Every finding on record at Newaldaya Lifescapes

Based on observations, staff interviews, and the facility's Safe Food Handling policy the facility failed to clean 3 fans in the 2nd floor dining room. The facility reported a census of 97.Findings include: On 7/7/26 at 11:45 AM an observation of the second-floor dining room revealed the following:a fan on the left side of the dining room faced the ceiling next to the television near two dining room tables.a fan in the right upper corner of the dining room near the ceiling pointed toward multiple tables and contained gray debris (dirt).a fan on the middle right side of the dining room blew air toward the ceiling over two carts with several room trays near the food serving counter and contained gray debris (dirt). On 7/7/26 at 12:50 PM the Dietary Manager (DM) indicated kitchen staff cleaned the kitchen fans but the maintenance department handled the dining area fans. The DM noted she expected clean fans. On 7/8/26 at 2:30 PM the Director of Nursing (DON) indicated she expected staff to clean the fans. On 7/8/26 at 3:33 PM the Administrator indicated she expected clean dining room fans. The Food Handling and Preparation policy reviewed on 10/23/25 didn't include instructions to keep the fans clean.

Based on observation, staff interview, and facility policy review, the facility failed to maintain proper infection control practices during the distribution of resident drinking water. This affected 5 resident rooms observed during water distribution. The facility reported a census of 97 residents.Findings include:On 7/8/26 at 3:43 PM a continuous observation revealed Staff D, Certified Nurse Aide (CNA), failed to maintain proper infection control and hand hygiene (hand washing) protocols during an afternoon water pass. Staff D donned (put on) clean gloves, entered resident rooms to retrieve water cups, brought them out to the hallway to fill with ice from a portable ice chest, and returned the cups to the rooms. While wearing the same pair of gloves, Staff D knocked on a resident's door, retrieved a dirty water mug, brought it out to the hallway to fill with fresh ice, and delivered the water into the resident's room. Without removing her gloves or performing hand washing, Staff D proceeded to room [ROOM NUMBER]. She knocked on the door and retrieved a contaminated, dirty water cup from room [ROOM NUMBER]'s resident while wearing the same gloves. Staff D then entered room [ROOM NUMBER] to speak with room [ROOM NUMBER]'s resident. She didn't perform hand washing upon room entry and handled room [ROOM NUMBER]'s resident's water cup using the same contaminated gloves. While in the room, Staff D touched room [ROOM NUMBER]'s resident's shoulder and answered questions. She traveled to the kitchenette (small kitchen area), filled the cup with water, and returned it to the room, all while continuing to wear the same pair of gloves. Staff D proceeded to room [ROOM NUMBER], knocked on the door, retrieved room [ROOM NUMBER]'s resident's water mug, and filled it with ice from the communal ice chest while wearing the same gloves. Staff D proceeded to room [ROOM NUMBER], knocked on the door, and handled room [ROOM NUMBER]'s resident's ice mug while wearing the same gloves. She then handled an additional water mug belonging to room [ROOM NUMBER]'s resident using the same pair of gloves. At 3:53 PM, after 10 minutes of continuous care across five resident rooms, Staff D removed her gloves and performed hand washing at the handwashing sink located at the nurse's station. On 7/8/26 at 1:15 PM Staff B, Nurse Manager, stated staff must perform hand washing before, during, and after resident care, after touching their own face or hair, after touching a dirty surface, and between all glove changes. On 7/8/26 at 3:59 PM Staff E, Licensed Practical Nurse (LPN), stated staff shouldn't wear the same pair of gloves continuously across multiple resident tasks or rooms. On 7/8/26 at 4:05 PM Staff D stated staff required hand washing and glove changes when activities changed. However, Staff D acknowledged she intended to change her gloves only after completing the entire ice water distribution process. On 7/8/26 at 4:08 PM the Director of Nursing (DON) stated the first and second shifts utilize a mobile ice chest to distribute fresh drinking water. The DON stated employees shouldn't wear gloves during water distribution unless a resident is on active transmission-based isolation precautions (infection containment steps). The DON explicitly stated staff must perform hand washing any time they enter or exit a resident's room. The Hand Washing policy dated 12/29/25 instructed all personnel to perform handwashing to clean the hands and prevent the spread of germs. The policy directed employees to perform hand washing at specific times, including between handling individual residents, after touching any dirty area, and immediately after removing gloves, noting gloves don't offer full protection. The Gloves: Putting on and Taking Off policy dated 12/1/25 instructed staff the outside of gloves is considered contaminated and soiled. The policy directed staff to maintain a distinction between clean and soiled areas, specifying clean should only touch clean and soiled should only touch soiled. The policy mandated employees must wash their hands immediately following the removal of gloves.

Based on clinical record review, observation, resident interview, staff interview, and facility policy the facility failed to provide the necessary activities of daily living (ADL) care regarding nail care for a dependent resident. This failure resulted in a resident having a brown substance embedded under multiple fingernails over two days. This affected 1 of 2 residents reviewed for personal hygiene (Resident #11). The facility reported a census of 96 residents. Findings include:Resident #11's Minimum Data Set (MDS) assessment dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The assessment also noted Resident #11 experienced impaired vision (poor eyesight). The Care Plan revised on 7/7/26 identified a focus area for a self-care deficit (incapacity for self-grooming) related to decreased mobility (limited movement). The document established a daily goal for Resident #11 to remain clean and neatly groomed. To achieve this goal, the text directed staff to provide setup assistance for personal hygiene and one-person physical assistance for bathing via a shower chair. The instructions explicitly required staff to provide nail care with every scheduled shower. Previous entries from 1/7/24, updated on 4/21/26, noted Resident #11 experienced impaired vision with an associated self-care deficit, specifying blindness in the right eye. The document recorded Resident #11 had trouble seeing and instructed staff to closely monitor Resident #11 for ongoing visual declines. On 7/7/26 at 9:05 AM Resident #11 stated during an interview she relies on staff to perform nail care because her poor eyesight prevents her from seeing dirty nails. Resident #11 reported staff didn't trim or clean her fingernails during her shower earlier today. On 7/7/26 at 9:05 AM Resident #11 exhibited a dark brown substance under the thumbnail and middle fingernail of her right hand, and under the index, middle, and ring fingernails of her left hand. On 7/7/26 at 3:32 PM Resident #11 continued to display the dark brown substance under the thumbnail and middle fingernail of her right hand, and the index, middle, and ring fingernails of her left hand. On 7/8/26 at 10:35 AM Resident #11 sat upright in her wheelchair in her room. Resident #11's fingernails remained visibly dirty with the dark brown substance. On 7/8/26 at 1:15 PM Staff B, Licensed Practical Nurse (LPN) Nurse Manager, stated residents receive scheduled showers twice a week unless otherwise indicated. Staff B noted staff must clean and trim fingernails with every shower, when visibly dirty, or as needed. Staff B clarified a licensed nurse must perform nail care if a resident is diabetic; otherwise, Certified Nurse Aides (CNAs) provide nail care during bathing or bed days. During the same interview, Staff B stated following a bath or shower, staff must complete a shower sheet documenting whether they completed nail care or determined it didn't equal a current need. Resident #11's Task record directed staff to provide bathing and shower assistance every Tuesday and Friday on the day shift. The documentation specified Resident #11 required one-person physical assistance to transfer to the shower chair. The entries instructed staff to provide nail care and apply lotion to Resident #11's extremities with every shower. A review of the completed facility Shower Sheet dated 7/7/26 for Resident #11 documented staff didn't trim her fingernails, noting they omitted the care because they deemed it unnecessary. The document recorded the nurse maintains responsibility for verifying completion of all grooming needs. Staff C, LPN, signed and verified the document on 7/7/26. The facility policy titled Personal Care Nails: Care of dated 5/13/26 instructed staff to complete fingernail care by pushing back the cuticle, gently removing dirt from under the nails with a file, and using a clipper or nail file to shape the fingernails into a moon shape.

Based on clinical record review, observation, resident interview, staff interview, and facility record review, the facility failed to ensure sufficient nursing staff were available to provide care and answer call lights within a 15-minute timeframe. This affected 3 of 3 residents reviewed for sufficient staffing (Residents #49, #65, and #98) in a sample of 1 of 5 resident halls. The facility reported a census of 97 residents. Findings include:1. Resident #98's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #98's Care Plan revised 7/6/26 identified a focus area for a self-care deficit (inability to care for oneself) related to decreased mobility (limited movement), hypertensive heart disease (high blood pressure heart condition), chronic kidney disease (long-term kidney damage), and heart failure (weakened heart muscle). To manage care dependencies, the Care Plan directed staff to provide the following nursing assistance:Provide physical assistance of one person for bathing via a shower chair.Provide physical assistance of one person for upper body dressing and physical assistance of two persons for lower body dressing.Provide physical assistance of one person utilizing a gait belt and front-wheeled walker (FWW) to complete stand-pivot transfers.Provide physical assistance of one person for bed mobility tasks.Provide physical assistance of one person to complete transfers to and from the toilet, and provide physical assistance of one person for routine toileting checks and incontinence changes. On 7/7/26 at 7:45 AM Resident #98 stated during an interview her call light frequently required longer than 15 minutes for staff to answer. She stated the facility routinely didn't maintain enough staff, noting the morning shift experienced the most significant delays, usually before and after scheduled meal times. 2. Resident #65's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Resident #65's Care Plan revised 7/7/26 identified a focus area for a self-care deficit (inability to care for oneself) related to decreased mobility (limited movement) and chronic obstructive pulmonary disease (COPD) (progressive lung disease) weakness. To manage his high physical care needs, the Care Plan directed staff to provide the following nursing assistance:Provide physical assistance of one person for bathing, applying lotion, and trimming fingernails during showers.Provide physical assistance of one person for upper and lower body dressing.Provide physical assistance of one person utilizing a gait belt and front-wheeled walker (FWW) for transfers and ambulation within his room.Provide physical assistance of two staff members for hallway ambulation, with one person directly assisting the resident and a second person following behind with a wheelchair.Provide physical assistance of one person for bed mobility tasks.Provide physical assistance of one person utilizing a gait belt and FWW to complete toilet transfers. On 7/6/26 at 10:53 AM Resident #65 stated during an interview the facility lacked sufficient staff and frequently didn't have enough help. He stated call light response times routinely exceeded 15 minutes, noting these delays occurred most frequently during the day shift. Resident #65 further noted due to staffing shortages, residents waited in the upstairs dining room for up to an hour for their food after staff brought them to the dining area at 11:00 AM, then additionally had to wait for staff to assist them back to their rooms afterward. 3. On 7/8/26 at 1:22 PM an observation revealed Resident #49's active call light for room [ROOM NUMBER]. A review of the facility's electronic call light master board at the time revealed the call light remained active and staff hadn't answered it since 12:59 PM, resulting in a 23-minute response delay. On 7/8/26 at 2:25 PM the Director of Nursing (DON) stated during an interview the facility policy required staff to answer all call lights within 15 minutes of activation. DON stated staff must prioritize bathroom call lights to prevent resident falls or accidents. She stated the facility doesn't excuse any employee, from direct floor staff to the administrator, from answering active call lights. When asked how leadership monitors call light response, DON stated leadership conducts physical hall rounds, reviews internal audits, and pulls electronic call light data log reports. A review of the facility's electronic call light log report and audits covering 7/1/26 through 7/8/26 for one of the five facility nursing halls revealed 73 individual instances where call light response times didn't meet the 15-minute facility limit. The log report documented these delayed responses included 16 instances for Resident #49, 4 instances for Resident #65, and 3 instances for Resident #98.

Based on observations, staff interviews, and facility's Safe Food Handling policy the facility failed to cover the garbage containers when not in use. The facility reported a census of 97. Findings include: On 7/6/26 at 10:40 AM an initial kitchen tour revealed an uncovered trash container next to the 2-compartment sink and an uncovered trash container by the food preparation table. On 7/7/26 at 11:30 AM a follow-up visit of the kitchen revealed an uncovered trash container next to the 2-compartment sink and an uncovered trash container by the food preparation table. On 7/8/26 at 10:15 AM the Dietary Manager (DM) acknowledged the garbage container lacked a lid, indicated she expected the lid to remain on it when not in use, and closed the lid. The Food Handling and Preparation policy reviewed on 10/23/25 lacked instructions on keeping the garbage containers covered.

