1, LPN, and Nurse #2 LPN arrived to room [ROOM NUMBER] B within a minute and arrived within seconds of each other. Both assessed the situation and realized the resident had his head up to the bridge of his nose stuck in the side rail. Nurse #1 left the room to get a lubricant. Nurse #1 returned with the lubricant and both nurses began to move his legs off of the bed to line his body up. They worked to free resident #1 from the side rail for approximately 5 minutes. He began to say he was hurting. The nurses stopped and Nurse #2 LPN called 911. The procedure for implementing the acceptable plan of correction for the specific deficiency cited; Director of clinical operations in serviced the administrator and maintenance director and Environmental service director on the current federal regulation changes. All department heads, licensed/certified staff were in-serviced on the bed rail regulation changes. This will be included in the new hire orientation. On 11/18/17 the Director of Clinical Operations in-serviced the administrator, maintenance director and Environmental service director and multiple other staff. The facility self-assessment tool will be reviewed by the Administrator, DON, ADON, Medical Director, Activity Director, Dietary Director, Environmental service director Maintenance director, social services and MDS Director and revised to incorporate the tags received from this immediate jeopardy and will be brought to QA monthly for the next three months and at least annually to assure compliance. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements; DON and or Administrator will review and revise the facility assessment tool by November 18, 2017 to incorporate the cited deficiencies outlined in the immediate jeopardy. Administrator will review this process. o The title of the person responsible for implementing the acceptable plan of correction. Director of Nursing and Administrator We certify that as of November 18, 2017 the immediate jeopardy will be removed. Immediate Jeopardy was removed on 11/18/17 when interviews with nurses who validated they had received in-service training on bed side rail regulation changes. They also confirmed they had received in-service training on the new side rail assessment forms. Administrative staff which included the EVS Director and Maintenance Director were interviewed and stated they had been in-serviced on bed side rail regulation changes. The Maintenance Director confirmed he would conduct inspections of beds, mattresses and side rails on a regular basis. 5. Cross refer to F 461: Based on observations, record review and staff interviews the facility failed to conduct regular inspection of all bed frames, mattresses and bed rails as a part of a regular maintenance program and a resident (Resident #1) got his head stuck in the side rail of his bed and his head had to be released from inside the rail by fire rescue personnel in 1 of 81 beds with side rails with openings that had the potential for entrapment out of a total of 130 beds in the facility. The facility was cited at tag F461 at a scope and severity level of E.

Based on record reviews and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) of a resident for use of side rails as a potential restraint. The resident (Resident #1) got his head stuck in the side rail of his bed and his head had to be released from inside the side rail by fire rescue personnel for 1 of 4 sampled residents who had side rails on their beds. Immediate Jeopardy began on 10/24/17 when on the admission MDS side rails were not coded as a restraint for Resident #1. Immediate Jeopardy was removed on 11/18/17 when the facility provided and implemented a Credible Allegation of Compliance. The facility remains out of compliance at a scope and severity level of D (Isolated no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put into place are effective. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was severely impaired in cognition for daily decision making. The MDS also indicated Resident #1 was totally dependent on staff for bed mobility and transfers and side rails were not coded as a restraint. A facility document titled Initial or Annual Side Rail assessment dated [DATE] indicated Resident #1 had half side rails on each side of the bed at the head of the bed. The document further indicated Resident #1 needed total assistance from care givers. During an interview on 11/17/17 at 3:56 PM, Nurse #4 confirmed she had completed a nursing admission assessment and a side rail assessment for Resident #1 but did not do any coding on MDS assessments. She explained she had documented on the admission nursing assessment that side rails were indicated for Resident #1 because it was her (Nurse #4) usual routine to check the side rails box since all resident beds had side rails on them. She stated she had not considered the side rails on Resident #1's bed to be a restraint but when he got his head stuck in the side rail then she felt they were a restraint. Resident #1 had an unplanned discharge to the hospital on [DATE] and was readmitted to the facility on [DATE]. A facility document titled Initial or Annual Side Rail assessment dated [DATE] indicated Resident #1 had quarter length side rails on both sides of his bed at the head of the bed. The document further revealed Resident #1 had decreased level of consciousness and needed extensive assistance for bed mobility. During an interview on 11/17/17 at 4:37 PM, Nurse #5 confirmed she completed an admission nursing assessment for Resident #1 on 11/04/17 because he had been gone to the hospital for 3 days. She stated she did not do any coding on an MDS. She stated she would consider a side rail to be a restraint when a resident would not be able to get out of bed or the side rail was blocking their exit. A review of an incident report dated 11/15/17 at 6:30 AM completed by the Assistant Director of Nursing (ADON) revealed NA#1 entered Resident #1's room to check his blood pressure and Resident #1 was observed with the top of his head in the upper side rail. The report indicated when Resident #1 was asked what he was doing, he replied he was trying to break his neck, then stated no he was trying to get cooler and get more air. The report further indicated NA#1 attempted to reposition Resident #1 to slip his head from the opening of the rail but Resident #1 was minimally cooperative. The report revealed lubricant was applied to Resident's #1's head and the fire department was called for assistance on moving Resident #1 and they arrived and assisted with easy removal of his head from the side rail. The report indicated Nurse #2 assessed Resident #1 for injuries and he had redness to his nose and left cheek. The report also indicated half-length side rails were on Resident #1's bed and immediate actions taken were to provide one on one supervision with a staff member and physician and responsible party (RP) were notified. During an interview on 11/17/17 at 5:11 PM, the MDS Nurse explained she had not coded the side rails as restraints on Resident #1's MDS because there was no place to code side rails on the MDS unless they were used as a restraint. She stated she had not considered the side rails on Resident #1's bed to be a restraint until he got his head stuck in the side rail. During an interview on 11/18/17 at 2:57 PM, the Director of Nursing explained the Administrator had oversight of MDS. She further stated it was her expectation for MDS assessments to be coded accurately. During an interview on 11/19/17 at 2:43 PM, the Administrator stated it was his expectation MDS assessments to be coded accurately. The Administrator, ADON, Regional Consultant of Clinical Services and Corporate Consultant of Clinical Services were informed of Immediate Jeopardy on 11/18/17 at 11:13 AM. The facility provided an acceptable credible allegation for immediate jeopardy removal on 11/18/17 at 9:54 PM. Credible allegation for Hendersonville Health and Rehabilitation for F278 - Hendersonville Health and Rehab will assure that each resident receives an accurate assessment by a qualified staff member who will assess relevant care areas and have specific knowledge about the resident's status, needs, strengths, and areas of decline. On 11/18/17 Hendersonville Health and Rehab re-evaluated their process to ensure the residents right to an accurate assessment as outlined below. The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited; On 11/4/17 Resident #1 was assessed by the licensed admissions nurse using the side rail assessment from the electronic medical record. Following the incident with resident #1 the Director of Clinical Operations updated the side rail evaluation to include the (residents cognitive status, bed mobility status, danger zone status and the proper bed sizing status) to be completed by the licensed nurses upon admission, readmission, significant change in condition and quarterly to ensure a more accurate evaluation of resident safety. The procedure for implementing the acceptable plan of correction for the specific deficiency cited; On 11/18/17 a 100% audit was completed by the ADON, DON and Regional Clinical Manager to assure accuracy of resident assessments related to side rails. On 11/18/17 a 100% MDS audit was completed by the by the ADON, DON and Regional Clinical Manager to assure accuracy of resident assessments related to side rails. On 11/18/17 100% MDS nurses were re-educated by the DON/ADON on accurate coding of the MDS assessments according to the RAI manual. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements; 1. On 11/18/17 a 100% audit was completed by the ADON, DON and Regional Clinical Manager to assure accuracy of resident assessments related to side rails. On 11/18/17 a 100% MDS audit was completed by the ADON, DON and Regional Clinical Manager to assure accuracy of resident assessments related to side rails. Any negative findings were addressed by the DON, ADON, Unit Manager, maintenance director and environmental services director to assure resident safety. 2. Side rail assessments will be completed upon admission, re-admission, quarterly, and with any significant change in the resident's condition by a licensed nurse. Identified problems will be addressed by the DON, ADON, Unit Manager, licensed nurse, maintenance director and or environmental services director. 3. On 11/18/17 100% MDS nurses were re-educated by the DON/ADON on accurate coding of the MDS assessments according to the RAI manual. DON and ADON will audit residents MDS assessments for accuracy x 2 weeks. Then 50% will be audited x 2 weeks, then 10% weekly x 4. The results of the audits will be reviewed weekly by the Regional Clinical Manager x 8 weeks to ensure the facility is in compliance with F278. The QA Executive Committee members will then determine the continued need and frequency of audits for F278. The title of the person responsible for implementing the acceptable plan of correction: Director of Nursing and Administrator We certify that as of November 18, 2017 the immediate jeopardy will be removed. Immediate Jeopardy was removed on 11/18/17 when interviews with nurses validated they had received in-service training on side rail assessments on admission, readmission, quarterly and with any significant change in the resident's condition. Interviews with MDS nurses revealed they had also received in-service training regarding accuracy of coding the MDS and accuracy related to side rail assessments.

