Every finding on record at Pruitthealth - Bethany

Based on staff interviews, record review, and review of the facility's policy titled Abuse Identification, the facility failed to protect the resident's right to be free from sexual abuse by a resident for one of two residents (Resident (R) 50) reviewed for abuse out of a total sample of 21. Specifically, on 06/04/2026, R36 was sitting on R50's bed and kissing R50 on the mouth. This failure had the potential to place R60 at risk for physical injury or distress.Findings include: Review of the facility's policy titled Abuse Identification dated 10/21/2025 revealed that the facility endeavors to maintain an environment that is free of abuse.1. Review of R36's electronic medical record (EMR) Face Sheet under the Profile tab revealed a readmission date of 06/15/2026 with diagnoses of chronic obstructive pulmonary disease (COPD), Alzheimer's disease, dementia, and traumatic brain injury (TBI).Review of R36's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/04/26 with a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive impairment.2. Review of R50's EMR Face Sheet under the Profile tab revealed a readmission date of 12/12/2025 with diagnoses of COPD, Alzheimer's disease, dementia, schizophrenia, and generalized anxiety disorder. Review of the MDS with an ARD of 03/18/2026 with a BIMS score of three out of 15 indicating severe cognitive impairment.Review of a Facility Reported Incident (FRI) dated 06/04/2026 indicated, On 06/04/2026 at 2:30 PM, [R36] was observed by a staff member to be sitting on the bed of [R50] and . leaning in and kissing her on the mouth. [R36] was immediately taken from the room, and actions were taken by the facility to secure the safety of [R50] and others. Interview on 08/10/2026 at 11:08 AM, the Activities Director (AD) stated that on 06/04/2026 at 2:30 PM, she went to R50's room and observed R36 sitting on R50's bed, leaning over and kissing her. AD explained that she and a Certified Nurse Aide (CNA) were able to get him out of the room, though he protested that he wanted to stay and hold R50's hand. AD stated that during this occurrence R50 and R36 were fully clothed and R50 had a blanket covering her and that R36 was not seen touching R50 in any other way. AD immediately notified the Administrator, who came directly to the room. R50 was interviewed and according to AD . did not seem frightened or distraught. Review of the Facility Reported Incident (FRI) report completed by the DON on 06/04/2026 indicated that the DON interviewed R50 and asked whether she felt she had been sexually abused. R50 denied feeling sexually abused and denied that a man had entered her room, kissed her, or held her hand.During an interview on 08/10/2026 at 4:19 PM, the Social Service Director (SSD) stated that she talked about R36's behavior the day of his admission. He was asking SSD for a kiss, and he was blowing kisses at staff members. The SSD stated that she did not notify any staff of this behavior because she had been told by a nurse he was blowing kisses and asking for kisses on the unit. SSD thought it was generally known, and the SSD did not perceive any interventions were needed.Review of the EMR Progress Notes under the Progress Notes tab following the incident indicated that R36 was immediately placed on one-to-one supervision. R36 was transferred to an outside behavioral health facility and later returned to the facility.During an interview on 08/11/2026 at 2:50 PM, CNA1 stated that she worked the afternoon of the incident, 06/04/2026. She said she helped remove R36 from the room. CNA1 said that when she walked into R50's room, R36 was holding R50's hand and saying that she was his long-lost friend. CNA1 stated that R36 walked the halls a lot but had not come across as having behavior issues. During an interview on 08/12/2026 at 7:42 AM, Licensed Practical Nurse Charge Nurse (LPNCN)1 stated that she was R36's and R50's nurse on the day of the incident, 06/04/2026. LPNCN1 said she had known R36 to ask staff and residents for kisses, though he never attempted to touch anyone. She said redirection was an intervention staff used successfully when he would ask for kisses. LPNCN1 stated that she asked R50 if she was okay, and the initial response was not really; however, within the hour, R50 had no memory of the incident. Review of R50's EMR Progress Notes under the Progress Notes tab dated 06/05/2026 indicated that R50 was referred to behavioral health for care. The General Nurse Practitioner (GNP) evaluated the resident on 06/05/2026. Review of the GNP's notes revealed that R50 had a past history of schizophrenia, dementia, depression, insomnia, and suicidal ideation. GNP documented that R50 was calm and cooperative, alert and orientated, and in a fair mood. R50 had no recollection of the occurrence on 06/04/2026.The facility implemented the following corrective actions after becoming aware of the allegation on 06/04/2026:1. On 06/04/2026, the facility submitted an incident report to the State Survey Agency (SSA).2. On 06/04/2026, the facility notified local law enforcement. Case number 2026-06-10164.3. On 06/04/2026, the facility notified the Medical Director and the Responsible Parties for R36 and R50.4. On 06/04/2026, a skin assessment was completed for R50 and no injuries were identified. 5. On 06/04/2026, R36 had a room change, away from R50. 6. From 06/04/2026 through 06/08/2026, R36 was on documented continuous one-to-one observations. 7. From 06/04/2026 to 06/05/2026, all residents were screened for signs of sexual abuse. No findings indicative of sexual abuse were identified.8. On 06/04/2026, R36's care plan was updated to include inappropriate behavior toward a female resident of kissing her without her consent. 9. On 06/04/2026, R50's care plan was updated to include a male resident demonstrating inappropriate behavior toward her by kissing her without her consent. 10. On 06/05/2026, R50 received psychiatric services.11. On 06/05/2026, the facility conducted an Ad Hoc Quality Assurance and Performance Improvement meeting to discuss the incident. All required members were in attendance. 12. From 06/04/2026 through 06/05/2026, the facility provided education on Abuse and Sexual Abuse to all staff.13. On 06/08/2026, R36 was discharged to a Behavioral Health Facility.

Based on observations, record review, staff interviews, and review of the facility's policy titled Trach Decannulation Emergency Procedures, the facility failed to ensure emergency supplies, specifically a resuscitation bag, were at bedside for one of two residents (Resident (R) 60) reviewed for tracheostomies of 21 sample residents. This failure had the potential to affect resuscitation efforts for R60. Findings include: Review of the facility's policy titled, Trach Decannulation Emergency Procedures, revised 01/25/22, revealed Equipment.Ambu bag and mask.Review of R60's Face Sheet, located under the Resident Face Sheet tab of the electronic medical record (EMR), revealed that the resident was admitted on [DATE] with diagnoses that included tracheostomy. Review of R60's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/09/2026 revealed a Brief Interview for Mental Status (BIMS) score was unavailable. The Staff Assessment for Mental Status revealed R60 was severely cognitively impaired. During an observation on 08/09/2026 at 9:56 AM, the resident appeared sleeping with trach in place, in no apparent distress, and no resuscitation bag noted at bedside. During an observation and interview on 08/09/2026 at 10:38 AM, the Licensed Practical Nurse Charge Nurse (LPNCN) 1 looked throughout the resident's room and confirmed the resuscitation bag was not there. At 10:47 AM, she stated the purpose of the resuscitation bag was to help aid resuscitation. During an interview on 08/09/2026 at 10:56 AM, the Assistant Director of Nursing (ADON) stated the resuscitation bag was kept outside of the tacklebox, in the room, due to the size. She stated she completed daily rounds and had not yet completed this morning's rounds for the resuscitation bags. She obtained a resuscitation bag and replaced it in R60's room. During an interview on 08/11/2026 at 10:17 AM, the Director of Nursing (DON) stated that they completed tracheostomy training with staff on hire during orientation and at the annual skills fair. She stated she was not aware that the resuscitation bag was missing Sunday morning. She stated she would review the cameras to determine who was responsible. During an interview on 08/11/2026 at 10:37 AM, the Administrator stated they had a lot of resuscitation bags available for use, and one should have been in place at R60's bedside.

Based on staff interview, record review, and review of the facility policy titled Monitoring of Antipsychotics, the facility failed to monitor targeted behaviors for the use of an antidepressant medication for one of five residents reviewed for unnecessary medications (Resident (R )40) out of 23 sampled residents. This failure had the potential for residents to receive unnecessary medications. Findings include: Review of the facility's policy Monitoring of Antipsychotics with a revision date of 7/20/2020 and provided by the facility indicated, .Every patient/resident on a psychotropic medication will have an order for behavior monitoring in the EMAR [electronic medication administration record] system. This must be filled out by every nurse every shift and must spell out what behaviors have occurred on that shift . Review of R40's undated Face Sheet located under the Resident tab in the electronic medical record (EMR) indicated R40 was readmitted to the facility on [DATE] with the diagnosis of depressive episodes. Review of R40's significant change in status Minimum Data Set (MDS) located under the RAI tab in the EMR with an Assessment Reference Date (ARD) of 2/23/2025 with a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated R40 was severely cognitively impaired. R40 was also coded as taking an antidepressant. Review of R40's Physician Orders located under the Resident tab in the EMR indicated an order dated 2/20/2025 for Lexapro [an antidepressant medication] 20 milligrams (mg) every day. Review of R40's Medication Administration Report (MAR) dated February, March, and April 2025 and located under the Resident tab in the EMR indicated there was no behavioral monitoring while R40 was taking Lexapro. During an interview on 5/8/2025 at 4:00 pm, the Director of Nursing (DON) confirmed there were no targeted behaviors monitored while R40 was administered Lexapro. The DON stated, I know the staff was thinking because the daughter asked the doctor to put the resident back on the antidepressant, the nurses thought they did not have to monitor the targeted behaviors.

Based on observations, staff interviews, and review of the facility policy titled Medication Administration: General Guidelines, the facility failed to ensure infection control was maintained for one of three residents (Resident (R) 20) observed during medication administration. Specifically, the facility failed to ensure that pills were not touched with bare hands or dropped during medication administration, which increased the risk for cross-contamination and infection. Findings include: Review of the facility policy titled, Medication Administration: General Guidelines dated 4/10/2019 provided by the facility indicated, .A clean spatula, razor blade, or knife is used to avoid contact with the tablet. During observation and interview of medication administration on 5/7/2025 from 9:00 am to 9:10 am, with Licensed Practical Nurse (LPN) 5, revealed LPN5 was opening multiple pill packs for R20 and pouring them into the pill cup when one of the pills missed the cup and ended up on the top of the medication cart. LPN5 picked up the unknown pill with a bare hand and placed it back into the pill cup with the other pills. LPN5 confirmed she picked up the pill with a bare hand and placed it in the pill cup with other pills and stated, I'm so nervous. LPN5 then administered the medications to R20. During an interview on 5/8/2025 at 11:05 am, the Director of Nursing (DON) stated, If a pill is dropped on the med cart outside of the pill cup, I would expect the nurse to pick up the pill, discard the pill, then obtain the medication from the last pill pack and contact the pharmacy to replace the medication.