Based on clinical record review, facility records, policy review, and staff interviews, the facility failed to prevent a resident from being physically restrained when a gait belt was placed around the resident's waist and a secured with a second gait belt to the recliner for 1 of 3 residents (Resident #1) reviewed. The facility reported a census of 104.Findings Include:Resident #1's Minimum Data Set assessment dated [DATE] documented an admission date of 12/28/25. The MDS identified a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. The MDS listed potential indicators of psychosis (mental health symptom involving a disconnection) of hallucinations (Sensing, seeing, or hearing things that are not actually there). Resident #1 required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for lying to sitting on the side of the bed, sitting to standing, chair/bed-to-chair transfer and walking. The MDS included active diagnoses of Alzheimer's disease, cerebrovascular accident (stroke caused by interrupted blood flow to the brain), and anxiety disorder. The Care Plan Report initiated 11/28/25 identified Resident #1 identified the following Focuses:Self-care deficit related to impaired cognition, decreased mobility and cerebral infarction (when blood flow to the brain is blocked).Likes to be busy. Please provide meaningful activities. Enjoys folding towels/matching socks.Likes to go to bed around 8:30-9:00 PM. If she gets up in the night provide towels to fold and then attempt to lay back down.Enjoys Christian music.Transfer/ambulation: assist of one with gait belt and walker. Walk around the unit twice daily. Provide positive reinforcement for increased activity.Disruptive behavior problems evidenced by expressing frustration, agitation, rummaging, and having hallucinations.Determine if behavior is stimulated by certain activities, noise levels, person involved or time of day.Specify: over stimulation, lonelinessDiscuss behavior with resident; watch for behavioral clues to understandDivert attention from stimulusGive assistance when needed in activities such as cueing, reminders and directionMonitor behavior to assist in determining causeTalk with resident in a calm mannerUse relaxation techniquesGive a baby dollExerciseMusicThe Care Plan Report lacked Resident #1 frequently attempts to rise unassisted. Resident #1's February 2026 Documentation Survey Report identified Staff A, Certified Nursing Assistant (CNA), documented on 2/24/26 at 11:16 PM no behaviors occurred for the overnight shift for behavior monitoring and interventions. The Incident Note dated 2/25/26 at 2:30 AM, indicated a staff member used a gait belt inappropriately by fastening it to another gait belt around Resident #1's waist while they sat in the recliner. With the incorrect use of the gait belt, Resident #1 could move her arms, legs, and torso forward but couldn't stand up on her own. The note described the situation as an unsafe and unauthorized use of a gait belt. The nurse assessed Resident #1 for any injuries, finding no redness or bruising noted. The Social Service Progress Note dated 2/25/26 at 4:39 PM documented the Social Worker met with Resident #1. She appeared happy, holding a baby doll. When asked if anyone has said or done anything to her to make her feel uncomfortable or unset, she stated no. When asked if staff treated her nicely, she stated yes. Resident #1 smiled and told the Social Worker about how well the baby behaved and never cried. The Progress Notes lacked documentation for attempted interventions, medical necessity for placement of a physical restraint, physician notification, family education and/or consent. On 4/21/26 at 11:35 AM, observed Resident #1 sitting in a rocking recliner in the common area, with her walker positioned in front of her within reach. She wore glasses and tennis shoes. Resident #1 didn't appear agitated, anxious, or attempt to rise unassisted. On 4/21/26 at 1:25 PM, observed Resident #1 sitting in a rocking recliner in the common area. She sat with her right leg crossed over her left at the knees, with her left foot on the floor. Resident #1 sat quietly awake with her front wheeled walker within reach on her left. She had a gait belt looped on the front of the walker. Resident #1 didn't appear agitated, anxious, or attempt to rise unassisted. On 4/21/26 at 3:01 PM Staff B, Certified Nurse Aide (CNA), confirmed her knowledge of resident rights, Dependent Adult Abuse (DAA), and the proper use of a gait belt for a resident transfer and ambulation. Staff B stated she reports allegations of abuse immediately to the nurse, Assistant Director of Nursing (ADON) or the Director of Nursing (DON). Staff B described Resident #1 as a very sweet resident requiring 1-assist for transfers with a gait belt and walker. Staff B verbalized Resident #1 at times rises independently and can get wobbly. Staff B reported she found Resident #1 on an unspecified date at approximately 2:40 AM, with one gait belt loosely around Resident #1's waist and a second belt wrapped tightly around the side of recliner preventing Resident #1 from rising. Staff B required assistance from Staff C, Registered Nurse (RN), to remove the secured gait belt. Staff B stated she didn't witness any staff members apply the gait belts to Resident #1 or the recliner. Staff B didn't know how long Resident #1 sat with the gait belts restraining her from rising. Staff B toileted Resident #1, walked her around the unit, and sat next to her until her shift ended at 3:00 AM. Staff B reported Resident #1 didn't appear agitated or scared. She didn't notice redness or injuries when she assisted her to the toilet. On 4/21/26 at 3:2, Staff A, CNA, stated he showed dignity and respect by explaining things, allowing privacy, asking what made the residents feel comfortable, and let them have a voice. He received training on resident rights and DAA. He verbalized he would report DAA allegations to a nurse. Staff A acknowledged he received training on the proper use of a gait belt for resident transfer and confirmed staff shouldn't use a gait belt to prevent a resident from rising. Staff A reported Resident #1 required assistance from one staff. She needed watched 24/7 because she often attempted to rise on her own. He verbalized when Resident #1 tried to rise unassisted, he tried to keep her close, visit with her, or give her food to keep her occupied. Staff A admitted he used a gait belt improperly on an unspecified date. Staff A reported Resident #1 experienced days without sleep and hallucinated. She tried to get up and becoming combative. Staff A placed a gait belt around her waist, buckled it in the back, then used a second gait belt as an extender, looping it around the side of the recliner to prevent her from falling. Staff A admitted the action prevented Resident #1 from rising. Staff A thought this acted as a safety measure since he didn't want her to fall, but later recognized his judgment was wrong because he didn't follow the care guide. He reported he never did that prior to the incident. On 4/21/26 at 3:50 PM, Staff B demonstrated how she found the 2 gait belts. She placed one buckled gait belt in the seat of the recliner. She next looped a second gait belt through the first gait belt. The second gait belt was buckled and placed over the right side (facing the recliner) of the backrest. The back rest of the recliner has sections on both sides of the back rest that extend out even with the arms of the recliner. The recliner had the gait belt looped over the top of that section and tucked under the bottom where it met the arm rest. On 4/21/26 at 3:21 PM Staff C confirmed Resident #1 often attempted to rise by herself and fell in the past. Staff C reported the staff used a gait belt to ambulate residents. Staff C received report that a staff improperly used a gait belt on Resident #1. Staff C reported they used 2 gait belts with one of the belts tucked into the recliner. Staff C acknowledged she assessed Resident #1 and found no injuries. Staff C reported she informed Staff A he couldn't use gait belts that way. Staff C acknowledged she educated Staff A that doing so is a restraint. On 4/22/26 at 3:25 PM, the DON explained they expected the staff to assess the resident for reasons of restlessness (checking for pan, toileting needs, hunger). The DON reported staff should ambulate, reposition, use all non-pharmacological interventions, and consult with team members including the nurse. The DON reported they need to use gait belts to safely ambulate or steady a resident who needed assistance. The DON acknowledged they must remove a gait belt once they finish ambulating the resident. The DON voiced Resident #1 wouldn't be able to rise if she had a gait belt around her waist with a second gait belt looped around the side of the recliner. The DON reported she didn't know of any emergent situation requiring a physical restraint to permit medically necessary treatment. The DON revealed the staff member should've assessed the resident's needs (toilet, ambulate) and use non-pharmacological interventions before talking with team members and the nurse. The DON confirmed the facility expected the staff members to not physically restrain residents. Review of the facility video footage with a date time stamp of 2/25/26 at 2:45 AM, revealed as Resident #1 sat in a recliner facing the fireplace, Staff A approached her and leaned her forward, securing the second gait belt to the recliner. The video showed Resident #1 able to move in the recliner and grab things. Review of Staff A's Employee File documented a hire date of 3/14/23 for a CNA position. The file included the following:The Job Description/Evaluation form Certified Nurse Aide position signed 3/14/23 by Staff A describe the position as to provide assigned residents with routine daily nursing care, following established nursing procedures and supervisor directives.The CNA Orientation Checklist signed by Staff A on 3/22/23 indicated they received training for gait belts.Staff A received Dependent Adult Abuse Mandatory Reporter Recertification training on 2/17/24.The CNA Orientation Checklist signed by Staff A on 6/9/24 indicated they received training for gait belts.Review of the facility's Safety Fair 2025 signed by Staff A on 12/12/25, included gait belt use and resident rights. Review of the Resident Rights facility policy revised 2/18/26 instructed the facility to ensure all direct care and indirect care staff member received education on the rights of residents and the responsibility of the facility. The resident has the right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility. The resident has a right to be treated with respect and dignity.The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms.The resident has a right to a safe, clean, comfortable and homelike environment including but not limited to receiving treatment and supports for daily living safely. Review of the Gait Belt/Transfer Belt facility policy dated 2/17/94 directed the following:All CNAs are assigned a transfer belt at the beginning of employment.The CNA must keep the transfer belt with him/her at all times while working on the unit.The CNA must use the transfer belt when assisting any resident.The CNA will check their care guide and any resident who is stand by assist or physical assist of 1 or 2 must use the belt.The Gait Belt/Transfer Belt policy lacked directions for transfer belt not to be used as a physical restraint. Review of the Restraint Free Environment facility policy reviewed 12/29/25, instructed the following:Each resident shall attain and maintain his/her highest practicable we-being in an environment prohibits the use of physical or chemical restraints for discipline or conveniency and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of such restraints.Physical restraint refers to any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body. Physical restraints may include, but are not limited to:Using devices in conjunction with a chair, such as trays, tables, cushions, bars or belts, that the resident cannot remove and prevents them from rising.Placing a resident in a chair that prevents the resident from rising independently.

Based on observation, clinical record review, policy reviews and staff interviews, the facility failed to ensure the staff who applied lidocaine patches (topical medication that delivers local anesthetic lidocaine through the skin to provide pain relief) signed the Treatment Administration Record (TAR). Instead, another staff member documented the administration of the treatments for 2 of 2 residents reviewed (Residents #16 and #20). The facility reported a census of 102 residents. Findings include: Resident #16's Minimum Data Set (MDS) assessment dated [DATE] reflected they received pain medication in the previous 5 days and had occasional pain. Resident #16's May 2025 Treatment Administration Record (TAR) included an order dated 10/5/24 for lidocaine external patch 5%. The order directed to apply to left hip topically for pain in the morning (AM) and then off at hour of sleep (hs). Resident #16's MDS assessment dated [DATE] reflected they received pain medication in the previous 5 days and had occasional pain. Resident #20's May 2025 TAR listed an order dated 7/12/24 for a lidocaine external patch 4%. The order directed to apply to the right side of neck topically one time a day for pain then remove per schedule. On 5/21/25 at 9:49 AM, observed Staff C, Certified Medication Aide (CMA), apply a lidocaine patch to Resident #20. On 5/21/25 at 10:00 AM, observed Staff C, CMA apply a lidocaine patch to Resident #16. Review of Resident #16's and Resident #20's TARs on 5/21/25 at 11:15 AM, revealed Staff A, Licensed Practical Nurse (LPN), signed off the administration of Resident #16's and Resident #20's lidocaine patch applications on 5/21/25. During an interview on 5/21/25 at 11:34 AM Staff A reported the CMAs had training on how to apply lidocaine patches. Staff A added if the CMA forgot to sign off a treatment they completed, including the application of lidocaine patches, she assured the application of the patches and then sign off the TAR the completion of the treatment. During an interview on 5/21/25 at 11:37 AM, Staff B, Assistant Director of Nursing (ADON), explained they expected the CMAs to sign off treatments they completed and if a nurse signed a treatment they didn't actually complete themselves, that is an issue. Review of facility policy titled, Medication Administration of Drug-Unit Dose System, revised 12/9/24 instructed when giving medications, confirm the resident's 7 rights including right recording/charting. The policy documented staff may choose to handle medication administration in one of two ways: a. Prepare medication, initial MAR (medication administration record)/TAR, and give to resident b. Prepare medication, give to resident, initial MAR/TAR Review of the facility policy titled, Documentation in Medical Record, revised 9/9/24 directed to not document false information. During an interview on 5/22/25 at 7:50 AM, Staff C, CMA, stated Staff A had her apply lidocaine patches to residents since they started working on the unit, about 4 months. Staff C added Staff A always documented the completion of the lidocaine patches that they applied. During an interview on 5/22/25 at 9:44 AM, the Director of Nursing reported whomever completed the treatment should document they completed it. If a nurse delegated the completion of a treatment, the nurse still had the responsibility to ensure the completion of the treatment and document who completed the treatment.

Based on observation, electronic health record (EHR) review, personnel file review, policy review and staff interviews the facility failed to demonstrate proper Enhanced Barrier Precautions (EBP) when flushing a Percutaneous Endoscopic Gastrostomy (PEG) tube (a thin, flexible tube inserted into the stomach through a small incision in the abdominal wall also referred to as a g-tube) for 1 of 1 residents reviewed. The facility reported a census of 102 residents. Findings include: Resident #117's Minimum Data Set (MDS) assessment dated [DATE] listed an admitted [DATE]. The MDS identified a Brief Interview for Mental Status (BIMS) score of 7, indicating moderately impaired cognition. The MDS included diagnoses of cancer, anemia (low iron level in the blood), quadriplegia (inability to move all four extremities of the body), non-Alzheimer's dementia, and chronic atrial fibrillation (abnormal heart rhythm. Resident #117's EHR reviewed 5/21/25 reflected she had an Infection Prevention Control measure of Enhanced Barrier Precaution in place. It documented Resident #117 had an indwelling (left within a bodily organ or passage to maintain drainage, prevent obstruction, or provide a route for administration of food or drugs) medical device. The personal protective equipment (PPE) requirements directed staff to wear gloves and gown for all high contact activity. Resident #117's Clinical Physician Orders reviewed 5/21/25 included the following: a. 3/31/25: Regular (general) diet, regular texture, regular/thin consistency b. 12/30/24: Cleanse g-tube site every day with normal saline, pat dry and apply split gauze one time a day for g-tube. c. 2/1/25: Flush every day with 120 cubic centimeter (cc) of water one time a day for PEG Tube. The Care Plan Focus revised 3/2/25 identified Resident #117 had a self-care deficit related to impaired cognition, decreased mobility, a diagnosis of incomplete quadriplegia (weakness or the inability to move all four limbs but with some sensation and some control) due to a spinal cord lesion. The Interventions directed the following: a. Utilize EBP due to enteral tube feeding (a method of delivering nutrition directly into the gastrointestinal tract through a tube feeding). b. Provide tube feeding and water flushes (using a syringe to introduce water into the tube to clear formula, medications, or other debris) as ordered and supplement (if applicable) as ordered. During an initial walk through of the unit on 5/19/25 at 10:32 AM, observed a U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC) poster for Enhanced Barrier Precautions on the door to Resident #117's room. The poster directed providers and staff to wear gloves and a gown for the following high-contact resident care activities: * Dressing * Bathing/showering * Transferring * Changing Linens * Providing hygiene * Changing briefs or assisting with toileting * Device care or use: * Central line, urinary catheter, feeding tube, tracheotomy * Wound care: any skin opening requiring a dressing On 5/21/25 at 9:20 AM, Staff A, Licensed Practical Nurse (LPN), and Staff B, Assistant Director of Nursing (ADON), entered Resident #117's room. During the observation, Staff A cleaned Resident #117's PEG-tube site and performed a water flush with 120 cc of water. Staff A failed to put on a gown prior to performing high-contact resident care as directed under the EBP. During an interview on 5/21/25 09:33 AM with Staff A, LPN and Staff B, ADON, Staff A acknowledged Resident #117 had been on EBP. Staff B, acknowledged a gown should have been donned prior to cleansing the site and performing the water flush for the PEG-tube. Staff B, ADON indicated gowns were located in Resident#117's closet. Staff A acknowledged she should have worn a gown on. A review of Staff A's personnel file included a completed Nurse Orientation Checklist that showed competency of all of the skills, policies, and procedures listed, including EBP. Staff A, LPN signed the document on 6/7/24. The Enhanced Barrier Precautions-Infection Control policy updated 12/24/24 instructed the residents indicated for EBP implementation as: a. Infection or colonization with a CDC-targeted Multidrug-Resistant Organism (MDRO - refers to microorganisms, such as bacteria, that have become resistant to multiple classes of antibiotics) when contact precautions do not otherwise apply b. Wounds and/or indwelling medical devices even if the resident is not known to have an infection or has a colonized MDRO. The policy continued with directions for any staff member performing high-contact resident cares, they will implement the use of an isolation gown for any resident on EBP (in addition the gloves used as part of standard precautions). The policy listed a nonlimited list of high-contact resident cares: a. Dressing b. Bathing/showering c. Transferring In general, performing transfers didn't require gowns and gloves when in common areas such as a dining room. The contact is less likely to transmit potential MDROs to the staff members' clothing as the contact is anticipated shorter in duration. d. When closer contact is expected, the staff must use gowns and gloves with a transfer in a non-public area such as a shared shower/bathing room or in a therapy room. e. Providing personal hygiene f. Device care or use The facility would communicate EBP to staff by putting signs on the door and added to the resident's plan of care. The staff could enter the resident's room without PPE on and prior to initiation of a high-contact care identified above, staff will apply PPE. The staff don't need to wear PPE while in a resident's room when they didn't perform any high-contact resident cares.