Based on observations, record review and physician and staff interviews the facility failed to provide a safe environment and maintain safe use of side rails on a resident's bed for a resident (Resident #1) who got his head stuck in the side rail of his bed and his head had to be released from inside the rail by fire rescue personnel in 1 of 81 beds with side rails with openings that had the potential for entrapment out of a total of 130 beds in the facility. Immediate Jeopardy began on 11/15/17 when Resident #1 had his head stuck in the left side rail at the head of his bed and had to be released from inside the side rail by fire department personnel. Immediate Jeopardy was removed on 11/18/17 when the facility provided and implemented a Credible Allegation of Compliance. The facility remains out of compliance at a scope and severity level of D (Isolated no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put into place are effective. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was severely impaired in cognition for daily decision making. The MDS also indicated Resident #1 was totally dependent on staff for bed mobility and transfers. A facility document titled Initial or Annual Side Rail assessment dated [DATE] indicated Resident #1 had half-rails times (x) 2 sides, was able to participate appropriately in decision making, was not able to get out of bed independently and desired to have side rails in raised position while in bed. The document further indicated Resident #1 was alert and oriented for bed mobility and needed total assistance from care givers. A section labeled Side Rail Conclusions indicated side rails defined the perimeter of the bed, side rails do not prevent resident from getting out of bed, side rails are not considered a restraint, and side rails are not considered a restraint while in use. A review of an Admission Nursing Evaluation dated 10/25/17 in a section labeled orientation to facility indicated side rails were indicated. During an interview on 11/17/17 at 3:56 PM, Nurse #4 explained nurses were expected to complete a nursing admission assessment and a side rail assessment when a resident was admitted . She stated nurses were also expected to complete these assessments again when a resident was readmitted if the resident was out of the facility for longer than 24 hours. She confirmed she had completed a nursing admission assessment and a side rail assessment for Resident #1 on 10/18/17 but indicated the date on the nursing admission assessment from the computer system was 10/31/17 and she was not sure why. She explained she had indicated in the section on the admission nursing assessment in a section for orientation to the facility that side rails were indicated for Resident #1 because it was her usual routine to check the side rails box since all resident beds had side rails on them. She further explained she had indicated on the side rail assessment Resident #1 was able to participate appropriately in decision making because he could hold onto the side rail and it was easy for staff to turn him and change him and reposition him because of the side rails on the bed. She stated she thought side rails defined the perimeter of the bed and she thought they were safe. She explained she had indicated Resident #1 desired to have side rails in raised position in bed because that was what she usually put on the assessment. She stated she would consider a side rail to be a restraint when a resident could not get out of bed by themselves. She then confirmed Resident #1 could not get out of bed by himself and stated when he got his head stuck in the side rail then it was a restraint. She stated every resident had side rails on their bed and residents' used them to get in and out of bed. She further stated she had received no training in the facility to determine the length of side rails but based on her nursing experience the side rails that were on Resident #1's bed when he got his head stuck were half-length side rails. She explained Resident #1 was calm at times but at other times he moved and squirmed in bed and there were a few times when she had seen him twisted in bed and she and the NAs had repositioned him. Resident #1 had an unplanned discharge to the hospital on [DATE] and was readmitted to the facility on [DATE]. A review of an Admission Nursing Evaluation dated 11/04/17 indicated in a section labeled orientation to facility Resident #1 was unable to be oriented. A facility document titled Initial or Annual Side Rail assessment dated [DATE] indicated Resident #1 had quarter side rail in use x 2 sides. The assessment further revealed Resident #1 was able to participate appropriately in decision making, was not able to get out of bed independently and desired to have side rails in raised position while in bed. The assessment also revealed Resident #1 had decreased level of consciousness and needed extensive assistance for bed mobility. A section labeled Side Rail Conclusions indicated, side rails do not define the perimeter of the bed, side rails do not prevent resident from getting out of bed, side rails are not considered a restraint, and side rails are not considered a restraint while in use. During an interview on 11/17/17 at 4:37 PM, Nurse #5 confirmed she completed an admission nursing assessment for Resident #1 on 11/04/17 because he had been gone to the hospital for 3 days. She explained she indicated on the admission nursing assessment Resident #1 was unable to be oriented to the facility because when he came back from the hospital he was not as alert as he had been before. She stated nurses were expected to complete a side rail assessment with every nursing admission assessment to determine if the side rail was a restraint. She further stated they did not use half-length side rails in the facility and only used quarter-length side rails because half-length side rails would be considered a restraint. She explained when she completed Resident #1's side rail assessment on 11/04/17 she determined from a mobility standpoint his preferences for side rails. She stated Resident #1 used the side rail to hold on to when staff repositioned him but he could not turn himself in bed. She further stated Resident #1 would wiggle and squirm in bed at times. She confirmed Resident #1 did not say he desired to have the side rails up but he used them as an aid when turning and repositioning. She stated, in regard to bed mobility, Resident #1 was extensive assist with 2 staff and stated she did not think the side rails defined the perimeter of the bed because the side rails did not cover the whole bed since they were only at the top. She further stated she would consider a side rail to be a restraint when a resident would not be able to get out of bed or the side rail was blocking their exit. She then verified Resident #1 was not able to get out of bed by himself but she had not considered the side rail on Resident #1's bed as a restraint. She stated every bed in the facility had side rails on them and there were different types of beds and side rails. A review of a care plan with a problem onset date of 11/06/17 revealed Resident #1 had activities of daily living (ADL) deficits and impaired physical mobility. The goals indicated in part Resident #1 would remain free from immobility complications and the interventions were listed in part to provide bed mobility and transfers and turn and reposition frequently. There were no interventions documented regarding side rails. A review of a nurse's note documented by Nurse #2 indicated on 11/15/17 at 6:00 AM revealed Nurse Aide (NA) #1 who was also a Medication Aide reported that Resident #1 had his head through the side rail of his bed and was stuck. The notes indicated nurses x 2 applied lubrication to his face in an attempt to slide his head out without success. The notes further indicated 911 was called and the fire department and Emergency Medical Services (EMS) was sent to the facility to attempt to free Resident #1's head without injury. The notes further revealed Resident #1 was turned in the bed and his head eventually slid out and there was a red mark and indentation on his left cheek from pressure from the side rail but there was no apparent injury. A review of an incident report dated 11/15/17 at 6:30 AM completed by the Assistant Director of Nursing (ADON) revealed NA #1 entered Resident #1's room to check his blood pressure and Resident #1 was observed with the top of his head in the upper side rail. The report indicated when Resident #1 was asked what he was doing, he replied he was trying to break his neck, then stated no he was trying to get cooler and get more air. The report further indicated NA#1 attempted to reposition Resident #1 to slip his head from the opening of the rail but Resident #1 was minimally cooperative. The report revealed lubricant was applied to Resident's #1's head and the fire department was called for assistance on moving Resident #1 and they arrived and assisted with easy removal of his head from the side rail. The report indicated Nurse #2 assessed Resident #1 for injuries and he had redness to his nose and left cheek. The report also indicated half-length side rails were on Resident #1's bed and immediate actions taken were to provide one on one supervision with a staff member and physician and responsible party (RP) were notified. A review of a Fire and Rescue Report dated 11/15/17 at 7:17 AM indicated 2 rescue personnel responded to a call from the facility and Resident #1 had his head stuck in a side rail. The report further indicated rescue personnel had nurses rotate Resident #1's body while they pushed his head toward the mattress in order to free him. The report also indicated there were no injuries or complaints of pain by Resident #1 after his head was released from the side rail. During a telephone interview on 11/16/17 at 4:05 PM, NA#1 who was also a Medication Aide stated she took medications to Resident #1 on 11/15/17 at 5:30 AM and he was fine. She explained she went back into Resident #1's room to take his blood pressure at 6:30 AM and found him lying across the bed with his head in the left side rail and his legs were off the right side of the bed. She stated she asked him what he was doing to get into that position and he said he was trying to break his neck then said he was trying to get some air. She stated he had a nasal cannula with oxygen on and had an air mattress on his bed which was inflated. She explained she called for Nurse Aides (NAs) #2 and #6 to help and then NA#2 went to get Nurse #1 and Nurse #2. She stated the nurses went and got lubricant and rubbed it on Resident #1's head to try to slide his head out but he wasn't tolerating that well so they stopped and called the fire department and they were able to get Resident #1 repositioned and got his head out of the side rail. She further stated