Based on staff interviews, record review, review of the facility policy titled, Antibiotic Stewardship Program, and review of McGeer's criteria, the facility failed to have an Antibiotic Stewardship Program that followed current standards of practice for prescribing an antibiotic for two of three residents (Resident (R)13 and R15) reviewed for antibiotic stewardship out of total sample of 23. This failure had the potential to cause residents to be prescribed antibiotics that were potentially unnecessary. Findings include: Review of the facility's policy Antibiotic Stewardship Program, with a revision date of 11/30/2023, and provided by the facility stated, . The antibiotic time out should be performed within 24-48 hours after antibiotics are initiated . The ASP [Antibiotic Stewardship Program] Team will monitor and review the following data: i. Infections and antibiotic usage patterns on a regular basis . v. Include a separate report for the number of residents on antibiotics that did not meet criteria for active infection . An antibiotic time-out (ATO) will be performed after the initiation of all antibiotics prescribed in the facility . The IP [Infection Preventionist] will be responsible for infection surveillance and multi-drug resistance organism (MDRO) tracking. The IP, along with the DHS, will collect and review the following data such as: i. Documentation of completion of antibiotic choice, dosage, duration, indication and route of administration. ii. Whether appropriate tests, such as labs and/or cultures, were obtained before ordering antibiotic. iii. Whether the antibiotic was changed during the course of treatment . Each quarter a Prescriber Practitioner Summary will be presented to the QAPI committee for review and provided for feedback to the prescribing practitioner(s) on their antibiotic prescribing patterns as indicated . Review of McGeer's Criteria (11/5/2024) revealed, Table 1. Constitutional Criteria for Infection Fever, Leukocytosis, Acute Mental Status Change, Acute Functional Decline . Table 2. Urinary Tract Infection (UTI) Surveillance Definitions Syndrome: UTI without indwelling catheter Criteria: 1. At least one of the following sign or symptom: Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate Fever or leukocytosis, and one or more of the following: acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency If no fever or leukocytosis, then greater than 2 of the following: suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency 2. At least one of the following microbiologic criteria greater than or equal to 100,000 Colony Forming Units (CFU) per milliliter (mL) of no more than 2 species of organisms in a voided urine sample greater than or equal to 100 of any organism(s) in a specimen collected by an in-and-out catheter . Selected Comments: The following two comments apply to both UTI with or without catheter: UTI can be diagnosed without localizing symptoms if a blood isolate is the same as the organism isolated from urine and there is no alternate site of infection In the absence of a clear alternate source of infection, fever, or rigors with a positive urine culture resulting in the non-catheterized resident or acute confusion in the catheterized resident will often be treated as UTI. However, evidence suggests that most of these episodes are likely not due to infection of a urinary source 1. Review of R13's undated Face Sheet located under the Resident tab in the electronic medical record (EMR) indicated R13 was originally admitted to the facility on [DATE] with the diagnosis of diabetes mellitus. Review of R13's Nursing Progress Notes dated March 2024 located under the Progress Notes tab in the EMR indicated there was no documentation of R13 experiencing any signs or symptoms of a Urinary Tract Infection (UTI). Review of R13's Physician's Orders located under the Orders tab in the EMR indicated on 3/19/2024 an order for a urinalysis with culture and sensitivity to be obtained. There was also an order dated 3/20/2024 for Augmentin 500/125 milligram. Give one tablet by mouth twice a day, seven times a day for UTI. Review of R13's Urinalysis Results provided by the facility and dated 3/19/2024 had the following abnormal results: Protein 2+ (plus), Leukocytes 3+, Blood 1+, WBC (White Blood Cell) greater than 100, and Bacteria rare. Review of R13's Urine Culture Results, which was provided by the facility and dated 3/21/2024, indicated, Mixed genital flora isolated. These superficial bacteria are not indicative of a urinary tract infection. No further organism identification is warranted on this specimen . Review of R13's Infection Control - Infection Tracker with McGeer's Criteria provided by the facility and dated 3/19/2024 indicated, Acute dysuria or acute pain, swelling, or tenderness of the testes, epididymis, or prostate. R13 was a female. Continued review of the Infection Tracker indicated that under the section Signs and Symptoms of UTI, Pain or Burning During Urination and Feelings of Pressure in Lower Abdomen were marked. For Antibiotic Reassessment (Antibiotic Time Outs) Performed and was marked No. During an interview on 5/8/2025 at 4:00 pm, the Director of Nursing (DON) stated, This resident goes directly to the NP [Nurse Practitioner] and will tell her of the symptoms she [R13] is experiencing. The NP will order the urinalysis and the culture. There won't be any documentation in the nurses' notes because the resident does not tell them [nurses] of the symptoms she [R13] is experiencing. The DON confirmed this resident's antibiotic usage did not meet McGeer's Criteria. 2. Review of R15's undated Face Sheet located under the Resident tab in the EMR indicated R15 was readmitted to the facility on [DATE] with the diagnosis of diabetes mellitus. Review of R15's Nursing Progress Notes located under the Progress Notes tab in the EMR and dated 10/1/2024 through 10/31/2024 indicated on 10/16/2024 at 6:54 am stated, Resident has recently started yelling behaviors in the afternoon. Constantly yells for someone . Review of R15's Physician's Orders located under the Orders tab in the EMR indicated on 10/17/2024 an order for a urinalysis to be obtained. Further review of the physician's orders revealed that a urine culture was not ordered. There was also an order dated 10/18/2024 for Macrobid 100 milligrams every 12 hours times five days for UTI. Review of R15's Urinalysis Results, which was provided by the facility and dated 10/17/2024, had the following abnormal results: Nitrate Positive, Blood 2+ (plus), Leukocytes 1+, and Bacteria 2+. Review of R15's Infection Control - Infection Tracker with McGeer's Criteria, provided by the facility and dated 10/18/2024, indicated there were no signs or symptoms that R15 was experiencing. For Antibiotic Reassessment (Antibiotic Time Outs) Performed and was marked as No. Review of R15's Temperature documentation on the Infection Tracker revealed R15's documented temperatures from 10/19/2024 through 10/22/2024 ranged from 97 degrees Fahrenheit (F) to 97.3 degrees F. During an interview on 5/8/2025 at 4:00 pm, the DON confirmed the antibiotic usage for R15 did not meet McGeer's Criteria due to not having a urine culture performed and not knowing if the organism, if any, in the urine was sensitive to the antibiotic that R15 was prescribed on 10/18/2024. The DON also stated, I will go to the provider if the antibiotic that was ordered did not meet McGeer's Criteria and speak to them of why it did not meet this criteria, but I don't report this in the Quality Assurance and Program Improvement [QAPI] meetings or to the medical director. I didn't realize that I needed to do that. The DON reviewed with the surveyor the monthly Line Listing for Infections and stated, I see where the information that is needed is not documented as it should be. Review of the facility's monthly Line Listing for Infections which was provided by the facility and was dated January 2024 through March 2025 revealed it was not documented if the infections met or not met McGeer's Criteria; did not consistently have the antibiotic with the dosage and duration documented each month; signs or symptoms the resident was experiencing were not consistently documented along with if a culture was obtained; and documentation of what the organism was identified.

Based on staff interviews, record review, review of the facility policy titled, Pneumococcal Vaccinations, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer or provide documentation of consent or refusal for three of five residents (Residents (R)13, R40, and R60) and/or their resident representatives the opportunity for the residents to receive influenza and/or pneumonia vaccines out of 23 sample residents. This failure had the potential to put these residents at an increased risk of developing influenza and/or pneumonia. Findings include: Review of the facility's policy Pneumococcal Vaccinations dated 8/29/2023 and provided by the facility stated, . The admission process will include determining whether the patient/resident has received the pneumococcal vaccine in the past. This will be the responsibility of the Director of Health Services or designee. Every effort will be made to obtain documentation of the date of prior immunization and what type of vaccine, Pneumovax (PPSV23), Pneumococcal 20-valent Conjugate Vaccine 20 (PCV20), Pneumococcal 15-valent Conjugate Vaccine (PCV15), or Pneumococcal 13-valent Conjugate Vaccine (PCV13), was administered. If reliable documentation of previous immunization is obtained, the date should be entered on the Immunization Record and made a part of the clinical record. (Attach supporting documentation to the immunization record.) If no reliable date of previous vaccination can be obtained, the patient/resident should be considered eligible for vaccination . Permission or refusal to receive the vaccine within the CDC guidelines will be obtained on admission using the Pneumococcal Vaccine Consent/Refusal Form. A separate consent for each type of vaccine is required . Review of CDC website titled, Pneumococcal Vaccination: Summary of Who and When to Vaccinate, https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html, last reviewed 09/12/24, indicated . CDC recommends pneumococcal vaccination for all adults [AGE] years or older. The tables below provide detailed information . For adults [AGE] years or older who have not previously received any pneumococcal vaccine, CDC recommends you . Give one dose of PCV20 [pneumococcal conjugate vaccines] or PCV21 . If PCV15 is used, this should be followed by a dose of PPSV23 [pneumococcal polysaccharide vaccine] at least one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak . If PCV20 or PCV21 is used, Give a dose of PCV15 at least one year later . For adults [AGE] years or older who have only received a PPSV23, CDC recommends you . May give one dose of PCV20 or PCV21 . The PCV20 or PCV15 dose should be administered at least one year after the most recent PPSV23 vaccination. Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it. For adults [AGE] years or older who have only received PCV13, CDC recommends you . Give PPSV23 as previously recommended. For adults who have received PCV13, Give one dose of PCV20 or PCV21 or PPSV23 to be administered at least a year later . If PCV20 and PCV21 are used, their pneumococcal vaccinations are complete . 1. Review of R13's undated Face Sheet located under the Resident tab in the electronic medical record (EMR) indicated R13 was readmitted to the facility on [DATE] and was currently [AGE] years old. Review of R13's Immunizations located under the Preventive Health Care tab in the EMR revealed R13 had refused the pneumococcal vaccination on 2/28/2022. There was no documentation of further administration or refusal of any pneumococcal vaccine for R13. 2. Review of R40's undated Face Sheet located under the Resident tab in the EMR indicated R40 was originally admitted to the facility on [DATE] and was currently over [AGE] years old. Review of R40's Immunizations located under the Preventive Health Care tab in the EMR revealed R40 had received an influenza vaccine on 10/19/2024 while a resident in the facility. Review of R40's EMR did not reveal documentation of a consent for the influenza vaccine that was administered to R40 on 10/19/2024. Further review of R40's Immunizations revealed R40 had a PPSV23 on 10/25/2020. There was no further documentation of R40 receiving any further administration or refusals of any pneumococcal vaccinations. 3. Review of R60's Immunizations located under the Preventive Health Care tab in the EMR revealed R60 had refused the influenza vaccine on 10/29/2024. Review of R60's EMR did not reveal documentation of a refusal form signed on or before 10/29/2024 for the influenza vaccine. During an interview on 5/8/2025 at 3:00 pm, Registered Nurse-Clinical Competency Coordinator (RN-CCC) stated, I have given you all the information that I can find for the flu and pneumococcal vaccines. During an interview on 5/8/2025 at 3:20 pm, the Director of Nursing (DON) stated, If it is recommended for the resident to receive another dose of pneumococcal vaccine, then I expect the Infection Preventionist (IP) to obtain consent or refusal from the resident for it. The nurses should obtain consent prior to administering any vaccines to the resident. During an interview on 5/8/2025 at 3:30 pm, Registered Nurse (RN)1 stated, When we admit a resident to the facility, we will ask them or the responsible party what vaccinations they have had and if they have any documentation of these. I don't have access to the state website to check the immunizations, but when the person who does have access, I go and get her to look at that website for any immunizations the resident has had.

Based on record review, staff interviews, and review of the facility policy titled Abuse Prevention and Reporting, the facility failed to protect the resident's right to be free from neglect by staff for one of five sampled residents (R) (R1) during Activities of Daily Living (ADL) care. Specifically, the Certified Nursing Assistant (CNA) CC was providing ADL care to R1 unassisted when R1 rolled away from CNA CC, falling from the bed, landing face down on the floor with blood noted on the head with a large open area, 14 cenimeter (cm) head laceration, and the scalp was pulled away from the head, exposing the skull. R1 expired at the hospital 50 minutes post fall. On [DATE], it was determined that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Senior Nurse Consultant (SNC) was informed of the Immediate Jeopardy on [DATE] at 4:06 pm. The noncompliance related to the Immediate Jeopardy was determined to have existed on [DATE]. Findings include: Review of the facility's policy titled Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property Mission Statement, effective date [DATE], revised date [DATE], defined Abuse as Any intentional or grossly negligent act or series of acts or intentional grossly negligent omission to act which causes injury to a resident, including but not limited to, assault or battery, failure to provide treatment or care, or sexual harassment of the resident. The policy defined Neglect as The failure to provide goods and services necessary to avoid harm, mental anguish, or mental illness. The policy statement indicated the center will not tolerate abuse, neglect, or exploitation of its residents by anyone. Record review of the Electronic Medical Record (EMR) for R1 revealed diagnoses included infection and inflammatory reaction due to internal right knee prosthesis, sequela, peripheral vascular disease, and presence of left artificial knee joint. Record review of the most recent quarterly Minimum Data Set (MDS) for R1 dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. Section GG (Functional Abilities and Goals) documented that R1 was dependent on staff for self-care and mobility requires two persons assistance for ADL care. The helper does all of the effort. The resident does none of the effort to complete the activity. A review of the Resident Progress Note for R1 dated [DATE] at 3:59 pm revealed at approximately 10:50 am, nursing was alerted to the room by CNA (CNA CC). The resident was face down on the floor on the right side of the bed. The CNA stated she was giving care to the patient (changing brief), and when she rolled over, the CNA was unable to catch her, and she rolled off the bed onto the floor. Blood was noted on the head. She had a large open contusion to the head, and the scalp was open to expose the skull. Emergency Medical Services (EMS) was called, and dressings were applied. Wound to top of head covered with ABD pad (Army Battle Dressing [a gauze pad used to absorb heavy drainage]) and roll gauze. Hospice notified. The resident's family was notified. A report was given to the local hospital. EMS left with R1 at 11:15 am. Interview on [DATE] at 10:08 am with Licensed Practical Nurse (LPN) BB revealed she worked on Sunday, [DATE], and R1 was on her hall. She stated around 10:00 am, she was finished with her medication pass, and she stuck her head in R1's room. She stated both R1 and her roommate were in the room with their eyes closed. LPN BB stated CNA CC alerted her around 10:50 am to 11:00 am that the resident was on the floor. LPN BB stated that CNA CC and Registered Nurse (RN) AA/Weekend Supervisor were in R1's room. LPN BB further revealed when she entered the room, R1 was on the floor to the right of the bed, face down, with a lot of blood around the resident's head. LPN BB stated RN EE came from the other hall and they assessed R1 to see where the blood was coming from. She stated they saw that the blood was coming from her head, and she told CNA CC to call 911. LPN BB stated that 911 was asking questions over the phone that CNA CC could not answer, and RN AA went to talk to 911. LPN BB stated she and RN EE turned R1 onto her back, put a sheet under her, and held her head straight. LPN BB further stated RN AA assessed the wound and applied ABD pads, placing a pressure dressing on R1's head. LPN BB confirmed that the scalp was pulled up at the top of her head, exposing the bone, and the scalp was detached from that area of the head. LPN BB further revealed that R1 was moaning and was unresponsive. LPN BB confirmed that CNA CC had always changed R1 without any assistance. LPN BB stated that when she changed R1 alone, the resident would roll over and hold on to the side of the mattress. However, this did depend on the day and if you were liked by R1. She stated she did not know when R1 was last assessed for side rails. LPN BB revealed that she called the doctor, hospice nurse, and the family and called the hospital to give a report. She stated the resident left the facility via EMS around 11:20 am. LPN BB confirmed that the doctor called her between 12:00 pm and 12:30 pm, stating that R1 had expired at the hospital. Interview on [DATE] at 10:25 am with RN EE revealed that on [DATE], when walking to the nurse's station, CNA CC told him they needed assistance in R1's room. RN EE stated when he entered the room, the resident was lying diagonally on the right side of the bed on the floor. He stated LPN BB and RN AA were in the room. RN EE further revealed that he lifted R1's right leg and was sure that the leg was broken because there was no alignment. He further stated he picked up the leg and felt what he thought was bone. RN EE confirmed that he told CNA CC to call 911. He stated he assessed the scalp wound and stated it was very bad. RN EE described the head wound as a horseshoe shape attached to the front of the head but detached from the sides and the back of the head. RN EE stated he went to get some ABD pads. RN EE stated that CNA CC could not answer the question from 911, so RN AA went to talk with 911. He stated he asked for a sheet to put under R1 because she was lying face down. RN EE revealed when EMS came, they lifted the sheet and put her on the gurney, and at that time, he saw her eyes roll backward in her head. RN EE further revealed he is not sure if R1 died en route to or at the hospital. He further described R1's bed as being up high and stated it was at least a three-foot drop. RN EE stated CNA CC had the bed up high because she was a tall lady. He further stated he had not worked with R1 and was unaware of her baseline status. A follow-up interview on [DATE] at 10:57 am with RN EE revealed at the time of the incident, staff got a sheet, rolled R1 on it, and put her in the bed because he could not get an accurate assessment to see if she was breathing. RN EE revealed that R1 was a large woman, and he could not see a visual rise in her chest. RN EE further revealed that he could not make out the left side of her face because of how she was positioned on the floor, and he did not know if there were more lacerations, so they put her back in bed. Interview on [DATE] at 2:15 pm with RN AA/Weekend Supervisor revealed at the time of the incident, CNA CC was yelling out for help. RN AA stated that R1 was in her room lying on the floor face down on the right side of the bed, but she did not realize that R1 was that hurt. RN AA further revealed that she went to her head and noticed her breathing was agonal (gasping for air), not what it should be, and was very limited breathing. RN AA stated at that time, she realized R1 was bleeding, and she raised R1's head to facilitate breathing. She stated she noticed blood was matted in her hair, but it wasn't dry at that time. RN AA stated she yelled for somebody to call 911 and left R1's side to speak with 911 while other nursing staff assisted R1. RN AA stated nursing staff put a pressure dressing on the resident before EMS arrived at the facility. She stated she noticed the resident was not responding as they put the dressing on her head, and after applying the dressing, R1 had a blank stare and a bluish color around her mouth. RN AA stated that she did not work directly at the bedside with R1, but she did not feel the resident could hold on to anything because she did not think the resident had the gripping capability. RN AA confirmed that R1 required maximum assistance, and one person provided care to her all the time. A telephone interview on [DATE] at 8:43 am with CNA CC revealed on [DATE] at around 10:53 am she went in to change R1 and raised the bed to her waist because she was tall. CNA CC stated she asked R1 to turn over, and R1 turned over so fast that her feeding pump rolled on top of the bed. She stated when she ran around to the other side of the bed, she saw R1 on the floor. CNA CC further revealed she and the feeding pump were both on the left side of the bed, and the feeding pump with the pole fell on to the bed, still connected to R1. CNA CC stated the RN AA/Weekend Supervisor went to the front desk and called 911, and EMS arrived quickly. CNA AA stated that for the past two years, she cared for R1. She further stated that sometimes R1 needed assistance with ADLs, but sometimes CNA CC could complete her ADLs without assistance. CNA CC confirmed that she did not need help with R1 that day ([DATE]) because they (CNA CC and R1) were conversing, and she went off of that conversation to provide ADLs. CNA CC stated she thought she could do R1's ADL care alone. CNA CC further revealed that R1 rolled over for her, and if she had thought that R1 could not roll over that day, she would have asked for help from her nurse. A telephone interview on [DATE] at 9:50 am with CNA DD revealed she had worked with hospice since 2019 and came to the facility twice a week to provide care to R1. CNA DD stated she bathed, washed her hair, and changed bed linens for R1. CNA DD further revealed that R1 required two person assistance. She stated at one time she had a rail on her bed to assist with turning. CNA DD stated the hospice social worker helped her with R1 during ADL care by holding her over while she changed R1. She stated that R1's bed did not have bed rails, which helped out a lot, and it was unsafe to roll R1 because her bed was not against the wall. CNA DD revealed that R1 would roll towards her to change her, but R1 could not help with care. CNA DD confirmed that R1 could not roll over by herself. An interview on [DATE] at 3:00 pm with Administrator HH revealed CNA CC was suspended pending the outcome of the investigation to determine what happened with the R1 incident. The Administrator stated that R1 was able to assist with turning and repositioning. The Administrator further revealed that some people could provide ADL care for R1 alone. The Administrator further revealed that they initiated a self-imposed Immediate Jeopardy and immediately began education with the staff.

