Every finding on record at Monroe Health and Rehabilitation Center

Based on facility policy review, observations, and interviews, the facility failed to clean and store kitchen equipment in 1 of 1 kitchen and failed to maintain 1 of 1 walk in freezers in a sanitary condition which had the potential to affect 65 of 65 residents residing in the facility. The findings include: Review of the facility's policy titled, Sanitization, dated 12/2008, revealed .All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means . Review of the facility's policy titled, Food Safety Requirements, dated 3/26/2025, revealed .Food safety practices shall be followed throughout the facility's entire food handling process .all equipment used in the handling of food shall be cleaned and sanitized in a manner to prevent contamination . Review of the facility's undated policy titled, Sanitation Inspection, revealed It is the policy of this facility .part of the .sanitation program, to conduct inspections to ensure food service areas are clean, sanitary, and in compliance .Sanitation inspections will be conducted .Daily: Food service staff shall inspect .freezers daily . During an observation and interview with the Certified Dietary Manager (CDM) on 2/23/2026 at 9:45 AM, in the utensil storage area revealed 5 dish scoops with dried and crusted food particles under the mechanical blade and in the metal bowl of the scoop, 1 saute/fry pan with dried beef and dried particles on the pan and 1 full deep pan with dried food particles on the inside of the pan. The CDM and Assistant Dietary Manager both confirmed the scoops, saute/fry pan, and full deep pan had not been clean and sanitized correctly and were ready and available for use. The CDM confirmed it is the expectation for all utensils used for food service to be free of food debris to prevent food born illness and further confirmed there had not been any food borne illnesses in the facility. During an observation and interview on 2/23/2026 at 10:00 AM, with the CDM in the walk-in freezer revealed 4 frozen biscuits, 2 thermometers not in use, and scattered frozen peas in the walk-in freezer on the floor under the bottom shelf of the food storage rack. The CDM confirmed the loose food items had not been removed, the thermometers were not to be placed on the floor out of view, and the freezer had not been cleaned properly.

Based on facility policy review, observations, and interviews, the facility failed to maintain a clean and sanitary environment for 5 resident rooms (room [ROOM NUMBER], #114, #116, #117 and #118) of 8 rooms observed on 1 of 2 hallways for a clean and sanitary environment.The findings include:Review of the facility policy titled, Routine Bathroom Cleaning, dated 6/2025, revealed .provide a clean and sanitary environment for residents .clean entire toilet including handle and underside of flush rim. Apply disinfectant and allow sufficient contact time .report areas of .damaged items in need of repair .Review of the facility policy titled, Routine Cleaning and Disinfection, dated 6/2025, revealed .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 .During observations on 2/23/2026 at 10:56 AM, 2/24/2026 at 11:00 AM, and 2/25/2026 at 2:00 PM, revealed room [ROOM NUMBER]-B contained a motorized wheelchair, with dried debris on the cushion, arms of the chair, and a large amount of multi-colored debris, small pieces to quarter size chunks, on the undercarriage.During observations on 2/23/2026 at 10:58 AM, 2/24/2026 at 11:02 AM, and 2/25/2026 at 2:02 PM, revealed room [ROOM NUMBER]'s bathroom contained a trash can without a bag, with a dried brown substance on the outside, the rim, and the inside of the trash can. Further observation revealed the toilet had 2 areas of dried yellow residue on the seat, and a yellow/orange substance around the base of the toilet.During observations on 2/23/2026 at 11:10 AM, 2/24/2026 at 11:04 AM, and 2/25/2026 at 2:10 PM, revealed room [ROOM NUMBER]'s bathroom had a yellow/orange substance around the base of the toilet.During an observation on 2/23/2026 at 11:18 AM, 2/24/2026 at 11:06 AM, and 2/25/2026 at 2:13 PM, revealed room [ROOM NUMBER]-A contained a wheelchair with a fabric heel protector cushion attached to the right arm as an armrest. The cushion was spattered with small to pea-size unknown multi-colored particles.During observations on 2/23/2026 at 11:21 AM, 2/24/2026 at 11:08 AM, and 2/25/2026 at 2:14 PM, revealed room [ROOM NUMBER]'s bathroom had brown residue at the front base of the toilet. During observations on 2/23/2026 at 11:25 AM, 2/24/2026 at 11:15 AM, and 2/25/2026 at 2:25 PM, revealed room [ROOM NUMBER]'s bathroom had a yellow/orange substance around the base of the toilet.During an observation and interview on 2/26/2026 at 2:30 PM, in room [ROOM NUMBER]'s bathroom, revealed the Administrator stated the substance around the toilets may be related to the wax ring. The Administrator used a wet wipe to determine if the yellow/orange substance could be easily cleaned, and after wiping a small area around the toilet, the substance was easily removed. The Administrator confirmed the area around the toilet was not clean.

Based on facility policy review, medical record review, and interviews, the facility failed to report an allegation of verbal abuse to the State Designated Authority (State Agency) for 1 resident (Resident #37) of 6 residents reviewed for abuse.The findings include:Review of the facility's policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, dated 7/2025, revealed .it is the guideline of this facility to report all allegations of abuse/neglect/exploitation or mistreatment .immediately to the Administrator of the facility and to other appropriate agencies .when suspicion of abuse .occur .the licensed nurse will notify the Administrator or designee .the Administrator or designee .will notify the appropriate agencies .obtain statements from direct care staff .suspend the accused employee .Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including Dementia, History of a Stroke with Right Hemiparesis (weakness), and Chronic Obstructive Pulmonary Disease.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #37 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had severe cognitive impairment.Review of the comprehensive care plan dated 1/13/2026, revealed Resident #37 had .Impaired thought processes r/t [related to] dementia, other cerebrovascular diseases .During an interview on 2/24/2026 at 9:05 PM, CNA D stated on her second night shift of training, about 1-2 weeks ago, she was training with CNA C. Resident #37's call light was on, and CNA D and CNA C went to the room. Resident #37 started yelling at them to put her roommate to bed. CNA C told Resident #37, Shut the f--- up, and Don't tell me what to do. CNA C and Resident #37 were yelling and bickering with each other back and forth while they were putting Resident #37's roommate to bed. As they were leaving the room, CNA C told Resident #37, I said don't tell me what the f--- to do, you can just sit on it and f---ing spin. Then CNA C said to CNA D, Come on, let's go, and left the room. CNA D stated she turned back to Resident #37 to check on (Resident #37) and helped the resident get dressed and ready for bed. When (CNA D) was done, CNA D found CNA C and said to [CNA C], You shouldn't have talked to her (Resident #37) like that, aren't you [CNA C] afraid (Resident #37) will tell on you? and CNA C replied, No, actually, that resident won't tell anything. CNA D stated she told LPN A about the incident including the details of CNA C and Resident #37 bickering back and forth, and CNA C cursing at Resident #37.During an interview on 2/24/2026 at 9:15 PM, LPN A stated CNA D told her the following: CNA C was bickering back and forth with Resident #37 while they were caring for the roommate. CNA D was cursing at Resident #37, using the F word including, Don't tell me what to do, shut the f--- up .You can f---ing sit on it and rotate. LPN A stated it was no more than 10 minutes when (LPN A) checked on Resident #37. Resident #37 wasn't crying at this time. When Resident #37 was asked about the incident, Resident #37 said no. LPN A stated Resident #37 has dementia and has sundowning, when she gets more confused at night. LPN A stated she notified the Administrator, who called the Director of Nursing (DON) with a conference call. LPN A relayed the information CNA D told her, including CNA C allegedly cursing at Resident #37, yelling back and forth with Resident #37. LPN A stated the DON told her to obtain a written statement from CNA C, and escort her off the premises. LPN A stated she obtained a written statement from CNA C and escorted her off the premises as instructed. LPN A wrote a statement herself and obtained a written statement from CNA D. LPN A stated she put all 3 statements under the DON's door as instructed.Review of the nursing schedule assignments for 2/2026 revealed CNA C went home during the night shift on 2/14/2026.During an interview on 2/25/2026 at 11:00 AM, the DON confirmed LPN A had called her when the alleged incident occurred and instructed LPN A to escort CNA C off the premises. The DON stated when she came to work the following day, she asked other residents and staff if there had been any issues with CNA D and there had been no concerns identified. The DON stated CNA D was PRN status (as needed only), and the facility decided not to schedule her anymore due to poor customer service. The DON stated Resident #37 denied the incident when questioned, therefore the facility did not consider the reported allegation to be abuse. The DON denied possessing any written statements and confirmed there was no documentation of an investigation.Review of the Human Resources (HR) file revealed CNA C was hired on 11/9/2024. New hire orientation for CNA C included the abuse program policies and procedures. The HR file did not contain documentation of the alleged abuse incident on 2/14/2026, documentation of CNA C being sent home during the shift on 2/14/2026, or documentation of the DON's intent to no longer place CNA C on the schedule.During an interview on 2/26/2026 at 2:30 PM, with the Administrator and DON, the Administrator stated he was the facility's Abuse Coordinator, confirmed allegations of abuse should be reported to the State Agency and other entities as required, and confirmed this incident had not been reported to the State Agency or other entities.

Based on facility policy review, medical record review, and interviews, the facility failed to ensure an allegation of verbal abuse was investigated for 1 resident (Resident #37) of 6 residents reviewed for abuse.The findings include:Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 7/2025, revealed alleged violation is a situation or occurrence that is observed or reported by staff .but has not yet been investigated and, if verified, could be an indication of .abuse .An Immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur . Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations . providing complete and thorough documentation of the investigation .taking all necessary actions as a result of the investigation .Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including Dementia, History of a Stroke with Right Hemiparesis (weakness), and Chronic Obstructive Pulmonary Disease.Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #37 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident had severe cognitive impairment.Review of the comprehensive care plan dated 1/13/2026, revealed Resident #37 had .Impaired thought processes r/t [related to] dementia, other cerebrovascular diseases .During an interview on 2/24/2026 at 9:05 PM, CNA D stated on her second night shift of training, about 1-2 weeks ago, she was training with CNA C. Resident #37's call light was on, and CNA D and CNA C went to the room. Resident #37 started yelling at them to put her roommate to bed. CNA C told Resident #37, Shut the f--- up, and Don't tell me what to do. CNA C and Resident #37 were yelling and bickering with each other back and forth while they were putting Resident #37's roommate to bed. As they were leaving the room, CNA C told Resident #37, I said don't tell me what the f--- to do, you can just sit on it and f---ing spin. Then CNA C said to CNA D, Come on, let's go, and left the room. CNA D stated she turned back to Resident #37 to check on (Resident #37) and helped the resident get dressed and ready for bed. When (CNA D) was done, CNA D found CNA C and said to [CNA C], You shouldn't have talked to her (Resident #37) like that, aren't you [CNA C] afraid (Resident #37) will tell on you? and CNA C replied, No, actually, that resident won't tell anything. CNA D stated she told LPN A about the incident including the details of CNA C and Resident #37 bickering back and forth, and CNA C cursing at Resident #37.During an interview on 2/24/2026 at 9:15 PM, LPN A stated CNA D told her the following: CNA C was bickering back and forth with Resident #37 while they were caring for the roommate. CNA D was cursing at Resident #37, using the F word including, Don't tell me what to do, shut the f--- up .You can f---ing sit on it and rotate. LPN A stated it was no more than 10 minutes when (LPN A) checked on Resident #37. Resident #37 wasn't crying at this time. When Resident #37 was asked about the incident, Resident #37 said no. LPN A stated Resident #37 has dementia and has sundowning, when she gets more confused at night. LPN A stated she notified the Administrator, who called the Director of Nursing (DON) with a conference call. LPN A relayed the information CNA D told her, including CNA C allegedly cursing at Resident #37, yelling back and forth with Resident #37. LPN A stated the DON told her to obtain a written statement from CNA C, and escort her off the premises. LPN A stated she obtained a written statement from CNA C and escorted her off the premises as instructed. LPN A wrote a statement herself and obtained a written statement from CNA D. LPN A put all 3 statements under the DON's door as instructed.Review of the nursing schedule assignments for 2/2026 revealed CNA C went home during the night shift on 2/14/2026.During an interview on 2/25/2026 at 11:00 AM, the DON confirmed LPN A had called her when the alleged incident occurred and instructed LPN A to escort CNA C off the premises. The DON stated when she came to work the following day, she asked other residents and staff if there had been any issues with CNA D and there had been no concerns identified. The DON stated CNA D was PRN status (as needed only), and the facility decided not to schedule her anymore due to poor customer service. The DON stated Resident #37 denied the incident when questioned, therefore the facility did not consider the reported allegation to be abuse. The DON denied possessing any written statements and confirmed there was no documentation of an investigation.Review of the Human Resources (HR) file revealed CNA C was hired on 11/9/2024. New hire orientation for CNA C included the abuse program policies and procedures. The HR file did not contain documentation of the alleged abuse incident on 2/14/2026, documentation of CNA C being sent home during the shift on 2/14/2026, or documentation of the DON's intent to no longer place CNA C on the schedule.During an interview on 2/26/2026 at 2:30 PM, with the Administrator and DON, the Administrator stated he was the facility's Abuse Coordinator, confirmed allegations of abuse should be reported to the State Agency and other entities as required, and confirmed this incident had not been reported to the State Agency or other entities and had not been thoroughly investigated.

Based on facility policy review, Lippincott Nursing Center website review, medical record review, observation, pharmacy documentation review, and interviews, the facility failed to ensure basic standards for the rights of medication administration were followed for 1 resident (Resident #25) of 3 residents reviewed for medication administration.The findings include:Review of the facility's undated policy titled, Medication Administration, revealed .ensure that the six rights of medication administration are followed .Right resident .Right drug .Right dosage .Right route .Right time .Right documentation .Review MAR [Medication Administration Record] to identify medication to be administered .Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, time .Review of the Lippincott Nursing Center Website resource of the Nursing Drug Handbook dated 2025- 2026, revealed .Medication Errors in Nursing .As a final step in the administration process .and the .defense against medication errors .nurses must follow the rights of medication administration .Right Patient .Right medication .Right dose .Right route .Right time .Right Documentation .Right reason .Right response .Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Hypertension (high blood pressure), Polyneuropathy (nerve damage), and Alcohol Use, Unspecified, With Withdrawal.Review of a comprehensive care plan for Resident #25 dated 1/19/2026, revealed .The resident has altered cardiovascular status r/t [related to] Hypertension .Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #25 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed Resident #25 had an active diagnosis of Hypertension. Review of the Physician's Orders for Resident #25 revealed the following orders prescribed by the Nurse Practitioner (NP):1. An order dated 1/16/2026, .Lisinopril 40 mg one time a day . to start 1/17/2026. This was discontinued on 1/19/2026.2. An order 1/19/2026, . Lisinopril 40 mg one time a day .hold for sbp [systolic blood pressure] < [less than] 115 .for 7 days . scheduled to start 1/20/2026 and end 1/26/2026.3. An order dated 1/19/206, . Lisinopril 40 mg one time a day . with no blood pressure parameters, scheduled to start on 1/27/2026. This was discontinued on 1/22/2026.4. An order dated 1/22/2026, .Lisinopril 10 mg one time a day .hold for sbp <115 . scheduled to start 1/23/2026 and end 1/26/2026.5. An order dated 1/22/2026, .Lisinopril 10 mg one time a day . with no blood pressure parameter, to start on 1/27/2026 to present (2/24/2026). Review of the pharmacy's delivery manifests for Resident #25 from admission on [DATE] through 2/24/2026, revealed the pharmacy sent the following medications to the facility for Resident #25:1. 1/16/2026 Lisinopril 40 mg - quantity of 30 tablets2. 1/19/2026 Lisinopril 40 mg - quantity 37 tablets2. 1/23/2026 Lisinopril 10 mg - quantity of 4 tablets3. 1/26/2026 Lisinopril 40 mg - quantity of 37 tabletsReview of the Automated Medication Dispensing System (AMDS) transaction report for Resident #25 from admission on [DATE] through 2/24/2026, revealed there were no doses of Lisinopril retrieved from the AMDS for Resident #25, until 2/24/2026 by Registered Nurse (RN) D.Review of the MAR dated 2/1/2026 to 2/28/2026 revealed, .Lisinopril 10 mg .one time a day . was signed daily as administered. Further review revealed the MAR was signed off primarily by Medication Aide (MA) A 7 times, and by MA B 10 times.During an observation of medication administration on 2/24/2026 at 8:20 AM, RN D was observed preparing morning medications for Resident #25. RN D viewed the order on the MAR, which read .Lisinopril [medication used to lower blood pressure] 10 mg [milligrams] .daily . RN D retrieved the card of Lisinopril from the medication cart drawer, and checked the pharmacy label which read, .Lisinopril 40 mg . RN D did not give the medication off this card and retrieved the correct dose of Lisinopril 10 mg for Resident #25 from the Automated Medication Dispensing System (AMDS).During an interview on 2/25/2026 at 2:15 PM, MA B stated she gave Resident #25 medication from the card that was on the medication cart. When she was told the pharmacy only sent 4 tablets of Lisinopril 10 mg, and the only other Lisinopril that had been sent from the pharmacy was Lisinopril 40 mg, MA B stated, .if that's the case, I may have given that . MA B confirmed the rights of medication administration, including right dose, were supposed to be followed by checking the MAR and the medication card label before preparing the medication for administration, and confirmed she may not have done that.During an interview on 2/26/2026 at 12:30 PM, MA A stated she only gave Resident #25 medication from the card on the medication cart. When she was told the pharmacy only sent 4 tablets of Lisinopril 10 mg, and the only other Lisinopril that had been available from the pharmacy was Lisinopril 40 mg, MA A stated, .if that's all that was in the cart, I guess that's what I gave . MA A confirmed the rights of medication administration, including right dose, were supposed to be followed by checking the MAR and the medication card label before preparing the medication for administration, and stated, I may have missed it.During an interview on 2/26/2026 at 1:30 PM, the Director of Nursing (DON) stated the expectation is to check the order on the MAR against the medication card to ensure it is the correct medication and dosage. After reviewing the pharmacy manifests and the AMDS transaction report for Resident #37, the DON confirmed Lisinopril 10 mg was only available for 4 doses from the order date of 1/22/2026 through 2/24/2026, and the incorrect dosage of Lisinopril 40 mg was the only one available on the medication cart for resident use. The DON confirmed the standard of practice for the rights of medication administration were not followed.