the left side of Resident #1's face was red from the pressure from the bed rail. During a follow up interview on 11/17/17 at 9:12 AM, NA #1 clarified Resident #1 came back to the facility from the hospital at 1:08 AM on 11/15/17 and his blood pressure was high so she was keeping a check on it about every hour. She stated each time she went in his room he was on his back and the head of his bed was elevated approximately 45 degrees and both side rails were raised up at the head of his bed. She explained at 5:30 AM she took his morning meds to him and he was fine and the head of the bed was still up at approximately 45 degrees. She stated at approximately 6:30 AM she went back to check Resident #1's blood pressure and found Resident #1 with his head stuck in the left side rail from the back of his head to the bridge of his nose. She explained Resident #1 did not seem to be in distress and was calm but his head seemed to be really stuck. She further explained when Nurse #1 and Nurse #2 were putting lubricant on Resident #1's head and face Resident #1 put his hands on the bed rail and was pulling himself further into the opening of the side rail and they told him to stop pulling on the rail. She stated she and NA #6 were holding Resident #1's legs because they were hanging off the side of the bed and when the fire department and EMS got there they said they had cutters and were going to cut the side rail but when they pulled Resident #1's legs toward the head of the bed and he was straight across the mattress then his head came out of the side rail. She further stated side rails were common in the facility and as far as she knew, every resident had side rails on their bed. During an interview on 11/17/17 at 6:45 AM, NA #2 stated she worked the night shift on 11/15/17 and made rounds around 5:20 AM with NA #6 and checked on Resident #1 and at that time Resident #1 was asleep with oxygen on. She further stated she did not know anything had happened until NA#1 told her to get a nurse. She explained NA #1 stayed with Resident #1 and NA #2 told Nurse #1 to go to Resident #1's room. She stated after Nurse #1 went into Resident #1's room she then went to get lubricant and Nurse #1 told her to go get the ADON. NA #2 further stated Resident #1 said he was trying to get fresh air but she did not know how he could have gotten his head stuck in the side rail. During an interview on 11/17/17 at 7:05 AM, NA #6 stated on 11/15/17 she assisted NA #2 and they had checked Resident #1 during their last round around 5:20 AM and he was lying on his left side. She explained later she was coming off her assigned hall when NA #1 motioned for her to come to Resident #1's room. She explained when she got to Resident #1's room he had his head caught in the left side rail. She stated Resident #1 said he was looking for fresh air and they tried to get his head out with lubricant but his head wouldn't budge. She explained they called the fire department and EMS and they came and got his head out and Resident #1 had an indention on the left side of his face from the side rail. During an interview on 11/17/17 at 7:15 AM, Nurse #1 stated on 11/15/17 she walked to a medication room and NA #2 came in and told her NA#1 needed her help in Resident #1's room. She explained she walked into Resident #1's room and he was lying on his left side with his head stuck inside the side rail. She stated she asked Resident #1 why his head was stuck in the side rail and he said it is cooler on the other side. She explained she told Resident #1 she was going to get some stuff to lubricate his head and free him and then she met Nurse #2 and took her to Resident #1's room and they put the lubricant on his head but it didn't work to get his head out of the side rail. She stated she told someone but could not remember who to go get the ADON and she came in Resident #1's room and they decided to call the fire department and EMS. She explained the only time Resident #1 said anything was when they tried to move him and he said it hurt and his face started to swell. During an interview on 11/16/17 at 11:17 AM, Nurse #2 explained she worked third shift on 11/15/17 and a NA signaled for her to come to Resident #1's room. She stated she could not recall which NA called to her but as she walked by the nurse's station Nurse #1 was coming out of the medication room with a box of lubricant and stated she was going to Resident #1's room. She explained when she entered Resident #1's room he was on his back but leaning toward his left side and his head was stuck in the open part of the left side rail. She stated Resident #1 wasn't talking much but she and Nurse #1 applied lubricant to Resident #1's face and tried to pull him out but it didn't work. She explained NA #2 went to get the ADON to come to Resident #1's room. She stated she thought if they turned Resident #1's body in alignment with his head they could slide him out but that didn't work. She explained he ADON said they should call the fire department and Nurse #2 called 911 and explained the problem and the dispatcher said they would send the fire department and EMS. She stated when the fire department and EMS arrived they turned Resident #1's body to be across the bed and the rescue personnel pushed Resident #1's head back through the rail and his head slid out. She explained Resident #1 had an indentation and a red mark from the side rail on his left cheek but there was no broken skin. She stated she did not know how he got his head stuck in the rail. During an interview on 11/16/17 at 12:09 PM, the ADON explained NA #2 came and got her around 6:30 AM on 11/15/17 and told her to come to Resident #1's room. She stated when she entered Resident #1's room, he was lying sideways in the bed with his upper body toward the left side of the bed and his head was in the left side rail up to the bridge of his nose and his left cheek was pressed into the rail. She explained Resident #1 was groaning and someone had put lubricant on his face and forehead to try to slide his head out but it didn't help. She stated Nurse #2 called 911 and the fire department and EMS came but she wasn't in the room when they got his head out of the side rail. She explained she called the Nurse Practitioner (NP) and was told a physician would be at the facility later that day to see Resident #1. She stated the NP also stated she would talk with the Medical Director to let him know but to continue to provide Resident #1 with one-on-one supervision. The ADON stated she then called Resident #1's RP. During an interview on 11/16/17 at 1:30 PM, Nurse #6 stated she arrived at work on 11/15/17 at 6:45 AM and staff were in Resident #1's room waiting for the fire department and EMS. She explained Resident #1 normally slept a lot during the day but sometimes during the evening he had a tendency to be restless. She stated she had noticed twice lately Resident #1 had his legs thrown over the side of the bed. She stated she asked him why he was restless but he couldn't tell her. During an interview on 11/16/17 at 3:00 PM, NA #3 stated she was told yesterday morning on 11/15/17 around 7:00 AM during report from third shift Resident #1 had his head stuck into the side rail. She explained the left side of his face was a little red yesterday but there was no redness today. She stated she was surprised Resident #1 had his head stuck in the side rail because she had not seen him try to get out of bed. During an interview and observation on 11/16/17 at 1:05 PM, the Environmental Services (EVS) Director stated he was notified about 7:30 AM on 11/15/17 by the ADON that Resident #1 needed a Hi-Low bed because they had a problem with the side rails on his current bed. He stated he went to Resident #1's room and placed zip ties to secure the side rails to the frame of the bed so they could not be pulled back up and then he called the company to order a Hi-Lo bed. He stated the new bed was delivered around 3:45 PM on 11/15/17 and he took the old bed to a service hall with the side rails still attached to the bed. The EVS Director pointed to a bed in the service hallway and confirmed it was the bed he had removed from Resident #1's room. He then raised the left side rail of the bed and measured the diameter of the 2 largest openings of the side rail. He confirmed both of the large openings were 7.5 inches wide X 7.0 inches high. During an interview on 11/16/17 at 2:10 PM, Physician #1 who was also the facility Medical Director stated a NP had called him yesterday morning on 11/15/17 and told him Resident #1 made the statement about wanting to break his neck and asked if we should send him for psychiatric services. He stated Physician #2 saw Resident #1 on 11/15/17 and did not think Resident #1 was a risk to himself. Physician #1 stated he thought Resident #1 had dementia but did not think he was suicidal. During an observation on 11/16/17 at 5:11 PM Resident #1 was sitting up in bed and had no visible red areas or bruises on his face. During an interview on 11/16/17 at 5:40 PM, NA #4 stated Resident #1 was usually confused when she was assigned to his care and he needed total assistance with activities of daily living. She further stated Resident #1 could scoot down in the bed. During an interview on 11/16/17 at 5:55 PM, NA #5 stated she had provided care to Resident #1 and in the past she had seen him with his legs off the left side of the bed and she had to go and reposition him. During an observation on 11/17/17 at 8:05 AM Resident #1 was lying in bed and NA #3 was on the right side of his bed. Resident #1 had his eyes closed and there were no red areas or bruised visible on his face or neck. During a follow up interview on 11/17/17 at 8:29 AM, the EVS Director explained the type of bed Resident #1 had his head caught in the side rail were old beds from a local hospital that were put in the facility years ago. He stated over the years they had purchased some Hi-Low beds and they had side rails with spaces that were much smaller than the old bed side rails. He stated all beds in the facility had side rails on them because beds came delivered with side rails already on them. He explained they had taken the rails off the beds at the foot because if they had rails at the top and foot they would be restraints. He stated he thought the side rail on the bed that Resident #1's head was stuck in was a quarter-length side rail. He stated there were 130 beds in the facility but he did not have an inventory list of the type of side rails on each bed. During an interview on 11/17/17 at 5:11 PM, the MDS Nurse confirmed she had completed Resident #1's MDS assessment. She stated there was no place to code side rails on the MDS unless they were used as a restraint. She further stated side rails were not listed on Resident #1's care plan because they were not considered restraints. She explained the facility was restraint