Based on record review, staff interviews, and review of the facility policy titled Care Plans, the facility failed to develop an accurate person-centered comprehensive care plan for one of five sampled residents (R) (R1) that specified the need for two-person assistance with Activities of Daily Living (ADL) care. On 7/9/2024, it was determined that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Senior Nurse Consultant (SNC) was informed of the Immediate Jeopardy on 7/9/2024 at 4:06 pm. The noncompliance related to the Immediate Jeopardy was determined to have existed on 6/30/2024. Findings include: A review of the facility policy titled Care Plans, revised 7/27/2023, revealed it is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) Manual and the patient/resident choice. Admission Comprehensive Care Plan: Number 3. The comprehensive care plan should describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Number 4. The care plan will contain 4 main components: Problem, Goal, Approaches, and Role or Accountability. The care plan approach serves as instructions for the patient/resident's care and provides continuity of care by all partners. When approaches that involve the CNA have been added to the care plan, those approaches should also be included on the CNA Care Record or Resident Profile/Care Plan. Record review of the most recent quarterly Minimum Data Set (MDS) for R1, dated 5/26/2024, revealed section GG (Functional Abilities and Goals) documented for roll left and right and toileting hygiene; the resident is dependent, the helper does all of the effort. The resident does none of the effort to complete the activity. Or, the assistance of two or more helpers is required for the resident to complete the activity. A review of the care plan for R1 revised 7/1/2024, revealed that R1 requires staff assistance for ADLs due to physical deficits and the disease process of multiple diagnoses. Requires maximum to total assistance with ADL care, including but not limited to bed mobility, transfers, locomotion, and toileting. Approaches to one - two persons assistance for ADL care. A review of the Resident Progress Note for R1 dated 6/30/2024 at 3:59 pm revealed at approximately 10:50 am, nursing was alerted to the room by CNA CC. The resident was face down on the floor on the right side of the bed. The CNA stated she was giving care to the patient (changing brief), and when she rolled R1 over, the CNA was unable to catch her, and she rolled off the bed onto the floor. Blood was noted on the head. She had a large open contusion to the head and scalp open exposed the skull. Emergency Medical Services (EMS) was called, and dressings were applied. Wound to top of head covered with ABD pad (abdominal gauze pad used to absorb heavy drainage) and roll gauze. Hospice notified. The resident's family was notified. A report was given to the local hospital. EMS left with R1 at 11:15 am. Interview on 7/3/2024 at 10:08 am with Licensed Practical Nurse (LPN) BB revealed R1 could roll over and hold on to the mattress, but it depended on what day it was and if she liked you. She stated she had changed R1 by herself, and CNA CC has always changed her by herself. She stated that the resident could wash her hands and drink a soda. She stated that R1 held on to the side of the mattress when she changed her by herself. A telephone interview on 7/9/2024 at 8:43 am with CNA CC revealed she had cared for R1 for two years. She stated some days she needed help with ADL care for R1, but some days she didn't need help. She stated that she did not need help with her the day of the fall because they were conversing, and she went off of the conversation. CNA CC stated she thought she could do R1's ADLs by herself. She further stated that R1 rolled over for her, and if she thought that R1 could not roll over that day, she would have also gotten her nurse to help. A telephone interview on 7/9/2024 at 9:50 am with Hospice CNA DD revealed she came to the facility twice a week. She stated that R1 was a two-person assist. CNA DD further revealed that sometimes the hospice nurse or the social worker is in the facility, and they would help her with R1. She stated a few of the aides at the facility would assist her with care, but R1 could not roll over by herself. She stated that R1's bed was not to the wall, and it was unsafe to roll her because it was not up against the wall. An interview on 7/3/2024 at 12:16 pm with LPN FF/Case Mix Director revealed that R1 was dependent on staff for ADLs. She stated that it depended on how R1 felt each day to determine if she needed one or two staff assistance. LPN FF further revealed that some staff can do ADLS for R1 alone. LPN FF confirmed that the MDS section GG stated that R1 was dependent on staff for ADLS, but it did not specify if she required one or two-person assistance. She stated that she puts in the care plans for CNAs to observe to see if residents need increased assistance and to notify the nurse for increased assistance. LPN FF stated that she put on the care plan that R1 required one to two people to assist with ADLs.

Based on staff interviews and record review, the facility failed to provide adequate assistance for bed mobility for one of five residents (R) (R1) reviewed for falls. Specifically, R1 fell from the bed during Activities of Daily Living (ADL) care on [DATE], resulting in death within 50 minutes post-fall. On [DATE], it was determined that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Senior Nurse Consultant (SNC) was informed of the Immediate Jeopardy on [DATE] at 4:06 pm. The noncompliance related to the Immediate Jeopardy was determined to have existed on [DATE]. Findings include: A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed section GG (Functional Abilities and Goals) documented that R1 was dependent on staff for self-care and mobility. The helper does all of the effort. The resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity. A review of a document titled Fall Form dated [DATE] at 8:33 pm, completed by Licensed Practical Nurse (LPN) BB, indicated R1 was in bed receiving ADL care. Fall with a head injury from witnessed fall. A review of the emergency room Summary Report dated [DATE] at 11:27 am revealed R1 arrived with a large, approximately 14 centimeter (cm) laceration to the top of her head, exposing bone, no spontaneous respirations, pulseless, after a fall from her bed. R1 had a witnessed fall out of bed and must have hit her head on the side table. Additionally, R1 had a loss of scalp integrity, bruises noted to arms, 6cm x 2.5 cm left knee skin tear, 1 cm diameter skin tear to right hand, and 3.5 cm x 2.5 right shoulder skin tear. R1 expired at the hospital on [DATE] at 11:40 am. A review of a document titled SBAR (situation, background, appearance, review) dated [DATE] revealed the [Situation] The change in condition, symptoms, or signs observed and evaluated is/are R1 rolled out of bed, head injury. [Background] Unresponsiveness, Contusion, Skin tear, Wound, S/t (secondary to) to L (left) knee and RUA (right upper arm). Contusion/wound to top of head, moaning and flinching, altered level of consciousness (hyperalert), drowsy but easily aroused, difficult to arouse, unarousable. R1 was a Do Not Resuscitate. [Appearance] Resident rolled from bed causing head injury. Nurses Note revealed Nursing was alerted to room by Certified Nursing Assist (CNA). R1 was face down on the floor at right side of bed. CNA stated she was giving care to patient (changing brief) and when she rolled over the CNA was unable to catch her and she rolled off the bed onto the floor. Blood was noted to head. She had a large open contusion to the head and scalp open to expose skull. Emergency Medical Services (EMS) was called, and dressings applied. Interview on [DATE] at 10:08 am with LPN BB revealed CNA CC alerted her between 10:50 am to 11:00 am that the R1 was on the floor. LPN BB stated when she entered the room, R1 was on the floor to the right of the bed face down with a lot of blood around the head. LPN BB further revealed Registered Nurse (RN) EE came from the other hall, and they assessed R1 and saw blood coming from her head. She stated that the scalp was pulled up at the top of her head, you could see the bone, and the scalp was detached in that area of the head. Interview on [DATE] at 10:25 am with RN EE revealed that when walking to the nurse's station, CNA CC told him they needed assistance in R1's room. RN EE stated when he entered the room, the resident was lying diagonally on the left side of the bed on the floor. RN EE further revealed that he lifted R1's right leg, thought he felt bone, felt no alignment, and was sure the leg was broken. He stated the scalp wound was horseshoe-shaped attached to the front but detached from the and the back of the head. RN EE stated that R1's bed was raised up high and at least a three-foot drop. RN EE stated CNA CC had the bed up high because she was tall. A telephone interview on [DATE] at 8:43 am with CNA CC revealed at around 10:53 am on [DATE], she went to change R1 and raised the bed to her waist because she was tall. CNA CC stated she asked R1 to turn over, and R1 turned over so fast that her feeding pump rolled on top of the bed. She stated when she ran around to the other side of the bed, she saw the resident on the floor. CNA CC further revealed that she and the feeding pump were both on the left side of the bed, and the feeding pump with the pole fell on the bed, still connected to R1. CNA AA stated she had cared for R1for two years. She further stated at times, she needed assistance with providing R1's ADL care, but at other times, CNA CC could provide R1's ADL care without assistance. CNA CC confirmed that she did not need help with R1 that day ([DATE]) because they (CNA CC and R1) were conversing, and she went off of that conversation to provide ADLs. CNA CC stated she thought she could provide R1's ADL care alone. CNA CC further revealed that R1 rolled over for her, and if she thought that R1 could not roll over that day, she would have asked for help from her nurse.

Based on record review, staff interviews, and review of the facility's Administrator and Director of Health Services (DHS) job descriptions, the facility Administration failed to ensure one of five sampled residents (R) (R1) was free from neglect during Activities of Daily Living (ADL) care. This failure resulted in R1 falling from the bed and expiring at the hospital 50 minutes post-fall. On 7/9/2024, it was determined that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Senior Nurse Consultant (SNC) was informed of the Immediate Jeopardy IJ on 7/9/2024 at 4:06 pm. The noncompliance related to the Immediate Jeopardy was determined to have existed on 6/30/2024. Findings include: Review of the facility-provided document titled Position Description-Administrator dated 12/27/2016, revealed the job purpose is to direct the day-to-day functions of the nursing center in accordance with federal, state, and local regulations that govern long-term care centers, and as may be directed by the Area [NAME] President, to provide appropriate care for our patients/residents. Review of the facility-provided document titled Position Description-Director of Health Services dated 12/27/2016, revealed the job purpose is plans, organizes, develops, and directs the overall operation of our 'Nursing Services Department' in accordance with current federal, state, and local regulations governing our nursing center, and as may be directed by the Administrator and the Medical Director, to provide appropriate care. Facility Administration, specifically the Administrator and the DHS, failed to protect residents and effectively oversee areas of the facility that were included in their job descriptions. 1. The facility failed to ensure R1 was free from neglect by facility staff during the provision of ADL care. Cross refer F600 2. The facility failed to develop a comprehensive person-centered care plan that specified the need for two-person assistance with ADL care. Cross refer F656 3. The facility failed to protect R1 from a fall during ADL care, resulting in her death at the hospital. Cross refer F689 An interview on 7/2/2024 at 3:00 pm with Administrator HH revealed she was not at the facility at the time of the incident but was informed of the incident by the weekend supervisor, Registered Nurse (RN) AA. Administrator HH further revealed Certified Nursing Assistant (CNA) CC was sent home and suspended pending the outcome of the investigation to determine what happened with R1. Administrator HH stated that some staff could do R1's ADL care by themselves. She stated that the facility had initiated a self-imposed Immediate Jeopardy and immediately began educating the staff. An interview on 7/2/2024 at 4:09 pm with the DHS revealed the weekend supervisor RN AA met with CNA CC and obtained a statement. She stated CNA CC was sent home on Sunday, 6/30/2024. She further stated CNA CC was off Monday but was called in and spoke with Administrator HH and the DHS. She stated CNA CC was suspended pending the investigation. The DHS stated that R1 could assist with turning, and she held on to the mattress while turning.