Based on facility policy review, medical record review, observations, and interviews the facility failed to ensure an order was obtained for oxygen (O2) administration, failed to ensure O2 warning signs were placed on the resident's door, and failed to ensure tubing was changed timely for 1 resident (Resident #61), failed to ensure oxygen tubing (nasal cannula) was stored appropriately for 2 residents (Residents #61 and #41), and failed to administer O2 at the prescribed physician rate for 1 resident (Resident #5) of 6 residents reviewed for O2 administration. The findings include: Review of the facility's policy titled, Oxygen Administration, dated 1/8/2024, revealed .Oxygen is administered under orders of a physician .Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy .Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated .Keep delivery devices covered in plastic bag when not in use .Oxygen warning signs must be placed on the door of the resident's room where oxygen is in use .Types of delivery systems include .Nasal Cannula . Review of the medical record revealed Resident #61 was admitted to the facility on [DATE] with diagnoses including Acute Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, and Heart Failure. Review of the comprehensive care plan for Resident #61 dated 1/21/2026, revealed .resident has altered respiratory status/difficulty breathing . Review of the O2 Sats (oxygen saturation- measures oxygen levels in the blood) Summary dated 1/22/2026 at 9:07 AM, revealed Resident #61's oxygen saturation was .98.0% [percent] .Method .Oxygen via Nasal Cannula . Review of the Occupational Therapy Evaluation & Plan of Treatment dated 1/22/2026, revealed .Diagnoses .Acute respiratory failure with hypoxia .Patient Referral and History .66 yo [[AGE] year old] male admitted to hospital for shortness of breath .now presents to this facility to continue therapy program to improve strength, adl [activities of daily living] and mobility .Oxygen .Is Oxygen needed? .Yes .Continuous .Nasal cannula .Liters of Oxygen needed .2 . Review of the Physical Therapy Evaluation & Plan of Treatment, dated 1/23/2026, revealed .Diagnoses .Acute respiratory failure with hypoxia .Heart failure .Chronic obstructive pulmonary disease with (acute) exacerbation .Patient Referral and History .66 y.o [year old] .admitted to the hospital for SOB [shortness of breath] .Now in this facility to continue rehb [rehab] program to improve strength and mobility .Oxygen .Is Oxygen needed? .Yes .Continuous .Nasal cannula .Liters of oxygen needed .2 . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #61 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the Nurses Note for Resident #61 dated 2/11/2026 at 10:15 AM, revealed . Resident wearing O2 this morning, stated he has 'some trouble' in the night with being short of breath. Lungs are clear, denies any respiratory distress at this time, no increase in respiratory effort assessed .O2 sat varies on oximeter reading .Out to smoke per his normal routine, has been up walking per usual, denies any distress . Review of the O2 Sats Summary dated 2/16/2026 at 2:01 AM, revealed Resident #61's oxygen saturation was .93.0% .Method .Oxygen via Nasal Cannula . Review of Resident #61's medical record revealed no order for oxygen administration. During an observation on 2/23/2026 at 11:42 AM, Resident #61 was not in the room. There was an oxygen concentrator beside Resident #61's bed with oxygen tubing attached. The oxygen tubing was lying on the bedside table uncovered, undated, and open to air. There was no storage bag at Resident #61's bedside to store the oxygen tubing in when not in use. There was no warning signage posted outside the resident's room that indicated Resident #61 was on oxygen. During an observation on 2/23/2026 at 1:09 PM, Resident #61 was observed smoking during the facility smoking time with no concerns noted. Resident #61 was not wearing oxygen. During an observation and interview on 2/24/2026 at 9:17 AM, Resident #61 returned to his room from smoking outside. Resident #61 was seated on the side of bed and stated he had been wearing oxygen for the last 5 years and since he was admitted to the facility .mostly at night . Resident #61 stated he removed the oxygen to go outside to smoke and when ambulating throughout the facility. There was an oxygen concentrator at the bedside set at 2 liters by nasal cannula. The oxygen tubing was lying across Resident #61's bed uncovered, undated, and open to air. There was no storage bag at the bedside for the oxygen tubing to be stored in when not in use. This surveyor asked Resident #61 how he stored the oxygen tubing when he took it off and he stated .I just lay it on the bed or the table . Resident #61 confirmed facility staff had not educated him on storing oxygen tubing when he was not using it. During an interview and medical record review on 2/24/2026 at 9:21 AM, outside Resident #61's room, revealed Registered Nurse (RN) A confirmed she was assigned to Resident #61 today and provided care for him often. This surveyor asked RN A if Resident #61 received oxygen therapy and RN A stated she was unaware. RN A and this surveyor reviewed Resident #61's physician's orders and RN A confirmed there was no order for oxygen administration for Resident #61. RN A stated oxygen tubing was to be stored in a bag when not in use. Oxygen tubing was to be changed .every 2 weeks . and documented on the Treatment Administration Record (TAR). RN A confirmed there was no documentation on Resident #61's TAR regarding when oxygen tubing had been changed. RN A confirmed there was no warning signage outside Resident #61's room. RN A was unaware if warning signage was to be posted outside the room of resident's receiving oxygen therapy. During an observation and interview on 2/24/2026 at 9:26 AM, with RN A in Resident #61's room, revealed the resident seated on the side of the bed. Resident #61's oxygen concentrator at bedside was set on 2 liters per minute and the oxygen tubing was lying across the bed uncovered, undated, and open to air. RN A asked Resident #61 if he used oxygen and the resident stated .yes .RN A asked Resident #61 if the oxygen helped him and he stated .yes . RN A confirmed the nasal cannula was open to air, undated, and not stored appropriately. RN A confirmed oxygen tubing was to be stored in a bag when not in use. RN A confirmed the oxygen tubing was undated and was unaware when it was changed last. RN A stated she was going to take care of obtaining a physician's order for the oxygen .right now . During an observation on 2/24/2026 at 9:31 AM, with RN A, in Resident #61's room, revealed Resident #61 was lying in bed with oxygen infusing at 2 liters via nasal cannula. Resident #61's respirations were slightly labored at 24 per minute and oxygen saturation was 66% and came up to 96% while deep breathing with the oxygen on. Resident #61 denied shortness of breath and stated he had just placed the oxygen back on after returning from his smoke break. During an observation on 2/24/2026 at 9:47 AM, with RN A, in Resident #61's room, revealed RN A changed Resident #61's oxygen tubing and placed a plastic bag at the bedside to store the oxygen tubing in when not in use. RN A educated Resident #61 to keep the oxygen tubing in the bag when not in use. During an interview on 2/24/2026 at 8:59 PM, Certified Nursing Assistant (CNA) A stated they were a regular caregiver for Resident #61. Resident #61 had worn oxygen periodically since he arrived at the facility. During an interview on 2/25/2026 at 8:32 AM, the Director of Nursing (DON) confirmed Resident #61 did not have an order for oxygen until 2/24/2026. The DON stated .My guess is he [Resident #61] was satting low .nurse put him on oxygen .and did not obtain the order . The DON confirmed there should be an order for oxygen prior to oxygen administration. The DON confirmed oxygen tubing was to be stored in a plastic bag when not in use to maintain infection control practices. The DON confirmed residents that remove their oxygen on their own would be provided with a bag and educated to store the tubing in the bag when not in use. The DON confirmed warning signage was to be placed outside the resident's door for residents on oxygen therapy. During an observation on 2/25/2026 at 8:43 AM, Resident #61's room had no warning signage indicating that oxygen was in use in the room. During an interview on 2/25/2026 at 8:46 AM, RN B stated she was a regular caregiver for Resident #61. RN B stated Resident #61 started using oxygen .at least a couple weeks ago .he had low sats on night shift . RN B stated Resident #61 mostly wore oxygen when sleeping. During an observation on 2/25/2026 at 9:00 AM, the DON confirmed no warning signage was posted outside Resident #61's room to indicate the resident was on oxygen. During an interview on 2/25/2026 at 11:26 AM, the DON confirmed oxygen tubing was to be changed every 7 days and as needed and was to be documented on the TAR. The DON stated night shift nurses were responsible for checking and changing oxygen tubing on Saturday or Sunday night. The DON confirmed she was unaware when Resident #61's tubing was changed because it wasn't dated and there was no order for the initiation of the oxygen so it wouldn't show up on the TAR. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Acute Kidney Failure, Atherosclerotic Heart Disease, Anxiety, and Chrondrocostal Junction Syndrome (benign inflammatory condition characterized by chest pain and swelling where ribs meet sternum). Review of the admission MDS assessment dated [DATE], revealed Resident #41 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Resident #41 did not receive oxygen therapy. Review of a physician's order for Resident #41 dated 2/23/2026 revealed . O2 @[at] 2 liters per minute via nasal cannula continuously. May titrate to keep O2 sats above 94% .every shift related to Chondrocostal Junction Syndrome . Review of the comprehensive care plan for Resident #41 revised on 2/23/2026, revealed .OXYGEN SETTINGS: O2 at 2 lpm [liters per minute] via nasal cannula continuously. Resident prefers to use O2 at night only . Review of Resident #41's Treatment Administration Record (TAR) for February 2026, revealed Resident #41 was started on oxygen on 2/23/2026. During an observation and interview on 2/23/2026 at 11:50 AM, in Resident #41's room, Resident #41 was seated in the wheelchair beside the bed. Resident #41 had an oxygen concentrator at the bedside with a nasal cannula attached that was lying on the bed, uncovered, and open to air. This surveyor was unable to visualize the flow rate due to resident positioning. Resident #41 reported she wore oxygen at night. There was no bag available in the room to store the oxygen tubing in when not in use. During an observation and interview on 2/24/2026 at 11:20 AM, in Resident #41's room, Resident #41 was seated in the wheelchair beside the bed. Resident #41's oxygen concentrator was beside the bed with a nasal cannula attached that was lying on the bed uncovered and open to air. There was no bag at the bedside to store the oxygen tubing in when not in use. This surveyor asked Resident #41 where she stored the nasal cannula when she wasn't using it and she stated .I just lay it on the bed . Resident #41 stated staff had not provided her education or a plastic bag to store the nasal cannula in when not in use. During an observation and interview on 2/25/2026 at 8:55 AM, with RN B, in Resident #41's room, revealed Resident #41 seated outside the door of her room awaiting smoking time with no oxygen on. RN B and this surveyor entered Resident #41's room with the resident's permission. There was an oxygen concentrator in the room with a nasal cannula attached to it. The nasal cannula was lying in between the mattress and the bedrail of Resident #41's bed uncovered and open to air. There was no bag in the resident's room to store the oxygen tubing when not in use. RN B stated oxygen tubing was to be stored in a plastic bag when not in use and confirmed there was no bag available for Resident #41 to store the tubing in when not in use. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Diabetes, and End Stage Renal Disease. Review of the comprehensive care plan dated 8/1/2025, revealed Resident #5's care plan included .the resident has dx [diagnoses] acute/chronic respiratory failure, COPD .O2 [oxygen] via [by] nasal cannula as ordered . Review of a Physician's Order for Resident #5 dated 10/10/2025, revealed .oxygen at 2 liters per minute via nasal canula .every shift . Review of a quarterly MDS assessment dated [DATE], revealed Resident #5 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed Resident #5 had shortness of breath while lying flat, and oxygen was in use continuously while in the facility. During an observation on 2/24/2026 at 11:15 AM, revealed Resident #5 was lying in bed with oxygen in use by nasal cannula which was set at 3 liters per minute. During an observation and interview on 2/24/2026 at 3:47 PM, the Director of Nursing (DON) confirmed Resident #5 was lying in bed with oxygen in use by nasal cannula which was set at 3 liters per minute. The DON confirmed Resident #5 had a Physician's Order for oxygen at 2 liters per minute, and the resident's oxygen was not set at the prescribed rate.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure care needs related to dialysis were consistent with professional standards of practice and the comprehensive person-centered care plan for 1 resident (Resident #5) of 2 residents reviewed for dialysis. The findings include: Review of the facility's policy titled, Hemodialysis, dated 12/2024, revealed .The facility will provide the necessary care and treatment, consistent with professional standards of practice .the facility will coordinate and collaborate .to assure that the resident's needs related to dialysis treatments are met .the facility will ensure that the physician's orders for dialysis include .The type of access for dialysis (e.g. [for example] graft, arteriovenous shunt, external dialysis catheter) and location .the dialysis schedule .nephrologist name and phone number .dialysis facility name and phone number .transportation arrangements to and from the dialysis facility .any medication administration or withholding of specific medications .Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus, End Stage Renal Disease, and Dependence on Hemodialysis (use of machinery to filter wastes from the blood).Review of the comprehensive care plan dated 8/1/2025, revealed Resident #5's care plan included, .The resident receives dialysis r/t [related to] ESRD [End Stage Renal Disease] .check and change dressing daily at access site as ordered .do not draw blood or take B/P [blood pressure] in arm with graft .encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis Tuesday, Thursday, and Saturday .Review of the current Physician's Orders for Resident #5 revealed the following orders related to dialysis:1. Physician's Order dated 10/10/2025, .Dialysis communication form - send form with resident to dialysis . scheduled Monday, Wednesday, and Friday.2. Physician's Order dated 10/10/2025, .Dialysis: check access site for bleeding every shift .3. Physician's Order dated 10/10/2025, .Do not administer any medications through or flush dialysis catheter .4. Physician's Order dated 1/15/2026, .Dialysis - obtain weight before and after dialysis . scheduled Monday, Wednesday, and Friday.5. Physician's Order dated 2/20/2026, .Sack lunch sent with resident for dialysis . scheduled Monday, Wednesday, and Friday.Continued review of the current Physician's Orders for Resident #5 revealed no orders were present for the type and location of the dialysis access site, the dialysis clinic or schedule, the nephrologist's name and phone number, transportation arrangements, and no order to adjust the medication schedule on dialysis days.During an observation and interview on 2/23/2026 at 12:15 PM, revealed Resident #5 was not in the facility. RN D stated the resident went to the dialysis clinic on Monday, Wednesday, and Friday. During an observation on 2/24/2026 at 10:30 AM, revealed Resident #5 lying in bed. Resident #5 stated the dialysis access site was in his chest, and showed this surveyor his dialysis catheter, which was observed in the left chest area and had a dressing in place at the insertion site.Review of the Physician's Orders and the Medication Administration Record (MAR) dated 2/1/2026 - 2/28/2026, revealed the following medications and supplements were held with the documented code of a 5 which meant the resident was out of the facility.1. Physician's Order dated 2/19/2026 for house shake (nutritional supplement) 4 oz [ounces] - scheduled at noon daily - not given on Friday 2/20/2026 and Monday 2/23/20262. Physician's Order dated 2/10/2026 for Metoclopramide (medication given to treat slow stomach emptying) 5 mg before meals - scheduled at 6:30 AM, 11:30 AM, and 4:30 PM - not given at 11:30 AM on Monday 2/11/2026, Tuesday 2/12/2026, Wednesday 2/13/2026, Monday 2/16/2026, Wednesday 2/18/2026, Friday 2/20/2026, and Monday 2/23/2026.3. Physician's Order dated 2/10/2026, Guaifenesin Syrup (medication to thin lung secretions and help relieve chest congestion) 10 mL (milliliters) four times a day for 10 days (ended 2/20/2026) - not administered at 12:00 PM on Monday 2/11/2026, Tuesday 2/12/2026, Wednesday 2/13/2026, Monday 2/16/2026, Wednesday 2/18/2026, and Friday 2/20/2026.4. Physician's Order dated 12/3/2025 for Insulin Lispro [fast-acting injectable medicine used to lower blood glucose levels] sliding scale, not given at noon on Monday 2/2/2026, Thursday 2/5/2026, Friday 2/6/2026, Monday 2/9/2026, Tuesday 2/11/2026, Wednesday 2/12/2026, Thursday 2/13/2026, Monday 2/16/2026, Wednesday 2/18/2026, Friday 2/20/2026, and Monday 2/23/2026.During an interview on 2/26/2026 at 3:30 PM, the Director of Nursing confirmed Resident #5 did not have Physician's Orders per the facility policy for the type and location of the dialysis access site, the dialysis clinic or schedule, the nephrologist's name and phone number, and transportation arrangements, and Resident #5's care plan for dialysis was incorrect for the dialysis days and the access site, and confirmed Resident #5's medication schedule had not been adjusted for the when the resident is out at the dialysis clinic.

Based on facility policy review, medical record review, observation, and interviews, the facility failed to ensure the pharmacy provided an accurate physician prescribed medication for 1 resident (Resident #25) of 3 residents observed for medication administration. The findings include:Review of the Pharmacy Services Agreement, dated 2/2023 and continued as current agreement, revealed .Responsibilities of the Pharmacy .maintain accurate drug profiles, consistent with the information provided to the Pharmacy, on each facility resident served by pharmacy .Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Hypertension (high blood pressure), Polyneuropathy (nerve damage), and Alcohol Use, Unspecified, With Withdrawal.Review of a comprehensive care plan for Resident #25 dated 1/19/2026, revealed .The resident has altered cardiovascular status r/t [related to] Hypertension .Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #25 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed Resident #25 had an active diagnosis of Hypertension. Review of the Lisinopril pharmacy card for Resident #25 available in the medication cart revealed the pharmacy label read, .Lisinopril 40 mg .give 1 tablet .daily .for 7 days hold for sbp <115 . Further review revealed an order date of 1/19/2026, and a refill date of 1/26/2026.Review of the Physician's Orders for Resident #25 revealed the following orders prescribed:1. An order dated 1/16/2026, .Lisinopril 40 mg one time a day . to start 1/17/2026. This was discontinued on 1/19/2026.2. An order 1/19/2026, . Lisinopril 40 mg one time a day .hold for sbp [systolic blood pressure] < [less than] 115 .for 7 days . scheduled to start 1/20/2026 and end 1/26/2026.3. An order dated 1/19/206, . Lisinopril 40 mg one time a day . with no blood pressure parameters, scheduled to start on 1/27/2026. This was discontinued on 1/22/2026.4. An order dated 1/22/2026, .Lisinopril 10 mg one time a day .hold for sbp <115 . scheduled to start 1/23/2026 and end 1/26/2026.5. An order dated 1/22/2026, .Lisinopril 10 mg one time a day . with no blood pressure parameter, to start on 1/27/2026 to present (2/24/2026).Review of the pharmacy's delivery manifests for Resident #25 from admission on [DATE] through 2/24/2026, revealed the pharmacy sent the following medications to the facility for Resident #25:1. 1/16/2026 Lisinopril 40 mg - quantity of 30 tablets2. 1/19/2026 Lisinopril 40 mg - quantity 37 tablets2. 1/23/2026 Lisinopril 10 mg - quantity of 4 tablets3. 1/26/2026 Lisinopril 40 mg - quantity of 37 tabletsDuring an observation of medication administration on 2/24/2026 at 8:20 AM, RN D was observed preparing morning medications for Resident #25. RN D viewed the order on the MAR, which read .Lisinopril [medication used to lower blood pressure] 10 mg [milligrams] .daily . RN D retrieved the card of Lisinopril from the medication cart drawer, and checked the pharmacy label which read, .Lisinopril 40 mg . RN D did not give the medication off this card and retrieved the correct dose of Lisinopril 10 mg for Resident #25 from the Automated Medication Dispensing System (AMDS). During an interview on 2/26/2026 at 1:15 PM, the Pharmacy Director confirmed Physician Orders are electronically sent to the pharmacy when entered into the Electronic Health Record and confirmed Lisinopril 40 mg was sent to the facility on 1/26/2026, instead of Lisinopril 10 mg which was ordered on 1/22/2026.