Based on clinical record review, staff and resident interviews, policy review and observations the facility failed to notify a family member about a resident's fall with injury for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 101. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS included diagnoses of medically complex illness, coronary artery disease (problems with the arteries of the heart), osteoporosis, and anxiety. Resident #1 had a which indicated Resident #1 alert and oriented. The Bedside Kardex Report dated 1/22/25 directed the staff to check and change Resident #1 and use a Hoyer lift with 2 staff for transfers to the commode. The report included to not leave Resident #1 alone on the commode. Resident #1 utilized a wheelchair and a walker for mobility. The Incident Note dated 1/23/25 at 3:01 AM, Staff B, Licensed Practical Nurse (LPN), reported as Staff A, Certified Nurse Aide, provided care to Resident #1, she began to jerk. When nervous, Resident #1 display a jerking behavior. Resident #1 fell which resulted in an injury to her head. The notes indicated Staff B only notified the Primary Care Physician (PCP) but failed to notify Resident #1's family of the fall or the edematous bump she got from the fall. During an interview on 2/24/25 at 9:00 AM, Staff C, Registered Nurse (RN), stated she became aware of the fall upon starting her shift during report. Staff C stated the departing nurse, Staff B reported he didn't contact Resident #1's family member of the fall. During an interview on 2/25/24 at 8:30 AM Staff B admitted he failed to notify Resident #1's family because she only had a bump on her head with a low pain score. Resident #1 denied any other pain in her body. Staff B reviewed the policy for family notification and admitted he should have contacted the family because she had a head injury. Interview on 2/24/25 at 11:00 AM Staff D, Director of Nursing, stated Staff B notified her on 1/23/25 of Resident #1's fall. Staff D acknowledged Staff B failed to notify the family at the time of the injury accordance to the facility policy. Review of the Accident/Incident Report Policy dated 2/24/03 directed the staff to notify a resident's family as soon as possible after an incident. The nurse who assessed the incident is responsible for calling the family. The nurse assessing the resident is responsible for seeing that the doctor is notified. For witnessed falls, if there has been no serious injury or signs and symptoms of pain that warrants immediate medical attention. If the fall is unwitnessed, notify PCP of fall, regardless of time of day/night, as we are not sure if the resident hit their head or not.

