Every finding on record at Heritage Park Health Center by Harborview

Based on record review and staff interviews, the facility failed to ensure staff responsible for providing Cardiopulmonary Resuscitation (CPR) demonstrated the competency, knowledge, and skills necessary to perform CPR in accordance with professional standards and facility policy for one resident (#1) of two reviewed for CPR.Findings included: Review of the facility's Nursing Job description revealed the following: Major Duties and responsibilities:Participates in end-of-life care as requiredPromotes teamwork, mutual respect, and effective communicationTreats all residents with dignity and respect. Promotes and protects all residents' rights.Establishes a culture of compliance by adhering to all facility policies and proceduresFulfills responsibilities as assigned during implementation or activation of the facility's emergency plan. On [DATE] at 10:56 AM, during a phone interview, Staff A, Licensed Practical Nurse (LPN)stated on [DATE], Staff B, Certified Nursing Assistant (CNA) notified them Resident #1 was not breathing. Staff A stated upon entering Resident #1's room they assessed for a pulse and, finding none, began CPR without calling Code Blue. Staff A reported stopping CPR after approximately 15 minutes to get Staff B, CNA, to act as a witness and assist with cleaning up the resident. Staff A stated they resumed CPR upon returning to the room. Staff A further stated they did not call a Code Blue because the family member made them nervous and acknowledged they did not follow facility CPR policy.On [DATE] at 11:47 AM, during a phone interview, Staff B, CNA stated they informed Staff A the resident was not breathing but did not return to the room with Staff A. Staff B stated they later encountered Staff A, who instructed them to gather washcloths to help clean Resident #1. Staff B stated they did not observe CPR being performed and were not instructed to call 911 or initiate a Code Blue. Staff B stated they had not received guidance regarding CPR, code status, or Code Blue procedures and believed only nurses could call a Code Blue.On [DATE] at 12:06 PM, Staff C, LPN stated they were not notified of the incident until later in the day and were not called to assist. Staff C reported no Code Blue announcement was made and the crash cart remained in the utility room with no equipment removed. Staff C stated an Ambu bag would have been removed during a Code Blue but was not.On [DATE] at 2:16 PM, the resident's Primary Care Provider (PCP) stated Staff A stepped outside their training, broke the facility's system, and acted independently. The PCP stated when a resident is full code, the process included checking code status, initiating CPR, calling 911, and continuing compressions until EMS arrives. The PCP stated they believed staff were trained and did not know why the system was not followed. The PCP stated Staff A did not appear to have participated in many required steps and reiterated the expectation to follow standard of care when advance directives are in place. The PCP stated it was their expectation CPR be initiated, emergency services contacted, and compressions continued until EMS arrival for any full code resident.On [DATE] at 3:06 PM, the Director of Nursing (DON) stated they were notified via text on [DATE] at 2:14 PM Resident #1 had expired. The DON stated Staff A reported performing CPR for 15 minutes. The DON stated Staff A did not call a Code Blue and no staff were aware CPR was being performed. The DON reported the crash cart had not been accessed and they could not verify CPR had occurred. The DON stated facility process requires checking code status, beginning CPR, calling a Code Blue, and ensuring 911 is called.On [DATE] at 5:35 PM, Staff E, LPN/Unit Manager stated Staff A reported performing CPR for 15 minutes, ceasing CPR, leaving the room to get Staff B, then returning to resume CPR. Staff E stated Staff A did not call a Code Blue, did not call 911, and did not contact the physician. Staff E stated staff had been informed the resident remained a full code despite hospice involvement.Record review showed Resident #1 was admitted [DATE], readmitted [DATE], and had diagnoses including dementia, diabetes, chronic kidney disease, and heart failure. A [DATE] Quarterly minimum [NAME] Set (MDS) dated [DATE] documented a brief interview for mental status (BIMS) score of 02, indicating severe cognitive impairment. The resident's Care Plan documented the resident as a full code. Orders reviewed confirmed full code status as of [DATE] with no end date.Review of a [DATE] at 2:54 PM progress note by Staff A, LPN documented: Resident family was in the room, said to the aid at 11:30 AM resident was unresponsive to call the nurse, went in the room check no pulse, provided CPR for 15 full mins, called the aid come in the room tried CPR again resident, still unresponsive, called death at 12:15 PM.Review of Staff A's education transcripts revealed no CPR training completed.Review of facility CPR policy dated [DATE], stated staff will provide basic life support, including CPR, for residents experiencing cardiac arrest in accordance with advance directives.Review of the facility's Abuse, Neglect, and Exploitation Policy dated [DATE], defined neglect as failure to provide goods and services necessary to avoid physical harm.The facility did not provide a competency policy.

Based on record review, interviews, and review of facility policy, the facility failed to ensure staff administered CPR (Cardiopulmonary Resuscitation) in accordance with professional standards of practice and the facility's CPR policy, for one resident (#1) of two residents reviewed. The facility staff did not call a Code Blue, did not activate EMS (Emergency Medical Service), did not utilize the crash cart or emergency equipment, and did not provide CPR continuously as required for a resident with a full code status. Findings Included: On [DATE] at 10:56 AM, a phone interview was conducted with Staff A, Licensed Practical Nurse (LPN). Staff A stated on [DATE], Staff B, Certified Nursing Assistant (CNA), advised them Resident #1 was not breathing. Staff A stated upon arriving to Resident #1's room, they checked Resident #1's pulse and, when no pulse was found, they started CPR. Staff A stated the family member said Resident #1 had stopped breathing around 11:12 AM. Staff A stated while they were performing CPR, the family member asked why CPR was being done since the resident had already passed away, and Staff A advised the family member they had to continue CPR until EMS arrived. Staff A stated after about 15 minutes, they stopped performing CPR to get Staff B to be a witness and help clean up the resident. Once Staff A and Staff B returned to the room, Staff A stated they began CPR a second time. Staff A stated they did not call a Code Blue because the family member made them nervous and acknowledged they did not follow the facility's CPR policy, adding they did not know why they did not call a Code Blue or why they stopped CPR.On [DATE] at 11:47 AM, a phone interview was conducted with Staff B, CNA. Staff B stated they were in Resident #1's room feeding the roommate when the family member said Resident #1 was not breathing. Staff B stated they found Staff A, who was transporting another resident, and informed them of the situation. Staff B stated they took over Staff A's task so Staff A could check Resident #1. Staff B stated when they saw Staff A about 20 minutes later, Staff A advised them to get washcloths and help clean up Resident #1. Staff B stated Staff A asked the family member for the time and then called the time of death. Staff B stated they did not see Staff A perform CPR but were told by Staff A CPR had been done while they were writing their statements. Staff B stated they did not know who called 911 and were not instructed to call a Code Blue. Staff B stated they received no guidance on performing CPR, code status, or what to do when there is a Code Blue and believed only nurses could call a Code Blue. Staff B stated Staff A never advised them to call a Code Blue for Resident #1.On [DATE] at 12:06 PM, an interview was conducted with Staff C, LPN, who was assigned to the south end of the unit and did not provide care to Resident #1 day. Staff C stated Staff A did not mention Resident #1 passing until later in the day when asking what to do regarding after-death care. Staff C stated they were never called to assist and never heard a Code Blue called. Staff C stated they told Staff A they should have notified others so assistance could have been provided. Staff C stated they were unaware a code situation had occurred until more than an hour after the incident. Staff C stated they did not see the crash cart outside Resident #1's room; instead, they saw it in the utility room with nothing removed or documented as used. Staff C stated the Ambu bag should have been removed during a Code Blue but was not. Staff C stated hospice residents receive the same lifesaving interventions as any other resident unless they have a DNR (Do Not Resuscitate) order, and confirmed Resident #1 was not a DNR at the time. Staff C stated when a resident is unresponsive, the aide notifies a nurse, who then checks code status and follows the facility's Code Blue protocol.On [DATE] at 2:16 PM, an interview was conducted with Resident #1's primary care provider (PCP). The PCP stated Staff A stepped outside their training, broke the facility's system, and acted independently. The PCP stated when a resident is full code, the process includes checking code status, initiating CPR, calling 911, and continuing compressions until EMS arrives. The PCP stated they believed staff were trained and did not know why the system was not followed. The PCP stated EMS would then determine next steps in consultation with an ER provider. The PCP stated Staff A did not appear to have participated in many required steps and reiterated the expectation to follow standard of care when advance directives are in place.On [DATE] at 3:38 PM, an interview was conducted with Staff D, LPN, the Saturday Weekend Supervisor. Staff D stated they were not notified until 2:00 PM that Resident #1 had expired at 12:00 PM. Staff D stated an expectation to have been notified sooner as the supervisor so they can also notify the administration.On [DATE] at 5:35 PM, an interview was conducted with Staff E, LPN/Unit Manager. Staff E stated they were notified by Staff D via text Resident #1 had expired around 12 PM. When Staff E asked whether a Code Blue had been called, Staff D stated no. Staff E stated they then contacted Staff A, who stated Staff B had told them the resident was in cardiac arrest. Staff A told Staff E they had not called a Code Blue but had performed 15 minutes of CPR, stopped, went to get Staff B, returned, resumed CPR, and called time of death at 12:15 PM. Staff E stated Staff A did not call 911 or the physician when they stopped CPR. Staff E stated once Resident #1's guardian agreed to hospice services, they had made it abundantly clear to all care staff Resident #1 remained a full code.On [DATE] at 3:06 PM, an interview was conducted with the Director of Nursing (DON) and Nursing Home Administrator (NHA). The DON stated they were notified by text at 2:14 PM on [DATE] Resident #1 had expired. The DON stated Staff A told them they had completed CPR for 15 minutes. The DON stated during their conversation, they realized Staff A had not administered CPR in accordance with facility policy. The DON stated Staff A did not call a Code Blue and they did not know why Staff A failed to follow expected procedures. The DON stated all staff on the shift were unaware a Code Blue had occurred, and Staff A did not alert anyone or request help. The DON stated they checked the crash cart and verified it had not been opened. The DON stated they were unable to confirm whether CPR was actually performed. The DON stated the facility's process requires staff to check code status, begin compressions, call a Code Blue, and have someone call 911. The DON stated Staff A did not follow this process and they could not determine why, noting they found no system failure during their review.Record review showed Resident #1 was admitted [DATE], readmitted [DATE], and had diagnoses including dementia, diabetes, chronic kidney disease, and heart failure. A [DATE] Quarterly minimum data Set (MDS) dated [DATE] documented a brief interview for mental status (BIMS) score of 02, indicating severe cognitive impairment. The resident's Care Plan documented the resident as a full code. Orders reviewed confirmed full code status as of [DATE] with no end date.Review of Resident #1's progress notes revealed a progress note from Staff A, LPN on [DATE] at 2:54 PM stating: Resident family was in the room, said to the aid at 11:30 AM resident was unresponsive to call the nurse, went in the room check no pulse, provided CPR for 15 full mins, called the aid come in the room tried CPR again resident, still unresponsive, called death at 12:15 PM.A review of the undated facility's Advance Directives policy revealed, Advance directives are honored in accordance with state law and facility policy.Review of the facility's CPR policy dated [DATE] revealed the following: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement guidelines regarding CPR. If a resident experiences cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and: in accordance with the resident's advance directives; in the absence of advance directives or a DNR order.A review of the facility's Abuse, Neglect and Exploitation policy dated [DATE] revealed the following: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions revealed Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 'Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Review of the facility's Nursing Job description revealed the following: Major Duties and responsibilities:Participates in end of life care as requiredPromotes teamwork, mutual respect, and effective communicationTreats all residents with dignity and respect. Promotes and protects all residents' rights.Establishes a culture of compliance by adhering to all facility policies and proceduresFulfills responsibilities as assigned during implementation or activation of the facility's emergency plan.

Based on record review and interview the facility did not ensure Preadmission Screening and Resident Reviews (PASARRs) were completed accurately for five residents (#6, #74 #14, #58, and #66) out of six residents sampled for PASARRs.Findings Included: 1. Record review for Resident #6 revealed the resident was admitted on [DATE] with a primary diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Other diagnoses included mood disorder due to known physiological condition with mixed features, schizoaffective disorder, unspecified, unspecified intellectual disabilities, and depression A review of a level I PASARR for Resident #6 dated 6/12/2025 revealed an incomplete Assessment with only the diagnosis of Schizoaffective disorder checked. The PASARR did not show Resident #6 had a primary diagnosis of Dementia. The review showed a level II PASARR was not submitted for consideration following the qualifying diagnoses. 2. Review of Resident #74's admission record revealed an admission date of 6/16/2020 with diagnoses to include Bipolar disorder, Borderline personality disorder, generalized anxiety disorder, major depressive disorder, anxiety disorder, and primary insomnia. A review of Resident #74's level I PASSAR dated 6/16/2020, revealed there were no diagnoses marked under Section A-Mental Illness (MI) or suspected MI. The review showed the level I PASARR was incomplete, and a level II was not submitted for consideration following qualifying diagnoses. During an interview with the Minimum Data Set (MDS) Coordinator on 4/08/2026 at 2:50 p.m., she stated Resident #74's diagnoses should be on the resident's PASSAR. The MDS coordinator stated Resident #74 would need an updated PASSAR. 3. A review of Resident #14's admission record revealed an admission date of 10/16/2025 with diagnoses to include anxiety disorder, and unspecified and bipolar disorder, unspecified. A review of Resident #14's level I PASSAR screen, dated 10/17/2025, showed anxiety disorder was marked under section A – MI or suspected MI. Further review of section A showed there were no other diagnoses marked. 4. A review of Resident #58's admission record revealed an admission date of 2/3/2026 with diagnoses to include dementia in other diseases classified elsewhere, unspecified severity, with mood disturbance, major depressive disorder, recurrent, unspecified, and unspecified mood [affective] disorder and other symptoms and signs involving cognitive function and awareness. A review of Resident #58's level I PASSAR screen, dated 1/21/2026, showed depressive disorder was marked under section A – MI or suspected MI. Further review of section A showed no other diagnoses were marked. A level II PASSAR evaluation and determination was not found in Resident #58's medical record or provided by the facility. The review showed the level I PASARR was incomplete, and a level II was not submitted for consideration following qualifying diagnoses. 5. Review of Resident #66's admission record revealed an original admission date of 10/16/2024 and a readmission of 2/2/2025. Resident #66 was admitted to the facility with diagnoses to include mood disorder due to known physiological condition with mixed features, anxiety disorder, insomnia and depression. Review of Resident #66's level I PASSAR dated 1/27/2025 revealed Section I PASSAR screen decision making, A. MI or suspected MI was blank. During an interview on 4/8/2026 at 2:50 p.m., the MDS Coordinator stated, I review the PASARR for the residents on admission. I confirm the diagnoses to make sure they match and are on the PASSARs. The MDS coordinator stated they determine at that time if the resident required a level II PASSAR. The MDS coordinator stated the majority of people they get have dementia, depression and anxiety. They stated they would look deeper for their history to determine if they need a level II PASSAR. The MDS coordinator said, I have been doing the PASRR for about two years and I have not submitted any PASSARs for a Level II. There are currently no residents hat need a level II PASSAR. The MDS coordinator stated for Resident #66 the PASSAR was blank and the diagnosis should have been added to the PASSAR. Review of the facility policy dated 3/1/2022, titled, Resident Assessment coordination with PASSAR program, revealed, Policy: The facility coordinates assessments with the pre-admission screening and resident review(PASSAR ) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the state's Medicaid rules for screening. A. PASSAR level I initial prescreening that is completed prior to admission negative lever one screen permits admission to proceed and ends the PASSAR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive level I screen necessities a PASSAR level II evaluation prior to admission. B. PASSAR level II - comprehensive evaluation by the appropriate state designated authority cannot be completed by the facility that determines whether the individual has MI, MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and or rehabilitative services the individual needs.the social services director shall be responsible for keeping track of each resident's PASSAR screening status, and referring to the appropriate authority.

Based on observations, interviews, and record review, the facility did not ensure expired medications were discarded in a timely manner and did not ensure proper storage of chemicals and medications in two medications carts (North 100 and North 200) of five carts observed.Findings included: An observation on 4/6/2026 at 2:30 PM of North 100 medication cart revealed a bottle of diphenhydramine with the expiration date worn off. The expiration dates could not be identified. An observation was made of the same cart with an opened vial of insulin that expired on 4/3/2026.An observation on 4/7/2026 at 3:25 PM of the North 200 medication cart revealed a container of bleach wipes stored in the same drawer with oral, topical, and rectal medications. The observation revealed there was no divider/separation in the bottom drawer in which both medications and cleaning chemicals were stored.An interview on 4/7/2026 at 4:45 PM with the Director of Nursing (DON) was conducted. The DON said the expired medications should have been removed from the medication cart. The DON said if the medication expiration date was worn off, the medication should have been discarded. The DON said the bleach wipes should not be stored with the medications.A review of a policy revised on 5/1/2025 titled, Medication Administration revealed the policy explanation and compliance guidelines 13: Identify expiration date. If expired, notify nurse manager. Review of the facility policy titled, Medication Storage, revised 3/1/2025, revealed it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medications rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security.3. External products: Disinfectants and drugs for external use are stored separately from internal and injectable medications.(Photographic Evidence Obtained)

Based on interview and record review, the facility failed to ensure four (Resident #2, #9, #10, and #18) of 16 residents reviewed were treated with respect and dignity that promoted the resident's quality of life by ensuring staff were able to communicate in a language the residents comprehend. Findings included:An interview was conducted with Resident #2's representative (RR) on 12/15/2025 at 2:59 p.m. Resident #2's RR stated staff did not speak English and Resident #2 did not speak another language. Since the staff did not understand Resident #2's preferences, Resident #2's preferences were not followed. An interview was conducted with Resident #9 on 12/15/2025 at 10:23 a.m. Resident #9 stated the aids speak other languages, and it is difficult to communicate with them.Review of Resident #9's MDS, dated [DATE], Cognitive Patterns, showed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition not impaired.An interview was conducted with Resident #10 on 12/15/2025 at 10:40 a.m. Resident #10 stated some staff speak Spanish. Resident #10 said the staff help people, but they don't understand what you are saying.Review of Resident #10's Minimum Data Set (MDS), dated [DATE], Cognitive Patterns, showed a BIMS score of 6/15, indicating cognition severely impaired.An interview was conducted with Resident #18 who serves as resident council president, on 12/15/2025 at 3:14 p.m. Resident #18 stated there are language issues with the Certified Nursing Assistants (CNAs), as the CNAs do not speak English. Resident #18 said most of the residents have cognition issues and get frustrated with having to explain things multiple times since the staff do not understand them. Resident #18 said some residents can be mean about having to explain things to the staff due the language barrier. Resident #18 said it is very hard to communicate with the staff, due to the language barrier. Resident #18 stated most of the non-English speaking staff usually work at night.Review of Resident #18's MDS, dated [DATE], Cognitive Patterns, showed a BIMS score of 15/15, indicating the resident's cognition was not impaired.An interview was conducted with Staff A, Licensed Practical Nurse (LPN), on 12/15/2025 at 12:42 p.m. Staff A stated there were complaints about CNAs who did not speak English. Staff A stated not sure if the staff still work at the facility or if they quit. An interview was conducted with the Social Services Director (SSD) on 12/15/2025 at 12:54 p.m. The SSD stated numerous complaints have been received regarding the language barrier with staff and residents, since October 2025. The SSD stated when a grievance is received by a staff member, the staff member writes the grievance and files with social services. Social Services takes the grievance to the morning meeting for discussion. The grievances about the language barrier are assigned to the Nursing Home Administrator (NHA). The SSD said most residents have hearing issues, and the difference in language makes it difficult for the residents to communicate. The SSD stated, We do have a couple of staff who do not speak English.An interview was conducted with the Director of Nursing (DON) on 12/15/2025 at 4:26 p.m. The DON stated the facility has a language line and bilingual staff members who help with translation for residents who need assistance. The DON said the staff can go and ask another staff member to assist them with communication, if needed. The DON stated the facility does not provide training to staff in different languages. The DON confirmed they have no documented training regarding language barriers. The DON confirmed having heard concerns about staff with thicker accents, being difficult to understand, those concerns have been conveyed to the NHA. The DON said there are a couple of CNAs that have language barriers and difficultly understanding English. The DON said that if there are any complaints, then staff would create a grievance. Administration would then follow up with that staff member. The DON stated she is not sure if a policy for language barriers exists. The DON confirmed not being aware of issues with nurses and the language barrier. The DON stated no care issues have occurred due to language barriers. The DON said , This is a fairly new thing in our facility and staff speaking another language to each other in front of a resident is a dignity concern.Review of the facility policy titled Resident Rights, with a revision date of 2/1/2025 revealed the following: . 4. If a resident's knowledge of English or the predominant language of the facility is inadequate for comprehension, a means to communicate the information concerning rights and responsibilities in a language familiar to the resident will be made available and implemented.Review of the facility Resident Rights document not dated revealed: Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons [sic] and services inside and outside the facility. 4. Respect and Dignity. The resident has a right to be treated with respect and dignity, including: . right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents.

Based on observations, interviews and record review, the facility failed to ensure a safe, clean, comfortable and homelike environment to include resident bathrooms had functioning toilets, and the environment was maintained and sanitary from raw sewage odor in six (A, B, C, D, E, and F) of six-unit zones. Findings included:On 12/15/2025 at 9:10 a.m. upon facility entrance to the facility there was a heavy raw sewage odor.An interview was conducted with Staff I, receptionist, on 12/15/2025 at 9:10 a.m. Staff I confirmed the sewage odor and believed it came from the public bathrooms, located in the lobby area. Staff I said the odor is really bad in the a.m. but later in the day it seems to go away. Staff I stated reporting the odor to the Maintenance Director (DOM). Staff I stated receiving complaints from visitors as well as residents in the building, regarding the odor. Staff I stated not knowing how long the sewage odor had been on, but it has been ongoing since her employment, which was in the beginning of 11/2025. The sewage odor was present in the corridors and outside of the conference room. On 12/15/2025 at 9:20 a.m. and 12:20 p.m., a facility tour, including all 68 resident rooms were entered for observation. During tour, the strong sewage odor was present in the main hallway of the 300 hall and beginning of the 200 hall to include outside resident rooms 200 - 206. The following was observed: a. Resident room [ROOM NUMBER]-bathroom toilet bowl water was continuously running and would not stop even after jiggling the tank handle.b. Resident room [ROOM NUMBER]-bathroom toilet bowl was clogged and filled with fecal matter and brown paper towels. The toilet would not flush with over three attempts. The Housekeeping Director (HD) came into the bathroom with a plunger trying to unclog the toilet, unsuccessfully.c. Resident room [ROOM NUMBER] bathroom had a clogged toilet, filled with fecal matter and brown paper towels. The toilet would not flush, after repeated attempts.d. Resident room [ROOM NUMBER]-bathroom toilet bowl had low water fill and would not flush.e. Resident room [ROOM NUMBER]-bathroom had a clogged toilet, filled with fecal matter and brown paper towels. The toilet would not flush, after repeated attempts.f. The main hallway at and around resident rooms 200 - 206 with sewage odor.g. Resident room [ROOM NUMBER]-bathroom toilet had low water fill and would not flush. h. Resident room [ROOM NUMBER]-bathroom toilet would not flush, after repeated attempts.i. Resident room [ROOM NUMBER]-bathroom toilet would not flush, after repeated attempts.j. Resident room [ROOM NUMBER]-bathroom toilet would not flush, after repeated attempts.k. Resident room [ROOM NUMBER]-bathroom had a clogged toilet, filled with fecal matter. The toilet would not flush, after repeated attempts.l. Resident room [ROOM NUMBER]-bathroom had a clogged toilet filled with fecal matter and brown paper towels. The toilet would not flush, after repeated attempts.m. Resident room [ROOM NUMBER]-bathroom toilet had a clogged toilet filled with fecal matter. The toilet would not flush, after repeated attempts.n. Resident room [ROOM NUMBER]-bathroom toilet was clogged. The toilet would not flush, after repeated attempts.On 12/15/2025 at 9:25 a.m. the HD was observed in resident room [ROOM NUMBER] bathroom utilizing a plunger in the toilet. The HD said the staff continually unclog toilets in either resident bathrooms or other bathrooms in the facility. The HD said each time the clog occur the staff report the incident to the DOM. The DOM follows up by either fixing a toilet and at times contacting an outside plumbing service. The HD confirmed the facility does have a sewage odor, especially in the morning. The HD said not knowing exactly where the odor comes from or what the administration and maintenance department are doing about that odor but does know they are aware of it and working on. The HD confirmed the toilet clogs are ongoing, and the sewage odor has been on and off for a couple of months.On 12/15/2025 during the 7-3 shift from approximately 9:20 a.m. through to 12:00 p.m., interviews with various staff were obtained. Staff B, Licensed Practical Nurse (LPN); Staff C, Certified Nursing Assistant (CNA); Staff D, CNA; Dietary Manager (DM); Staff F, Social Service (SS); and the Business Office Manager (BOM) all confirmed the sewage odor throughout the facility Staff B, LPN, Staff C, CNA, Staff D, CNA, DM, Staff F, SS, and the BOM also confirmed the sewage odors have been ongoing for months and there are resident rooms that have clogged toilets that have to be unclogged, regularly. Staff B, C, D, E, F, and G all said they have contacted the administration and maintenance department about the odors and feel they are constantly working on getting the issue fixed, to no avail. An interview was conducted on 12/15/2025 at 2:15 p.m. with the Nursing Home Administrator (NHA), and the DOM. The NHA and DOM confirmed the facility physical plant has been having issues with toilet flushing and with sewage odor for several months. The DOM said the staff can usually fix the toilet flushing problems with simple plunging. The DOM said they are constantly educating staff and residents certain products cannot be flushed down the toilet. Only physical matter and toilet paper should be placed in the toilet; this would prevent clogging. The DOM said a work order is completed to identify a toilet as clogged, then housekeeping or maintenance staff will unclog the toilet. The Maintenance Director said work orders are brought to his attention by staff either verbally, or of course in writing. The DOM said clogged toilets are always high priority to correct. The DOM said over the last two months, several toilets needed unclogging and fixing. He was not aware of the thirteen toilets observed today (12/15/2025), that were clogged and or not working properly. He confirmed there were no current work orders for toilet clogs today (12/15/2025). The NHA and the DOM confirmed the sewage odor being present for the past several months. The NHA and DOM stated staff and residents have complained about the odor. The DOM said he has been employed at the facility for many years and from time to time this sewage odor occurs. The DOM provided the following documentation to show how they have been working on the problem.1. An outside sourced commercial plumbing services reported to the facility on [DATE] to include work relating to sewage back up in the front desk area restrooms and provided maintenance and repair.2. An outside sourced commercial plumbing services reported to the facility on [DATE] to include work relating to clearing a rooftop vent. There was nothing noted related to responding to sewage problems.3. An outside sourced commercial plumbing services reported to the facility on 6/23/2205 to include work related to a water pipe leak in the front entrance area. There was nothing noted related to responding to sewage problems4. An electronic communication mail (Email) dated 3/17/2025 indicating order for toilet wax rings (package of 6).No current documentation was provided. Review of the facility policy titled, Routine Cleaning and Disinfection with a revision date of 11/1/2025 revealed: Policy - It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Definitions: Cleaning refers to the removal of visible soil from objects and surface and is normally accomplished manually or mechanically using water and detergents or enzymatic products. Disinfection refers to thermal or chemical destruction of pathogenic and other types of microorganisms. Policy Explanation and Compliance Guidelines: 1. Routine cleaning and disinfection of frequently touched or visibly soiled surface will be performed in common areas, resident rooms, and at times of discharge. The policy did not specifically speak to odors and toilet clogs. However, the NHA confirmed foul odors and toilet unclogging would fall under this policy.Review of the facility policy titled, Preventative Maintenance Program, revision date of 6/1/2024, revealed: Policy - The preventative maintenance program shall be developed and implemented to ensure the provision of a safe, functional, sanitary environment for residents, staff and the public. Policy Explanation and Compliance Guidelines revealed: 1. The Maintenance director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.Interview with the NHA and the Maintenance Director both revealed this policy does not specifically speak to constant sewage odors, but this area of odors would fall under this policy. Review of the facility policy titled, Resident Rights, revision date 2/1/2025, revealed: Policy - The facility will inform the resident [NAME] orally in writing, in language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility will also provide the residents with prompt notice (if any) of changes in any State or Federal laws related to resident rights or facility rules during the resident's stay in the facility. Receipt of any such information must be acknowledged in writing. Policy Explanation and Compliance Guidelines revealed to include but not limit: . 8. Safe environment - The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Photographic evidence obtained.