Based on facility policy review, medical record review, and interviews, the facility failed to accurately assess the dental status and assist in providing alternate funding sources or delivery systems to meet the dental needs of 1 resident (Resident #43) of 3 residents reviewed for dental services. The findings include:Review of the facility's policy titled, Dental Services, dated 11/2024, revealed .It is the policy of this facility to assist residents in obtaining routine .and emergency dental care .'Routine dental services' means .smoothing of broken teeth .'Emergency dental services' includes services needed to treat an episode of acute pain in teeth .broken, or otherwise damaged teeth .the dental needs of each resident are identified through the physical assessment and MDS [Minimum Data Set] assessment processes, and are addressed in each resident's plan of care .oral/dental status shall be documented according to assessment findings .Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including History of a Stroke with Aphasia (difficulty speaking), Chronic Obstructive Pulmonary Disease, Chronic Pain Syndrome, and Diabetes.Review of a care plan for Resident #43 revealed a problem dated 6/6/2024, .The resident dips snuff on a regular basis . with interventions including, .monitor oral hygiene .Review of a referral for dental appointment transportation for Resident #43 revealed .f/u [follow up] dental r/t [related to] mouth pain . the appointment date was scheduled for 3/6/2025.Review of a dental evaluation for Resident #43 dated 3/6/2025, revealed .Pt [patient] [Resident #43] will need several fillings/exts [extractions] & [and] a debridement. Pt will need more advanced care that we [outside dental office] can provide @ [at] our office . Further review revealed the resident needed 8 teeth extracted.Review of a referral for dental appointment transportation for Resident #43 revealed .f/u oral surgeon . The appointment date was scheduled for 4/15/2025.Review of a Patient Benefit Summary from the dental office for Resident #43 dated 4/16/2025 (for the appointment on 4/15/2025), revealed the resident required simple extractions of 13 teeth, surgical extraction of 3 teeth, and Alveoplasty (reshaping and smoothing of the jawbone after extractions). Further review revealed a total expense estimate of $5,780.00, which included an upfront cost in the amount of $1855.00 due at the time of surgery.Review of the medical record for Resident #43 revealed no further dental visits had been conducted after the 4/15/2025 visit.Review of an annual MDS assessment dated [DATE], revealed Resident #43 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed Resident #43 had no behavior such as rejection of care, required set-up or clean-up assistance of staff for oral hygiene, used tobacco, and had no natural teeth or tooth fragment(s) (edentulous).Review of a care plan for Resident #43 revealed a problem dated 11/18/2025, .The resident has potential for oral/dental health problems r/t [related to] poor oral hygiene .coordinate arrangements for dental care .Review of a quarterly MDS assessment dated [DATE], revealed Resident #43 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed Resident #43 required set-up or clean-up assistance of staff for oral hygiene, During an interview and observation on 2/23/2026 at 10:40 AM, Resident #43 had difficulty speaking due to aphasia and was unable to form words other than yes and no. When asked if the resident had difficulty chewing food, Resident #43 stated, Yes. When asked if he was able to tolerate eating and drinking despite current dental issues, Resident #43 stated, Yes. Resident #43 opened his mouth for this surveyor to view his teeth, and the resident was observed with darkened or decayed teeth, with what appeared to be broken and/or chipped areas throughout. When asked if the resident wanted to have the teeth extracted that were recommended by dental services, Resident #43 stated, Yes.Review of the Electronic Health Record's (EHR's) documentation of Activities of Daily Living (ADL's) dated 2/2/2026 - 2/25/2026, revealed Resident #43 received oral care 1 to 3 times daily and typically consumed 100% of meals.Review of the Physician's Orders from 1/1/2026 - 2/25/2026, revealed Resident #43 received a regular diet, no added salt, and did not require any changes to his diet due to the resident's dental status. During an interview on 2/24/2026 at 2:00 PM, the Social Services Director (SSD) stated Resident #43's mother attended the dental appointment with the resident on 4/15/2025. Resident #43's mother had told the Social Services Director she did not have the money to pay the fee required of $1855.00 before dental services could be completed.During an interview on 2/25/2026 at 3:30 PM, the SSD confirmed the facility had not provided assistance to Resident #43 or his mother to help obtain alternate funding sources or delivery systems for the dental services Resident #43 needed. The SSD stated, I didn't give them [Resident #43 or the resident's mother] any other options. I should have tried to find maybe somewhere that does charity cases, or maybe a grant, but I didn't .During an interview on 2/26/2026 at 4:25 PM, the Director of Nursing (DON) confirmed Resident #43's annual MDS dated [DATE] was inaccurate for dentition and Resident #43's care plan did not include the resident's dental issues including the need for extractions.

Based on facility policy, medical record review, and interviews, the facility failed to maintain an accurate and complete medical record for 3 residents (Resident's #77, #5, and #6) of 24 sampled residents.The findings include: Review of the facility policy titled Fall Prevention Program, revised 10/01/2025, revealed .When any resident experiences a fall, the facility will .document all evaluations/assessments and actions taken . Review of the facility's undated policy titled Medication Administration, revealed .Review MAR [Medication Administration Record] to identify medication to be administered .Remove medication from source .Administer medication as ordered .Sign MAR after administered . The findings include: Review of the facility policy Fall Prevention Program dated 10/08/2024, revised 10/01/2025, revealed .When any resident experiences a fall, the facility will .document all evaluations/assessments and actions taken . Review of the medical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Difficulty in Walking, Heart Failure and Breast Cancer. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #77 scored an 11 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Further review revealed Resident #77 had a history of falls. Review of a comprehensive care plan dated 9/15/2025, revealed Resident #77 had a .ADL [activities of daily living] self-care performance deficit related to CVA [stroke] .at risk for falls . Review of a Fall Scene Investigation Report for Resident #77 dated 10/3/2025 5:30 PM, .found on the floor . Review of an unwitnessed Fall with head injury record dated 10/3/2025 at 17:30, revealed Resident #77 found in room on the floor at foot of bed. During an interview on 2/25/2026 at 9:45 AM, Director of Nursing (DON) stated that on 10/3/2025 Resident #77 had a fall on 10/3/2025 at 5:30 PM and confirmed the documentation in Resident #77's medical record was not accurate and did not reflect the fall. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus, End Stage Renal Disease, and Dependence on Hemodialysis (use of machinery to filter wastes from the blood). Review of the comprehensive care plan dated 8/1/2025, revealed Resident #5's care plan included, .The resident has Diabetes Mellitus .Administer Diabetes medication as ordered by doctor . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of a Physician's Order for Resident #5 dated 10/13/2025, revealed .Lacosamide Oral Solution 100 MG [milligrams]/10 ML [milliliter] .Give 10 mL .in the evening every Mon [Monday], Wed [Wednesday], and Fri [Friday] for seizure disorder, give after HD [Hemodialysis] sessions . Review of the MAR for Resident #5 dated 2/1/2028-2/28/2028, revealed Lacosamide was scheduled for the PM med pass (3:00 PM-6:00 PM). Further review revealed no documentation the lacosamide was administration on 2/23/2026. Review of a Physician's Order for Resident #5 dated 10/30/2025, revealed .Levothyroxine Sodium .75 mcg [micrograms] . give 1 tablet .one time a day . Review of the MAR for Resident #5 dated 2/1/2028-2/28/2028, revealed no documentation the levothyroxine was administered on 2/21/2026 at 6:00 AM. Review of a Physician's Order for Resident #5 dated 12/2/2025, revealed .Insulin Lispro Injection Solution .Inject as per sliding scale: if 0 - 150 = 0 units; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12 units; 451+ = Notify MD, subcutaneously every 6 hours for Diabetes .glucose <60 or >451 notify MD . Review of the MAR for Resident #5 dated 2/1/2028-2/28/2028, revealed no documentation of the blood glucose level (required to determine the amount of insulin units to administer) on 2/2/2026 at 6:00 PM, 2/5/2026 at 6:00 PM, 2/7/2026 at 6:00 PM, and 2/23/2026 at 6:00 PM. Review of a Physician's Order for Resident #5 dated 2/10/2026, revealed .[metoclopramide] .5 mg .give 1 tablet .before meals for nausea . Review of the MAR for Resident #5 dated 2/1/2028-2/28/2028, revealed no documentation the metoclopramide was administered on 2/21/2030 at 6:30 AM, 2/23/2026 at 4:30 PM, and 2/24/2026 at 6:30 AM. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Type 1 Diabetes Mellitus with Chronic Kidney Disease, History of a Stroke, and Congestive Heart Failure. Review of the comprehensive care plan dated 8/4/2025, revealed Resident #6's care plan included .The resident has Diabetes Mellitus .Administer Diabetes medication as ordered by doctor . Review of a quarterly MDS assessment dated [DATE], revealed Resident #6 scored a 12 on the BIMS assessment, which indicated the resident had moderate cognitive impairment. Review of a Physician's Order for Resident #6 dated 2/20/2026, revealed .Insulin Lispro Injection Solution 100 units/mL .Inject as per sliding scale: if 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 - 450 = 12units; >451 notify physician, subcutaneously three times a day every Mon [Monday], Wed [Wednesday], Fri [Friday] for dm [Diabetes Mellitus] . Review of the MAR for Resident #6 dated 2/1/2026-2/28/2026, revealed no documentation of the blood glucose level (required to determine the amount of insulin units to administer) on 2/23/2026 at 5:00 PM. During an interview on 2/26/2026 at 4:00 PM, the Director of Nursing (DON) confirmed medications should be documented on the MAR when administered or withheld and should contain the reason for holding a medication. The DON confirmed the MAR for Residents #5 and #6 contained blanks which meant those doses of scheduled medications were not documented.

Based on facility policy review, medical record review, facility investigation documentation review, and interview, the facility failed to prevent abuse for 3 residents, (Residents #3, #4, and #5) of 7 residents reviewed for abuse or neglect. The facility failures resulted when the facility failed to protect Residents #3, #4, and #5 from abuse by Resident #2, who was involved in 3 separate altercations between 1/16/2024 and 1/20/2024 in which he slapped Resident #4 on 1/16/2024, slapped Resident #3 on 1/19/2024, and grabbed Resident #5's arm on 1/20/2024. The Findings Include: Review of the facility policy titled, Abuse, Neglect, and Exploitation, implemented 9/18/2023, revealed .Abuse .the willful infliction of injury .Physical abuse includes but is not limited to hitting, slapping, punching, biting, and kicking .The facility will make efforts to ensure all residents are protected from physical abuse . Review of the medial record revealed Resident #2 was admitted to the facility 2/8/2022 with diagnoses including Unspecified Dementia with Behaviors, Type 2 Diabetes, Hypertension, Congestive Heart Failure, Arteriosclerotic Vascular Disease, Peripheral Vascular Disease, Chronic Obstructive Pulmonary Disease, and Stage 3 Chronic Kidney Disease. Review of the Care Plan for Resident #2 dated 1/16/2024, revealed the resident had impaired cognition, elopement risk, and verbal behaviors. The care plan inclued new interventions for physical behaviors directed toward others. Review of the re-admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated severe cognitive impairment. Resident #2 had impaired thought processes, mobility limitations, and required assistance of one or two persons for activities of daily living. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Cerebral Atherosclerosis, Age Related Debility, Unspecified Dementia with Behaviors, Anxiety Disorder, and Hypertension. Review of the quarterly MDS assessment dated [DATE], revealed Resident #4 scored a 3 on the BIMS assessment which indicated severe cognitive impairment. Resident #4 required assistance of one or two persons for ADLs. Resident #4 had no history of behaviors towards self or others. Review of the facility investigation documentation dated 1/16/2024 at 5:50 PM, revealed Resident #2 and Resident #4 were seated in the lobby. Resident #2 slapped Resident #4 on the right cheek as the two interacted without provocation. Staff immediately separated the residents, notified the facility Director of Nursing (DON), the Administrator, and the Hospice Providers for both residents of the incident. Neither resident recalled the incident within 5 minutes of its occurrence and denied an altercation had happened at all. Resident #4 did not sustain injuries in the incident. Resident #4 had no injuries or recall of the incident. Resident #2's family declined recommended medication adjustments made by the hospice provider. No changes were recommended by hospice for Resident #4. Resident #2 was placed on increased supervision with every 15- minute checks for 3 days. Resident #4 was followed by the facility social worker for 3 days with no evidence any recall of the incident, psychosocial harm or decline in condition. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Dementia with Psychosis, Malnutrition, Congestive Heart Failure, Generalized Anxiety Disorder, Impulse Disorder, and Stage 3 Chronic Kidney Disease. Review of the quarterly MDS assessment dated [DATE], revealed Resident #3 had severe cognitive impairment and the BIMS assessment was unable to be obtained due to impaired thought processes. The MDS revealed Resident #3 had mobility impairments, and required 2 persons assistance for ADLs. Review of the care plan for Resident #3 showed the resident was care planned for verbal and physical behaviors directed toward others and was resistant to personal care. Review of the facility investigation documentation dated 1/19/2024 at 3:30 PM, revealed Resident #2 was seated in a wheelchair in the lobby near Resident #3 who was seated in a gerichair (A specialty chair for persons with impaired trunk control or mobility). Resident #2 slapped Resident #3 on the left side of the face. Staff separated the residents. Resident #2 was placed on 1 to 1 supervision until the resident was transferred by Emergency Medical Services (EMS) to a local emergency department (ED) for psychiatric evaluation. Resident #3 was taken to her room where she was examined by the nurse and no injuries were noted. Resident #3 had no recall of the incident shortly after it occurred. Resident #2 had no recall of the altercation by the time EMS arrived to the facility. The Hospice Provider for both residents were notified of the altercation. The hospice nurse evaluated Resident #3, determined no changes in the treatment plan were warranted, and notified the hospice physician of the altercation for both residents. The Resident #2 was examined at the hospital, was diagnosed with a urinary tract infection, and was discharged back to the facility on 1 to 1 supervision for monitoring on 1/19/2024. During an interview on 6/5/2024 at 1:15 PM, the Maintenance Director stated he witnessed the incident between Resident #2 and Resident #3. The Maintenance Director reported he separated the residents and reported the situation to the nursing staff and the DON immediately. The Maintenance Director stated Resident #2 and Resident #3 were seated in wheelchairs in the front lobby where Resident #2 tried to take a piece of paper from Resident #3 who was reading the paper. Resident #3 pulled the paper back from Resident #2's grasp, at which time Resident #2 lightly slapped Resident #3 on the cheek before he could intercede. The Maintenance Director reported both residents were severely confused at baseline, and neither resident recalled the incident 5 minutes or less after it occurred. The Maintenance Director stated he witnessed the altercation as .a very light tap . on Resident #3's cheek and no injuries were noted to either resident. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Adult Failure to Thrive, Type 2 Diabetes, Iron Deficiency Anemia, Unspecified Dementia without Behaviors, Atrial Fibrillation, Metabolic Encephalopathy and Long-Term Anticoagulant Use. Review of the quarterly MDS assessment dated [DATE], revealed Resident #5 scored a 3 on the BIMS assessment which indicated severe cognitive impairment. Resident #5 had limited ability to comprehend speech or express needs, mobility limitations and required assistance of one or two persons for ADLs. Resident #5 had no history of behaviors directed at self or others. Review of the facility investigation documentation dated 1/20/2024 at 11:25 AM, revealed Resident #5 while being rolled in a wheelchair by a staff member passed Resident #2 in the hallway who was also being rolled by a staff member in the opposite direction. (Resident #2 was on 1 to 1 supervision due to behaviors at the time). As the residents were rolled in their wheelchairs by staff past each other, Resident #2 reached out and grabbed Resident #5's right hand and arm. Resident #5 became briefly agitated and pulled away. The Certified Nurse Aides (CNA A and CNA B) quickly separated the residents and continued in opposite directions to their respective rooms. Nursing staff immediately responded, assessed Resident #5 for any injuries and none were noted.The Nurse Practitioner (NP) for both residents were notified of the incident, ordered precautionary mobile X rays of Resident #5's arm, which were performed the same day and were negative. Resident #2 was transferred by EMS back to the local hospital for psychiatric evaluation and was admitted to the hospital for acute psychiatric care. Review of the nursing notes dated from 1/20/2024 to 1/27/2024, revealed Resident #5 had no recall of the altercation a few hours after the incident occurred and experienced no negative outcomes or injuries from the incident. During interview on 6/6/2024 at 11:15 AM, the DON stated Resident #2 had several prior stays at the facility prior to 2022 and no prior history of physical aggression directed at others had been observed before 1/16/2024. The DON stated Resident #2 had severe cognitive impairment and occasionally had verbal behaviors but had never shown physical aggression towards other residents. The DON further stated Resident #2 was occasionally resistant to ADL care related his cognition and diagnosis of Dementia. The DON confirmed Resident #2's aggression towards Resident #4 appeared unprovoked, and Resident #2 had slapped Resident #4. Continued interview revealed the DON confirmed on 1/19/2024, Resident #2 was the aggressor and had slapped Resident #3 during the altercation. The DON stated Resident #2 was aggressive towards Resident #5 and Resident #2 grabbed Resident #5 on the arm and hand. The DON confirmed the facility failed to prevent abuse of Residents #3, #4, and #5 by Resident #2. During an interview on 6/10/2024 at 2:52 PM, CNA A stated she had been providing 1 to 1 care for monitoring with Resident #2 on 1/20/2024 and the resident had become agitated after lunch. CNA A stated after Resident #2 finished the lunch meal, she took Resident #2 to his room for a less noisy environment and to provide ADLs assistance. CNA #2 reported as she rolled Resident #2 in his wheelchair down the hall, in the opposite direction, past Resident #5 , who was being transported by CNA B in a wheelchair, Resident #2 without warning, abruptly reached out and grabbed Resident #5 by the right hand and arm. CNA A stated Resident #5's arm was resting on the wheelchair arm at the time of the incident. CNA A stated Resident #5 pulled away forcefully, which exacerbated Resident #2's agitation. CNA A stated she and CNA B immediately separated the residents and continued along their ways to their respective rooms as nursing staff responded from the nursing station. Nursing staff examined Resident #5 and no injuries were noted. The nursing staff notified the NP and X-rays were obtained for Resident #5's hand and arm. CNA A confirmed Resident #2 was the aggressor in the altercation and reported shortly afterwards, EMS personnel arrived and took him to the hospital.

Based on facility policy review, medical record review, facility investigation, and interview the facility failed to prevent abuse for 1 Resident (#2) of 7 residents reviewed for physical abuse. The findings include: Review of facility abuse policy titled Abuse Prevention/Reporting Policy and Procedure reviewed 5/9/2018, showed .Abuse .the willful infliction of injury .Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Resident #2 was admitted to the facility on [DATE] with diagnoses including Acute Kidney Failure, Depressive Episodes, Traumatic Brain Injury, Impulse Disorder, and Cognitive Impairment. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9 indicating severe cognitive impairment. Review of a comprehensive care plan last revised 5/25/2023 revealed Resident #2 potential for inappropriate behaviors related to traumatic brain injury. Resident #1 was admitted to the facility on [DATE] with diagnoses including Hypothyroidism, Hypertension, Unspecified Intellectual Disabilities, and Heart Failure. Review of a quarterly MDS assessment dated [DATE] revealed Resident #1 had a Brief Interview for BIMS score of 14 indicating the resident was cognitively intact. Review of a comprehensive care plan last revised 3/26/2023 showed Resident #1 had resident to resident altercation. Review of Resident #2's nurses progress note dated 3/26/2023 by Licensed Practical Nurse (LPN) #1 revealed .observed a resident [Resident #1] .stand up with his fist raised his back was turned but .[Maintenance Director] observed resident [Resident #2] was hit on his chest. Residents separated and assessed .no injuries . During an interview on 6/5/2023 at 12:37 PM, Resident #1 stated he recalled the incident with Resident #1. He stated Resident #1 made him mad and he hit him. During an interview on 6/5/2023 at 12:50 PM, the Maintenance Director stated he witnessed the altercation between Resident #1 and Resident #2. The Maintenance Director said he was in the private dining room adjacent to the main dining room, heard someone shouting, and saw Resident #1 stand up and had his hand in a fist. The Maintenance Director stated Resident #1 hit Resident #2 in the chest.

Based on review of the facility's assessment, facility's nursing staff schedules, daily nursing staff posting sheets, time clock punches, and interviews, the facility failed to provide the services of a Registered Nurse (RN) for the minimum requirement of 8 consecutive hours a day for 30 days (during the 4th quarter 10/1/2022-12/31/2022) of 92 days reviewed. The findings included: Review of the Facility assessment dated [DATE] showed .staffing plan .Facility Resources needed to provide competent support and care for our resident population every day and during emergencies .Nursing Services DON [Director of Nursing], RN [Registered Nurse] . Review of the facility's nursing staff schedule, facility's daily staffing posting sheets, and facility's time clock punches revealed no RN coverage on 10/3/2022, 10/4/2022, 10/5/2022, 10/7/2022, 10/8/2022, 10/11/2022, 10/17/2022, 10/18/2022, 10/21/2022, 10/22/2022, 10/23/2022, 10/26/2022, 10/27/2022, 11/4/2022, 11/5/2022, 11/10/2022, 11/15/2022, 11/19/2022, 11/23/2022, 11/24/2022, 11/28/2022, 11/29/2022, 12/7/2022, 12/8/2022, 12/12/2022, 12/13/2022, 12/16/2022 and 12/21/2022. Continue review of the facility staffing documentation revealed there was 4 hours of RN converage on 12/26/2022 and 12/31/2022 for the residents in the facility. During an interview on 3/21/2023 at 2:23 PM, the Administrator confirmed the facility had not provided RN coverage for 8 consecutive hours a day, for 30 days out of 92 days reviewed to provide care and services to the residents in the facility.