Based on observation, interview and record review, the facility failed to ensure residents' rooms and bathrooms were safe and maintained to promote a pleasant and homelike environment in 24 of 53 rooms (101, 102, 103, 104, 105, 106, 107, 108, 110, 112, 115, 117, 118, 119, 120, 121, 122, 123, 124, 126, 127, 128, 130 and 132) observed. Findings include: During an environmental tour of the facility on 09/28/23 at 9:45 am, the following maintenance items were observed: 1. Resident rooms 105, 106, 107,108, 110, 112, 121, 122, 123, 124, 126, 128, 130 and 132 had missing threshold strips on one or both sides of the entrance into the bathroom. The missing strip was between the tile floor and the laminate floor, which created an uneven surface going into and out of the bathroom. 2. Resident rooms 101, 103, 127 had missing baseboards. 3. The bathroom between resident rooms [ROOM NUMBERS] was observed to have an over the toilet assistive device in disrepair. All four legs were heavily coated with a rust-colored substance. 4. Resident rooms 110, 112, 115, 118, 120, 130, and 132 had bathroom toilets with a rust-colored substance covering the inside surface of the toilet bowl. 5. Resident rooms 101, 103, 105, 106, 107, 108, 121, and 123 bathroom sink faucets were either rusted and/or constantly dripping. 6. Resident rooms 101, 102, 103, 104, 105, 107, 110, 112, 117, 118, 119, 120 had rust-colored heaters on the wall with peeling paint. Observation of resident rooms [ROOM NUMBERS] revealed two holes in the floor filled with white caulking from where the old heater had been removed. During an interview on 09/28/2023 at 10:30 am, the Maintenance Director (MD) stated that the caulking was a temporary fix until he can find tile to patch over the holes in rooms [ROOM NUMBERS]. 7. Observation of resident rooms [ROOM NUMBER] revealed the doors were buckling with loose laminate. The bathroom door in room [ROOM NUMBER] and 124 had loose laminate wood with sharp edges sticking up and room [ROOM NUMBER] had a hole in the door. Resident rooms 101, 103, 118, and 120 had broken or missing bathroom tiles: During an interview on 09/28/2023 at 11:00 am the MD stated that the toilets and sinks were rusty, and the building needed many repairs. Review of a Work Order Report dated 09/27/2023 provided by the MD indicated 25 work orders pending, including replacing toilets and sinks. During an interview on 09/29/2023 at 11:00 am, the MD stated that there were about 10 sinks that need to be replaced. The MD stated that he did not know how many rusty heaters were still on the walls.

Based on observation, staff interviews, record review, and a review of the facility policy titled, Admission Orders, the facility failed to have a physician order for administering oxygen for one of two resident (R) (66) reviewed for oxygen and failed to have a physician order for the tracheostomy size and type for one of one (R81) resident reviewed for tracheostomy (a tube inside of the windpipe in the throat to allow for breathing) care. This placed R66 at risk for receiving too much or too little oxygen and placed R81 at risk of having respiratory issues related to the incorrect size or type of tracheostomy appliance. Findings include: Review of a facility policy titled Admission Orders, dated September 2022, provided by the facility indicated, .Policy: At the time of admission to a healthcare center/agency, in order to assure quality patient/resident care and to comply with Federal law it is necessary that complete and accurate physician orders for the patient/resident's immediate care be obtained. 1. The orders must be reviewed by the admitting nurse and should at least address the patient/resident's .routine care to maintain or improve the patient/resident functional abilities. 2. The admitting nurse will make every effort to obtain admission orders prior to the patient/resident's arrival .and should occur no later than at the time of admission .5. Once all admission orders have been verified and documented appropriately, they are to be transcribed by the admitting nurse on the appropriate documents in the record. 1.Review of R66's Resident Face Sheet, located under the Face Sheet tab of the Electronic Medical Record (EMR) indicated a diagnoses to include Chronic Systolic Heart Failure and Acute Respiratory Failure with hypoxia (low oxygen). Review of hospital Discharge Instructions dated 09/05/2023, located in the Document Tab of R66's EMR, indicated .Pulmonary Status .Patient requires 3L (liters) O2 (oxygen) via nasal cannula to maintain SAO2>90 (oxygen saturation of arterial blood). Patient has diagnosis of CHF (congestive heart failure.) During an observation on 09/25/2023 at 1:41 pm, 09/26/2023 at 10:37 am and 09/27/2023 at 11:59 am, R66 had a nasal cannula with oxygen running at 3 L. Review of R66's active Orders, located in the Orders tab of the EMR, revealed no physician's order for oxygen or monitoring of oxygen saturations. During an interview on 09/27/2023 at 12:22 pm, Licensed Practical Nurse (LPN) 2 confirmed there were no physician order for R66's oxygen. During an interview on 09/28/2023 at 12:51 pm, the Director of Nursing (DON) confirmed that R66 did not have a physician order for oxygen administration or oxygen saturations. 2. Review of R81's Resident Face Sheet, located under the Face Sheet tab of the EMR, indicated an admitted [DATE]. R81 had diagnoses to include cancer of the trachea and placement of a tracheostomy. Review of active Orders, located in the Orders tab of F81's EMR revealed an order, Trach Care-Trach Size: #______ Trach Type: ______. Review of Hospice Plan of Care dated 08/17/2023, located in the Documents tab of R81's EMR indicated .facility staff to do tracheostomy care every shift. The Hospice Plan of Care did not document the size or type of tracheostomy appliance. During an interview on 09/27/2023 at 10:30 am, the Minimum Data Set (MDS) Coordinator confirmed there are no physician orders for the size and type of tracheostomy appliance. During an interview on 09/27/2023 10:37 am, the DON confirmed R81 did not have a physician order for the size, type or make of the tracheostomy. Review of a facility procedure titled, Tracheostomy Care dated 2019, provided by the facility indicated, Procedure .2. Verify orders.

Based on observations, interviews, record review, and facility policy, the facility failed to maintain oxygen equipment (including changing and dating oxygen tubing, cleaning oxygen concentrator filters, and storing nasal cannula tubing in clear bags) for three residents of four residents (Resident (R) 19, R43, and R47) reviewed for respiratory/oxygen therapy. Additionally, the facility failed to maintain emergency equipment for one resident of one resident (R7) with a [CONDITION(S)]. The deficient practice had potential to affect four of eleven residents receiving respiratory treatment by increasing respiratory germs exposure; cause R43 respiratory distress due to inaccurate oxygen flow rate; and the potential for the emergency [CONDITION(S)] kit to have outdated or missing supplies. Findings include: Review of the facility-provided policy titled Oxygen Administration, revised [DATE], revealed .Regulate liter flow to ordered/desired flow rate . O2 [oxygen] humidifier bottles should be used on all patients receiving higher than 2 Liters/minute of oxygen flow. The large external, black filter should be washed with soap and water once each week and PRN [as needed]. Do not change internal filter (This may alter warranty on equipment. The contracted Durable Medical Equipment (DME) Company will perform maintenance on oxygen concentrators). Review of the facility-provided policy titled, Respiratory Equipment Changeouts, revised [DATE], stated To provide guidelines to help prevent infections associated with respiratory equipment and to prevent transmission of such infections to patient/residents and staff. Nasal cannula (low flow) and tubing shall be changed weekly. Documentation shall be maintained in the patients/resident medical record. Humidifier bottles shall be changed weekly. 1. Observation of R47's room on [DATE] at 10:31 AM revealed the oxygen concentrator was fully bagged not being administer. R47 was lying in bed with no sign or symptoms of distress. Observation of R47 on [DATE] at 2:44 PM revealed the resident lying in bed receiving oxygen treatment. The tubing on the machine was not dated to indicate the last time it was changed. Record review of R47's Face Sheet'' located in the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders, dated [DATE], revealed Oxygen @2L [liters] via N/C [nasal cannula] continuously. Review of the Medication Administration Record (MAR) along with the Director of Nursing (DON) on [DATE] at 4:29 PM revealed R47 did not have an order to change out the tubing weekly and therefore the task was not documented as completed on the MAR. 2. Review of R19's EMR under Face Sheet tab revealed R19 was admitted to the facility on [DATE] (latest return). R19's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R19's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE] revealed R19 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R19's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .O2 per nasal cannula @ 2 L [liters]/M[minute] at night PRN for shortness of breath. dated [DATE]. R19 did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R19's MAR revealed no information for maintaining oxygen equipment (specifically, changing the oxygen tubing, cleaning the oxygen concentrator filter (large external black filter), changing the oxygen concentrator water bottle), indicating the respiratory equipment maintenance was not documented as performed. Review of R19's care plan under the Care Plan tab in the EMR with an approach start date of [DATE] revealed, .Administer oxygen as needed. R19's care plan did not include approaches or interventions for changing oxygen tubing, changing water bottle (dating), storing oxygen tubing (nasal cannula in clear bag with date of change) or cleaning oxygen concentrator filter, which indicated the task of respiratory maintenance was not implemented. During an observation on [DATE] at 10:57 AM in R19's room, oxygen tubing was not stored in a bag and did not contain a date of change on the tubing. The nasal cannula was uncovered hanging on the trapeze bar over the top of R19's bed. The water bottle did not have a date on it. The bottle was approximately ,d+[DATE] full of clear liquid. The tubing connecting the concentrator and the water bottle was bent and occluded and did not contain a date on it. The cover over the oxygen concentrator filter was not clean and had moderate amount of dust. A second observation was conducted on [DATE] at 10:13 AM. R19 was not being administered oxygen. R19's oxygen tubing (nasal cannula) was uncovered hanging on her trapeze bar. The nasal cannula tubing was not stored in a clear bag. The oxygen water bottle on concentrator was light tan in color, no date of change was on the bottle, and it was ,d+[DATE] full of opaque liquid. The tubing connecting the water bottle and concentrator was twisted and occluded and had no date of change on the tubing. The filter on the oxygen concentrator was stored behind a plastic cover. The plastic cover vents were not clean and had dust particles on it. R19 stated, I wore oxygen last night. During an observation and interview on [DATE] at 10:25 AM, Skin Integrity Coordinator Registered Nurse (SIC RN) confirmed and verified R19's oxygen tubing connecting the water bottle with concentrator was twisted and occluded. SIC RN confirmed R19's oxygen water bottle was opaque and not clear as it should be. SIC RN confirmed R19's water bottle did not have a date of change on it. SIC RN confirmed R19's nasal cannula did not have a date of change on it. SIC RN confirmed R19's nasal cannula oxygen tubing was hanging on her trapeze bar and not stored in a clear bag. SIC RN confirmed R19's oxygen concentrator filter had a cover over it, on the posterior right upper corner. SIC RN removed the cover to expose a clear plastic device containing a concentrator filter with the date of [DATE] handwritten on it. SIC RN confirmed R19's concentrator filter inside the plastic device was black, covered with dust, and not clean. SIC RN confirmed R19 had a plastic vent covering the second oxygen concentrator filter (the large external black filter) and the vent cover was not clean and was covered with dust. SIC RN confirmed the second concentrator filter (the large external black filter) was not visible, and SIC RN was unsure how to remove the oxygen concentrator filter cover. SIC RN confirmed R19's unclean oxygen concentrator filter and vent cover, nasal cannula oxygen tubing stored outside of a clear bag, the opaque undated water bottle was unsanitary and put at risk R19 for respiratory germs and or infection. During an interview on [DATE] 3:20 PM, the DON confirmed R19's oxygen tubing should not be stored on R19's trapeze bar and oxygen tubing should be stored in a clear bag on the oxygen machine when not in use. The DON stated, the oxygen concentrator filter (large black filter) should be checked daily for cleanliness (dust) on the compliance rounds by the facility's staff. The DON confirmed the nursing staff were responsible for changing R19's oxygen tubing and cleaning R19's oxygen concentrator filter which should be cleaned weekly and as need by the nursing staff. DON confirmed the task should be documented on R19's MAR. DON confirmed, the facility's deficient practice placed R19 at risk (no date of change, opaque water bottle, oxygen tubing not changed and undated, and the unclean oxygen concentrator filters) for exposure to respiratory germs or cause the oxygen equipment not to operate to its optional level. 3. Review of R43's EMR under the Face Sheet tab revealed R43 was admitted to the facility on [DATE]. Review of the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R43's admission MDS with an ARD of [DATE] revealed R43 had a BIMS score of 13 out of 15, which indicated the resident was cognitively intact. Review of R43's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Oxygen: Change respiratory circuit/supplies weekly., dated [DATE] and .Oxygen: Oxygen at 2 LPM [liters per minute] via nasal cannula continuous., dated [DATE]. There was not a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R43's MAR dated for [DATE] through [DATE] revealed there was no information for oxygen concentrator filter cleaning, indicated the maintenance of cleaning oxygen concentrator filter was not documented on the MAR. Review of R43's care plan under Care Plan tab in the EMR revealed .Problem Start Date: [DATE]. CARDIAC/RESPIRATORY CARE PLAN: [R43] is at risk for cardiac and respiratory decline r/t [related to] DX [diagnoses] of [CONDITION(S)] and [CONDITION(S)] [hypertension]. Long Term Goal Target Date: [DATE] Maintain optimal breathing and oxygen level within constraints of disease process through next 3 months Approach Start Date: [DATE]. No maintenance of oxygen equipment information was located on her care plan, indicating task was not implemented by the facility. During an observation and interview on [DATE] at 12:01 PM, R43 was wearing the oxygen nasal cannula prongs in her nose. There was no date of change labeled on her oxygen tubing. R43's oxygen concentrator was turned on and set at 2.5 liters flow rate. There was a cover on the back of the oxygen concentrator over the filter. The filter cover was not clean and had moderate amount of dust on it. R43 had an oxygen tank on the back of her wheelchair. The oxygen tank was connected to a nasal cannula oxygen tubing. The nasal cannula oxygen tubing was not stored in a bag. There was no date indicating the date of change on the nasal cannula oxygen tubing. The oxygen tubing was laying on the wheelchair, with the nasal cannula prongs touching the seat of the wheelchair and exposed. R43 stated, the staff borrow my oxygen tank off my wheelchair for other residents and I am not sure if they replace the nasal cannula tubing or use the same [oxygen tubing] on me and the other resident. A second observation and brief interview were conducted on [DATE] at 3:08 PM with Licensed Practical Nurse (LPN) 2 who confirmed R43 had oxygen being administered by nasal cannula. LPN2 confirmed there was not a date of change on the nasal cannula oxygen tubing. LPN2 confirmed R43's oxygen concentrator flow rate was set at 2.5 liters per minute. LPN2 confirmed R43's water bottle and oxygen tubing connecting the water bottle to the concentrator were not dated. LPN2 confirmed R43's oxygen concentrator vent covering the filter was not clean and contained dust. LPN2 confirmed the oxygen tank on R43's wheelchair was turned off. LPN 2 confirmed R43's oxygen nasal cannula tubing was connected to the oxygen tank on the wheelchair and was not store in a bag and did not contain a date of change on it. LPN2 confirmed the nasal cannula oxygen tubing was draped over her oxygen tank. LPN2 confirmed R43's oxygen concentrator flow rate was set incorrectly between 2 and 2.5 liters and her physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN2 stated, I will replace [R43's] nasal cannula oxygen tubing and include a date of change on the tubing because I am unsure when it was changed. LPN2 removed R43's cover (on the posterior side of the oxygen concentrator) revealing an unclean (dusty) oxygen concentrator filter. LPN2 exposed a plastic container with a date of [DATE] and stated, I do not know what that was. LPN2 verified and confirmed the plastic container was labeled blue tag filter and was changed on [DATE]. LPN2 verified the concentrator filter should be clean on R43's oxygen concentrator. LPN2 stated, I am not sure who was responsible for cleaning R43's oxygen concentrator filter. LPN2 stated, I will clean it now. LPN2 confirmed R43's oxygen tubing should be changed and the date of change should be labeled on the tubing. LPN2 confirmed R43 did not have an oxygen water bottle connected to her concentrator. LPN2 confirmed R43's oxygen tubing connected to portable oxygen tank should be stored in a clear and should have a date of change labeled on the tubing. LPN2 confirmed and verified R43's oxygen tubing was not stored in a bag or was not labeled with the date of change. LPN2 confirmed the facility failure to change R43's oxygen tubing (including labeling with date of change), failure to store oxygen tubing in a bag, and not ensuring R43's oxygen concentrator filter was clean could potentially expose R43's to respiratory germs. LPN2 confirmed receiving incorrect oxygen flow rate could potentially cause respiratory distress for R43. An interview was conducted [DATE] at 3:39 PM with the DON who confirmed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed the facility's nurses were responsible for ensuring R43's flow rate was set correctly on her concentrator. The DON confirmed the nurse should assess the resident's oxygen flow rate every shift. The DON stated the nurses at the facility worked two shifts, 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM. The DON confirmed not ensuring correct flow rate for R43's (according to physician orders) could potentially cause R43 respiratory distress. 4. Review of the facility's policy titled, [CONDITION(S)] Supple PAR Levels revised [DATE], indicated, The healthcare center will maintain [CONDITION(S)] supply PAR levels that meet or exceed the patient/resident's [CONDITION(S)] supply needs. The [CONDITION(S)] supplies will be kept in the central supply room, nursing unit and patient/resident's bedside. Medical Supply Room Ambu Bag [manual resuscitation bag ] with Facemask, 6/CS (each [CONDITION(S)] patient should have one at bedside.). The licensed nurses will be responsible for stocking and maintaining the following [CONDITION(S)] supplies at the patient/resident's bedside. Observation of R7 on [DATE] at 4:04 PM revealed the resident has a [CONDITION(S)] ([CONDITION(S)]). The emergency kit was not in eyesight or near bedside. Observation of R7 on [DATE] at 10:07 AM revealed the resident still had her [CONDITION(S)]. Further observation revealed the emergency box was in the closet. Observation of the [CONDITION(S)] emergency kit revealed the kit was last checked [DATE]. During an observation with two surveyors on [DATE] at 10:40 AM, R7 was lying on her bed. R7 had a [CONDITION(S)] collar oxygen mask with a date of [DATE]. R7's oxygen concentrator was set a 5 liters flow rate. R7's [CONDITION(S)] size was not visible due to [CONDITION(S)] collar oxygen mask. R7 did not have an emergency [CONDITION(S)] kit visible or an ambu bag. R7 had a suction machine cover with clear plastic bag on her nightstand. Record review of R7's Face Sheet located in the EMR revealed the resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review found in the Orders tab of the EMR revealed the resident had an order, dated [DATE], for Oxygen - Humidified [CONDITION(S)] Collar at 5 liters per minute (L/MIN) via [CONDITION(S)] Collar continuously Every Shift Days, Nights Review of the Progress Notes tab in the EMR indicated, on [DATE] at 6:47 AM, [CONDITION(S)] Care-. Emergency equipment at bedside. Will continue to monitor. On [DATE] at 2:42 PM, Emergency equipment remains at bedside Interview with LPN1 on [DATE] at 11:16 AM revealed the nurses provided [CONDITION(S)] care and provided suction once daily and changed out the inner canula and dressing. LPN1 stated, This morning I changed her dressing only. LPN1 stated R7 had an obturator and syringe in the closet. On observation during the interview, LPN1 went straight to the closet and obtained the emergency kit. LPN1 realized the ambu bag was missing from the emergency kit and stated the bag was there the last day she worked which was [DATE]. LPN1 confirmed she checked to the see if the ambu bag was in the room today. LPN1 stated the emergency kit was checked every three months. When asked was this information documented, she stated it was not. LPN1stated there was no place to document it had been checked on the kit. Further review of the box with LPN1 revealed there was a slip on the box where to document it had been checked. LPN1 confirmed the last date noted on the box was [DATE]. Review of the emergency kit along with LPN1 revealed the following content. 3 [CONDITION(S)] ties 3 lubricating jelly 5 drain sponges size 4 shiley size 6 shiley 2 sterile water cups expired [DATE] 1 syringe 1 suction catheter kit 2 [CONDITION(S)] care tray 1 adult track mask There was no hemostat in the emergency kit. Further interview with LPN1 revealed when there was a new staff member they were oriented to the patients and explained the emergency kit it was in the closet. LPN1 stated when the emergency kit was bedside it got moved around and misplaced. When asked about the documentation in the progress notes stating the kit should be bedside, LPN1 stated maybe we should change that. When asked what could happen if the [CONDITION(S)] became dislodged LPN1 stated it became an emergent situation. LPN1 confirmed the sterile water had expired. Interview with the DON on [DATE] at 4:21 PM revealed they did not have a system check list for the [CONDITION(S)] box. The DON stated, Moving forward we are putting in a flow sheet, have it attached to the box and be specific and they have to check it like they check the crash. The crash cart is checked daily. The DON confirmed the box was last checked [DATE]. The DON stated she did not know the emergency kit was in the closet.