Based on observation, staff interview, and facility record review, the facility failed to ensure; 1. One of one dish washing machine was operating at its low temperature wash and rinse specifications; 2. One of one walk in freezer was free from icing, ice sheeting build up on floors, inside walls, shelving and packaged food items; 3. One of one walk in refrigerator had an internal thermometer to gauge the internal temperatures; and 4. One of one hand washing sink had soap available to wash hands. Findings included: 1. On 10/16/2023 at 9:32 a.m., a kitchen tour was conducted with the Certified Dietary Manager (CDM). There was a hand pump soap dispenser attached to the wall directly above the hand sink. The soap dispenser was empty. The Dietary Manager confirmed the wall mounted soap dispenser was empty and did not know how long it had that way. She further confirmed the sink was where the staff who come into the kitchen washed their hands. She confirmed using an alcohol base sanitizer was not acceptable for her and her staff to use in lieu of washing their hands at the sink with soap and water. 2. On 10/16/2023 at 9:37 a.m., the CDM said the the kitchen had a Low temperature sanitizer dish washing machine. She revealed the wash cycle temperature and the rinse cycle temperature should reach 120 degrees Fahrenheit (F), and the sanitizer parts per million (PPM) should reach 100 - 200 PPM. She reviewed the last two months of the dish machine temperature log. Both months 10/2023 and 9/2023 the dish machine temperature logs showed appropriate temperatures logged, reaching at least 120 degrees F for both the wash and rinse cycle and the sanitizer was 50 ppm. The CDM pointed out on the wall next to the dish machine, informational posters that showed what the PPM expectations were for the sanitizer. She pointed out the machine's specification plate on the lower end of the machine. Both indicated a Low temperature dish machine with chemical sanitizer at optimum levels of 50-100 ppm for the sanitizer, and 120 degrees F for the wash and rinse cycles. The Dietary Manager confirmed the chemical sanitizer should be at 50 - 100 PPM. While speaking with the Dietary Manager, Staff A, dietary aide and Staff B, dietary aide were operating the dish machine. Staff A and Staff B said the dish machine had been running for about 15 minutes. Both Staff A and B confirmed the machine was operating well and there were no problems with it. Staff A and B said the machine was a Low temperature dish washing machine and temperatures for both wash and rinse should reach at least 120 degrees F. They also both said the chemical sanitizer was tested on ce every meal service. Staff A and B did not know the PPM range for the sanitizer. On 10/16/23 at 9:43 a.m., both Staff A and B demonstrated the use of the dish machine. Staff B ran a crate of dishes through the machine. After the crate of dishes was in the machine, the wash temperature only reached 103 degrees F ,according to the machine's analog thermometer. After the rinse cycle finished, and the machine clicked, the rinse cycle revealed a temperature only reaching 119 degrees F. The thermometer attached to the machine was heavily fogged and difficult to read. The CDM said, I can read it just fine. Photographic evidence obtained. On 10/16/23 at 9:44 a.m., a second dish machine demonstration was observed. Staff B ran another crate of dishes though the machine. After the crate of dishes were sent through the machine, the wash temperature only reached 115 degrees F. After the wash cycle ended and the machine clicked, the rinse cycle reached only 118 degrees F. Both Staff A and B said they primed the machine prior to washing the first crate of dishes. They said the wash and rinse temperatures were at 120 degrees F. before they started running crates of dishes through the machine. Staff B said she could not read the temperature gauge. The Dietary Manager said she would notify the dish machine company of the issue and have them come out to fix the gauge and the water temperature. 3. As the kitchen tour continued, the walk in refrigerator was found without a thermometer. The CDM and cook were unable to locate the refrigerator thermometer. During this observation, the internal temperature of the walk in refrigerator could not be confirmed. The Dietary Manager was unable to provide the daily/weekly/monthly temperature log for the walk in refrigerator. 4. As the kitchen tour continued, the walk in freezer was observed with a thick sheeting of ice on the floor on the left side of the unit. The sheeting of ice was approximately three feet long and three feet wide, with a thickness of about two inches or more in some spots. Further observations revealed the top left side shelf was observed with heavy icing and long icicles, with heavy icing built up on three boxes of packaged food items. Also, the flow pipes leading from the motor fan housing to the back of the unit wall were observed with heavy ice build up. An interview with the Dietary Manager revealed she was not aware of the icing on the floor and on the packages of food items. She confirmed the freezer iced up at times and believed the Maintenance Director was aware of the situation. Photographic evidence obtained. On 10/19/2023 at 1:00 p.m., an interview with the Maintenance Director confirmed he was aware of the walk in freezer ice build up but did not have a work order to show what he was currently doing to fix the issue. On 10/19/2023 at 2:00 p.m. the Nursing Home Administrator provided the undated Dish Machine Policy and Procedure. The Policy showed the following procedures: 1. The dirty carts/dishes must enter the dirty area and exit the clean area when possible considering architectural design and kitchen layout. 2. Check unit chemical container levels and run dish machine while empty (as many times as necessary) to get desired temperature. 3. Run dishes through the unit cycles of wash and rinse. 4. Record temperature and chemical level of unit at least 3 times per day. 5. Follow unit specifications for proper temperature and chemical levels to assure proper sanitation.

Based on observation, record review, and interview, the facility failed to develop care plan problem areas with goals and interventions related to Post Traumatic Stress Disorder (PTSD), for one (Resident #151) of two sampled residents, who had a history of PTSD. Findings included: On [DATE] at 10:15 a.m., Resident #151 was observed in her room with two visiting family members. She was seated on the side of her bed and was dressed for the day and well groomed. Resident #151 was not presenting with any behaviors, pain, or discomfort. She appeared to be comfortable around and with her family members. Resident #151 was interviewed and revealed she felt generally safe at the facility and was happy to have her brother and nephew who visited regularly. She did not have any immediate concerns with her care and services while at the facility. Review of Resident #151's medical record revealed she was admitted to the facility on [DATE] and was at the facility for short term rehabilitation. Review of the advance directives revealed Resident #151 was her own decision maker. Review of the diagnosis sheet revealed diagnoses to include but not limited to: Dysphagia, muscle weakness, acute chronic respiratory failure, pain, and Anxiety. Review of the Minimum Data Set (MDS), 5 day assessment, dated [DATE] revealed; Cognition/Brief Interview for Mental Status (BIMS) score of 13 of 15, which indicated intact cognition. Mood - checked yes for mood interview to be conducted, checked yes as feeling down, checked yes as trouble falling asleep, checked yes as poor appetite, checked yes as feeling bad about self; Behaviors - none marked as exhibited; Active Diagnosis section was not checked for Post Traumatic Stress Disorder PTSD. Review of the nurse progress notes dated [DATE] at 12:47 p.m., revealed Resident #151 was admitted for short term rehab with a diagnosis of pneumonia. She was alert and oriented. She presented with moderate signs and symptoms of depression. The note further added that the resident had disclosed she had a history of being abused. The note also revealed; Referral made to psych. services. No behaviors noted. Review of the interim care plans as completed within the first forty-eight hours of Resident #151's admission, revealed the following but not limited to problem areas: 1. Risk for alteration in psychosocial wellbeing, mood, behavior, cognition, and functioning. Resident is at risk to experience adverse psychosocial changes such as increased depression and anxiousness with potential to affect wellbeing with interventions to include; Psych consult and follow up as needed. Observe and report changes in mood, behaviors, cognition, and level functioning caused by situational stressors to Medical Doctor. Reinforce appropriate expression of feelings. 2. Receives Antianxiety meds due to history of anxiety making resident at risk for medication side effects with interventions to include: Provide medications as ordered, Pharmacy consultant review every month, Observe resident's mood and response to medication, Observe medication side effects, Attempt non pharmacological interventions such as 1 on 1 and or TLC for increased anxiety, attempts to gradually dose reduction if warranted. On [DATE] at 8:00 a.m., an interview with both the Director of Nursing (DON) and the Minimum Data Set (MDS)/Care Plan coordinator Staff D, revealed Resident #151 was newer to the facility but they knew of her and her daily routines. Staff D and the DON confirmed the resident was visited by family on a daily basis and she participated in therapy. Staff D and the DON confirmed Resident #151 had been marked on the facility's Resident Matrix, which indicated she had Post Traumatic Stress Disorder (PTSD). Staff D revealed Resident #151 had PTSD related to behaviors that occurred to her as a child and also while with her now deceased husband. Staff D revealed after the Admission MDS/5-day assessment, dated [DATE] was completed, it was brought to her attention the resident had PTSD. She revealed the care plan for the resident did not include PTSD with goals and interventions. Staff D reviewed the progress note, dated [DATE], and confirmed the 5 Day MDS assessment should have reflected Resident #151 had PTSD. She said there should have been a PTSD care plan developed. The Director of Nursing confirmed Resident #151 was not care planned with a specific problem area, goals and interventions related to PTSD as of yet, and they should have care planned that problem area during the interim care planning phase, within forty-eight hours of her admission. On [DATE], the Nursing Home Administrator (NHA) provided the Comprehensive Care Plans, policy with a last review date of ,d+[DATE], for review. The Policy revealed; All residents will have a Comprehensive Care Plan (CCP) completed in accordance with Federal and State requirements. The CCP will include measurable objectives and timetables in order to meet the resident's medical and psychosocial needs that are identified from the comprehensive assessment (MDS). All applicable Care Area Assessment (CAA) will be reviewed. Any issues may be identified by members of the comprehensive care plan team and should be evaluated for inclusion in the comprehensive care plan. The Policy continued to reveal; The CCP will be developed within 7 days after the completion of the comprehensive assessment. The CCP will be periodically reviewed and revised by a team of qualified Clinicians after each MDS assessment and reassessment. Key points include but not limited to: Initial admission, readmission, and significant change; Episodically as plan of care changes. The Procedure section of the policy revealed; 1. The CCP will be initiated by all members of the team on admission. a. Problems will be identified from the MDS triggers and review of the CAA, and from the resident assessment, interviews, and direct observation. b. Team disciplines will write identified problems directly onto the care plan problem sheet. All disciplines are responsible for reviewing the plan of care and documenting interventions and initiating responsibility in the disciplinary column. c. Disciplines will be responsible for updating the plan of care when there is a new problem that requires the discipline to intervene. d. Any discipline can initiate a special care plan meeting.

Based on observation, record review, and interview, the facility failed to ensure two (Resident #26, and #67) of three sampled residents for quality of care received treatment and care in accordance with professional standards of practice related to 1. Responding to a change in condition timely related to a skin condition for Resident #26, and 2. Monitor and provide care to an occlusive dressing for Resident #67. Findings included: 1. On 10/16/23 at 10:58 a.m., Resident #26 was observed in her room sitting in the wheelchair next to her bed. A tube of [over-the-counter (OTC) medicated ointment, used for skin irritation] was observed sitting on the bedside table. She stated her husband always brought the [OTC medicated ointment] because she wanted to make sure she had it. She had an open area around her anus and in the groin area. Resident #26 stated it was very painful from sitting for so long. The wound care doctor came on Monday, and she needed to see them. She stated it hurt very bad when she urinated. They checked her for a Urinary Tract Infection (UTI) and it was negative. On 10/18/23 at 1:29 p.m., Resident #26 was observed in her room sitting in the wheelchair next to her bed. She received a phone call during the interview. Resident #26 reported to the person on the other end of the phone that her bottom was in pain and she needed to see the wound care doctor. On 10/19/23 at 9:20 a.m., Resident #26 was observed in her room sitting in the wheelchair next to her bed. She stated she had been feeling the pain on her buttocks and when she urinated for more than three months. She asked for the wound doctor to see her, and staff acted as if it was unusual. Staff were telling her it was just a raw opening and that was why the area was sore. Resident #26 stated when staff changed her, her bottom rubbed against the bed and it hurt. She stated sitting in the chair was hard. Every move she made hurt those places. She stated she wished staff could explain things to her better. At one point, they moved her to another room because her sores were so bad. It had not gotten any better. It started with just a burning on her buttocks. She could not consider going home because she was in so much pain. The burning and soreness have been going on for the last three months. When the pad was wet, it stayed up against her and it burned. She drank a lot of water, so she urinated a lot. Staff told her yesterday that she could not use the[OTC medicated ointment]. The ointment that was ordered for her was not helpful at all. The areas were really raw. The last person talked to her said it was raw with open patches with little flaky skin. Sometimes the staff would say it cleared up in a day and then it would come right back. A review of the Resident Face Sheet revealed Resident #26 was admitted into the facility on [DATE] with diagnoses to include urinary tract infection. The Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicted intact cognition. A review of the active orders revealed the following: Apply zinc cream to buttocks 3 times a day for redness and Head to toe skin checks weekly once a day. Special instructions: Complete non-pressure observation or wound management form if appropriate. There was no order on the active orders list for the [OTC medicated ointment]. A review of the Medication Administration Record (MAR) for August, September, and October 2023, showed the zinc cream was applied three times daily for all three months and skin assessments were completed as ordered. Resident Progress Notes revealed the following: 10/18/23 18:57 (6:57 p.m.) - Patient showing increasing confusion and agitation. The doctor was notified. New orders for Urinalysis and Culture and Sensitivity to be completed. 10/13/23 10:53 a.m.- Weekly skin assessment completed, resident had excoriation to her coccyx and groin, continue current treatment until healed, and will continue to monitor for any changes in condition. 10/11/23 15:41 (3:41 p.m.) - Resident had reddened area to groin and coccyx, continue current treatment until healed, will continue to monitor for changes of condition. 10/09/23 13:57 (1:57 p.m.) - Patient had non-blanching area to coccyx, purple in center. Notified doctor and he requested for wound care to follow. 10/06/23 12:05 p.m. - Weekly skin assessment complete. Resident has no skin impairments at this time, resident had reddened area to sacrum with treatment, will continue to monitor for any changes of condition. 09/30/23 12:01 p.m.- Weekly skin assessment complete. Resident had reddened area to coccyx, no other skin issues noted, continue current treatment until resolved. Will continue to monitor for any changes of condition. 09/22/23 8:20 a.m.- Weekly skin assessment complete. Coccyx reddened, continue current treatment until healed, will continue to monitor for any changes in condition. 09/14/23 20:58- (8:58 p.m.) Weekly skin assessment complete. Resident had reddened area to her buttocks, continue current treatment until healed. 09/07/23 1:04 a.m. - Weekly skin check complete. Reddened area left buttocks. Continue current treatment. Will continue to monitor for any changes in conditions. 09/04/23 18:17 (6:17 p.m.) - Weekly skin assessment completed. Open area to right buttock. No signs and symptoms of infection noted. Treatment order in place. 09/01/23 14:46 (2:46 p.m.) - Weekly skin assessment complete. Patient had open area on right buttock, treatment in place. Will continue to monitor. 08/25/23 18:54 (6:54 p.m.) - Weekly skin assessment. Patient had open area on right buttock, treatment in place. 08/24/23 14:22 (2:22 p.m.) - Weekly skin assessment complete. Resident had small open area on right side below her coccyx. Continue current treatment until healed. Will continue to monitor for any changes in condition. 08/20/23 19:23 (7:23 p.m.)- The doctor was notified of new open areas on back of thigh. Orders placed. 08/20/23 0:07 (12:07 a.m.)Certified Nursing Assistant (CNA) reported skin alteration to the patient's right buttock. On observation, the patient had slight excoriation to the right buttock, on the fold of skin. The area was cleansed with soap and water. Barrier cream applied. Skin alert completed and placed in the unit manager's box. 08/18/23 11:19 a.m. - Weekly skin assessment completed. No new skin conditions noted. Will continue to monitor. 08/16/23 17:52 (5:52 p.m.) - Weekly skin assessment completed. No new skin issues noted. 08/11/23 11:07 a.m. - Weekly skin check completed. Resident had reddened area to coccyx. Continue current treatment until healed. 08/04/23 10:10 a.m. - Weekly skin check complete. Reddened area to coccyx. Continue current treatment until healed. Will continue to monitor for any changes in condition. 08/02/23 14:53 (2:53 p.m.) - Weekly assessment completed. No new skin issues noted. The progress notes showed on 10/11/23, Resident #26 was noted to have a new reddened area to her groin and on 10/13/23 she was noted to have a new area of excoriation to her groin with no orders in place for treatment. The most Recent Wound Evaluation and Management Summary dated 07/10/23, showed the patient presented for follow up of wound on her sacrum. Prior healing wound had improved. The progress notes showed on 10/09/23 the doctor requested for wound care to follow up. There was no evidence of a follow up from the wound care doctor. The care plan related to skin integrity with a problem date of 12/09/20 showed the resident had a risk for skin integrity. Interventions included but were not limited to report changes in skin status to the physician. There was no evidence the physician was contacted related to the changes in skin condition. On 10/18/23 at 1:30 p.m., Staff E, CNA, stated Resident #26 had complained of pain to her buttocks and groin area but it was getting better. The nurse was aware, and the nurse was responsible for doing treatment. On 10/19/23 at 9:32 a.m., Staff F, Licensed Practical Nurse (LPN) stated Resident #26 had not complained to her about pain on her buttocks or groin area. She did not like the wheelchair and she would not let them turn her because she said it was uncomfortable. She hated the wheelchair and preferred to lay in bed. She had been very confused and agitated so the doctor was contacted. They ordered a urinalysis because of the agitation and confusion. Staff F stated the resident had a pack of sour cream and was saying it was a cream for her bottom. Staff F reported the resident had not reported to her about the pain while urinating. She stated, Well that would be perfect for a UTI. On 10/19/23 at 10:21 a.m., Staff G, LPN/Unit Manager (UM), reported she saw Resident #26 a couples of times a day; but, the resident did not say anything to Staff G about pain when she urinated. The resident would always report that the areas were sore. She got excoriated. It went away and came back. Resident #26 seemed to like the [OTC medicated ointment] and she knew she was not supposed to have it. The resident never told Staff G the cream she had ordered was not working and never asked her about seeing the wound care doctor. Staff G said if there was anything other than a red area, the resident could be seen by the wound care doctor. The area was not open so she was not on the schedule to see the wound care doctor. Staff G, LPN/UM stated they could send a wound care referral. The area to the groin was observed during the middle of last week when she did a skin assessment. She confirmed the resident did not have an order in place for treatment to the groin area. On 10/19/23 at 10:12 a.m., the Director of Nursing (DON) stated the resident had a history of pain. The resident had not reported any skin concerns to her. She was ordered a barrier cream that the nurse put on her twice a day. When the nurses perform skin checks, and the note indicated redness or excoriation, she or Staff G, LPN/UM would look at the area. If there was a concern, they would fax that information to the wound care doctor and the wound care doctor would see them that following Monday. If the area was open, then the wound care doctor would see the resident. The wound care doctor was here on Monday. She stated the wound care doctor did not see the resident because the area was not open. The nurse would indicate the area of concern on the 24-hour report, the UM would review the report, and then the UM would go assess the patient. She confirmed the resident was not seen by the wound care doctor as ordered by the physician because on 10/11/23, the resident was seen and assessed by the UM and the area was red. There was no need to see the wound care doctor. The [NAME] Wound Round Policy provided by the facility revised on 05/22 revealed the following: In addition to the Attending Physician, the residents will receive services from consultants if ordered by the attending physician. 39866 2. Review of Resident #67's face sheet revealed she was admitted on [DATE] from an acute care hospital. Resident #67 had medical diagnoses to include but were not limited to, infection and inflammatory reaction due to her internal orthopedic prosthetic devices, implants and grafts, sepsis due to Methicillin susceptible staphylococcus aureus, osteomyelitis, fracture of right femur, encounter for closed fracture with routine healing, periprosthetic fracture around internal prosthetic right hip joint, and the need for assistance with personal care. An observation was conducted on 10/16/23 at 10:48 a.m. Resident #67 was observed to be lying in bed with an intravenous (IV) pole next to her bed. The resident was observed to have an IV in her left arm with a clear dressing that was intact and dated 10/16/23. The resident was observed to also have a bandage on her right upper arm which was dated 10/12 the bandage was intact but soiled with dark reddish brownish substance that filled more than half of the occlusive bandages absorbent pad. Resident #67 said she used to have an IV in that arm and they took it out and put the bandage on. Photographic evidence obtained. Review of Resident #67's physician orders did not reveal any orders related to the right upper arm occlusive dressing. An interview was conducted on 10/16/23 at 11:13 a.m., with Staff L, Certified Nursing Assistant (CNA) who was Resident #67's assigned CNA. She stated she had not worked with Resident #67 in a while, and she did not know anything about the bandage. An interview was conducted on 10/16/23 at 11:31 a.m., with Resident #67's nurse Staff K, Licensed Practical Nurse (LPN). She said Resident #67 used to have an IV in her right arm but it got clogged and the IV team came and put a new one in. They did not take the old one out so on Thursday last week, Staff K contacted the doctor and received an order to remove the old IV. Staff K said, The DON removed it and I put a bandage on it last Thursday. I'm pretty sure I dated the dressing. I didn't work yesterday but on Saturday I tried to take the bandage off but the resident didn't want me to so I told her it is going to have to come off in a week. Review of Resident #67's progress note dated 10/12/23 at 3:12 p.m. showed old PICC [peripheral intravenous central catheter] line removed 40 cm long. Pressure applied, and no bleeding noted. An interview was conducted with the Director of Nursing (DON) on 10/19/23 at 2:01 p.m. She said, Resident #67 had an IV upon admission. It was removed because it was leaking and not flushing, so a new IV was inserted. Review of the facility's Clean Dressing Change policy undated, revealed Intent: It is the policy of the facility to ensure change in dressings in accordance with State and federal Regulations, and national guidelines. Procedure: 1. Verify and review physician's order for procedure. .27. Document the completion of dressing change on the treatment record. 46498

Based on observation, interview, and record review, the facility failed to prevent enteral feeding complications related to not providing the ordered nutrition for one (Resident #28) out of 32 residents sampled. Findings included: Review of Resident #28's face sheet revealed she was admitted to the facility on [DATE]. Resident #28 was receiving hospice services. Her medical diagnoses included but were not limited to dysphagia, gastrostomy status, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, muscle weakness, major depressive disorder, and dementia. Review of Resident #28's physician orders revealed an order with a start date of 8/23/23 without an end date for enteral feeding: Formula Jevity, strength 1.5 calorie, Flow rate 70 ml/hr. (milliliters per hour) for 20 hours. Further physician order review revealed an order with a start date of 8/16/23 without an end date for free water flush 250 ml via peg tube every 4 hours. Another order with a start date of 6/20/23 without an end date for off Tube feeding at 10 AM once a day and another order with a start date of 6/20/23 without an end date for Start tube feeding at 2 PM once a day. On 10/16/23 at 9:08 a.m., Resident #28 was observed lying in bed. She was nonverbal but was intermittently moaning. The resident was observed to be hooked up to her enteral feeding pump. The pump was running a bottle of Jevity 1.5 calories and the pump was set for the resident to receive 65 ml' s' per hour with 250 ml water flush every 4 hours. Further observations were conducted on 10/17/23 at 10:18 a.m. Resident #28 was observed lying in bed, eyes closed, with her enteral feeding pump turned off. On 10/17/23 at 2:19 p.m. Resident #28 was observed lying in bed, eyes closed, with her enteral feeding pump turned off. On 10/17/23 at 2:35 p.m. Resident #28 was observed lying in bed, eyes closed, and her enteral feeding pump turned off. On 10/17/23 at 3:07 p.m., Resident #28 was observed lying in bed, eyes closed, her enteral feeding pump was turned on and running Jevity 1.5 calories. The pump rate was set for Resident #28 to receive 65 ml/hr, and the water flush was set for Resident #28 to receive D2000 of water every four hours. Photographic Evidence Obtained. An interview was conducted on 10/17/23 at 3:20 p.m. with Staff K, Licensed Practical Nurse (LPN). She reviewed the physician orders for the feeding rate, went into the resident's room, placed the pump on hold and said, I'm going to put this on hold because I thought it was supposed to be going at 65 ml/hr. Let me see if the dietitian changed the order. Staff K, LPN reviewed the feeding order and confirmed the order had been in place since August 23, 2023. She reviewed the record and said she was having trouble finding the dietitian's note but the night nurse, who was an agency nurse, gave her in report the pump was at a rate of 65 ml/hr. Staff K, LPN also said she took the resident off of her tube feeding at 10:00 a.m. and put her back on at 2:00 p.m. like the order says. Staff K, LPN went into the resident's room cleared the volume infused and changed the feeding pump rate to 70 ml' s' per hour and said she would need to talk to her unit manager to see what the dietitian said. Review of Resident #28's October Medications Administration History revealed on 10/17/23 the physician's orders Off Tube feeding at 10 AM and Start tube feeding at 2 PM were signed off as administered. Review of Resident #28's progress note dated 9/22/23 at 7:18 p.m., written by the facility's dietitian revealed, Unstageable sacrum wound. On Jevity 1.5 @ 70 mls/hour X [times] 20 hour via PEG [Percutaneous Endoscopic Gastrostomy]. Add [brand name of liquid protein supplement] AWC [advanced wound care] 30 mls via PEG daily for 200 Kcals and 30 grams protein, administer per enteral instructions on bottle. Significant loss noted from 113.5 lbs [pounds] to weight 100 lbs on 7-12-23. [Resident #28] is on hospice. NPO [nothing by mouth] diet order continues. F/U PRN [follow up as needed]. A progress note dated 8/15/23 at 9:58 a.m. revealed, called hospice about getting residents tube feed orders adjusted r/t [related to] weight loss, and about her pain meds not being sent from pharmacy due to insurance, they to [sic] call back with new orders. A progress note dated 8/15/23 at 2:54 p.m. revealed, spoke to hospice they called and got the billing corrected with the pharmacy, meds to be delivered today, referral sent to hospice dietitian to review the tube feeding and give recommendations. A progress note dated 8/23/23 at 8:51 a.m. revealed, Pt [patient] seen by [Hospice] dietitian orders to increase Jevity to 70 ml/hr running for 20 hours. Orders confirmed and carried out. Review of Resident #28's care plan, last reviewed on 10/12/23 revealed, Resident has a need for use of a feeding tube related to: (insufficient caloric intake, dysphagia, failure to thrive, cognitive impairment). Resident has risk for complication secondary to tube feeding use. The goal included, Resident will remain free from complications r/t [related to] the use of a feeding tube AEB [as evidence by] no s/s [signs and symptoms] of aspiration, no N&V [nausea and vomiting], no diarrhea, no abdominal distension. The interventions included but were not limited to Administer tube feeding formula and flushes as ordered. An interview was conducted on 10/18/23 at 3:37 p.m. with the Director of Nursing (DON). She said, I am aware she was not getting the ordered amount. We educated the nurse. I also talked to the dietitian, she is new to us, and I educated her that we don't do weights on hospice residents. Review of the facility's Enteral Nutrition policy undated revealed Physician Orders For Enteral Feeding Policy: Enteral formulas are provided to meet the nutritional needs of those residents unable to take liquids or food by normal means. .Quantum Feeding Pump Policy: Tube feedings will be administered as per MD orders, using the Quantum Enteral Feeding Pump .