Based on facility policy reviews, observations, and interviews, the facility failed to maintain a safe and sanitary kitchen for 1 of 1 reach in cooler, in 1 of 1 walk-in freezers, in 1 of 1 milk cooler, and failed to ensure a beard covering was used for 1 of 4 employees working in the kitchen affecting 56 of 56 residents in the facility. The findings include: The facility policy titled, Refrigerators and Freezers, dated 12/2008 showed .Monthly tracking sheets for all refrigerators .will be posted to record temperatures .will include .temperature .'action taken' .if temperatures are not acceptable .The supervisor will take immediate action if temperatures are out of range .All food shall be appropriately dated to ensure proper rotation by expiration dates .'Use by' dates will be completed with expiration dates on all prepared food in refrigerators . The facility policy titled, Food Preparation and Service, dated 10/2017 showed .staff will adhere to proper hygiene and sanitary practices .staff shall wear hair restraints ( .beard restraint .) so that hair does not contact food . During an observation and interview on 3/19/2023 at 10:16 AM, the reach in cooler showed temperature log sheets were to be checked twice daily (AM and PM)and temperatures were to be maintained at or below 41 degrees. The log showed the following information: - On 3/1/2023 the PM temperature was recorded at 44 degrees. - On 3/4/2023 the AM temperature was recorded at 44 degrees and the PM temperature were recorded at 42 degrees. - On 3/8/2023 the AM temperature was recorded at 44 degrees and the PM temperature was recorded at 44 degrees. - On 3/9/2023 the AM temperature was recorded at 44 degrees. - On 3/12/2023 the PM temperature was recorded at 44 degrees. - On 3/13/2023 the AM temperature was recorded at 42 degrees. - On 3/14/2023 the PM temperature was recorded at 44 degrees. - On 3/15/2023 the PM temperature was recorded at 44 degrees. The Dietary Supervisor confirmed the temperatures were recorded as out of range. She stated staff were to recheck the temperatures and if the temperatures remain out of range, then maintenance was to be notified to check the thermostat and the food was to be moved from the cooler. During an observation and interview on 3/19/2023 at 10:17 AM, showed in the reach in cooler was 4 1/2 peanut butter sandwiches prepared and ready for resident consumption. The sandwiches were not dated when prepared or an use by date. She confirmed prepared food must be dated. During an observation and interview of the walk-in freezer on 3/19/2023 at 10:24 AM showed 14 frozen Salisbury Steaks were unsealed, open to air, and available for resident consumption. The Dietary Supervisor stated all opened food was to be sealed. She confirmed the frozen steaks were not sealed and were available for resident use. During an observation and interview of the milk cooler temperature logs on 3/19/2023 at 10:30 AM, showed no AM temperatures were recorded on 3/16/2023 or 3/17/2023. The Dietary Supervisor confirmed the milk cooler temperatures had not been recorded. During an observation on 3/19/2023 at 11:15 AM, the Cook had a full short beard with no beard covering. During an interview on 3/19/2024 at 11:24 AM, the Cook confirmed he was not wearing a beard cover to prevent cross contamination.

Based on facility policy review, medical record review, and interview, the facility failed to act upon the consulting Pharmacist's recommendations for 2 residents (Residents #2 and #6) of 5 residents reviewed for unnecessary medications. The findings include: Review of the facility policy titled, Physician Services, revised 4/2013, showed .The attending physician will determine the relevance of any recommended interventions from any discipline .physician is not obligated to accept these recommendations if .clinically valid reasons for not doing so . Resident #2 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease and Hyperlipidemia (high blood cholesterol). Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #2 was cognitively intact and recieved hospice care. Review of the Consultant Pharmacist Communication for review period 7/2022 showed, .resident is currently Hospice Care .evaluate the following med(s) to determine if continued use is still required .Recommendations .Dc [discontinue] Lovastatin [a medication used to treat high blood cholesterol] . Review showed the pharmacy recommendations made by the Pharmacist were not addressed by the physician. The form was not signed or acknowledged by the physician. Review of the Consultant Pharmacist Communication for review period 11/2022 showed, .all psychoactives .are subject to attempts at gradual dose reduction (GDR) .Please review .determine if the following dose reduction .would be appropriate .Restoril to 7.5mg [milligram] . Review showed The pharmacy recommendations made by the Pharmacist were not addressed by the physician. The form was not signed or acknowledged by the physician. 41291 Resident #6 was admitted to the facility on [DATE] with diagnoses including Post-Traumatic Stress Disorder, Impulse Disorder, Insomnia, Type 2 Diabetes Mellitus, Major Depressive Disorder, and Anxiety Disorder. Review of the admission MDS assessment dated [DATE] showed Resident #6 was cognitively intact and received insulin injections on 7 of the 7 days during the look back review. Review of the Consultant Pharmacist Communication to the Physician form dated 5/2022 showed the pharmacist recommended to discontinue the sliding scale insulin. Review showed the physician response was left blank, and the form was not signed or acknowledged by the physician. During an interview on 3/21/2023 at 10:20 AM, the Director of Nursing confirmed the physician failed to acknowledge pharmacy recommendations for Residents #2 and #6.

Based on facility policy review, observation, and interview, the facility failed to post daily staffing for 1 day of 3 days reviewed. The findings include: Review of the facility policy untitled and undated showed .The nurse staffing data needs to be posted on a daily basis at the beginning of each shift . Observation on 3/19/2023 at 9:40 AM, showed daily staffing sheet was dated Saturday 3/18/2023. During an interview on 3/19/2023 at 9:49 AM, the Therapy Director confirmed the daily staffing sheet was dated Saturday 3/18/2023. During an interview on 3/19/2023 at 11:00 AM, the Director of Nursing stated it was her expectation daily staffing would be posted daily. The nurse manger is responsible for posting the daily staffing sheet Monday through Friday, and the weekend manager is responsible for posting daily staffing Saturday and Sunday. She confirmed daily staffing had not been posted for 3/19/2023.

Based on facility policy review, review of a facility investigation, medical record review, observation, and interview, the facility failed to notify the Physician or Nurse Practitioner (NP), the Director of Nursing (DON), and the family of a fall for 1 resident (Resident #1) of 3 residents reviewed for a notification of change. The findings include: Review of the facility policy titled, Assessing Falls and Their Causes, dated 3/2018, showed .procedure .for assessing a resident after a fall .notify .the resident's family, the attending Physician .the Director of Nursing . Resident #1 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Dysphagia, Impulse Disorders, Severe Intellectual Disabilities, Adult Failure to Thrive, and Vascular Dementia with other Behavioral Disturbances. Review of a fall investigation, dated 2/9/2023, showed Resident #1 had an unobserved fall on 2/5/2023 at 10:30 AM, .Resident was sitting up in room in w/c [wheelchair] and fell out of wheelchair .assessed for injuries .has good rom [range of motion] with no facial grimacing or pain noted . Further review showed Reported to Supervisor: No, Physician and Family Notified: left blank with no documentation, and Exam by Physician: No. Additional follow-ups showed the DON was made aware of the fall on 2/9/2023, with the NP and family notified the same day on 2/9/2023. Review of the Departmental Notes, dated 2/9/2023, showed .charting for 2/5/2023 .resident sitting up in chair and slid out of chair observed on floor beside of bed .resident assessed for injuries good range of motion .no redness or bruising noted on resident at that time .vital signs . signed by Licensed Practical Nurse #1. A Departmental Notes, dated 2/10/2023, showed .bruising to right forehead and neck/shoulder . Review of an Annual Minimum Data Set (MDS), dated [DATE], showed Resident #1 had scored 0 for his Brief Interview of Mental Status (BIMS), indicating severe cognitive impairment, was rarely understood, and required total dependence on staff to perform Activities of Daily Living (ADLs) including transfer, eating, and personal hygiene. He was unable to walk and used a wheelchair for mobility. Observation on 2/15/2023 at 9:30 AM, of Resident #1 showed an alert, nonverbal resident in a lowered bed. No bruising was noted to his right forehead. His shoulder was not visible. During a telephone interview on 2/15/2023 at 1:00 PM, Certified Nursing Assistant #1 stated she found Resident #1 on the floor next to his wheelchair in his room. She notified Licensed Practical Nurse (LPN) #1. During a telephone interview on 2/15/2023 at 2:35 PM, LPN #1 stated she was informed by CNA #1 of Resident #1's fall. LPN #1 stated she assessed him for injuries, observed none, and obtained vital signs which were within normal limits. She stated Resident #1 did not lose consciousness and had no change in mentation. She stated she was the Charge Nurse for the shift. She confirmed she failed to inform and report the fall to the oncoming nursing shift, the Director of Nursing (DON), Physician or Nurse Practitioner (NP), and the family of Resident #1's fall on 2/5/2023. During an interview on 2/15/2023 at 2:45 PM, the DON confirmed LPN #1 failed to notify herself (the DON), the Physician or NP, and the family of a fall sustained by Resident #1 on 2/5/2023 until 2/9/2023.

Based on review of facility policy, review of a facility investigation, medical record review, observation, and interview, the facility failed to investigate a fall in a timely manner for 1 resident (Resident #1) of 3 residents reviewed for falls. The findings include: Review of the facility policy Assessing Falls and Their Causes, dated 3/2018, showed .guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall .observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall .document findings in the medical record .document any observed signs or symptoms of pain, swelling, bruising .changes in levels of responsiveness/consciousness and overall function .complete an incident report for resident falls no later than 24 hours after the fall occurs . Resident #1 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Dysphagia, Impulse Disorders, Severe Intellectual Disabilities, Adult Failure to Thrive, and Vascular Dementia with other Behavioral Disturbances. Review of a fall investigation, dated 2/9/2023, showed Resident #1 had an unobserved fall on 2/5/2023 at 10:30 AM, .Resident was sitting up in room in w/c [wheelchair] and fell out of wheelchair .assessed for injuries .has good rom [range of motion] with no facial grimacing or pain noted . Additional follow-ups, showed the DON was made aware of the 2/5/2023 fall on 2/9/2023 with .bruising on (r) [right] forehead and (r) shoulder .no incident report had been recorded .cause of bruising a CNA [Certified Nursing Assistant] said it was probably related to a fall on Sunday (2/5) [2/5/2023] . Review of the Departmental Notes, dated 2/9/2023, showed .charting for 2/5/2023 .resident sitting up in chair and slid out of chair observed on floor bedside of bed .resident assessed for injuries good range of motion .no redness or bruising noted on resident at that time .vital signs . signed by Licensed Practical Nurse #1. A Departmental Notes, dated 2/10/2023, showed .bruising to right forehead and neck/shoulder . Review of the Care Plan: Potential for Falls due to poor safety awareness and debility, showed the care plan was updated 2/9/2023. Review of an Annual Minimum Data Set (MDS), dated [DATE], showed Resident #1 had scored 0 for his Brief Interview of Mental Status (BIMS), indicating severe cognitive impairment, was rarely understood, and required total dependence on staff to perform Activities of Daily Living (ADLs) including transfer, eating, and personal hygiene. He was unable to walk and used a wheelchair for mobility. Review of a Long-Term Progress Note, dated 2/10/2023, the Nurse Practitioner (NP) showed .seen today for a recent fall .no obvious signs or symptoms of uncontrolled pain .bruising of the right forehead, right neck, and right shoulder that is resolving .no obvious swelling .no obvious injuries . Observation on 2/15/2023 at 9:30 AM, of Resident #1 showed an alert, nonverbal resident in a lowered bed. No bruising was noted to his right forehead. His shoulder was not visible. During a telephone interview on 2/15/2023 at 1:00 PM, Certified Nursing Assistant #1 stated she found Resident #1 on the floor next to his wheelchair in his room. She notified Licensed Practical Nurse (LPN) #1. During a telephone interview on 2/15/2023 at 1:20 PM, the Nurse Practitioner (NP) confirmed she was notified on 2/9/2023 of Resident #1's fall and conducted a physical assessment the next day. She stated his bruises were resolving, he displayed no change in his level of consciousness, no pain, and no extremity deformity. She did not write any orders on 2/10/2023 for Resident #1. During a telephone interview on 2/15/2023 at 2:35 PM, LPN #1 stated she was informed by CNA #1 of Resident #1's fall. LPN #1 stated she assessed him for injuries, observed none, and obtained vital signs which were within normal limits. She stated Resident #1 did not lose consciousness and had no change in mentation. She stated she was the Charge Nurse for the shift. She confirmed she failed to inform and report the fall to the oncoming nursing shift, the Director of Nursing (DON), Physician or NP, and the family. She confirmed she failed to begin and/or complete the documentation of the fall. During an interview on 2/15/2023 at 2:45 PM, the DON confirmed LPN #1 failed to initiate a falls incident report on 2/5/2023 on Resident #1. The DON stated the facility failed to initiate the fall investigation within 24 hours of Resident #1's fall on 2/5/2023.

Based on review of facility policies, observation, and interviews, the facility failed to wash hands before donning clean gloves in the kitchen, failed to maintain the dietary kitchen and food service equipment in a clean and sanitary manner, and failed to properly store food in a safe and sanitary manner, during 1 of 1 observations of the dietary department affecting 39 of 40 residents. The findings included: Review of the facility's policy titled Sanitation, last revised ,d+[DATE], showed .All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects .All utensils, counters, shelves and equipment shall be kept clean .all equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary .Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime . Review of the facility's policy titled Food Receiving and Storage, revised ,d+[DATE], showed .Food Services, or other designated staff, will maintain clean food storage areas at all times .food in designated dry storage areas will be kept off the floor .all foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) .Refrigerators/walk-ins will not be overcrowded . Review of the facility's policy titled Preventing Foodborne Illness-Employee Hygiene and Sanitation, dated ,d+[DATE], showed .Food and nutrition service employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness .Employees must wash their hands .after handling soiled equipment or utensils . Observation and interview on [DATE] at 8:50 AM, showed Medical Records Clerk #1 in the dish room washing dishes using the dish machine. Further observation showed Medical Record Clerk #1 was wearing gloves while handling dirty dishes, then proceeded to change her gloves prior to removing clean dishes from the dish machine but did not wash her hands prior to donning clean gloves. The Medical Records Clerk #1 confirmed she did not wash her hands prior to re-gloving and removing the clean dishes from the dish machine. Observation and interview on [DATE] from 8:55 AM to 9:05 AM, with the Certified Dietary Manager (CDM) showed the following: a buildup of thick dried brown debris on the table leg of the dirty dish table a buildup of thick dried brown debris on the water line under the dirty dish table 2 dry storage bins for sugar and flour, both with a sticky dusty debris on the lid. The sugar bin was approximately ,d+[DATE] full and was not labeled with a use by date (UBD), the flour bin was approximately ¼ full and did not have a UBD. 6 of 6 burners on the gas stove had black dried crusty debris. 4 of 4 doors on the gas oven showed dried splatters of food like debris, 2 of 2 ovens on the gas oven had dark black debris on the racks and on the bottom of the ovens. A buildup of dark crumbly debris on the can opener and a dark sticky substance on the base of the can opener holder. The deep fryer showed a buildup of grease and food particles on the sides, back splash, and front plate. The paper products storage room showed a box of 1000 cup lids stored on the floor under the paper storage rack. Small pieces of cardboard, a full can of cola, bread ties, an aerosol can of pan spray, crumbly food like debris, and dusty debris under the food storage rack in the dry food storage room. Observation of the walk-in cooler showed paper, box tape, and an onion peeling on the floor of the walk-in cooler. A food shelf in the walk-in cooler showed a gallon bag ¾ full of candied pecans sealed but not labeled and no UBD and a bag of orange gelatin with no UBD. A full 30-pound box of French fries, a 48-count box of pizza ¼ full, and a full 24-pound box of baby carrots stored on the floor in the walk-in freezer. The perimeter of the kitchen showed a dark sticky crumbly debris in front of the base boards and in all corners of the kitchen. The CDM confirmed the storage bins should be kept clean and should be labeled with a UBD and all open food items should be labeled with a UBD. Further interview confirmed the gas stove and oven had not been cleaned .in quite some time . Further interview confirmed the can opener was last used the previous evening and had not been cleaned after it was last used. The CDM confirmed the deep fryer should be wiped down after each use and the facility had failed to do so. Continued interview confirmed the kitchen floors should be swept and mopped daily and it had not been done .in some time . During an interview on [DATE] at 11:50 AM, Dietary Cook #1 stated she had not seen a kitchen daily cleaning assignment sheet for over a year. During an interview on [DATE] at 11:55 AM, Dietary Aide #1 stated she had been at the facility since [DATE] and she had never been given a daily cleaning schedule. During an interview on [DATE] at 1:15 PM, the CDM stated the facility was not currently utilizing a daily or weekly equipment/kitchen cleaning schedule. The CDM confirmed the facility failed to maintain kitchen equipment, kitchen, storage areas and dish room environments in a clean and sanitary manner.

Based on review of the facility's nursing staff schedules and interview, the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 hours a day for 14 days of 122 days reviewed. The findings include: Review of the facility's nursing staff schedules for (MONTH) 2019, (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019 revealed no RN on duty for 7/7/2019, 7/20/2019, 7/21/2019, 8/3/2019, 8/4/2019, 8/10/2019, 8/17/2019, 8/18/2019, 9/28/2019, 9/29/2019, 10/12/2019, 10/13/2019, 10/19/2019, and 10/20/2019. Interview with the Director of Nursing (DON) on 10/29/19 at 12:20 PM, in the conference room, confirmed she was aware there was no RN on duty 7 days a week for at least 8 hours a day in the facility. Interview with Human Resource (HR) #1 on 10/29/19 at 3:10 PM, in the Human Resource Office, confirmed there was no RN coverage for the dates of 7/7/2019, 7/20/2019, 7/21/2019, 8/3/2019, 8/4/2019, 8/10/2019, 8/17/2019, 8/18/2019, 9/28/2019, 9/29/2019, 10/12/2019, 10/13/2019, 10/19/2019, and 10/20/2019. Interview with the Assistant Director of Nursing (ADON) on 10/30/19 at 8:19 AM, in the DON's office, confirmed .no we have not always had RN coverage for at least 8 hours a day . Interview with the Administrator on 10/30/19 at 8:40 AM, in the Administrator's Office, confirmed the Administrator was aware there was not an RN on duty 7 days a week for at least 8 hours a day .yes on some weekends we have not had RN coverage .

Based on facility policy review, medical record review, review of facility fall investigations, interview and observation, the facility failed to implement assitive devices to prevent an accident, resulting in a laceration requiring sutures, for 1 resident (#52) of 4 residents reviewed for falls of 45 residents sampled. The facility's failure to ensure assitive devices to prevent accidents were implemented resulted in actual harm to Resident #52. The findings include: Review of the facility policy Falls- Clinical Protocol revised 10/2010 revealed .the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling . Medical record review revealed Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a 14 day Minimum Data Set ((MDS) dated [DATE] revealed the resident had severe cognitive impairment. Review of a facility fall investigation dated 8/14/18 revealed, .during med (medication) pass I saw res (resident) up trying to walk et (and) was starting to fall to his left, ran to him et braced him under both armpits et eased him to sitting position on my feet. (resident) did not have any impacts or injury .Immediate actions taken .remain in view of staff . Review of Fall Risk Evaluation dated 8/15/18 revealed the resident scored a 22 (10 or higher is at risk) revealed, .Interventions .clip alarm to bed, pressure alarm to w/c (wheelchair) . Review of a facility fall investigation dated 9/2/18 revealed .res (resident) found on floor at bedside . res c/o (complained of) left side head pain beside eye/temple area . Continued review revealed, .resident does have decreased safety awareness and does not remember to call for help. Resident was to have alarm .staff noted alarm not sounding .interventions to prevent future falls .Bed Bolsters, Bedside floor mat . Review of a facility fall investigation dated 9/3/18 revealed, .Resident was found in his room by his bed on the floor, clip alarm sounding, head on the floor with blood coming from Left brow. Laceration to left brow, skin tear to Left elbow .(floor/safety) mat was not at bedside .Resident rolled out of bed . Continued review revealed the resident was sent to the emergency room due to a laceration to the left eyebrow and returned to the facility with sutures to the left eyebrow. Further review of the fall investigation revealed the floor mats were not in place at the time of the fall, and no documentation the bed bolsters were in place. Interview with the Director of Nursing (DON) on 10/24/18 at 12:35 PM, in the conference room, confirmed the intervention of the use of a clip-alarm was not in place and functioning at the time of the resident's fall on 9/2/18. Continued interview with the DON confirmed the facility failed to ensure floor mats and bed bolsters were in place at the time of Resident #52's fall from the bed on 9/3/18. Continued interview confirmed the resident had sustained a laceration requiring sutures due to the fall from the resident's bed on 9/3/18. Interview and observation of Resident #52 on 10/24/18 at 1:12 PM, in the resident's room, with the DON, revealed Resident #52 lying on the bed without bed bolsters in place. Continued observation and interview with the DON confirmed the facility had failed to ensure the bed bolsters were in place. Further interview confirmed the facility had failed to prevent falls and to ensure assistive devices were implemented to protect the resident from injury from falls, resulting in a [MEDICAL CONDITION] requiring sutures.