Based on clinical record review, document review, observation, facility policy, resident, family and staff interviews, the facility failed to assess and reassess residents for the safe use of bed rails and failed to provide risks and benefit education to the resident and/or their legal representative, including entrapment and death since [DATE] for 3 of 3 residents sampled (Residents #68, #73, and #314). The failure resulted in the [DATE] death of Resident #73 when the staff found her with her head wedged between the bed rail and the mattress with injuries consistent with asphyxiation (suffocation). The facility reported a census of 101 residents with 94 of those 101 residents utilizing bed rails. The State Agency informed the facility on [DATE] of the Immediate Jeopardy (IJ) situation to the residents' health and safety that began on [DATE] . The State Agency determined the facility removed the immediacy by lowering the deficiency from a K (pattern of the deficiency with actual harm) level deficiency to a H level deficiency (harm that is not immediate) on [DATE] by completing the following: a. Immediately following the incident, the Administrator and the Director of Nursing (DON) began an immediate investigation in the building on [DATE]. b. Meeting held on [DATE] discussed the following regarding a review of the incident: i. Side Rail Policy reviewed ii. Bed rail assessment form reviewed - noted the risks and benefits not listed in the electronic charting record form that as the form only included a statement identifying they learned of the risks and benefits. iii. Bed rail assessment forms initiated on all residents in the building on [DATE], as they reassessed, every resident, and notified them of the risks and benefits. c. The facility used the paper form which identified the risks and benefits of using a side rail. d. The facility reevaluated the new admissions using the paper form, which indicated the risks and benefits. e. Maintenance completed side rail and checked the bed functionality on [DATE] as a preventative measure in the entire nursing facility for all beds and rails. f. The facility completes Side Rail assessments quarterly, however the facility completed side rails assessments as a preventative on all current resident in the building on [DATE] until completed. g. On [DATE] any beds in empty rooms had the side rails removed in order to try other interventions upon admission to facility, prior to side rail use. Findings include: The United States Food and Drug Administration (FDA) Hospital Bed Safety Workgroup [DATE] Guide for Modifying Bed Systems and Using Accessories to Reduce the Risk of Entrapment specified FDA received approximately 691 entrapment reports over a period of [AGE] years from [DATE], to [DATE]. In these reports, 413 people died , 120 received injuries, and 158 had near miss events with no serious injury as a result of intervention. The entrapment events occurred in the openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Entrapments have occurred in a variety of patient care settings, including hospitals, nursing homes, and private homes. Long term care facilities reported the majority of the entrapments. The FDA Recommendations for Health Care Providers Using Adult Portable Bed Rails dated [DATE] directed to avoid the routine use of adult bed rails without first conducting an individual patient or resident assessment. When installing and using bed rails use caution when using bed rails with a soft mattress as this may increase risk of entrapment between the mattress and bed rail. Be aware that movement or compression of the mattress, patient weight, patient movement or bed position, or by using a specialty mattress can cause a gap between the bed and side rails. The undated FDA Recommendations for Consumers and Caregivers about Adult Portable Bed Rails reviewed on [DATE] directed some people have a high risk for entrapment, falls or other injury from adult portable bed rails. High risk people include those with pre existing conditions such as confusion, restlessness, lack of muscle control, or a combination of these factors. Additionally, people who are cognitively impaired from the use of medication or from a medical condition, such as Alzheimer's or dementia, are at a higher risk of entrapment and injury. The Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings dated [DATE] instructed the facility complete an assessment and incorporate risk as part of the individual patient's assessment, and steps to address the risk into the patient's care plan. In relation to risks staff should minimize use of medications that alter mental status. The gap under the rail between the mattress, may allow for dangerous head entrapment. The FDA recommended space less than four and three quarters of an inch (4 ,d+[DATE]). The area is the space between the inside surface of the bed rail and the mattress, and if too big can cause a risk of head entrapment. Entrapment as defined by the FDA is an event in which a someone is caught, trapped, or entangled in the spaces in or about the bed rail, mattress, or hospital bed frame. Entrapment can result in serious injury or death. The term bed rails are used in this document. Commonly used synonymous terms are side rails, bed side rails, and safety rails. Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one half, one quarter, or one eighth lengths. Also, some bed designs don't include rails as part of the bed by the manufacturer and may install on or used along the side of a bed. Examples of bed rails include, but are not limited to: o Side rails, bed side rails, and safety rails; and o Grab bars and assist bars. 1. Resident #73's Minimum Data Set assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Resident #73 required substantial/maximal assistance (the helper does more than half the effort. The helper lifts or holds trunk or limbs and provides more than half the effort) with rolling side to side in bed and required total assistance with bed to chair transfers. The MDS included diagnoses of unspecified dementia, non Alzheimer's disease, and cerebral palsy. Resident #73's MDS assessment dated [DATE] documented Resident #73 exhibited other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) 1 3 days per week. The Resident required substantial/maximal assistance with rolling in bed and required total staff assistance for bed to chair transfers. The Care Plan Focus revised [DATE] indicated Resident #73 had a self care deficit related to impaired cognition, decreased mobility, weakness, cerebral palsy, and tremors. The Care Plan directed the staff to utilize bilateral ,d+[DATE] bed rails for bed mobility and independence. The Care Plan revised [DATE] to use a full-body mechanical lift with two staff assistance with transfers and no ambulation. The Bed Rail assessment dated [DATE] completed by Staff A, MDS Coordinator, documented the following: a. Resident #73's Information i. Didn't walk ii. Level of consciousness didn't fluctuate. iii. Had an alteration in safety awareness due to cognitive decline. iv. Had a history of falls. v. Displayed poor bed mobility or difficulty moving to a sitting position on the side of the bed. vi. Had difficulty with balance/poor trunk control. vii. Didn't have difficulty with postural hypertension. viii. Expressed a desire to have side rail/bar for safety and/or comfort. ix. No visual challenges. b. Interventions i. Lower the bed to the floor. ii. Provide restorative care to enhance abilities to safely stand and walk. iii. Provide frequent staff monitoring at night. iv. Provide assisted toileting for the resident at night. v. Visual and verbal reminders to use the call bed. c. Side Rail Placement i. Bilateral Side Rails ii. Side Rails/Assist Bar indicated and serve as an enabler to promote independence iii. The resident expressed a desire to have side rails/assist bars. The [DATE] Psych Order Sheet documented a physician order to increase Resident #73 brexpiprazole (atypical antipsychotic medication that works by changing the activity of certain natural substances in the brain; this class of agents is associated with an increased risk of mortality in elderly patients with dementia related psychosis per the National Library of Medicine; 2016) to 1 milligram (MG) by mouth at hour of sleep starting [DATE]. An Incident Report dated [DATE] at 9:13 AM documented an unwitnessed fall. Staff C, Registered Nurse (RN) documented she entered Resident #73 room to administer medications and obtain a blood sugar. Staff C walked into the room to find Resident #73 lying completely prone (stomach down) on the edge of the bed, wedged between the mattress and wall (bed approximately 10 inches away from the wall and in the lowest position) with the right side of her neck pressed up against the bed rail next to the wall wedged between the mattress and the bed rail with her head and neck twisted up towards the ceiling. Her face had dark, deep ecchymosis (bruising caused by blood leaking from broken blood vessels into the tissues resulting in purple/blue discoloration), left side of the neck and face looked swollen and tight. She had her eyes closed and mouth slightly open with saliva dripping out. Resident #73's right arm dangled partially off the bed with the back of her hand touching the floor. The right arm and hand had ecchymosis. The nurse couldn't visualize the left arm due to her positioning. The assessment revealed Resident #73 didn't breathe; no radial (wrist) pulse, or carotid (neck) pulse to her right side. The nurse couldn't palpate (feel) left radial or carotid pulse due to positioning. The report described Resident #73's level of consciousness as comatose (unarousable to verbal or physical stimuli) with Predisposing Physiological Factors of confusion with an impaired memory and a Predisposing Situational Factor as the side rails in upright position. The Progress Note dated [DATE] at 9:13 AM included the same information from the Incident Report at the same time. The Progress Note included the staff moved Resident #73 to the floor in a supine position. Staff C auscultated (listened) for heart and lung sounds, while continuing to try to arouse Resident #73 and check for pulses. Staff F, RN, came into the room to assist Staff C, and reported Resident #73 as a DNR (do not resuscitate). Staff C and Staff F continued to assess for pulses, listen to the heart, and lung sounds for 2 3 minutes. They attempted to obtain vital signs and checked her pupils, her pupils were fixed, dilated, and non reactive to light. The staff called time of death at 9:20 AM after they determined Resident #73 had no signs of life or vital signs. At 11:00 AM Staff C notified the on call physician of Resident #73's passing and nature of how they found her. The Physician gave instructions to call the Medical Examiner for further instructions. At 11:55 AM the Medical Examiner arrived at the facility. A Photo Reenactment [DATE] provided by the facility showed a mannequin positioned with the body (shoulders, chest, arms, waist, hips, legs) against the room wall and the mannequin's head positioned with the head facing up to the ceiling trapped between the positioning rail and the bed mattress. The Photo Reenactment Document contained a notation the nurse described Resident #73's lower body as more prone (positioned down toward the floor) position and her head faced more upward. A [DATE] review of the Facility Admission Agreement lacked any education or risk/benefit information regarding the use of side rails while a resident at the facility. On [DATE] at 11:27 AM Resident #73's room still had her bed. The bed had two grab bars, with the right outer rail missing the rail knob to release the bar on the outside rail. Further inspection showed less than a 3 inch gap from the mattress to the grab bar. Witnessed the facility admitting a new resident to the room. No one removed the grab bars from the bed prior to the new resident's admission to the room. During an interview on [DATE] at 11:41 AM the Administrator confirmed the bed frame in the room as Resident #73's bed. She stated Resident #73 used a wedged/lipped mattress, a different one than laid on that bed frame. That mattress did have the same width as Resident #73's mattress. During an observation on [DATE] at 12:53 PM the newly admitted resident, not included in the sample, laid in the same bed as Resident #73 used with the grab rails already in place on the bed. The resident sat up in bed eating from a bedside table, with both grab bars observed in the up position. During an interview on [DATE] at 1:26 PM Staff A explained when they switched electronic health record (HER) system the Bed Rail Assessment Form no longer included the outlined risk and benefits. The form contained one unspecific line. She reported she hadn't reviewed the risk factors including entrapment since the [DATE] change with the Residents and/or their Legal Representative. She voiced when asked if she explained the bed rails risks since the resident changed from a standing mechanical lift to a Hoyer lift in [DATE], she responded no. She verbalized none of the residents (using bed rails) had the risk factors reviewed with them since [DATE]. On [DATE] at 1:27 PM the Administrator agreed none of the residents had the bed rail risk reviewed in detail since [DATE]. They identified it after Resident #73's incident. They went back and completed a paper side rail use assessment form for all residents as part of their state investigation that included the risks and benefits. During an interview on [DATE] at 2:26 PM, Staff E, Certified Nursing Assistant (CNA), reported when she entered Resident #73's room on [DATE], she didn't see Resident #73 breathing. She had her hips still on the bed, turned on her side with her right side of her neck wedged against the grab bar. She noted her feet looked mottled (purple) by the time they lifted her to the floor. Her face had a faint purple discoloration. Staff E reported they had an in service on bed rails. Sometimes with certain people they are restraints, for some residents who have lost strength in their arm or legs, it can help enable their mobility. When she first started, she had a skills checklist sheet and videos they have to watch, but she can't remember any specific training on bed rails. On [DATE] at 2:54 PM the Administrator reported Resident #73 used the Panacea mattress with raised border perimeters. The mattress measured 34.5 inches across. When tested with compression weight less then Resident #73 last recorded weight of 222 pounds, the upper outer right perimeter cushion portion of the upper mattress rolled over to the side with any weight (compression) applied to the outside edge of the mattress. The Med [NAME] Beds came with the U shaped grab bars installed. The Med [NAME] bed frame measured 36.5 inches consistent with the pictures the facility provided as part of the facility investigation showing a rail to mattress gap of less than 3 inches (with no weight compression on the perimeter border in the picture). On [DATE] at 3:42 PM Staff K, Licensed Practical Nurse (LPN), reported the charge nurse has the responsibility to do a bed rail assessment when a resident admits to the facility. It is one of the questions that they have to ask the resident if they do or do not want a bed rail. They converse with the Resident about the bed rails if they want the rails for comfort or to help steady themselves when they stand from the bed. The Resident can choose if they want 1 or 2 bed rails. They (residents) know the risks of the side rails. When specifically asked by the Surveyor how a resident would know the risks of using a bed rail, Staff K responded she didn't have the paper in front of her to have the exact language. Staff K didn't know if the bed rail information went to the nurse manager. During an interview on [DATE] at 3:52 PM Staff L, CNA reported she into Resident #73's room sometime between 8:30 AM 8:40 PM to switch out a Hoyer lift sling. She noted Resident #73 lying supine (on her back) resting with her eyes closed in her low bed with the fall mat on the left side of the bed. She recalled she looked positioned well in the center of her bed. At that time, she first physically laid eyes on Resident #73 since the start of her shift. She confirmed she did hear Resident #73 yell out as she closed the room to leave. She didn't go back in to check on Resident #73 because she knew she was in a safe position in bed and couldn't move on her own. Resident #73 required two staff to roll her in bed. Resident #73 yelled daily and interventions usually didn't work. Staff L voiced Resident #73 couldn't use the grab bars on her bed. She couldn't reposition herself since she came to that neighborhood in [DATE]. Staff L voice she thought Resident #73 had grab bars on her bed since her admission to the neighborhood. On [DATE] at 4:13 PM Staff D, CNA, reported she completed walking rounds with the third shift CNA between 6:30 AM 7:00 AM. She remembered the CNA reported Resident #73 made weird sexual remarks during the night which were odd and unusual for her. She heard Resident #73 yelling between 6:30 6:40 AM. She didn't check on her at that time. She didn't have eyes on Resident #73 during walking rounds and didn't see her before the incident (on [DATE]). When she entered Resident #73's room on [DATE] she had her body turned toward the wall with her head stuck in the bed rail. She didn't have her eyes open and she didn't see her breathing. Resident #73 screamed and yelled a lot, as she wanted someone with her at all times. She originally used a standing lift, but when she came to that neighborhood, she had weakness in her arms and she required the full-body mechanical lift. Staff D recalled Resident #73 always had the U shaped grab bars on her bed, but she couldn't use the grab bars. On [DATE] at 6:19 PM Staff F reported when she entered Resident #73 room on [DATE] she saw an abrasion or chaffing to the right of Resident #73's neck in a linear line. When she checked her pupils, they didn't react. She looked mottled up to her knees. The call light was pulled-out of the wall and underneath Resident #73's torso. Staff F voiced she never seen Resident #73 use the grab bars on the bed. They had to do all her bed mobility for her. The Resident weighed almost 300 pounds and she didn't help in any way. She typically had two staff to reposition her in bed. Staff F explained she would only recommend bed rails for someone that could use them to assist with their bed mobility. In her opinion, Resident #73 needed full support to turn in bed and with her cognition, she probably wasn't appropriate to have grab bars. During an interview on [DATE] at 11:29 AM Resident #73 family member reported she had utilized bed rails for a long time. He voiced she didn't have any recent falls from the bed and she definitely needed help getting in and out of bed. He stated he didn't recall discussing the risks of using bed rails, including entrapment. He added she never used her call light. When he visited, he put the call light on for her, but she couldn't push the call light herself. A Device Activity Report provide by the facility documented the activation of Resident #73 call light at 8:55 AM. During interview on [DATE] at 12:43 PM the Director of Nursing (DON) reported the nurses complete the Bed Rail Assessment upon admission, readmission from the hospital, significant changes, and every 6 months to ensure the completion of the assessment. She explained the nurses are supposed to go over the risks of using side rails with harm, significant injury, and benefits, but she couldn't speak to what the nurses actually went over with the family after they changed to the EHR Bed Rail Assessment as the risk and benefits no longer remained on the form. She still expected the nurses to discuss the risk/benefits of the side rails even if it wasn't on the form. She reported if they couldn't use the bed rail for positioning, then they shouldn't use the rails. She didn't know who had the role of reassessing the bed rails as time went on. She needed to look specifically at the policy to see who had that responsibility. Typically, the MDS Coordinator looked at the Bed Rail assessments. The DON added they completed the Bed Rail Assessment on the first nursing shift of the admission. The nurse goes through all the questions on the Bed Rail assessment and the computer directed them to go over risks and benefits. During an interview on [DATE] at 12:53 PM the Administrator explained the nurses must do a Bed Rail Assessment when the resident admits to the facility. The nurses assess to see if the resident is appropriate for the use of bed rails. The staff probably didn't try interventions prior to applying bed rails on the bed as they assess the need for bed rails on the day of admission. If the use of bed rails isn't appropriate for the resident, then they have maintenance remove the rails. Interview with the Maintenance Director on [DATE] at 1:05 revealed Staff M is the main maintenance personal that inspects the beds. Maintenance measures the mattresses and rails when they get in new beds. Maintenance didn't do new measurements from the mattress to the railings when someone swapped the mattress. Interview on [DATE] at 1:13 PM Staff M reported they wait to hear from the nursing staff as to what they are supposed to do. The beds come with the bed rails on and nurses let them know if they need to remove the bed rails. A [DATE] review of the Six-Month Bed Rail Safety Check showed Resident #73's room checked off for the [DATE] check. The Document contained a [DATE] hand written statement by Staff M, Inspected bed for operation and functionality. Also hazard that could be considered potential issues to entrapment and health of residents. On [DATE] at 1:57 PM Staff A explained they discuss the Bed Rail Assessments at Care Conferences. She didn't attend all Care Conferences. She would ask whoever went to the Care Conference to discuss it. They used to go into more detail about the risks when they used the paper assessment. The EHR lacked the risks and benefit when they started that Bed Rail Assessment. The charge nurses completed the Bed Rail Assessment when they did an MDS assessment. No one ever told her a resident didn't use their bed rails, to go up and reassess a resident. Different family members voiced they thought mom or dad would fall out of bed if they didn't have the rails and the family thought it was appropriate to have a side rail. If information came in from the aides that the resident didn't use the rails, they would reassess. She didn't know of any documentation of interventions done prior to the implementation of bed rails. On [DATE] at 2:23 PM Staff B, MDS Coordinator, reported the staff complete the Bed Rail Assessment upon admission. They discuss with the resident and family what they want for side rails. The facility switched to an electronic Bed Rail assessment in [DATE]. The assessment went into how the resident or family feel about the side rails, why they need or use the rail, if they need 1 or 2 rails or no rails. A lot of it is the resident's preference. If they are in bed the rails are up. When the resident wishes to have the bed rails used, the nurse must go over the risks with the resident/family when they do the bed rail assessment. They don't really do anything more than a conversation about if they want bed rails, unless therapy is involved. Her understanding is they review the bed rail assessment quarterly with the resident or family member, regarding if they want to continue with the side rails or if they want it changed. She hasn't had a conversation about entrapment or injuries regarding side rails in care conferences as she is usually not involved in those. During an interview on [DATE] at 3:13 PM the Legal Medical Death Investigator reported Resident #73's death showed external findings consistent of an asphyxiated (suffocation) death. During an interview on [DATE] at 5:12 PM Staff I, LPN/Nurse Manager, explained the nurses assess the bed rails by asking the questions on the bed rails assessment. She acknowledged the bed rails assessment didn't specifically address with the Resident and/or Legal Representative questions or information specific to injury, entrapment or death from the use of bed rails. She reported she agreed the form couldn't attest to what the nurses specifically addressed with the Resident or Legal Representative. An Untitled Document provided by the facility on [DATE] documented 94 of the 101 residents in the facility utilized a bed rail or grab bar of some type. During an interview on [DATE] at 10:22 AM Staff N, LPN, reported she asked all the questions on the EHR Bed Rail Assessment. The Bed Rail Assessment didn't address the resident's height and weight, as they document it in the clinical admission record. Staff N reported she didn't have any training on bed safety in relation to looking for gaps between the mattress and the bed rail. She didn't know anything about measurements or how to check for gaps. She said if she found a loose railing, she would let maintenance know. They completed the Bed Rail assessment the day of admission by asking the resident the questions on the assessment. Staff N voiced she didn't do any actual observation of the resident to see if they could properly use the bed rail. Therapy many times may make a recommendation, but they don't usually do it on the day of admission. Staff N responded no when asked if the nurse made the decision to use a side rail, she explained it is up to the resident. If the resident wanted to keep the rails on the bed, then they kept them on, as the decision is the residents. She said it was a good question if they should try interventions prior to using side rails, but she didn't know if they did that. On [DATE] at 10:34 AM Staff T, RN, reported they ask the resident if they want bed rails. If the resident didn't want bed rails, then they remove the rails from the bed. The beds come with the bed rails in place, but some residents request to have removed. If she noted a gap between the bed rail and the mattress, she placed a rolled up blanket to fill the gap, the she contacted maintenance to get an appropriate size mattress. On [DATE] at 10:35 AM Staff O, CNA, voiced the nurse assesses the resident on admission on if they need a bed rail. The nurse kept in contact with them on what to watch for, but she thought they could use more training. She didn't have any training on the danger zones or gaps from the mattress to the rails. On [DATE] at 10:42 AM Staff P, CNA, voiced she had received training on bed rails. The bed rails couldn't be over five inches from the mattress and they must position the resident off the rail more in the middle of the bed. On [DATE] at 10:44 AM Staff Q, CNA, reported she didn't really have education about the bed rail, but if she had a concern with the bed rail she reported it to the charge nurse. When asked if she knew of a resident that didn't use the bed rails on their beds, she responded, yes. On [DATE] at 10:45 AM Staff R, CNA, reported she didn't have any recent bed rail education and only received education on how to move the bed rail. On [DATE] at 11:01 AM Staff S, CNA, reported they could have a few residents that didn't use their bed rails. On [DATE] at 11:05 AM when inquired if she received bed rail safety training, Staff K replied they read a bed rail form to the family and they sign it. She couldn't recall the stated risk details on the form. She reported she would observe the resident rolling in bed/transferring with the bed rail when she did the skin assessment but the decision to have a bed rail is up to the resident and the family. If she had concerns about gaps in the bed rails she would contact maintenance. During an interview on [DATE] at 1:45 PM the Administrator reported she had created a new paper form that addressed the assessment and risk/benefits better until they updated the EHR form in the computer. They started using the EHR on [DATE] for everything except the electronic medication administration records (EMARs) that went live on [DATE]. On [DATE] the Administrator provided an email dated [DATE] that documented the facilities go live date for the EHR as [DATE]. A [DATE] review of the General Orientation Checklist, CNA/Certified Medication Aide (CMA) Orientation Checklist and Nursing Orientation Checklists utilized by the nursing staff prior to Resident #73's incident didn't include any orientation on bed rail safety. During an interview on [DATE] at 11:16 AM the DON reported she couldn't guarantee that a family member would always understand and remember their education on. The floor nurses should know how to do the processes on the policies. She holds the nurses accountable since they received education on the updated bed rail policy. If staff are gone for a day or two, it is their responsibility to see if the facility had any policy updates and follow the policies. The Assistant Directors of Nursing (ADONs) should double check what the floor nurses did. The ADONs need to review the side rail assessments to ensure they completed the assessment, and not just sign it. If nurses didn't follow the policy, depending on the severity of it, they could receive a write up or worse, as they are liable for these resident lives. During an interview on [DATE] at 11:45 AM the Administrator reported she expected maintenance to remove the side rails on unused beds. The nurses must try interventions prior to using side rails; perform the Bed Rail assessment, and reassessments per policy as well as utilize the risk and benefits education form per the policy. The Facility's General Nursing Side Rail Policy, revised [DATE] by the Administrator documented the facility would attempt to use appropriate alternatives prior to installing a side rail or bed rail. The Policy included the following procedure: 1. Each resident will have a side rail assessment completed on admission, then reviewed quarterly to ensure if they have side rails placed, they still remain appropriate based on the resident's condition. 2. The nurse reviewed the risks and benefits with the resident or resident's representative. Prior to installing side rails, the facility must obtain an informed consent. 3. A resident may or may not use side rails if the assessment determines the side rails as appropriate or not appropriate for the following reasons: a. The assessment indicates the use of side rails enable independence. b. The resident expressed a desire to have side rails raised while in bed and understood the risks and the benefits associated with using side rails. c. The assessment didn't indicate side rails at that time. d. The assessment indicated side rails due to the resident's medical conditions/symptoms 4. The facility will ensure that the bed's dimensions are appropriate for the resident's size and weight. 6. The facility will follow the manufacturer's recommendations and specification for installing and maintaining bed rails [TRUNCATED]