free and they had never put side rails on a care plan but now she could see side rails were not adequate for some residents. She stated she visited with Resident #1 after he got his head stuck in the side rail and asked him what had happened and he said he was trying to get out there and get some more air but he was not trying to get out of bed. She explained when she had visited with him in the past and he was lying on his side he had his hand resting on top of the side rail. She stated she would not have anticipated the side rail on his bed would have endangered Resident #1. She stated she thought most of the beds in the facility had side rails on them but they did not use half-length side rails. She further stated it was her understanding that side rail assessments were done to determine if the resident wanted the side rails up or down and Resident #1 could answer simple questions but if the questions was complex he had trouble answering them. During an interview on 11/17/17 at 5:39 PM, the Maintenance Director stated every bed in the facility had quarter-length side rails and he thought the side rails were on the beds because that was the way they were delivered. He explained he did maintenance on beds if they squeaked or the brakes didn't work or if the side rails were loose. He confirmed most of the beds in the facility were beds like the one Resident #1 got his head caught in the side rail. He stated newer beds had more compact openings with less space in the openings. He further stated he had not received any work order requests for Resident #1's bed or side rails. He explained the type of bed Resident #1 was in when his head was stuck in the side raid was an older hospital bed manufactured before 1997 because he had found inspection stickers on them from a local hospital dated 1997 and he had ordered replacement parts for the beds that were dated 1996 and 1997. During a follow up interview on 11/17/17 at 5:55 PM, the ADON stated every bed in the facility had quarter-length side rails but if a resident did not want side rails they took them off. She explained a side rail assessment was completed by the nurse when a resident was admitted or readmitted to the facility and the side rail assessment was supposed to determine how the resident used side rails and if the side rails restricted their movements. She stated she knew when Resident #1's head was caught in the side rail it was a problem and if it happened to him it could happen to another resident. During a record review on 11/18/17 at 9:45 AM a service manual for a resident bed revealed the bed was configured to accept sectionalized half-length side rails. The manual further indicated the bed must have the head section side rails because both head section rails contained head and knee controls and hi-low activators to raise the bed up or down. During a follow up interview on 11/18/17 at 10:15 AM, the EVS Director confirmed the service manual for a resident bed was for the same type bed Resident #1 was in when he got his head stuck in the side rail. He also provided a bed audit he had completed on 11/17/17 of all beds in the facility and explained there were 81 beds which were the same type as the bed Resident #1 got his head stuck in the side rail, 33 Hi-Low beds the facility owned, 15 rental beds and 1 personal bed to equal 130 beds in the facility. During an interview on 11/18/17 at 2:57 PM, the Director of Nursing stated she was on vacation earlier in the week but was called by the ADON after Resident #1 got his head stuck in the side rail and she came back to the facility. She further stated she had not considered the side rails on Resident #1's bed to be quarter-length rails but after review of the service manual for the bed she now realized they were half-length side rails. She explained the older beds like the one Resident #1 got his head stuck in the side rail came when the facility was opened years ago. She stated Resident #1 leaned significantly toward his left side regardless of how he was positioned and if his body was in the direction of the side rail with his head near the rail that would have been a red flag. She stated it was her expectation for staff to look and see if the side rail was a positioning device and should not restrict movement of the resident. During an interview on 11/18/17 at 4:05 PM, Physician #1 who was also the facility Medical Director stated he was notified promptly when Resident #1 got his head caught in the side rail. He further stated the incident was left over to [AGE] years with use of beds with older side rail designs. During an interview on 11/19/17 at 2:43 PM, the Administrator stated it was his expectation that any kind of equipment needed to be looked at for potential for harm. He stated when he came to work at the facility earlier this year he did not think to look at the assessments of beds or side rails. He stated it was his expectation staff could not let their guard down but needed to protect residents from harm. The Administrator, ADON, Regional Consultant of Clinical Services and Corporate Consultant of Clinical Services were informed of Immediate Jeopardy on 11/1717 at 2:33 PM. The facility provided an acceptable credible allegation for immediate jeopardy removal on 11/18/17 at 4:58 PM. Credible Allegation for Hendersonville Health and Rehabilitation for F 323- HHR will ensure that the resident's environment will remain free from accident hazards and that each resident will receive adequate supervision to prevent accidents. On 11/15/17 Hendersonville Health and Rehab re-evaluated their processes to ensure that the resident's environment will remain free from accident hazards and that each resident will receive adequate supervision to prevent accidents as outlined below. The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited; On 11/15/17 at approximately 6:30AM resident # 1 (Room 108 B) was found by an employee #1. Employee #1, the NA/MA, was working as his medication aide on the 100 hall. She had been working the 7 PM to 7 AM shift. She was on the 100 hall from 7 PM to 7 AM. Employee #1 was in room 108 B @ 5:30 AM and resident #1 was in the bed with his head elevated at approximately 45 degrees. Employee #1 gave him his morning medications and noted nothing abnormal about the resident. Employee #1 returned to room 108 B at approximately 6:30 AM to check his blood pressure. At that time, Employee #1 noted the top of resident #1's head up to the bridge of his nose was stuck through the side rail on the left side of his bed and his legs were still in the bed. The side rails on both sides of his bed were up. He was on an air mattress. He was talking and answering questions that Employee #1 was asking him. Employee #1 did not attempt to assist resident #1 at that point. Employee #1 immediately stepped outside the door and asked Employee #2 (CNA) to get a nurse. Nurse #1, LPN, and Nurse #2 LPN arrived to room 108 B within a minute and arrived within seconds of each other. Both assessed the situation and realized the resident had his head up to the bridge of his nose stuck in the side rail. Nurse #1 left the room to get a lubricant. Nurse #1 returned with the lubricant and both nurses began to move his legs off of the bed to line his body up. They worked to free resident #1 from the side rail for approximately 5 minutes. He began to say he was hurting. The nurses stopped and Nurse #2 LPN called 911. EMS arrived at approximately 6:45 AM. The nursing staff, EMS and the fire department repositioned the resident in the bed and his head freed from the side rail easily. EMS assessed the resident and left the facility. Resident was evaluated by Nurse #2 (LPN). Redness was noted to bridge of the nose and left cheek. Resident #1 remained 1:1 until a new bed arrived. Resident #1's medical professional was notified of the incident at 7:00 AM on 11/15/17. NP was notified that resident #1 was one on one supervision. She stated a medical professional would be in later on 11/15/17 to assess resident #1. No orders were given. The RP was notified of the incident at 7:15 AM on 11/15/17. ADON pulled a facility census and identified all residents' cognitive status to determine appropriateness of side rails. The ADON then did a facility assessment to determine all residents were safe. MD was in the facility on 11/15/17 at approximately 8:50 AM and assessed the resident. The ADON was in the facility at the time of the incident. The Administrator was notified of the incident by the ADON at 7:13 AM on 11/15/17. The Director of Nursing was notified of the incident by the ADON at 6:40 AM on 11/15/17. The Regional Director of Operations was notified by the Administrator of the incident at 7:30 AM on 11/15/17. The Corporate Nursing Team was notified by the Administrator and ADON of the incident by 7:15 AM and a plan of correction was initiated immediately. o The procedure for implementing the acceptable plan of correction for the specific deficiency cited; Resident #1 was placed on one on one supervision and remained one on one until his new bed arrived. He was placed in his new bed at approximately 4:00 PM on 11/15/17. After evaluation of the resident in the new bed it was determined that the side rails would not be secured in the down position. Brief Interviews for Mental Status (BIM's) scores for all residents were pulled from our electronic medical record (EMR). On November 15, 2017 we assessed all residents for safe use of side rails. Side rail assessments will be completed upon admission, re-admission, quarterly, and with any significant change in the resident's condition. An in-service with the nursing department was done by the unit manager and ADON: proper use of side rails related to mental status and not to remove the zip ties (No staff has or will work until they have received the in-service). All licensed nurs(TRUNCATED)