Based on facility policy review, medical record review, review of a medical dictionary, observation, and interview the facility failed to provide prompt treatment for [REDACTED]. The facility's failure resulted in harm for resident #75. The findings included: Review of facility policy Skin Care Guidelines dated December 2012, revealed "...orders for wound care will be obtained and initiated at the time a wound is identified...Pressure ulcers must be assessed and measured at least once a week...A pressure ulcer is a localized injury to the skin and/or underlying tissueusually over a boney prominence, as a result of pressure, or pressure in combination with shear and/or friction..." Resident # 75 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a hospital Discharge Summary dated May 26, 2012, revealed "...admitted [DATE], Hospital Course: decubitus ulcer on the coccygeal area had grown out proteus mirabilis [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staphylococcus Aureus)...patient underwent muscle flap surgery for [REDACTED]. Medical record review of the Treatment Record Dated May 2012, revealed "...May 28, 2012,...ST (stage) II ulcer R buttock..." Medical record review of a Weekly Wound Progress Note dated May 28, 2012, revealed "...Location: R buttock/sacrum ...Date of Onset: 5-28-12...Stage II appears as Stage II...Size: L (length) 4.5 cm (centimeter) W (width) 4.0 cm D (depth) 0.2 cm...Periwound: intact surgical scars visible...no odor...resembles shear/friction..." Medical record review of a Braden Scale for Predicting Pressure Sore Risk dated June 7, 2012, revealed Total Score 14 moderate risk..." Medical record review of a Social Services Notes dated June 11, 2012, revealed "...application request for a sand bed to (insurance) today...awaiting response..." (a "sand bed" is a fluidized air bed. Review of Mosby's Medical Dictionary, 8th Edition, 2009, revealed a fluidized air bed: "minimizes pressure and distributes weight evenly over the support surface. A gentle flow of temperature contrilled air is projected upward through numerous yiny openings called ceramic microspheres.") Medical record review of a Weekly Wound Progress Note dated June 12, 2012, (two weeks since last documented assessment) revealed "...Location: R buttock/sacrum...Date of Onset: 5-28-12...Stage II appears as Stage II...Size: L (length) 12 cm (centimeter) W (width) 5.5 cm D (depth) UTD (unable to determine)...Periwound: denuded...Odor: yes...Exudate: moderate...Other descriptions: Wound bed is 100 % slough..." Medical record review of a Physician's Progress Note dated June 13, 2012, revealed "...S/P (status [REDACTED]. Medical record review of a Social Services Notes dated June 13, 2012, revealed "...the precert application (for the sand bed) was missing a CPT (Current Procedure Terminology) code...faxed back..." Medical record review of a Weekly Wound Progress Note dated June 19, 2012, revealed "...Location: R buttock/sacrum...Stage UNST (unstageable)...Tissue Depth Full Thickness...undermining /tunneling: unknown..." Medical record review of a Social Services Note dated June 20, 2012, revealed "...(insurance) requested clinical info (information) on this patient (in relation to the June 11, 2013 order for the sand bed)...info r/t (related to) pressure ulcers faxed..." Medical record review of a Weekly Wound Progress Note dated June 25, 2012, revealed "...Location: R buttock/sacrum...Tissue Type: Necrotic/Eschar (dead tissue) Odor: yes...6-25-12 wound c/s (culture and sensitivity) collected..." Medical record review of a Social Services Note dated June 25, 2012, revealed "...called (insurance) today to f/u (follow up) on status regarding sand bed..." Medical record review of a Social Services Note dated June 29, 2012, revealed "...spoke with (insurance) today to f/u on progress with sand bed...SSD (Social Service Director) clarified that this patients doctor was wanting him/her to have a sand bed..." Medical record review of a Physician's Progress Note dated June 30, 2012, revealed "...wound still draining...wound c/s grew [MEDICAL CONDITION]" Medical record review of a Weekly Wound Progress Note dated July 2, 2012, revealed "...Location: R buttock/sacrum...Date of Onset: 5-28-12...Stage unst appears as unst...Periwound: excoriation shearing from tape...Exudate: copious...Other descriptions:[MEDICAL CONDITION] infection. Surgeon to be called today to have apt (appointment) made...Pain: 0..." Medical record review of a Social Services Note dated July 2, 2012, revealed "...resident was sent to...(surgeon) r/t wounds..." Medical record review of a Social Services Note dated July 3, 2012, revealed "...called (insurance) explained urgency (to receive sand bed)..." Medical record review of a Social Services Note dated July 9, 2012, revealed "...(insurance) rep (representative) stated bed was approved..." Medical record review of a Weekly Wound Progress Note dated July 11, 2012, revealed "...Location: R buttock/sacrum...Date of Onset: 5-28-12...Stage unst appears as Stage IV...Undermining/Tunneling: 12 clock - 3 clock 0.5 cm...Pain: 0..." Medical record review of a Weekly Wound Progress Note dated July 16, 2012, revealed "...Location: R buttock/sacrum...Dakin's (solution used to treat wound infections) used to [MEDICAL CONDITION]: 0..." Medical record review of a Weekly Wound Progress Note dated July 23, 2012, revealed "...Location: R buttock/sacrum...Decline from last measurement wound more friable (breakable) today...MD notified D/T (due to) increase drainage/odor...Pain Scale: (0-10) 5..." Medical record review of a Social Services Note dated July 24, 2012, revealed "...followed up with (insurance) today...will cont (continue) to push (insurance) for this...product (sand bed)..." Medical record review of a Physician's Progress Note dated July 27, 2013, revealed "...To Whom It May Concern...lack of bed mobility without assistance...bed bound; had developed decubitus ulcers which required surgery to heal...done very well only with sand bed as evidenced by failed surgery in past (February 2, 2012) when out of sand bed to support..." Medical record review of a Weekly Wound Progress Note dated July 30, 2012, revealed "...Location: R buttock/sacrum...Exudate: large...copious...Odor: yes...Other description: Abt (antibiotic) started again for tx (treatment) of wound. Tip of coccyx bone noted..." Medical record review of a Physician's Progress Note dated July 31, 2012, revealed "...wound worsening...awaiting sand bed insurance company approval...decubitus ulcer with wound infection...Plan: awaiting sand bed, surgical eval (evaluation) pending arrival of bed without sand bed to help will continue to deteriorate..." Medical record review of a Physician's Telephone Order dated July 31, 2012, revealed "...Please have Social Worker check on status of sand bed and let me know..." Medical record review of a Weekly Wound Progress Note dated August 6, 2012, revealed "...Location: R buttock/sacrum...Exudate: copious...Other description: deeper wound bed from coccyx to upper half of wound bed..." Medical record review of a Social Services Notes dated August 7, 2012, revealed "...contacted (insurance) again...haven't received approved sand bed..." Medical record review of a Weekly Wound Progress Note dated August 8, 2012, revealed "...Location: R buttock/sacrum...Size: L 10 cm W 10.5 cm D 2 cm...Exudate: copious...Last tx order chg (change) 6/30/12..." Medical record review of a Weekly Wound Progress Note dated August 8, 2012, revealed "...Location: R Ischium...Pressure Ulcer: Stage II appears as Stage II...Date of Onset: 8/8/12...Periwound: H20 (water)blister intact...Exudate: fluid filled..." Medical record review of a Weekly Wound Progress Note dated August 8, 2012, revealed "...Location: R Lateral Malleolus (ankle)...Date of Onset: 8/8/12...Pressure Ulcer: Stage IV appears as a Stage IV...Size: L 1.5 W 2 cm D 0.3...Other descriptions/comments: silver surgical appliance noted to wound bed. The top of screw is noted..." Medical record review of a Braden Scale for Predicting Pressure Sore Risk dated August 8, 2012, revealed Total Score 13 moderate risk..." Medical record review of a Social Services Notes dated August 9, 2012, revealed "...Per Administrator's advice this writer called a representative of (sand bed company) to see if they could help us get our patient a sand bed writer explained urgent nature of the situation..." Medical record review of a Weekly Wound Progress Note dated August 13, 2012, revealed "...Location: R buttock/sacrum...Size: L 10 cm W 10.5 cm D 1 cm...Exudate: copious..." Medical record review of a Weekly Wound Progress Note dated August 13, 2012, revealed "...Location: R Ischium...Pressure Ulcer: Stage II appears as Stage I...Date of Onset: 8/8/12...Periwound: H20 (water) blister intact...Exudate: fluid filled..." Medical record review of a Weekly Wound Progress Note dated August 13, 2012, revealed "...Location: R Lateral Malleolus...Date of Onset: 8/8/12...Pressure Ulcer: Stage IV appears as a Stage IV...Size: L 2 W 1.5 cm D 0.2..." Medical record review of a Social Services Notes dated August 14, 2012, revealed "...left VM (voice mail)...to check on progress (of sand bed)..." Medical record review of a Social Services Notes dated August 17, 2012, revealed "...sand bed finally arrived today...patient smiled when first laid on it seemed to breathe easier..." Medical record review of a Physician's Telephone Order dated August 17, 2013, revealed "...D/C (discontinue) order for surgeon r/t (related to) decubitus ulcer try trial with sand bed..." Medical record review of a Physician's Progress Note dated August 19, 2012, revealed "...doing better sand bed received has been on it several days wound in gluteal area healing...healing decubitus ulcer..." Medical record review of a Weekly Wound Progress Note dated August 20, 2012, revealed "...Location: R buttock/sacrum...Size: L 10 cm W 10 cm D 1 cm...Exudate: copious...Other description/comments: area around coccyx bone is deeper...Other: (sand bed) 8-17-12..." Medical record review of a Weekly Wound Progress Note dated August 20, 2012, revealed "...Location: R Ischium ...Resolved...(sand bed manufacturer's name) bed August 17, 2012..." Medical record review of a Weekly Wound Progress Note dated August 21, 2012, revealed "...Location: R Lateral Malleolus...Date of Onset: 8/8/12...Pressure Ulcer: Stage IV appears as a Stage IV...Size: L 1.8 W 0.8 cm D 0.2...Other descriptions/comments: silver appliance is still visible..." Medical record review of a Weekly Wound Progress Note dated August 27, 2012, revealed "...Location: R buttock/sacrum...Size: L 9 cm W 9 cm D 0.8 cm...Odor: none...Undermining/Tunneling: none..." Medical record review of a Weekly Wound Progress Note dated August 27, 2012, revealed "...Location: R Lateral Malleolus...Date of Onset: 8/8/12...Pressure Ulcer: Stage IV appears as a Stage IV...Size: L 1.5 W 0.8 cm D 0.2..." Medical record review of a Weekly Wound Progress Note dated September 3, 2012, revealed "...Location: R buttock/sacrum...Size: L 7 cm W 8.5 cm D 0.5cm...Odor: none...Undermining/Tunneling: none..." Medical record review of a Weekly Wound Progress Note dated September 10, 2012, revealed "...Location: R buttock/sacrum...Size: L 6.5 cm W 8 cm D 0.3 cm...Odor: none...Undermining/Tunneling: none..." Medical record review of a Weekly Wound Progress Note dated September 17, 2012, revealed "...Location: R buttock/sacrum...Size: L 6 cm W 7 cm D 0.2 cm...Odor: none...Undermining/Tunneling: none..." Medical record review of a Weekly Wound Progress Note dated September 24, 2012, revealed "...Location: R buttock/sacrum...Size: L 5.8 cm W 6.8 cm D 0.2 cm...Odor: none...Undermining/Tunneling: none..." Medical record review revealed the resident had been discharged to the hospital on September 30, 2012, readmitted on [DATE], discharged to the hospital on November 27, 2012, and readmitted [DATE]. Continued medical record review revealed the resident had surgical correction of decubitus ulcers. Observation on August 27, 2013, at 1:30 p.m., in the resident's room, revealed the resident on a sand bed and the wound care nurse provided wound care/dressing change. The decubitus on the right buttocks had two areas measuring 1) 1.5 cm x 0.8cm; 2) 0.06 x 0.5cm with no depth, odor, and/or drainage noted. Interview with the Social Service Director (SSD) on August 28, 2013, at 9:00 a.m., in the SSD office, revealed the SSD stated attempted to obtain insurance approval for payment and delivery of the sand bed for resident #75, June 11 to August 17, 2012. Further interview revealed "The facility considered paying for the (sand) bed at the end due to the resident had not been getting any better." Interview with the Assistant Director of Nursing (ADON) on August 28, 2013, at 9:41 a.m., in the Administrator's Office, revealed the resident's physician had been notified the facility was having problems obtaining the sand bed. Continued interview revealed the physician stated he wanted the resident to have the sand bed and continue to try 9to obtain the bed). Interview with the Administrator on August 28, 2013, at 9:43 a.m., in the Administrator's Office, revealed the facility did not purchase/rent the sand bed because the facility did not have a contract with any of the companies furnishing sand beds. Continued interview revealed the facility had attempted to get insurance approval for the sand bed from a supplier from June 11, 2012, through August 17, 2012 (67 days). Further interview confirmed the resident's decubitus ulcer on the R buttock/sacrum continued to deteriorate and the resident developed two more pressure ulcers. Interview with the resident's physician by telephone on August 28, 2013, at 11:40 a.m., revealed the resident had been hospitalized for [REDACTED]. Continued interview revealed the resident had done well on a sand bed in the hospital. Further interview revealed the physician had been unsure of the time frame but stated "It took a while for the insurance company to approve the bed and the resident's wounds continued to deteriorate."