Based on observation, clinical record review, policy review, resident and staff interview, the facility failed to respect the resident's right and dignity to have a bath twice a week per resident request for 1 of 1 resident reviewed (Resident #98); and failed to provide toileting in a timely manner which resulted in bowel incontinence and emotional distress for 1 of 1 resident (Resident #311). The facility reported a census of 101 residents. Findings include: 1. Resident #98's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #98 required substantial to maximal assistance (a helper does more than half the effort. The helper lifts or holds the trunk or limbs and provides more than half the effort with showering/bathing). The MDS included diagnoses of anemia (low blood iron), hypertension (high blood pressure), urinary tract infection (UTI), diabetes, pneumonia and stage 3 pressure ulcer. The Activities of Daily Living (ADL) Care Plan dated 5/31/24 lacked documentation of Resident #98's preference for an evening bath. The December 2023 Documentation Survey Report V2 lacked documentation of Resident #98's preference for an evening bath. The Survey Report V2 lacked documentation of Resident #98 getting a bath until 6/3/24. In addition, the report listed she refused a bath on 6/10/24 and 6/13/24. On 6/24/24 at 11:30 AM Resident #98 explained she doesn't always get her shower twice a week like she wants. On 6/26/24 at 4:15 PM Resident #98 reported she didn't refuse showers when the staff offered her a shower. She reported having a long time before she got her first shower offered and they still didn't offer her a shower every week. She explained she told to the nurse be couldn't remember which one. During an interview on 6/26/24 at 4:50 PM, the Director of Nursing reported she couldn't find any documentation that Resident #98 received a shower from 5/24/24 to 6/2/24. She added she couldn't find any documentation of Resident #98 refusing a shower or if someone offered her one at another time. She reported Resident #98 should have two showers a week. The facility policy titled Personal Care Bathing: Residents revised 5/17/21 directed residents shall have either a shower, whirlpool bath, or a bed bath at a minimum two times per week or per the residents' preferences noted on their plan of care. In addition, if a resident refused a bath/shower the Certified Nurse Aide must notify the nurse and document the refusal in the resident's electronic record computerized charting. The next day or the next shift the resident will be re approached for a bath/shower and given as the resident allows. 2. The Baseline Care Plan Assessment completed 6/20/24 documented Resident #311 receives assistance of 1 with dressing, personal hygiene, bed mobility, transfers, and toilet use. In addition, the assessment listed Resident #311 as cognitively intact. On 6/24/24 at 11:07 AM, Resident #311 verbalized for the past few days his call light didn't not work. He began crying and reported he sat in his feces for an hour and a half on Sunday night due to the call light not working. He reported he yelled out for staff but no one came so he finally called his daughter on his cell phone. She called the facility to get staff to come to his room to help him. He reported staff gave him a hand bell to ring since his call light didn't work. He verbalized being so embarrassed and uncomfortable that he had a bowel movement in his pants. On 6/26/24 at 4:30 PM, Resident #311 reported his call light worked the past two days but they kept the bell in his room just in case. Resident #311 had tears and said he didn't ever want to sit in feces that long again if he had an accident. During an interview on 6/26/24 at 5:00 PM, the Director of Nursing verbalized the facility has hand bells for residents, if the call light didn't work. She reported she didn't know of any call lights not working recently. She expressed concern and denied knowing that Resident #311 sat in feces for an hour and a half. The facility policy titled Resident Rights revised 11/18/22 instructed to treat residents with dignity and respect. The policy indicated residents have the right to voice grievances to the staff of the facility or any other person, without fear of discrimination or reprisal. The facility must resolve the issue promptly.

Based on record review, staff interviews, and policy review the facility failed to accurately code 2 of 16 residents (Residents #87 and #54) Minimum Data Set (MDS) assessments. The facility reported a census of 101 residents. Findings include: 1. Resident #87's Preadmission Screening and Resident Review (PASRR) assessment dated [DATE] listed her as a Level II PASRR (a person with a serious mental illness). Resident #87's Minimum Data Set (MDS) assessment dated [DATE] coded Resident #87 as a PASRR Level I (a person without a serious mental illness). During an interview on 6/27/24 at 11:50 AM, Staff B, MDS Coordinator reported she coded Resident #87's MDS dated [DATE] inaccurately as the MDS should list her as a PASRR Level II, and she would go fix it. Review of a facility policy dated MDS Entry/Computerization reviewed on 4/12/24 instructed the facility to prepare timely, accurate, and comprehensive MDS. 48003 2. Resident #54's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The MDS included diagnoses of hypertension (high blood pressure), anxiety, quadriplegia (paralysis of all four extremities), type II diabetes, and schizophrenia (mood disorder that can cause hallucinations and delusions). The MDS documented the resident had a stage 4 pressure ulcer. The Progress Note dated 2/12/24 at 3:00 PM reflected Resident #54's Stage 4 pressure ulcer on his coccyx as healed. During an interview on 6/25/24 at 1:01 PM Staff A, MDS Coordinator, reported she would have to look back at her notes for Resident #54's MDS about his Stage 4 pressure ulcer. During an interview on 6/26/24 at 1:43 PM Staff A reported she made an error when she coded Resident #54 had a stage 4 pressure ulcer. She reported it healed on 2/12/24. She reported the facility followed the MDS policy and also the Resident assessment Instrument (RAI) Manual.

Based on record review, staff interviews, and policy review the facility failed submit a new Pre admission Screening and Resident Review (PASRR) for review for 1 of 1 resident (Resident #72) for review after receiving new diagnoses in his medical record. The facility reported a census of 101 residents. Findings include: Resident #72's Minimum Data Set (MDS) assessment dated [DATE] identified a Staff Assessment for Mental Status indicating he had a memory problem and severely impaired decision-making skills. The MDS included diagnoses of dementia, depression, and psychotic disorder. Record review of a Progress Note for Resident #72 dated 5/8/24 by his Nurse Practitioner documented new diagnosis of: a. Dementia with behavioral disturbance b. Current severe episode of major depressive disorder with psychotic features without prior episode c. Anxiety disorder due to known physiological condition Record review of Resident #72 current PASRR on 6/26/24 lacked diagnoses of: a. Dementia with behavioral disturbance b. Current severe episode of major depressive disorder with psychotic features without prior episode c. Anxiety disorder due to known physiological condition During an interview on 6/26/24 at 12:50 PM Staff G, Social Worker (SW), explained she reviewed the resident's Progress Notes quarterly, looking for new diagnoses, and the Nurse Managers constantly looked at the new orders and diagnoses. The nurses communicated via email or in person to her if the resident's medical record had new diagnoses. She reported no one told her about Resident #72 new diagnoses, she reported she would submit a referral to PASRR for review. The Social Services PASRR Screens reviewed 3/26/24 lacked direction on the facility's process when a current resident had new diagnoses what the facility process is for PASRR review.

Based on record review, staff interview, and policy review the facility failed to include the use of psychotropic medications and what to look for when using the medications for 1 of 1 resident (Resident #35) on the Baseline Care Plan upon admission. The reported a census of 101 residents. Findings include: Resident #35's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The Progress Note dated 4/19/24 listed Resident #35's admission orders to the facility on [DATE]. The orders included anti depressants, opioids, and anti anxiety medications. Resident #35's Admission Baseline Care Plan dated 5/16/24 lacked documentation that she received psychotropic medications and what side effects for staff to monitor related to the use anti depressants, opioids, and anti anxiety drug class medications present upon admission. During an interview on 6/27/24 at 11:13 AM Staff I, Licensed Practical Nurse (LPN), explained she expected the Baseline Care Plan include adverse reactions and side effects of psychotropic medications. The Care Plans policy reviewed 4/11/24 directed the Baseline Care Plan include the minimum healthcare information necessary to properly care for a resident including but not limited to: a. Initial goals based on admission orders b. Physician orders c. Dietary orders d. Therapy Services e. Social Services

Based on record review, staff interviews, and policy review the facility failed update the Care Plan to include interventions related to new mental health diagnoses for 1 of 1 resident (Resident #72). In addition, the facility failed to revise the Care Plan for 1 of 1 resident (Resident #31) after initiating antibiotic therapy. The facility reported a census of 101 residents. Findings Include: 1. Resident #72's Minimum Data Set (MDS) assessment dated [DATE] identified a Staff Assessment for Mental Status indicating he had a memory problem and severely impaired decision-making skills. The MDS included diagnoses of dementia, depression, and psychotic disorder. Record review of a Progress Note for Resident #72 dated 5/8/24 by his Nurse Practitioner documented new diagnosis of: a. Dementia with behavioral disturbance b. Current severe episode of major depressive disorder with psychotic features without prior episode c. Anxiety disorder due to known physiological condition Resident #72's Care Plan dated 6/26/24 lacked interventions and goals related to the new diagnoses on 5/8/24 documented in his medical record. 2. Resident #31's MDS assessment dated [DATE] identified a BIMS score of 11, indicating moderately impaired cognition. Resident #31's Clinical Physician Orders reviewed on 6/28/24 at 1:27 AM included an order for antibiotic medication starting on 6/17/2024 for 10 days for a bacterial infection. The Care Plan dated 6/26/24 lacked the use of an antibiotic and interventions related to the use of the antibiotics. During an interview on 6/27/24 at 10:36 AM Staff I, Licensed Practical Nurse (LPN), explained she updated the residents' Care Plans if a resident received a new diagnosis and reviewed the reason for the new diagnoses with the Advanced Registered Nurse Practitioner (ARNP). Afterwards, she updated the Care Plan. If a resident received an antibiotic she would add that to the Care Plan. The Care Plan policy updated 4/11/24 lacked instruction regarding when a resident received a new diagnosis during their stay.

Based on record review, staff interview, and policy review the facility failed to complete routine pre- and post-dialysis assessments for 1 of 1 resident who received dialysis services at the facility (Resident #33). The facility reported a census of 101 residents. Findings include: Resident #33's Minimum Data Set (MDS) assessment dated [DATE] reflected he received dialysis services. Resident #33's Clinical Physician Orders included the following orders a. Dated 8/16/23: Weekly weights on Wednesdays. b. Dated 6/26/24: Nurse to complete pre/post dialysis assessments on Mondays, Wednesdays, Fridays, and as needed on dialysis days. Resident #33's Weights and Vitals reviewed on 6/27/24 lacked weights on 1/10/24, 1/24/24, 4/10/24, 8/8/24 and 6/5/24. Resident #33's electronic health record (EHR) assessments reviewed on 6/27/24 lacked pre and post dialysis assessments from 4/25/24 to 6/13/24 on Monday, Wednesday and Friday. During an interview on 6/27/24 at 11:09 AM with Staff J, Licensed Practical Nurse (LPN), verbalized she knew they missed many days of pre- and post-dialysis assessments for Resident #33 due to his EHR not having an automated assessment for him set up. The Dialysis policy reviewed 6/15/23 directed the nurses to assess and document the residents' vital signs, including blood pressure in the location the access site is NOT located in, weights as ordered by the physician, visual monitoring of the access site before and after dialysis, and any other pertinent health information regarding the resident. The nurse will communicate with the dialysis facility prior to and post dialysis when abnormalities are noted.

Based on record review, staff interview, and policy review the facility failed to complete an Annual Minimum Data Set (MDS) assessment in the required timeframe for 1 of 1 resident reviewed (Resident #54). The facility reported a census of 101 residents. Findings include: Resident #54's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 8, indicating moderately cognitive impairment. The MDS included diagnoses of hypertension (high blood pressure), anxiety, quadriplegia (paralysis of all four extremities), type II diabetes, and schizophrenia (mood disorder that causes hallucinations and delusions). Resident #54 MDS Summary reviewed on 6/27/24 at 9:17 AM reflected an assessment reference date (ARD) for the annual MDS as 4/17/24. The summary listed a completion and locked date of 6/5/24. During an interview on 6/25/24 at 1:01 PM Staff A, MDS Coordinator, reported when the facility changed to electronic charting software, Resident #54 kept having a discharge MDS come up and so it didn't trigger the annual assessment so, the facility missed it and noticed it late. During an interview on 6/26/24 at 1:43 PM Staff A reported the facility followed the MDS policy and the Resident Assessment Instrument (RAI) Manual. The facility policy titled MDS Entry/Computerization reviewed 4/12/24 directed the facility must establish the ARD to ensure the commonality of the assessment period. Each discipline is required to compete on the computer their appropriate section of the MDS and sign off electronically under the appropriate section on or before the MDS date. This is set to ensure data entry and completion of the MDS. Review of the Long Term Care Facility RAI 3.0 User's Manual dated 10/1/23 directed the Annual MDS is required to be completed by the ARD plus 14 days.

Based on clinical record review, Center for Medicare and Medicaid (CMS) Long Term Care (LTC) Facility Resident assessment Instrument (RAI) 3.0 User's Manual review, and staff interview the facility failed to completed a Significant Change in Status Minimum Data Set (MDS) assessment within the required time frame for 1 of 3 residents sampled for hospice care (Resident #96). The facility reported a census of 101 residents. Findings include: Resident #96 Electronic Census showed they started hospice level of care on 5/2/24. Resident #96's Minimum Data Set (MDS) 3.0 Summary Page reflected a Significant Change in Status MDS assessment dated [DATE]. Sections D, E, F, and Q reflected a green color indicating completed for those assessment sections. Sections A, B, C, GG, H, I, J, K, L, N, M, N, O, P were colored yellow indicating in-progress. The box listed as Completed showed a red color directing to complete by 5/23/24. The Care Area Assessments (CAA) box indicated complete by 5/23/24 and complete the Care Plan Decision by 5/30/24. The Signature Box highlighted in yellow reflected 603 areas of the MDS assessment not signed. During an interview on 6/26/24 at 1:41 PM Staff A, MDS Coordinator, reported obviously the assessment they set up the assessment, but didn't finish it. She reported she would have to check on some things and would get back to the Surveyor. She voiced the facility did have an MDS policy and they also followed the RAI Manual for completing the MDS. On 6/26/24 at 3:19 PM Staff B, MDS Coordinator, explained she completed Resident #96's significant change in status assessment (SCSA) MDS, but she didn't sign and lock the assessment to complete it. During an interview on 6/26/24 at 3:41 PM Staff B reported they had an MDS Policy they followed, along with the RAI Manual. The MDS Entry/Computerization Policy, reviewed 4/12/24, documented the facility would utilize the MDS to comprehensively assess all residents. The Policy identified a purpose to prepare a timely, accurate and comprehensive MDS. The Policy Procedure directed each discipline to complete their appropriate section of the MDS on the computer and sign off electronically on or before the MDS date. The MDS date is set to ensure data entry and completion of the MDS. The Policy didn't address the completion of SCSA MDS assessments. The LTC RAI 3.0 User's Manual Version 1.18.1 October 2023 indicated the RAI process had multiple regulatory requirements. Federal regulations at 42 CFR (Code of Federal Regulations) 483.20 (b)(1)(xviii), (g), and (h) require that the assessment accurately reflects the resident's status. In addition, the manual directed the completion of the MDS completion date is no later than the 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days). The facility must complete a SCSA when a terminally ill resident enrolls in a hospice program (Medicare certified or State licensed hospice provider) or changes hospice providers and remains a resident at the nursing home.