Based on record review and interviews, the facility failed to implement pharmacy services procedures to acquire and have available for administration, medication ([MEDICATION(S)]), for one (Resident #1) of three residents reviewed for availability of medication. Findings include: A review of Resident #1's clinical chart, the Admission Record, reflected an admission to the facility on [DATE] at 17:58 (5:58 p.m.) from a local hospital. The diagnosis list included: Acute chronic diastolic (congestive) heart failure; presence of cardiac pace maker; need for assistance with personal care; other lack of coordination; difficulty in walking, not elsewhere classified; muscle weakness (generalized) mild cognitive impairment, so stated; anxiety disorder (unspecified); major depressive disorder, single episode, moderate; and hypothyroidism; essential (primary). A review of Resident #1's hospital records, reflected her current medication list included a physician order for [MEDICATION(S)] 0.5 mg tab, 1 mg bedtime by mouth, start order of 08/19/2022. A review of Resident #1's hospital discharge orders, dated 08/22/2022, run time of 15:57 (3:57 p.m.) reflected an order for the [MEDICATION(S)] ([MEDICATION(S)]), 1 mg, at bedtime as needed, and the prescription was forwarded to a local pharmacy. A review of Resident #1's physician orders, reflected an order, for [MEDICATION(S)] ([MEDICATION(S)])-Schedule IV tablet, 1 mg tablet; oral, once a day, PRN (as needed), HS (bedtime), start date of 08/22/2022, discontinue date of 08/24/2022. In addition, the physician orders listed a second order for [MEDICATION(S)] ([MEDICATION(S)])-Schedule IV tablet, 1 mg tablet oral, once a day, HS 19:00-23:00 (7:00 p.m.-11:00 p.m.) start date of 08/24/2022. A review of Resident #1's Medication Administration Record for 08/2022, reflected no administration of the [MEDICATION(S)], on 08/22/2022 or 08/23/2022. The record reflected the first administration was on 08/24/2022 at bedtime. On 09/07/2022 at 2:00 p.m., an interview was conducted with Resident #1's family member. He confirmed he was involved with Resident #1's care. He stated, from his understanding, his mom had a prescription for [MEDICATION(S)] ([MEDICATION(S)]). On a regular basis, she would take this, sometimes a 1/2 a pill in the evening to help her sleep. On 09/07/2022 at 2:55 p.m., a phone interview was conducted with Staff A, Licensed Practical Nurse (LPN). She confirmed she worked on 08/23/2022, beginning at 7:00 p.m., until 7:00 a.m. on 08/24/2022. When asked about Resident #1's [MEDICATION(S)], she said, [Resident #1] had asked for it one night, I did not have it in the cart. Then one night I had the script, but not pills. When asked if the medication was available in the Emergency Drug Kit, she reported, I do not have the numbers to get into the kit. I believe I got the numbers when I started. Do not know if the other nurses have the numbers to get into the kit. On 09/07/2022 at 4:00 p.m., a phone interview was conducted with the Consultant Pharmacist. She confirmed the facility should have the medication available for the resident's use. She stated there was a process to go through, the nurse would have to call the doctor for the prescription. Then they call to the pharmacy once they had the script for the code to get into the emergency medication machine. The nurses have their own access code. She stated, if the prescription for the medication was sent to (local pharmacy), the nurse would have to contact the local pharmacy to transfer the prescription. On 09/07/2022 at 4:30 p.m., in an interview with the Director of Nursing (DON), she stated the facility had two emergency medication machines, one on the north wing and one on the south wing. She said, to access the machine, all the nurses have a code, first initial, last name, social security number and also a code. The DON reported she did not have a list of nursing staff who had access to the machine. She stated, All the nurses have access, that is what I have been told. The agency nurse can ask the 2nd nurse to access the machine. Training for accessing the machine, I do not do that, it is part of their floor training. A review of the facility policy and procedures for Medication Orders Controlled Substance Medication Orders, dated 05/16, Nursing Care Center Pharmacy Policy & Procedure Manual, 2007 [name of company], Controlled Substance Medication Orders, documented the policy: Before a controlled substance medication can be dispensed, the pharmacy must be in receipt of a clear, complete, valid prescription from a person lawfully authorized to prescribe them. The pharmacy can dispense a Schedule II controlled substance medication only after the receipt of a practitioner signed valid Schedule II prescription (original and/or FAX) or in the case of an emergency, the practitioner may speak directly to the pharmacist providing an emergency authorization for the pharmacy to supply a small quantity of the Schedule II medication until the practitioner can provide a valid signed prescription. The Procedures included: .The pharmacist can receive a verbal emergency authorization for Schedule II controlled medications if communicated directly to the pharmacist by the prescriber. If a verbal authorization is received by the pharmacist, the pharmacist will contact the facility nurse. If the controlled substance is needed as an emergency, the pharmacist may provide authorization to the nurse to access the controlled substance from the emergency supply located in the facility. A review of the facility policy and procedures for Medication Reconciliation Tool, last revised 11/06/2019, documented the purpose: The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. The Guidelines steps included: .2. Using an approved medication reconciliation form (follow instructions provided on form), list medications from the medication history, the discharge summary, and/or the admitting orders that need to be reconciled .4. If there is a discrepancy or conflict in medications, dose, route or frequency, determine appropriate action to resolve the discrepancy. For example: a. Contact the nurse from the referring facility; b. Contact the physician form the referring facility; c. Contact the resident's attending physician at the facility; d. Contact resident's consulting physician at the facility (if applicable). 5. Document findings and actions.

Based on observation, interviews with facility staff, Nursing Home Administrator (NHA), Director of Nursing (DON), Primary Care Physician (PCP), and Medical Director (MD), medical record review and facility policies and procedures the facility failed to provide competent nursing care to assure the safety of residents. The facility failed to reassess a resident to update the care plan and implement measures to prevent an elopement on 6/14/22 of a vulnerable ambulatory, Resident (#1), out of eleven residents sampled for elopement. Resident (#1), admitted to the facility on [DATE] for rehabilitation services after a hospitalization for shortness of breath and difficulty walking resulting in diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was assessed on admission to the facility to be severely cognitively impaired and not an elopement risk. He was ambulatory and was known by staff to walk freely around the facility. On 6/8/2022 he left his unit through an alarmed door and was located by staff on the sidewalk just outside. Staff assisted him back inside however, staff did not reassess his elopement risk or implement new measures based on this behavior to ensure his safety. On 6/14/2022 he walked towards an exit door, told staff members he wanted to leave and that he had a ride coming for him. Staff members let him out the front door of the facility at 8:10 p.m. He traveled 1.1 miles along a four-lane divided highway with a speed limit of 40 mph, passed through three stoplights to reach a store parking lot where he was found by facility staff at 10:10 p.m. Resident #1 stated to nurse (Staff B, Licensed Practical Nurse) upon his return at 10:38 p.m. he was at church and was going home, but his family member wasn't there so he thought he would [NAME] it and see how the leg would hold up, didn't do so good. Resident #1 was at risk of being hit by a vehicle, becoming lost or going without food, water and needed medications for diabetes, hypertension and [CONDITION(S)]. The facility's lack of reassessment of the resident after an attempted elopement, lack of development and implementation of new interventions to assist in preventing the elopement resulted in the finding of Immediate Jeopardy beginning on 6/14/22 and removed on 6/20/22 with the scope and severity reduced to a D, after verification of implementation of the removal actions. Findings included: A review of the 2022 Facility Assessment completed on 4/2022 showed the facility is equipped to treat non-Alzheimer's dementia memory impaired residents. The facility assessment indicated staffing is sufficient for residents with cognitive mental behaviors, cognitive impairment, and cognitive dementia. On 7/7/22 at 9:22 a.m. an interview was conducted with the Nursing Home Administrator (NHA) and Regional Care Consultant. They stated the facility assessment indicates the staff are competent, sufficiently educated, and prepared to care for residents considered elopement risks. They stated residents identified as elopement risk in preadmission screening would be referred to a facility with a secured unit. They further stated the facility was capable of caring for elopement risk residents, but the preference is not to accept them. The NHA stated the facility is fully staffed, the building is safe, they can take residents with dementia who are elopement risks, but they prefer not to take them. On 7/6/22 at 8:10 a.m. a phone interview was conducted with Staff F, LPN. He stated he cared for Resident #1 when he lived on the North 100 Unit. Staff F stated on 6/8/22 at around 11:00 p.m. he heard an alarm go off on the north side back door. He stated he went to see what was happening and saw Staff G, CNA outside on the sidewalk with Resident #1. Staff F stated Resident #1 had gone out the locked, alarmed door. He stated he was dealing with another resident in distress. Staff F stated he spoke to Resident #1 and asked him why he went outside. He stated Resident #1 told him he was just went out for a walk. Staff F stated Resident #1 was a confused gentleman, but was not injured, so he went back to care for his other residents. Staff F stated he forgot to do the paperwork or write a note because the other resident ended up being sent out to the hospital. On 7/5/22 at 2:54 p.m. an interview was conducted with Staff E, Certified Nursing Assistant (CNA). Staff E stated Resident #1 lived on the North 100 hallway prior to moving to the South 100 hallway. He stated Resident #1 used to walk around the facility and had exited the facility prior to the elopement on 6/14/22 but he was unable to give an exact date and time. Staff E described the previous elopement saying he heard the door alarm sound, then he shouted for another CNA (Staff G) who was working on the unit. He stated when Resident #1 pressed on the door, the alarm sounded, and after 15 seconds it opened automatically. Resident #1 walked outside. Staff E, CNA stated Staff F, Licensed Practical Nurse (LPN), on the unit, came outside to assist both aides with getting Resident #1 back inside the facility. He stated this incident occurred not very long before Resident #1 eloped on 6/14/22. Staff E confirmed he did not report the incident to anyone because he expected the nurse to do so. He stated Resident #1 always walked the hallways looking for his wife in the evening. He stated he never reported the resident voicing concerns related to looking for his wife. Staff E stated on 6/14/22 he was assigned to the South 100 hall (unit) when he heard Resident #1 was missing from his room on the North 100 hall (unit). He stated he went room to room, performed a head count, and searched outside to look for Resident #1 but could not locate him. Staff E stated he was told by the other aides Resident #1 had been missing since just after 8:00 p.m. On 7/5/22 at 3:42 p.m., a phone interview was conducted with Staff G, CNA. Staff G stated she had cared for Resident #1 when he was on the North 100 Unit. Staff G stated Resident #1 left the building about a week and a half prior to the elopement on 6/14/22. She stated she heard the door alarm sound (on 6/8/22) and observed Staff E, CNA as he checked to see which alarm sounded. Staff G stated Staff E realized Resident #1 had gone out the door. She stated she went through the side door and caught Resident #1 on the sidewalk in front of the facility. Staff G stated Resident #1 resisted her when she tried to get him to come back inside. Staff E, CNA and Staff F, LPN came to assist with Resident #1. Staff G stated Resident #1 was able to be guided back into the facility. Staff G stated she did not report the incident because she expected Staff F, LPN to do so. Staff G stated she found out after the elopement on 6/14/22, Staff F had not reported the previous elopement. Staff G stated Resident #1 frequently ambulated around the facility in the evening looking for his wife. She stated the nursing staff, and the unit managers were aware of behaviors related to Resident #1 frequently looking for his wife. Staff G stated Resident #1's wife would visit daily but would leave after dinner. A review of the Resident #1's Face Sheet revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged to another a memory care unit at another facility on 6/16/22. A review Resident #1's Admission Minimum Data Set (MDS) assessment, dated 6/1/22, revealed in Section C: Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. In Section G: Functional Status Resident #1 required supervision or limited physical assistance at a minimum by one person for Activities of Daily Living (ADLs). A review of the comprehensive care plan for Resident #1 revealed the following: Problem: Falls Problem Start date 6/1/22. Resident is at risk for falls related to: Weakness, decreased safety awareness, need for assistance with transfers, history of falls prior to admission. Goals: Resident will not sustain injury related to falling through next review date. Approach: Assist for toileting and transfers as needed (PRN). Complete designated fall risk screening tool on admission. Place bell within easy reach. Problem: Activity of Daily Living (ADL) Functional/ Rehabilitation Self Care deficit as evidenced by: weakness, cognitive impairment. Resident requires assistance with transfers, toileting, bathing, personal hygiene, and locomotion. The amount of assistance needed varies. Goals: Resident will have reduced risk regarding complications related to decreased mobility and will be appropriately groomed and dressed daily through next review. Approach: Observe need for referral/screen and provide as indicated. Provide ADL care to ensure daily needs are met. Provide restorative programs. The medical record showed a care plan for elopement was first initiated on 6/16/22. A review of the Admission assessment dated [DATE] revealed under exit/elopement review Resident #1 was ambulatory, exhibited no behaviors, and was not considered an elopement risk. Review of the medical record showed no elopement assessment on 6/8/2022 to 6/14/22. A review of the nursing progress notes revealed the following entries: 6/3/22- Resident awoke in the night at 11pm and wandered over to the South Unit. He was easily redirected to his room. Offered resident pudding, he ate 100% and was able to sleep the rest of the evening. 06/15/22 at 06:38 a.m. describes the following event. At approximately 09:40 HS [bedtime] med pass, entering pt.'s [Resident #1] room for HS med pass, noted pt. not in room or pt.'s bathroom; assigned CNA reported she had just seen pt. going into bathroom earlier; alerted staff, CNA to look through building for patient; noted pt. not signed out in LOA [Leave of Absence] book, nor note written in progress note from day nurse pt. was out on leave; no picture or form in elopement book; at approximately 09:45 p.m. called over intercom code yellow three times (per interview on 7/5/22 at 2:09 p.m. with Staff A, CNA this should have been a code green); printed out pics of patient; went to other side of building, some in lobby; asked nurse (Staff C, LPN) and CNA (Staff A), showed picture, they stated I we let him out, he said he was catching a ride; this nurse asked what time that was about, other nurse reported about 10 minutes after 8; this nurse immediately called 911 at approx. 09:52 p.m., they transferred me to police dispatch, pt. info given along with description of height and weight, glasses, white beard, mustache, bald, and looks like Santa Claus; police said sending a unit to facility; at approximately 10:10 p.m. police asking what he was wearing, nurse and CNA standing by said have to ask assigned CNA and other nurse and CNA who let patient out; at approximately 09:43 Administrator was called and informed of situation, instructed to call DON; DON returned two unanswered phone calls while this nurse speaking with police, and stated she was aware of the situation and requested spouses name and phone number; CNA assisted police to other unit to ask nurse and CNA for more information about clothing patient wearing when let him out; while later, CNA told this nurse, she had a phone call, answering phone call, another nurse from unit on phone, reported they found patient, was in car with unit manager and administrator; pt arrived through front door of facility via wheelchair at approximately 10:30; 10:38 pt. in room sitting up at side of bed; pt stated he was at church and was going home, but Resident #1's family member wasn't there so thought I would [NAME] it and see how the leg would hold up, didn't do so good manual b/p [blood pressure] 108/62, tympanic [temperature]= 97.5, SpO2 [Oxygen] 96% RA[Room Air], Pulse=76, Respirations= 20, blood sugar 274; pt is now 1:1; pt denied any pain, saying I'm ready to go on another [NAME], smiling, chuckling. The resident exited the facility on a Tuesday night through the main door and traveled north along a road with sidewalks along both sides and consisting of one lane in each direction with a middle turn lane. The speed limit on the road was 40 mph. The resident was found in a multi-store parking lot 1.1 miles from the facility, at the corner of the two-lane road and a four-lane divided highway. The resident had to pass through three stoplights to reach the destination. A hospital is located at the first stoplight from the facility with busy traffic and ambulances coming and going into the hospital. Resident #1 had to cross the two-lane road to end up in the multi-store parking lot where he was found at 10:10 p.m., approximately two hours after he left the facility. A review of the weather on Tuesday 6/14/22 from 6:00 p.m. until 12:00 a.m. indicated a humidity of 70% with passing clouds and wind NNW (north, northwest) at 6.214 miles per hour (mph). At 8:53 p.m. the temperature was reported as 85F (Fahrenheit), and at 9:53 p.m. the temperature was reported as 84 degrees F. Sunset on 6/14/22 was recorded as 8:26 pm. https://www.timeanddate.com/weather On 7/5/22 at 2:09 p.m. a phone interview was conducted with Staff A, CNA. She stated she let Resident #1 out of the facility through the front door using the code to unlock the door. She stated she was going to lunch on 6/14/22 at 8:05 p.m. and was instructed by Staff C, LPN to allow Resident #1 to exit the facility, so she did. She stated neither of them were familiar with Resident #1. Staff A stated Resident #1 walked down the North 100 hall towards the front door and stated he was waiting to catch a ride. Staff A stated about two hours later a code was called for missing resident. She stated when she saw Resident #1's photo, she verified she let him out because she thought he was a visitor. Staff A stated sometime after the incident she found out from another staff member Resident #1 had gotten out of the facility before. Staff A stated before the incident the practice was to let people enter and exit the facility. Staff A stated she did not utilize the elopement book when letting visitors out of the facility prior to the elopement on 6/14/22. She stated Resident #1 was fine when she let him out, he was wearing shorts, a shirt, and a baseball cap. Staff A stated she assumed he was walking to the parking lot to catch his ride. She said she did not see which way Resident #1 went after letting him out the door. A review of the punch card detail dated 6/14/22 for Staff A revealed an out punch for lunch at 8:05 p.m. On 7/6/22 at 7:56 a.m. a phone interview was conducted with Staff C, LPN. She stated she was present when the elopement occurred on 6/14/22 at around 8:05 p.m. She stated she was the nurse for the 100 South Unit. She stated Resident #1 was observed walking in the hallway while grasping the handrails to balance himself. She stated she asked Resident #1 if he was lost, and he stated No, I am going to catch my ride. She stated she directed him to the front entrance of the building where Staff A, CNA would let him out. She stated an aide came to the 100 South Unit between 8:30 and 9:00 p.m. looking for Resident #1. She stated at 9:45 p.m. an elopement code was called for Resident #1. Staff C, LPN stated after looking at an outdated photo of Resident #1, she informed the nurse he was the man who was looking to catch his ride. She stated she showed Staff A, CNA, the photo of Resident #1, Staff A confirmed that she let him out the door. Staff C, LPN, stated the photo did not resemble Resident #1. The photo of Resident #1 revealed a long bushy beard and hair. Staff C, LPN stated Resident #1 was clean shaven with short hair when she observed him. Staff C, LPN, stated she thought Resident #1 was a visitor because there was no way to tell he was a resident. Staff C, LPN, stated residents were supposed to wear a clear bracelet but no residents ever did. Staff C stated she assessed Resident #1 when he returned to the facility. Staff C stated Resident #1 had no injuries but was very hot and sweaty as the weather was very hot and humid that day. On 7/5/22 at 2:34 p.m. a phone interview was conducted with Staff D, CNA. She stated she went into Resident #1's room at 5:30 p.m. on 6/14/22 to deliver dinner. Staff D stated the last time she saw Resident #1 was when she gave him water before dinner break, she could not confirm the exact time. Staff D described Resident #1 as sitting in a chair, dressed, and acting normal the last time she saw him. Staff D stated another aide approached her in the lobby and asked her where Resident #1 was. Staff D reported the last time she saw him he was in his room. Staff D stated she got in her car to assist in the search for Resident #1 and drove down the road surrounding the facility looking for him and could not find him. She stated she was notified by phone informing her Resident #1 had been located. She stated following the incident on 6/14/22, she was informed by another staff member Resident #1 had exited the facility before. A review of punch detail card for Staff D revealed a punch out for dinner at 9:20 p.m. on 6/14/22. On 7/6/22 at 11:00 a.m. a phone interview was conducted with Staff B, LPN. She stated she had been assigned to care for Resident #1 for at least a week. Staff B stated on occasion Resident #1 would ask for assistance to call his family member and she assisted him to dial. Staff B stated she was responsible for the South 100 hallway with 27 residents and 5 admissions, the night of the elopement on 6/14/22. Staff B stated she began the medication pass at 9:00 p.m. Staff B stated when she pulled the supplies to check Resident #1's blood sugar, she noticed he was not in his room. She stated she thought he may have been in the bathroom and checked but he was not there. Staff B stated she looked for Staff D, CNA but could not find her right away so she walked to the North 100 hall side towards the other nurse's station and asked another nurse's aide to find Staff D. Staff B, LPN stated the other aide told her Staff D was on break. Staff B stated she checked everywhere on the unit including the shower rooms on the 100 hall and she could not find another nurse, aide, or anyone else. Staff B stated she returned to her assigned unit as other staff were searching for Resident #1. Staff B stated she went to the front lobby and Staff C, LPN, and Staff A, CNA informed her they had let Resident #1 out of the facility because he looked like a visitor. Staff B stated they informed her Resident #1 was let out around 8:10 p.m. Staff B stated she immediately called an elopement code, called the NHA, and called 911. Staff B stated she received a phone call from the DON who informed her they found Resident #1. Staff B stated Resident #1 was returned to his room around 10:38 p.m. on 6/14/22. Staff B stated there was no way to identify a resident versus a visitor unless you were familiar with them. On 7/5/22 at 12:38 p.m. an interview was conducted with the NHA, DON, and ADON (Assistant Director of Nursing). The NHA stated she received a call at 9:43 p.m. from Staff B, LPN. She stated Staff B called an elopement code and was searching for Resident #1. She stated elopement procedures were completed inside and outside of the building. She stated the ADON, Unit Managers, and DON met at the facility. She stated staff were searching in all resident rooms and outside around the facility. She stated the DON, ADON, and Unit Managers were all in cars driving around the area looking for Resident #1. She stated Resident #1 was in a store parking lot on the corner of where the two lane and four-lane roads met. The NHA stated she recognized Resident #1 at approximately 10:05-10:10 p.m. and stopped to pick him up. The NHA stated Resident #1 told her he was ok and was just going for a walk. She stated Resident #1 was transported back to the facility in the Unit Manager's vehicle. The DON stated when they arrived back to the facility, a complete head-to-toe assessment, pain assessment, skin check, and vitals were completed on Resident #1. The DON stated Resident #1 was given water and immediately placed on 1 to 1 observation. The DON stated the physician and family were notified. The NHA stated a root cause analysis was completed and it was determined Staff C, LPN and Staff A, CNA, did not follow protocol when they assumed Resident #1 was a visitor. The NHA stated Staff C, LPN was a long term contracted nurse, on her second twelve-week contract at the time of the elopement on 6/14/22. The DON stated Staff A, CNA was employed at the facility for more than a year. The DON stated both staff members confirmed they were aware of the facility procedures and had prior education related to elopement. The DON stated Resident #1 had severe cognitive impairment due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated exit seeking behavior would constitute an elopement risk, and Resident #1 had no history of exit seeking or attempting to exit. The DON stated the progress note dated 6/03/22 indicating Resident #1 was wandering did not use the correct terminology because Resident #1 was free to walk around the unit. The DON stated the incident did not signify an exit seeking attempt, Resident #1 had walked to the other side of the building and was not considered exit seeking. The NHA stated during the screening process if a resident is ambulatory, exit seeking or wandering at home they explain to the family, the facility does not have an electronic wandering system in place or a secured unit. The NHA stated the Nurse Liaison is part of the admissions screening process. The NHA stated prior to the elopement on 6/14/22 the facility had an elopement policy and elopement assessments in place, exit seeking behaviors listed, and all staff were educated on elopement policies and elopement risks. On 7/5/22 at 1:17 p.m. an interview was conducted with the Admissions Liaison, Registered Nurse (RN). The RN stated she conducts the screening process for all new admissions. She stated she does not keep notes related to the screening process and information gathered on the residents prior to admission. On 7/5/2022 at 12:04 p.m. an interview was conducted with the Medical Director (MD). He stated he was notified on 6/14/22, the night of the elopement. He stated to his knowledge Resident #1 was a model patient and he was not exit seeking. He stated he was not the Primary Care Physician (PCP). He stated he was informed the staff involved was agency/contracted nurse. He stated agency staff who just come in for a shift are not familiar with the residents. He stated he was told, Resident #1 asked if he could go out and a staff member who was not familiar with Resident #1 allowed him to go out. He stated staff informed him Resident #1 was gone for less than an hour. He stated staff found the resident down the road, the resident was very apologetic and stated he did not know he was not supposed to leave the facility. He stated the facility screens residents who are elopement risks or have severe dementia. He stated an obvious indicator would be if a resident was admitted to the hospital from a memory unit; the resident would require a secured unit. He stated the BIMS score was an indicator, but BIMS could be altered with medications, mental fatigue, etc. He stated policies and procedures were implemented to avoid accepting these residents at the facility. He confirmed the facility did not have a memory unit, it was too close to the road, and it would be too much work for staff to care for exit seeking residents. He stated if a resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated 80 percent of the residents at the facility fit the criteria with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated if it was a resident that ambulated around the during the day, had a [CONDITION(S)] (urinary tract infection) and stated they were going home today that would have been considered an at-risk resident. He stated he was not aware of any incident related to wandering for Resident #1 prior to the elopement on 06/14/22. On 7/6/22 at 11:29 a.m. an interview was conducted with the Primary Care Physician (PCP) for Resident #1. He stated the night of the elopement, the MD was contacted by the ADON. He stated the Medical Director called him and explained the incident. He stated he was instructed to be at the facility to rectify the situation the next morning. He stated he wanted to examine Resident #1. He stated to his knowledge, Resident #1 was not exit seeking and there were no prior incidents or behaviors. He stated after the elopement on 6/14/22 Resident #1's only complaint was a little soreness because he did a lot of walking. He stated the facility informed him Resident #1 was missing for about an hour. On 7/5/22 at 4:10 p.m. a phone interview was conducted with Resident #1's family member. She stated Resident #1 was doing great. She stated Resident #1 needed a secured unit and they had not realized that prior to his elopement on 6/14/22. She stated before Resident #1 was admitted , he was asleep most of the time. She stated he was diagnosed with dementia three years ago. She stated Resident #1 had a few falls from the bed, at home prior to his admission to the hospital. She stated Resident #1 was confused with the year, date, month, etc. She stated he had been this way for a year. She stated Resident #1 used to think he was leaving with her when she left the facility, he would ask her if she was taking him home. She stated she was not notified Resident #1 had tried to exit the facility prior to the incident on 6/14/22. She stated when Resident #1 was in the hospital he would run down the hall looking for her. She stated she had reported to the facility that Resident #1 was exit seeking but could not remember who she reported it to. She stated the facility informed her they did not have a memory unit. She stated if the doors were locked, he would not be able to get out unless someone lets him out. She stated she was notified by the facility when they found Resident #1. She stated the facility informed her Resident #1 said he took a walk, he was safe, in his room, and he was ok. She stated the facility did not tell her where Resident #1 was found, when he left, or how long he was gone from the facility. She stated the facility informed her Resident #1 was a flight risk and the facility could no longer keep him. She stated, Someone had to let him out that did not realize he was a patient. On 7/6/22 at 11:43 a.m. a follow up interview was conducted with the NHA and the Regional Care Consultant. They stated before the elopement on 6/14/22, they were informed Resident #1 pushed the bar on an exit door causing the alarm to sound. They stated they were not aware Resident #1 had exited the building prior to the incident on 6/14/22. They stated the staff member involved in not reporting the previous incident was educated and suspended. She stated she was not aware the resident breached the door and had gone outside the facility. A review of the facility Comprehensive Care Plan policy, revised 7/19/18, revealed the following: Policy Statement: A person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs, goals, and preferences. Guideline: Person-centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. 1. The nurse/Interdisciplinary Team (IDT) develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. The Comprehensive Care Plan will be developed with participation from the resident, resident's family or resident representative as indicated. 2. The Comprehensive Care Plan is based on a thorough assessment that included, but is not limited to, the Resident Assessment Instrument. 3. Each resident has the right to participate in choosing treatment options and will be given the opportunity to participate in choosing treatment options and will be given the opportunity to participate in the development, review, and revision of their care plan. 4. Each resident's Comprehensive Care plan is designed to: a. Incorporate identified problem areas b. Incorporate risk factors associated with identified problems c. Build on resident's strengths d. Reflect on residents expressed wishes regarding care and treatment goals e. Reflect treatment goals, timetables and objectives in measurable outcomes f. Identify the professional services that are responsible for each element of care g. Include any specialized services or specialized rehabilitative services to be provided as identified in Preadmission Screening & Resident Review (PASARR) recommendations h. Aid in preventing or reducing declines in the resident's functional status and/or functional levels i. Enhance the optimal functioning of the resident by focusing on a rehabilitative program and j. Reflect currently recognized standards of practice for problem areas and conditions. 5. The Comprehensive Care Plan will include the goals for admission and desired outcomes gathered from the resident and the resident representative 6. The resident's preference, potential for discharge and return to community will be evaluated. Referrals made to the local agencies or entities and will be documented as indicated. 7. The Comprehensive Care Plan will be person- centered to include the discharge plans to meet the resident's preferences and goals to address the resident's medical, physical, mental and psychosocial needs. 8. The Minimum Data Set (MDS) will be used to assess the resident's clinical condition, cognitive functional status, and use of services. The Care Area Assessments (CAA) are used in the development of the comprehensive care plan. 9. Care plan interventions are implemented after consideration of the resident's problem areas and their causes. Interventions address the underlying source(s) of the problem area(s), rather than addressing the symptoms or triggers. The interventions will reflect action, treatment, or procedure to meet the objectives toward achieving the resident goals. 10. The resident's Comprehensive Care Plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS/CAA). 11. The Comprehensive Care Plan is prepared by an Interdisciplinary team including at least: The attending physician or Nurse Practitioner (NP)/Physician Assistant (PA) Registered Nurse who shares responsibility for the resident Nurse Aide who shares responsibility for the resident Member of the food and nutrition services team The resident and the resident representative will participate to the extent practicable 12. The medical record will reflect the reason when the participation is not practicable for the resident and resident representative. 13. Care Plans are ongoing and revised as information about the resident and the residents condition change 14. The nurse/Interdisciplinary Team is responsible for the review and updating of care plans. The care plan should reflect the current status of the resident and be updated with changes in the resident's status: a. When there has been a significant change in the resident's condition b. Changing goals c. When desired outcome is not met d. When the resident has been readmitted to the facility from a hospital stay e. At least quarterly 15. The resident has the rig