Based on Guidance for Industry and FDA (Food and Drug Administration March 2006) medical record review, facility policy review, observation, and interview, the facility failed to assess side rails as a restraint, failed to ensure siderails did not pose a risk for entrapment, and failed to reduce or eliminate side rail restraints for six residents (#41, #60, #18, #83, #55, #57) of forty three residents reviewed. The facility's failure to follow a systematic process of assessing for appropriate use of the restraint and failure to reduce or eliminate side rail restraints placed residents #41, #60, and #18 in Immediate Jeopardy (situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious harm, injury, impairment or death). The Nursing Home Administrator (NHA) and Director of Nursing (DON) were notified of the Immediate Jeopardy on February 6, 2012, at 7:50 p.m., in the small dining room. The Immediate Jeopardy constitutes substandard quality of care and was effective September 27, 2011, and is ongoing. An extended survey was conducted on February 21, 2012. The findings included: Review of the facility restraint policy dated August 2010, revealed,"...A restraint includes, but is not limited to any article, device, or garment that interferes with freedom of movement of the pt (patient) and that cannot be removed by the pt easily...Restraints must be used only after all other measures have failed...there must be a link between restraint use & (and) how it benefits pt...All restraints must have: physicians order including the type of restraint, when & where the restraint should be used, the medical necessity of the restraint and restraint reduction attempts documented on the care plan. Resident #41 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Fall Risk assessment dated [DATE], revealed "...moderate risk for falls...include side rails..." Medical record review revealed no pre-restraint assessment for the use of the side rails and no physician order for [REDACTED]. Medical record review of the MDS Care Area Assessment Documentation Notes reference date September 30, 2011, revealed "...bed rail restraint used in bed...climbs out of bed over rails...currently...both side rails up...". The full side rails were not care planned. Medical record review of a Nurse's Event Note dated September 27, 2011, at 6:15 a.m., revealed "...found resident lying in bathroom floor..." Medical record review of the facility investigation dated September 27, 2011, revealed "...side rails up...(intervention)...pressure release alarm applied to bed..." Medical record review of a Nurse's Event Note dated September 30, 2011, at 8:15 p.m., revealed "...found sitting in floor...bed rails were up...alarm in place...not sounding..." No new interventions for removal of full side rails were noted. Medical record review of the facility investigation dated September 30, 2011, revealed "...side rails up...(intervention)...in-serviced staff on how to properly operate bed alarm..." Medical record review of a Nurse's Event Note dated October 4, 2011, at 4:30 a.m., revealed "...pt (patient) on his knees at side of bed holding on to raised bed (bring up) rails...abrasion x (times) 3..." Medical record review of the Nurse's Readmission assessment dated [DATE], revealed "...required assist with all activities of daily living...incontinent of bowel and bladder...combative at times...unable to make decisions...and history of falls..." Medical record review of the Fall Risk assessment dated [DATE], revealed "...high risk for falls...side rails..." Medical record review of a Physical Restraint assessment dated [DATE], revealed the resident had no signed consent for use of restraints, and "no restraint reduction or elimination is planned". Further medical record review revealed no prior physical restraint assessment and no physician order for [REDACTED]. Medical record review of a Nurse's Event Note dated November 23, 2011, at 6:00 a.m., revealed "...found on the floor beside bed resident had climbed over the side rails...skin tear...abrasion..." Review of the facility investigation report dated November 23, 2011, completed by the DON revealed "...climbed over the side rails...(intervention)...low bed with mats..." No new interventions for removal of the full side rails were noted. Medical record review of the Interdisciplinary Plan of Care reviewed on December 22, 2011, revealed "...confusion alteration in thought process...at risk for falls...bed rails up to define edge of bed and for mobility...low bed...bed alarm...monitor alarm...do not leave resident unattended while up in chair...at risk for bleeding secondary to anti coagulation therapy...". Medical record review of the January 2012, Physician's Recapitulation Orders revealed "...low bed with mats...", and no order for side rails. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had severe cognitive impairment, required extensive assistance with bed mobility, transfers and ambulation, and full side rail restraints were used daily. Medical record review of the February 2012, Physician's Recapitulation Orders revealed "...low bed...", and no order for side rails. Observation on February 6, 2012, at 5:28 p.m., in the resident's room, revealed full side rails on the bed and the bed rail on the left side of bed in the up position. Interview with Licensed Practical Nurse (LPN) #1 on February 14, 2012, at 7:50 a.m., at the Nurse's Station, confirmed the resident was in the bed prior to the fall on September 30, 2011; the full side rails were in the up position; the alarm did not sound, and the resident was placed back in the bed with the full side rails in the up position on September 30, 2011. Telephone interview with LPN #3, on February 14, 2012, at 6:45 a.m., confirmed the resident was found on the floor on October 4, 2011, at 4:30 a.m., and the full side rails were in the up position. Interview with the DON on February 14, 2012, at 12:53 p.m., in the small dining room, confirmed the facility used full bed rails daily to prevent the resident from transferring unassisted. Interview with the resident's Medical Doctor (MD) on February 14, 2012, at 2:40 p.m., in the Nurse's Station, revealed the resident, "A 100 percent absolute risk for bleeding, and head injuries with bleed, due to multiple falls and on anticoagulation therapy." Further interview confirmed the MD stated was unsure how many falls the resident has experienced, unaware the facility was using full side rails daily as a restraint, "I do not agree with side rails at all times, and feel the facility should have had the resident in a low bed to keep the risk factors down." Interview with DON on February 17, 2012, at 10:15 a.m., in the small dining room, confirmed the resident had exited the bed with the full side rails in the up position four times, there was no physician order for [REDACTED]. Resident #60 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed "...required extensive assistance with bed mobility...moderately impaired for decision making...feeds self after set up...no restraints in use..." Medical record review of the Interdisciplinary Plan of Care dated December 5, 2011, revealed "...res (resident) requires bedrails so...may assist with...repositioning...cannot transfer or ambulate without assist at this time...resident must be sitting upright for all meals..." Medical record review of a Fall Risk assessment dated [DATE], revealed "...risk scale moderate...equipment issues side rails..." Medical record review of the Pre-Restraint assessment dated [DATE], revealed "...disoriented at times...attempts to transfer/ambulate without assistance...restraint is not recommended..." Medical record review of the February 2012 Physician Recapitulation Orders revealed "...restraint orders...side rails up while in bed to facilitate bed mobility..." Observation on February 6, 2012, at 2:12 p.m., in the resident's room, revealed the resident lying on the bed with bilateral full side rails in the up position, head of bed elevated approximately forty-five degrees and a gap between the top of the mattress and the bottom of the side rails. Observation on February 6, 2012, at 4:50 p.m., in the resident's room, revealed the resident lying on the bed with the full side rails in the up position, the head of bed elevated approximately forty-five degrees and a gap between the top of the mattress and bottom of the side rails. . Observation and interview with DON and Maintenance Director in the resident's room, on February 6, 2012, at 5:35 p.m., revealed the resident's head of the bed elevated to forty five degrees; the Maintenance Director measured the full side rails from the top of the mattress to the bottom of the full side rail in the middle of the bed and measured the gap to be seven and one fourth inches. Review of Guidance for Industry and FDA (Food and Drug Administration) Staff dated March 10, 2006, revealed "...Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment...evaluating the dimensional limits of the gaps in hospital beds is one component of an overall assessment and mitigation strategy...most vulnerable to entrapment are elderly patients... especially those who are frail, confused...incontinence, pain or who get out of bed and walk unsafely without assistance...one component of a bed safety program includes a comprehensive plan for patient assessment...FDA recommends ...a risk benefit analysis to reduce entrapment...FDA using a head breadth dimension 4 3/4 inches as the basis for its dimensional recommendations...FDA recommends space be small enough to prevent neck entrapment...head entrapment under the rail less than 4 3/4 inches...in some positions the potential for entrapment exist when the deck is articulated... movement of the bed deck is known as articulation...we recommend that patient assessment procedures be used to assess the risk of entrapment when clinical care is provided in an articulated position...FDA have defined zones...could potentially become trapped...Zone...2(head entrapment under the rail)...accounting for 80% of entrapment events reported...some rails have high and low locking position...requires testing at both positions...Zone 2 test...if the space becomes larger as the bed moves find the bed position that creates the largest space...perform the test with the bed in the position where the space is the largest...common mistakes...not articulating the bed enough to create the largest possible gap..." Interview with Restorative Aid #2, on February 13, 2012, at 10:07 a.m., in the Nurse's Station, confirmed full side rails are up while the resident is in the bed, and was unsure why full side rails are in use for this resident. Interview with LPN #7 on February 13, 2012, at 10:59 a.m., in the small dining room, verified the resident "has always had the full side rails up while in bed". Interview with the DON, in the small dining room, on February 6, 2012, at 6:12 p.m., confirmed the most recent pre-restraining assessment was completed December 10, 2010, and confirmed the facility had not completed any restraint assessment after December 10, 2011. Interview with the MDS Coordinator on February 6, 2012, at 6:30 p.m., in the small dining room, confirmed the facility had no formal assessment for identifying the type of side rails to use; no specific order for type of side rails to be used; the facility is in process of changing the side rails to one-half side rails, "only able to order so many at a time due to financial reasons," and the concern with full side rails (used as a restraint) was identified back in the summer 2011. Interview with the DON on February 14, 2012, at 8:05 a.m., in the Nurse's Station, confirmed the resident was capable of exiting the bed, and an assessment to determine if use of the side rails was the least restrictive device had not been completed prior to February 6, 2012, after the Maintenance Director measured the seven and one-forth inch gap between the mattress and bottom of the side rail. Interview with the resident's Physician at 9:12 a.m., on February 21, 2012, by telephone, confirmed no physician's order had been given for use of side rails and "was not aware" of the facility using side rails for resident #60. Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS assessments dated August 20, 2011, and November 14, 2011, revealed the resident required extensive assistance with all ADLs (Activities of Daily Living) and required the use of a non-self release seatbelt when in WC (wheelchair) due to poor safety awareness. No other restraints were identified on the comprehensive quarterly assessments. Review of the resident's Care Plan dated February 6, 2012, revealed, "...Transfer in and out of bed using 2 person assist...non self release soft belt when up in wheelchair due to poor safety awareness...Make sure bedrails are up X2 (both sides) when in bed to assist with mobility..." Medical record review revealed no assessment for siderail use. Continued medical record review of the January 2012 and February 2012 Physician's Recapitulation Orders revealed no order related to side rail use as a restraining device or as a mobility aide. Observation with the Maintenance Director, on February 6, 2012, at 6:55 p.m., revealed the resident in bed, with the head of the bed elevated to approximately forty-five degrees. Continued observation revealed full siderails bilaterally, but raised only on the left side of the bed, leaving a gap between the bottom of the siderail and mattress on the left side. Continued observation revealed the Maintenance Director measured a gap between the bottom of the siderail and the top of the mattress at six and one-half inches, with the head of the bed elevated revealing potential entrapment risk. Observation on February 13, 2012, at 3:30 p.m. revealed the resident resting in bed with half side rails up bilaterally at the resident's chest position extending to the knee position. Interview with the DON on February 6, 2012, at 6:10 p.m., in the small dining room, confirmed the side rails had not been assessed as a restraint. Resident #83 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS assessments dated August 28, 2011, and January 5, 2012, revealed the resident required extensive assistance of one to two staff members for all activities of daily living. Continued MDS review revealed no restraints were used. Medical record review of a Care Plan dated March 21, 2011, and updated November 29, 2011, revealed "...Resident relies on staff for all transfers and mobility and could not prevent...self from falling...Bedrails up X 2." Continued care plan review revealed an added intervention dated October 5, 2011, stating "...ensure that side rails are locked in place before leaving the room." Further medical record review revealed no prerestraint assessment on admission or prior to the March 21, 2011, care plan for side rails., nor subsequent restraint assessments had been done to ensure the least restrictive device was in place. Medical record review of February 2012, Physicians Recapitulation Orders revealed "...may have SR (siderail) up X (times) 2 (bilateral side rails in the up position) for bed mobility. Continued review of physician's orders revealed a telephone order dated February 9, 2012, instructing: "DC (discontinue) full siderails, change to ? rails." Observations of the resident on February 6, 2012 at 9:07 a.m., February 7, 2012, at 8:23 a.m., and February 9, 2012 at 10:10 a.m., revealed the resident in the bed, alone in the room, with both full side rails locked in the "up" position. Observations of the resident on February 14, 2012 at 10:10 a.m. and at 3:06 p.m. revealed the resident resting in bed with ? length side-rails extending from the top of the bed to knee position in the "up" position. Interview with the DON on February 14, 2012, at 1:20 p.m., in the nurse's station confirmed the side rail (full or 3/4 rails) would impede resident #83's freedom of movement from the bed; the side rails could not be lowered by the resident without staff assistance; and the use of side-rails was not assessed and treated as a restraint per facility policy. Resident #55 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], revealed restraint-bedrails used daily. Review of the MDS Care Area Assessment Documentation Notes dated December 15, 2011, revealed, "...Resident has used a non self release belt when up in wheelchair and bedrails on...bed long term...Will continue to monitor restraint to assure it is the least restrictive while still maintaining...safety..." Medical record review of the care plan dated December 15, 2011, revealed, "...Bedrails x 2 as gentle reminder to call for assist and for positioning..." Medical record review revealed no pre-restraint assessments or restraint reduction assessments had been completed. Observation on February 6, 2012, at 1:50 p.m. revealed the resident lying on the bed with full siderails up bilaterally. Interview on February 15, 2012, at 10:40 a.m., with the Director of Nursing, in the small dining room confirmed no assessment for the use of the siderails had been completed prior to February 6, 2012. Resident #57 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident had severe cognitive impairment, was independent for locomotion on and off unit, was placed in a chair that prevented the resident from rising and bed side rails were used daily as restraints. Medical record review of the Interdisciplinary Plan of Care dated January 5, 2012, revealed "...side rails up times two per resident request for mobility...do not leave resident on commode unassisted...chair alarm when OOB (out of bed)..." Medical record review of the January 2012, Physician Recapitulation Orders revealed no order for side rails. Medical record review of the February 2012, Physicain Recapitulation Orders revealed no order for side rails. Medical record review revealed no documentation of a pre-restraint assessment or a restraint reduction assessment for the use of the chair and the side rails. Observation on February 6, 2012, at 4:02 p.m., in the resident's room, revealed the resident lying on the bed with one-half side rails in the up position on both sides of the bed. Interview with LPN #7 on February 7, 2012, at 11:17 a.m., in the break room, confirmed the resident has one-half side rails used daily, and the resident is capable of exiting the bed without assistance. Interview with the DON on February 8, 2012, at 8:42 a.m., in the Nurse's Station, confirmed facility had not completed a pre-restraint assessment or restraint reduction assessment. Interview with the Director of Nursing (DON) on February 6, 2012, at 6:12 p.m., in the small dining room, confirmed the DON was unaware of any residents attempting to exit the beds over the side rails; the facility performs side rail assessments on admission only; the facility has no formal assessment for use of side rails or what type to put in place; the facility has no policy and procedure/guidelines for side rails; and if a resident attempted to exit a bed with side rails in use they would be placed in a low bed. Further interview confirmed the DON attended a meeting this past year and was informed the facility needed to start reducing side rail use. In summary, the facility failed to provide a system to ensure residents were assessed prior to the use of side rails to determine medical necessity, and if the side rails were the appropriate least restrictive device to maintain the resident's safety.

Based on medical record review, observation, and interview, the facility failed to conduct a comprehensive assessment on six residents (#41, #60, #18, #83, #55, #57) of forty three residents reviewed. The facility's failure to follow a systematic process of assessing for appropriate use of the restraint and failure to reduce or eliminate side rail restraints placed residents #41, #60, and #18 in Immediate Jeopardy (situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious harm, injury, impairment or death). The Nursing Home Administrator (NHA) and Director of Nursing (DON) were notified of the Immediate Jeopardy on February 6, 2012, at 7:50 p.m., in the small dining room. The Immediate Jeopardy was effective September 27, 2011, and is ongoing. An extended survey was conducted on February 21, 2012. The findings included: Resident #41 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a Fall Risk assessment dated [DATE], revealed "...moderate risk for falls...include side rails..." Medical record review revealed no pre-restraint assessment for the use of the side rails and no physician order for [REDACTED]. Medical record review of the MDS Care Area Assessment Documentation Notes reference date September 30, 2011, revealed "...bed rail restraint used in bed...climbs out of bed over rails...currently...both side rails up..." The full side rails were not care planned. Medical record review of a Nurse's Event Note dated September 27, 2011, at 6:15 a.m., revealed "...found resident lying in bathroom floor..." Medical record review of the facility investigation dated September 27, 2011, revealed "...side rails up...(intervention)...pressure release alarm applied to bed..." Medical record review of a Nurse's Event Note dated September 30, 2011, at 8:15 p.m., revealed "...found sitting in floor...bed rails were up...alarm in place...not sounding..." No new interventions for removal of full side rails were noted. Medical record review of the facility investigation dated September 30, 2011, revealed "...side rails up...(intervention)...in-serviced staff on how to properly operate bed alarm..." Medical record review of a Nurse's Event Note dated October 4, 2011, at 4:30 a.m., revealed "...pt (patient) on his knees at side of bed holding on to raised bed (bring up) rails...abrasion x (times) 3..." Medical record review of the Nurse's Readmission assessment dated [DATE], revealed "...required assist with all activities of daily living...incontinent of bowel and bladder...combative at times...unable to make decisions...and history of falls..." Medical record review of the Fall Risk assessment dated [DATE], revealed "...high risk for falls...side rails..." Medical record review of a Physical Restraint assessment dated [DATE], revealed the resident had no signed consent for use of restraints, and "no restraint reduction or elimination is planned". Further medical record review revealed no prior physical restraint assessment and no physician order for [REDACTED]. Medical record review of a Nurse's Event Note dated November 23, 2011, at 6:00 a.m., revealed "...found on the floor beside bed resident had climbed over the side rails...skin tear...abrasion..." Review of the facility investigation report dated November 23, 2011, completed by the DON revealed "...climbed over the side rails...(intervention)...low bed with mats..." No new interventions for removal of the full side rails were noted. Medical record review of the Interdisciplinary Plan of Care reviewed on December 22, 2011, revealed "...confusion alteration in thought process...at risk for falls...bed rails up to define edge of bed and for mobility...low bed...bed alarm...monitor alarm...do not leave resident unattended while up in chair...at risk for bleeding secondary to anti coagulation therapy..." Medical record review of the January 2012, Physician's Recapitulation Orders revealed "...low bed with mats..." and no order for side rails. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had severe cognitive impairment, required extensive assistance with bed mobility, transfers and ambulation, and full side rail restraints were used daily. Medical record review of the February 2012, Physician's Recapitulation Orders revealed "...low bed..." and no order for side rails. Observation on February 6, 2012, at 5:28 p.m., in the resident's room, revealed full side rails on the bed and the bed rail on the left side of bed in the up position. Interview with Licensed Practical Nurse (LPN) #1 on February 14, 2012, at 7:50 a.m., at the Nurse's Station, confirmed the resident was in the bed prior to the fall on September 30, 2011; the full side rails were in the up position; the alarm did not sound, and the resident was placed back in the bed with the full side rails in the up position on September 30, 2011. Telephone interview with LPN #3, on February 14, 2012, at 6:45 a.m., confirmed the resident was found on the floor on October 4, 2011, at 4:30 a.m., and the full side rails were in the up position. Interview with the DON on February 14, 2012, at 12:53 p.m., in the small dining room, confirmed the facility used full bed rails daily to prevent the resident from transferring unassisted. Interview with the resident's Medical Doctor (MD) on February 14, 2012, at 2:40 p.m., in the Nurse's Station, revealed the resident, "A 100 percent absolute risk for bleeding, and head injuries with bleed, due to multiple falls and on anticoagulation therapy." Further interview confirmed the MD stated was unsure how many falls the resident has experienced, unaware the facility was using full side rails daily as a restraint, "I do not agree with side rails at all times, and feel the facility should have had the resident in a low bed to keep the risk factors down." Interview with DON on February 17, 2012, at 10:15 a.m., in the small dining room, confirmed the resident had exited the bed with the full side rails in the up position four times, there was no physician order for [REDACTED]. Resident #60 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed "...required extensive assistance with bed mobility...moderately impaired for decision making...feeds self after set up and no restraints in use..." Observation on February 6, 2012, at 2:11 p.m., in the resident's room, revealed the resident lying on the bed with bilateral full side rails in the up position. Interview with the MDS Coordinator on February 17, 2012, at 8:00 a.m., in the MDS Office, confirmed the facility failed to complete a Comprehensive MDS Assessment to include the use of full side rails. Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS assessments dated August 20, 2011, and November 14, 2011, revealed the resident required extensive assistance with all ADLs (Activities of Daily Living) and required the use of a non-self release seatbelt when in WC (wheelchair) due to poor safety awareness. No other restraints were identified on the comprehensive quarterly assessments. Review of the resident's Care Plan dated February 6, 2012, revealed, "...Transfer in and out of bed using 2 person assist...non self release soft belt when up in wheelchair due to poor safety awareness...Make sure bedrails are up X2 (both sides) when in bed to assist with mobility..." Medical record review revealed no assessment for siderail use. Continued medical record review of the January 2012 and February 2012 Physician's Recapitulation Orders revealed no order related to side rail use as a restraining device or as a mobility aide. Resident #83 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS assessments dated August 28, 2011, and January 5, 2012, revealed the resident required extensive assistance of one to two staff members for all activities of daily living. Continued MDS review revealed no restraints were used. Medical record review of a Care Plan dated March 21, 2011, and updated November 29, 2011, revealed "...Resident relies on staff for all transfers and mobility and could not prevent...self from falling...Bedrails up X 2." Continued care plan review revealed an added intervention dated October 5, 2011, stating "...ensure that side rails are locked in place before leaving the room." Further medical record review revealed no prerestraint assessment on admission or prior to the March 21, 2011, care plan for side rails., nor subsequent restraint assessments had been done to ensure the least restrictive device was in place. Medical record review of February 2012, Physicians Recapitulation Orders revealed "...may have SR (siderail) up X (times) 2 (bilateral side rails in the up position) for bed mobility. Continued review of physician's orders revealed a telephone order dated February 9, 2012, instructing "DC (discontinue) full siderails, change to ? rails." Observations of the resident on February 6, 2012 at 9:07 a.m., February 7, 2012, at 8:23 a.m., and February 9, 2012 at 10:10 a.m., revealed the resident in the bed, alone in the room, with both full side rails locked in the up position. Observations of the resident on February 14, 2012 at 10:10 a.m. and at 3:06 p.m., revealed the resident resting in bed with ? length side-rails extending from the top of the bed to knee position in the up position. Interview with the DON on February 14, 2012, at 1:20 p.m., in the nurse's station confirmed the side rail (full or 3/4 rails) would impede resident #83's freedom of movement from the bed; the side rails could not be lowered by the resident without staff assistance; and the use of side-rails was not assessed and treated as a restraint per facility policy. Resident #55 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], revealed restraint-bedrails used daily. Review of the MDS Care Area Assessment Documentation Notes dated December 15, 2011, revealed, "...Resident has used a non self release belt when up in wheelchair and bedrails on...bed long term...Will continue to monitor restraint to assure it is the least restrictive while still maintaining...safety..." Medical record review of the care plan dated December 15, 2011, revealed, "...Bedrails x 2 as gentle reminder to call for assist and for positioning..." Medical record review revealed no pre-restraint assessments or restraint reduction assessments had been completed. Observation on February 6, 2012, at 1:50 p.m., revealed the resident lying on the bed with full side rails up bilaterally. Interview on February 15, 2012, at 10:40 a.m., with the Director of Nursing, in the small dining room confirmed no assessment for the use of the side rails had been completed prior to February 6, 2012. Resident #57 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident had severe cognitive impairment, was independent for locomotion on and off unit, was placed in a chair that prevented the resident from rising and bed side rails were used daily as restraints. Medical record review of the Interdisciplinary Plan of Care dated January 5, 2012, revealed "...side rails up times two per resident request for mobility...do not leave resident on commode unassisted...chair alarm when OOB (out of bed)..." Medical record review of the January 2012, Physician Recapitulation Orders revealed no order for side rails. Medical record review of the February 2012, Physicain Recapitulation Orders revealed no order for side rails. Medical record review revealed no documentation of a pre-restraint assessment or a restraint reduction assessment for the use of the chair and the side rails. Observation on February 6, 2012, at 4:02 p.m., in the resident's room, revealed the resident lying on the bed with one-half side rails in the up position on both sides of the bed. Interview with LPN #7 on February 7, 2012, at 11:17 a.m., in the break room, confirmed the resident has one-half side rails used daily, and the resident is capable of exiting the bed without assistance. Interview with the DON on February 8, 2012, at 8:42 a.m., in the Nurse's Station, confirmed facility had not completed a pre-restraint assessment or restraint reduction assessment. Interview with the Director of Nursing (DON) on February 6, 2012, at 6:12 p.m., in the small dining room, confirmed the DON was unaware of any residents attempting to exit the beds over the side rails; the facility performs side rail assessments on admission only; the facility has no formal assessment for use of side rails or what type to put in place; the facility has no policy and procedure/guidelines for side rails; and if a resident attempted to exit a bed with side rails in use they would be placed in a low bed. Further interview confirmed the DON attended a meeting this past year and was informed the facility needed to start reducing side rail use. In summary, the facility failed to provide a system to ensure residents were assessed prior to the use of side rails to determine medical necessity, and if the side rails were the appropriate least restrictive device to maintain the resident's safety. Refer to F221-SSQC- resident's right to be free from physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Refer to F323 - SSQC- facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Based on medical record review, observation, and interview, the facility failed to conduct a comprehensive assessment on six residents (#41, #60, #18, #83, #55, #57) of forty three residents reviewed. The facility provided a Credible Allegation of Compliance on March 5, 2012. A revisit conducted on March 12, 2012, revealed the corrective actions implemented on March 5, 2012, removed the Immediate Jeopardy. Non-compliance for F-221 continues at a "E" level citation (potential for more than minimal harm). The findings included: Validation of the Credible Allegation of Compliance was accomplished through medical record review, review of facility policy, observation, and interview with the nurses, nursing assistants, and administrative staff. The facility provided evidence Pre-Restraint Assessments and Physical Restraint Assessments were completed when indicated. The facility provided evidence of fall risk assessments and side rail assessments were completed for all residents, with removal of side rails when indicated. The facility provided evidence of in-service for all staff and random audits to ensure compliance. The facility will remain out of compliance at a "E" level until it provides an acceptable plan of correction to include continued monitoring to ensure the deficient practice does not recur and the facility's corrective measure could be reviewed and evaluated by the Quality Assurance Committee.