Based on observations, interviews, and review of facility policy, the facility failed to ensure proper consistency of the pureed meats for nine residents on pureed texture diets of 78 census residents. The deficient practice has the potential to create a choking risk and result in decreased resident intake. Findings include: Review of the facility's policy titled Pureed Texture undated, indicated The pureed texture provides foods with a semi-liquid to semi- solid consistency such as applesauce to mashed potatoes. The pureed texture consistency is normally that of applesauce or mashed potatoes. Some foods may be smooth, and some may have some texture but no lumps. During an observation of the main kitchen on 04/13/22 at 9:43 AM, the Dietary Manager (DM) said the Robot Coupe (motorized blender) was not working right now and they were having a hard time finding a replacement. They were using a small blender to puree the food. Dietary Aide (DA) 1 was observed pureeing diced chicken. DA1 placed some diced chicken in the blender along with some stock from the chicken. DA1 blended the chicken for a few seconds. DA1 then placed the mixture into a pan. DA1 continued this process until she had enough servings of the pureed mixture placed into the metal pan. DA1 then placed the metal pan into the oven. The pureed product had the appearance of shredded chicken flakes. The product did not have a smooth appearance. At 11:42 AM, the pureed chicken was on the steam table and had the appearance of dry, flaky shredded chicken. At 12:25 PM, a test tray was completed. The pureed chicken was dry with small, shredded meat throughout. The product was not smooth texture. During an interview on 04/13/22 at 12:31 PM, the DM stated pureed texture should be smooth like baby food. She stated the texture should have been nectar thick baby food consistency. She tasted the pureed chicken and said it was more like a chopped or ground really fine texture. She acknowledged the product was not proper texture for pureed food. During an interview on 04/14/22 at 10:52 AM, the Speech Therapist (ST) stated she had a resident on case load who was on the pureed texture. She observed the above meal and said her resident was able to swallow the food item with no concerns. She stated it was okay to have some texture to the mixture. She stated there was no leftover residue in the resident's mouth. During an observation on 04/14/22 at 12:31 PM of the Memory Support Unit (MSU) lunch meal, Resident (R) 62 received pureed texture. This resident' diet texture was changed this meal to pureed. The pureed ham was observed to have had a small, chopped ham consistency. The pureed food item was not smooth. The resident was observed to have taken small chunks of the ham from the pureed food item and placed them into an empty sherbet cup. During an interview on 04/14/22 at 12:38 PM, the ST stated they tasted the pureed ham, and it was chewier. She acknowledged the pureed food was not a proper texture. It had more texture to it. During an interview on 04/14/22 at 12:42 PM, Certified Nurse Aide (CNA) 2 was assisting R62 with her pureed meal. There was a stack of small ham pieces along the side on the resident's tray. CNA2 stated the resident did not like grainy so she took those pieces out. She stated the resident did well with the other pureed food items. During an interview on 04/14/22 at 12:42 PM, the ST stated the pureed texture was smooth when the kitchen had a functioning Robot Coupe. During an interview on 04/14/22 at 1:19 PM, the DM stated the Robot Coupe had been down for close to a month. They were able to use it a little before it completely broke down. She stated they ordered another Robot Coupe, but it was backordered. She stated she was going to find a replacement this day and ensured ST was involved with future trainings with the staff.

Based on observations, interviews, record review, and facility policy, the facility failed to ensure one resident of 24 sampled residents (Resident (R) 14) had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice created the potential for medication errors to occur. Findings include: Review of facility-provided policy titled, Self-Administration of Medications by Patient/Resident, revised 01/28/20, revealed .Each patient/resident who desires to self-administer medication is permitted to do so if the healthcare center's Licensed Nurse and physician have determined that the practice would be safe for the patient and other patients/residents of the healthcare center. medication self-administration also applies to family members who wish to administer medications. The opportunity to self-administer medications is reviewed during the routine assessment by the healthcare center's interdisciplinary team utilizing the Electronic Health Record Observation tool, Medication Self-Administration Observation. If the Licensed nurse determines the patient/resident or family member to be capable of self-administration of medications, the physician must write an order to that effect that includes the specific medications based off of the Self-Administration Medication Observation. Bedside Storage of Medication is permitted only when it does not present a risk to confused patient/residents who wander into the rooms of, or room with patient/residents who self-administer. The following conditions are met for bedside storage to occur: The manner of storage prevents access by other patients/residents. Locking drawers or cabinets are required only if unlocked storage is ineffective. Attending Physician enters an order, on the Electronic Health Record for bedside storage. Review of R14's electronic medical record (EMR) under Face Sheet tab revealed R14 was readmitted to the facility on [DATE]. R14's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R14's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 01/12/22 revealed R14 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R14's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R14's care plan under the Care Plan tab in the EMR revealed there was no information related to self-administration of medication or bedside storage of medications, indicated no intervention was performed. There was no information for R14's self-administration assessment under R14's MDS 3.0 Assessment tab, which indicated R14 was not assessed by the facility for self-administration of medication. Review of R14's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation was conducted on 04/11/22 at 11:14 AM of R14 lying on his bed in his room. R14's beside table had an open bottle of Gummie Immune with Vitamin D labeled with 45 tablets. R14 stated my sister brought those to me. R14's roommate (R67) was lying on his bed in their room. Review of R67's (R14's roommate) quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/15/22 revealed R67 had a Brief Interview of Mental Status (BIMS) score of six out of 15, which indicated R67 had severe cognitive impairment. A second observation of R14's room, on 04/11/22 at 3:38 PM, revealed the opened bottle of Gummies Immune with Vitamin D (labeled contained 45 tablets) remained on his bedside table. A third observation of R14's room, on 04/12/22 at 10:59 AM, revealed R14's opened bottle of Gummie Immune with Vitamin D (labeled contained 45 tablets) remained on his bedside table. R14 was sitting on his wheelchair beside his bed. R14's roommate (R67) was lying on his bed, in their room. An observation and brief interview were conducted on 04/12/22 at 11:01 AM with Certified Nursing Assistant (CNA) 1 who confirmed R14 had an opened medication bottle labeled Gummie vitamins (labeled containing 45 tablet) on his bedside table and verified R14 stated and confirmed he administered the medications to himself sometimes and staff did not administer the medication to him. An interview was conducted on 04/14/22 at 3:44 PM with the Director of Nursing (DON) who confirmed she was aware R14 had the opened bottle of gummie vitamins stored on his bedside table and had self-administered the medication without the facility assessing R14 for self-administration of medications. The DON confirmed the facility should not allow R14 to self-administer his medication without an assessment to self-administer or store his medication. The DON confirmed, the lack of assessment for R14's bedside medication and self-administration could have a negative outcome and other residents could have access to the medication.