Based on observation, interviews with facility staff, Nursing Home Administrator (NHA), Director of Nursing (DON), Primary Care Physician (PCP), and Medical Director (MD), medical record review and facility policies and procedures the facility failed to provide adequate supervision and services to prevent an elopement on 6/14/22 of a vulnerable ambulatory, Resident (#1), out of eleven residents sampled for elopement. Resident (#1), admitted to the facility on [DATE] for rehabilitation services after a hospitalization for shortness of breath and difficulty walking resulting in diagnoses of altered mental status, acute lymphonodular pharyngitis, and leukocytosis. Resident #1 was assessed on admission to the facility to be severely cognitively impaired and not an elopement risk. He was also ambulatory and was known by staff to walk freely around the facility. On 6/8/2022 he left his unit through an alarmed door and was located by staff on the sidewalk just outside. Staff assisted him back inside however, staff did not reassess his elopement risk or implement new measures based on this behavior to ensure his safety. On 6/14/2022 he walked towards an exit door, told staff members he wanted to leave and that he had a ride coming for him. Staff members let him out the front door of the facility at 8:10 p.m. He traveled 1.1 miles along a four-lane divided highway with a speed limit of 40 mph, passed through three stoplights to reach a store parking lot where he was found by facility staff at 10:10 p.m. Resident #1 stated to nurse (Staff B, Licensed Practical Nurse) upon his return at 10:38 p.m. he was at church and was going home, but his family member wasn't there so he thought he would [NAME] it and see how the leg would hold up, didn't do so good. Resident #1 was at risk of being hit by a vehicle, becoming lost or going without food, water and needed medications for diabetes, hypertension and [CONDITION(S)]. The facility's lack of reassessment of the resident after an attempted elopement, lack of implementation of new interventions and lack of a procedure to identify residents who could not be allowed to leave the facility unassisted resulted in the finding of Immediate Jeopardy beginning on 6/14/22 and removed on 6/20/22 with the scope and severity reduced to a D, after verification of implementation of the removal actions. Findings included: On 7/5/22 at 2:54 p.m. an interview was conducted with Staff E, Certified Nursing Assistant (CNA). Staff E stated Resident #1 lived on the North 100 hallway prior to moving to the South 100 hallway. He stated Resident #1 used to walk around the facility and had exited the facility prior to the elopement on 6/14/22 but he was unable to give an exact date and time. Staff E described the previous elopement saying he heard the door alarm sound, then he shouted for another CNA (Staff G) who was working on the unit. He stated when Resident #1 pressed on the door, the alarm sounded, and after 15 seconds it opened automatically. Resident #1 walked outside. Staff E, CNA stated Staff F, Licensed Practical Nurse (LPN), on the unit, came outside to assist both aides with getting Resident #1 back inside the facility. He stated this incident occurred not very long before Resident #1 eloped on 6/14/22. Staff E confirmed he did not report the incident to anyone because he expected the nurse to do so. He stated Resident #1 always walked the hallways looking for his wife in the evening. He stated he never reported the resident voicing concerns related to looking for his wife. Staff E stated on 6/14/22 he was assigned to the South 100 hall (unit) when he heard Resident #1 was missing from his room on the North 100 hall (unit). He stated he went room to room, performed a head count, and searched outside to look for Resident #1 but could not locate him. Staff E stated he was told by the other aides Resident #1 had been missing since just after 8:00 p.m. On 7/5/22 at 3:42 p.m., a phone interview was conducted with Staff G, CNA. Staff G stated she had cared for Resident #1 when he was on the North 100 Unit. Staff G stated Resident #1 left the building about a week and a half prior to the elopement on 6/14/22. She stated she heard the door alarm sound (on 6/8/22) and observed Staff E, CNA as he checked to see which alarm sounded. Staff G stated Staff E realized Resident #1 had gone out the door. She stated she went through the side door and caught Resident #1 on the sidewalk in front of the facility. Staff G stated Resident #1 resisted her when she tried to get him to come back inside. Staff E, CNA and Staff F, LPN came to assist with Resident #1. Staff G stated Resident #1 was able to be guided back into the facility. Staff G stated she did not report the incident because she expected Staff F, LPN to do so. Staff G stated she found out after the elopement on 6/14/22, Staff F had not reported the previous elopement. Staff G stated Resident #1 frequently ambulated around the facility in the evening looking for his wife. She stated the nursing staff, and the unit managers were aware of behaviors related to Resident #1 frequently looking for his wife. Staff G stated Resident #1's wife would visit daily but would leave after dinner. On 7/6/22 at 8:10 a.m. a phone interview was conducted with Staff F, LPN. He stated he cared for Resident #1 when he lived on the North 100 Unit. Staff F stated on 6/8/22 at around 11:00 p.m. he heard an alarm go off on the north side back door. He stated he went to see what was happening and saw Staff G, CNA outside on the sidewalk with Resident #1. Staff F stated Resident #1 had gone out the locked, alarmed door. He stated he was dealing with another resident in distress. Staff F stated he spoke to Resident #1 and asked him why he went outside. He stated Resident #1 told him he was just went out for a walk. Staff F stated Resident #1 was a confused gentleman, but was not injured, so he went back to care for his other residents. Staff F stated he forgot to do the paperwork or write a note because the other resident ended up being sent out to the hospital. A review of the Resident #1's Face Sheet revealed an admitted [DATE] with diagnoses to include Type 2 diabetes mellitus without complications, elevated white blood cell count, muscle weakness, difficulty in walking, [CONDITION(S)], [CONDITION(S)] without behavioral disturbance, hypertension, [CONDITION(S)] of native coronary artery without [CONDITION(S)] pectoris, chronic kidney disease, stage 3, shortness of breath, pain an [CONDITION(S)]. The resident was discharged to another a memory care unit at another facility on 6/16/22. A review Resident #1's Admission Minimum Data Set (MDS) assessment, dated 6/1/22, revealed in Section C: Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. In Section G: Functional Status Resident #1 required supervision or limited physical assistance at a minimum by one person for Activities of Daily Living (ADLs). A review of the comprehensive care plan for Resident #1 revealed the following: Problem: Falls Problem Start date 6/1/22. Resident is at risk for falls related to: Weakness, decreased safety awareness, need for assistance with transfers, history of falls prior to admission. Goals: Resident will not sustain injury related to falling through next review date. Approach: Assist for toileting and transfers as needed (PRN). Complete designated fall risk screening tool on admission. Place bell within easy reach. Problem: Activity of Daily Living (ADL) Functional/ Rehabilitation Self Care deficit as evidenced by: weakness, cognitive impairment. Resident requires assistance with transfers, toileting, bathing, personal hygiene, and locomotion. The amount of assistance needed varies. Goals: Resident will have reduced risk regarding complications related to decreased mobility and will be appropriately groomed and dressed daily through next review. Approach: Observe need for referral/screen and provide as indicated. Provide ADL care to ensure daily needs are met. Provide restorative programs. The medical record showed a care plan for elopement was first initiated on 6/16/22. A review of the Admission assessment dated [DATE] revealed under exit/elopement review Resident #1 was ambulatory, exhibited no behaviors, and was not considered an elopement risk. Review of the medical record showed no elopement assessment on 6/8/2022 to 6/14/22. A review of the nursing progress notes revealed the following entries: 6/3/22- Resident awoke in the night at 11pm and wandered over to the South Unit. He was easily redirected to his room. Offered resident pudding, he ate 100% and was able to sleep the rest of the evening. 06/15/22 at 06:38 a.m. describes the following event. At approximately 09:40 HS [bedtime] med pass, entering pt.'s [Resident #1] room for HS med pass, noted pt. not in room or pt.'s bathroom; assigned CNA reported she had just seen pt. going into bathroom earlier; alerted staff, CNA to look through building for patient; noted pt. not signed out in LOA [Leave of Absence] book, nor note written in progress note from day nurse pt. was out on leave; no picture or form in elopement book; at approximately 09:45 p.m. called over intercom code yellow three times (per interview on 7/5/22 at 2:09 p.m. with Staff A, CNA this should have been a code green); printed out pics of patient; went to other side of building, some in lobby; asked nurse (Staff C, LPN) and CNA (Staff A), showed picture, they stated I we let him out, he said he was catching a ride; this nurse asked what time that was about, other nurse reported about 10 minutes after 8; this nurse immediately called 911 at approx. 09:52 p.m., they transferred me to police dispatch, pt. info given along with description of height and weight, glasses, white beard, mustache, bald, and looks like Santa Claus; police said sending a unit to facility; at approximately 10:10 p.m. police asking what he was wearing, nurse and CNA standing by said have to ask assigned CNA and other nurse and CNA who let patient out; at approximately 09:43 Administrator was called and informed of situation, instructed to call DON; DON returned two unanswered phone calls while this nurse speaking with police, and stated she was aware of the situation and requested spouses name and phone number; CNA assisted police to other unit to ask nurse and CNA for more information about clothing patient wearing when let him out; while later, CNA told this nurse, she had a phone call, answering phone call, another nurse from unit on phone, reported they found patient, was in car with unit manager and administrator; pt arrived through front door of facility via wheelchair at approximately 10:30; 10:38 pt. in room sitting up at side of bed; pt stated he was at church and was going home, but Resident #1's family member wasn't there so thought I would [NAME] it and see how the leg would hold up, didn't do so good manual b/p [blood pressure] 108/62, tympanic [temperature]= 97.5, SpO2 [Oxygen] 96% RA[Room Air], Pulse=76, Respirations= 20, blood sugar 274; pt is now 1:1; pt denied any pain, saying I'm ready to go on another [NAME], smiling, chuckling. The resident exited the facility on a Tuesday night through the main door and traveled north along a road with sidewalks along both sides and consisting of one lane in each direction with a middle turn lane. The speed limit on the road was 40 mph. The resident was found in a multi-store parking lot 1.1 miles from the facility, at the corner of the two-lane road and a four-lane divided highway. The resident had to pass through three stoplights to reach the destination. A hospital is located at the first stoplight from the facility with busy traffic and ambulances coming and going into the hospital. Resident #1 had to cross the two-lane road to end up in the multi-store parking lot where he was found at 10:10 p.m., approximately two hours after he left the facility. A review of the weather on Tuesday 6/14/22 from 6:00 p.m. until 12:00 a.m. indicated a humidity of 70% with passing clouds and wind NNW (north, northwest) at 6.214 miles per hour (mph). At 8:53 p.m. the temperature was reported as 85F (Fahrenheit), and at 9:53 p.m. the temperature was reported as 84 degrees F. Sunset on 6/14/22 was recorded as 8:26 pm. https://www.timeanddate.com/weather On 7/5/22 at 2:09 p.m. a phone interview was conducted with Staff A, CNA. She stated she let Resident #1 out of the facility through the front door using the code to unlock the door. She stated she was going to lunch on 6/14/22 at 8:05 p.m. and was instructed by Staff C, LPN to allow Resident #1 to exit the facility, so she did. She stated neither of them were familiar with Resident #1. Staff A stated Resident #1 walked down the North 100 hall towards the front door and stated he was waiting to catch a ride. Staff A stated about two hours later a code was called for missing resident. She stated when she saw Resident #1's photo, she verified she let him out because she thought he was a visitor. Staff A stated sometime after the incident she found out from another staff member Resident #1 had gotten out of the facility before. Staff A stated before the incident the practice was to let people enter and exit the facility. Staff A stated she did not utilize the elopement book when letting visitors out of the facility prior to the elopement on 6/14/22. She stated Resident #1 was fine when she let him out, he was wearing shorts, a shirt, and a baseball cap. Staff A stated she assumed he was walking to the parking lot to catch his ride. She said she did not see which way Resident #1 went after letting him out the door. A review of the punch card detail dated 6/14/22 for Staff A revealed an out punch for lunch at 8:05 p.m. On 7/6/22 at 7:56 a.m. a phone interview was conducted with Staff C, LPN. She stated she was present when the elopement occurred on 6/14/22 at around 8:05 p.m. She stated she was the nurse for the 100 South Unit. She stated Resident #1 was observed walking in the hallway while grasping the handrails to balance himself. She stated she asked Resident #1 if he was lost, and he stated No, I am going to catch my ride. She stated she directed him to the front entrance of the building where Staff A, CNA would let him out. She stated an aide came to the 100 South Unit between 8:30 and 9:00 p.m. looking for Resident #1. She stated at 9:45 p.m. an elopement code was called for Resident #1. Staff C, LPN stated after looking at an outdated photo of Resident #1, she informed the nurse he was the man who was looking to catch his ride. She stated she showed Staff A, CNA, the photo of Resident #1, Staff A confirmed that she let him out the door. Staff C, LPN, stated the photo did not resemble Resident #1. The photo of Resident #1 revealed a long bushy beard and hair. Staff C, LPN stated Resident #1 was clean shaven with short hair when she observed him. Staff C, LPN, stated she thought Resident #1 was a visitor because there was no way to tell he was a resident. Staff C, LPN, stated residents were supposed to wear a clear bracelet but no residents ever did. Staff C stated she assessed Resident #1 when he returned to the facility. Staff C stated Resident #1 had no injuries but was very hot and sweaty as the weather was very hot and humid that day. On 7/5/22 at 2:34 p.m. a phone interview was conducted with Staff D, CNA. She stated she went into Resident #1's room at 5:30 p.m. on 6/14/22 to deliver dinner. Staff D stated the last time she saw Resident #1 was when she gave him water before dinner break, she could not confirm the exact time. Staff D described Resident #1 as sitting in a chair, dressed, and acting normal the last time she saw him. Staff D stated another aide approached her in the lobby and asked her where Resident #1 was. Staff D reported the last time she saw him he was in his room. Staff D stated she got in her car to assist in the search for Resident #1 and drove down the road surrounding the facility looking for him and could not find him. She stated she was notified by phone informing her Resident #1 had been located. She stated following the incident on 6/14/22, she was informed by another staff member Resident #1 had exited the facility before. A review of punch detail card for Staff D revealed a punch out for dinner at 9:20 p.m. on 6/14/22. On 7/6/22 at 11:00 a.m. a phone interview was conducted with Staff B, LPN. She stated she had been assigned to care for Resident #1 for at least a week. Staff B stated on occasion Resident #1 would ask for assistance to call his family member and she assisted him to dial. Staff B stated she was responsible for the South 100 hallway with 27 residents and 5 admissions, the night of the elopement on 6/14/22. Staff B stated she began the medication pass at 9:00 p.m. Staff B stated when she pulled the supplies to check Resident #1's blood sugar, she noticed he was not in his room. She stated she thought he may have been in the bathroom and checked but he was not there. Staff B stated she looked for Staff D, CNA but could not find her right away so she walked to the North 100 hall side towards the other nurse's station and asked another nurse's aide to find Staff D. Staff B, LPN stated the other aide told her Staff D was on break. Staff B stated she checked everywhere on the unit including the shower rooms on the 100 hall and she could not find another nurse, aide, or anyone else. Staff B stated she returned to her assigned unit as other staff were searching for Resident #1. Staff B stated she went to the front lobby and Staff C, LPN, and Staff A, CNA informed her they had let Resident #1 out of the facility because he looked like a visitor. Staff B stated they informed her Resident #1 was let out around 8:10 p.m. Staff B stated she immediately called an elopement code, called the NHA, and called 911. Staff B stated she received a phone call from the DON who informed her they found Resident #1. Staff B stated Resident #1 was returned to his room around 10:38 p.m. on 6/14/22. Staff B stated there was no way to identify a resident versus a visitor unless you were familiar with them. On 7/5/22 at 12:38 p.m. an interview was conducted with the NHA, DON, and ADON (Assistant Director of Nursing). The NHA stated she received a call at 9:43 p.m. from Staff B, LPN. She stated Staff B called an elopement code and was searching for Resident #1. She stated elopement procedures were completed inside and outside of the building. She stated the ADON, Unit Managers, and DON met at the facility. She stated staff were searching in all resident rooms and outside around the facility. She stated the DON, ADON, and Unit Managers were all in cars driving around the area looking for Resident #1. She stated Resident #1 was in a store parking lot on the corner of where the two lane and four-lane roads met. The NHA stated she recognized Resident #1 at approximately 10:05-10:10 p.m. and stopped to pick him up. The NHA stated Resident #1 told her he was ok and was just going for a walk. She stated Resident #1 was transported back to the facility in the Unit Manager's vehicle. The DON stated when they arrived back to the facility, a complete head-to-toe assessment, pain assessment, skin check, and vitals were completed on Resident #1. The DON stated Resident #1 was given water and immediately placed on 1 to 1 observation. The DON stated the physician and family were notified. The NHA stated a root cause analysis was completed and it was determined Staff C, LPN and Staff A, CNA, did not follow protocol when they assumed Resident #1 was a visitor. The NHA stated Staff C, LPN was a long term contracted nurse, on her second twelve-week contract at the time of the elopement on 6/14/22. The DON stated Staff A, CNA was employed at the facility for more than a year. The DON stated both staff members confirmed they were aware of the facility procedures and had prior education related to elopement. The DON stated Resident #1 had severe cognitive impairment due to a diagnosis of dementia and a BIMS score of 5. The DON stated exit seeking behavior would constitute an elopement risk, and Resident #1 had no history of exit seeking or attempting to exit. The DON stated the progress note dated 6/03/22 indicating Resident #1 was wandering did not use the correct terminology because Resident #1 was free to walk around the unit. The DON stated the incident did not signify an exit seeking attempt, Resident #1 had walked to the other side of the building and was not considered exit seeking. The NHA stated during the screening process if a resident is ambulatory, exit seeking or wandering at home they explain to the family, the facility does not have an electronic wandering system in place or a secured unit. The NHA stated the Nurse Liaison is part of the admissions screening process. The NHA stated prior to the elopement on 6/14/22 the facility had an elopement policy and elopement assessments in place, exit seeking behaviors listed, and all staff were educated on elopement policies and elopement risks. On 7/5/22 at 1:17 p.m. an interview was conducted with the Admissions Liaison, Registered Nurse (RN). The RN stated she conducts the screening process for all new admissions. She stated the screening process includes a review of the history and physical, progress notes, the payor source, and bed availability. She stated many of the referrals she receives are denied because the resident requires a memory care secured unit or has had wandering behaviors at home and the facility is unable to accommodate their needs. She stated she also speaks to family members and case managers to gather information about a resident. She stated she could not recall details related to Resident #1's screening process. She stated when an elopement risk is identified in the screening process, or a resident requires memory care/secured unit she would not accept the resident into the facility. She stated if a resident had a diagnosis of dementia, was exit seeking or voicing wanting to leave she would not accept the resident. She stated she does not keep notes related to the screening process and information gathered on the residents prior to admission. A review of the 2022 Facility Assessment completed on 4/2022 showed the facility is equipped to treat non-Alzheimer's dementia memory impaired residents. The facility assessment indicated staffing is sufficient for residents with cognitive mental behaviors, cognitive impairment, and cognitive dementia. On 7/7/22 at 9:22 a.m. an interview was conducted with the NHA and Regional Care Consultant. They stated the facility assessment indicates the staff are competent, sufficiently educated, and prepared to care for residents considered elopement risks. They stated residents identified as elopement risk in preadmission screening would be referred to a facility with a secured unit. They further stated the facility is capable of caring for elopement risk residents, but the preference is not to accept them. The NHA stated the facility is fully staffed, the building is safe, they can take residents with dementia who are elopement risks, but they prefer not to take them. On 7/5/2022 at 12:04 p.m. an interview was conducted with the Medical Director (MD). He stated he was notified on 6/14/22, the night of the elopement. He stated to his knowledge Resident #1 was a model patient and he was not exit seeking. He stated he was not the Primary Care Physician (PCP). He stated he was informed the staff involved was agency/contracted nurse. He stated agency staff who just come in for a shift are not familiar with the residents. He stated he was told, Resident #1 asked if he could go out and a staff member who was not familiar with Resident #1 allowed him to go out. He stated staff informed him Resident #1 was gone for less than an hour. He stated staff found the resident down the road, the resident was very apologetic and stated he did not know he was not supposed to leave the facility. He stated the facility screens residents who are elopement risks or have severe dementia. He stated an obvious indicator would be if a resident was admitted to the hospital from a memory unit; the resident would require a secured unit. He stated the BIMS score was an indicator, but BIMS could be altered with medications, mental fatigue, etc. He stated policies and procedures were implemented to avoid accepting these residents at the facility. He confirmed the facility did not have a memory unit, it was too close to the road, and it would be too much work for staff to care for exit seeking residents. He stated if a resident had a diagnosis of dementia and was previously identified as wandering, they should be identified as an elopement risk. He stated 80 percent of the residents at the facility fit the criteria with a diagnosis of dementia, but the difference is the reason for their wandering. He stated if it was a resident that ambulated around the during the day, had a [CONDITION(S)] (urinary tract infection) and stated they were going home today that would have been considered an at-risk resident. He stated he was not aware of any incident related to wandering for Resident #1 prior to the elopement on 06/14/22. On 7/6/22 at 11:29 a.m. an interview was conducted with the Primary Care Physician (PCP) for Resident #1. He stated the night of the elopement, the MD was contacted by the ADON. He stated the Medical Director called him and explained the incident. He stated he was instructed to be at the facility to rectify the situation the next morning. He stated he wanted to examine Resident #1. He stated to his knowledge, Resident #1 was not exit seeking and there were no prior incidents or behaviors. He stated after the elopement on 6/14/22 Resident #1's only complaint was a little soreness because he did a lot of walking. He stated the facility informed him Resident #1 was missing for about an hour. On 7/5/22 at 4:10 p.m. a phone interview was conducted with Resident #1's family member. She stated Resident #1 was doing great. She stated Resident #1 needed a secured unit and they had not realized that prior to his elopement on 6/14/22. She stated before Resident #1 was admitted , he was asleep most of the time. She stated he was diagnosed with dementia three years ago. She stated Resident #1 had a few falls from the bed, at home prior to his admission to the hospital. She stated Resident #1 was confused with the year, date, month, etc. She stated he had been this way for a year. She stated Resident #1 used to think he was leaving with her when she left the facility, he would ask her if she was taking him home. She stated she was not notified Resident #1 had tried to exit the facility prior to the incident on 6/14/22. She stated when Resident #1 was in the hospital he would run down the hall looking for her. She stated she had reported to the facility that Resident #1 was exit seeking but could not remember who she reported it to. She stated the facility informed her they did not have a memory unit. She stated if the doors were locked, he would not be able to get out unless someone lets him out. She stated she was notified by the facility when they found Resident #1. She stated the facility informed her Resident #1 said he took a walk, he was safe, in his room, and he was ok. She stated the facility did not tell her where Resident #1 was found, when he left, or how long he was gone from the facility. She stated the facility informed her Resident #1 was a flight risk and the facility could no longer keep him. She stated, Someone had to let him out that did not realize he was a patient. On 7/6/22 at 11:43 a.m. a follow up interview was conducted with the NHA and the Regional Care Consultant. They stated before the elopement on 6/14/22, they were informed Resident #1 pushed the bar on an exit door causing the alarm to sound. They stated they were not aware Resident #1 had exited the building prior to the incident on 6/14/22. They stated the staff member involved in not reporting the previous incident was educated and suspended. She stated she was not aware the resident breached the door and had gone outside the facility. A review of the facility policy titled, Safety and Supervision of Resident, with a reviewed date of 5/31/18 revealed the following: Policy Statement: Staff shall make routine resident checks to help maintain resident safety and well-being. Resident safety, supervision, and assistance, to prevent accidents are facility-wide priorities. Guideline: Facility Oriented Approach to Safety 1. Facility-oriented approach to safety addresses risks for groups of residents. 2. To ensure the safety and well-being of our resident's staff shall make routine residents and environmental checks. 3. Routine resident checks by nursing staff involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify any change in the resident's condition, identify whether the resident has any concerns and see if the resident is sleeping, needs toileting assistance, etc. 4. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training and reporting processes; Quality Assurance (QA) reviews of safety and incident/accident reports; and facility-wide commitment to safety at all levels of the organization. 5. When accident hazards are identified, the QA/Safety Committee shall evaluate and analyze the cause(s) of hazards and develop strategies to mitigate or remove the hazards to the extent possible. 6. Employees shall be trained and in- serviced on potential accident hazards and how to identify and report accident hazards and try to prevent avoidable accidents. 7. The QA Committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary. Resident-Oriented Approach to Safety 1. Resident-oriented approach to safety addressed safety and accident hazards for individual residents. 2. Staff shall use various sources to identify risk factors for residents, including the information obtained from the medical history, physical exam, observation of the resident, and MDS. 3. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target interventions to reduce the potential for accidents. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff b. Assigning responsibility for carrying out interventions c. Providing training, as necessary d. Ensuring that interventions are implemented, and documenting interventions 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently b. Evaluating the effectiveness of interventions c. Modifying or replacing interventions as needed d. Evaluating the effectiveness of new or revised interventions. A review of the facility policy titled, Elopement/Wandering, reviewed date of 5/30/18 revealed the following: Policy Statement- The intent of the facility is to maintain resident safety by identifying residents who are at risk for wandering/elopement behavior. Guideline: 1. An elopement/wandering assessment will be completed upon admission, located in the nursing admission information packet, and quarterly thereafter. 2. Any resident displaying significant wandering behavior will be assessed for elopement/wandering risk and care planned appropriately. 3. Care Plans and individual behavior plans will address wandering as a specific problem. Approaches will be formulated, patterns identified (if any), and the causes determined should be addressed. 4. A wandering/elopement notebook containing pictures and pertinent demographic information will be maintained by social services, kept at the nurse's station and receptionist desk. Updates will be done at least quarterly. 5. If a resident is identified as missing, refer to the missing resident procedure. A review of the facility's Exit Seekin [TRUNCATED]