Based on medical record review, observation, and interview the facility failed to evaluate and update the Care Plan for seven residents (#41, #60, #18, #83, #52, #55 and #57) of forty three residents reviewed. The facility's failure placed resident #41 and all residents with siderails in Immediate Jeopardy (situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious harm, injury, impairment or death). The Nursing Home Administrator (NHA) and the Director of Nursing (DON) were notified of the Immediate Jeopardy on February 6, 2012, at 7:50 p.m., in the small dining room. The Immediate Jeopardy was effective September 27, 2011, and is ongoing. An extended survey was conducted on February 21, 2012. The findings included: Resident #41 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Nurse's Event Notes dated September 27, 2011, Septmber 30, 2011, October 4, 2011, and November 23, 2011, revealed "...full side rails in up position...attempted to transfer without assist from bed...exited the bed with side rails in the "up" position...check bed/alarm for placement every shift..." Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed "...had severe cognitive impairment...required extensive assistance with bed mobility...transfers and ambulation...full bed rail restraints used daily..." Medical record review of the current Interdisciplinary Care Plan last reviewed by the facility on December 22, 2011, revealed the care plan had not been revised or updated to address interventions for full side rails as a restraint; attempts by the resident to self transfer and exit the bed with side rails in the "up" position, and staff to check the bed/alarm for placement. Interview with the MDS Coordinator on February 17, 2012, at 8:45 a.m., in the MDS office, confirmed the Interdisciplinary Care Plan had not been updated or revised to reflect interventions for full side rails as a restraint; attempts of self transfer and exit the bed with side rails in the "up" position, and staff to check the bed/alarm for placement. Resident #60 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed "...required extensive assistance with bed mobility...moderately impaired for decision making...feeds self after set up and no restraints in use..." Medical record review of the Interdisciplinary Plan of Care dated December 5, 2011, revealed "...res (resident) requires bedrails so...may assist with...repositioning...cannot transfer or ambulate without assist at this time...resident must be sitting upright for all meals..." Observation on February 6, 2012, at 2:11 p.m., in the resident's room, revealed the resident lying on the bed with bilateral full side rails in the up position. Interview with the MDS Coordinator on February 17, 2012, at 8:00 a.m., in the MDS Office, confirmed the care plan had not been updated or revised to reflect the side rails as a restraint. Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS assessments dated August 20, 2011, and November 14, 2011, revealed the resident required extensive assistance with all ADLs (Activities of Daily Living) and required the use of a non-self release seatbelt when in WC (wheelchair) due to poor safety awareness. No other restraints were identified on the comprehensive quarterly assessments. Review of the resident's Care Plan dated February 6, 2012, revealed, "...Transfer in and out of bed using 2 person assist...non self release soft belt when up in wheelchair due to poor safety awareness...Make sure bedrails are up X2 (both sides) when in bed to assist with mobility...". The Care Plan did not identify the siderails as a restraint. Medical record review revealed no assessment for siderail use. Continued medical record review of the January 2012 and February 2012 Physician's Recapitulation Orders revealed no order related to side rail use as a restraining device or as a mobility aide. Resident #83 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS assessments dated August 28, 2011, and January 5, 2012, revealed the resident required extensive assistance of one to two staff members for all activities of daily living. Continued MDS review revealed no restraints were used. Medical record review of a Care Plan dated March 21, 2011, and updated November 29, 2011, revealed "...Resident relies on staff for all transfers and mobility and could not prevent...self from falling...Bedrails up X 2." Continued care plan review revealed an added intervention dated October 5, 2011, stating "...ensure that side rails are locked in place before leaving the room." The Care plan did not identify the side rails as a restraint. Further medical record review revealed no prerestraint assessment on admission or prior to the March 21, 2011, care plan for side rails., nor subsequent restraint assessments had been done to ensure the least restrictive device was in place. Observations of the resident on February 6, 2012 at 9:07 a.m., February 7, 2012, at 8:23 a.m., and February 9, 2012 at 10:10 a.m., revealed the resident in the bed, alone in the room, with both full side rails locked in the "up" position. Observations of the resident on February 14, 2012 at 10:10 a.m. and at 3:06 p.m. revealed the resident resting in bed with ? length side-rails extending from the top of the bed to knee position in the "up" position. Interview with the DON on February 14, 2012, at 1:20 p.m., in the nurse's station confirmed the side rail (full or 3/4 rails) would impede resident #83's freedom of movement from the bed; the side rails could not be lowered by the resident without staff assistance; and the use of side-rails was not assessed and care planned as a restraint per facility policy. Resident #52 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the February 2012, Physician Recapitulation Orders revealed "...lap tray while up in W/C (wheel chair)...may use sling to help support (right arm)..." Observation on February 8, 2012, at 12:50 p.m., on the 200 hallway, revealed the resident in the wheelchair, the lap tray in place, the shoulder immobilizer around the resident's chest and the right arm secured to the chest with a Velcro strap on the immobilizer. Observation on February 15, 2012, at 10:15 a.m., in the resident's room, revealed the resident lying on the bed, and the three quarter side rails in the up position. Medical record review of the current Interdisciplinary Plan of Care last reviewed by the facility on December 7, 2011, revealed the care plan had not been updated or revised to reflect the side rails as a restraint and the use of the shoulder immobilizer. Interview with the MDS Coordinator on February 17, 2012, at 8:00 a.m., in the MDS Office, confirmed the care plan had not been updated or revised to reflect the side rails as a restraint and the use of the shoulder immobilizer. Resident #55 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], revealed restraint-bedrails used daily. Review of the MDS Care Area Assessment Documentation Notes dated December 15, 2011, revealed, "...Resident has used a non self release belt when up in wheelchair and bedrails on...bed long term...Will continue to monitor restraint to assure it is the least restrictive while still maintaining...safety..." Medical record review of the care plan dated December 15, 2011, revealed, "...Bedrails x 2 as gentle reminder to call for assist and for positioning..." Medical record review of the care plan dated December 15, 2011, revealed the use of the full side rails not care planned as a restraint. Medical record review revealed no pre-restraint assessments or restraint reduction assessments had been completed. Observation on February 6, 2012, at 1:50 p.m. revealed the resident lying on the bed with full side rails up bilaterally. Interview on February 15, 2012, at 10:40 a.m., with the Director of Nursing, in the small dining room confirmed no assessment for the use of the side rails had been completed prior to February 6, 2012. Resident #57 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident had severe cognitive impairment, was independent for locomotion on and off unit, was placed in a chair that prevented the resident from rising and bed side rails were used daily as restraints. Medical record review of the Interdisciplinary Plan of Care dated January 5, 2012, revealed "...side rails up times two per resident request for mobility...do not leave resident on commode unassisted...chair alarm when OOB (out of bed)..." Medical record review of the January 2012, Physician Recapitulation Orders revealed no order for side rails. Medical record review of the February 2012, Physicain Recapitulation Orders revealed no order for side rails. Medical record review revealed no documentation of a pre-restraint assessment or a restraint reduction assessment for the use of the chair and the side rails. Observation on February 6, 2012, at 4:02 p.m., in the resident's room, revealed the resident lying on the bed with one-half side rails in the up position on both sides of the bed. Interview with LPN #7 on February 7, 2012, at 11:17 a.m., in the break room, confirmed the resident has one-half side rails used daily, and the resident is capable of exiting the bed without assistance. Interview with the DON on February 8, 2012, at 8:42 a.m., in the Nurse's Station, confirmed facility had not completed a pre-restraint assessment or restraint reduction assessment. Interview with the Director of Nursing (DON) on February 6, 2012, at 6:12 p.m., in the small dining room, confirmed the DON was unaware of any residents attempting to exit the beds over the side rails; the facility performs side rail assessments on admission only; the facility has no formal assessment for use of side rails or what type to put in place; the facility has no policy and procedure/guidelines for side rails; and if a resident attempted to exit a bed with side rails in use they would be placed in a low bed. Further interview confirmed the DON attended a meeting this past year and was informed the facility needed to start reducing side rail use. Interview with the MDS Coordinator on February 17, 2012, at 8:00 a.m., in the MDS Office, confirmed the care plan had not been updated or revised to reflect the side rails as a restraint. In summary, the facility failed to provide a system to ensure residents were assessed prior to the use of side rails to determine medical necessity, and if the side rails were the appropriate least restrictive device to maintain the resident's safety. The facility failed to provide a plan of care (for residents who utilized side rails) that identified interventions for the restraint.

Based on medical record review, observation, and interview the facility failed to evaluate and update the Care Plan for seven residents (#41, #60, #18, #83, #52, #55 and #57) of forty three residents reviewed. The facility provided a Credible Allegation of Compliance on March 5, 2012. A revisit conducted on March 12, 2012, revealed the corrective actions implemented on March 5, 2012, removed the Immediate Jeopardy. Non-compliance for F-221 continues at a "E" level citation (potential for more than minimal harm). The findings included: Validation of the Credible Allegation of Compliance was accomplished through medical record review, review of facility policy, observation, and interview with the nurses, nursing assistants, and administrative staff. The facility provided evidence Care Plans were reviewed and revised for all residents to reflect the residents current status. The facility provided evidence of in-service for all staff and random audits to ensure compliance. The facility will remain out of compliance at a "E" level until it provides an acceptable plan of correction to include continued monitoring to ensure the deficient practice does not recur and the facility's corrective measure could be reviewed and evaluated by the Quality Assurance Committee.