Based on interview and record review, the facility failed to ensure that Minimum Data Set (MDS) assessments were encoded and transmitted for two of two residents (Resident (R) 1 and R2) reviewed for Resident Assessment. This failure creates a potential discrepancy or delay in benefits due to payor sources not notified of a resident's admission status. Findings include: 1. Review of R1's Face Sheet located in the electronic medical record (EMR) showed a facility admitted [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the Face Sheet indicated the resident's status as Expired. Review of R1's Progress Notes located in the EMR revealed on [DATE] at 1:37 PM, the Nurses Note, indicated, [Local Hospital] center called to check on resident status. Was reported resident was transferred to [Regional Hospital]. Review of R1's MDS located in the EMR in the under the RAI Tab showed the following assessment completed on [DATE] coded the resident as death in facility. 2. Review of R2's Face Sheet located in the EMR showed the resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS located in the EMR under the RAI Tab revealed the Quarterly MDS status was Early- In Process the Completion Due Date was [DATE]. During an interview on [DATE] at 1:31 PM, Case Mix Director (CMD) 1 & CMD2, who were responsible for completing the MDS, acknowledged the MDSs were late. The CMDs stated, We have a compromise with staffing, so we have to do the floor cart and be the Certified Nursing Assistant (CNA) some days, so that would put a delay in the MDS. We are currently working on the March to the beginning of April. In regard to [R2's] MDS, it is just about completed, it just has to be transmitted. Regarding [R1], I overlooked it because it's not even open. So, it [the MDS] had not been completed at all. During an interview on [DATE] at 1:39 PM, The Director of Nursing stated she was not aware the MDSs were late but expected them to be completed on time. Review of the RAI Manual, provided by the facility, [DATE] edition, indicated, .For the other comprehensive MDS assessments, Significant Change in Status Assessment and Significant Correctio to Prior Comprehensive Assessment, the CAA [sic] Completion Date . must be no later then 14 days from the ARD . and no later than 14 days from the determination date of the significant change in status or the significant error, respectively. For Entry and Death in Facility tracking record, the MDS Completion Date . must be no later than 7 days from the Event Date .

Based on observation, interview, record review, and policy review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight, for one of one resident (Resident (R) 18) reviewed for nutritional status; resulting in continued significant weight loss. Findings include: Review of the facility's policy titled Patients/Residents at Nutritional Risk revised June 2016 indicated It is the policy of [facility name] for the in-house Registered Dietitian (RD) or Consulting Dietitian to routinely assess patients/residents at nutritional risk. Documentation must be completed at a minimum of quarterly and/or as needed based on change in enteral feedings, tolerance, changes with nutritional interventions, and/or significant weight loss. Review of R18's Face Sheet, undated, located in R18's electronic medical record (EMR) under the Face Sheet tab, indicated a current admitted to the facility of 09/10/21 and readmission on 04/11/22. The Face Sheet indicated R18 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R18's EMR for the April 2022 physician orders, under the Orders tab revealed the following orders: Standard 2.0 (a nutritional supplement) 90 milliliters (ml) twice a day (BID), started 09/22/21 and discontinued 04/13/22; Standard 2.0 90 ml three times a day (TID), started 04/13/22; and a no added salt (NAS) chopped diet, started 09/13/22. According to the Minimum Data Set Assessment (MDS) with an Assessment Reference Date (ARD) of 12/15/21, R18 had a Brief Interview for Mental Status (BIMS) of 10 out of 15, which indicated the resident had moderately impaired cognition. Review of R18's Care Plan tab of the EMR revealed a care plan initiated on 09/10/21 with a revision date of 04/12/22 that listed a problem of at risk for nutrition and/or hydration risk as evidenced by consumes less than 75% of food and/or fluids at most meals and missing/broken teeth. R18's approaches included monitor weight as ordered supplements as ordered, provide diet as ordered, and Speech Therapy (ST) to evaluate and treat. Review of R18's EMR for weights, under the Vitals tab revealed the following weights: On 03/07/22: 94.7 pounds (lbs.) On 03/16/22: 96 lbs. On 03/23/22: 90.9 lbs. (5.3% weight loss x one week) On 04/06/22: 89.2 lbs. (5.8% weight loss x one month) On 04/13/22: 86 lbs. (10.4% weight loss x one month) Review of the Registered Dietitian (RD) assessment located in the EMR under the Observations. tab dated 09/22/21, revealed R18 had a current body weight of 81 lbs. R18 had a body mass index of 14.81, which indicated underweight status. R18's ideal body weight was 110 lbs. Recommendations included Standard 2.0 90 ml BID. There were no other RD assessments, and no RD progress notes after this assessment. Review of nursing progress note dated 04/13/22 (during the survey) at 5:08 PM, revealed NP [Nurse Practitioner] aware of weight loss. Weekly weight obtained due to [CONDITION(S)] [CHF] diagnosis. At this time resident medication regimen reviewed by Medical Doctor [MD] and NP. RP [Responsible Party] aware of weight loss. Review of the nursing progress note dated 04/13/22 at 7:33 PM revealed order received from NP to increase Standard to TID. RP made aware. During an interview on 04/12/22 at 9:30 AM, R18 stated she was not usually hungry, but tried to eat. During an observation on 04/13/22 at 7:40 AM of R18's lunch meal, R18 received grits, scrambled eggs, mechanical sausage, and pancakes. R18 was able to set up the food items and fed herself. By 9:00 AM, R18 was observed to have consumed approximately half of her sausage, eggs, grits, and bites of her pancake. During an interview on 04/13/22 at 3:21 PM, Licensed Practical Nurse (LPN) 2 stated R18 took the med pass supplement (Standard 2.0). LPN2 stated R18 consumed close to 50% of her meals. She confirmed R18 had lost seven pounds since March. During an interview on 04/13/22 at 3:28 PM, Certified Nursing Assistant (CNA) 2 stated R18 disliked snacks, ice cream, milk, and cookies. CNA2 stated R18 was anxious at times, so they let her do what she wanted. During an interview on 04/13/22 at 4:27 PM, the Registered Nurse Supervisor (RNS) stated R18's meal intakes fluctuated. The RNS stated significant weights would trigger on the weight variance report. She stated the Director of Nursing (DON) and she pulled the report every month. She stated they tried to have a weight meeting regularly. She stated she had not attended lately, because she had been working nights. She stated all leadership nurses attended the weight meetings and the Dietary Manager (DM), if available. She stated the RD looked at the weights and notes. She stated she had not met with the RD. She acknowledged she was unable to find a note from the RD or medical doctor/nurse practitioner related to R18's weight loss. She stated for residents with weight loss, they talked to the RD for reassessment, put the resident on a high calorie diet, and notified the medical doctor. During an interview on 04/14/22 at 2:15 PM, the RD stated the facility had a weight team that addressed weight losses. She stated the weight team would intervene first and she would assist. The RD stated she had not documented weight losses for this month yet. She stated R18 did not have weight loss the previous month. She stated she had not talked with this resident. She stated she was not aware of who was on the weight team. During an interview on 04/14/22 at 10:52 AM, the DON stated they did not have any weight meetings for this month (April). At 2:55 PM, the DON stated they tried to have weight meetings once a month. The DON stated they completed weights by the eighth and they were put into the system by the 10th. She stated if they had any concerns, they would talk to the RD. She stated the RD put her own orders into the system. She stated they always added a supplement for residents with weight losses. The DON stated R18 triggered a five percent weight loss this month and they requested a reweigh.

Based on record review, review of the facility policy titled Care Plans, and staff interviews, the facility failed to develop and implement a care plan for assist rails for one resident (R) (#1) of 13 residents with bedrails. On [DATE] a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy (IJ) on [DATE] at 10:00 a.m. The noncompliance related to the IJ identified to have existed on [DATE] when R#1, who was not obese, received a standard low air loss (LAL) mattress which was placed on a bariatric bed (a large bed for the severely obese residents) leaving a gap between the mattress and assist rail. The IJ is outlined as follows: R#1 was admitted to the facility on [DATE] under Hospice services. R#1 had a room change on [DATE] and was placed on a bariatric bed with assist rails (the resident weighed 150 pounds and was not considered obese). On [DATE], R#1 received a standard LAL mattress ordered by Hospice. The bariatric bed frame was too large for LAL mattress which caused gaps between the mattress and assist rail. R#1 was found on [DATE] with her head and neck between the assist rail and mattress, expired. The resident had multiple areas of redness and bruising to her neck. The IJ was related to the facility's noncompliance with the program requirements as follows: C.F.R. 483.25(n) Bedrails (F 700 Scope and Severity (S/S): J) C.F.R. 483.21(b) Comprehensive Care Plans (F 656 S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at C.F.R. 483.25(n) Bedrails (F 700 S/S: J). A Removal Plan was received on [DATE]. Based on the validation of the Removal Plan, the State Survey Agency determined that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures governing the use of bedrails. Findings include: Review of the facility policy titled Care Plans reviewed [DATE] documented the following: It is the policy of the health care center for each patient/resident to have a person centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data Set (MDS) and Care Area assessment (CAA) portions of the comprehensive assessment according to the Resident Assessment Instrument (RAI) manual and the patient/resident choice. Comprehensive Care Plans should be reviewed not less than Quarterly .following the completion of an assessment. Care plan update reviews will be preformed within 7 days of each quarterly assessment, each acute change in condition and as needed following a hospital stay. A review of the clinical record revealed R#1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Significant Change MDS dated [DATE] revealed R#1 had a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. R#1 was also assessed to require extensive two person assist for transfer, but was totally dependent for bed mobility and toileting. Review of the clinical record revealed that R#1 was found on [DATE] on the floor in a semi-upright position on her bottom lateral to the bed on the left side with her head positioned between the bed mattress and assist rail facing towards the door, expired. The resident was noted to be on a bariatric bed with a standard LAL mattress which left a gap between the mattress and assist rail. The Physician Orders for R#1 between [DATE] at admission through [DATE] revealed no orders the use of assist/bedrails or a bariatric bed. R#1 did not have a care plan for a bariatric bed with assist rails. An interview with the MDS Coordinator on [DATE] at 11:00 a.m. revealed care plans are reviewed and updated during Annual, Quarterly and Significant Change assessments and as needed when a resident's plan of care changes. MDS stated that whenever there is any change to a resident's plan of care it should be immediately updated on the current care plan. MDS Coordinator stated she gathers all the information to complete the MDS by reviewing physician orders, physician notes, progress notes, vitals, weights, face sheet with [DIAGNOSES REDACTED]. MDS Coordinator stated she does not document any of this process. She does write notes as she gathers information but throws the notes away after updating the MDS. An interview with LPN EE on [DATE] at 3:35 p.m. revealed a charge nurse/floor nurse will contact the doctor to get a physician's order for any device/equipment that a resident has been assessed to have, including assist rails. LPN EE stated this should be documented in progress notes and the physician's order should be updated. LPN EE stated the care plan should be updated to reflect the assistive device. During an interview on [DATE] at 2:30 p.m., Social Services (SS) stated that she assisted with R#1's last move on [DATE] and R#1 was placed on the bariatric bed with assist rails that was already in the room when R#1 was moved into that room. SS stated she did not check to see if R#1 was care planned for a bariatric bed with assist rails. SS stated that she usually just assists with the move itself and relies on Certified Nursing Assistant (CNA) and nursing staff to ensure what equipment is appropriate for a resident. An interview with the Care Plan Coordinator (CPC) on [DATE] at 10:10 a.m. revealed she runs a facility event report that she brings to the morning meetings and the residents are discussed. CPC stated when an event occurs, the nurse on duty will be responsible for updating the care plan immediately, but the care plan will be reviewed during the morning meeting. CPC stated that if there are other interventions identified for a resident during the morning meeting, the care plan will be updated during the meeting. However, CPC stated that outside of the meeting as new areas of concern or interventions are identified the care plan will be updated to reflect those changes. CPC stated she was unaware when R#1 was placed into the bariatric bed with assist rails and she does not recall any discussion during any of the morning meetings about R#1's need for the bariatric bed or assist rails and there was never discussion about updating R#1's care plan to reflect the need or use for either of those. CPC stated that during the audit that was completed on and after [DATE] related to resident's with bedrails, she was provided with a list of all the residents in the facility who had bedrails and she had to check each care plan to ensure that each resident was care planned to have bedrails. An interview with the DHS on [DATE] at 1:15 p.m. revealed that safety assessments related to equipment/devices should be completed prior to initial use by the resident and Quarterly, Annually and with Significant Change to ensure there is continued need for equipment/devices and no changes in safety related to use. DHS stated that a resident's care plan should be updated to reflect all interventions in place for a resident's current plan of care. DHS stated that CNA and nursing staff should be familiar with a resident's current care plan therefore, they would be able to quickly recognize if a resident is using any device/equipment they are not currently care planned for, including assist rails. DHS stated that staff should always be observant whenever interacting with or providing care to residents to ensure their environment is safe and all equipment is directly in line with their current plan of care. DHS stated that it is the responsibility of the DHS and Unit Managers to ensure this process is followed. The DHS stated that R#1 returned to the facility on [DATE] and that she is certain that R#1 was not placed in the bariatric bed at that time. DHS stated that she saw R#1 in her room on [DATE] after her last room change on [DATE] but does not remember seeing anything in R#1's room that was concerning. DHS stated that she is very disappointed that staff never observed and reported that R#1 was in a bariatric bed with assist rails for which there was no care plan; and that the mattress that was too small for the bed. The facility implemented the following actions to remove the IJ: 1. On [DATE], resident #1 was found on the floor with the lower half of her body on the floor and her head between the assist rail and mattress on her bed. Resident was expired. 2. An immediate investigation was initiated by the Administrator and DHS at 7:10 am to determine the root cause of the incident involving staff interviews, a review of the resident medical record and a review of the scene. 3. On [DATE], Maintenance completed a 100% bed check audit on 72 of 72 beds to review correct mattress position, proper inflation of mattresses and to ensure no gaps were noted in between mattress and assistive rails. 12 of 72 beds were identified as having assist rails. 2 of 12 beds have an air mattress and assist rail. One concern was identified with a small gap created by a sliding mattress and in this process, it was immediately corrected by adjusting the mattress by applying Dycem under the mattress to prevent it from sliding. The facility still currently has 12 beds with assist rails and 2 of those 12 have air mattresses as of [DATE]. This audit will be completed weekly and will be ongoing. The last audit was completed on [DATE]. 4. 12 of 12 resident care plans were verified on [DATE] to ensure assistive side rails were documented. 5. DHS/Unit Manager and CCC were educated on [DATE] on the process of therapy referrals to seek alternative measures for bed mobility, determining of assistive devices for bed mobility, nurses notification to Responsible Parties for informed consent related to assist rails including risk and benefits, documentation of informed consent, obtaining physician orders for assistive side rails, placement of this information on the care plans and completion of the restraint adaptive use observation. 6. On [DATE], the Care Plan Policy was reviewed with Clinical Leadership included 3 of 3 LPNs and 4 of 4 RNs. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. R#1 expired on [DATE]. 2. Review of facility timeline report revealed the following events on [DATE]: 5:30 a.m. - Administrator received a text message from agency nurse that there had been a death of a hospice patient and hospice nurse had been notified to pronounce. 6:40 a.m. - Administrator received phone call from DHS notifying her that resident was found on the floor with no pulse or respirations and placed back in the bed. 7:00 a.m. - Hospice nurse notified Administrator of how resident was found on the floor with her head positioned between the bed mattress and the assist rail, and that discoloration was noted as well. 7:10 a.m. - Administrator spoke with agency nurse to get report on the events that surround the death of resident. 7:15 a. m. - Administrator notified unit manger to advise any staff that was involved with resident care or events to stay at facility until police arrived and to start writing statements to be collected. 7:45 a.m. - Administrator arrived at facility and entered residents' room and noted that there was a visible space between the mattress and the ¼ assist rail on the bariatric bed. 8:15 a.m. - Family of R#1 was notified of residents' death and the manner of which the resident was found on the floor. 8:30 a.m. - Police was notified and requested to visit to report an incident. 8:40 a.m. - Report submitted to HFRD online 8:55 a.m. - Coroner was notified to report events who declined involvement due to residents age and hospice status. 9:00 a.m. - Police Detective arrived to facility to collect statements and view body and attempted to call coroner with no answer. 10:15 a.m. - Coroner returned call details were reviewed again and stated he would be at facility shortly. 10:30 a.m. - Coroner arrived at the facility, reviewed findings, assessed the resident, and called the state medical examiner's office. Autopsy was not recommended 11:45 a.m. - The funeral home was called to pick up resident's body. 3. Review of facility assist rails audit for [DATE] revealed 72 of 72 beds were audited and assist rail placement and proper installation was indicated for 12 beds with assist rails. Bed with instance of sliding mattress was addressed by applying Dycem to the left and right side of bed frame to prevent mattress from dislodging during resident self-transfer. R#8 was observed with Dycem in place with no concerns on [DATE] at 10:00. It was also confirmed that 2 of 12 beds with air mattresses were inflated correctly. The audit was completed again on [DATE], [DATE], and [DATE]. 4. Review of the care plan for R#2 revealed the use of assist rails, right and left (R & L). Review of the care plan for R#3 revealed the use of assist rails (R). Review of the care plan for R#4 revealed the use of assist rails. Review of the care plan for R#5 revealed the use of assist rails (L). Review of the care plan for R#6 revealed the use of assist rails (R & L). Review of the care plan for R#7 revealed the use of assist rails (R & L). Review of the care plan for R#8 revealed the use of assist rails (L). Review of the care plan for R#9 revealed the use of assist rails (R & L). Review of the care plan for R#10 revealed the use of assist rails (R). Review of the care plan for R#11 revealed the use of assist rails (L). Review of the care plan for R#12 revealed the use of assist rails (R). Review of the care plan for R#13 revealed the use of assist rails (R). The above listed residents had CNA care plans that also reflected the use of assist rails. 5. Review of the facility in-service records dated [DATE] revealed the DHS, Clinical Care Coordinator (CCC), and Unit Managers received education on the process of therapy referrals and the expectation that staff should seek alternative measures for bed mobility, notification to responsible parties for informed consent and documentation that informed consent was given, obtaining physician orders, updating the care plan and observation of restraint adaptive devices. Also verified via the following staff interviews on [DATE] at 1:00 p.m. with Unit Manager CC, and on [DATE]: 8:34 a.m. with the DHS, and 8:35 a.m. with the CCC, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 6. Review of the facility in-service records dated [DATE] revealed the clinical leadership which consisted of 3 of 3 LPNs and 4 of 4 RNs received instruction and review of the care plan policy. Also verified via the following staff interviews on [DATE] at 1:00 p.m. with Unit Manager CC, 1:43 p.m. with LPN DD; and on [DATE] at 8:35 a.m. with the CCC, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. Cross Refer to F700.