Based on record review and staff interviews the facility's Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification survey of 07/20/17. This was for one recited deficiency which was originally cited in July 2017 and was subsequently recited on a complaint survey on 11/19/17. The repeat deficiency was in the area to develop a comprehensive care plan. The continued failure of the facility during two federal surveys of record show a pattern of the facility's inability to sustain an effective Quality Assurance Program. Immediate Jeopardy began on 11/06/17 when the facility failed to develop a comprehensive care plan for the use of side rails for Resident #1. Immediate Jeopardy was removed on 11/18/17 when the facility provided and implemented a Credible Allegation of Compliance. The facility remains out of compliance at a scope and severity level of D (Isolated with no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put into place are effective. The findings included: This tag is cross referred to: F279: Develop a Comprehensive Care Plan: Based on observation, record review and staff interviews the facility failed to develop a comprehensive care plan which included side rails as a potential restraint when a resident got his head stuck in the side rail of his bed and his head had to be released from inside the side rail by fire rescue personnel for 1 of 1 resident reviewed for restraints (Resident #1). During the recertification survey of July 20, 2017 the facility was cited at F 279 for failure to develop a comprehensive care plan to include side rails as a restraint for 1 or 1 sampled resident. During an interview on 11/19/17 at 2:40 PM, the Administrator explained the facility conducted monthly Quality Assurance meetings and the Administrator, Director of Nursing (DON), Medical Director, Pharmacist and all of the department managers attended the meetings. The Administrator stated he had no excuse as to why the F279 was a repeat citation but he would work his hardest to prevent it from happening again. The Administrator, Assistant Director of Nursing (ADON) and Regional Consultant of Clinical Services and Corporate Consultant of Clinical Services were informed of Immediate Jeopardy on 11/18/17 at 3:00 PM. The facility provided an acceptable credible allegation for immediate jeopardy removal on 11/18/17 at 7:33 PM. Credible Allegation for Hendersonville Health and Rehabilitation for F279 - Hendersonville Health and Rehab will assure the facility develops and implements a baseline care plan for each resident that includes the instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care. On 11/15/17 Hendersonville Health and Rehab re-evaluated their processes to ensure the residents proper development and implementation of the baseline care plan. The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited; Resident #1 did not have a care plan that addressed the use of side rails. The for implementing the acceptable plan of correction for the specific deficiency cited; On November 18, 2017 DON, ADON and RCM audited all the residents care plans in regards to the proper use of side rails. 100 % of the CNA Care Guides, Interim Care Plans and Care Plans were updated to reflect the usage of side rails. Side rail assessments will be completed upon admission, re-admission, quarterly, and with any significant change in the resident's condition. In addition MDS completed a 100% of all MDS assessments for accuracy in regards to proper side rail usage with no discrepancies. The monitoring procedure to ensure the plan of correction is effective and the specific deficiency cited remains corrected and/or in compliance with the regulatory requirements; Upon admission the DON, ADON will review the 48 hour care plan then will review the working care plan and the 21 day care plan in order to ensure continued compliance. Any future significant changes will be documented on the care plan and the DON and ADON will review for compliance. The title of the responsible for implementing the acceptable plan of correction. Director of Nursing and Administrator We certify that as of November 18, 2017 the immediate jeopardy will be removed. Immediately Jeopardy was removed on 11/18/17 when interviews with the nurses and NA's revealed they were inserviced on the resident care plans that had been updated regarding the use of side rails.

Based on observations, record review and physician and staff interviews the facility failed to provide an environment free from restraints when a resident (Resident #1) got his head stuck in the side rail of his bed and his head had to be released from inside the side rail by fire rescue personnel in 1 of 81 beds with side rails with openings that had the potential for entrapment out of a total of 130 beds in the facility. Immediate Jeopardy began on 11/15/17 when Resident #1 had his head stuck in the left side rail at the head of his bed and had to be released from inside the side rail by fire rescue personnel. Immediate Jeopardy was removed on 11/18/17 when the facility provided and implemented a Credible Allegation of Compliance. The facility remains out of compliance at a scope and severity level of D (Isolated no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put into place are effective. Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was severely impaired in cognition for daily decision making. The MDS also indicated Resident #1 was totally dependent on staff for bed mobility and transfers. A facility document titled Initial or Annual Side Rail assessment dated [DATE] indicated Resident #1 had half-rails times (x) 2 sides, was able to participate appropriately in decision making, was not able to get out of bed independently and desired to have side rails in raised position while in bed. The document further indicated Resident #1 was alert and oriented for bed mobility and needed total assistance from care givers. A section labeled Side Rail Conclusions indicated side rails defined the perimeter of the bed, side rails do not prevent resident from getting out of bed, side rails are not considered a restraint, and side rails are not considered a restraint while in use. During an interview on 11/17/17 at 3:56 PM, Nurse #4 explained nurses were expected to complete a side rail assessment when a resident was admitted and again when readmitted if the resident was out of the facility greater than 24 hours. She confirmed she had completed a side rail assessment for Resident #1 on 10/18/17 and explained she indicated Resident #1 was able to participate appropriately in decision making because he could hold onto the side rail and it was easy for staff to turn him and change him and reposition him because of the side rails on the bed. She stated she thought side rails defined the perimeter of the bed and she thought they were safe. She explained she had indicated Resident #1 desired to have side rails in raised position in bed because that was what she usually put on the assessment. She stated she would consider a side rail to be a restraint when a resident could not get out of bed by themselves. She then confirmed Resident #1 could not get out of bed by himself and stated when he got his head stuck in the side rail then it was a restraint. She stated every resident had side rails on their bed and residents' used them to get in and out of bed. She further stated she had received no training in the facility to determine the length of side rails but based on her nursing experience the side rails that were on Resident #1's bed when he got his head stuck were half-length side rails. She explained Resident #1 was calm at times but at other times he moved and squirmed in bed and there were a few times when she had seen him twisted in bed and she and the NAs had repositioned him. A review of an Admission Nursing Evaluation dated 10/25/17 in a section labeled orientation to facility side rails were indicated. Resident #1 had an unplanned discharge to the hospital on [DATE] and was readmitted to the facility on [DATE]. A review of an Admission Nursing Evaluation dated 11/04/17 indicated in a section labeled orientation to facility Resident #1 was unable to be oriented. A facility document titled Initial or Annual Side Rail assessment dated [DATE] indicated Resident #1 had quarter side rail in use x 2 sides. The assessment further revealed Resident #1 was able to participate appropriately in decision making, was not able to get out of bed independently and desired to have side rails in raised position while in bed. The assessment also revealed Resident #1 had decreased level of consciousness and needed extensive assistance for bed mobility. A section labeled Side Rail Conclusions indicated, side rails do not define the perimeter of the bed, side rails do not prevent resident from getting out of bed, side rails are not considered a restraint, and side rails are not considered a restraint while in use. During an interview on 11/17/17 at 4:37 PM, Nurse #5 explained nurses were expected to complete a side rail assessment with every nursing admission assessment to determine if the side rail was a restraint. She stated they did not use half-length side rails in the facility and only used quarter-length side rails because half-length side rails would be considered a restraint. She explained when she completed Resident #1's side rail assessment on 11/04/17 she determined from a mobility standpoint his preferences for side rails. She stated Resident #1 used the side rail to hold on to when staff repositioned him but he could not turn himself in bed. She further stated Resident #1 would wiggle and squirm in bed at times. She confirmed Resident #1 did not say he desired to have the side rails up but he used them as an aid when turning and repositioning. She stated, in regard to bed mobility, Resident #1 was extensive assist with 2 staff and stated she did not think the side rails defined the perimeter of the bed because the side rails did not cover the whole bed since they were only at the top. She further stated she would consider a side rail to be a restraint when a resident would not be able to get out of bed or the side rail was blocking their exit. She then verified Resident #1 was not able to get out of bed by himself but she had not considered the side rail on Resident #1's bed as a restraint. She stated every bed in the facility had side rails on them and there were different types of beds and side rails. A review of a care plan with a problem onset date of 11/06/17 revealed Resident #1 had activities of daily living (ADL) deficits and impaired physical mobility. The goals indicated in part Resident #1 would remain free from immobility complications and the interventions were listed in part to provide bed mobility and transfers and turn and reposition frequently. There were no interventions documented regarding side rails. A review of a nurse's note documented by Nurse #2 indicated on 11/15/17 at 6:00 AM indicated Nurse Aide (NA) #1 who was also a Medication Aide reported that Resident #1 had his head through the side rail of his bed and was stuck. The notes revealed nurses x 2 applied lubrication to his face in an attempt to slide his head out without success. The notes further revealed 911 was called and the fire department and Emergency Medical Services (EMS) was sent to the facility to attempt to free Resident #1's head without injury. The notes indicated Resident #1 was turned in the bed and his head eventually slid out and there was a red mark and indentation on his left cheek from pressure from the side rail but there was no apparent injury. A review of an incident report dated 11/15/17 at 6:30 AM completed by the Assistant Director of Nursing (ADON) revealed NA#1 entered Resident #1's room to check his blood pressure and Resident #1 was observed with the top of his head in the upper side rail. The report indicated when Resident #1 was asked what