Based on medical record review, facility policy review, Guidance for Industry and FDA (Food and Drug Administration) Staff, observation, and interview, the facility failed to reduce or eliminate a siderail restraint after multiple falls from the bed with full side rails in use, for one resident (#41) of two residents reviewed, failed to identify the risk for side rail entrapment for two residents (#18, #60) of two residents of twenty-three residents reviewed for siderails, failed to assure safety devices were on and properly operating for two residents (#57, #94) two of two residents of ten residents reviewed for accidents, and failed to supervise to prevent falls for one resident (#55) of forty-three residents reviewed. The facility's failure placed residents #41, #60 and #18, in Immediate Jeopardy (situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious harm, injury, impairment or death). The facility's failure to provide supervision to prevent falls resulted in harm for resident #55. The Nursing Home Administrator (NHA) and the Director of Nursing (DON) were notified of the Immediate Jeopardy on February 6, 2012, at 7:50 p.m., in the small dining room. The Immediate Jeopardy constitutes substandard quality of care and was effective September 27, 2011, and is ongoing. An extended survey was conducted on February 21, 2012. The findings included: Resident #41 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Current Nurse Aide Communication Worksheet revealed "...interventions put in place...don't leave in DR (dining room) unattended when up in W/C (wheelchair)...check alarm during daily routine for placement...monitor resident while in room and up in chair..." Medical record review of a Fall Risk assessment dated [DATE], revealed "...moderate risk for falls...equipment issues (types of equipment used)...include side rails..." Medical record review of the Admission Care Plan dated September 23, 2011, revealed "...Frog (falls reduction our goal) program...call light in reach..." Medical record review of the September 2011, Physician Recapitulation Orders revealed "...pressure alarm release applied to bed D/T (due to) decrease of safety awareness check every shift for placement rt (related to) function...Lovenox (anticoagulant) 40 mg (milligrams) subcutaneous every day..." Medical record review of the Physical Therapy Plan of Treatment dated SOC (start of care) dated September 25, 2011, revealed "...risk for falls can be combative..." Medical record review of a Nurse's Event Note dated September 27, 2011, at 6:15 a.m., revealed "...found resident lying in bathroom floor...c/o (complains of) R (right) hip...L (left) hip pain..." Review of the facility investigation report dated September 27, 2011, completed by the DON revealed "...side rails up..." Medical record review of a Physician's Order dated September 27, 2011, revealed "...pressure alarm release applied to bed D/T decrease of safety awareness check every shift for placement rt (related to) function..." Medical record review of the Interdisciplinary Team - Initial Care Meeting dated September 28, 2011, revealed "...Hx (history) of falls x (times)1 past 3 months..." Medical record review of a Nurse's Event Note dated September 30, 2011, at 8:15 p.m., revealed "...found sitting in floor...bed rails were up...alarm in place...not sounding..." Interview with Licensed Practical Nurse (LPN) #1on February 14, 2012, at 7:50 a.m., in the Nurse's Station, confirmed LPN #1 was on duty on September 30, 2011, when the resident fell . Continued interview revealed the resident was in the bed prior to the fall the side rails were in the up position, the alarm did not sound, and the resident was placed back in the bed with the side rails in the up position. Medical record review of the MDS (Minimum Data Set)Care Area Assessment Documentation Notes reference date September 30, 2011, revealed "...bed rail restraint used in bed...climbs out of bed over rails...currently...both side rails up..." Medical record review of a Nurse's Event Note dated October 4, 2011, at 4:30 a.m., revealed "...pt (patient) on his knees at side of bed holding on to (raised) bed rails...pulled self to standing position...both alarms appeared to be turned off...abrasion x (times) 3...". Continued review revealed no new interventions and no intervention to remove the siderails. Telephone interview with LPN #3, on February 14, 2012, at 6:45 a.m., confirmed the resident was found in the floor on October 4, 2011, at 4:30 a.m., and the side rails were in the up position. Medical record review of the Nurse's Readmission assessment dated [DATE], revealed the resident required assist with all activities of daily living, incontinent of bowel and bladder, combative at times, unable to make decisions, and history of falls. Medical record review of the Fall Risk assessment dated [DATE], revealed "...high risk for falls...equipment issues...include side rails..." Medical record review of a Physician's Order dated November 16, 2011, revealed "...D/C (discontinue) pressure bed alarm and W/C (wheel chair) alarm..." Medical record review of a physician's order dated November 23, 2011, revealed "...Coumadin (anticoagulant) 5 mg every day at 1600..." Medical record review of a Nurse's Event Note dated November 23, 2011, at 6:00 a.m., revealed "...found on the floor beside bed resident had climbed over the side rails...skin tear...abrasion..." Review of the fall investigation report dated November 23, 2011, completed by the DON revealed "...climbed over the side rails...". Continued review revealed no new interventions and no intervention to remove the siderails. Telephone interview with LPN #2, on February 13, 2012 at 3:19 p.m., confirmed LPN #2 was on duty when the resident was found on the floor and climbed over the side rails on November 23, 2011, at 6:00 a.m., and the alarm did not sound. Interview with Certified Nurse Aide (CNA) #1 on February 13, 2012, at 3:25 p.m., in the Nurse's Station, confirmed CNA #1 was on duty and assigned to resident #41, on November 23, 2011, at 6:00 a.m., when the resident climbed over the bed rails, was found in the floor, and the bed alarm did not sound. Medical record review of the Nurse's Event Notes dated October 31, 2011, revealed the resident was left up in the bedside chair unattended and had a fall. Continued review revealed from November 5, 2011, through February 6, 2012, the resident was left unattended in the resident's room, in the wheel chair and the resident experienced a total of five falls. Medical record review of the Nurse's Event Notes dated December 10, 2011, and January 13, 2012, revealed the resident was left unattended in the Dining Room and the resident fell on both dates. Medical record review of the Interdisciplinary Plan of Care as reviewed on December 22, 2011, revealed "...confusion alteration in thought process...at risk for falls...bed rails up to define edge of bed and for mobility...low bed...bed alarm...monitor alarm...do not leave resident unattended while up in chair...resident out of bed on awakening...at risk for bleeding secondary to anticoagulation therapy..." Medical record review of the January 2012, Physician's Recapitulation Orders revealed "...low bed with mats..." Medical record review of the February 2012, Physician's Recapitulation Orders revealed "...low bed..." Observation on February 6, 2012, at 5:28 p.m., in the resident's room, revealed full side rails on the bed and the bed rail on the left side of bed in the up position. Observation on February 13, 2012, at 7:42 a.m., revealed the resident lying on the bed with the clip alarm attached to the pillow case. Interview with the DON on February 13, 2012, at 7:42 a.m., confirmed the clip alarm was attached to the pillow case and if the resident attempted to exit the bed the clip alarm would not alarm. The DON states, "I'm just going to D/C (discontinue) it." Observation with the DON on February 14, 2012, at 1:53 p.m., revealed the resident lying on the bed, the bed was not in the lowest position, and the clip alarm was underneath the pillow and not attached to the resident. Interview with the resident's Medical Doctor (MD) on February 14, 2012, at 2:40 p.m., in the Nurse's Station, revealed the resident "100 percent absolute risk for bleeding, and head injuries with bleed, due to multiple falls and on anticoagulation therapy." Further interview confirmed the MD was unsure how many falls the resident had experienced, was unaware the facility was using full side rails daily as a restraint, and stated "I do not agree with side rails at all times, and feel the facility should have had the resident in a low bed to keep the risk factors down." Interview with the DON on February 14, 2012, at 12:53 p.m., in the small dining room, confirmed the resident was admitted with risk for falls, had experienced fourteen falls from September 25, 2011 through February 7, 2012, interventions were put in place not to leave the resident unattended in room/dining room, clip alarm while in bed/chair check for placement and function every shift, get out of bed when awakes, and lay down for rest periods. Continued interview confirmed the facility used full side rails daily to prevent the resident from transferring unassisted, the resident exited the bed with the full side rails in the up position four times, and the resident was placed back in the bed with full side rails in the up position until February 6, 2012, when the full side rails were removed from the resident's bed. Further interview confirmed the resident was left unattended in a bedside chair and wheel chair six times and the clip alarm failed to sound four times. Continued interview confirmed there was no documentation the clip alarm was checked for function and placement every shift. Observation with the DON on February 14, 2012, at 1:53 p.m., in the resident's room, revealed the resident lying on the bed, the bed not in the lowest position, and the clip alarm underneath the pillow not attached to the resident. Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the MDS assessments dated August 20, 2011 and November 14, 2011, revealed the resident required extensive assistance with all ADLs (Activity of Daily Living), required the use of a non-self release seatbelt when in a WC (wheelchair) due to poor safety awareness, and no siderail assessment had been identified. Medical record review of the resident's care plan dated February 6, 2012, revealed : Transfer in and out of bed using 2 person assist ...non self release soft belt when up in wheelchair due to poor safety awareness...Make sure bedrails are up X2 (both sides) when in bed to assist with mobility..." Observation with the Maintenance Director, on February 6, 2012, at 6:55 p.m., revealed the resident in bed, with the head of the bed elevated to approximately forty-five degrees. Continued observation revealed full siderails bilaterally, but raised only on the left side of the bed, leaving a gap between the bottom of the siderail and top of the mattress on the left side. Continued observation revealed the Maintenance Director measured a gap between the bottom of the siderail and the top of the mattress at six and one-half inches, with the head of the bed elevated revealing potential entrapment risk. Review of Guidance for Industry and FDA (Food and Drug Administration) Staff dated March 10, 2006, revealed "...Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment...evaluating the dimensional limits of the gaps in hospital beds is one component of an overall assessment and mitigation strategy...most vulnerable to entrapment are elderly patients... especially those who are frail, confused...incontinence, pain or who get out of bed and walk unsafely without assistance...one component of a bed safety program includes a comprehensive plan for patient assessment...FDA recommends ...a risk benefit analysis to reduce entrapment...FDA using a head breadth dimension 4 3/4 inches as the basis for its dimensional recommendations...FDA recommends space be small enough to prevent neck entrapment...head entrapment under the rail less than 4 3/4 inches...in some positions the potential for entrapment exist when the deck is articulated... movement of the bed deck is known as articulation...we recommend that patient assessment procedures be used to assess the risk of entrapment when clinical care is provided in an articulated position...FDA have defined zones...could potentially become trapped...Zone...2(head entrapment under the rail)...accounting for 80% of entrapment events reported...some rails have high and low locking position...requires testing at both positions...Zone 2 test...if the space becomes larger as the bed moves find the bed position that creates the largest space...perform the test with the bed in the position where the space is the largest...common mistakes...not articulating the bed enough to create the largest possible gap..." Interview with the DON on February 15, 2012 at 3:12 p.m., in the small dining room, confirmed, the faciltiy has no formal assessment tool for use of side rails or what type of siderail to put in place, and no policy and procedure/guidelines for side rail usage. Resident #60 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Pre-Restraint assessment dated [DATE], revealed "...disoriented at times...attempts to transfer/ambulate without assistance...restraint is not recommended..." Medical record review revealed no documentation of a pre-restraint assessment after December 11, 2010, and no restraint reduction assessment Medical record review of the MDS dated [DATE], revealed "...required extensive assistance with bed mobility...moderately impaired for decision making...feeds self after set up and no restraints in use..." Medical record review of the Interdisciplinary Plan of Care dated December 5, 2011, revealed "...res (resident) requires bedrails so...may assist with...repositioning...cannot transfer or ambulate without assist at this time...resident must be sitting upright for all meals..." Medical record review of a Fall Risk assessment dated [DATE], revealed "...risk scale moderate...equipment issues...side rails..." Medical record review of the February 2012 Physician Recapitulation Orders revealed "...restraint orders...side rails up while in bed to facilitate bed mobility..." Observation on February 6, 2012, at 2:12 p.m., in the resident's room, revealed the resident lying on the bed with bilateral full side rails in the up position, head of bed elevated approximately forty-five degrees and a gap between the top of the mattress and bottom of the side rails. Observation on February 6, 2012, at 4:50 p.m., in the resident's room, revealed the resident lying on the bed with the full side rails in the up position and the head of bed elevated approximately forty-five degrees, and a gap between the top of the mattress and the bottom of the siderails. Observation and interview with the resident on February 6, 2012, at 5:15 p.m., in the resident's room, confirmed the resident uses the side rails for bed mobility, is aware of the call light, and states, "I tried to get up once, I bumped my noggin (head) at times on the rails, that is why that stuff is on them, and my hand slips sometimes when I try to raise up." Continued observation revealed the upper part of the side rails closest to the resident's head is covered with a gray foam material and a gap is visible between the bottom of the side rail and the top of the mattress with the head of the bed elevated to approximately forty-five degrees. Observation and interview with the DON and the Maintenance Director in the resident's room, on February 6, 2012, at 5:35 p.m., revealed the resident's head of the bed elevated to forty five degrees. Continued observation and interview revealed the Maintenance Director measured the full side rails from the top of the mattress to the bottom of the full side rail in the middle of the bed and measured the gap to be seven and one fourth inch. Further interview with the DON in the resident's room confirmed the resident is usually up but has been sick today, has been in the bed most of the day, and the resident moves self in bed using the side rails. Interview with the Maintenance Director, on February 6, 2012, at 6:38 p.m., in the small dining room, confirmed the side rails were identified as needing to be replaced by his "boss" (Regional Maintenance Director). Continued interview with the Maintenance Director confirmed the Maintenence Director was aware of a tool that is available to measure the gap between the side rails and the mattress but the tool was never available to the facility and the Maintenance Director had no documentation of beds in the facility being measured by the tool. Interview with LPN #1 in the Nurses Station on February 14, 2012, at 7:42 a.m., confirmed the resident's head of bed is adjusted as far as possible while eating and is left elevated for at least forty-five minutes to one hour due to aspiration and choking and the resident ate lunch in bed on February 6, 2012. Interview with Restorative Aide #1 on February 16, 2012, at 8:50 a.m., in the Nurse's Station, confirmed the CNA lowers side rails, the resident can lift up from the lying position, put feet on floor, can hold to the wheel chair and attempts to self-transfer, self transfers from wheel chair to bed side chair, and if the rail on the bed and is in the down position can self-transfer chair to bed. Interview with the DON on February 14, 2012, at 8:05 a.m., in the Nurse's Station, confirmed the resident is capable of exiting the bed, and had not been assessed for a least restrictive device prior to February 6, 2012. Continued interview confirmed a seven and one fourth inch gap did exist from the bottom of the side rail and top of the mattress when the head of the bed is elevated. Further interview confirmed the resident's head of bed is elevated during meals and left elevated after meals due to risk of aspiration. Continued interview with the DON confirmed the facility did not consider the seven and one half inch gap between the side rails and mattress an entrapment risk. Interview at 9:12 a.m., on February 21, 2012, by telephone with the resident's Physician confirmed no physician's order had been given for side rails, the physician was not aware of the facility using side rails for the resident, and the risk associated with side rail usage. Resident #57 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Fall Risk assessment dated [DATE], revealed the resident was a high risk for falls and had experienced three falls in the past 90 days. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed "...severe cognitive impairment...independent for locomotion on and off unit...side rails used daily for restraints..." Medical record review of a Nurse's Event Note dated January 31, 2012, revealed "...found resident lying in floor...alarm not sounding..." Observation on February 17, 2012, at 9:10 a.m., in the resident bathroom, revealed Licensed Practical Nurse (LPN) #4 assisted the resident on the commode, instructed the resident to pull the string (call light) and left the resident unattended in the bathroom. Observation with the Nursing Home Administrator (NHA), on February 17, 2012, at 9:30 a.m., (twenty minutes later) in the resident's room, revealed the resident sitting in the wheel chair with feet elevated on the bed, and the clip alarm not in place. Interview with the Director of Nursing on February 17, 2012, at 9:35 a.m., in the Nurse's Station, confirmed the clip alarm was not functioning at the time of the fall on January 31, 2012, the clip alarm is to be in place and the resident was not to be left unattended in the bathroom. Resident #94 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident required extensive assistance of two for transfers, and limited assist of two persons with ambulation. Medical record review of the Plan of Care dated December 5, 2011, revealed "...At risk for falls due to gait disturbance related to weakness and prior falls at home. Resident needs limited to extensive assist with transfers, assistance with walking and toileting at this time..." Medical record review of a Fall Risk assessment dated [DATE], revealed the resident was at moderate risk for falls. Medical record review of a Nurse's Event Note dated December 11, 2011, at 6:00 p.m., revealed "...This nurse heard a resident call out that someone had fallen. I immediately went to hallway and this resident was laying in floor by...w/c (wheelchair). Resident stated...was trying to get up and push...w/c to...room. Resident able to move all extremities WNL (within normal limits). Resident assisted back into w/c et into room. no complaints voiced..." Review of facility investigation revealed the resident had forgotten to lock the brakes before getting up from the wheelchair and anti-roll back brakes were to be applied to the wheelchair. Medical record review of the Plan of Care updated on December 12, 2011, revealed place anti-roll back brakes to the wheelchair, and on December 20, 2011, a bed and chair alarm was applied. Medical record review of a Nurses's Event Note dated December 18, 2011, at 7:10 p.m., revealed "...CNA (Certified Nursing Assistant #7) came to this charge nurse stated resident had fallen. Upon further investigation CNA found resident on trash can, went to get assistance, when returned resident was on floor. CNA verbally/corrective action taken...Head to toe assessment performed at 7:10 p.m. no apparent injury noted. Full ROM (range of motion) in all extremities; denies any pain or discomfort..." Medical record review of the Plan of Care updated on December 20, 2011, revealed a bed and chair alarm was applied. Telephone interview on February 13, 2012, at 10:50 a.m., with LPN #2 confirmed when the resident fell on [DATE], the resident was left unattended on the trash can at the time of the resident's fall, and the CNA had been counseled related to leaving the resident unattended. Medical record review of a Nurses's Event Note dated February 3, 2012, at 7:00 p.m., revealed "...Nurse heard pt (patient) screaming 'help' and observed pt on the floor, fell on buttocks, no apparent injury. Pt was able to voice needs and move all extremities without difficulty..." Interview on February 16, 2012, at 10:20 a.m., with the DON, outside the DON's office confirmed the anti-roll back brakes were not applied to the resident's wheelchair at the time of the resident's fall on February 3, 2012. Continued interview revealed it was unknown if the resident had been using the correct wheelchair at the time of the fall. Observation and interview on February 13, 2012, at 8:45 a.m., with Registered Nurse (RN) #1 revealed the resident sitting in a wheelchair in the resident's room with anti-roll back brakes applied to the wheelchair, and confirmed the chair alarm was not attached to the resident. Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the fall risk assessment dated [DATE], revealed the resident was at moderate risk for falls. Medical record review of a Nurse's Event Note dated January 22, 2012 revealed "...went in res (resident) room and found laying in bathroom floor...res stated "I thought I could put myself on pot...immediate steps implemented to prevent recurrence: placed res in w/c (wheelchair) et (and) placed res in lobby where staff could monitor...comment/action taken bring to nurses station for closer monitoring..." Medical record review of a Nurse's Event Note dated January 23, 2012, revealed "...resident (up) in w/c in room. PTA #1 (Physical Therapist Assistant) observed resident sit up in chair and slid to floor-laying on r (right) side (no s/s (signs/symptoms) injury)...immediate steps implemented to prevent recurrence: keep in hallway in sight of staff-take to room if putting to bed comment/action taken bring to nurse's station for closer monitoring...don't leave in rm (room) unattended when up in w/c..." Medical record review of a Nurse's Event Note dated January 24, 2012 revealed "... PTA #1 across hall noticed resident standing in room-unable to reach (resident)-resident fell on floor next to wall-laying on (left) hip...immediate steps implemented to prevent recurrence: sent to ER (emergency room )-will re-evaluate use of restraint upon return..." Medical record review of a physician's order dated January 24, 2012, revealed, "...Send to ER...(left) hip pain..." Medical record review of a Nurse's Note dated January 24, 2012, revealed "...Resident returned to facility via ambulance/stretcher from (named hospital)...knee immobilizer...Fx (fractured) (left) patella (and) tibia..." Interview on February 13, 2012, at 9:10 a.m., in the small dining room, with PTA #1 (witness to the fall) confirmed PTA #1 had observed the resident to stand from the w/c in the resident's room and fall. Interview on February 13, 2012, at 9:15 a.m., with the DON, in the small dining room, confirmed the intervention to keep the resident in the hall in sight of staff when up in the wheelchair had not been followed on the January 23, and January 24, 2012, falls, resulting in a fractured patella and tibia.

Based on medical record review, facility policy review, review of training seminar information, review of Guidance for Industry and FDA (Federal Drug Administration) staff, dated 2006, observation, and interview, the facility failed to be administered in a manner to ensure seven residents (#41, #60, #18, #55, #94, #57, #83) were provided a safe enviornment of fourty-three residents reviewed. The facility's failure to provide a system to assess for the use of siderails, to reduce or eliminate full siderails to prevent falls and to reduce the risk of entrapment placed residents #41, #60, and #18 and any resident who used full side rails, in Immediate Jeopardy. The Administrator and the Director of Nursing were notified of the Immediate Jeopardy on February 6, 2012, at 7:50 p.m., in the small dining room. An extended survey was completed on February 21, 2012. The Immediate Jeopardy was effective September 27, 2011 and is ongoing. The findings included: Interview with the Director of Nursing (DON) on February 6, 2012, at 7:50 p.m., confirmed the faciity became aware of the potential for entrapment with the use of the current full length siderails and the use siderails as restraints while attending a training seminar the past summer "sometime prior to August 1, 2011." Interview with the Nursing Home Administrator (NHA) and the DON on February 7, 2012, at 9:50 a.m., confirmed the Corporate Office some time prior to August 1, 2011, had instructed the facility Administration to reduce the full siderails if possible. Continued interview confirmed the DON after return from the training seminar had made the Interdiscplinary Team aware and maintenance had started ordering siderails, entrapment proof bars and half siderails to replace them as needed. Interview with the NHA and review of a training seminar information form on February 17, 2012, at 3:20 p.m., confirmed the NHA had attended the same training seminar the DON had previously attended related to siderails as a restraint and as an entrapment risk on October 25, 2011. Continued interview and review of the training seminar information form confirmed the training seminar included training and information on use of siderails as restraints and the use of certain types of siderails with entrapment risks Refer to F221-SQC- resident's right to be free from physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Refer to F272 - facility must make a comprehensive, accurate, standardized assessment of each resident's need, and functional capacity. Refer to F280-facility must develop a comprehensive care plan and periodically review and revise. Refer to F323-SQC- facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Based on medical record review, facility policy review, observation and interview the Medical Director failed to provide oversight and participate in the development of policies and procedures to ensure resident safety and ensure that residents with restraints were properly assessed, managed, and restraint reduction or elimination was implemented where appropriate. The Medical Director's failure to collaborate with the facility to develop and implement policies and procedures related to resident safety placed residents #18, #41, and #60 in Immediate Jeopardy (situation in which a provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious harm, injury, impairment or death). The Nursing Home Administrator (NHA) and Director of Nursing (DON) were notified of the Immediate Jeopardy on February 6, 2012, at 7:50 p.m., in the small dining room. The Immediate Jeopardy was effective September 27, 2011 and is ongoing. The findings included: Interview with the Medical Director (MD) on February 16, 2012, at 12:00 p.m., in the small dining room, revealed the MD was never called by the facility related to siderail issues; was unaware of the types of siderails used in the facility; and was unaware of potential entrapment with the siderails, or of falls due to siderail use. The MD stated reviewed all falls in the facility either on rounds or in QA (Quality Assurance), but was unaware of falls with injuries due to siderails or entrapment issues until last week. The MD further stated "...residents who exit the bed with siderails should be placed in low beds with fall mats and siderails should be discontinued." Continued interview revealed the MD attended some of the Quality Assurance Committee Meetings; is not involved in oversight and implementation of facility policies and procedures related to resident safety; and there was no system in place to identify and respond to these safety risks. Refer to F221-SQC- the resident's right to be free from physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Refer to F272 - facility must make a comprehensive, accurate, standardized assessment of each resident's need, and functional capacity. Refer to F280-facility must develop a comprehensive care plan and periodically review and revise. Refer to F323-SQC- the facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Refer to F490- the facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Based on medical record review, facility policy review, observation and interview the Medical Director failed to provide oversight and participate in the development of policies and procedures to ensure resident safety and ensure that residents with restraints were properly assessed, managed, and restraint reduction or elimination was implemented where appropriate. The facility provided a Credible Allegation of Compliance on March 5, 2012. A revisit conducted on March 12, 2012, revealed the corrective actions implemented on March 5, 2012, removed the Immediate Jeopardy. Non-compliance for F-221 continues at a "E" level citation (potential for more than minimal harm). The findings included: Validation of the Credible Allegation of Compliance was accomplished through medical record review, review of facility policy, observation, and interview with the nurses, nursing assistants, and administrative staff. The facility developed a Side Rail Assessment Policy with the involvement of the Medical Director to include the utilization of the evaluation for the use of side rails. The facility provided evidence of side rail assessments for all residents, and removal of side rails when indicated, and evidence bed zone measurements were obtained to reduce or eliminate entrapment risk. The facility provided evidence Fall Risk Assessments, Pre-Restraint Assessments and Physical Restraint Assessments were completed. The facility provided evidence of in-service for all staff and random audits to ensure compliance. The facility will remain out of compliance at a "E" level until it provides an acceptable plan of correction to include continued monitoring to ensure the deficient practice does not recur and the facility's corrective measure could be reviewed and evaluated by the Quality Assurance Committee.

Based on medical record review, observation, facility policy review and interview, the facility failed to ensure the Quality Assurance Committee developed and implemented plans to address resident safety related to the use of full side rails likely entrapment and fallsfor three residents (#41, #18, #60) of forty-three residents reviewed. The facility's failure placed resident's #41, #18, and #60, and any resident who used full side rails in Immediate Jeopardy (situation in which a provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious harm, injury, impairment or death). The Nursing Home Administrator (NHA) and the Director of Nursing were notified of the Immediate Jeopardy on February 6, 2012, at 6:15 p.m., in the small dining room. The Immediate Jeopardy was effective September 27, 2011, and is ongoing. An extended survey was conducted on February 21, 2012. The findings included: Interview with the Nursing Home Administrator (NHA) and the Regional Director of Operations on February 21, 2012, at 9:15 a.m., in the NHA office, confirmed falls, and PT/INR (a blood test to monitor blood clotting) have been ongoing Quality Assurance Programs. Further interview with the NHA and Regional Director of Operations related to side rails as a restraint, and side rail entrapment confirmed the Quality Assurance (QA) Committee had not utilized data from Nurse's Event Notes or information obtained at a seminar the NHA had attended in October, 2011 in an effort to identify potential areas of improvement or implemented a plan to address areas of concerns. Refer to F221-SQC- resident's right to be free from physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Refer to F272 - facility must make a comprehensive, accurate, standardized assessment of each resident's need, and functional capacity. Refer to F280-facility must develop a comprehensive care plan and periodically review and revise. Refer to F323-SQC- facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Refer to F490- the facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Refer to F501 - the medical director is responsible for implementation of resident care policies; and the coordination of medical care in the facility.

Based on medical record review, observation, facility policy review and interview, the facility failed to ensure the Quality Assurance Committee developed and implemented plans to address resident safety related to the use of full side rails likely entrapment and fallsfor three residents (#41, #18, #60) of forty-three residents reviewed. The facility's failure placed resident's #41, #18, and #60, and any resident who used full side rails in Immediate Jeopardy (situation in which a provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious harm, injury, impairment or death). The facility provided a Credible Allegation of Compliance on March 5, 2012. A revisit conducted on March 12, 2012, revealed the corrective actions implemented on March 5, 2012, removed the Immediate Jeopardy. Non-compliance for F-221 continues at a "E" level citation (potential for more than minimal harm). The findings included: Validation of the Credible Allegation of Compliance was accomplished through medical record review, review of facility policy, observation, and interview with the nurses, nursing assistants, and administrative staff. The facility developed a Side Rail Assessment Policy with the involvement of the Medical Director to include the utilization of the evaluation for the use of side rails. The facility provided evidence of side rail assessments for all residents, and removal of side rails when indicated, and evidence bed zone measurements were obtained to reduce or eliminate entrapment risk. The facility provided evidence Fall Risk Assessments, Pre-Restraint Assessments and Physical Restraint Assessments were completed. The facility provided evidence of in-service for all staff and random audits to ensure compliance. The facility conducted a special session of the Quality Assurance committee on February 23, 2012, to review the Side Rail Assessment Policy for the assessment of all residents for the use of side rails, the review of Minimum Data Sets and Care Plans to ensure current interventions and accuracy; the monitoring by the Administrative staff to ensure systems are followed and revised as needed; and to ensure staff training is provided as needed for processes/systems implemented. The facility will remain out of compliance at a "E" level until it provides an acceptable plan of correction to include continued monitoring to ensure the deficient practice does not recur and the facility's corrective measure could be reviewed and evaluated by the Quality Assurance Committee.