Based on record review, review of the facility policy titled Bed Rails, review of the Food and Drug Administration (FDA) guidelines titled Recommendations for Health Care Providers about Bed Rails, and staff/family interviews, the facility failed to provide an environment free from the risk of entrapment between the assist rail and air mattress for one resident (R) (#1); and failed to obtain informed consent and attempt alternative methods for 12 of 13 residents prior to the use of assist rails (#2, #3, #4, #5, #6 #7, #8, #10, #11, #12 and #13). On [DATE] a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator and Director of Health Services (DHS) were informed of the Immediate Jeopardy (IJ) on [DATE] at 10:00 a.m. The noncompliance related to the IJ identified to have existed on [DATE] when R#1, who was not obese, received a standard low air loss (LAL) mattress which was placed on a bariatric bed (a large bed for the severely obese residents) leaving a gap between the mattress and assist rail. The IJ is outlined as follows: R#1 was admitted to the facility on [DATE] under Hospice services. R#1 had a room change on [DATE] and was placed on a bariatric bed with assist rails (the resident weighed 150 pounds and was not considered obese). On [DATE], R#1 received a standard LAL mattress ordered by Hospice. The bariatric bed frame was too large for LAL mattress which caused gaps between the mattress and assist rail. R#1 was found on [DATE] with her head and neck between the assist rail and mattress, expired. The resident had multiple areas of redness and bruising to her neck. The IJ was related to the facility's noncompliance with the program requirements as follows: C.F.R. 483.25(n) Bedrails (F 700 Scope and Severity (S/S): J) C.F.R. 483.21(b) Comprehensive Care Plans (F 656 S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at C.F.R. 483.25(n) Bedrails (F 700 S/S: J). A Removal Plan was received on [DATE]. Based on the validation of the Removal Plan, the State Survey Agency determined that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures governing the use of bedrails. Findings include: Review of facility policy titled Bed Rails revised [DATE] revealed that healthcare patients should be free from the use of bedrails, except where the use of bedrails has been appropriately determined to be medically necessary in accordance with this policy or its instances where the use of bedrails has been specifically requested by the patient or the patient's representatives. As further described in this policy, prior to using bedrails, the risks of doing so for a patient should be evaluated by appropriate staff of the healthcare center and discussed with the patient and/or the patient's representative. Procedure: 3. A partner from the Maintenance Department should examine the bed and determine that the dimensions of the bed are appropriate for the patient and confirm that the bedrails . are appropriate for the size and weight of the patient using the bed. Review of Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued [DATE] revealed reassessment of bed safety programs may be appropriate when accessories such as mattress overlays are added. Powered air mattress replacements are easily compressed by the weight of a patient and may pose additional risk of entrapment when used with conventional hospital bed systems. When these types of mattresses compress, the space between the mattress and the bedrail may increase and pose an additional risk of entrapment. When rail entrapment occurred the most commonly injured body parts were the head and neck and 143 out of 145 events resulted in fatalities. Use of bedrails should be based on patient's assessed medical needs and should be documented clearly and approved by the interdisciplinary team. Bedrail effectiveness should be reviewed on a regular basis. The patient's chart should include a risk-benefit assessment that identifies why other care interventions are not appropriate or not effective if they were previously attempted and determined not to be the treatment of [REDACTED]. Monitoring of the bed, mattress and accessories should be ongoing. 1. A review of the clinical record revealed R#1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Significant Change Minimum Data Sets ((MDS) dated [DATE] revealed R#1 had a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. R#1 was also assessed to require extensive two person assist for transfer, but was totally dependent for bed mobility and toileting. Review of the clinical record revealed that R#1 was found on [DATE] on the floor in a semi-upright position on her bottom lateral to the bed on the left side with her head positioned between the bed mattress and assist rail facing towards the door, expired. The resident was placed back in the bed. The Physician Orders, Progress Notes, and Observations for R#1 between [DATE] at admission through [DATE] revealed no documentation related to the use or need for assist/bedrails or a bariatric bed. There were no physician orders and no assessments for assist/bedrails. A review of Notification of Room Change forms revealed R#1 had a room change on [DATE] and [DATE] between her re-admitted on [DATE] and the date of expiration on [DATE]. At the time of the room change on [DATE], R#1 was placed on a bariatric bed. Review of the Client Coordination Notes Report dated [DATE] revealed Hospice Registered Nurse (RN) ordered a LAL mattress for the bariatric bed for R#1. Review of the Delivery Receipt revealed a LAL mattress was delivered on [DATE]. It is unclear on the delivery receipt whether the LAL mattress was bariatric or standard. Review of the facility's investigation documentation from [DATE] through [DATE] revealed that, at the time of the incident, the police, coroner, and Hospice were notified. Upon inspection, the resident was noted in a completely inflated, standard width LAL mattress with wings inflated. There was a visible space between the mattress and the ¼ assist rail on the bariatric bed. Upon further facility investigation, it was determined that the mattress that was received was a standard LAL mattress and not the bariatric LAL that was ordered. The Coroner's Death Investigation Report dated [DATE] documented that the resident was found on the floor and head between bedrail and mattress. The resident had several areas of redness/ bruising to the neck. The cause and manner of death was pending with Hospice. GBI declined to conduct an autopsy. During an interview on [DATE] at 3:35 p.m. LPN EE stated that it is an expectation for all staff that interact and provide care to resident's to be alert to concerns related to the resident's environment and or device/equipment in the residents room and these concerns should be brought to department heads attention immediately. An interview with Hospice RN SS on [DATE] at 11:45 a.m. revealed that she was R#1's nurse from the time R#1 was re-admitted to the facility on [DATE] until R#1 expired on [DATE]. Hospice RN SS stated that she made weekly visits to the facility to see R#1 and monitor R#1's care. She was the primary nurse and would make recommendations for devices/equipment for R#1. Hospice RN SS stated she made three visits to the facility to see R#1 after [DATE] when R#1 was moved to room [ROOM NUMBER]B and placed on a bariatric bed with assist rails. Hospice RN SS stated she never requested that R#1 be placed on a bariatric bed or have assist rails and she never requested a physician order for [REDACTED].#1 was on or that R#1 had assist rails on her bed that were never ordered. Hospice RN SS stated that she never questioned why there were assist rails on R#1's bed. Hospice RN SS never documented any safety concerns with R#1's environment. Hospice RN SS stated that the Hospice Aide also visits weekly and never reported any concerns with R#1's environment. During an interview on [DATE] at 2:30 p.m., Social Services (SS) stated that she assisted with R#1's last move on [DATE] and R#1 was placed on the bariatric bed with assist rails that was already in the room when R#1 was moved into that room. SS stated she did not observe any concerns with placing R#1 in the bariatric bed with assist rails. SS stated she did not check to see if R#1 was care planned for a bariatric bed with assist rails. SS stated that she usually just assists with the move itself and relies on Certified Nursing Assistant (CNA) and nursing staff to ensure what equipment is appropriate for a resident. SS stated she cannot remember what other specific staff assisted her when R#1 was moved on [DATE]. An interview with Licensed Practical Nurse (LPN) HH on [DATE] at 3:35 p.m. revealed the process related to ordering equipment/devices only differs slightly when a resident is on Hospice. LPN HH stated when a resident is on Hospice, the Hospice RN will handle obtaining physician orders and ordering the equipment/device and will make facility staff aware. LPN HH stated whoever delivers the equipment is the person who will set it up and install it in the resident's room. LPN HH stated she was the staff member who signed for the low air flow mattress that was delivered to R#1 on [DATE] that was ordered by R#1's Hospice RN. LPN HH stated she is unsure if a unit manager was made aware that the low air flow mattress was delivered and set up in R#1's room. LPN HH stated she does remember notifying the Hospice RN but did not document that anywhere. LPN HH stated she would normally go into the resident's room to check after the equipment/device has been installed but she did not that night because it was at the end of the shift and she had other tasks to complete. LPN HH stated when the low air flow mattress was delivered, she only signed acknowledging that it was delivered not that it was the correct low air flow mattress. LPN HH stated she never informed maintenance that the low air flow mattress was delivered but she did report it to the oncoming nurse, but she did not document that. LPN HH stated she did go into R#1's room after that but she does not recall any issue with the low air flow mattress size or observing a gap between the low air flow mattress and assist rails. An interview with Family of R#1 on [DATE] at 4:00 p.m. revealed R#1's Hospice RN contacted him to make him aware of the low air flow mattress that was ordered for R#1. Family of R#1 stated he was unaware that R#1 had been placed on a bariatric bed with assist rails. He stated he never received any notification related to the use of assist rails for R#1 and he never provided informed consent for R#1 to use them. Family of R#1 stated the Hospice RN would contact him weekly to inform him of the weekly visit with R#1 and at no time did she ever report any concerns related to R#1's bed or devices/equipment. An interview with CNA AA on [DATE] at 12:35 p.m. revealed that she provided care to R#1 on several occasions. CNA AA stated she was the CNA assigned to R#1's hall on the night of [DATE]. CNA AA stated her shift started that night at 11 p.m. and that she started making her rounds about 11:45 p.m. CNA AA stated she is not sure what time she first went into R#1's room that night but R#1 was sleeping and CNA AA informed R#1 that she was in the room and R#1 opened her eyes briefly but went back to sleep. CNA AA stated that R#1 was not soiled and did not require any care at that time, so she left R#1's room. CNA AA stated she made her second round about 1:45 a.m. but at that time R#1 was still not soiled and was sleeping so CNA AA left the room. CNA AA stated that on her third round about 4:30 a.m. is when CNA BB found R#1 on the floor in the room and CNA BB ran out of the room to get the charge nurse. CNA AA stated she did observe that R#1 had a new mattress on her bed, and she observed the bedrails, but the bedrails had been on the bed before. CNA AA stated she did not observe any concerns with the mattress or the bed. CNA AA stated she thought R#1 needed bedrails since she had a fall in the facility about a week prior. An interview with CNA BB on [DATE] at 1:15 p.m. revealed she is an CNA in training and she always works alongside another CNA. CNA BB stated on [DATE] she worked alongside CNA AA on R#1's hall. CNA BB stated during that night, she along with CNA AA checked on R#1 multiple times that evening before 4:30 a.m. when they found R#1 laying on the floor. CNA BB stated when they found R#1, she ran to get the charge nurse on duty to alert her. CNA BB stated that she never saw anything in R#1's room that appeared unsafe or was a concern. CNA BB stated that she had never received training related to bedrails or safety concerns related to bedrails. CNA BB stated that R#1 did twist and turn a lot in bed during the night when she worked on R#1's hall. An interview with RN FF on [DATE] at 3:00 p.m. revealed that she was not familiar with R#1 and prior to [DATE] she had never worked on R#1's hall or provided care to her. RN FF stated on [DATE] at around 4:40 a.m. she was alerted by staff to come to R#1's room and RN FF instructed staff to call 911 but she was informed that R#1 was on Hospice. RN FF stated she observed R#1 on the floor and that she had other staff assist her with getting R#1 back into bed. RN FF stated that while doing this she had to free R#1's head from being wedged in between mattress and assist rail. RN FF stated she had not been in R#1's room prior to the incident but while she was in there that night, she observed that R#1 appeared to be on a full-size bed with a twin-size mattress. RN FF stated there was an obvious gap between the mattress and the assist rail that appeared to be about a foot in length. RN FF stated this should have been immediately observed as a concern for any staff that observed R#1 lying in that bed. An interview with RN JJ on [DATE] at 4:00 p.m. revealed she is an agency rapid response nurse and she is only in a facility for a specific amount of time before she is sent to another facility within the state. RN JJ stated she was the floor nurse assigned to R#1's hall on the night of [DATE] and that she had worked on that hall prior to that and was familiar with R#1. RN JJ stated that she passed medications that night to all the residents on that hall including R#1. RN JJ stated that she doesn't recall any concerns in R#1's room. RN JJ stated that she was alerted by CNA staff that evening after they found R#1 on the floor and she went to the room to assist. RN JJ stated she checked that R#1 had no respiration, no heart rate and her pupils were fixed. RN JJ stated that she assisted staff with placing R#1 back into bed. RN JJ stated that before they could pick R#1 up to place her in the bed RN JJ had to reposition her body so she could free R#1's head that was stuck between the mattress and rail and at that time she remembers observing a gap between the mattress and the assist rail. After the incident with R#1, a bed check audit was completed on [DATE] for all beds related to the use of assist rails and some corrective action was taken by the facility, including obtaining physician orders, completing Adaptive Equipment Use assessments and care plans. 2. A review of the clinical record revealed R#2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS dated [DATE] revealed R#2 had a BIMS score of 12, indicating moderate cognitive impairment. R#2 was also assessed to require supervision of one person assist for bed mobility and transfer, and limited assistance of one with toileting. R#2 had a Physician Order dated [DATE] for bilateral assist rails as tolerated. A care plan was developed on [DATE] for the use of right and left assist rails. Review of Observation Detail List Report for R#2 revealed a Restraint-Adaptive Equipment Use Assessment was completed on [DATE]. However, there were no documented alternatives to the use of the assist rails. Further review of the clinical record revealed no documentation related to obtaining informed consent from R#2 or the resident's representative for the use of assist rails. 3. A review of the clinical record revealed R#3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission MDS dated [DATE] revealed R#3 had a BIMS score of 15, indicating no cognitive impairment. R#3 was also assessed to require two-person extensive assistance with bed mobility, and total dependence with transfer and toileting. R#3 had a Physician Order dated [DATE] for bariatric bed with right and left assist rails to assist with turning and repositioning. Review of the care plan revealed R#3 required assist rails initially on [DATE]. Review of Observation Detail List Report for R#3 revealed a Restraint-Adaptive Equipment Use Assessment was not completed until [DATE]; and there were no documented alternatives to the use of the assist rails. Further review of the clinical record revealed no documentation related to obtaining informed consent from R#3 or the resident's representative for the use of assist rails. 4. A review of the clinical record revealed R#4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS dated [DATE] revealed R#4 had a BIMS score of 03, indicating severe cognitive impairment. R#4 was also assessed to require two-person extensive assistance with bed mobility, total dependence with transfer, one-person limited assistance with eating and two-person total dependence with toileting. R#4 had a Physician Order dated [DATE] for bilateral half rails to assist with bed mobility. A care plan was developed on [DATE] for bilateral assist rails to aid with bed mobility. Review of Observation Detail List Report for R#4 revealed a Restraint-Adaptive Equipment Use Assessment completed on [DATE]. However, there were no documented alternatives to the use of the assist rails. Further review of the clinical record revealed no documentation related to obtaining informed consent for R#4 for the use of assist rails. Staff were unable to provide any documentation that the resident or resident's representatives provided informed consent. 5. A review of the clinical record revealed R#5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission MDS dated [DATE] revealed R#5 had a BIMS score of 03, indicating severe cognitive impairment. R#3 was also assessed to require two-person extensive assistance with bed mobility, transfer, and toileting. R#5 had a Physician Order dated [DATE] for left assist rail as tolerated. Review of the care plan revealed R#5 required left assist rail initially on [DATE]. Review of Observation Detail List Report for R#5 revealed a Restraint-Adaptive Equipment Use Assessment was completed on [DATE]. However, there were no documented alternatives to the use of the assist rails. Further review of the clinical record revealed no documentation related to obtaining informed consent for R#5 for the use of an assist rail. Staff were unable to provide any documentation that the resident or resident's representatives provided informed consent. 6. A review of the clinical record revealed R#6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission MDS dated [DATE] revealed R#6 had a BIMS Score of 13, indicating no cognitive impairment. R#6 was also assessed to require two-person extensive assist with bed mobility, transfer, and toileting. R#6 had a Physician Order dated [DATE] for a right and left assist rails as tolerated. A care plan was developed on [DATE] for the use of a right and left assist rail. Review of Observation Detail List Report for R#6 revealed a Restraint-Adaptive Equipment Use Assessment was completed on [DATE]. However, there were no documented alternatives to the use of the assist rails. Further review of the clinical record revealed no documentation related to obtaining informed consent from R#6 or the resident's representative for the use of assist rails. 7. A review of the clinical record revealed R#7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admissions MDS dated [DATE] revealed R#7 had a BIMS score of 11, indicating moderate cognitive impairment. R#7 was also assessed to require two-person extensive assistance with bed mobility and one-person limited assistance for transfer and toileting. R#7 had a Physician Order dated [DATE] for a bariatric bed with right and left assist rails to assist with turning and repositioning during ADL (activities of daily living) care. A care plan was developed on [DATE] for right and left assistive devices. Review of Observation Detail List Report for R#7 revealed a Restraint-Adaptive Equipment Use Assessment was not completed until [DATE]; and there were no documented alternatives to the use of the assist rails. Further review of the clinical record revealed no documentation related to obtaining informed consent from R#7 or the resident's representative for the use of assist rails. 8. A review of the clinical record revealed R#8 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Admissions MDS dated [DATE] revealed R#8 had a BIMS score of 10, indicating moderate cognitive impairment. R#8 was also assessed to require one-person limited assistance with bed mobility, and transfer. R#8 had a Physician Order dated [DATE] for left side assist rail to bed. Review of the care plan initiated on [DATE] revealed R#8 required left side assist rail to bed for mobility and wc (wheelchair) to bed transfers. Review of Observation Detail List Report for R#8 revealed a Restraint-Adaptive Equipment Use Assessment was not completed until [DATE]; and there were no documented alternatives to the use of the assist rails. Further review of the clinical record revealed no documentation related to obtaining informed consent from R#8 or the resident's representative for the use of assist rails. 9. A review of the clinical record revealed R#10 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS dated [DATE] revealed R#10 had a BIMS score of 03, indicating severe cognitive impairment. R#10 was also assessed to require one-person limited assistance with bed mobility, transfer, and toileting. R#10 had a Physician Order dated [DATE] for right side assist rail as tolerated to assist with bed mobility. A care plan was developed on [DATE] for right assist rail to assist with mobility. Review of Observation Detail List Report for R#10 revealed a Restraint-Adaptive Equipment Use Assessment was not completed until [DATE]; and there were no documented alternatives to the use of the assist rails. Further review of the clinical record revealed no documentation related to obtaining informed consent from R#10 or the resident's representative for the use of assist rails. 10. A review of the clinical record revealed R#11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Annual MDS dated [DATE] revealed R#11 had a BIMS Score of 99, indicating severe cognitive impairment. R#11 was also assessed to require one-person limited assistance with bed mobility, and transfer, and two-person extensive assistance with toileting. R#11 had a Physician Order dated [DATE] for bilateral assist rails. Review of the care plan revealed R#5 had been using bilateral assist rails since [DATE]. Review of Observation Detail List Report for R#11 revealed a Restraint-Adaptive Equipment Use Assessment was not completed until [DATE]; and there were no documented alternatives to the use of the assist rails. Further review of the clinical record revealed no documentation related to obtaining informed consent for R#11 for the use of assist rails. Staff were unable to provide any documentation that the resident or resident's representatives provided informed consent. 11. A review of the clinical record revealed R#12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS dated [DATE] revealed R#12 had a BIMS Score of 08, indicating moderate cognitive impairment. R#12 was also assessed to require one-person extensive assistance with bed mobility, transfer, and toileting. R#12 had a Physician Order dated [DATE] for right side assist rail as tolerated. Review of the care plan initiated on [DATE] revealed R#12 had an assist rail to right side to aid in bed mobility. Review of Observation Detail List Report for R#12 revealed a Restraint-Adaptive Equipment Use Assessment was not completed until [DATE]; and there were no documented alternatives to the use of the assist rails. Further review of the clinical record revealed no documentation related to obtaining informed consent from R#12 or the resident's representative for the use of assist rails. 12. A review of the clinical record revealed R#13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS dated [DATE] revealed R#13 had a BIMS score of 13, indicating no cognitive impairment. R#13 was also assessed to require one-person extensive assistance with bed mobility, and one-person limited assistance with transfer and toileting. R#13 had a Physician Order dated [DATE] for bilateral assist rails to bed. A care plan was developed on [DATE] for bilateral assist rails on bed. Review of Observation Detail List Report for R#13 revealed a Restraint-Adaptive Equipment Use Assessment was completed on [DATE]; However, there were no documented alternatives to the use of the assist rails. Further review of the clinical record revealed no documentation related to obtaining informed consent from R#13 or the resident's representative for the use of assist rails. An interview with the Rehab Manager on [DATE] at 11:45 a.m. revealed that when Occupational Therapy (OT) evaluates a resident and identifies a need for assistive devices/equipment such as bedrails, that is verbally communicated to the Rehab Manager and then it is brought to the Interdisciplinary Team (IDT) meeting for discussion. The Rehab Manager stated the results of the assessments should be documented by the Occupational Therapist who completed the assessment but, up until today, that was not being done. The Rehab Manager stated that prior to today there was no current process in place to ensure that all OT evaluation/assessments are documented. The Rehab Manager was unable to provide a report that would show the date a resident received an evaluation/assessment for devices/equipment or the date the resident received the ok to begin using the equipment/device. The Rehab Manager stated she would have to go through each resident's charts to see if she could get the date each resident began using their device/equipment. An interview with Director of Health Services (DHS) on [DATE] at 1:15 p.m. revealed the process for residents to receive assistive devices and/or bedrails is initially for the resident to be assessed by therapy to see if the resident would benefit from having assistive devices and/or bedrails. DHS stated that a safety assessment should be completed related to the device to ensure there is not a better or safer alternative. DHS stated nursing staff would then notify the physician to get an order for [REDACTED]. DHS stated that orders for equipment are generally received within eight hours of being placed. DHS stated when the order is delivered the nurse who signs for the equipment/device should ensure it is the correct equipment and there is a current physician order on file and document. DHS stated after nursing staff have verified the correct equipment/device has been received the nurse would notify maintenance to install the equipment/device. DHS stated that nursing staff should ensure there is no safety concerns related to the equipment/device and report it immediately if there is one observed. DHS stated that safety assessments related to equipment/devices should be completed prior to initial use by the resident and again at Quarterly, Annual and Significant Change assessments to ensure there is continued need for equipment/devices and no changes in safety related to use. DHS stated that a resident's care plan should be updated to reflect all interventions in place for a resident's current plan of care. DHS stated that CNA and nursing staff should be familiar with a resident's current care plan therefore, they would be able to quickly recognize if a resident is using any equipment/device they are not currently care planned for. DHS stated that staff should always be observant whenever interacting with or providing care to residents to ensure their environment is safe and all equipment is directly in line with their current plan of care. DHS stated that it is the responsibility of DHS and Unit managers to ensure this process is followed. DHS stated that R#1 returned to the facility on [DATE] and that she is certain that R#1 was not placed in the bariatric bed at that time. DHS stated that she saw R#1 in her room on [DATE] after her last room change on [DATE] but DHS does not remember seeing anything in R#1's room that was concerning. DHS stated that she is very disappointed that staff never observed and reported that R#1 was in a bariatric bed with assist rails along with a mattress that was too small for the bed. DHS stated that she feels the facilities entire process failed R#1. An interview with Mainte(TRUNCATED)