Based on record reviews and interviews, the facility failed to ensure that it developed and implemented an effective discharge plan to ensure a safe and orderly discharge for three (Residents #1, #3 and #4) of four sampled residents as evidenced by failure to submit referrals for home health prior to or at the time of discharge resulting in prolonged delays of care and services post discharge for Resident #1, #3, and #4. Findings included: 1. A phone interview was conducted on 12/10/21 at 3:38 p.m. with Resident #1's son. He reported that Resident #1 was admitted to the facility at the beginning of April 2021 due to her falling at home which resulted in a broken left kneecap. She was admitted to the facility for rehabilitation. He further stated that upon discharge the facility recommended her to have physical therapy with Home Health services. He said the facility did not follow up with the resident after she was discharged . He stated that he called the facility three times regarding Home Health services but no one called him back. He then called the Nursing Home Administrator (NHA), and she finally got the ball rolling. Resident #1's son stated that Home Health services did not show up until he started to make the calls. It was an excessive amount of time, about a week before she [Resident #1] got [Home Health] services. A review of Resident #1's face sheet documented an admission on 04/15/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was discharged to home on 04/25/21. A review of Resident #1's Care Plan, reflected no focus area for a Discharge Plan. On 12/13/21, the facility was asked to provide the baseline care plan for Resident #1 with no further documentation provided to the surveyor. A review of Resident #1's progress notes, reflected the following entries: 04/23/21, 15:36 (3:36 p.m.): [Resident #1] returned from scheduled doctor's appointment requesting discharge today, writer educated on discharge planning including obtaining physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident in agreement to discharge Sunday, 04/25/21, allowing writer to coordinate appropriate discharge. Friend to transport at 11:00 a.m. Resident continues to be alert/oriented x 4, makes all needs known . (Social Service Director (SSD) note). 04/25/21, 11:26 a.m.: Pt (patient) discharged home to spouse via personal vehicle, pt ambulated to vehicle with staff. Pt discharged home with all personal belongings including electric hair [NAME] and all medications. Educated on medications and regimen. Pt stable upon discharge. (Nursing note). 05/05/21, 14:10 (2:10 p.m.): Writer followed up on home health, referred to (Home Health Agency) to contact ASAP (as soon as possible), spoke with (Home Health Representative). Writer also spoke with (Resident #1), reporting doing fine, will see PCP (Primary Care Physician) end of the month (SSD). 05/05/21, 18:34 (6:34 p.m.): Writer spoke with family member (son) to advise of follow up to home health agency and educated on home health services requested. (Son) thanked writer for follow-up (SSD). On 12/13/21 at 2:00 p.m., an interview was conducted with the Social Service Director (SSD), the Nursing Home Administrator (NHA), and Regional Nurse. For Resident #1, SSD stated that she did not recall when a phone call from [Resident #1's] son came in. Only that she called the home health company and then, she followed up with the son. The NHA stated that she did not recall the son calling her. The SSD stated that she only recalls calling the son to discuss the home health. In addition, the SSD stated that she calls the residents a couple days after discharge. On 12/13/21 at 6:11 p.m., the SSD presented an Admission Consent for Home Health services for Resident #1. The SSD reported that the date that she faxed over the Home Health referral was 05/06/21 and she confirmed that this was the date that was indicated on the (Home Health Agency) fax receipt document. She stated that she had called the Home Health agency to obtain the documentation. She also provided a copy of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Home Health /PT (Physical Therapy)/ OT (Occupational Therapy)/ SN (Skilled Nursing)/ HHA (Home Health Aide). During the interview, the SSD stated, I realized I did not send the referral, so, I called the resident, faxed over the referral on 05/06/21. I do not recall speaking to the son beforehand. 2. A review of Resident #3's AHCA (Agency for Health Care Administration) form 5000-3008, Medical Certification for Medicaid Long-Term Services and Patient Transfer form, dated and signed by the physician on 10/29/21, documented Resident #3's medical conditions shortness of breath, [CONDITION(S)] ([CONDITION(S)]), and bilateral lower leg [CONDITION(S)]. A review of Resident #3's Progress notes revealed: 11/02/21, 12:18 p.m., SSD note: Writer met with resident, alert, able to make needs known, speech clear, some anxiety observed. Resident has questions related to medications, writer immediately notified attending nurse, who stated she is aware and will revisit with resident. Discharge goal to return home, more detailed information necessary. Code status reviewed . 11/16/21, 10:05 a.m., SSD note: Writer met with resident to review upcoming discharge tomorrow, 11/17/21, resident returning home with family assist, no DME (durable medical equipment) needs, encouraged follow-up with PCP (primary care physician). Resident wishes to arrange transport with family, aware of discharge time and educated on discharge coordination. Resident continues to be alert, able to make needs known, . 11/17/21, 11:31 a.m., SSD note: Writer met with resident pre-discharge, observed walking around room, oxygen provided in home, has portable O2 as well, friend bringing portable tank, has nebulizer at home as well, no DME needs. Resident thanked writer for information and assist with discharge update. 11/17/21, 12:24 p.m., nursing note: Alert, able to make needs known. Tolerated medications well by mouth with Oxycodone with relief of pain. Remains on oxygen via nasal cannula. Educated on medication, advised to see her primary care physician within 7 days. discharged home with her medication, with home health SN (skilled nursing)/ to (occupational therapy)/ pt (physical therapy) via personal vehicle with ex-husband, no concerns or questions concerning discharge. Review of Resident #3's telephone physician orders, dated 11/17/21 read, Discharge home with (Home Health agency) (Home Health, PT/ OT/ SN/ HHA & MSW (Master of Social Work) to identify community resources. No DME needs. On 12/16/21 at 1:45 p.m., an interview was conducted with Representative A, (Home Health representative). She reported that a referral from the facility was received on 11/29/21, 12 days post discharge. We had a nurse go out there on 11/30 for the assessment. We did not start services due to the condition that the resident was found in. A review of an Assessment for Resident #3, dated 11/30/21 at 15:29 (3:29 p.m.), completed by EMS (Emergency Medical Services), documented: EMS called out to transport pt to (hospital) so she can be admitted to NH. Home Health called local county Sheriff's Office because PT (patient) is unable to take care of herself. Pt has no new medical complaints. Pt is chronically short of breath due to [CONDITION(S)] exacerbation. Pt able to ambulate to stretcher outside. Pt is awaiting a room at a [skilled nursing facility] or possibly moving in with brother that lives in South Carolina. Pt transported to ER for eval w/o (without) incident. On 12/13/21 at 5:30 p.m., the regional nurse reported that the Transition of Care/Discharge Summary for Resident #3 was not completed for the date of discharge, dated 11/17/21. Review of the summary that was provided reflected blanks in the areas of Clinical Discharge and Narrative, Care Team; Scheduled Appointments; Community Contacts; Special Instructions for dietary and therapy; Special treatments and procedures; medical equipment; Discharge medications. 3. A review of Resident #4's admission record documented an admission of 10/27/21. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission record documented a family member as a primary contact. Resident #4's record reflected that he was discharged from the facility on 11/18/21. A review of Resident #4's progress notes revealed: 11/09/21, 10:19 a.m., SSD notes: Writer spoke with resident, (mother) via phone, discharge goal follow-up, requires independence with walking as (mother) unable to assist or provide transferring assist. Writer educated resident and (mother) to give considerations to alternate discharge plan, or additional care in home. Resident received monthly disability, unable to afford private duty care. Discharge barrier may exist . 11/17/21, 18:44 (6:44 p.m.): Writer met with resident this morning, confirmed discharge upcoming for Thursday, 11/18/21, resident advising his PCP's office via phone during conversation of details related to discharge, writer also spoke with the same. Resident's family member to transport at 11:00 a.m., resident stated he has DME, walker, home health being initiated. Resident continues to be alert/ oriented, makes all needs known . 11/18/21, 11:05 a.m.: (nursing) discharged home with all personal belongings and meds. Medicated this am for pain with effect. Transported by private auto. Accompanied by family. A review of Resident #4's Care Plan, reflected No Discharge Plan, Goals, or interventions articulated in the plan. Review of Resident #4's telephone physician orders, dated 11/18/21 read, D/C home with family. Follow up with PCP (Primary Care Physician), Home Health, PT/OT/ SN. On 12/14/21, the facility provided a faxed document with a handwritten statement on the cover sheet that read, [doctor's office] set-up the home health with [name of home health agency] office. Attached to the fax document was a Certification of face to face for Home Care Services, signed by the physician, which documented a face-to-face encounter occurred on 11/29/21 (11 days post discharge). The facility did not provide documentation that would indicate communication to the primary care physician prior to the discharge or on the date of discharge that would indicate the delay was a result of the primary physician's schedule. On 12/13/21, at 11:03 a.m., the Regional RN reported that the facility did not have a Post Discharge policy and procedure. On 12/13/21 at 5:30 p.m., the Regional RN reported that the Transition of Care/Discharge Summary for Resident #4 was not completed for the date of discharge, dated 11/18/21. Review of the summary that was provided reflected blanks in the areas of Clinical Discharge and Narrative, Care Team; Scheduled Appointments; Community Contacts; Special Instructions for dietary and therapy; Special treatments and procedures; medical equipment; Discharge medications. 4. On 12/17/21 at 3:25 p.m., a phone interview was conducted with the Director of Nursing (DON). She was interviewed in regard to the facility discharge process. She stated that Social Services coordinates home health services prior to the resident's discharge. A fax should go over before the resident goes home. She confirmed that it was her expectation that the home health services were arranged prior to discharge. This was important because it was a continuation of care. The DON stated that the facility should make sure the fax was sent to the home health agency so the resident can be assessed. She reported that she was not sure what happened if there was no referral fax sent to the Home Health Agency. She reported that she was not sure if a follow-up call was conducted with the resident, post discharge. 5. On 12/17/21 at 4:00 p.m., the facility's Medical Director was interviewed via phone. He stated that the referral should happen before the resident gets discharged . The social service department helps with determining the match of payor source to the home health (HH). This is so there is no interruption of service. He stated that he was surprised by the greater than 10-day length of time, from the resident discharge until the referral was submitted to the HH agency. His expectation was that the staff would let the resident/family know the name and contact details of the HH agency, and to let us know if there were any concerns. He stated that for the determination of the resident being a safe discharge, that there was a process. The patient's cognition status and living arrangements were considerations to determine a safe discharge. 6. A review of the facility's Discharge Planning Process policy and guideline, last revised 07/29/19, documented the Policy Statement: The facility will ensure a discharge planning process is in place to address each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies, as appropriate, and involve the resident and if applicable, the resident representative, and the interdisciplinary team in developing the discharge plan. The Guideline included: .The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. 1. Discharge planning begins upon admission and is based on the resident's assessment and goals for care, desire to be discharged , and the resident's capacity for discharge. 2. The comprehensive care plan is ongoing and will include identified changes in the resident's condition, which have been determined to likely impact the discharge plan, warranting revisions to interventions. 3. The comprehensive care plan will be developed and: Involve communication with the resident and if applicable, the resident representative; Address the resident's goals for care and treatment preferences; Identify needs that must be addressed before the resident can be discharged , (such as education, rehabilitation, and caregiver support and education): Be re-evaluated regularly and updated when the resident's needs or goals change; Include any referrals made to the local contact agency as agreed by the resident; Identify post-discharge needs such as nursing and therapy services, medical equipment or modifications to the home, or Activities of Daily Living (ADL) assistance. Resident Discharge to the Community: 1. Determine if appropriate and adequate supports are in place, including capacity and the capability of the resident's caregivers at home . 6. If a resident chooses to be discharged to a setting which does not appear to meet the post-discharge needs or appears unsafe, the situation will be treated as a refusal of care and: a. Discuss with the resident and representative the implications and risks of the discharge to the location and attempt to determine why the destination is chosen; b. Provide more suitable options to meet the resident's needs; c. Document (a) and (b) and despite being offered other options that could meet the resident's needs, the resident refused the option of an appropriate discharge setting; Determine if a referral to Adult Protective Services or other state entity is necessary; and if so the referral should be made at the time of discharge.

Based on record review, interviews, and policy review, the facility did not ensure the consultant pharmacist's recommendations were acted upon for one resident (#26) of five residents sampled for unnecessary medications. Findings included: Resident #26 was admitted to the facility with a diagnosis of dementia without behavior disturbance, according to the face sheet in the admission record. Review of the Minimum Data Set (MDS) assessment dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 5, indicating cognitive impairment. Further review of the assessment indicated Resident #26 did not have any mood or behavior symptoms at the time of the assessment. A review of the Physician Order Report dated 6/27/21 - 9/15/21 in the medical record revealed the following medications: 6/27/21 [MEDICATION(S)] 25 mg (milligram) give 1/2 tablet (12.5 mg) by mouth at bedtime, with a discontinue date of 6/28/21 6/28/21 [MEDICATION(S)] 25 mg give 1/2 tablet (12.5 mg) by mouth at bedtime Additional review of physician orders revealed an order was received to discontinue [MEDICATION(S)] on 6/27/21 with a discontinue date of 6/28/21 and signed by the resident's attending physician. A review of the 7/10/21 MRR (medical record review) from the consultant pharmacist revealed a recommendation as: Federal Guidelines for long-term care facilities require an evaluation of antipsychotic usage within two weeks of admission. This resident (#124) was recently admitted with an order for [MEDICATION(S)] 12.5 mg QHS (bedtime) to treat Major Depressive Disorder. Please consider a trial dose reduction to assess continued need for treatment and check one of the following: ()Medication to be continued as ordered. Discontinuation of therapy likely will be harmful to resident and/or others or it will interfere significantly with the provision of care for others. ()Reduce the current order as indicated below. ()Evaluation of the antipsychotic medication was completed by Psych. See Psych progress notes dated ___. The section for the physician/prescriber response was blank. None of the boxes were checked off as Agree, Disagree, or Other, nor was there a signature indicating the physician received/reviewed the recommendation. Review of the Medication Administration Records (MAR) for the months of July, August, and September 2021 revealed the [MEDICATION(S)] 12.5 mg continued to be administered. On 9/15/21 at 10:38 a.m. an interview was conducted with the Admissions Nurse Liaison. She said the unit managers fax the recommendations to the physicians. On 9/15/21 at 11:09 a.m. an interview was conducted with the Regional Nurse. She said the pharmacist may have reviewed the medications before it ([MEDICATION(S)]) was discontinued. She confirmed the physician signed a discontinue order on 6/27 for [MEDICATION(S)] and that it was being administered for the months of July, August, and September 2021. On 9/16/21 at 10:39 a.m. a telephone interview was conducted with the Consultant Pharmacist. She said when the facility receives her recommendations they put them in the practitioner's folders, or it may go to the behavior meeting for psychiatric services to review. On 9/16/21 at 1:10 p.m. a follow up interview was conducted with the Regional Nurse. She said the pharmacist sends the recommendations to the DON (Director of Nursing). The DON disperses them to the unit managers and they get them to the doctors. On 9/16/21 at 1:12 p.m. an interview was conducted with the Nursing Home Administrator (NHA). She said she prints off the recommendations and gives them to the unit manager. They also go to the ADON (Assistant Director of Nursing). Sometimes they come to herself too. She doesn't know where they go after that; that's nursing. Review of the policy, [CONDITION(S)] Medications, revised 9/5/18, reflected the following: Policy Statement Physicians and mid-level providers will use [CONDITION(S)] medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation, and monitoring. Guideline: 7. If a clinical contraindication for a gradual dose reduction (GDR)/tapering has been indicated, it must be properly and fully documented on the physician order sheet and care plan. Primary Care Physician, Physician Assistant (PA) or advanced nurse practitioner (APRN) 8. If contraindicated, the prescriber will document in the medical record the clinical rationale why the attempt would likely impair the resident's function or cause instability. 11. Review reports from the consultant pharmacist and documents in the medial record the identified irregularity has been reviewed and what, if any, action has been taken to address the irregularity. If the physician determines there is to be no change in the medication; the physician will document the rationale in the resident's medical record. Pharmacist and/or consulting pharmacist 4. The consultant pharmacist and the nursing care center follow up on the recommendations to verify appropriate action has been taken. Recommendations shall be acted upon within 30 calendar days.

Based on record review, observation, interviews, and policy review the facility did not ensure treatment orders for a pressure ulcer were obtained for one resident (#124) of five residents reviewed for care and services of pressure ulcers. Findings included: Resident #124 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 9/15/21, revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating her cognition was intact. Review of the Admission Observation, dated 9/9/21, reflected an ulcer on the sacrum 0.6 x 0.6 x 0.2 cm [centimeters]. A review of nurse progress notes in the medical record dated 9/9/21 revealed Pt. (patient) stated hospital staff caused her to have sacrum/coccyx wound during transfer from w/c (wheelchair) to her husband's truck, they slammed me in the truck. Small open sacral wound with surrounding large area including buttocks redness/purple, by sacral area, non-blanchable. Further review of the progress notes dated 9/13/21 revealed Resident [#124] educated to stay off sacral wound to prevent further complications. Assisted resident up and on side to assist with further wound deterioration. Review of the Observation dated 9/13/21 reflected Patient continues with raw excoriation to buttocks and sacrum area. No new areas. Staring to open a little on the sacrum from excoriation. Encouraged to stay tilted on sides. A review of the care plan dated 9/9/21 reflected Impaired Skin Integrity. Sacral wound. Approaches included: See current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/13/21 at 11:29 a.m. an observation was conducted. Resident #124 was in her bed lying on her back in a semi Fowler's position (head of bed raised). She was clean and groomed. She was resting on a regular mattress. A wound vac was noted on the floor near the left side of the bed. The resident reported that was for a spider bite on her leg. On 9/15/21 at 8:43 a.m. an interview was conducted with Staff C, Certified Nursing Assistant (CNA). She said Resident #124 went to the wound care center this morning right after breakfast. She does have a sore on her bottom. She hasn't gotten up. She can't. Therapy hasn't said we can get her up yet. She won't sit in a wheelchair. On 9/15/21 at 8:47 a.m. an interview was conducted with Staff D, Licensed Practical Nurse (LPN). Staff D, LPN said, She has a wound vac on her left lower leg. We manage the wound vac while she is here. The wound clinic manages the wound and gives us new orders as needed. She is a left hip fracture with surgery. She is new to me. Her sacral area is excoriated. I haven't seen it yet. Today is my first day with her. There is a dressing on it. I am not showing any orders for it. When she returns I will evaluate the situation and contact the doctor. Treatment orders are obtained on admission. On 9/15/21 at 9:07 a.m. an interview was conducted with the Regional Nurse, NHA, and the Admissions Nurse. The Regional Nurse reviewed Resident #124's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Regional Nurse said there should be a treatment order of some kind. The Admission Observation only indicates the leg. The first indication on the bottom is 9/13, excoriation to buttocks and sacrum. She was admitted ,d+[DATE] (2021). She confirmed the 9/9 care plan had the sacral wound on it. After reviewing the record further the Regional Nurse said, I do see the the sacral wound on the Admission Observation. She stated, they need to get treatment orders on admission. On 9/15/21 at 9:37 a.m. a follow up interview was conducted with the Regional Nurse, the Unit Manager and Registered Nurse(RN) for the long term care unit, and the Admissions Nurse. They said the Unit Manager checks the charts. There is morning meeting where wounds and new admissions are discussed. There is also a weekly risk management meeting where residents are reviewed. On 9/15/21 at 12:15 p.m. a follow up interview was conducted with Staff D, LPN. She said Resident #124 just returned from the wound care center. There is a dressing on it from the wound care center. Staff D said she will call the wound care center and see what they want on the pressure ulcer. On 09/15/21 at 12:16 p.m. an observation was conducted. Resident #124 was in bed covered with a sheet. Staff D, LPN and Staff E, CNA entered Resident #124's room and asked permission to look at the dressing. She yelled and said they just put a dressing on it at the wound care center. After Staff D explained that she needed to see it, the resident agreed. There was a large, undated, padded dressing on her entire bottom and sacral-coccyx area. Resident #124 refused to allow Staff D to remove the dressing. Review of the policy, Skin Observation/Evaluation and Prevention, last revised 1/8/20, revealed the following: Guideline: 3. If the admitting nurse identifies an alteration in resident's skin integrity, the findings will be documented in the EMR (electronic medical record). The nurse will notify the physician for a treatment order and document this communication in the progress note in the EMR. Review of the policy, Pressure Ulcer/Injury Risk Evaluation, revised 6/8/21, revealed the following information: Purpose: The purpose of this procedure is to provide guidelines for evaluation and identification of residents at risk of developing a pressure ulcer/injury. Evaluation: 4. Because a resident at risk can develop a pressure ulcer/in [NAME] within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. The admission evaluation helps define those initial care approached and interventions. 5. In addition, the admission evaluation may identify pre-existing signs (such as purple or very dark area that is surrounded by profound redness, [CONDITION(S)], or induration) suggesting that deep tissue damage has already occurred, and additional deep tissue loss may occur. This deep tissue damage could lead to the appearance of an unavoidable Stage III or IV pressure ulcer/injury or progression of an unavoidable stage I pressure ulcer/injury to an ulcer with eschar or exudate within days after admission. (Some situations that may have contributed to this tissue damage include pressure resulting from immobility during hospitalization or surgical procedures, during prolonged ambulance transport, or while waiting to be discovered or assisted after a debilitating event, such as a fall or [CONDITION(S)].) Steps in the procedure 5. Proceed to care planning and interventions individualized for the resident and their particular risk factors.

Based on interviews, record reviews, and review of facility policy, the facility failed to provide written notice of bed hold upon a facility initiated transfer for two residents (#41 and #72) of two residents sampled for hospitalization s. Findings included: A review of Resident #41's Resident Face Sheet revealed that Resident #41 was admitted to the facility on [DATE], with a readmission to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #41's Resident Face Sheet also revealed Resident #41 was her own responsible party. A review of Resident #41's Progress Notes revealed a note, dated 07/24/2021 at 5:38 p.m., which documented Resident #41 was transferred to the hospital due to complaints of abdominal pain and decreased bowel sounds. A review of Resident #41's Progress Notes also revealed a note, dated 07/24/2021 at 11:20 p.m., which documented Resident #41 was admitted to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted on 09/15/2021 at 3:17 p.m. with the facility's Nursing Home Administrator (NHA). The NHA stated that a notice of bed hold document was not sent in the transfer paperwork upon Resident #41's transfer to the hospital on 07/24/2021, that the transfer paperwork was probably dropped. The NHA also stated Resident #41 was her own responsible party and that she made her own health care decisions. An interview was conducted on 09/15/2021 at 3:34 p.m. with Resident #41. Resident #41 stated she was recently admitted to the hospital due to a urinary tract infection that bothered her kidneys and that she was in the hospital for a couple of days. Resident #41 also stated that she did not remember signing any documentation related to the facility bed hold notice and did not remember receiving the notice at all during her time in the hospital. Resident #41 stated that she was her own responsible party and that she made her own health care decisions. A review of Resident #41's Minimum Data Set (MDS) Assessment, dated on 07/31/2021, revealed under Section C - Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 12, which indicated that Resident #41 was cognitively intact. A review of the facility policy titled, Facility Bedhold, last revised on 11/12/2018, revealed under the section titled Policy Statement, that the facility will notify the resident/responsible party of the facility's bed hold and re-admission policies at admission and anytime a resident is transferred to the hospital or goes out on therapeutic leave. The facility policy also revealed, under the section titled Guideline, that the facility's Bedhold and Re-admission policies will be discussed with the resident/responsible party and the facility will provide written notice of the bed hold and re-admission policies at the time of admission and before a resident's transfer to the hospital or for overnight therapeutic leave, included in the resident's transfer packet. Resident #72 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 0, indicating severe cognitive impairment. Review of the physician orders revealed an order dated 7/4/21, send patient to ED (emergency department) for evaluation and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the resident's medical record reflected there wasn't a bed hold policy on file for the date of the transfer (7/4/21). An interview with the NHA on 9/15/21 at 3:11 p.m. was conducted. She said the admission paperwork has the bed hold policy in it. He went out on July 4th. We don't have a copy of the bed hold policy. We don't know if it was sent or not. The NHA also said there is a whole packet that is provided when they go out to the hospital.

Based on interviews, record reviews, and review of facility policy, the facility failed to notify the Office of the State Long-Term Care (LTC) Ombudsman of a facility initiated transfer for one resident (#41) of two residents sampled for hospitalization s. Findings included: A review of Resident #41's Resident Face Sheet revealed that Resident #41 was admitted to the facility on [DATE], with a readmission to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #41's Resident Face Sheet also revealed Resident #41 was her own responsible party. A review of Resident #41's Progress Notes revealed a note, dated 07/24/2021 at 5:38 p.m., which documented Resident #41 was transferred to the hospital due to complaints of abdominal pain and decreased bowel sounds. A review of Resident #41's Progress Notes also revealed a note, dated 07/24/2021 at 11:20 p.m., which documented Resident #41 was admitted to the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted on 09/15/2021 at 3:17 p.m. with the facility's Nursing Home Administrator (NHA). The NHA stated that the LTC Ombudsman was not notified of Resident #41's transfer to the hospital on 07/24/2021 and that the notification should have been made by the facility's Social Services Director (SSD). An interview was conducted on 09/15/2021 at 3:34 p.m. with Resident #41. Resident #41 stated she was recently admitted to the hospital due to a urinary tract infection that bothered her kidneys and that she was in the hospital for a couple of days. Resident #41 stated that she was her own responsible party and that she made her own health care decisions. An interview was conducted on 09/16/2021 at 11:08 a.m. with the SSD. The SSD stated they were not sending notification of transfers to the LTC Ombudsman but they were working on putting a plan in place to make sure the notifications were being completed. A review of the facility policy titled, Discharge or Transfer Summary, last reviewed on 06/28/2018, revealed under the section titled Guideline, that prior to a resident transfer or discharge, the facility will notify the resident and/or the resident's representative of the transfer or discharge and the reason for the move in writing and in a language and manner they understand and the facility will send a copy of the notice to a representative of the Office of the State LTC Ombudsman.

Based on record review and interviews, the facility failed to ensure the advance directive for a resident was identified in the medical record for one resident (#184) out of the sampled thirty-five residents. Findings included: A review of the Resident Face Sheet revealed Resident #184 was admitted into the facility on [DATE] with primary diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the banner on the electronic medical record did not reflect an advance directive for Resident #184. A review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the care plans initiated on [DATE] for Resident #184 did not reflect a care plan related to advance directives. On [DATE] at 11:35 a.m., Staff A, Registered Nurse (RN), reported the code status for all residents should be listed on the top of the screen in the electronic health record. She stated that if a resident was coding, she would look at the top of the screen to check the code status. On [DATE] at 1:19 p.m., the Nurse Liaison, stated if a resident was coding, staff should look on the Software Program at the top left under the identifiers and there was a book on the unit for Do Not Resuscitate status. She stated the code status should be at the top of the electronic medical record with the demographics. The Nurse Liaison stated the expectation was that the code status should be in the medical record. The policy provided by the facility Advance Directive Procedure, revised [DATE], revealed the following: 3. If the resident or the resident's representative states that the resident has completed an advance directive, it shall be documented in the medical record. The policy provided by the facility Florida Cardiopulmonary Resuscitation, last revised [DATE], revealed the following general guideline: 2. During a resident's admission and/or stay, Facility should ask about and document a resident's choices regarding CPR [cardiopulmonary resuscitation], with two witnesses signing off on same. Faciilty should seek to obtain a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and interviews the facility did not ensure treatment and care in accordance with standards of practice and physician orders [REDACTED].#1, #2) of three residents reviewed for weight loss. Findings included: 1. Resident #1 was admitted to the facility on [DATE] and discharged on [DATE] with a [DIAGNOSES REDACTED]. A review of Resident #1's physician's orders [REDACTED]. Diet: meal consumption at breakfast Special Instructions: assign breakfast and fluids to the poc (plan of care) task, once a day 7:00 a.m.-11:00 a.m. Diet: meal consumption at dinner Special Instructions: add dinner and fluid consumption to the poc task, once an evening; evening meal 16:00-20:00 (4 p.m.-6 p.m.) Diet: meal consumption at lunch Special Instructions: assign lunch and fluids to poc task, once a day; mid day Review of the meal percentages in the electronic medical record reflected the following: 11/22/20, 11/25/20- no record of breakfast and lunch meal percentages. 11/24/20, 11/30/20, 12/1/20. 12/2/20 - no record of dinner meal percentages. 11/26/20 - no record of breakfast meal percentages. 11/27/20, 11/28/20, 11/29/20, and 12/3/20 - no record of any meal percentages. 2. Resident #2 was admitted to the facility on [DATE] and discharged to the hospital on [DATE], with a [DIAGNOSES REDACTED]. Review of the hospital record dated 7/27/20-8/6/20 reflected that Resident #2 came to the emergency room from the facility for altered mental status (AMS) and abnormal labs. The resident was admitted to the hospital for severe dehydration and [MEDICAL CONDITION] (elevated sodium). A review of the physician's orders [REDACTED]. Diet: meal consumption at breakfast Special Instructions: assign breakfast and fluids to the poc (plan of care) task, once a day 7:00 a.m.-11:00 a.m. Diet: meal consumption at lunch Special Instructions: assign lunch and fluids to the poc task, once a day; mid day Diet: meal consumption at dinner Special Instructions: add dinner and fluid consumption to the poc task, once an evening; evening meal 16:00-20:00 (4 p.m.-6 p.m.) A review of the meal percentage documentation in the medical record revealed the following missing documentation: 7/2/20, 7/3/20, 7/5/20, 7/11/20, 7/12/20, 7/13/20, 7/25/20, and 7/26/20- no record of any meal percentages. 7/4/20 and 7/15/20- no record of breakfast and lunch meal percentages. 7/6/20, 7/16/20, and 7/21/20- no record of breakfast meal percentage. 7/7/20- no record of dinner meal percentage. 7/8/20, 7/17/20, 7/18/20, 7/19/20, and 7/24/20 - no record of breakfast and dinner meal percentages. Further review of the clinical record reflected fluid intakes were not documented. On 12/22/20 at 4:47 p.m., an interview was conducted with the DON (director of nursing). She said staff should be inputting the meal intake under tasks in the electronic record system. A request for the documentation was made at that time. At 5:38 p.m. on 12/22/20, a review of the meal percentage documentation was conducted with the DON. She confirmed not all meals had been documented. On 12/23/20 at 2:03 p.m., an interview was conducted with the attending physician for Resident #2 and Medical Director at the facility. He said when the resident first came to the facility he was about 115 pounds, and he didn't think he was going to make it. He had dementia. He didn't participate in anything without a lot of encouragement. He just laid there. I was aware he was refusing medications and care. He ended up testing positive for COVID and they moved him to the COVID unit. I saw him right after admission a couple of times. I ordered admission labs and when he tested positive, I didn't go into his room. Department of Health (DOH) discourages in person visits with COVID in the building, but I still make rounds. I did not see him on the COVID unit but when the staff told me he had a change, I ordered labs and I was in the building and reviewed the labs. I sent him out for hydration immediately when I saw the sodium was 158. His blood sugar did fluctuate because he wasn't eating. He just laid there and was not motivated to do anything. After he got COVID, I didn't think he was going to make it. He was on his way out, but I ordered the labs and sent him out for hydration and treatment.