he was doing, he replied he was trying to break his neck, then stated no he was trying to get cooler and get more air. The report further indicated NA#1 attempted to reposition Resident #1 to slip his head from the opening of the rail but Resident #1 was minimally cooperative. The report revealed lubricant was applied to Resident's #1's head and the fire department was called for assistance on moving Resident #1 and they arrived and assisted with easy removal of his head from the side rail. The report indicated Nurse #2 assessed Resident #1 for injuries and he had redness to his nose and left cheek. The report also indicated half-length side rails were on Resident #1's bed and immediate actions taken were to provide one on one supervision with a staff member and physician and responsible party (RP) were notified. A review of a Fire and Rescue Report dated 11/15/17 at 7:17 AM indicated 2 rescue personnel responded to a call from the facility and Resident #1 had his head stuck in a side rail. The report further indicated rescue personnel had nurses rotate Resident #1's body while they pushed his head toward the mattress in order to free him. The report also indicated there were no injuries or complaints of pain by Resident #1 after his head was released from the side rail. During a telephone interview on 11/16/17 at 4:05 PM, NA #1 who was also a Medication Aide stated she took medications to Resident #1 on 11/15/17 at 5:30 AM and he was fine. She explained she went back into Resident #1's room to take his blood pressure at 6:30 AM and found him lying across the bed with his head in the left side rail and his legs were off the right side of the bed. She stated she asked him what he was doing to get into that position and he said he was trying to break his neck then said he was trying to get some air. She stated he had a nasal cannula with oxygen on and he had an air mattress on his bed which was inflated. She explained she called for Nurse Aides (NAs) #2 and #6 to help and then NA#2 went to get Nurse #1 and Nurse #2. She stated the nurses went and got lubricant and rubbed it on Resident #1's head to try to slide his head out but he wasn't tolerating that well so they stopped and called the fire department and they were able to get Resident #1 repositioned and got his head out of the side rail. She further stated the left side of Resident #1's face was red from the pressure from the bed rail. During a follow up interview on 11/17/17 at 9:12 AM, NA #1 clarified Resident #1 came back to the facility from the hospital at 1:08 AM on 11/15/17 and his blood pressure was high so she was keeping a check on it about every hour. She stated each time she went in his room he was on his back and the head of his bed was elevated approximately 45 degrees and both side rails were raised up at the head of his bed. She explained at 5:30 AM she took his morning meds to him and he was fine and the head of the bed was still up at approximately 45 degrees. She stated at approximately 6:30 AM she went back to check Resident #1's blood pressure and found Resident #1 with his head stuck in the left side rail from the back of his head to the bridge of his nose. She explained Resident #1 did not seem to be in distress and was calm but his head seemed to be really stuck. She explained when Nurse #1 and Nurse #2 were putting lubricant on Resident #1's head and face Resident #1 put his hands on the bed rail and was pulling himself further into the opening of the side rail and they told him to stop pulling on the rail. She explained she and NA #6 were holding Resident #1's legs because they were hanging off the side of the bed and when the fire department and EMS got there they said they had cutters and were going to cut the side rail but when they pulled Resident #1's legs toward the head of the bed and he was straight across the mattress then his head came out of the side rail. She stated side rails were common in the facility and as far as she knew, every resident had side rails on their bed. During an interview on 11/17/17 at 6:45 AM, NA #2 stated she worked the night shift on 11/15/17 and made rounds around 5:20 AM with NA #6 and checked on Resident #1 and at that time Resident #1 was asleep with oxygen on. She stated she did not know anything had happened until NA #1 told her to get a nurse. She explained NA #1 stayed with Resident #1 and NA #2 told Nurse #1 to go to Resident #1's room. She stated after Nurse #1 went into Resident #1's room she then went to get lubricant and Nurse #1 told her to go get the ADON. NA #2 further stated Resident #1 said he was trying to get fresh air but she did not know how he could have gotten his head stuck in the side rail. During an interview on 11/17/17 at 7:05 AM, NA #6 stated on 11/15/17 she assisted NA #2 and they had checked Resident #1 during their last round around 5:20 AM and he was lying on his left side. She explained later she was coming off her assigned hall when NA #1 motioned for her to come to Resident #1's room. She explained when she got to Resident #1's room he had his head caught in the left side rail. She stated Resident #1 said he was looking for fresh air and they tried to get his head out with lubricant but his head wouldn't budge. She explained they called the fire department and EMS and they came and got his head out and Resident #1 had an indention on the left side of his face from the side rail. During an interview on 11/17/17 at 7:15 AM, Nurse #1 stated on 11/15/17 she walked to a medication room and NA #2 came in and told her NA#1 needed her help in Resident #1's room. She explained she walked into Resident #1's room and he was lying on his left side with his head stuck inside the side rail. She stated she asked Resident #1 why his head was stuck in the side rail and he said it is cooler on the other side. She explained she told Resident #1 she was going to get some stuff to lubricate his head and free him and then she met Nurse #2 and took her to Resident #1's room and they put the lubricant on his head but it didn't work to get his head out of the side rail. She stated she told someone but could not remember who to go get the ADON and she came in Resident #1's room and they decided to call the fire department and EMS. She explained the only time Resident #1 said anything was when they tried to move him and he said it hurt and his face started to swell. During an interview on 11/16/17 at 11:17 AM, Nurse #2 explained she worked third shift on 11/15/17 and a NA signaled for her to come to Resident #1's room. She stated she could not recall which NA called to her but as she walked by the nurse's station Nurse #1 was coming out of the medication room with a box of lubricant and stated she was going to Resident #1's room. She explained when she entered Resident #1's room he was on his back but leaning toward his left side and his head was stuck in the open part of the left side rail. She stated Resident #1 wasn't talking much but she and Nurse #1 applied lubricant to Resident #1's face and tried to pull him out but it didn't work. She explained NA #2 went to get the ADON to come to Resident #1's room. She stated she thought if they turned Resident #1's body in alignment with his head they could slide him out but that didn't work. She explained the ADON said they should call the fire department and Nurse #2 called 911 and explained the problem and the dispatcher said they would send the fire department and EMS. She stated when the fire department and EMS arrived they turned Resident #1's body to be across the bed and the rescue personnel pushed Resident #1's head back through the rail and his head slid out. She explained Resident #1 had an indentation and a red mark from the side rail on his left cheek but there was no broken skin. She stated she did not know how he got his head stuck in the rail. During an interview on 11/16/17 at 12:09 PM, the ADON explained NA #2 came and got her around 6:30 AM on 11/15/17 and told her to come to Resident #1's room. She stated when she entered Resident #1's room, he was lying sideways in the bed with his upper body toward the left side of the bed and his head was in the left side rail up to the bridge of his nose and his left cheek was pressed into the rail. She explained Resident #1 was groaning and someone had put lubricant on his face and forehead to try to slide his head out but it didn't help. She stated Nurse #2 called 911 and the fire department and EMS came but she wasn't in the room when they got his head out of the side rail. She explained she called the Nurse Practitioner (NP) and was told a physician would be at the facility later that day to see Resident #1. She stated the NP also stated she would talk with the Medical Director to let him know but to continue to provide Resident #1 with one-on-one supervision. The ADON stated she then called Resident #1's RP. During an interview on 11/16/17 at 1:30 PM, Nurse #6 stated she arrived at work on 11/15/17 at 6:45 AM and staff were in Resident #1's room waiting for the fire department and EMS. She explained Resident #1 normally slept a lot during the day but sometimes during the evening he had a tendency to be restless. She stated she had noticed twice lately Resident #1 had his legs thrown over the side of the bed. She stated she asked him why he was restless but he couldn't tell her. During an interview on 11/16/17 at 3:00 PM, NA #3 stated she was told yesterday morning on 11/15/17 around 7:00 AM during report from third shift Resident #1 had his head stuck into the side rail. She explained the left side of his face was a little red yesterday but there was no redness today. She stated she was surprised Resident #1 had his head stuck in the side rail because she had not seen him try to get out of bed. During an interview and observation on 11/16/17 at 1:05 PM, the Environmental Services (EVS) Director stated he was notified about 7:30 AM on 11/15/17 by the ADON that Resident #1 needed a Hi-Low bed because they had a problem with the side rails on his current bed. He stated he went to Resident #1's room and placed zip ties to secure the side rails to the frame of the bed so they could not be pulled back up and then he called the company to order a Hi-Lo bed. He stated the new bed was delivered around 3:45 PM on 11/15/17 and he took the old bed to a service hall with the side rails still attached to the bed. The EVS Director pointed to a bed in the service hallway and confirmed it was the bed he had removed from Resident #1's room. He then raised the left side rail of the bed and measured the diameter of the 2 largest openings of the side rail. He confirmed both of the large openings were 7.5 inches wide X 7.0 inches high. During an interview on 11/16/17 at 2:10 PM, Physician #1 who was also the facility Medical Director stated a NP had called him yesterday morning on 11/15/17 and told him Resident #1 made the statement