Based on observation, clinical record review, policy review, facility provided photos and staff interview, the facility failed to ensure the use of a gait belt and provide a proper mechanical lift for safe transfer for 2 of 8 residents reviewed (Resident #6 and #2). The facility identified a census of 118 residents. Findings include: 1. A Late Entry ID Note dated 8/19/22 documented Resident #6 admitted to the facility at 4:15 p.m. from the hospital for skilled physical and occupational therapy services, intravenous therapy, sternal wound infection treatment status post coronary artery bypass graft (CABG) and treatment for [CONDITION(S)]-resistant Staphylococcus aureus ([CONDITION(S)]) bacteremia (infection is caused by a type of staph bacteria that is resistant to many of the antibiotics used to treat ordinary staph infections). The 8/15/22 Hospital Occupational Therapy Initial Evaluation documented Resident #6 had generalized weakness, [CONDITION(S)] (low sodium levels), arthritis, chronic fatigue syndrome, [CONDITION(S)] [CONDITION(S)], anxiety, [CONDITION(S)], status post CABG x 5 and [CONDITION(S)] disc disease of the lumbar spine. The Evaluation specified the reason for referral as generalized weakness to assess for home safety with daily activity. The evaluation documented Resident #6 as sit to stand and stand to sit as contact guard assist with use of gait belt and walker; adaptive or assistive devise used; supervision and/or instruct for toilet transfer deficit; standing dynamic balance fair with forward wheeled walker (dynamic balance refers to the ability to maintain a position while moving, such as while walking, running, or standing up). A Facility Admission Order sheet dated 8/19/22, signed by the Provider on 8/22/22, documented Resident #6's activity level as both independent and assist of one. The 8/19/22 Hospital Discharge Medical List listed an order for aspirin 325 milligrams (mg) take one tablet by mouth daily and [MEDICATION(S)] 75 mg tablet (commonly known as Plavix; a medication that prevents platelets in the blood from sticking together to form an unwanted blood cloth that could block an artery) take one tablet by mouth daily. An Admission Assessment completed 8/19/22 by Staff A, Registered Nurse (RN) documented Resident #6 as able to walk only with assistance, can walk but must be led, understands verbal communication, is aware of time and place and uses the bathroom appropriately with assistance. A Fall Risk Assessment completed 8/19/22 showed a score of 12. A total score of 10 or above represents high (fall) risk. The Fall Risk Assessment contained the following information: 1. Alert 2. History of falls 3. One to two falls in the past 3 months 4. Balance problem while walking 5. Requires assistive device 6. Orthostatic BP check 120/68 lying to standing; 118/59 lying to standing, 116/62 laying to standing 7. Use of antihypertensive meds, antiseizure, benzodiazepines, cathartics, narcotics, psychotropics 8. Diseases: seizures, arthritis, fractures The Care Guide dated 8/19/22 at 2:12 p.m. created by the Assistant Director of Nursing (ADON) directed the staff to provide a gait belt, walker and one assist for transfers and ambulation/mobility. The Temporary Care Plan dated 8/20/22 documented Resident #6 as a new admission at risk for falls related to new environment and recent acute illness, medications and weakness with a note specifying Resident #6 gets up unassisted after numerous reminders. The Care Plan directed to follow the therapy recommendations, encourage to report if feeling weak or dizzy and to orientate them to the environment if cognitive able to understand: call light use, toileting, dining, bathing schedule. The Temporary Care Plan specified Resident #6 needed assistance with activities of daily living (ADL's) related to recent hospitalization and weakness and directed the staff to provide assist of 1 or 2 staff with dressing, peri-care, hygiene, assist of one for toileting/bathing and to follow therapy recommendations. A Temporary Care Plan dated 8/20/22 documented Resident #6 needed assist with mobility related to recent hospitalization and weakness. The Care Plan directed the staff to use an assist of one with gait belt and walker for transfers and ambulation unless otherwise indicated. An Incident Report dated 8/20/22 at 2:00 a.m. completed by Staff A at 3:27 a.m. documented she had been called to Resident #6's room. A Certified Nursing Assistant, (C.N.A.) had the Resident sitting on the shower chair. The C.N.A. stated the Resident lost her balance and sat down on the shower chair and hit her head on the shower bar. The Incident Report documented the staff obtained a gait belt, grabbed with staff to assist up from the shower chair. The physician was called after an assessment had been completed. Assessment negative other than a large bump on the back of her head. An Employee Counseling Form, dated 8/20/22, provided by the facility, documented Staff B received counseling on 8/20/22 at 2:05 a.m. provided by Staff C, Licensed Practical Nurse (LPN). The Employee Counseling Form documented the following description of the incident: Entered Resident #6's room for a fall. Resident was sitting on the shower chair and had been transferred and lost her balance falling backwards. There had not been a gait belt on the resident at the time of the fall. The Charge Nurse/Supervisor Coaching/Counseling documented Staff B was asked if she has a gait belt to which she replied, no, my partner does. Staff B received education that she needs to wear a gait belt with all transfers. The Counseling Form lacked documentation that Staff B had actually been given a gait belt to use after the incident or if the gait belts were present in the Resident's room for use at the time of the incident. An Emergency Department History of Present Illness from the local hospital dated 8/20/22 at 3:37 a.m. documented Resident #6 reported she had been standing in the bathroom and lost her balance. She reports she hit her head against the grab bar. She also reported left ankle pain and is on blood thinning medication. Resident #6 reported a headache with a pain level of 10/10 on a 1-10 pain scale (10 being the worst level of pain possible). The Review of Systems documented the skin as positive for posterior head bruise. The Physical Exam Skin Exam findings documented bruising posterior head golf-ball sized, ecchymosis (black and blue) scattered and [CONDITION(S)] (redness) posterior head present. A Head Computed tomography (commonly referred to as a CT scan. A CT scan is a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body. It shows detailed images of any part of the body, including the bones, muscles, fat, organs and blood vessels) without contrast showed a subdural hemorrhage extending into the left measuring up to 11.5 millimeters (mm) causing mild mass effect. Small right posterior (rear) parafalcine (parafalcine subdural hematoma may represent a distinct clinical entity with differing clinical behavior) subdural hemorrhage measuring 7.2 mm extending into the right tentorium. Moderate soft tissue swelling and hematoma formation in the left occipital (back of) scalp. Clinical Impressions: subarachnoid hemorrhage and subdural hematoma (A subdural hematoma is a serious condition that carries a high risk of death, particularly in older people and those whose brain was severely damaged. Acute subdural hematomas are the most serious type because they're often associated with significant damage to the brain). The Document documented at 5:41 a.m. the Practitioner spoke with Resident #6 and confirmed the treatment plan. She wished to pursue whatever treatment was necessary. A Temporary Staff Packet, dated 8/21/22, provided by the facility directed agency staff that care guides are utilized in the facility to update staff on changes to the resident activities of daily living (ADL's). The Packet detailed the main objective when providing care is to ensure that no resident is injured. The Packet further detailed the nurse in charge is responsible for the safety of all residents and in that capacity they are expected to direct staff and maintain adequate staffing (i.e.staffing emergencies). The Packet directed staff that a care guide and gait belt were requirements for each work shift. A gait belt is a requirement for resident transfers and ambulation for those requiring assistance. If they do not have a gait belt, contact the charge nurse to find one. It is never acceptable to not use a gait belt. Please return the gait belt back to the charge nurse at the end of the shift. An Investigation Report Witness Statement for Staff B, C.N.A., dated 8/22/22, completed by the Director of Nursing (DON) documented Staff B had worked on the night shift on 8/19/22 and assisted Resident #6 at the time of her fall. The first encounter she had with Resident #6 was when the Resident put her call light on to request a blanket due to being cold. Staff B got her a blanket at that time. It had been around midnight or so. At that time, she made her comfortable and had her call light in place before leaving the room. Around 12:30 a.m. - 1:00 a.m. the Resident put her call light on for assistance to the bathroom. Staff B assisted Resident #6 to the bathroom per assist of one and her wheeled walker without any issues. Then around 1:45 a.m. the Resident called again to go to the bathroom. After she was done going to the bathroom, Resident #6 stood up and as we were going to walk out of the bathroom, she suddenly started to fall backwards. Staff B tried to hold her from the front and set her on the shower bench in the bathroom right next to the toilet. Resident #6 hit her head on the handrail directly next to the shower bench. Everything happened so fast. The other aide that worked with her, Staff D, C.N.A., came because he said he heard something out in the hallway. Staff B informed Staff D that Resident #6 had fell . Staff D left the room to find the nurse to assess the resident. Staff A was assisting another resident, so Staff D went to River Ridge and grabbed a different nurse. Staff C Licensed Practical Nurse (LPN) came to Resident #6's room to check the resident and shortly after that Staff A came to the room. At this time, they did an assessment and placed a gait belt on the resident. They walked her back to her bed with assist of 2 (staff). The nurse continued with her evaluation and Staff B left the room. An Investigation Report Witness Statement for Staff D, dated 8/22/22, completed by the DON documented Staff D came on shift at 10:30 p.m. on 8/19/22 on the Bay/Bay Suites working with Staff B from agency staffing. At 11:00 p.m. Staff D answered Resident #6's call light. The Resident was in her wheelchair and wanted transferred to bed. Staff D placed a gait belt on her and assisted her to her bed at that time. He asked her if she needed to use the restroom prior to transfer and Resident #6 stated, no. She had the call light in her reach when Staff D left the room. Directly prior to the fall occurring, Staff D was in the hallway working on his charting when Resident #6's call light went off. He started to walk that way, but Staff B made it to Resident #6's room before he did, so he went back to charting. While he was sitting in the hallway charting, he noticed something weird like a vibration on the wall or noise coming from Resident #6's room so he got up and went to the Resident's room. Staff B was present with the Resident whom was at the time sitting on the shower chair in the shower in her bathroom. Resident #6 reported she had bumped her head from falling back in the bathroom. He immediately left the room to look for the nurse who was not at the nurses' station at the time. He then went to the next unit over and grabbed another nurse, Staff C, to check out the Resident. Staff C came to check Resident #6 out in the bathroom and he went to grab Staff A from another resident's room to come assess the Resident. There were 4 people in the bathroom in a tight space so he left the room and continued on with his duties. An Investigation Report Witness Statement for Staff C, dated 8/22/22, completed by the DON documented Staff C had been alerted by Staff D from Bay that he needed assistance in Resident #6's room as Resident #6 had a fall in the bathroom. When she entered the room, she saw Resident #6 sitting on the shower bench. She had a hematoma noted to the back of her head where she had fell back and hit her head on the handrail in the shower. The Resident did not have a gait belt on which she questioned Staff B about. Staff C provided Staff B education on the use of the gait belt for every transfer that she is assisting with. The Resident was further evaluated and assisted back to her bed with assistance of two staff. Staff A took over the assessment at that time. An Investigation Report Witness Statement for Staff A, dated 8/22/22, completed by the DON documented Staff A had been the nurse on Bay the night of 8/19/22 starting at 10:30 p.m. and ending at 7:00 a.m. on 8/20/22. She was gathering materials needed for another resident at the time of the fall. She had been alerted from Staff C that Resident #6 had fallen while in the bathroom and hit her head on the hand rail. Staff A went into the room to further assess the Resident and noted a golf ball size raised area to the back of her head. She completed her neurological assessment and vitals. Notified her family and primary care provider following the fall. The Resident requested to go to the emergency department, so she called the ambulance to get her sent to the local hospital. The Facility Investigation Report signed by the Administrator and DON 8/22/22 and 8/24/22 documented procedure or care plan changes that were made in respect to the incident, if any: 1. On 8/20/22 both C.N.A.'s that worked bay (skilled) unit when the resident fell were removed from the schedule until further investigation could be completed. 2. On 8/20/22 contact made to the staffing agency to report the events that occurred with Staff B. 3. Agency Staff member B removed from the building and will no longer be able to pick up hours through her agency for the facility. 4. The Facility will continue to provide all new agency employees with an educational packet with information about the facility and expectations with use of gait belts being a requirement. 5. All agencies contracted with the Facility have been re-educated on the requirement to use gait belts with all transfers requiring assistance. Completed 8/26/22. 6. All Facility staff re-educated on requirements to use gait belts for all transfers requiring assistance. Completed 8/26/22. 7. Nursing Leadership to completed routine audits for staff usage of gait belts in the building, alternating shifts, with all units as focus. The Facility Investigation Report failed to address if gait belts were already in Resident #6's room accessible for the staff to use or if the charge nurses had checked to see if the gait belts were accessible in the room at the time of the incident. On 8/26/22 a Text Message Notification generated from Staff P, Human Resources, at 2:50 p.m. providing notification to nurses, therapists and C.N.A.'s detailing that gait belts and care guides are part of the uniform. Staff must use both for all transfers. On 9/13/22 at approximately 11:00 a.m. a walk thru completed of the lower level and upper level neighborhoods revealed not all rooms had gait belts placed on hooks behind the entrance room door. During an interview on 9/13/22 at 12:22 p.m. Staff D, C.N.A. He had been near Resident #6's room charting. He heard some sort of noise or vibration. He thought something happened so he went to the Resident's room. He observed the Resident sitting on the shower chair. Staff B stated the Resident had fallen and to go get the nurse. The Resident had an area on her head but he didn't know if it had been new or not. He went to get a nurse and the nurse came to the room. He had cared for Resident #6 earlier in the shift right after he came on shift. He reported shortly after he came on shift Resident #6 wanted to transfer from her wheelchair to the bed. He didn't know the amount of assistance she needed, so he went back out to check the care guide. He saw that she needed a one assist so he got his gait belt and returned to the room. The Resident stood by the wheelchair when he went back into the room. He placed the gait belt on her and transferred her from the wheelchair to the bed. She did accept to have the gait belt put on her. He worked from 10:30 p.m. to 6:30 a.m. (8/19/22 - 8/20/22). Resident #6 had been a new resident. He had to use the care guide to check on how to take care of her. During an interview on 9/13/22 at 1:24 p.m. Staff A reported Resident #6 admitted to the facility with a wound vac on her chest. She recalled the Resident being very upset and not wanting to be at the nursing home. The Resident kept getting up unassisted in her room. They were in the room a lot. As the night transpired, she had to go to memory care to get a catheter for another resident. When she got back, another nurse and C.N.A. were in Resident #6's room. Resident #6 had fallen back into the shower chair. Staff C said to get a gait belt. She asked Staff B where the gait belt was at. They assisted Resident #6 back to bed. The Resident had a large immediate hematoma on the back of her head and complained of pain. Staff A assumed she got up from the toilet, lost her balance and went down on the shower chair, banging her head on the shower hand rail. The Resident commented that she had hit her head. She had been focused on the Resident's head as there had been such a large bump on the back of her head. It appeared to line up with the shower rail. The Resident remained in her usual orientation. She kept saying, I have a brain bleed. She remained coherent when they transferred her to the bed. Staff A reported she left the room to go call an ambulance. The staff do a room to room report with the off going C.N.A. shift. They had a care guide that they follow for resident care. During an interview on 9/13/22 at 3:25 p.m. Staff C, reported she is an agency staff nurse that had been coming to the facility since November 2021. The facility has a care sheet that is printed out at night on third shift to have available to communicate care to all shifts as well as a communication notebook. The C.N.A.'s do a walking round report off at the end of every shift. The C.N.A's are required to use a gait belt for anyone that is transferring a resident. They are supposed to have their own gait belt as part of their uniform. The gait belts are to be in the resident rooms hanging behind the door. C.N.A.'s can also go to the charge nurse to get a gait belt, but there should be gait belt in the resident rooms. There have been gait belts in the rooms on the skilled unit as long as she has been there, but she didn't know about the rest of the rooms (not on the skilled unit). She had been the nurse on River Ridge that night (8/20/22). She had been the first nurse to respond to the incident. When entering the room Resident #6 sat on the shower chair next to the toilet. The Resident said she had been to the toilet and lost her balance and ended up in the shower chair. She bumped her head on the shower railing behind the shower chair. Staff C reported, it reminded her of an old cartoon where there was a bat to the head and the lump just raises up. There was a little lump at the base of her head. Staff C performed an assessment on the resident. Resident #6 answered questions appropriately. A family member had called the facility to let them know that the Resident had called them. Staff C notified the family member of the fall, Resident's condition and plan to transfer to the local hospital. On 9/13/22 at approximately 3:00 p.m. an observation of a room with the same layout as Resident #6's room observed with the Director of Nursing (DON). Observation revealed the toilet is seated next to a small shower unit on the right-hand side with a shower chair that sits toward the middle of the small shower unit. A 2-3 inch solid, round, heavy metal hand rail ran approximately 4 foot along the inside wall of the shower behind the shower chair. Interview with the DON at this time further revealed she had interviewed Staff B via telephone after the incident as Staff B had been sent home. They had contacted the staffing agency and informed them that Staff B would not be allowed back to the facility for not following the policy regarding the use of gait belt. The DON reported the gait belt is considered part of the C.N.A. uniform. All aides are to have or wear their gait belt on them. During an interview on 9/14/22 at 7:58 a.m. the Administrator reported there were two nurses working on the incident that night. Staff C did the assessment and talked to the Resident's niece. Staff C informed the niece of the incident, resident condition and said she would take care of notifying the daughter. She reported she feels it had been a communication issue between the nurses in documentation. Staff A documented the Resident's daughter had been notified on the incident report. She stated she didn't feel the nurse mis-documented on purpose. Staff C provided immediate education to Staff B. Staff B was given a gait belt so immediate correction had been done. She reported it is expected that the C.N.A.'s have a gait belt as part of the uniform. She stated they had ordered more gait belts to place in rooms and to have extra on hand for use. She reported the staffing agencies had been notified and agreed to ensure their C.N.A.'s have gait belts, but more were ordered so they would be available to all staff. All resident rooms are to have gait belts in the rooms. She stated they ordered more gait belts on 8/26/22, but their representative informed them it would take too long to get the order, so on 8/30/22 another order had been placed to obtain the gait belts from a different vendor from Texas. The Administrator reported all rooms were to have gait belts behind the doors, not just the rooms of the resident that required the use of gait belts. An Order Invoice dated 8/30/22, provided by the facility, showed 133 gait belts had been ordered. The Invoice detailed the gait belt order had been originally placed on 8/26/22. The sales representative canceled that order and re-ordered from a different warehouse on 8/30/22. The facility received the gait belts on the 9/6/22 and started putting them out in the rooms on September 7, 8th and 9th. The memory care unit had the gait belts placed in the rooms on September 12th, 2022. During an interview on 9/14/22 at 9:50 a.m. Staff B reported Resident #6 had been a new admission. She came in on night shift that night and Resident #6 seemed like she knew what she was doing. She could tell you what she needed. She had been told the resident tried to get up unassisted. The other aide saw her try to stand up by herself. A little after midnight, Resident #6's call light came on. She wanted to go to the bathroom. Staff A and B walked the Resident to the bathroom, toileted the resident and walked her back to bed. She did fine. She then went in around 1:30- 2:00 a.m. the resident had her call light on and wanted to go to the bathroom again. She did not use the gait belt to walk Resident #6 to the bathroom as she was independent at that time. She received report from the prior shift (2:00 p.m. - 10:00 p.m.). Staff H, C.N.A., reported to her the resident was independent. Staff B stated Resident #6 had not been listed on the Care Guide at that time. Resident #6 had been steady when she got out of bed and walked to the bathroom. Staff B reported she had been standing on the Resident's left side. The Resident stood up from the toilet and started to immediately fall to the right falling back into the shower chair. It happened very quick. She fell backward into the shower chair. The moment she stood up, she lost her balance and went backwards into the shower chair. She twisted to the right and went backwards. Staff B reported she grabbed the Resident by the waist and her back to try to balance, but she couldn't and she went down on the shower chair very fast and hard, hitting her head on the back of the shower handrail. After the fall the Resident wanted to get up out of the shower chair. She tried not to move her as she didn't know if she was hurt. The Resident said the back of her head was hurting. Staff B called out for help. She told the Resident not to get up. She needed to be assessed by the nurse. After the nurse assessed the resident they assisted her back to bed. The Resident had a knot on the back of her head. Staff B reported she had been coming to the facility for about a month. She stated she had her gait belt on her all the time but she doesn't recall being given anything on gait belts by the facility or the staffing agency. She had her gait belt but didn't take it in the Resident's room with her. She has been a C.N.A. since 2010. Staff B stated Resident #6 went down forcefully and hit her head bad. During an interview on 9/14/22 at 12:35 p.m. Staff I, RN, reported Resident #6 could communicate her needs but was a little dramatic. She kept trying to get up unassisted. They were trying to keep her call light close, gripper socks on and do frequent checks on her. She hadn't had any therapy yet so they were supposed to use two staff assist with a gait belt on her but she had been getting up with her walker by herself. Staff I didn't know about the care guide. This had been the first shift she had worked on the skilled unit. Staff I did recall looking at the Resident and thinking she just didn't look well. During an interview on 9/14/22 at 5:21 p.m. Staff A reported she knew Resident #6's transfer level had been communicated through the C.NA. to C.N.A. report. It had been reported in the nursing report that Resident #6 needed to be a two person assist with gait belt as she hadn't been seen by Physical Therapy yet. She stated after Resident #6's fall, Staff J, C.N.A./Certified Medication Aide, had commented that she had specifically heard it reported to the night shift C.N.A.'s that Resident #6 needed to be a two assist transfer with a gait belt as physical therapy had not seen her yet. Staff A reported she works Monday thru Friday and she prints off at least 10 Care Guides for the C.N.A.'s to have on shift. The Care Guide lists how to take care of the residents (transfer assistance level, baths, diets, etc.). She stated the Director of Nursing or the Assistant Director of Nursing are the ones that update the Care Guides in the computer. She does not have access to the Care Guide in the computer to update it. Staff A reported she did not recall going in to help any of the C.N.A.'s answer Resident #6's call light. She doesn't recall if the staff had gait belts on them when they were coming and going from Resident #6's room. She stated Staff D is really good about wearing his gait belt. He always has it on. She couldn't recall if Staff B had her gait belt on her prior to the incident. They had been in Resident #6's room many times checking on her as she kept getting up unassisted, but she doesn't recall if the C.N.A.'s had gait belts on coming and going from the room. She stated Staff B is new and she just couldn't recall if she had her gait belt on earlier that night. She stated it is an expectation that the gait belt is part of the uniform. All the aides know they are supposed to have their gait belt on them. She talked to Staff B right after the incident and told her, this is huge and this is going to follow-you. She just couldn't believe this had happened. She said Staff B did not have a response when she asked her why she didn't have a gait belt on the resident. Staff B never said a word. Staff A assumed that Staff B went to get a gait belt after that. Staff A reported she could not recall if Staff B had a gait belt on her after the incident. She just assumed she probably did. During an interview on 9/15/22 at approximately 7:30 a.m. the Administrator reported they had already had gait belts in the bay rooms (skilled unit) prior to the incident. The gait belts were available. She stated the facility had taken a picture from the camera footage of Staff B wearing her gait belt right after the incident occurred. She stated she would provide the picture and a cot could be seen in the background of the picture as they were preparing to send Resident #6 out to the emergency room . On 9/15/22 The Administrator provided a Process Change Alert, effective Wednesday 1/22/20, Posting that documented the following information: please note if you are working Bay/Bay Suites there will be gait belts located inside the back of the door of each individual room. These are labeled with NURSING. They are to stay in the room with the patient and not leave that room. When finished hang back up on the back of the door. Do not remove from the room. It is still expected that you bring your own gait belt as you always have as part of your uniform. Continue to keep your gait belt with you. If a replacement is needed in a room (after searching the unit for extras) please notify your nurse Manager. Please let me know if you have questions - the purpose of this is to increase the availability of always having access to a gait belt as it is against our policy to transfer any resident without one, as well as help promote infection control practices. If this system seems to work well and is liked by the staff we will work on implementing this throughout the facility. Please give feedback good or bad about how this works either through email, AOD message (electronic health record system), or a note under the Administrator's door or a voicemail. The Administrator provided supplier invoices to show 30 gait belts had been ordered in January 2020 for the skilled unit. On 9/15/22 at 7:30 a.m. The Administrator provided a copy of Staff B's Time Card Report. Staff B's Time Card Report dated 8/08/22 - 8/21/22 showed Staff B worked from 10:30 p.m. - 7:00 a.m. for a total of 8.5 hours. Staff B had finished her work shift for 8/19/22 thru 8/20/22. The Time Card showed Staff B had not been sent home after the incident. During an interview on 9/15/22 at 7:14 a.m. Staff J reported she worked second shift on the evening of 8/19/22. She stated after Resident #6 admitted , Staff L, Health Information Manager/Compliance Officer, came down to the nurses' station with paperwork and told her and three evening shift C.N.A.'s, Staff M, N, and H. Resident #6 needed to be a two assist with gait belt until therapy could evaluate the Resident. Staff J didn't know if the actual care guide was out, but they had been directed to use a two assist with gait belt for Resident #6. Staff J reported the first shift nurse had said in report that the hospital had Resident #6 down as a one assist but they were specifically directed to use a two assist with gait belt. Right after Resident #6 had been admitted , the DON and ADON had gone down to put a wound vac on the resident's chest incision. Staff J reported she would not have used less than two staff to assist Resident #6 with that wound vac on her chest. She had been passing medications that evening and watched staff come and go from the Resident's room. The staff on the evening shift were using two assist and a gait belt for transfers during the evening shift. Resident #6 did appear several times in her doorway as she had been getting up unassisted with her walker, so staff had been in the room frequently. Staff J reported she did go in to give Resident #6 a medication for anxiety and she did note the Resident had a cell phone and had been talking to someone on the phone at that time. The C.N.A. to C.N.A. report going into the night shift should have communicated the Resident required a two assist with a gait belt for transfers. During an interview on 9/15/22 at 8: [TRUNCATED]