Based on observations, interviews with the maintenance director, nursing and therapy staff, and the Nursing Home Administrator (NHA), and record reviews, the facility failed to identify and ensure the safety for resident use of 51 of 117 beds with side rails, used as assistive devices, which were malfunctioning or potentially unsafe and posed the risk of entrapment or injury and were not manufactured for the model beds used (100 hall: 100 B; 101 A; 103 A; 104 B; 106 A; 107 A;107 B;109 B;110 A; 112B; 113 A;115 A; 115 B; 120 A;122 B; 123 A;125A;125 B;127 A;128 A; 129 A, and 131 B: 200 hall: 200 B; 201 A; 202 B; 203 A; 203 B;204 A;206 A; 206 B; 209 A; 213 A; 217 A; 218A; 219 A; 221 A; 222 A; 222 B; 223 A; 224A; 225 A; 225 B; 228 A; 229 B; 230 A; and 231 A.:300 hall: 301 A and 302 A and 400 hall: 400, P (Private); 401 B; and 404 A) and three (Residents # 3, #7, and # 55) of 45 sampled residents with various levels of cognition and physical needs for bed mobility, safety, and the prevention of potential hazards such as entrapment and falls. Residents were dependent on staff for daily care and transfers who occupied the beds and who presented with compromised physical or cognitive conditions which posed a threat to continued use of the side rail assistive devices. These findings resulted in the findings of Immediate Jeopardy which was abated at 10:00 a.m. on March 22, 2012, after the facility had all the T 100 model half rails removed from the building and replaced. The scope and severity was reduced to E. Findings include: 1. Record review for resident #55, revealed that he was admitted to the facility on [DATE] from the hospital, per the facesheet. Review of the hospital physician ' s consultation revealed concerns about his continued deterioration with manifestations of increased confusion, an increased level of agitation, and a loss of muscle tone related to the diseases. Per the attending physician ' s visit form, dated 10/12/11, the resident was weak and lethargic. He had [DIAGNOSES REDACTED]. Care plans were initiated on 02/25/11 for: a. Impaired Cognition related to multiple diseases and impulsiveness with safety awareness. Multiple interventions included minimizing or eliminating environmental hazards. b. Care Deficit including mobility related to disease processes. An intervention included to assist with turning and repositioning to enhance circulation and to provide adaptive and safety equipment as needed. c. Fall Precautions related to a history of falls, impaired balance and mobility. Intervention and approaches included provide and monitor use of adaptive devices, verbal cues, assist with transfer and ambulation, provide call light and rehabilitation services as ordered. A hand written entry, dated 01/27/12, stated that resident #55 was "lowered to floor. " A facility summary, dated 01/13/12 at 9:45 p.m., stated that the nurse was notified by an aide, Employee F, that the resident was on the floor. The aide stated on the form that she was in the room but did not see the fall. The conclusion was that the resident stood, fell , and the aide could not get to him. The resident remained at high risk for falls and, upon his return to the facility therapy, was initiated. On 03/19/12 at 2:29 p.m. a random observation of resident #55 was done by two surveyors passing by the room. Resident #55 was observed with both feet and legs off the bed pointed toward the door. The half rail on the right side was collapsed inward to his chest and pointed upward in a displaced position. The resident was holding the rail with his left hand. The call bell was not on. An aide was called to the room by the surveyors. She repositioned the resident on the bed, and tightened the side rail by turning a black knob in the center of the rails. She stated it was a common occurrence with the rails becoming displaced. This rail was later identified as a T100 model half rail, used throughout the building. An interview with Employee D on 3/19/12 at 4:45 PM confirmed that resident #55 used side rails for mobility. On inspection the right rail was loose, and the left rail was also loose. Even after being tightened down, the right rail still rocked front to back. Employee D stated that the rails were ordered separately from the frames. The rails observed were T shaped with black knob designed to tighten the rails, later identified as T100 model. On 03/21/12 3:45 p.m. an observation and interview was conducted for resident #55. The resident was resident in his room. He was seated in a wheelchair, with a chair alarm in place. He was dressed in shorts and a golf shirt on. He was clean and odor free. He was listening to opera on his personal music player. He was confused and unable to answer questions about his side rail use. 2.On 03/19/12 at 4:38 p.m. during an interview with the ADON, the Unit Manager of North wing, it was revealed that the ADON had prior concerns about the rails when one rail became disconnected from the bed as a resident was holding on to it. She did not have direct knowledge of the event because she stated she did not work that day, but thought the event occurred about one month ago. This event was later identified as a fall involving resident #7 that occurred in December 2011. The ADON stated she was concerned about many rails that were not stable and were "wobbly." She reported it to a person in the Admissions office that she thought was working on new equipment. She did not recall any injuries related to side rail failure and was unsure if the Nursing Home Administrator (NHA) was aware of her concerns. The ADON stated that of the 60 beds on north wing, 39 sets were of the style that was loose and unstable, requiring staff to tighten them using the black knob. She stated that beds were moved around the facility so the number could be different at this time. The ADON confirmed with the surveyor that other rails continued to need tightening by the staff. There was no formal education conducted with the staff for how to tighten the rails. 3. An interview with Employee E, an aide, on 3/20/12 at 4:45 p.m. revealed that she stated that there had been minor problems with side rails since she had started working at the facility, four months ago. She also stated that the standard procedure was to tighten the rails using the black knob and if that did not work then there was a maintenance log book to enter the information in and that maintenance took care of the problem within 24 hours or less. She stated that in addition to notifying maintenance that nursing was also notified. She had no formal training with how to tighten side rails. 4. On 03/20/12 at 8:25 a.m. an interview was conducted with the NHA and NHA assistant (ANHA). The NHA stated that bed rails were checked out yesterday evening, 03/19/12, by the maintenance man, and one set was changed out last night. She stated she had been here 9 years and the facility had never had an injury to a resident regarding side rails. The facility had some residents that requested not to have them. She stated that six or seven years ago the facility took the full rails off the beds. They replaced them with this style of half rail, T100. She stated that they were told by the manufacture that this model rail was the one facilities were using, as a universal style rail. Last night she called the corporation and sent a picture of the rail. They had no further guidance. The NHA confirmed that the black screw was used to tighten the rail. She was not sure how many were tightened routinely. She stated that she could not recall a resident rail collapsed or a side rail associated with a fall. She restated did not know of any rails giving way. 5. At 10:15 a.m. on 03/20/12 the maintenance department head brought an unopened box of this model side rail, T100, for demonstration. He stated he had been here 2 years and continued to order the product based on past experience going on before he came. He did not know who made the decision to purchase this product. 6. Review of the FDA medical device incident reports revealed one event dated 09/13/2000. The details included the resident was receiving care when the rail broke and she fell to the floor. She sustained injuries in the fall. The model identified was the T100 half rail, the same model and manufacturer used by this facility. 7. On 03/21/12 at 9:00 a.m. the NHA and ANHA were interviewed again. The NHA stated she read all falls and incidents back to August 2011, the date of the last annual survey. She did not find any event regarding side rails and residents or staff. She stated she remained in the facility to speak with the entire 11-7 staff on 03/20/12 regarding the reporting of emergencies or incidents. The NHA asked staff if there were any problems with side rails, the timeliness of repairs, and how repairs were requested. The NHA reeducated the staff in the reporting of safety concerns immediately. 8. The NHA stated, on 03/21/12 at 9:00 a.m. , that she was not aware of any report of a side rail that had broken until she heard from Employee H last night, 03/20/12. The aide, Employee H, recounted to the NHA that a resident #7, was standing alone in her room touching the night stand. Employee H observed the resident from the hallway and called out to the resident. The employee felt she may have startled the resident and the resident grabbed the side rail. The aide, Employee H, observed the resident falling, grabbing the side rail, and the side rail came away from the bed and fell to the floor with the resident. This event happened in December of 2011. The aide was asked by the NHA how the rail was repaired. Employee H stated that the rail did not break and another aide picked up the parts and replaced the side rail onto the frame of the bed, using the black knob to tighten it on. No maintenance report was made, as the staff felt there was no equipment failure or repair needed. There was no injury. The resident was subsequently discharged to assisted living on 02/10/12. 9. Review of the closed medical record for resident #7, a [AGE] year old female, revealed that she was readmitted to the facility on [DATE] after hospitalization for a change in mental status. Per the hospital physician's history and physical, dated 12/12/11, the resident had resided in this facility for the prior several weeks while receiving therapy and recovering from a distal right lower leg fracture. The injury prevented her from bearing weight. Per the physician, she was recovering "nicely" and anticipated returning to her home and living independently. Another physician reported that a recent CT scan of the brain was "unrevealing". The resident was hospitalized to evaluate the change of mental status. The dictating hospital physician who also attended her in the facility, recalled her as very alert and vibrant. On page 2 of 4 the physician history stated that the review of symptoms was very limited because she was "markedly impaired with her mental function". The primary admitting [DIAGNOSES REDACTED]. Review of a fall prevention care plan, initiated 11/03/11, stated that she had impaired balance and mobility. Approach #6 stated "side rails as enabler". Another care plan, initiated 11/03/11, stated she had a self-care deficit. It was updated on 12/30/11, after the fall, stating she had increased weakness, decreased vision, and cognition changes. A Nursing Admission Information form contained a hand written note stating that at 4:30 p.m. the resident was admitted to room 217B by stretcher. The nurse documented that she was at risk for falls and had confusion at times. The nurse wrote that "rails x 2 were up" (upward arrow) in bed for positioning and independence. She was oriented to herself only, not time or place. The assessment stated she required supervision with bed mobility; one person assistance with transfer; and dependent on one person assistance for walking, toileting, hygiene, and bathing. The fall risk score was 24, with scores over 10 indicating high risk. The interim care plan, dated 12/15/11 but no time specified, stated she was to have a bed alarm and positioning devices. There were five additional interventions A nurse's note at 7:45 (a.m. or p.m. not written), the same nurse wrote that the resident was on the floor, having hallucinations that someone was smoking in her room and "standing over her and she had to move". She was assisted back to bed after the nurse checked her for injury. She denied pain. There was no further documentation on this page. Review of the facility provided documentation related to the fall of 12/15/11, involving resident #7, revealed four documents: 1. A facility investigation form, dated 12/15/11, stated she had poor safety awareness and interventions were in place prior to the fall, including safety foot ware, call light in reach, water in reach, and assistive devices for ambulation. One section stated that the care plan was revised to include a bed alarm and verbal cuing for the resident to use the call light. 2. A communication to physician form (SBAR) stated that a resident fall had occurred with resident #7. The back of the form stated that at 7:30 p.m. on 12/15/11 the nurse was notified by the aide that the resident was sitting on the floor. The fall was witnessed by the aide and described to the nurse. The resident was alert and confused, again stating that someone was smoking in the room and she could not tolerate smoking. The resident denied pain and was re-educated for use with the call bell. A personal bed alarm was placed on the bed. There were two additional nurses ' notes, 12/16 and 12/17/11 stating that the resident had no pain or injuries. 3. An undated hand written statement by Employee H stated that she, the employee, was working with another resident, walked out into the hall, glanced over and saw "her (resident #7) standing on the right side of her bed holding on to her side table". The employee wrote that she "yelled out her (the resident ' s) name" and ran into the room. The resident turned to her left to look at the employee and began to fall. She grabbed the side rail "to catch herself" but the rail "broke off her bed and she fell right on her bottom". The employee called for help. This document did not contain this resident's name or the date of the occurrence. The facility NHA ANHA, and DON stated on 03/21/12 that the document belonged with this investigation for resident #7, concerning the fall on 12/15/11. 4. A second hand written statement by The NHA and ANHA was dated 03/20/12. It stated that Employee H verbalized to them that the side rail detached from the rail. Employee H stated that the rail was reattached and tightened by another employee and functioning properly. Further review of the closed medical record revealed that the resident was discharged on [DATE] to an assisted living facility. The nurse ' s notes on that day at 11:00 a.m. stated she propelled herself in a wheelchair and had no complaints. Review of the facility census on 03/19/12 revealed that resident #7 currently resided in the facility. On 03/19/12 a brief observation was made and the resident was resting in bed. She was confused. The side rails attached to the bed were found by the surveyor to be "wobbly". The new record stated she had been readmitted on [DATE] and continued on fall precautions. 5. On 03/19/2012 at 4:00 p.m. an observation was made of resident #3 ' s bed. The side rails were T style and were not locked in placed. The rails moved in a clock like motion and stopped when the side of the rails reached the floor. This was an abnormal finding for side rail stability. The resident was not in the bed at the time of this observation. On 03/19/2012 an interview was conducted with resident #3 at 4:40 p.m. The resident revealed that she used the side rails for positioning to get comfortable and to assist with getting out of bed. She used a wheelchair for mobility. On 03/20/2012 at 9:30 A.M. a second observation was made of the side rails in resident #3 ' s room. The resident was seated in her wheelchair at the time. The rails, again, were unstable and rocked back and forth, head to foot, and laterally, side to side, along the bed and extended to the floor, in an abnormal position. The aide stated the rails were used by the resident to assist with support to a standing position. Per the MDS for resident #3, dated 02/08/12, section C, related to recall, and revealed the resident required verbal cues to recall sock and blue. She could not recall the word bed. The mood section interview stated she had a severity score of 5.The functional status section, Section G, stated she required extensive assistance with mobility including bed mobility and transfers. She required the assistance of one staff member for all care. Section G0300 stated she was not steady and only able to stabilize with human assistance. The section D0350 related to safety was blank. Section 1 of the active [DIAGNOSES REDACTED]. 5. On 03/20/2012 at 4:45 P.M., Employee G called the surveyor into resident #3 ' s room to demonstrate to the surveyor that the bed had been repaired by maintenance. Employee G stated that he had called maintenance to report the problem. The rails were then changed and did not touch the floor, but still had some unstable movement. The employee stated he had been working in the facility five years and the rails had been the same since he began working here. He stated that he tightened them as necessary after the rails became loose from usage. He stated the policy was to notify maintenance for any problem that needs fixing, but he did not consider this a problem, and did not report them as unstable. He stated he did not know of any resident falling because of side rails or of any injury related to side rails. 6. From 03/19 to 03/20/12 at about noon the survey team identified 51 of the current 117 beds (100B, 101A, 103A, 104B, 106A, 107A, 107B, 109B, 110A, 112B, 113A, 115A, 115B, 120A, 122B, 123A, 125A, 125B, 127A, 128A, 129A, 131B, 200B, 201A, 202B, 203A, 203B, 204A, 206A, 206B, 209A, 213A, 217A, 218A, 219A 221A, 222A, 222B, 223A, 224A, 225A, 225B, 228A, 229B, 230A, 231A, 301A, 302A, 400P, 401B, and 404A) were equipped with the T100 model side rail. Multiple observations by five surveyors revealed that 45 of the 51 beds were currently occupied (100B, 101A, 103A, 104B, 106A, 107A, 107B, 109B, 110A, 113A, 115A, 115B, 120A, 122B, 123A, 125A, 125B, 127A, 128A, 129A, 131B, 200B, 201A, 202B, 203A, 203B, 204A, 206A, 206B, 209A, 213A, 219A 221A, 222A, 222B, 223A, 228A, 229B, 230A, 231A, 301A, 302A, 400P, 401B, and 404A). Thirty nine of the 51 beds were found to have loose rails allowing for excess movement toward the mattress, away from the mattress, and a rocking motion from the head of the bed to the foot of the beds. Some rails observed rocked parallel to the mattress to a degree almost touching the floor. Resident use and comprehension ranged from residents stating they did not use the rail to 23 of the 45 residents unable to answer the question due to cognition impairment. 7. Observations made on 3/20/12 between 8:30 AM - 10:10 a.m. revealed that 14 (217/A, 218/A, 219/A, 221/A, 222/A, 222/B, 223/A, 224/A, 225/A, 225/B, 228/A, 229/B, 230/A, 231/A) beds were identified as having the "T" shape side rails on the north wing. All were identified as being loose in all 4 directions (in/out from the bed and the rocking head/foot motion). Room 224/A was identified as having a 2 finger gap between the left rail and the mattress, even after tightening the loose rail. 8. Multiple interviews with aides on two different shifts revealed that they considered loose, unstable rails that needed periodic tightening to be a routine finding and not reported as needing maintenance. The staff reported that other staff, peer to peer, instructed each other on the tightening of the rails. There was no formal instruction on tightening side rails. 9. On 03/20/12 at 3:45 p.m. the maintenance supervisor was interviewed. He stated he kept a log book of needed repairs throughout the facility. Some repairs were fixed immediately if he was stopped in the hall by staff. When the repair was completed he recorded the date and signed the log book. He checked the book every morning and three times daily. He stated he had worked for the facility for two years and continued to order the type and style of half side rails that were ordered prior, the T100 model. He had not been told to order any other rail. He stated side rails were checked once a month and aides tightened the rails themselves and did not routinely notify maintenance. There were five styles of bed frames in the facility and none were manufactured by the maker of the T100 rails. Six months of repairs were reviewed with the surveyor. He, the maintenance director, stated that some of the frames were no longer in production. Review of the log revealed three complaints of broken side rails. 1. October 13, 2011-the side rail " came off " , no room specified. It was resolved the same day. 2. October 14.2011-the bed rail was broken in room 128A. it was resolved the same day. 3. March 13, 2012-the right bed rail room 218B was difficult to get down. It was resolved the same day. There was no documentation if the rails in question were replaced or repaired. 10. On 03/20/12 from 4:00 to 4:45 p.m. telephone interviews were conducted with the medical device salesman and the manufacturer of the T100 side rails. The medical device salesman for the supplier of the T100 side rail stated that the bed frames used by the facility were not manufactured any longer. Specific side rails were available for these frames at the time the frames were ordered. 11. The manufacturer representative was interviewed by telephone at 4:40 p.m. He stated that the T100 rail was not recommended for any of the five bed frames in this facility. He stated that they were made for a bed frame specifically manufactured by the same company for home care. 12. On 03/21/12 at 9:00 a.m. the NHA, ANHA and two surveyors toured the building with the intent of looking at specific beds reported as remaining unsteady or broken. The NHA stated that all beds were tightened during the night of 03/20 to 03/21/12. 13. The findings were: Room 225, window bed: one of the side rail bars was missing on the left side, leaving an enlarged gap allowing for possible entrapment. Room 225 door: The NHA stated the side rails were replaced on 03/20/12. The replacement rails were the T100 type. Room 101door: The left side rail flexed inward toward the mattress and rocked back and forth with an extensive amount of play. It was very unsteady. The right side rail collapsed to the floor near the head of the bed. When the mattress was elevated it revealed that the metal piece that secured the rail to the frame was missing one of two bolts. When the rail was moved the metal piece under the mattress elevated the mattress off the frame about 2 inches. It was very unsteady. An elderly resident seated in a wheel chair was next to the bed. The NHA confirmed it was the elderly confused resident ' s bed. 14. On 03/21/12 at 3:44 p.m. a telephone interview was conducted with the medical director, at her office locally. She confirmed she was the Medical Director and had been in that role since 2005. The physician stated she had spoken with the NHA yesterday and was made aware of the concerns with side rails. The physician stated she reviewed all reports and had no knowledge of failed, faulty, or unstable side rails prior to 03/20/12. She stated she was grateful that no residents were injured. She was working with the facility for a quick resolution. The physician stated she would do everything to make it right for the residents. The call ended at 3:55 p.m. 15. During an interview on 03/22/2012 at 3:30 p.m. the Admissions Director stated that she has been with this facility for 2 years, and with the corporation 9 years. She is a member of the QA committee. She stated participated in the room rounds " for a while " , making sure nothing was broken in preparation for admitting a resident, including the condition of the side rails. She stated she checked the side rails prior to a new resident admission, but said she had not found any of the side rails to be loose or have a lot of " give " in them. She did not order new equipment except special equipment. She did not recall any conversation related to any side rail problems. 16. On 03/22/12 at 9:15 a.m. interviews with the NHA, ANHA, and the nurse consultant with the corporation were conducted. The consultant stated the facility completed 100 % of side rail assessments on 03/21/12. The administration staff physically reviewed each side rail in the facility. They also completed a facility wide side rail assessments for every resident in the building. Findings included the removal of some rails, and they called all the family members of affected changes, and their attending physicians. . The corporate nurse stated " We removed all the T100 model rails in the facility " . The NHA stated 49 sets of T100 rails were removed from 03/21 to 03/22/12. Side rails were replaced by using some unoccupied beds with attached rails, and some of the residents were found to no longer need side rails. Those beds with rails were cleaned and then used to replace the beds with the T100 rails. The NHA stated they only replaced the T100 model. They did not physically remove any side rails other than the T 100 model. The NHA in serviced the maintenance director with repairs, rounds processes .In addition to documentation provided to the surveyor on 03/21/12 for the night shift reeducation. a copy of the sign in log of employees in attendance was given. She also stated she met with all managers on 03/21/12 and asked if they were aware of any incidents regarding side rails with residents or staff. All managers denied any knowledge of such incidents. The entire staff was in serviced from 03/21 to 03/22/12 regarding the process of safety checks, reporting problems, what to do, and identification of faulty equipment. The corporate nurse stated staff was informed of specific findings of abnormal side rails. The NHA stated she called the manufacturer and he did not call her back. She stated that he must have called the supply company because the owner of the local supply company called her back. She was offered no additional information regarding the rail and was unaware of the fact that this rail was made for a home care bed frame. She attempted again to call the manufacturer and spoke with someone She asked for information in addition to the manual. She then left a message for the supervisor. The NHA then spoke with a representative from another medical supply vendor. That supplier pointed out the limited three year warranty on the T100 side rail. The NHA stated they did not track when the rails were added to a bed frame. She was informed that this make and model was popular and the manufacturer did not inform consumers that it was made for a specific frame. The facility ' s corporation removed the rails T 10 model of half side rails from all of its facilities in multiple states. They knew of no other side rail failures in other facilities but made a corporate decision to remove them. The maintenance director received one to one education regarding the need to monitor safety equipment. The immediate jeopardy was reduced and the scope and severity of the citation was reduced to E.