about wanting to break his neck and asked if we should send him for psychiatric services. He stated Physician #2 saw Resident #1 on 11/15/17 and did not think Resident #1 was a risk to himself. Physician #1 stated he thought Resident #1 had dementia but did not think he was suicidal. During an observation on 11/16/17 at 5:11 PM Resident #1 was sitting up in bed and had no visible red areas or bruises on his face. During an interview on 11/16/17 at 5:40 PM, NA #4 stated Resident #1 was usually confused when she was assigned to his care and he needed total assistance with activities of daily living. She further stated Resident #1 could scoot down in the bed. During an interview on 11/16/17 at 5:55 PM, NA #5 stated she had provided care to Resident #1 and in the past she had seen him with his legs off the left side of the bed and she had to go and reposition him. During an observation on 11/17/17 at 8:05 AM Resident #1 was lying in bed and NA #3 was on the right side of his bed. Resident #1 had his eyes closed and there were no red areas or bruised visible on his face or neck. During a follow up interview on 11/17/17 at 8:29 AM, the EVS Director explained the type of bed Resident #1 had his head caught in the side rail were old beds from a local hospital that were put in the facility years ago. He stated over the years they had purchased some Hi-Low beds and they had side rails with spaces that were much smaller than the old bed side rails. He stated all beds in the facility had side rails on them because beds came delivered with side rails already on them. He explained they had taken the rails off the beds at the foot because if they had rails at the top and foot they would be restraints. He stated he thought the side rail on the bed that Resident #1's head was stuck in was a quarter-length side rail. He stated there were 130 beds in the facility but he did not have an inventory list of the type of side rails on each bed. During an interview on 11/17/17 at 5:11 PM, the MDS Nurse stated there was no place to code side rails on the MDS unless they were used as a restraint. She stated the facility was restraint free and they had never put side rails on a care plan but now she could see that side rails were not adequate for some residents. She stated she visited with Resident #1 after he got his head stuck in the side rail and asked him what had happened and he said he was trying to get out there and get some more air but he was not trying to get out of bed. She explained when she had visited with him in the past and he was lying on his side he had his hand resting on top of the side rail. She stated she thought most of the beds in the facility had side rails on them but they did not use half-length side rails She further stated it was her understanding that side rail assessments were done to determine if the resident wanted the side rails up or down and Resident #1 could answer simple questions but if the questions was complex he had trouble answering them. During an interview on 11/17/17 at 5:39 PM, the Maintenance Director stated every bed in the facility had quarter-length side rails and he thought the side rails were on the beds because that was the way they were delivered. He explained he did maintenance on beds if they squeaked or the brakes didn't work or if the side rails were loose. He confirmed most of the beds in the facility were beds like the one Resident #1 got his head caught in the side rail. He stated newer beds had more compact openings with less space in the openings. He further stated he had not received any work order requests for Resident #1's bed or side rails. He explained the type of bed Resident #1 was in when his head was stuck in the side raid was an older hospital bed manufactured before 1997 because he had found inspection stickers on them from a local hospital dated 1997 and he had ordered replacement parts for the beds that were dated 1996 and 1997. During a follow up interview on 11/17/17 at 5:55 PM, the ADON stated every bed in the facility had quarter-length side rails but if a resident did not want side rails they took them off. She explained a side rail assessment was completed by the nurse when a resident was admitted or readmitted to the facility and the side rail assessment was supposed to determine how the resident used side rails and if the side rails restricted their movements. She stated she knew when Resident #1's head was caught in the side rail it was a problem and if it happened to him it could happen to another resident. During a record review on 11/18/17 at 9:45 AM a service manual for a resident bed revealed the bed was configured to accept sectionalized half-length side rails. The manual further indicated the bed must have the head section side rails because both head section rails contained head and knee controls and hi-low activators to raise the bed up or down. During a follow up interview on 11/18/17 at 10:15 AM, the EVS Director confirmed the service manual for a resident bed was for the same type bed Resident #1 was in when he got his head stuck in the side rail. He also provided a bed audit he had completed on 11/17/17 of all beds in the facility and explained there were 81 beds which were the same type as the bed Resident #1 got his head stuck in the side rail, 33 Hi-Low beds the facility owned, 15 rental beds and 1 personal bed to equal 130 beds in the facility. During an interview on 11/18/17 at 2:57 PM, the Director of Nursing stated she was on vacation earlier in the week but was called by the ADON after Resident #1 got his head stuck in the side rail and she came back to the facility. She further stated she had not considered the side rails on Resident #1's bed to be quarter-length rails but after review of the service manual for the bed she now realized they were half-length side rails. She explained the older beds like the one Resident #1 got his head stuck in the side rail came when the facility was opened years ago. She stated Resident #1 leaned significantly toward his left side regardless of how he was positioned and if his body was in the direction of the side rail with his head near the rail that would have been a red flag. She stated it was her expectation for staff to look and see if the side rail was a positioning device and should not restrict movement of the resident. During an interview on 11/18/17 at 4:05 PM, Physician #1 who was also the facility Medical Director stated he was notified promptly when Resident #1 got his head caught in the side rail. He further stated the incident was a left over to [AGE] years with use of beds with older side rail designs. During an interview on 11/19/17 at 2:43 PM, the Administrator stated it was his expectation that any kind of equipment needed to be looked at for potential for harm. He stated when he came to work at the facility earlier this year he did not think to look at the assessments of beds or side rails. He stated it was his expectation staff could not let their guard down but needed to protect residents from harm. He further stated he could now see how side rails were beneficial and hazardous and it was his expectation for all staff to be inserviced to make everyone was aware of bed and side rail safety and unsafe zones. The Administrator, ADON, Regional Consultant of Clinical Services and Corporate Consultant of Clinical Services were informed of Immediate Jeopardy on 11/1717 at 2:33 PM. The facility provided an acceptable credible allegation for immediate jeopardy removal on 11/18/17 at 7:33 PM. Credible Allegation for Hendersonville Health and Rehabilitation for F 221-The resident has the right to be treated with respect and dignity, including: the right to be free from physical restraints. On 11/15/17 Hendersonville Health and Rehab re-evaluated their processes for the use of side rails to ensure all residents are treated with dignity and respect which includes their right to be free from physical restraints as outlined below. The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited; On 11/15/17 at approximately 6:30 AM resident # 1 (room [ROOM NUMBER] B) was found by an employee #1. Employee #1, the NA/MA, was working as his medication aide on the 100 hall. She had been working the 7 PM to 7 AM shift. She was on the 100 hall from 11 PM to 7 AM. Employee #1 was in room [ROOM NUMBER] B @ 5:30 AM and resident #1 was in the bed with his head elevated at approximately 45 degrees. Employee #1 gave him his morning medications and noted nothing abnormal about the resident. Employee #1 returned to room [ROOM NUMBER] B at approximately 6:30 AM to check his blood pressure. At that time, Employee #1 noted the top of resident #1's head up to the bridge of his nose was stuck through the side rail on the left side of his bed and his legs were still in the bed. The side rails on both sides of his bed were up. He was on an air mattress. He was talking and answering questions that Employee #1 was asking him. Employee # 1 did not attempt to assist resident #1 at that point. Employee #1 immediately stepped outside the door and asked Employee # 2 CNA to get a nurse. Nurse #1, LPN, and Nurse #2 LPN arrived to room [ROOM NUMBER] B within a minute and arrived within seconds of each other. Both assessed the situation and realized the resident had his head up to the bridge of his nose stuck in the side rail. Nurse #1 left the room to get a lubricant. Nurse #1 returned with the lubricant and both nurses began to move his legs off of the bed to line his body up. They worked to free resident #1 from the side rail for approximately 5 minutes. He began to say he was hurting. The nurses stopped and Nurse #2 LPN called 911. EMS arrived at approximately 6:45 AM. The nursing staff, EMS and the fire department repositioned the resident in the bed and his head freed from the side rail easily. EMS assessed the resident and left the facility. Resident was evaluated by Nurse #2 LPN. Redness was noted to bridge of the nose and left cheek. Resident #1 remained 1:1 until a new bed arrived. Resident #1's medical professional was notified of the incident at 7:00 AM on 11/15/17. NP was notified that resident # 1 was one on one supervision. She stated a medical professional would be in later on 11/15/17 to assess resident #1. No orders were given. The RP was notified of the incident at 7:15AM on 11/15/17. ADON pulled a facility census and identified all residents' cognitive status to determine appropriateness of side rails. The ADON then did a facility assessment to determine all residents were safe. MD was in the facility on 11/15/17 at approximately 8:50 AM and assessed the resident. The ADON was in the facility at the time of the incident. The Administrator was notified of the incident by the ADON at 7:13 AM on 11/15/17. The Director of Nursing was notified of the incident by the ADON at 6:40 AM on 11/15/17. The Regional Director of Operations was notified by the Administrator of the incident at 7:30 AM on 11/15/17. The Corporate Nursing Team was notified by the Administrator and ADON of the incident by 7:15 AM and a plan of correction was initiated immediately. o The procedure for implementing the acceptable plan of correction for the specific deficiency cited; Resident #1 was placed on one on one supervision and remained one on one until his new bed arrived. He was placed in his new bed at approximately 4:00 PM on 11/15/17. After evaluation of the resident in the new bed it was determined that the side rails would not be secured in the down position. On November 15, 2017 we assessed all residents for safe use of side rails. Side rail assessments will be completed upon admission, re-admission, quarterly, and with any significant change in the resident's condition. The assessments were complete on 11/15/17. All residents that are on a high low bed/air mattresses were assessed for proper use of side rails. An in-service with the nursing department was done by the unit manager and ADON: proper use of side rails related to mental status and not to remove the zip ties (No staff has or will work until they have received the in-service). All licensed nursing staff that have worked since the in-service will be educated on the updated side rail assessment. 