Based on clinical record review, observation, staff interview and review of manufacturer's recommendations, facility staff failed to administer insulin per directions for 2 out of 2 residents observed (Residents #57 and #260). The facility reported a census of 110 residents. Findings include: 1. According to the Minimum Data Set assessment of 10/5/21, Resident #57 had the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #57's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation of insulin administration on 12/1/21 at 11:52 a.m. Staff A, Licensed Practical Nurse (LPN) dialed the correct dose for [MEDICATION(S)] insulin on the pen, then cleansed the barrel with alcohol and applied the needle. Staff A then administered 7 units of insulin subcutaneously to Resident #57. Staff A did not prime or waste 2 units of [MEDICATION(S)] insulin before administering the insulin to the resident. 2. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The order instructed staff to administer 2 units of insulin for a blood sugar measurement of 150 - 200 and a documented blood sugar measurement of 178 the morning of 12/2/21. During an observation of insulin administration on 12/2/21 at 7:51 a.m. Staff B, LPN dialed the correct dose for [MEDICATION(S)] insulin on the pen, then cleansed the barrel with alcohol and applied the needle. Staff B then administered the [MEDICATION(S)] 2 units subcutaneously to Resident #260. Staff B did not prime or waste 2 units of [MEDICATION(S)] insulin before administering the insulin to the resident. An interview on 12/2/21 at 8:00 a.m. with the Assistant Director of Nursing (ADON) revealed she would expect staff to prime the insulin pen with 2 units prior to drawing up the dose of insulin to be administered. The [MEDICATION(S)] Kwik Pen package insert directed staff to prime the pen before each injection. Priming the pen meant removing the air from the needle and cartridge that may collect during normal use and ensured the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. The package insert directed staff to: a. Select a dose of 2 units by turning the dosage selector. b. Hold the pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. c. Continue holding the pen with it's needle pointing up. Push the dose knob in until it stops and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. You should see insulin at the tip of the needle.