Based on observation, resident and staff interviews and record reviews including facility policies and procedures, the facility administrator failed to provide effective resource management to promote and ensure the physical well-being and safety of all facility residents. Administration failed to provide administrative oversight of maintenance department performance to assure that essential equipment, used in the provision of resident care, was maintained in a safe and operable manner in regards to resident bed side rails. Observations of 117 resident beds (120 certified capacity) revealed 51 beds (100B, 101A, 103A, 104B, 106A, 107A, 107B, 109B, 110A, 112B, 113A, 115A, 115B, 120A, 122B, 123A, 125A, 125B, 127A, 128A, 129A, 131B,200B, 201A, 202B, 203A, 203B, 204A, 206A, 206B, 209A, 213A, 217A, 218A, 219A 221A, 222A, 222B, 223A, 224A, 225A, 225B, 228A, 229B, 230A, 231A, 301A, 302A, 400P, 401B, and 404A) with unstable side rails. Of the 51 observed beds with unstable side rails, 6 beds were unoccupied (217A,218A, 224A, 225A, 225B and 112B) and the remaining 45 beds (100B, 101A, 103A, 104B, 106A, 107A, 107B, 109B, 110A, 113A, 115A, 115B, 120A, 122B, 123A, 125A, 125B, 127A, 128A, 129A, 131B,200B, 201A, 202B, 203A, 203B, 204A, 206A, 206B, 209A, 213A, 219A 221A, 222A, 222B, 223A, 228A, 229B, 230A, 231A, 301A, 302A, 400P, 401B, and 404A) were occupied by vulnerable at-risk residents dependent on facility staff for assistance with activities of daily living. This included three (Residents # 3, #7, and # 55) of 45 sampled residents who occupied beds with the side rails and who presented with compromised physical or cognitive conditions which posed a threat to continued use of the resident care equipment. In addition, administration failed to ensure that all nursing staff had demonstrated understanding of facility expectations in the reporting of maintenance and repair issues specifically related to bed side rail maintenance. Lack of administrative oversight, as demonstrated, led to the findings of immediate jeopardy on March 21, 2012. Following verification of the corrective measures instituted by the facility, immediate jeopardy was removed on March 22, 2012 at 10:00 a.m. and the scope and severity was reduced to an E. Findings include: 1. A copy of the job description for the position of Administrator, created April 2002, was provided by the facility. The document noted a job title of Administrator in the department of Operations who reported to the Director of Operations. In the section titled " Facility Management, " bullet points outlined a list of duties for this position. Bullet point number four stated that the Administrator will monitor each department ' s activities, communicate policies, and evaluate performance. Bullet point number 6 stated that the Administrator will oversee regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of the facility, morale of the staff, and ensure resident needs are being addressed. Bullet point number nine noted that the Administrator will verify that the building and grounds are maintained appropriately and that equipment and work areas are clean, safe and orderly, and any hazardous conditions are addressed. 2. Record review for resident #55, revealed that he was admitted to the facility on [DATE] from the hospital, per the face sheet. Review of the hospital physician ' s consultation, dated 2/5/2011, revealed concerns about his continued deterioration with manifestations of increased confusion, an increased level of agitation, and a loss of muscle tone related to the diseases. Per the attending physician ' s visit form, dated 10/12/11, the resident was weak and lethargic. He had [DIAGNOSES REDACTED]. A hand written entry, dated 01/27/12, stated that resident #55 was " lowered to floor. " A facility summary, dated 01/13/12 at 9:45 p.m., stated that the nurse was notified by an aide, Employee F, that the resident was on the floor. The aide stated on the form that she was in the room but did not see the fall. The conclusion was that the resident stood, fell , and the aide could not get to him. The resident remained at high risk for falls and, upon his return to the facility, therapy, was initiated. Care plans were initiated on 02/25/11 for Resident # 55: a. Impaired Cognition related to multiple diseases and impulsiveness with safety awareness. Multiple interventions included minimizing or eliminating environmental hazards. b. Care Deficit including mobility related to disease processes. An intervention included assisting with turning and repositioning to enhance circulation and to provide adaptive and safety equipment as needed. c. Fall Precautions related to a history of falls, impaired balance and mobility. Intervention and approaches included provide and monitor use of adaptive devices, verbal cues, assist with transfer and ambulation, provide call light and rehabilitation services as ordered. On 03/19/12 at 2:29 p.m., a random observation of resident #55 was done by two surveyors passing by the room. Resident #55 was observed with both feet and legs off the bed pointed toward the door. The half rail on the right side was collapsed inward to his chest and pointed upward in a displaced position. The resident was holding the rail with his left hand. The call bell was not on. An aide was called to the room by the surveyors. She repositioned the resident on the bed, and tightened the side rail by turning a black knob in the center of the rails. She stated it was a common occurrence with the rails becoming displaced. This rail was later identified as a T100 model half rail, used throughout the building. An interview with Employee "D" on 3/19/12 at 4:45 PM confirmed that resident #55 used side rails for mobility. On inspection the right rail was loose, and the left rail was also loose. Even after being tightened down, the right rail still rocked front to back. Employee D stated that the rails were ordered separately from the frames. The rails observed were T shaped with black knob designed to tighten the rails, later identified as T100 model. On 03/21/12 3:45 p.m. an observation and interview was conducted for resident #55. The resident was in his room. He was seated in a wheelchair, with a chair alarm in place. He was dressed in shorts and a golf shirt on. He was clean and odor free. He was listening to opera on his personal music player. He was confused and unable to answer questions about his side rail use. 3. An interview was conducted with the Assistant Director of Nurses (ADON) on 3/19/12 at 4:38pm. She stated that she was aware of one event " about one month prior " involving a resident whose side rail came off. She stated she had no other details as it occurred on a weekend when she was not working. This resident was later identified as Resident #7 and the event occurred in December 2011. The ADON also stated that she had reported concerns with unstable bed rails to the Admissions Director (AD) as she thought the AD was heading a project involving new equipment procurement. At the time of her report to the AD, she identified 39 of 60 beds on the North wing as having side rails that required adjustment with a black knob to tighten the rails to the bed frame. However, she noted that beds were frequently moved about in the facility, so the current number of adjustable rails on North wing with stability issues could be different. She was unsure if the NHA was aware of her concerns at the time. The NHA stated, on 03/21/12 at 9:00 a.m., that she was not aware of any report of a side rail that had broken until she heard from Employee H last night, 03/20/12. The aide, Employee H, recounted to the NHA that a resident #7, was standing alone in her room touching the night stand. Employee H observed the resident from the hallway and called out to the resident. The employee felt she may have startled the resident and the resident grabbed the side rail. The aide, Employee H, observed the resident falling, grabbing the side rail, and the side rail came away from the bed and fell to the floor with the resident. This event happened in December of 2011. The aide was asked by the NHA how the rail was repaired. Employee H stated that the rail did not break and another aide picked up the parts and replaced the side rail onto the frame of the bed, using the black knob to tighten it on. No maintenance report was made, as the staff felt there was no equipment failure or repair needed. There was no injury. The resident was subsequently discharged to assisted living on 02/10/12. Review of the closed medical record for resident #7, a [AGE] year old female, revealed that she was readmitted to the facility on [DATE] after hospitalization for a change in mental status. Per the hospital physician's history and physical, dated 12/12/11, the resident had resided in this facility for the prior several weeks while receiving therapy and recovering from a distal right lower leg fracture. The injury prevented her from bearing weight. Per the physician, she was recovering "nicely" and anticipated returning to her home and living independently. Another physician reported that a recent CT scan of the brain was "unrevealing." The resident was hospitalized to evaluate the change of mental status. The dictating hospital physician who also attended her in the facility, recalled her as very alert and vibrant. On page 2 of 4 the physician history stated that the review of symptoms was very limited because she was "markedly impaired with her mental function." The primary admitting [DIAGNOSES REDACTED]. Review of a fall prevention care plan, initiated 11/03/11, stated that she had impaired balance and mobility. Approach #6 stated "side rails as enabler." Another care plan, initiated 11/03/11, stated she had a self-care deficit. It was updated on 12/30/11, after the fall, stating she had increased weakness, decreased vision, and cognition changes. A Nursing Admission Information form contained a hand written note stating that at 4:30 p.m. the resident was admitted by stretcher. The nurse documented that she was at risk for falls and had confusion at times. The nurse wrote that "rails x 2 were up" (upward arrow) in bed for positioning and independence. She was oriented to herself only, not time or place. The assessment stated she required supervision with bed mobility; one person assistance with transfer; and dependent on one person assistance for walking, toileting, hygiene, and bathing. The fall risk score was 24, with scores over 10 indicating high risk. The interim care plan, dated 12/15/11, but no time specified, stated she was to have a bed alarm and positioning devices. There were five additional interventions. A nurse's note at 7:45 (a.m. or p.m. not written), the same nurse wrote that the resident was on the floor, having hallucinations that someone was smoking in her room and "standing over her and she had to move." She was assisted back to bed after the nurse checked her for injury. She denied pain. There was no further documentation on this page. Review of the facility provided documentation related to the fall of 12/15/11, involving resident #7, revealed four documents: 1. A form, dated 12/15/11, stated she had poor safety awareness and interventions were in place prior to the fall, including safety foot ware, call light in reach, water in reach, and assistive devices for ambulation. One section stated that the care plan was revised to include a bed alarm and verbal cuing for the resident to use the call light. A communication to physician form (SBAR) stated that a resident fall had occurred with resident #7. The back of the form stated that at 7:30 p.m. on 12/15/11 the nurse was notified by the aide that the resident was sitting on the floor. The fall was witnessed by the aide and described to the nurse. The resident was alert and confused, again stating that someone was smoking in the room and she could not tolerate smoking. The resident denied pain and was re-educated for use with the call bell. A personal bed alarm was placed on the bed. There were two additional nurses ' notes, 12/16 and 12/17/11 stating that the resident had no pain or injuries. An undated hand written statement by Employee H stated that she, the employee, was working with another resident, walked out into the hall, glanced over and saw "her (resident #7) standing on the right side of her bed holding on to her side table." The employee wrote that she "yelled out her (the resident ' s) name" and ran into the room. The resident turned to her left to look at the employee and began to fall. She grabbed the side rail "to catch herself" but the rail "broke off her bed and she fell right on her bottom." The employee called for help. This document did not contain this resident's name or the date of the occurrence. The facility NHA ANHA, and DON stated on 03/21/12 though that the document belonged referred to Resident #7, concerning the fall on 12/15/11. A second hand written statement by the NHA and ANHA was dated 03/20/12. It stated that Employee H verbalized to them that the side rail detached from the rail. Employee H stated that the rail was reattached and tightened by another employee and functioning properly. Further review of the closed medical record revealed that the resident was discharged on [DATE] to an assisted living facility. The nurse ' s notes on that day at 11:00 a.m. stated she propelled herself in a wheelchair and had no complaints. Review of the facility census on 03/19/12 revealed that resident #7 currently resided in the facility. On 03/19/12 at 4:40 p.m., a brief observation was made and the resident was resting in bed. She was confused. The side rails attached to the bed were found by the surveyor to be "wobbly." The new record stated she had been readmitted on [DATE] and continued on fall precautions. 4. Per the MDS for resident #3, dated 02/08/12, section C, related to recall, revealed the resident required verbal cues to recall sock and blue. She could not recall the word bed. The mood section interview stated she had a severity score of 5.The functional status section, Section G, stated she required extensive assistance with mobility including bed mobility and transfers. She required the assistance of one staff member for all care. Section G0300 stated she was not steady and only able to stabilize with human assistance. The section D0350 related to safety was blank. Section 1 of the active [DIAGNOSES REDACTED]. On 03/19/2012 at 4:00 p.m. an observation was made of resident #3 ' s bed. The side rails were T style and were not locked in placed. The rails moved in a clock like motion and stopped when the side of the rails reached the floor. This was an abnormal finding for side rail stability. The resident was not in the bed at the time of this observation. On 03/19/2012 an interview was conducted with resident #3 at 4:40 p.m. The resident revealed that she used the side rails for positioning to get comfortable and to assist with getting out of bed. She used a wheelchair for mobility. On 03/20/2012 at 9:30 A.M. a second observation was made of the side rails in resident #3 ' s room. The resident was seated in her wheelchair at the time. The rails again were unstable and rocked back and forth, head to foot, and laterally, side to side, along the bed and extended to the floor, in an abnormal position. The aide stated the rails were used by the resident to assist with support to a standing position. On 03/20/2012 at 4:45 P.M., Employee G called the surveyor into resident #3 ' s room to demonstrate to the surveyor that the bed had been repaired by maintenance. Employee G stated that he had called maintenance to report the problem. The rails were then changed and did not touch the floor, but still had some unstable movement. The employee stated he had been working in the facility five years and the rails had been the same since he began working here. He stated that he tightened them as necessary after the rails became loose from usage. He stated the policy was to notify maintenance for any problem that needs fixing, but he did not consider this a problem, and did not report them as unstable. He stated he did not know of any resident falling because of side rails or of any injury related to side rails. 5. The survey team conducted an inspection of all beds and side rails concluding on 3/20/12. The inspection revealed 51 beds with adjustable half rails that were observed to be unstable with excessive movement (100B, 101A, 103A, 104B, 106A, 107A, 107B, 109B, 110A, 112B, 113A, 115A, 115B, 120A, 122B, 123A, 125A, 125B, 127A, 128A, 129A, 131B,200B, 201A, 202B, 203A, 203B, 204A, 206A, 206B, 209A, 213A, 217A, 218A, 219A 221A, 222A, 222B, 223A, 224A, 225A, 225B, 228A, 229B, 230A, 231A, 301A, 302A, 400P, 401B, and 404A). Of the 51 observed beds, 45 beds were resident-occupied (100B, 101A, 103A, 104B, 106A, 107A, 107B, 109B, 110A, 113A, 115A, 115B, 120A, 122B, 123A, 125A, 125B, 127A, 128A, 129A, 131B,200B, 201A, 202B, 203A, 203B, 204A, 206A, 206B, 209A, 213A, 219A 221A, 222A, 222B, 223A, 228A, 229B, 230A, 231A, 301A, 302A, 400P, 401B, and 404A). 6. On 3/20/12 at 8:35am, the Nursing Home Administrator (NHA) and Assistant Nursing Home Administrator (ANHA) requested a meeting. The NHA stated that full rails were eliminated facility-wide approximately six to seven years ago. Half rails were purchased and installed at that time. She noted that there are also newer beds that have rails that are a permanent part of the bedframe. Maintenance and Housekeeping were requested to do an audit last night (3/19/12) to check security of the half-rails currently in place. She stated that one set was changed out in 222B and replaced with new rails of the same type. She did not have a record of how many rails required adjustment during the audit. She stated that to her knowledge no injury has occurred in relation to side rail use or failure. She was asked if any incidents had occurred involving side rails that did not result in injury, such as rails collapsing or coming off the bed. She stated there were no incidents of which she was aware. She noted that a Maintenance log was kept of staff requests regarding issues with side rails. 7. Random interviews were conducted on 3/20/12 with five licensed staff nurses and eight Certified Nursing Assistants (CNA) working day and evening shifts. Staff members # I, J, K, L, M, E, N, O, P, Q, R, S, and T were asked if they had any knowledge of any side rail issues. Staff members interviewed were not aware of any falls, accidents or injuries involving side rails. One CNA referenced " minor problems " with side rails, but would not offer specifics. Staff members were aware of the existence of a Maintenance Log where requests could be entered for repairs. Staff noted that the Maintenance Supervisor was on-call to respond immediately for emergency needs. Non-emergency repairs were usually completed within 24 hours. All staff interviewed indicated that periodic adjustments to tighten loose side rails were done on a routine basis. If there were problems making the rails " tight " , Maintenance would then be notified. 8. An interview was conducted with the Maintenance Supervisor at 3:45 pm on 3/20/12. He was asked to describe the process for reporting requests for equipment repairs and how the issues get resolved. He stated that there was a Maintenance Log book on each unit. He replied, " If nurses stop me in the hall I go fix what they need fixed. When it is done I date it and sign it in each log book on the unit. I check the log books each morning and at least three times a day. If it ' s serious, they will come to the door and tell us. " He was asked what information he could provide regarding bed side rails. He stated, " I have been here two years and that is what they ordered before and I still order them for replacements. I have not considered using any different kind of side-rails. " When asked who monitors the side rails and how often, he replied, " We check side rails at least once a month and housekeeping looks at rooms when they are in there, and CNA ' s look and use the side rails. " He noted that the CNAs tightened the adjustment knobs themselves when needed and did not always notify maintenance. 9. On 3/21/12 at 9:00 am, the NHA stated that she had read all reports back to the most recent annual survey in August 2011. She stated she did not find any references involving side rails and residents or staff. She also stated she had met with all managers on 3/20/12 and asked if they had any knowledge of events involving side rails. She stated all managers denied knowledge of any such incidents. She noted that the ADON was not in the facility when the managers meeting was held. The NHA stated she remained in the facility to speak with the 11-7 staff regarding timely reporting of incidents, as well as procedures for maintenance requests. She noted that at that time, she was informed by Employee " H " that Resident #7 had sustained a fall in December 2011 that involved a side rail separating from the bed. Employee " H " stated that the resident was apparently startled when the CNA called her name, turned and grabbed the side rail as she began to fall. The CNA noted that the side rail came away from the bed and fell to the floor with the resident. When the NHA asked Employee H how the side rail was repaired, the CNA stated that the side rail was not broken. The CNA told the NHA that another CNA picked up the side rail parts and replaced the side rail on the bed frame, using the black knob to tighten it on. The NHA noted that no maintenance report was made, as the staff indicated that there had been no equipment failure that required repair. 10. The facility policy titled, " Maintenance Schedules, " dated January 2005, page 3-10 from the Plant Operations Policy and Procedure Manual, was reviewed on 3/21/12. Item number one under the sub-heading of Procedure stated that the maintenance director is responsible for following a schedule provided to assure that the buildings, grounds and equipment are maintained in a safe and operable manner. The facility policy, titled " Maintenance Service, " dated January 2005, pages 3-11 from the Plant Operations Policy and Procedure Manual, was reviewed on 3/21/12. Item number one under sub-heading Procedure stated that the maintenance department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times. Item 2b listed the maintenance function to maintain the building in good repair and free from hazard. Item 2f listed the maintenance function to establish priorities in providing repair service. Item 2i listed the maintenance function to provide routinely scheduled maintenance service to all areas. Item 2j listed the maintenance function to include others that may become necessary or appropriate. The facility policy titled, " Work Orders, " dated January 2005, page 3-16 from the Plant Operations Policy and Procedure Manual, was reviewed 3/21/12. It stated that maintenance work orders shall be completed in order to establish a priority of maintenance service. The following numbered items were located under subheading Procedure. Item 1 noted that work orders must be filled out and forwarded to the maintenance director. Item 2 noted that it shall be the responsibility of the department directors or any staff member identifying needed repairs to fill out and forward such work orders to the maintenance director. Item 3 noted that a supply of work orders is maintained at each nurses ' station. Item 4 noted that work orders should be placed in the appropriate file basket for daily pick-up. Item 5 noted that emergency requests will be given priority in making necessary repairs. 11. The maintenance log was reviewed on 3/21/12 for maintenance requests recorded since the last annual survey in August, 2011. Three requests related to side rails were noted during that time period. On 10/13/11, a request was noted for room [ROOM NUMBER]P that stated " Right side rail came off. " On 3/14/11, a request was noted for room [ROOM NUMBER]A that stated " Bed rail broken, please fix bed ASAP " . On 3/13/12, a request was noted for room [ROOM NUMBER]B that stated " Right bed rail hard to come down. " 12. A second interview was conducted with the Maintenance Director at 12:30 pm on 3/22/12 regarding three reports of broken side rails noted on the Maintenance Log. The director was asked how the side rail in room [ROOM NUMBER]B was broken. He could not recall specifics of the request made on 3/13/12, but that the rail was repaired or removed. He was next asked about the broken side rail on 10/14/11. The director stated that a former maintenance staff person repaired it and that he could not remember how it was resolved. He was asked about the right side rail that came off a bed as reported on 10/13/11. He responded that the repair was done by a former maintenance staff person. He stated he thought that the bed rail was replaced. He stated he had not noticed any trends about broken side rails nor complaints from nursing staff. He noted that if the bed rails were broken they were replaced, but no one had any issue with them. The maintenance director stated he does a monthly audit of the room environment including checking the bed. He stated he checks the whole bed, including the side rails to make sure they are tight. He was asked if any of the audits had shown any problems and he replied "yes, the side rails." He further stated that the brace for the adjustable side rails frequently gets bent and has to be replaced. The maintenance director stated he participates in the quality assurance committee where he discusses things such as vents, water temperatures, the kitchen ventilation hood, and life safety rounds. He was asked if he has trained the nursing staff regarding how to adjust or tighten the side rails. He stated that when nursing staff would call to report a loose side rail, he would come in and show them how to tighten the side rails. The maintenance director stated that he does not provide formal training at orientation or in-service on how to make adjustments to the side rails. 13. On 03/20/12 at 4:25 p.m. a telephone interview was conducted with the medical supply company supplying the T 100 side rail to this facility. The representative informed the surveyor that the bed frames identified by the facility maintenance supervisor were no longer manufactured. The representative stated that the T 100 or T 120 models were not recommended for the bed frames identified by the facility. 14. On 03/20/12 at 4:40 p.m. a telephone interview was conducted with the representative for the manufacturer of the T 100 and T120 side rails. The surveyor was informed that both the T100 and T120 side rail models were made specifically for a home care bed frame made by this manufacturer. 15. An interview was conducted with the NHA as part of the Quality Assessment and Assurance (QAA) Review at 2:15pm on 3/22/12. The Corporate Regional Nurse Consultant and the DON were also in attendance. The NHA confirmed that the QAA committee met monthly and provided sign-in sheets for all meetings held since the last annual survey in August, 2011. She noted that the committee had an established agenda and any new concerns were added as needed. When asked how concerns were identified, the NHA noted that the facility had a Quality Assurance policy manual. She stated that each department head completed a checklist prior to the meeting and then the lists were discussed at the meeting to identify concerns. In addition, any staff member could bring concerns to the committee directly or address their concerns at an Employees meeting, also held monthly. She noted that tracking and trending was done as indicated and referred to the QAA tracking related to falls. She provided graphs of data entered to track falls in relation to factors including time of day, location and staffing. She noted that side rails were not identified as a factor in the tracking of falls. The NHA stated there had been no prior tracking of side rails in any form. She stated that she was unaware, prior to 3/21/12, that any problems existed with side rails in the facility. 16. Immediate Jeopardy was removed on 03/22/12 at 10:00 a.m. and the scope and severity reduced to an E as a result of information provided by the NHA and the Corporate Nurse Consultant. The NHA stated that the Medical Director was notified of the faulty side rails and the correction plan on 3/21/12. The Corporate Nurse Consultant stated that the facility completed a side rail assessment for all facility residents on 03/21/12. Residents who still required side rails were placed in beds with stable side rails that were securely attached to the bed frame. Attending physicians were contacted for new side rail orders as indicated and physicians and family members of affected residents were notified of bed changes. She stated that each side rail in the facility was observed and assessed by the administration staff and all T100 model rails, numbering 39 sets, were removed from the facility. This was verified by surveyor team observations on 3/22/12. The NHA stated that the maintenance director received individualized in-service pertaining to maintenance rounds and the reporting process for maintenance repairs. Documents were presented to the surveyors that all staff had received re- education on safety reporting including how to identify faulty equipment and what actions to take following identification. The NHA stated that the QAA committee would add additional oversight to the scheduled maintenance procedure with room rounds to include weekly checks for one month, monthly checks for three months and then every three months ongoing. She stated that the facility policy called for different identified key personnel to conduct the additional room checks. She stated there would be on-going discussion and monitoring of side rail stability in the monthly QAA committee meetings.

Based on observation, facility document review and administrative staff interviews the facility failed to utilize the Quality Assurance Committee to assure all systems within the facility, including maintenance, were functioning with the common goal of resident safety and wellbeing. The committee members failed to identify broken and unstable side rails and trends in side rail instability throughout the building. The trends were identified by staff at the bedside making frequent adjustments to tighten and realign the rails. At least one member of the committee, the maintenance director, was aware of the need for staff intervention with the rails on a regular basis. The facility failed to identify and ensure the safety for resident use of 51 of 117 beds with side rails which were malfunctioning or potentially unsafe and not manufactured for the model beds used (100 hall: 100 B; 101 A; 103 A; 104 B; 106 A; 107 A;107 B;109 B;110 A; 112B; 113 A;115 A; 115 B; 120 A;122 B; 123 A;125A;125 B;127 A;128 A; 129 A, and 131 B: 200 hall: 200 B; 201 A; 202 B; 203 A; 203 B;204 A;206 A; 206 B; 209 A; 213 A; 217 A; 218A; 219 A; 221 A; 222 A; 222 B; 223 A; 224A; 225 A; 225 B; 228 A; 229 B; 230 A; and 231 A.:300 hall: 301 A and 302 A and 400 hall: 400, P (Private); 401 B; and 404 A) and three (Residents # 3, #7, and # 55) of 45 sampled residents who occupied the beds and who presented with compromised physical or cognitive conditions which posed a threat to continued use of the resident care equipment. These findings resulted in the findings of Immediate Jeopardy which was removed at 10:00 a.m. on March 22, 2012, after the facility had all the T 100 model half rails removed from the building and replaced. The scope and severity was reduced to E. Findings include: 1. An interview was conducted with the NHA as part of the Quality Assessment and Assurance (QAA) Review at 2:15pm on 3/22/12. The Corporate Regional Nurse Consultant and the DON were also in attendance. The NHA confirmed that the QAA committee met monthly and provided sign-in sheets for all meetings held since the last annual survey in August, 2011. She noted that the committee had an established agenda and any new concerns were added as needed. When asked how concerns were identified, the NHA noted that the facility had a Quality Assurance policy manual. She stated that each department head completed a checklist prior to the meeting and then the lists were discussed at the meeting to identify concerns. In addition, any staff member could bring concerns to the committee directly or address their concerns at an Employees meeting, also held monthly. She noted that tracking and trending was done as indicated and referred to the QAA tracking related to falls. She provided graphs of data entered to track falls in relation to factors including time of day, location and staffing. She noted that side rails were not identified as a factor in the tracking of falls. The NHA stated there had been no prior tracking of side rails in any form. She stated that she was unaware, prior to surveyor identification 3/21/12, that any problems existed with side rails in the facility. 2. Review of the maintenance log book revealed two entries in October, 2011. The first entry, dated 10/13/11, stated a right side rail came off the bed in room [ROOM NUMBER], P. An employee no longer with the facility signed it as repaired the same day. On 10/14/11, an entry stated the bed rail in room [ROOM NUMBER]A was broken. The entry stated, "please fix ASAP." The repair was noted as completed on the same date. On 10/26/11, the QA committee sign in sheet did not contain the signature of the maintenance director. On 11/23/11, the QA committee sign in sheet did not contain the signature of the maintenance director. There was no evidence to support that an adequate system of identification and the reporting of safety concerns with faulty safety equipment, such as side rails, was in place and utilized by the QA committee for tracking, trending and actions as indicated. 3. A handwritten note, referencing a fall for Resident #7 on 12/15/11, revealed that resident #7 fell in her room and the side rail she was holding for stability, separated from the bed frame and she fell holding on to the disconnected side rail. Review of the closed medical record for resident #7, a [AGE] year old female, found that she was readmitted to the facility on [DATE] after hospitalization for a change in mental status. She was recovering from an injury that prevented her from bearing weight. Per the attending physician's statement on 12/12/11, she was recovering "nicely" and anticipated returning to her home and living independently. Another physician reported that a recent CT scan of the brain was "unrevealing". The resident was hosptalized on [DATE] to evaluate the change of mental status. The dictating hospital physician who also attended her in the facility, recalled her as very alert and vibrant. On page 2 of 4 of the physician history, he stated that the review of symptoms was very limited because she was "markedly impaired with her mental function." The primary admitting [DIAGNOSES REDACTED]. Review of a fall prevention care plan, initiated 11/03/11, stated that she had impaired balance and mobility. Approach #6 stated "side rails as enabler". Another care plan, initiated 11/03/11, stated she had a self-care deficit. It was updated on 12/30/11, after the fall, stating she had increased weakness, decreased vision, and cognition changes. A Nursing Admission Information form, dated 12/15/2011, contained a hand written note stating that at 4:30 p.m. the resident was admitted to her room by stretcher. The nurse documented that she was at risk for falls and had confusion at times. The nurse wrote that "rails x 2 were up" (upward arrow) in bed for positioning and independence. She was oriented to herself only, not time or place. The assessment stated she required supervision with bed mobility; one person assistance with transfer; and dependent on one person assistance for walking, toileting, hygiene, and bathing. The fall risk score was 24, with scores over 10 indicating high risk. The interim care plan, dated 12/15/11, but no time specified, stated she was to have a bed alarm and positioning devices. There were five additional interventions A nurse's note at 7:45 (a.m. or p.m. not written), the same nurse wrote that the resident was on the floor, having hallucinations that someone was smoking in her room and "standing over her and she had to move". She was assisted back to bed after the nurse checked her for injury. She denied pain. There was no further documentation on this page. Review of the facility provided documentation related to the fall of 12/15/11, involving resident #7, revealed four documents: a. One form, dated 12/15/11, stated she had poor safety awareness and interventions were in place prior to the fall including safety foot ware, call light in reach, water in reach, and assistive devices for ambulation. Section 1 stated that the care plan was revised to include a bed alarm and verbal cuing for the resident to use the call light. b. A communication to physician form stated that a resident fall had occurred with resident #7. The back of the form stated that at 7:30 p.m. on 12/15/11 the nurse was notified by the aide that the resident was sitting on the floor. The fall was witnessed by the aide and described to the nurse. The resident was alert and confused, again stating that someone was smoking in the room and she could not tolerate smoking. The resident denied pain and was re-educated for use with the call bell. A personal bed alarm was placed on the bed. There were two additional nurses' notes, 12/16 and 12/17/11, stating that the resident had no pain or injuries. c. An undated hand written statement by Employee H stated that she, the employee, was working with another resident, walked out into the hall, glanced over and saw "her (resident #7) standing on the right side of her bed holding on to her side table". The employee wrote that she "yelled out her (the resident ' s) name" and ran into the room. The resident turned to her left to look at the employee and began to fall. She grabbed the side rail "to catch herself" but the rail "broke off her bed and she fell right on her bottom." The employee called for help. This document did not contain this resident's name or the date of the occurrence. The facility NHA ANHA, and DON stated on 03/21/12 that the document belonged with this investigation for resident #7, concerning the fall on 12/15/11. d. A second hand written statement by the NHA and ANHA was dated 03/20/12. It stated that Employee H verbalized to them that the side rail detached from the rail. Employee H stated that the rail was reattached and tightened by another employee and functioning properly. 4. Review of the Quality Assurance Agenda, dated 12/21/11, revealed a hand written entry stated no reported incidents with safety. Review of the sign in sheet for the meeting minutes revealed that the maintenance director did attend the meeting and signed in. Review of the sign in sheet for 01/18/12 revealed that the maintenance director did not sign in to this meeting. On 02/15/12 the maintenance director did sign in to the meeting. There was no evidence that the unstable side rails were discussed with the committee for evaluation and tracking. 5. An interview with Employee E, an aide, on 3/20/12 at 4:45 p.m. revealed that she stated that there had been minor problems with side rails since she had started working at the facility, four months ago. She also stated that the standard procedure was to tighten the rails using the black knob and if that did not work then there was a maintenance log book to enter the information in and that maintenance took care of the problem within 24 hours or less. She stated that, in addition to notifying maintenance, that nursing was also notified. She had no formal training with how to tighten side rails. 6. An interview was conducted with the Maintenance Supervisor at 3:45 pm on 3/20/12. He was asked to describe the process for reporting requests for equipment repairs and how the issues get resolved. He stated that there was a Maintenance Log book on each unit. He replied, " If nurses stop me in the hall I go fix what they need fixed. When it is done I date it and sign it in each log book on the unit. I check the log books each morning and at least three times a day. If it ' s serious, they will come to the door and tell us. " He was asked what information he could provide regarding bed side rails. He stated, " I have been here two years and that is what they ordered before and I still order them for replacements. I have not considered using any different kind of side-rails. " When asked about the monitoring of the side rails he replied, "We check side rails at least once a month and housekeeping looks at rooms when they are in there, and aides look and use the side rails." He stated that he was aware that the staff tightened the adjustment knobs themselves when needed and did not always notify maintenance. 7. A second interview was conducted with the Maintenance Director at 12:30 pm on 3/22/12 regarding the three reports of broken side rails noted on the Maintenance Log. The director was asked how the side rail in room [ROOM NUMBER]B was broken. He could not recall specifics of the request made on 3/13/12, but that the rail was repaired or removed. He stated that the broken side rail on 10/14/11 was repaired by a former maintenance staff person and that he could not remember how it was resolved. He was asked about the right side rail that came off a bed as reported on 10/13/11. He responded that the repair was also done by a former maintenance staff person. He stated he thought that the bed rail was replaced. He stated he had not noticed any trends about broken side rails nor complaints from nursing staff. Committee. He noted that if the bed rails were broken they were replaced, but no one had any issue with them. The maintenance director stated he does a monthly audit of the room environment including checking the bed. He stated he checks the whole bed, including the side rails to make sure they are tight. He was asked if any of the audits had shown any problems and he replied "yes, the side rails." He stated further that the brace for the adjustable side rails frequently bent and had to be replaced. He was asked if he has trained the nursing staff regarding how to adjust or tighten the side rails. He stated that when nursing staff would call to report a loose side rail, he would come in and show them how to tighten the side rails. The maintenance director stated that he did not provide formal training at orientation or in-service on how to make adjustments to the side rails. The maintenance director stated he participated in the quality assurance committee where he discusses things such as vents, water temperatures, the kitchen ventilation hood, and life safety rounds, but did not bring the topic of side rails to the committee. 8. During observations in the hallway on 03/19/12 at 2:29 p.m., two surveyors observed resident #55, in the window bed, with his feet and legs hanging off the bed. The call light was not on. The right upper bed half side rail was collapsed inward to the resident ' s chest and tilted at an abnormal angle toward the ceiling. The resident was gripping the rail with his left hand. The surveyors entered the room and stood by the bed while calling for assistance. Employee C entered the room and assisted the resident to a safe position in the bed. She then realigned the side rail and, without cueing or assistance, tightened the side rail using a black knob in the center of the rail. Employee C later stated that she did not consider this an abnormal finding of equipment failure and did not report this to the maintenance department. Review of the MDS for resident #55, dated 01/3/12, section C, cognitive patterns, revealed that he required verbal cues to recall the words sock and blue. He could not recall the word bed. The summary section C0500 recorded 99, unable to complete the interview. Section C1000 stated that he was moderately impaired for daily decision making. Section G functional status stated he required extensive assistance and was totally dependent for locomotion off the unit. He required the assistance of two staff members for mobility including bed mobility and transfers. An interview with Employee D on 3/19/12 at 4:45 PM confirmed that resident #55 used side rails for mobility. On inspection the right rail was loose, and the left rail was also loose. Even after being tightened down, the right rail still rocked front to back. Employee D stated that the rails were ordered separately from the frames. The rails observed were T shaped with black knob designed to tighten the rails, later identified as T100 model. Continued record review for resident #55, revealed that he was admitted to the facility on [DATE] from the hospital, per the face sheet. Review of the hospital physician ' s consultation, dated 2/5/2011, revealed concerns about his continued deterioration with manifestations of increased confusion, an increased level of agitation, and a loss of muscle tone related to the diseases. Per the attending physician ' s visit form, dated 10/12/11, the resident was weak and lethargic. He had [DIAGNOSES REDACTED]. A hand written entry, dated 01/27/12, stated that resident #55 was " lowered to floor. " A facility summary, dated 01/13/12 at 9:45 p.m., stated that the nurse was notified by an aide, Employee F, that the resident was on the floor. The aide stated on the form that she was in the room but did not see the fall. The conclusion was that the resident stood, fell , and the aide could not get to him. The resident remained at high risk for falls and, upon his return to the facility therapy, was initiated. Care plans were initiated on 02/25/11 for Resident # 55: a. Impaired Cognition related to multiple diseases and impulsiveness with safety awareness. Multiple interventions included minimizing or eliminating environmental hazards. b. Care Deficit including mobility related to disease processes. An intervention included assisting with turning and repositioning to enhance circulation and to provide adaptive and safety equipment as needed. c. Fall Precautions related to a history of falls, impaired balance and mobility. Intervention and approaches included provide and monitor use of adaptive devices, verbal cues, assist with transfer and ambulation, provide call light and rehabilitation services as ordered. 9. On 03/19/2012 at 4:00 p.m. an observation was made of resident #3 ' s bed. The side rails were T style and were not locked in placed. The rails moved in a clock like motion and stopped when the side of the rails reached the floor. This was an abnormal finding for side rail stability. The resident was not in the bed at the time of this observation. On 03/19/2012 an interview was conducted with resident #3 at 4:40 p.m. The resident revealed that she used the side rails for positioning to get comfortable and to assist with getting out of bed. She used a wheelchair for mobility. On 03/20/2012 at 9:30 A.M. a second observation was made of the side rails in resident #3 ' s room. The resident was seated in her wheelchair at the time. The rails, again, were unstable and rocked back and forth, head to foot, and laterally, side to side, along the bed and extended to the floor, in an abnormal position. The aide stated the rails were used by the resident to assist with support to a standing position. Per the MDS for resident #3, dated 02/08/12, section C, related to recall, and revealed the resident required verbal cues to recall sock and blue. She could not recall the word bed. The mood section interview stated she had a severity score of 5. The functional status section, Section G, stated she required extensive assistance with mobility including bed mobility and transfers. She required the assistance of one staff member for all care. Section G0300 stated she was not steady and only able to stabilize with human assistance. The section D0350 related to safety was blank. Section 1 of the active [DIAGNOSES REDACTED]. 10. On 03/20/2012 at 4:45 P.M., Employee G called the surveyor into resident #3 ' s room to demonstrate to the surveyor that the bed had been repaired by maintenance. Employee G stated that he had called maintenance to report the problem. The rails were then changed and did not touch the floor, but still had some unstable movement. The employee stated he had been working in the facility five years and the rails had been the same since he began working here. He stated that he tightened them as necessary after the rails became loose from usage. He stated the policy was to notify maintenance for any problem that needs fixing, but he did not consider this a problem, and did not report them as unstable. He stated he did not know of any resident falling because of side rails or of any injury related to side rails. 11. On 03/20/12 at about noon the survey team members confirmed multiple concerns of wobbly and unsecure side rails throughout the building. It was determined that 51 of the 117 beds currently in the facility contained the wobbly, easily displaced and unsecure side rails (100B, 101A, 103A, 104B, 106A, 107A, 107B, 109B, 110A, 112B, 113A, 115A, 115B, 120A, 122B, 123A, 125A, 125B, 127A, 128A, 129A, 131B,200B, 201A, 202B, 203A, 203B, 204A, 206A, 206B, 209A, 213A, 217A, 218A, 219A 221A, 222A, 222B, 223A, 224A, 225A, 225B, 228A, 229B, 230A, 231A, 301A, 302A, 400P, 401B, and 404A). Of these 51 beds, 45 were occupied by residents (100B, 101A, 103A, 104B, 106A, 107A, 107B, 109B, 110A, 113A, 115A, 115B, 120A, 122B, 123A, 125A, 125B, 127A, 128A, 129A, 131B,200B, 201A, 202B, 203A, 203B, 204A, 206A, 206B, 209A, 213A, 219A 221A, 222A, 222B, 223A, 228A, 229B, 230A, 231A, 301A, 302A, 400P, 401B, and 404A). Of the 45 occupied beds with the T style of half side rails with a black knob in the middle, 39 were observed by surveyors to be loose with excessive movement ranging from movement toward the mattress, away from the mattress, and/or a rocking motion from the head of the bed to the foot of the bed. Some rails were observed to have an extensive rocking motion to a degree almost touching the floor, such as room [ROOM NUMBER] by the door. The use of these rails ranged from residents receiving rehabilitation services using the rails for bed positioning to long term care residents using the bed rails for safety and stability. Per staff interviews, twenty three residents identified with confusion and diminished cognitive capacity were in the beds with the affected rails, but were unable to provide information regarding their use of the rails. 12. Random interviews were conducted from 2:00-4:00 p.m. on 3/20/12 with five licensed staff nurses and eight Certified Nursing Assistants (CNA) working day and evening shifts. Staff members # I, J, K, L, M, E, N, O, P, Q, R, S, and T were asked if they had any knowledge of any side rail issues. Staff members interviewed were not aware of any falls, accidents or injuries involving side rails. One CNA referenced "minor problems" with side rails, but would not offer specifics. Staff members were aware of the existence of a Maintenance Log where requests could be entered for repairs. Staff noted that the Maintenance Supervisor was on-call to respond immediately for emergency needs. Non-emergency repairs were usually completed within 24 hours. All staff interviewed indicated that periodic adjustments to tighten loose side rails were done on a routine basis. If there were problems making the rails " tight," maintenance would then be notified. 13. 8. On 03/20/12 at 4:25 p.m. a telephone interview was conducted with the medical supply company supplying the T 100 side rail to this facility. The representative informed the surveyor that the bed frames identified by the facility maintenance supervisor were no longer manufactured. The representative stated that the T 100 or T 120 models were not recommended for the bed frames identified by the facility. 14. On 03/20/12 at 4:40 p.m. a telephone interview was conducted with the representative for the manufacturer of the T 100 and T120 side rails. The surveyor was informed that both the T100 and T120 side rail models were made specifically for a home care bed frame made by this manufacturer. 15. On 03/22/12 at 11:27 a.m., the Director of Therapy was interviewed. The surveyor asked the Director of Therapy if the therapy staff had any input regarding the type of side rails used for residents. She stated that if there was a reason a resident needed a certain type of side rail, they, therapy, could recommend it. She stated that she was not aware of any problems with any side rails. The surveyor asked if therapy had any input for the placement or position of resident ' s side rails on the bed. She indicated that if therapy had specific recommendations, they would let the facility staff know. The Director of Therapy was aware of side rails that were loose and she stated that all of the side rails have some " play". She stated further that the therapy staff knew how to tighten the rails and have tightened the side rails in the past. She stated if they can't tighten them, they then notified the Maintenance Director and there was a book to log the issue. The surveyor asked if the therapy department had any input into the reassessment of the new side rails installed on the bed on 03/21/12 and 03/22/12 and she stated they were not asked for any recommendations on the new side rails, but she assisted with the installation of the new side rails. 16. On 03/22/12 at 11:53 a.m., an interview was conducted with one of the facility's occupational therapist (OT). The surveyor asked the OT if she demonstrated to residents the use of side rails, and she replied that if they need it, therapy would show them how to use the side rails. She was asked if she ever had to tighten the side rails and she replied that some were loose, but she personally had not tightened them. The surveyor asked if she reported any of the side rails being loose and the OT responded "no." She stated further that she doesn ' t know how to tighten the "T"-shaped rails with the knob. The therapist stated that she would report needed repairs to maintenance. The OT stated further that she was not aware of any problems with side rails coming off the bed or breaking. 17. On 03/22/12 at 2:15 p.m., the NHA stated she would begin tracking equipment failure and that the maintenance director had been reeducated with his responsibilities to the QA committee. 18. Immediate Jeopardy was removed on 03/22/12 at 10:00 a.m. and the scope and severity reduced to an E as a result of information provided by the NHA and the Corporate Nurse Consultant. The NHA stated that the Medical Director was notified of the faulty side rails and the correction plan on 3/21/12. The Corporate Nurse Consultant stated that the facility completed a side rail assessment for all facility residents on 03/21/12. Residents who still required side rails were placed in beds with stable side rails that were securely attached to the bed frame. Attending physicians were contacted for new side rail orders as indicated and physicians and family members of affected residents were notified of bed changes. She stated that each side rail in the facility was observed and assessed by the administration staff and all T100 model rails, numbering 39 sets, were removed from the facility. This was verified by surveyor team observations on 3/22/12. The NHA stated that the maintenance director received individualized in-service pertaining to maintenance rounds and the reporting process for maintenance repairs. Documents were presented to the surveyors that all staff had received re- education on safety reporting including how to identify faulty equipment and what actions to take following identification. The NHA stated that the QAA committee would add additional oversight to the scheduled maintenance procedure with room rounds to include weekly checks for one month, monthly checks for three months and then every three months ongoing. She stated that the facility policy called for different identified key personnel to conduct the additional room checks. She stated there would be on-going discussion and monitoring of side rail stability in the monthly QAA committee meetings.