Based on record review and staff interviews, the facility failed to ensure one resident (R)#47 had a Preadmission screening/ Resident Review (PASRR) Level II review (comprehensive evaluation by the appropriate state designated authority determining whether the individual has a mental disorder or related condition and determines the appropriate setting for the individual and recommends, what if any, specialized services the individual needs) completed prior to admission. R#47 was admitted with a serious mental illness [DIAGNOSES REDACTED]. Findings include: Record review revealed that R#47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her current medications (not an all inclusive list) are: [MEDICATION NAME], [MEDICATION NAME], insulin and [MEDICATION NAME]. An interview on 8/13/19 at 10:27 a.m. with the Admissions/Marketing Director AA, revealed that she only looks at the PASRR to get a number off of it for care and reimbursement. She does not look at the resident's [DIAGNOSES REDACTED]. She stated she thought Social Services may do that. An interview on 8/13/19 at 1:30 p.m. with the Administrator revealed that Admission collects the admission information on new admits and she enters it into the computer. She stated if the Physician completes the PASRR, she goes by that information only. She stated that if there was a new [DIAGNOSES REDACTED]. She stated that it's only needed if the psychiatric [DIAGNOSES REDACTED]. An interview on 8/13/19 at 2:36 p.m, with the Nurse consultant BB revealed that facility does not have a policy on PASRR rather they just follow the regulations.