Based on record review, resident interview and review of signed facility witness statements, the facility failed to ensure the safety of Resident #3. A staff member failed to walk with the resident and use a gait belt device when taking the resident to the toilet. The resident fell and sustained a fracture of the tibia (lower leg) and an injury to the knee area. The facility reported a census of 112 residents and the sample consisted of 4 residents. Findings include: 1. Resident #3 had a MDS (Minimum Data Set) assessment with a reference date of 8/9/15. The MDS identified the resident had a BIMS (Brief Interview for Mental Status) test score of 13 out of 15. A score of 13 identified the resident had no cognitive impairment. The MDS reflected the resident required extensive assistance of one staff person for bed mobility, transfers, walking, dressing, toilet use and personal hygiene. The MDS reflected the resident had impaired balance and not steady. The resident could only stabilize self with staff assistance while walking. According to admission orders [REDACTED]. The resident ' s [DIAGNOSES REDACTED]. The Care Plan dated 9/9/15 identified the resident had a problem with self-care deficit related to decreased mobility, recent fall with hip fracture and the increased need for assistance with cares and mobility. The Care Plan approaches instructed the staff to assist the resident with the use of a gait belt and a walker for transfers. The Care Plan dated 6/23/15 identified the resident had a problem with potential fall and potential for injury related to weakness, fractured hip with weight bearing restriction and the use of psychotropic medications. The approaches included and directed the staff to monitor the resident for changes in gait and balance and to assist the resident with ambulation as health dictates. A Fall Risk assessment dated [DATE], identified the resident at a high risk for falls due to a recent history of falls, chair bound, gait/balance problems, medication use and predisposing diseases. The Fall Risk assessment dated [DATE] identified a score of 10. A total score of 10 or above represented high risk. The CNA (Certified Nursing Assistant) Worksheet dated for Friday 9/4/15 (1st shift) instructed the staff the resident transferred and walked with the assistance of one person, a gait belt and a walker. The resident was limited to partial weight bearing on the right leg. The staff were to walk the resident in the hallway twice a day with a wheelchair to follow. The staff were instructed to assist the resident to the bathroom with the walker and gait belt. A Nurse's Note dated 9/3/15 at 8:15 p.m. indicated while attempting to prepare for urine collection, the resident lost his/her balance while standing in the bathroom with staff. The resident fell to the floor onto bottom/right hip. The staff attempted to soften the landing however the walker was kitty-corner between them. The resident immediately complained of right knee/shin pain. Staff noted bruising to the top of the left hand/wrist, under the resident's watch. The resident complained of pain when he/she bore weight on the leg. At 8:45 p.m. the physician ordered the staff to obtain an x-ray. At 9:45 p.m. the resident reported he/she did not want to walk on his/her leg until after the x-ray due to the pain. The resident reported continued pain since the fall. Staff noted a small amount of edema present. At 10:00 p.m. the physician instructed the staff to send the resident to the emergency room for an evaluation and treatment. A Nurse's Note dated 9/4/15 at 4:00 a.m. reflected the resident returned from the hospital with a new [DIAGNOSES REDACTED]. New orders included: fall precautions, elevate right knee with level above heart for 60 minutes three times a day for three days, keep right sleeve on right knee during the day, follow up with physician in two to three days, and apply ice for thirty minutes four times a day for three days. The Incident Report dated 9/3/15 at 8:15 p.m. identified the resident fell to the floor after losing balance, standing at walker in bathroom doorway with CNA beside the resident. The CNA attempted to ease the resident ' s fall and the resident landed on bottom/right hip area. In a sitting position. The resident complained of right knee and shin pain. The resident had an ecchymosis (characteristics of being bruised) area to the left wrist. A Nurse's Note dated 9/9/15 at 5:10 p.m. noted new orders to obtain a CT (Computed tomography) scan of the right knee if the resident continued to have pain. The resident reported continued pain when using leg. The Radiologist report dated 9/11/15 noted a comminuted fracture of the medial tibial plateau. The fracture demonstrated both vertical and transverse/oblique components. The fracture was separated by up to 1 mm (millimeter). According to a Major Injury Determination Form dated 9/14/15 the physician determined the resident sustained [REDACTED]. According to a statement dated 9/4/15 a C.N.A., Staff A reported she was assisting the resident to the bathroom. The resident walked into the bathroom with a walker. Staff A reached away from the resident to grab gloves. The resident fell backwards. Staff A held onto the resident's arm to ease the fall. The resident fell . Staff A admitted that she did not have a gait belt on the resident at the time of the fall and she knew she should have. Staff A reported she understood and knew gait belts were required for all resident transfers. According to a statement dated 9/4/15 a registered nurse, Staff B reported she was called to the resident's room. She observed the resident seated on the floor. Staff A reported to Staff B she assisted the resident to the bathroom, she reached for gloves when the resident began to fall backwards. Staff A reported she grabbed at the resident's arm to help ease the fall. The nurse observed a bruise on the resident's arm. The resident did not wear a gait belt. According to a statement by the Assistant Director of Nursing, on 9/4/15 she met with Staff A regarding the resident's fall. Staff A admitted she did not use a gait belt while transferring and assisting the resident. Staff A stated she knew she should have and that it was required. Staff A stated she knew she was in trouble the minute it happened. When interviewed on 1/27/16 at 4:00 p.m. the resident stated last fall, the facility staff normally used a gait belt to assist him/her with transfers. One day, Staff A did not use a gait belt and did not walk with him/her to the bathroom. Staff A walked ahead of him/her to the bathroom. Staff A was at the bathroom sink and turned around quickly. The resident went to step back out of the staff's way when he/she lost his/her balance and fell backwards. Staff A grabbed his/her wrist and it hurt. The resident stated he/she fell anyway and his/her wrist bruised. The resident stated he/she had some pain in his/her knee at the time of the fall. The resident stated it was not unusual for him/her to have pain in his/her knee, however, when the pain did not go away he/she thought something might be wrong. The resident stated he/she knew at the time it was wrong for the staff not to use a gait belt, not to walk with him/her and to grab the resident by the wrist.

Based on record review and staff interviews, the facility failed to provide adequate supervision to ensure against hazards to self and failed to revise the care plan to ensure provisions were implemented to prevent a resident from deactivating alarmed devices (Resident #2) and failed to safely ambulate a resident with a gait belt (Resident #5). Staff released the gait belt and the resident fell (Resident #5). The sample consisted of 4 residents and the facility identified a census of 122 residents. Findings include: 1. Resident #2 had a Minimum Data Set (MDS) assessment with a reference date of 4/1/2013 which identified [DIAGNOSES REDACTED]. The MDS reflected the resident required extensive assistance of one for bed mobility and transfer, and scored a 9 on the Brief Interview for Mental Status (BIMS). A score of 9 indicated the resident had moderately impaired cognitive ability. A care plan for fall prevention dated 1/1/13 included a problem of potential for falls related to poor safety awareness and a [DIAGNOSES REDACTED]. a. Assess toileting needs(1/1/13) b. Toilet per individual plan-routine(10/1/11) c. Call light in reach, remind to use with every care(1/1/13) d. Footwear: shoes or gripper socks(2/11/13) e. Pressure alarm f. Clip alarm g. Motion alarm in room h. Low bed with mats(1/11) i. Do not leave in room in wheelchair unattended, leave room door open for visualization during the day time, may close at night (10/1/11). The plan of care made no indication the resident turned his/her alarms off and interventions to prevent the occurrence. The plan of care included no specific directive for visual or safety checks. An incident report dated 1/1/13 at 4:30 p.m., documented the resident ' s alarms had been sounding and the resident had been found sitting on the floor in front of a wheelchair. The incident report indicated the resident had been repositioned and toileted ten minutes prior to the fall. An intervention had been placed to assess and monitor for a urinary tract infection An incident report dated 2/11/13 at 6:25 p.m., documented the resident had been sitting in a wheel chair in the bathroom at the sink, went to stand up, and the wheel chair rolled back. The resident lost his/her balance and fell on the floor. At that time an intervention had been placed to ensure proper foot wear/gripper socks. A fall risk assessment dated [DATE], documented the resident had scored 16. A score of 10 and higher identifies a resident at high risk for falls. An incident report dated 6/18/13 at 11:10 a.m., documented the resident had shut all alarms off and initiated ambulation. A nurse ' s note entry at that time revealed the nurse went to an oxygen closet and a housekeeper came and informed the nurse the resident (laid) on the floor at the nurses ' station. An entry in the nurse ' s notes at 12:30 p.m. on 6/18/2013, documented the paramedics transferred the resident to a local emergency room . A radiology report dated 6/18/13 at 1:06 p.m., documented the resident had sustained a periprosthetic fracture (fracture around a joint replacement prostheses) of the mid to distal femoral diaphysis. The facility Investigation Report completed on 6/19/2013 indicated the resident would have surgery on 6/19/2013 for repair of the fracture. The resident would return to the facility on [DATE]. On 7/15/13 at 1:03 p.m., Staff C, Certified Nurse Aide, Restorative Aide, stated he/she had ambulated the resident to the lounge prior to the fall and sat the resident in a chair. Staff C stated he/she made sure the resident had a pressure alarm and clip alarm on and on high volume but also stated the resident had a history of [REDACTED]. Staff C stated the clip alarm box had been placed next to the resident on a walker. On 7/15/13 at 3:30 p.m., the facility Director of Nursing was interviewed and stated he/she did not know why a motion sensor alarm had been care planned for use in the resident ' s room but not in the lounge where the resident had frequently been left alone. The DON stated after the fall, an intervention had been placed to give the resident a bell to use for a call light when in the lounge alone. The Director of Nursing stated this had not been implemented prior to the fall because the resident had not attempted to get up alone when left in the lounge. The DON verified the resident had previous falls when attempting to get up alone in his/her room, and it may or may not have prevented the fall if the motion sensor alarm or call bell had been placed as interventions when the resident had been in the lounge prior to the fall/fracture. The DON stated the staff were to check on the resident frequently, but this had not been added to the care plan and there really had been no specific directive to staff on how often to check on the resident. The DON verified the resident had a history of [REDACTED]. On 7/16/13 at 1:35 p.m., Staff B, Licensed Practical Nurse, was interviewed and stated the resident had been alone sitting in a lounge prior to the fall. Staff B stated he/she had gone to get oxygen tubing when a housekeeping staff person came to report the resident had fallen. Staff B stated he/she had just gone in to check the resident ' s alarms before leaving to go to the oxygen room. The alarms had all been on and the resident had been sitting with eyes closed. Staff B stated the resident had reported after the fall that he/she had been going to the bathroom and had turned the alarms off. Staff B stated the resident did not ever really try to get up alone before when in the lounge, and the resident usually just sat there with eyes closed and listened to music or read a book. Staff B stated the resident had been very forgetful, and it had been a part of the resident ' s routine to sit in the lounge. Staff B stated the resident had been in a straight back chair prior to the fall, and also stated the resident frequently turned his/her alarms off (deactivated) and staff were aware of this. 2. Resident #5 had an MDS with a reference date of 4/6/13, which identified [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance of two staff members to ambulate in his/her room. A fall risk assessment dated [DATE], documented the resident had scored a 16 (high risk for falls). The Care Plan, updated on 4/11/13, revealed the resident had a potential for falls with injury due to decreased mobility and impaired cognition related to cerebrovascular accident and dementia. The approaches directed staff to: a. Follow Physical Therapy recommendations b. Fall risk assessment upon admission and as needed c. See fall components for interventions d. Assist resident with ambulation as health dictates e. Use non-skin foot wear f. Keep call light within reach g. Be aware of orientation level h. Monitor for changes in gait and balance i. Transfer and ambulate with assist of 1-2 An incident report dated 5/8/13, documented at approximately 8:50 a.m., the Certified Nursing Assistant, CNA called the nurse to the resident ' s room because the resident had fallen backwards against the door in the bathroom and then down to the floor. The incident report documented the resident had a lot of pain in his/her back and staff notified 911. An intervention added to prevent falls indicated the staff was educated. The nurse ' s notes of 5/8/2013 at 1:00 p.m. reflected the facility received a telephone call from the emergency room that the resident had a compression fracture of the 12th thoracic vertebrae. The note indicated the resident had been given Morphine and Dilaudid for pain management. The nurse ' s notes at 1:45 p.m. indicated the resident arrived at the facility. The resident voiced feeling very uncomfortable from the ride to the facility. The staff assisted the resident to the bed. The resident sat on the side of the bed and had a small emesis A radiology report dated 5/8/13 at 9:44 a.m., confirmed the new T12 (Thoracic 12th vertebrae) compression fracture. A facility investigation related to the incident dated 5/10/13 revealed the facility concluded the fall had been related to improper use of the gait belt. On 7/10/13 at 1:00 p.m., Staff D, Assistant Director of Nursing stated the resident fell and sustained a compression fracture when a staff person let go of the resident ' s gait belt. On 7/17/2013 at 9:30 a.m., Staff E, CNA was interviewed and stated she walked the resident into the bathroom and had a gait belt on the resident. Staff E stated she had a blank moment and let go of the resident ' s gait belt and opened the door. Staff E stated she had cared for the resident previously and had been aware the resident needed assistance of one staff person. Staff E stated a gait belt should be used for all residents who required assistance. Staff E stated when she let go of the resident ' s gait belt and the resident fell . On 7/17/13 at 12:15 p.m., the Director of Nursing was interviewed and stated all residents who require the assistance of staff for ambulation would be expected to have a gait belt properly used. The DON stated the bathrooms were small enough that you would not need to let go of a resident ' s gait belt to open the door.