Based on observations, interviews with the maintenance director, nursing and therapy staff, and the Nursing Home Administrator (NHA), and record reviews, the facility failed to identify and ensure the safety for resident use of 51 of 117 beds with side rails which were malfunctioning or potentially unsafe and not manufactured for the model beds used (100 hall: 100 B; 101 A; 103 A; 104 B; 106 A; 107 A;107 B;109 B;110 A; 112B; 113 A;115 A; 115 B; 120 A;122 B; 123 A;125A;125 B;127 A;128 A; 129 A, and 131 B: 200 hall: 200 B; 201 A; 202 B; 203 A; 203 B;204 A;206 A; 206 B; 209 A; 213 A; 217 A; 218A; 219 A; 221 A; 222 A; 222 B; 223 A; 224A; 225 A; 225 B; 228 A; 229 B; 230 A; and 231 A.:300 hall: 301 A and 302 A and 400 hall: 400, P (Private); 401 B; and 404 A) and three (Residents # 3, #7, and # 55) of 45 sampled residents who occupied the beds and who presented with compromised physical or cognitive conditions which posed a threat to continued use of the resident care equipment. These findings resulted in the findings of Immediate Jeopardy which was removed at 10:00 a.m. on March 22, 2012, after the facility had all the T 100 model half rails removed from the building and replaced. The scope and severity was reduced to E. Findings include: 1. During observations in the hallway on 03/19/12 at 2:29 p.m., two surveyors observed resident #55, in the window bed, with his feet and legs hanging off the bed. The call light was not on. The right upper bed half side rail was collapsed inward to the resident ' s chest and tilted at an abnormal angle toward the ceiling. The resident was gripping the rail with his left hand. The surveyors entered the room and stood by the bed while calling for assistance. Employee C entered the room and assisted the resident to a safe position in the bed. She then realigned the side rail and, without cueing or assistance, tightened the side rail using a black knob in the center of the rail. Employee C later stated that she did not consider this an abnormal finding of equipment failure and did not report this to the maintenance department. Review of the MDS for resident #55, dated 01/3/12, section C, cognitive patterns, revealed that he required verbal cues to recall the words sock and blue. He could not recall the word bed. The summary section C0500 recorded 99, unable to complete the interview. Section C1000 stated that he was moderately impaired for daily decision making. Section G functional status stated he required extensive assistance and was totally dependent for locomotion off the unit. He required the assistance of two staff members for mobility including bed mobility and transfers. An interview with Employee "D" on 3/19/12 at 4:45 PM confirmed that resident #55 used side rails for mobility. On inspection the right rail was loose, and the left rail was also loose. Even after being tightened down, the right rail still rocked front to back. Employee D stated that the rails were ordered separately from the frames. The rails observed were T shaped with black knob designed to tighten the rails, later identified as T100 model. Continued record review for resident #55, revealed that he was admitted to the facility on [DATE] from the hospital, per the face sheet. Review of the hospital physician ' s consultation, dated 2/5/2011, revealed concerns about his continued deterioration with manifestations of increased confusion, an increased level of agitation, and a loss of muscle tone related to the diseases. Per the attending physician ' s visit form, dated 10/12/11, the resident was weak and lethargic. He had [DIAGNOSES REDACTED]. A hand written entry, dated 01/27/12, stated that resident #55 was " lowered to floor. " A facility summary, dated 01/13/12 at 9:45 p.m., stated that the nurse was notified by an aide, Employee F, that the resident was on the floor. The aide stated on the form that she was in the room but did not see the fall. The conclusion was that the resident stood, fell , and the aide could not get to him. The resident remained at high risk for falls and, upon his return to the facility, therapy, was initiated. Care plans were initiated on 02/25/11 for Resident # 55: a. Impaired Cognition related to multiple diseases and impulsiveness with safety awareness. Multiple interventions included minimizing or eliminating environmental hazards. b. Care Deficit including mobility related to disease processes. An intervention included assisting with turning and repositioning to enhance circulation and to provide adaptive and safety equipment as needed. c. Fall Precautions related to a history of falls, impaired balance and mobility. Intervention and approaches included provide and monitor use of adaptive devices, verbal cues, assist with transfer and ambulation, provide call light and rehabilitation services as ordered. 2. On 03/19/12 at 4:38 p.m. an interview with the Assistant Director of Nursing/Unit Manager for the North wing (ADON) revealed that she was aware of frequent findings of loose side rails and the need to periodically tighten them using the black knob in the center of a certain type of half rail, commonly used throughout the facility. She stated " they are all like that. " She stated she was aware of one situation with a resident fall, where the half rail separated from the frame. She denied having firsthand knowledge of the incident, stating she did not work that day, but recalled that it occurred " about one month ago. " (This correlated to a fall of resident #7 in December 2011). She stated she identified 39 of the 60 beds on the north wing having the type of side rails that became loose and wobbly, and reported her concerns to the admission coordinator, who was working on a project regarding the purchase of new equipment. She stated she was unsure if the NHA was aware of her concerns. A large amount of instability was identified with beds 223 door and 229 window at this time. Bed 229, by the window, had side rails that rocked head to foot with significant displacement toward the mattress when tested by the surveyor. Both beds contained the T shaped half side rails, later identified as T 100. Review of the closed record for resident #7, revealed that the MDS completed on 11/25/11, documented the BIMS (Brief Interview for Mental Status) score was 13. The staff assessment was not conducted as she was able to complete the interview. The section C0700 for short term memory was blank. Section C0800 for long term memory was blank. Section C0900 for recall ability was blank. The section regarding functional status, Section G, indicated bed mobility, transfers, daily care, locomotion on and off the unit, and toileting needed the extensive assistance of one staff member. The section regarding transitions with surface to surface transfers required the stabilization with a human assistant. She was not steady. She was [AGE] years old. Continued review of the closed medical record for resident #7, a [AGE] year old female, revealed that she was readmitted to the facility on [DATE] after hospitalization for a change in mental status. Per the hospital physician's history and physical, dated 12/12/11, the resident had resided in this facility for the prior several weeks while receiving therapy and recovering from a distal right lower leg fracture. The injury prevented her from bearing weight. Per the physician, she was recovering "nicely" and anticipated returning to her home and living independently. Another physician reported that a recent CT scan of the brain was "unrevealing." The resident was hospitalized to evaluate the change of mental status. The dictating hospital physician who also attended her in the facility, recalled her as very alert and vibrant. On page 2 of 4 the physician history stated that the review of symptoms was very limited because she was "markedly impaired with her mental function." The primary admitting [DIAGNOSES REDACTED]. Review of a fall prevention care plan, initiated 11/03/11, stated that she had impaired balance and mobility. Approach #6 stated "side rails as enabler." Another care plan, initiated 11/03/11, stated she had a self-care deficit. It was updated on 12/30/11, after the fall, stating she had increased weakness, decreased vision, and cognition changes. A Nursing Admission Information form, dated 12/15/2011, contained a hand written note stating that at 4:30 p.m. the resident was admitted by stretcher. The nurse documented that she was at risk for falls and had confusion at times. The nurse wrote that "rails x 2 were up" (upward arrow) in bed for positioning and independence. She was oriented to herself only, not time or place. The assessment stated she required supervision with bed mobility; one person assistance with transfer; and dependent on one person assistance for walking, toileting, hygiene, and bathing. The fall risk score was 24, with scores over 10 indicating high risk. The interim care plan, dated 12/15/11, but no time specified, stated she was to have a bed alarm and positioning devices. There were five additional interventions. A 12/15/2011 nurse's note at 7:45 (a.m. or p.m. not written), the same nurse wrote that the resident was on the floor, having hallucinations that someone was smoking in her room and "standing over her and she had to move." She was assisted back to bed after the nurse checked her for injury. She denied pain. There was no further documentation on this page. Review of the facility provided documentation related to the fall of 12/15/11, involving resident #7, revealed four documents: 1. A form, dated 12/15/11, stated she had poor safety awareness and interventions were in place prior to the fall, including safety foot ware, call light in reach, water in reach, and assistive devices for ambulation. One section stated that the care plan was revised to include a bed alarm and verbal cuing for the resident to use the call light. A communication to physician form (SBAR) stated that a resident fall had occurred with resident #7. The back of the form stated that at 7:30 p.m. on 12/15/11 the nurse was notified by the aide that the resident was sitting on the floor. The fall was witnessed by the aide and described to the nurse. The resident was alert and confused, again stating that someone was smoking in the room and she could not tolerate smoking. The resident denied pain and was re-educated for use with the call bell. A personal bed alarm was placed on the bed. There were two additional nurses ' notes, 12/16 and 12/17/11 stating that the resident had no pain or injuries. An undated hand written statement by Employee H stated that she, the employee, was working with another resident, walked out into the hall, glanced over and saw "her (resident #7) standing on the right side of her bed holding on to her side table." The employee wrote that she "yelled out her (the resident ' s) name" and ran into the room. The resident turned to her left to look at the employee and began to fall. She grabbed the side rail "to catch herself" but the rail "broke off her bed and she fell right on her bottom." The employee called for help. This document did not contain this resident's name or the date of the occurrence. The facility NHA ANHA, and DON stated on 03/21/12 though that the document referred to Resident #7, concerning the fall on 12/15/11. A second hand written statement by The NHA and ANHA was dated 03/20/12. It stated that Employee H verbalized to them that the side rail detached from the rail. Employee H stated that the rail was reattached and tightened by another employee and functioning properly. Further review of the closed medical record revealed that the resident was discharged on [DATE] to an assisted living facility. The nurse ' s notes on that day at 11:00 a.m. stated she propelled herself in a wheelchair and had no complaints. Review of the facility census on 03/19/12 revealed that resident #7 currently resided in the facility. On 03/19/12 at 4:40 p.m., a brief observation was made and the resident was resting in bed. She was confused. The side rails attached to the bed were found by the surveyor to be "wobbly." The new record stated she had been readmitted on [DATE] and continued on fall precautions. 3. On 03/19/2012 at 4:00 p.m. an observation was made of resident #3 ' s bed. The side rails were T style and were not locked in placed. The rails moved in a clock like motion and stopped when the side of the rails reached the floor. This was an abnormal finding for side rail stability. The resident was not in the bed at the time of this observation. On 03/19/2012 an interview was conducted with resident #3 at 4:40 p.m. The resident revealed that she used the side rails for positioning to get comfortable and to assist with getting out of bed. She used a wheelchair for mobility. On 03/20/2012 at 9:30 A.M. a second observation was made of the side rails in resident #3 ' s room. The resident was seated in her wheelchair at the time. The rails, again, were unstable and rocked back and forth, head to foot, and laterally, side to side, along the bed and extended to the floor, in an abnormal position. The aide stated the rails were used by the resident to assist with support to a standing position. Per the MDS for resident #3, dated 02/08/12, section C, related to recall, and revealed the resident required verbal cues to recall sock and blue. She could not recall the word bed. The mood section interview stated she had a severity score of 5.The functional status section, Section G, stated she required extensive assistance with mobility including bed mobility and transfers. She required the assistance of one staff member for all care. Section G0300 stated she was not steady and only able to stabilize with human assistance. The section D0350 related to safety was blank. Section 1 of the active [DIAGNOSES REDACTED]. 4. On 03/20/2012 at 4:45 P.M., Employee G called the surveyor into resident #3 ' s room to demonstrate to the surveyor that the bed had been repaired by maintenance. Employee G stated that he had called maintenance to report the problem. The rails were then changed and did not touch the floor, but still had some unstable movement. The employee stated he had been working in the facility five years and the rails had been the same since he began working here. He stated that he tightened them as necessary after the rails became loose from usage. He stated the policy was to notify maintenance for any problem that needs fixing, but he did not consider this a problem, and did not report them as unstable. He stated he did not know of any resident falling because of side rails or of any injury related to side rails. 5. On 03/20/12 at about noon the survey team members confirmed multiple concerns of wobbly and unsecure side rails throughout the building. It was determined that 51 of the 117 beds currently in the facility contained the wobbly, easily displaced and unsecure side rails (100B, 101A, 103A, 104B, 106A, 107A, 107B, 109B, 110A, 112B, 113A, 115A, 115B, 120A, 122B, 123A, 125A, 125B, 127A, 128A, 129A, 131B,200B, 201A, 202B, 203A, 203B, 204A, 206A, 206B, 209A, 213A, 217A, 218A, 219A 221A, 222A, 222B, 223A, 224A, 225A, 225B, 228A, 229B, 230A, 231A, 301A, 302A, 400P, 401B, and 404A). Of these 51 beds, 45 were occupied by residents (100B, 101A, 103A, 104B, 106A, 107A, 107B, 109B, 110A, 113A, 115A, 115B, 120A, 122B, 123A, 125A, 125B, 127A, 128A, 129A, 131B,200B, 201A, 202B, 203A, 203B, 204A, 206A, 206B, 209A, 213A, 219A 221A, 222A, 222B, 223A, 228A, 229B, 230A, 231A, 301A, 302A, 400P, 401B, and 404A). Of the 45 occupied beds with the T style of half side rails with a black knob in the middle, 39 were observed by surveyors to be loose with excessive movement ranging from movement toward the mattress, away from the mattress, and/or a rocking motion from the head of the bed to the foot of the bed. Some rails were observed to have an extensive rocking motion to a degree almost touching the floor, such as room 101 by the door. The use of these rails ranged from residents receiving rehabilitation services using the rails for bed positioning to long term care residents using the bed rails for safety and stability. Per staff interviews, twenty three residents identified with confusion and diminished cognitive capacity were in the beds with the affected rails, but were unable to provide information regarding their use of the rails. 6. On 03/20/12 at 3:45 p.m. an interview was conducted with the Maintenance supervisor. The supervisor reviewed the process for reporting equipment repairs and resolution. He stated he kept a log book on each of the two units, with entries for the necessary repairs. He stated that if a nurse stopped him in the hall with a request to fix something he might address that at that time. When the repair was complete he dated and signed the entry. He checked the books in the morning and at least three times daily. If the necessary repair was deemed serious, staff might come to his office door and tell him. Review of the prior six months of entries in the log books revealed three entries related to side rails. 1. 10/13/11- Right side rail came off room 302, P. The repair was signed by an employee no longer working for the facility. There were no details of the faulty rail or whether the rail was repaired or replaced. The survey team was unable to correlate this rail coming off with any resident fall. 2. 10/14/11-room 128A, side rail " broken " . " Please fix bed ASAP " . The entry was dated as completed on 10/14/11 and signed by the same employee no longer working for the facility. 3. 3/13/12-room 218B. Right bed rail " hard to come down enabling the patient to become independent " . This request was assigned to a facility employee, not the supervisor, and dated as completed on 03/13/12. There were no further details on this document. The supervisor stated that he had worked for this facility for two years and the T style of half rails were ordered as replacement rails prior to his employment, and he continued ordering them as before. He did not consider other types of rails. This style was called the T100 style. He stated he checked rails at least monthly and as needed. Housekeepers, aides and nurses also tightened rails as needed. He stated that there were five different types of bed frames in the facility. He provided manufacturer ' s information on the five different bed frames and the T100 side rail manufacturer, and the local medical equipment supplier. The supervisor stated he had no information regarding the residents in the beds listed in the three log book entries. He stated the beds were moved around the building based on needs. The supervisor was aware of the three year limited warranty but did not keep specific information related to tracking and trending when the rails were placed on what frame. 7. On 03/20/12 from 08:30 to 10:00 a.m. all three of the beds identified on the maintenance complaint log were observed and all three of the beds currently contained loose, unstable bed rails. 8. On 03/20/12 at 4:25 p.m. a telephone interview was conducted with the medical supply company supplying the T 100 side rail to this facility. The representative informed the surveyor that the bed frames identified by the facility maintenance supervisor were no longer manufactured. The representative stated that the T 100 or T 120 models were not recommended for the bed frames identified by the facility. 9. On 03/20/12 at 4:40 p.m. a telephone interview was conducted with the representative for the manufacturer of the T 100 and T120 side rails. The surveyor was informed that both the T100 and T120 side rail models were made specifically for a home care bed frame made by this manufacturer. 10. . Review of the FDA medical device incident reports revealed one event dated 09/13/2000. The details included the resident was receiving care when the rail broke and she fell to the floor. She sustained injuries in the fall. The model identified was the T100 half rail, the same model and manufacturer used by this facility. 11. On 03/20/12 at 5:08 p.m., the DON and ADON accompanied two surveyors to room 122 B to check the side rails. The resident was out of the room at the time. The DON and ADON checked the side rails and found they were both loose, with the side rail on the left side of the bed not as loose as the one on the right side. The ADON denied that she was aware of any issue with rails. When asked specifically about her statements yesterday (03/19/12), regarding a resident fall (#7) where the side rail separated from the bed frame. She recalled on 03/19/12 that she "thought" a rail broke, but the resident was not injured. She did not know anything further. The surveyor asked the DON and ADON if they routinely did any bed environment safety assessments and they responded that they did not, except to check the rails periodically. They stated they believed the Maintenance director checked the rails for safety. 12. On 03/22/12 at 11:27 a.m., the Director of Therapy was interviewed. The surveyor asked the Director of Therapy if the therapy staff had any input regarding the type of side rails used for residents. She stated that if there was a reason a resident needed a certain type of side rail, therapy, could recommend it. She stated that she was not aware of any problems with any side rails. The surveyor asked if therapy had any input for the placement or position of resident ' s side rails on the bed. She indicated that if therapy had specific recommendations, they would let the facility staff know. The Director of Therapy was aware of side rails that were loose and she stated that all of the side rails have some " play". She stated further that the therapy staff knew how to tighten the rails and have tightened the side rails in the past. She stated if they can't tighten them, they then notified the Maintenance Director and there was a book to log the issue. The surveyor asked if the therapy department had any input into the reassessment of the new side rails installed on the bed on 03/21/12 and 03/22/12 and she stated they were not asked for any recommendations on the new side rails, but she assisted with the installation of the new side rails. 13. On 03/22/12 at 11:53 a.m., an interview was conducted with one of the facility's occupational therapist (OT). The surveyor asked the OT if she demonstrated to residents the use of side rails, and she replied that if they need it, therapy would show them how to use the side rails. She was asked if she ever had to tighten the side rails and she replied that some were loose, but she personally had not tightened them. The surveyor asked if she reported any of the side rails being loose and the OT responded "no." She stated further that she doesn ' t know how to tighten the "T"-shaped rails with the knob. The therapist stated that she would report needed repairs to maintenance. The OT stated further that she was not aware of any problems with side rails coming off the bed or breaking. 14. On 03/22/12 at 12:29 p.m., the maintenance director was interviewed a second time about the three reports of broken side rails. The director/supervisor reviewed the three reports and had no further details to add. The surveyor asked the maintenance director if he had trained the nursing staff about how to adjust or tighten the side rails. He replied that he showed some staff members how to tighten them. He stated that the nursing staff would call when a side rail was loose and he would come in and show them, the staff, how to tighten them. The maintenance director stated that he did not provide formal training to the staff about the side rails adjustments. 15. On 03/22/12 at 2:15 p.m. the NHA was interviewed regarding the Quality Assurance process. A corporate nurse and the assistant NHA were present during this interview. The NHA stated that, prior to this investigation; there had been no tracking of side rail safety. The NHA stated that until 03/19/12 she was unaware of problems with the facility side rails. She stated she reviewed resident falls and produced data entry results in graphs, identifying the time of day, day of the week and location of the falls. She reviewed weekend staffing and other times of low staffing. No trends were identified with falls. There was no mention of side rails broken or displaced related to any of the falls reviewed. She stated that the plan going forward was to monitor all rails. She stated " we are going to follow the maintenance procedure with room rounds, weekly checks for one month, and then monthly checks for three months, then every 3 months. Our policy calls for different key personnel to do the rechecks after the maintenance checks. We will discuss at the next QA meeting " . She stated that she had in-serviced the maintenance director one to one regarding the identification of broken or malfunctioning side rails. The NHA stated, and the corporate nurse confirmed that the T100 and T120 models of half side rails had been removed from all of the corporations ' facilities throughout multiple states. 16. Immediate Jeopardy was removed on 03/22/12 at 10:00 a.m. after the NHA informed the surveyors that all of the faulty side rails, 39 sets, were removed from resident beds during the night of 03/21/12 to 03/22/12. The NHA stated that the Medical Director was notified of the faulty side rails and the correction plan on 3/21/12 . All residents in the facility were re-evaluated for the need for side rails. Some residents were found to no longer need the side rails and physicians were notified. Residents still requiring side rails were placed in beds with safe rails that were attached to the bed frame. New orders were received as needed. The NHA stated that if the resident no longer needed rails, and occupied a bed with secure rails; the bed was exchanged, terminally cleaned, and given to a resident identified as needing side rails. The NHA also stated that the facility administration staff had contacted all residents ' family and attending physicians to inform them of the changes. The staff verified the resident ' s need and/or desire for the rail. Documents were presented to the surveyors that all staff had received re- education regarding resident safety, reporting of faulty equipment, and details of falls. The maintenance director received one to one education regarding the need to monitor safety equipment. The scope and severity of the citation was reduced to E.