100% of all staff will be in serviced before they return to work. Side rail assessments reviewed with nurses and to be completed upon admission, re-admission, quarterly, and with any significant change in the resident's condition. On 11/17/17 100% of all staff prior to assigned shift were in serviced on side rail usage protocol by the dietary manager, therapy manager, administrator, environmental services manager. Side rail management will be added to the general orientation. MDS nursing updated the working plan of care as well as the care plan in chart on all residents that had the side rails secured. All resident care plans were reviewed for appropriate use of side rails and care plans were updated based on results of side rail evaluation. On 11/17/17 Social services, administrative nursing staff and regional clinical manager conducted updated side rail assessments on 100 percent of all residents. Care plans were then updated by DON, ADON and regional clinical manager according to the results

Based on observations, record review and staff interviews the facility failed to develop a comprehensive care plan which included side rails as a potential restraint for 1 of 1 sample residents reviewed for physical restraints. Resident #1's head was entrapped in the side rail of his bed and he had to be released from the side rail by fire rescue personnel (Resident #1). Immediate Jeopardy began on 11/06/17 when the facility failed to develop a comprehensive care plan for the use of side rails for Resident #1. Immediate Jeopardy was removed on 11/18/17 when the facility provided and implemented a Credible Allegation of Compliance. The facility remains out of compliance at a scope and severity level of D (Isolated no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put into place are effective. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A facility document titled Initial or Annual Side Rail assessment dated [DATE] revealed in part the following assessment for Resident #1. The type of side rails on Resident #1's bed were 2 half rails, that Resident #1 was alert, oriented and able to participate appropriately in decision making. The assessment also indicated Resident #1 desired to have his side rails in the raised position, he required total assistance from caregivers and he could not get out of the bed independently. A section labeled Side Rail Conclusions indicated the side rails defined the perimeter of the bed, they did not prevent Resident #1 from getting out of bed while in use and the side rails were not considered a restraint while in use for Resident #1. A review of an admission Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was severely impaired in cognition for daily decision making. The MDS also indicated Resident #1 was totally dependent on staff for bed mobility and transfers. An Admission Nursing Evaluation dated 10/25/17, had a section labeled orientation to facility. The evaluation revealed side rails were indicated for Resident #1. Resident #1 had an unplanned discharge to the hospital on [DATE] and was readmitted to the facility on [DATE]. An Admission Nursing Evaluation dated 11/04/17, had a section labeled orientation to facility which indicated Resident #1 was unable to be oriented. A facility document titled Initial or Annual Side Rail assessment dated [DATE] revealed in part the following assessment for Resident #1. The type of side rails on Resident #1's bed were 2 quarter rails, that Resident #1 was able to participate appropriately in decision making, had a decreased level of consciousness and desired to have the side rails in the raised position while in bed. The assessment continued to indicate Resident #1 was not able to get out of bed independently and required extensive assistance for bed mobility. A section labeled side rail conclusions indicated the side rails on Resident #1's bed did not define the perimeter of his bed, the side rails did not prevent him from getting out of bed while in use and the side rails were not considered a restraint while in use for Resident #1. A review of a care plan with a problem onset date of 11/06/17 revealed Resident #1 had activities of daily living (ADL) deficits and impaired physical mobility. The goals indicated in part that Resident #1 would remain free from immobility complications and the interventions were listed in part to provide bed mobility and transfers and turn and reposition frequently. There were no interventions documented regarding side rails. Record review revealed a nurse's note documented by Nurse #2, and dated 11/15/17 at 6:00 AM. The Nurse's Note indicated Nurse Aide (NA) #1 who was also a Medication Aide reported that Resident #1 had his head through the side rail of his bed and was stuck. The notes revealed that two nurses applied lubrication to his face in an attempt to slide his head out without success. The notes further revealed 911 was called and the fire department and Emergency Medical Services (EMS) was sent to the facility to attempt to free Resident #1's head without injury. The notes indicated Resident #1 was turned in the bed and his head eventually slid out and there was a red mark and indention on his left cheek from pressure from the side rail but there was no apparent injury. Observation on 11/16/17 at 8:45 AM revealed Resident #1 was in bed with bilateral half rails on the of head of his bed and in the down position. During an interview on 11/17/17 at 3:50 PM, Nurse #4 confirmed she had completed both Side Rail Assessments on 10/18/17 and 11/04/17 and further indicated that on admission Resident #1 was able to grip the side rail to aide in turning and repositioning. During an interview on 11/17/17 at 5:11 PM the MDS Nurse stated she completed MDS assessments and care plans. The MDS Nurse continued to explain she had completed Resident #1's admission assessments. The MDS Nurse indicated she reviewed all information on the resident's chart including hospital information and interviewed the resident and/or the family members when she coded the MDS. The MDS Nurse stated she had observed Resident #1's hand on the side rail and did not believe the side rails would endanger him but she could see now that side rails are not adequate for some residents. The MDS Nurse further stated there was no place to code side rails on the MDS unless they were used as a restraint and this facility was restraint free so they had never put side rails on the care plan. During an interview on 11/18/17 at 2:57 PM, the Director of Nursing (DON) explained Resident #1 leaned significantly toward the left no matter how he was positioned in the bed but he never attempted to get up on his own. If we had any kind of warning signs, interventions would have been in place. I would have expected the side rails to be viewed as a positioning device and not a restraint. The DON explained the facility's practice was to complete a 24 hour interim (initial) care plan until day 21 when the (comprehensive) care plan was completed. The DON stated it was her expectation to complete the side rail information on the care plans after the new Side Rail Evaluation was completed on admission, readmission, quarterly and a change of resident's status. The Administrator, ADON and Regional Consultant of Clinical Services and Corporate Consultant of Clinical Services were informed of Immediate Jeopardy on 11/18/17 at 11:13 AM. The facility provided an acceptable credible allegation for immediate jeopardy removal on 11/18/17 at 7:33 PM. Credible Allegation for Hendersonville Health and Rehabilitation for F279 - Hendersonville Health and Rehab will assure the facility develops and implements a baseline care plan for each resident that includes the instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care. On 11/15/17 Hendersonville Health and Rehab re-evaluated their processes to ensure the residents proper development and implementation of the baseline care plan. The plan of correcting the specific deficiency. The plan should address the processes that lead to the deficiency cited; Resident #1 did not have a care plan that addressed the use of side rails. The for implementing the acceptable plan of correction for the specific deficiency cited; On November 18, 2017 DON, ADON and RCM audited all the residents care plans in regards to the proper use of side rails. 100 % of the CNA Care Guides, Interim Care Plans and Care Plans were updated to reflect the usage of side rails. Side rail assessments will be completed upon admission, re-admission, quarterly, and with any significant change in the resident's condition. In addition MDS completed a 100% of all MDS assessments for accuracy in regards to proper side rail usage with no discrepancies. The monitoring procedure to ensure the plan of correction is effective and the specific deficiency cited remains corrected and/or in compliance with the regulatory requirements; Upon admission the DON, ADON will review the 48 hour care plan then will review the working care plan and the 21 day care plan in order to ensure continued compliance. Any future significant changes will be documented on the care plan and the DON and ADON will review for compliance. The title of the responsible for implementing the acceptable plan of correction. Director of Nursing and Administrator We certify that as of November 18, 2017 the immediate jeopardy will be removed. Immediately Jeopardy was removed on 11/18/17 when interviews with the nurses and NA's revealed they were inserviced on the resident care plans that had been updated regarding the use of side rails.